- 62 year old male presented to freestanding ER with generalized body aches, blood in urine
- Diagnosed with a UTI
- Was set to discharge with an Rx for Omnicef
- 18:25: Was given IV Rocephin 1 g
- 18:30: "RN at bedside discussing DC with pt. Pt stated that "he doesn't feel good" denies CP/SOB. MD walked into room to discuss DC plan with pt and wife. Pt suddenly became very red and diaphoretic. Was sitting up in bed, suddenly fell back and became unresponsive. Pt became more responsive after bagging. Placed on bipap, meds given. Pt suddenly began ripping off bipap saying he is "drowning", unable to keep bipap on, pt was intubated at 1900. Positive CO2 color change noted with noted breath sounds. Pt lost pulse at 1903 and ACLS initiated.
- 18:39: SOLU-Medrol ordered
- 18:41: BiPAP ordered
- 18:48: Nitrostat given
- 18:49: SOLU-Medrol given
- 18:54: Sublimaze ordered
- 18:55: Amidate given
- 18:55: Sublimaze cancelled
- 19:05: CPR started
- 19:10: Ephinephrine cancelled (unclear when it was ever ordered)
- 19:15: Magnesium sulfate given
- 19:29: Magnesium sulfate given again
- 19:34: pt expired; code ended
Seems that Epi should have been administered immediately upon the realization he was in anaphylaxis, and they never intubated him, either. Are these breaches of the standard of care?
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Do you believe there might have been medical error?
Hi, thank you for the opportunity to comment. This case seems to involve a rapid recognition of anaphylaxis post antibiotics, and the standard of care is IM epinephrine, parenteral steroids, Benadryl, and Pepcid. Unclear of the timing/administration. As the anaphylactic reaction progresses, hemodynamic support and airway management are also part of the standard of care and per the description, this was not done. I would be happy to provide a full review of the records and render an expert opinion.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The lack of proper management likely lead to cardiac arrest and death.
What makes you a good expert for this case?
I am Board Certified by the American Board of Emergency Medicine (ABEM). My current clinical practice is a high volume community hospital in a major metropolitan area. ED volume >80k patients per year. I am recognized as a Fellow of the American College of Emergency Physicians. Well versed in the standard of care in Emergency Medicine as a full time practicing physician. Experience with credentials committee at community hospitals. Trusted to provide impartial and comprehensive evaluations based on the facts of the case. I assist plaintiff and defense medical malpractice attorneys establish the standard of care, and identify breaches in compliance. Experienced in preparing strategies in defense of litigation for health system attorneys, as well as reviewing third party claims and independent QA reviews. I offer a complimentary introductory video call at your convenience prior to any retainer agreements. Licensed in WA, OR
How often do you encounter cases similar to this one in your practice?
I regularly see and manage allergic reactions as a full time Emergency Physician
Do you believe there might have been medical error?
Based on the information provided so far, there was a delay in recognition of the patient's severity. While anaphylaxis can always occur, the response provided was limited as evidenced by the delay in intubation. It appears the diagnosis was note made until much later, given the orders for medications not typically used for anaphylaxis. Epinephrine should have been given earlier based on the info available. The peri-intubation arrest may have been preventable.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Delay in recognition of anaphylaxis Delay in airway management Possible shortcomings in peri-intubation physiologic management leading to cardiac arrest
What makes you a good expert for this case?
I am one of only a handful physicians in the US triple-boarded in prehospital emergency medicine, emergency medicine, and critical care medicine. I practice all three specialties, and work in a large academic medical center that sees highly complex patients. I serve as a medicolegal consultant through my LLC and have experience in reviewing cases and providing my expert opinion. I respond quickly to attorneys' inquiries and review medical records expeditiously.
How often do you encounter cases similar to this one in your practice?
I estimate that I see cases of severe anaphylaxis every 4-6 weeks. I perform critical airway management over a hundred times per year.
Do you believe there might have been medical error?
