On March 13, 2019, an 8-month-old female infant was brought into an emergency care center by her mother due to vomiting, constipation, and being lethargic for 3 days. In the emergency care center, the infant was cared for by a PA, supervised by a MD – Medical Doctor. Both had a prior doctor/patient relation with the infant.
The medical records note: “Onset 2 days. The severity of the problem is mild. The problem has not changed. The patient’s mother reports vomiting. The patient’s mother reported diarrhea and blood in her diaper. Symptoms are not associated with sick contact at home. Denies aggravating factors. Denies relieving factors. Associated symptoms include fatigue. Pertinent negatives include abdominal pain, cough, fever, rash, or weight loss”.
HR 104/min, RR 30/min.
Physical exam is reported as normal for each system, and the overall appearance is described as non-toxic.
The infant was discharged from the emergency care center with the diagnosis “Vomiting and diarrhea”.
Discharge instructions: Make sure your child gets plenty of rest. Have your child drink fluids slowly in small, frequent amounts, such as water or spot drinks (Gatorade, Powerade) to help prevent dehydration. Avoid caffeine. As symptoms improve, your child may begin eating mild foods, such as dry toast, yogurt, applesauce, bananas, and rice. Avoid anything spicy or greasy and milk or ice cream until they are feeling better. Take medication as prescribed. Avoid anti-diarrheal medication, which may worsen symptoms. It must be noted that no further testing or diagnostics were performed or documented.
On March 15, 2019, the 8-month-old infant stopped breathing while eating. The mother contacted an ambulance service. Apparently, the baby had been sick for the past few days and not able to keep any food down. In the EMS report clinical impression showed: Cardiovascular – Cardiac Arrest with a duration of 5 minutes.
The patient was transported emergently to the ED, where she arrived on March 15 at 12:31.
Physical exam:
Patient is intubated. CPR in progress, Physical Exam Limitation due to: cardiac arrest
Skin: Warm, dry.
Head: Atraumatic, anterior fontanelle soft and flat.
Neck: Trachea midline.
Eye: Pupils are fixed and dilated; non-reactive.
Respiratory: Breath sounds are equal, Symmetrical chest wall expansion, with bagging/ventilation.
Gastrointestinal: Soft.
Appropriate resuscitation was provided by the ED staff.
Unfortunately, this was unsuccessful, and the infant was declared dead on 03/15/2019 at 12:55pm.
Autopsy Report:
Cause of Death: Peritonitis, due to Intestinal Malrotation with Midgut Volvulus.
Conclusion: In consideration of the circumstances surrounding the death, and after examination of the body, and review of the available medical records histology and toxicology report, it is my opinion that this 8-month-old female infant died as the result of peritonitis, due to intestinal malrotation with midgut volvulus.
Autopsy Findings: Intestinal malrotation with midgut volvulus
a. Perforation of small intestine
b. Peritonitis
c. Probable sepsis
We would be interested to know whether it is likely that the care received by the infant at the emergency care center on March 13, 2019, fell below the standards of care.
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Do you believe there might have been medical error?
Several points I would like to comment on: 1. The child was described as being "lethargic." This is a red flag term, often used by concerned parents, but which clinically means something very specific: that the child is not fully arousable and not responding to stimuli appropriately. It is not consistent with the later description of the child being appearing "non-toxic." This inconsistentency needs to be clarified and if the child was truly lethargic than care should have been escalated to a more acute setting. 2. The mother's report of "blood in her diaper" is also a red flag symptom, especially in the setting of gastrointestinal symptoms. This warranted documentation of a rectal exam. 3. The documentation of the physical exam as being "normal for each system" was inadequate. There needed to be a proper abdominal exam with pertinent positives and negatives, including whether there was any guarding or rebound tenderness or palpable mass. 4. The discharge instructions do not appear to have any instructions to return if symptoms persist or worsen, 5. Vital signs inadequate, was the child's temperature taken?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Despite the inadequacies in documentation, the catastrophic event that occurred is extremely rare and thus difficult to predict. The PA made a judgment based on their evaluation of the child that the child appeared well enough to discharge home. The actions of the PA were thus unlikely to be causative of the overall outcome,
What makes you a good expert for this case?
I have 7 years experience in a high volume urgent care setting. I have had training in managing risk and proper medical documentation. I regularly guide my colleagues on how to lessen their medical legal risk.
How often do you encounter cases similar to this one in your practice?
I encounter pediatric patients with similar presentations on a regular basis in the urgent care setting.
Do you believe there might have been medical error?
Given the patient's symptoms, the evaluation was inadequate. Bloody diarrhea in an infant should have been evaluated further. The initial description of the case stated that an exam was not done. If true, that is a clear deviation from the standard of care.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The lack of additional evaluation likely led to a missed diagnosis. The discharge directions, as presented do not provide a list of reasons to return to the emergency department.
What makes you a good expert for this case?
I am not a great expert because I have not cared for pediatric patients for many years. It is obvious from the description of the case that a deviation of the standard of care took place and was likely the cause of the death of this infant.
How often do you encounter cases similar to this one in your practice?
Never. In my current practice, I do not see infants. The youngest patient I see is 14 years old. I have cared for infants in the past, but it has been years.
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