Physician and Pharmacist Discrepancy over Stevens Johnson Syndrome

June 1, 2010, 8:00AM. By Jane Mundy

San Francisco, CAEllen says that her son's Stevens Johnson Syndrome (SJS) could have been avoided if his pediatrician had listened to the pharmacist and prescribed a different antibiotic. "The good thing is that Connor was only two years old, so he doesn't remember suffering."

Connor was only seven weeks old when he developed an ear infection. He was given amoxicillin but the infection continued and he had an adverse reaction to the drug. "He had mottling over his entire body; it looked like someone had beaten him up," says Ellen. The pharmacist knew about Connor's adverse reaction, but the doctor prescribed him yet another penicillin.

"Why would the pediatrician give him this?" Ellen asked her pharmacist. She phoned the pediatrician right away and told him the drug he prescribed was a third-generation penicillin and Connor already had a reaction to penicillin. "Do not question me, I won't give him anything else," he replied.

"When a physician argues about the classification of a drug with a pharmacist, that is a huge arrogance issue with me," says Ellen. "There is no way a doctor can be knowledgeable and aware of side effects and classifications of so many new drugs. That is why they should be consulting the pharmacist—they should both be on the same page.

"My pharmacist dispensed the medication—she had no choice—and told me to watch Connor closely. The pediatrician told me to give him a second course because the infection didn't go away. On the third day of the second course, I was at work and I got a phone call from the babysitter.

"'Something is very wrong,' she said. I could hear my son crying in the background.

"She drove him to my work at the Fire Station (I'm a firefighter) about 10 minutes later. Blisters had popped all over his lower body. There was skin from his feet on her car floor. Right away we called an ambulance and treated him as a burn victim.

"The ambulance transferred us to Childrens' Hospital Oakland, which had a new pediatric burn unit. Connor was in hospital for 11 days and had skin grafts, taken from his thigh, from hip to hip. He ended up with second degree burns over 25 percent of his body. We were fortunate enough to have an extremely bright doctor who diagnosed SJS, but not before some people thought my son had been burned, either by me or the babysitter!

"The pediatrician never documented that my son had an allergy or any adverse reactions to antibiotics. I tried to sue him for malpractice—not for the money but for public awareness about SJS.

"But no one would take the case because it was over the statute of limitations. And nobody wanted to take on a case that would only compensate 25 percent for a minor with a cap of $250,000. If I had gone to an attorney in the first six months and sued on behalf of Connor and me, there is no cap on pain and suffering and you can get 40 percent in California. Frankly, I find this cap appalling. I have records from the pharmacist and the hospital that proves he had a reaction, and proves malpractice by the pediatrician.

"When Connor came home and the SJS had subsided, we went to a homeopathic MD who put him on mineral supplements to build his immune system. And of course we changed pediatricians. Connor is now 17 and still has scars from SJS. Fortunately he doesn't remember like I do."