The history is very limited and inconsistent. We need to know if the patient had any allergies or a history of anaphylaxis to determine if giving Rocephin was appropriate. Once it was obvious that he developed respiratory distress, he should have received epinephrine and Solumedrol immediately. He should have been placed on a cardiac monitor. If he did not respond immediately then he should have been intubated. Giving Sublimaze and Amidate to a patient in respiratory distress who is not intubated is a recipe for disaster as these are drugs that sedate and decrease the respiratory drive leading to a respiratory arrest in a patient who is already compromised by the anaphylactic reaction.. More information is needed regarding the patient's cardiac rhythm (if in fact he was placed on a cardiac monitor) in order to opine about the adequacy of the resuscitation efforts.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Inappropriate treatment of the anaphylactic reaction, making his respiratory status worse by administering sedating and narcotic medications, delay in intubation for airway control and ventilation and oxygenation support all speak to the lack of proper therapeutic intervention and in fact exacerbated the patient's respiratory distress which led to the cardiac arrest.
What makes you a good expert for this case?
I am board certified in Emergency Medicine by the American Board of Emergency Medicine. I am board certified in Internal Medicine by the American Board of Internal Medicine. I am board certified in Critical Care Medicine by the American Board of Internal Medicine. I am a Fellow of the American College of Emergency Physicians (FACEP), a Fellow of the American Academy of Emergency Medicine (FAAEM), a Fellow of the American College of Chest Physicians (FCCP), and a Fellow of the American College of Physicians (FACP). I am an emergency medicine physician with substantial professional experience over the past forty years while assigned to provide emergency medical coverage in a general acute care hospital emergency department. I have also relied upon my education, training and substantial experience as a practitioner and teacher for more than forty years. By virtue of my education, training, and continued substantial experience as an emergency medicine physician, I am intimately familiar with the standard of care for general acute care hospital emergency department physicians providing emergency medical coverage in the same or similar locality, in like cases, and under circumstances similar to those present in this case. During that time, I have taught emergency medicine to physicians in training and in practice, as well as to students, interns, residents, fellows, nurses, paramedics, nurse practitioners and physician assistants in all stages of their training. I am intimately familiar with the standard of care for emergency department physicians who assess patients with complaints of allergic reactions to medications, anaphylactic reactions and respiratory distress. I am intimately familiar with the standard of care for emergency medicine physicians who evaluate patients with signs and symptoms of allergic reactions, shortness of breath, respiratory distress and cardiac arrests.
How often do you encounter cases similar to this one in your practice?
Allergic reactions are commonly seen in emergency departments. Anaphylactic reactions are much less common but in my 40+ years of practice in a level 1 trauma center, I would estimate that I have seen more than 100 such cases. Of course, patients in respiratory distress are seen on a daily basis.
Do you believe there might have been medical error?
I would need additional information to move from Very Likely to Extremely Likely or Definitely yes. Did the patient report any allergies? Epinephrine is the mainstay of treatment for anaphylaxis, and its administration should not be delayed. Was it ordered but no administered in this case? It appears that other histamine blockers, Benadryl and Pepcid, were not administered as well. Was the patient unable to be intubated? Amidate was ordered at 1855 and the initial description states the patient was intubated at 1700.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
From the information provided, it does appear as though this patient suffered an anaphylactic reaction. Regardless of what the cause of the reaction was, the mainstay of treatment is to administer epinephrine.
What makes you a good expert for this case?
I am a board certified emergency physician with over 20 years of clinical practice. I am the Chair of the Dept of EM at one of the largest EDs in the country. I am currently vice chief of staff and elected to chief of staff starting January 2024. I am the chair for the hospital quality review committee. I participate in the hospital peer review committee as well as the ED peer review committee. I was awarded the Georgia College of Emergency Physicians (GCEP) medical director award for 2023
How often do you encounter cases similar to this one in your practice?
