Commentary
Educating staff members about emergency policies and evaluating emergency clinical skills are critical components in helping reduce the risk of malpractice claims.
Case Details
A 5 YOF (41”, 30 lb) patient presented to her pediatrician’s office with her mother for complaints of wheezing and cough. The patient’s medical history included extensive allergy testing, with identified allergies to milk, eggs, peanuts, tree nuts, strawberries, grapefruit, peanut butter, dogs, cats, and Tylenol. She had been seen in the emergency department (ED) 18 times over the course of five years with documented episodes of allergic reactions including mild pruritus, atopic dermatitis with open sores on her skin, allergic rhinoconjunctivitis, periorbital ocular conjunctivitis, lip swelling, shortness of breath, wheezing with retractions, and vomiting.
She was given an albuterol treatment in the office for wheezing and improved. She was also given an oral steroid. The mother was instructed to give the patient nebulizer treatments at home and return to the office at 3:00 p.m. the next day for a follow-up.
The following day, the patient and her mother arrived at the office approximately 30 minutes prior to her scheduled appointment time. She presented with complaints of fever and vomiting. The pediatrician was not in the office when the patient arrived. The mother asked if they should wait or go to the emergency room. The office staff contacted the pediatrician and she advised her staff to tell the patient’s mother to take the patient to the ED since she would not be in until 3:00 p.m. During the telephone call with the pediatrician, the staff provided the patient with a PediaSure SideKicks™ drink. While the pediatrician was on the phone with her staff, the call suddenly ended. She immediately called back and was told the patient had come out of the bathroom after vomiting, was struggling to breathe, and had turned blue. The pediatrician instructed the staff to initiate CPR and call 911. The office staff advised the mother not to use the EpiPen she carried before EMS arrived.
The pediatrician arrived at the office after the patient left by ambulance. Documentation from the ambulance service records showed the patient was diffusely cyanotic with agonal respirations, a heart rate of approximately 30 bpm, and secretions from the nose and mouth. Ambulance service documentation indicated that upon arrival to the pediatrician’s office, staff had initiated CPR, and it was in progress. The patient was intubated and given two rounds of epinephrine by EMS, with a return of spontaneous circulation (ROSC).
On arrival to the ED, the patient was in respiratory and cardiac arrest. The patient’s mother reported the pediatrician’s office staff gave the patient something to drink, and shortly thereafter, the child began to scream that she was in pain. The child had also reported her tongue was burning and her chest was hurting. A breathing treatment was given at the office. The patient’s mother saw the patient scratching her arms, suddenly gasping for air, and then turning purple. The staff told the mother to wait for EMS before administering the EpiPen.
On assessment in the ED, the patient appeared cyanotic, pupils fixed and dilated, unresponsive to stimuli, no palpable pulses, no auscultated heart sounds, and no spontaneous respirations. The skin had developed a maculopapular rash to the face, trunk, and lower extremities. Frothy pink secretions from the endotracheal tube (ETT) suggested pulmonary edema. The patient was diagnosed with multiple food allergies, asthma, respiratory arrest, cardiac arrest, anaphylaxis, rash, metabolic acidosis, and leukopenia. She was transferred to the ICU and two days later, the patient died. An autopsy confirmed the patient died of an anaphylactic reaction due to ingestion of a product containing milk.
The patient’s estate alleged that the pediatrician’s office gave the child a drink containing milk products while they waited to see the physician, despite her documented history of a milk allergy.
The office staff testified in deposition that they did not recall any written policy about employees giving patients food, drink, or medications, but that it was common knowledge that giving such to a patient was against office policy unless ordered by the pediatrician. The practice had no written policies or procedures for proper documentation of known allergies for a patient with asthma and/or severe food allergies.
The pediatrician testified that she trained the medical assistants to bring patients to the exam room, chart vitals, take a brief history, and note the reason for the visit. They were trained in CPR, but not in the use of an EpiPen or management of allergic reactions. While an emergency plan was in place, the pediatrician would be the one to evaluate the patient and provide direction.
Resolution
The case was settled for an undisclosed amount.
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