Young Man Dies from Flu After ED Discharge

Description

An 18-year-old male was discharged from the Emergency Department (ED) after presenting with symptoms of a viral syndrome, mottled skin, tachypnea, and tachycardia. He was readmitted within 12 hours with influenza, and died two days later from severe sepsis and multi-organ failure.

Key Lessons

• Abnormal vital signs should be reassessed and either explained or addressed prior to discharge.
• A concerning physical exam is a red flag for a physician considering management steps and discharge dispositions.
• Multiple visits over a short period of time with unresolved concerns is a patient safety risk.

Clinical Sequence

An 18-year-old male college student, previously in good health, developed diarrhea, vomiting, and body aches lasting three days prior to being seen at the student health clinic. Initially, he was seen by an NP and diagnosed with a viral syndrome and discharged with instructions for supportive care. The next day, he was seen again at the university clinic; the physician noted clear lungs, but prescribed azithromycin and an albuterol inhaler, in addition to fluids and anti-pyretics for bronchitis or early community-acquired pneumonia.

The patient’s symptoms of nausea, vomiting, body aches, and diaphoresis continued to worsen, and he decided to go home to be cared for by his parents and his own PCP. Because his symptoms continued to progress, he presented to the local urgent care center instead of waiting for his scheduled PCP appointment. There, he was found to have an HR of 157, RR of 28 per minute, and mottled skin. During this visit, he was seen by the urgent care physician, who ordered a single liter of IV fluids and anti-nausea medications. The patient was diagnosed with “vomiting/dehydration” and discharged to home with instructions to rest, take fluids, continue medications, and to return “if worse.” There is no documentation of vital signs after his initial presentation nor clinical re-evaluation after treatment. The entire encounter lasted just under an hour.

The next morning his parents took him to the ED as he became increasingly uncomfortable with labored breathing and severe diaphoresis. There he was found to be acutely ill, with grossly abnormal lab values (Hct 56, WBC 22.6, Na 126, and Bicarb 16). He was treated aggressively with antibiotics and IV fluids for presumed meningitis and sepsis, and was admitted to the Pediatric ICU. There, he continued to deteriorate despite all intensive care measures, including blood pressure support and mechanical ventilation. Less than 48 hours after being seen in the urgent care center, he suffered a cardiac arrest and died of septic shock and multi-organ dysfunction secondary to influenza A.

Allegation

The patient’s mother sued the urgent care physician, claiming that negligent failure to diagnose and treat flu symptoms resulted in her son’s death.

Disposition

Expert review confirmed that failure to repeat vital signs and make reassessments of the patient’s clinical status delayed his diagnosis and treatment of influenza and shock. The case was settled for more than $1 million.

Analysis

1. Vital signs are vital.
   Grossly abnormal vital signs—including heart rate, blood pressure, respiratory rate, and temperature—are compelling evidence of a patient's hemodynamic instability. Any significant vital sign abnormality should be addressed in the clinical record, and, if necessary, repeated after appropriate intervention. If they do not normalize as expected, re-consider the etiology of the abnormality and the need for further workup.
2. A complete history and physical exam, including an estimate of insensible volume loss, likely would have led to further laboratory investigation and identification of critical illness.
   Taking time to obtain a complete history and physical can provide a critical piece of the story and result in a more appropriate diagnosis. Early closure can discourage caregivers from thinking in broad terms—and puts them at risk of missing key aspects of a patient’s presentation.
3. The patient’s mother recalled that her son told the doctor that the patient “felt like he was dying,” but the doctor downplayed the information.
   Patients and families need to be heard, and their impressions should not be discounted without adequate evidence supporting an alternative theory. Incorporating the data obtained from family members into decision-making can often be helpful. In addition, doing so makes that person feel part of the team caring for their loved one.
4. Inadequate documentation hurt the physician’s ability to counter plaintiff allegations that the care was inadequate, in particular that the patient was under-resuscitated.
   Symptoms need to be addressed in the physician’s documentation. Charting needs to be thorough, especially with regard to clinically concerning details. Recommendations for follow up need to be noted. Subsequent assertions that are poorly documented are difficult to defend, especially when the plaintiff is alleging a contrary story. This can be avoided by clearly documenting decision-making and discharge instructions.
5. The patient saw multiple care providers at different facilities over the course of four days.
   Careful history-taking can reveal the trajectory of an illness and the patient’s prior attempts to get treatment. Multiple patient complaints within a short period of time demand further inquiry. Failure of symptoms to even begin to improve indicates a need to reconsider any prior diagnoses and investigate further.
6. Expert review confirmed that failure to repeat vital signs and make reassessments of the patient’s clinical status led to a delay in diagnosis and treatment of influenza and shock.
   Factors that can seriously hamper the ability to defend a case in front of a jury include: patient discharged with abnormal vital signs, the presence of concerning physical exam findings with no reevaluation, lack of documentation of stated follow-up, and perceptions by the family that the physician was minimizing the patient’s concerns.