As chair of the department of emergency medicine, chair of the hospital quality review committee, and peer reviewer for the ED, I routinely participate in the evaluation of medical care and adjudication of whether the standard of care has been met or breached. I have both witnessed and managed similar cases in my clinical practice.
Do you believe there might have been medical error?
The patient was there for a UTI. Suddenly after receiving Rocephin he turned red and diaphoretic and then lost consciousness. Severe anaphylaxis fits the most in terms of the story. He was treated however for lung or heart issues. Solumedrol was likely given not for anaphylaxis but for a considered lung, wheezing, asthma or COPD issue and not for anaphylaxis, Had anaphylaxis been considered first he would have chosen Benadryl, iv epi, solumedrol and Pepcid. However with meds chosen: solumedrol, nitro were ordered. This indicated the concern may have been for a heart or lung condition. Solumedrol we will use for wheezing, copd or asthma. (We also use solumedrol for anaphylaxis but as an anaphylaxis cocktail.) The amidate was likely given to intubate. Or appears that Mag sulfate was given for a perceived respiratory issue. The diagnosis of anaphylaxis appears to have not been considered at this encounter based on what information is given in this case. Epi would have been mainstay if it was considered.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Lack of treatment for anaphylaxis did result in a loss of a chance of survival. There’s a chance that the patient might have died either way, however I do believe this lack of treatment for anaphylaxis did contribute to his death.
What makes you a good expert for this case?
I have practiced Emergency Medicine for 20 years.
How often do you encounter cases similar to this one in your practice?
We treat a lot of allergic reactions and mild anaphylaxis. However a true severe anaphylaxis with full cardiopulmonary arrest this quickly is rare and may be encountered once every 5-10 years.
Do you believe there might have been medical error?
Immediately upon the patient developing symptoms consistent with anaphylaxis he should have been treated with epinephrine, Benadryl, iv steroids, iv fluid bolus. If the patient did not respond to this treatment rapidly, the patient should have been sedated and intubated. The description does indicate the patient was intubated at 1900. Whether or not the patient should have been intubated earlier can only be determined from a review of the medical records in detail. Whether or not the patient was intubated in a timely fashion, the lack of administration of the above described meds would be a deviation from the standard of care.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
More likely than not, the patient’s anaphylactic shock could have been successfully treated if medication’s were administered rapidly and in the timely fashion as described above. Had proper treatment been rendered the patient more likely than not would not have died.
What makes you a good expert for this case?
I am board certified in Emergency medicine, and have reviewed about 100 cases as a Emergency medicine expert witness on behalf of both plaintiff and defense. In clinical practice, I have frequently and regularly treated patients with allergic reactions and anaphylaxis. Therefore I am very familiar with the standard of care in such cases. I have testified in both state and federal court, and at deposition multiple times and I am adept at explaining medical concepts, concisely, and in an understandable way to attorneys, judges, jurors.
How often do you encounter cases similar to this one in your practice?
In Emergency medicine, most emergency physicians encounter anaphylaxis not on a daily or weekly basis but regularly, and at least several times a year during their clinical practice.
Do you believe there might have been medical error?
The patient clearly was exhibiting signs of anaphylactic shock. The life saving drug that should have been administered immediately was subcutaneous epinephrine. The patient should have had this administered at the time of recognition of anaphylactic shock (when he developed the rash and became unresponsive). Solumedrol, a steroid, the first medication ordered, is an appropriate medication used in anaphylaxis, but takes hours for onset of action. Antihistamines (diphenhydramine and pepcid) are indicated immediately with fast onset of action. Neither of these were apparently ordered at all. If a patient stops breathing from an anaphylactic reaction, rapid sequence intubation and sedation is the indicated intervention to stabilize the airway. This wasn't done until about 30 minutes after onset, shortly before he coded. The provider clearly waited too long to secure the airway. Bipap ventilation would only be appropriate if the patient was awake and oriented, and if he were exhibiting signs of bronchospasm (wheezing). There is NO indication for nitroglycerine in this setting, and little role for magnesium unless the provider detected wheezing/bronchospasm. In that case, bronchodilators (albuterol) would have been indicated and there is no evidence that was given. The timing of the magnesium suggests it was given as part of ACLS protocols for cardiac dysrhythmia (maybe Torsades?), rather than bronchospasm. Regardless, the actions of the provider from this narrative indicate poor understanding of the pathophysiology of anaphylaxis, which represents a breach of the standard of care for treatment of patients presenting in anaphylactic shock. I would be surprised if the provider were residency trained in emergency medicine.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Patients still die of anaphylactic shock despite optimal care. Fortunately this is rare as the medications and interventions commonly used are highly efficacious in the treatment of anaphylactic shock. Unfortunately, this patient did not receive those interventions. Had the patient received immediate epinephrine, antihistamines, and early airway support with endotracheal intubation if medications did not reverse the anaphylaxis immediately, the patient would have, more likely than not, survived this event.
What makes you a good expert for this case?
I have nearly 30 years of experience in high volume, high acuity emergency departments and encounter patients presenting with allergic reactions on a regular basis. I am teaching faculty at an emergency medicine residency program. I have an active medical expert witness consulting practice, currently involved in multiple matters nationwide, including testimony in deposition and preparation of written affidavits in support of my findings. I am registered with the Florida Medical Board as a certified medical expert witness and have provided opinions on several cases in that state. I have excellent public speaking skills and by the nature of my work, function effectively and think quickly under pressure. I pride myself on being skilled at communicating complex medical concepts in a manner that is easily understandable to legal professionals and lay juries.
How often do you encounter cases similar to this one in your practice?
This is "bread and butter" emergency medicine. Allergic reactions present on a daily basis to my emergency department, and I'd estimate I such a case at least every few shifts. Anaphylactic shock, the most severe form of allergic reaction, is less commonly encountered, and I would estimate I have seen that every 6 months or so. I have had to code patients in anaphylactic shock rarely, as with the appropriate interventions I outlined above, patients typically respond promptly and profoundly, prior to cardiac arrest.
Do you believe there might have been medical error?
Anaphylaxis, the most severe and life threatening form of an allergic reaction, can be defined in several ways. It seems this patient met criteria for anaphylaxis in a few ways. Specifically a sudden event manifested by skin changes and respiratory compromise and cardiovascular collapse. Recognition and timeliness of this condition is imperative. Epinephrine is the standard of care treatment as it effects hypotension and bronchoconstriction, the 2 feared affects of an allergic reaction/anaphylaxis. It seems apparent from the description that was an acute event, there were skin changes and respiratory compromise fully c/w anaphylaxis. Although the airway management (BiPaP) was a reasonable option for care, EPI should have been given immediately.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The effects of an anaphylactic reaction need to be stopped and reversed. EPI is the 1st line standard of care drug in this regard. Additional meds like benadryl and steroids are important adjuncts to the EPI. The addition of nitroglycerine was interesting as this causes vasodilation, likely exacerbating the vasodilation from the anaphylactic reaction. Airway management was initially attempted with BiPaP which was reasonable. The summary provided implies intubation occurred at 9PM but ;later, it is implied he was never intubated. If there was not some sort of airway management provided after the patient took off the BiPap, that is a deviation in the SOC. The lack of EPI, addition of nitro and poor airway management (this is a potential contributor) clearly resulted in this patient dying.
What makes you a good expert for this case?
1. Practicing EM in an academic setting where I have the responsibility of teaching residents and students for nearly 30 years. 2. I have been doing expert work for over 20 years mostly on the defense side. 3. I am well read in the area of general EM 4. I participate at a national level in the Certification of EM docs (oral board examiner) 5. I have also practiced in a community hospital ED 6. I supervise/teach residents, medical students, PAs and NPs
How often do you encounter cases similar to this one in your practice?
Thankfully, anaphylaxis is a relatively rare event. In my nearly 30 years of practice, I have encountered it 1-2x's per year.
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