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Special Report

Things Fall Apart

King, Brent R. MD

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doi: 10.1097/01.EEM.0000340950.69012.8d
    sagittal cross-section of the leg showing intraosseous needle insertion into the proximal tibia.

    Sometimes things don't go as planned in emergency medicine, despite our best intentions. And sometimes, things just fall apart. In our annual pediatric emergency medicine special report, we look at courses that veered off the path, leaving patients with avoidable consequences.

    Because of their sensitive nature, the cases presented here are amalgams, with details changed to protect patient identities. The point here, however, is to learn for future cases and prevent errors.

    CASE 1: “Let's Wait for Mary”

    A 9-month-old infant presented to the emergency department with vomiting and diarrhea. Her symptoms had been present for several days. On her grandmother's recommendation, her parents had been giving her rice water, but the vomiting and profuse, watery diarrhea continued.

    At triage, she was listless, with a pulse of 163 beats per minute and a blood pressure of 79/56 mm Hg. She was immediately placed in the treatment area and evaluated by a physician a few minutes later. The physician diagnosed significant dehydration, and ordered a 20 cc/kg bolus of normal saline, a complete blood count, and serum electrolytes.

    Two experienced nurses attempted to insert an intravenous catheter, but admitted defeat after 30 minutes and asked a colleague to try. After three unsuccessful attempts, she also gave up. At this point, someone suggested asking one of the nurses from the neonatal intensive care unit to come to the emergency department to lend a hand.

    They called the NICU, and were relieved to learn that “Mary,” one of the unit's most experienced nurses, was on duty and was willing to come to the ED as soon as she finished a few urgent tasks. Mary assured the emergency department nurses that she would be down within the hour. And so they waited. When the physician asked what was going on, the nurses assured him that they were “waiting for Mary.” By this time, the infant had waited nearly an hour for the intravenous fluid bolus so the physician suggested that he attempt an intraosseous line, but the nurses looked horrified. “It's just so invasive,” one said. “Can we please wait for Mary?” So, they kept waiting for Mary, and the little girl arrested and died.

    These providers succumbed to one of the most common problems in the emergency department. All of us who work there try to create an appropriate treatment plan for each patient. In this case, it was certainly reasonable to have an experienced neonatal nurse start a difficult intravenous line, but we sometimes fail to recognize that a disposition is usually only the first step in the chain of care. We diagnose an acute myocardial infarction, and call the cardiologist, who notifies the catheterization laboratory, and in a few minutes, the patient is whisked away for stenting. Our responsibility for his care ends.

    Sometimes, and more and more frequently nowadays, patients remain in the emergency department long after we have decided to admit them, and we forget to take the next steps in the care pathway. Rest assured; we are not alone. Many years ago, social scientists studied waiters in restaurants and found a curious thing. As long as the check was open, the waiters were attuned to the status of each table. They knew which tables were awaiting entrees and which were ordering desserts. Once customers paid the bill, however, they completely dropped out of the server's awareness. Customers who wanted something after the bill was paid had a great deal of difficulty because, in the waiter's mind, they simply did not exist.

    In addition to this mental lapse, these well-intentioned providers also closed off their options. They wrote off an intraosseous line as too invasive, when, in fact, it probably would have saved this child's life. To be fair, this case occurred some years ago, and the options for dealing with a dehydrated infant have expanded dramatically. In addition to intraosseous fluid administration, investigators have demonstrated the effectiveness of oral rehydration supplemented by ondansetron to limit vomiting and administration of fluids via a nasogastric tube using an IV pump to deliver a continuous stream of fluid and prevent gastric distention.

    Bedside ultrasound has made percutaneous central venous catheterization safer and more reliable. More recently, investigators have been experimenting with the use of an old and long abandoned treatment, clysis, sometimes called hypodermoclysis. This technique involves administering fluids into the subcutaneous tissues using an intravenous catheter and an IV pump. But the point is that when we have not succeeded in doing what we normally do, it is time to do something else. As in this case, doing otherwise can be disastrous.

    CASE 2: Hoofbeats Outside the Window

    A 3-year-old girl was taken to a minor emergency center in a Northeastern city on a late fall day. Her mother said the child had “hurt her knee,” and was limping. The mother explained that the little girl and the girl's older brother were roughhousing two days before the visit. Both children had had mild febrile illnesses, and the mother “knew they were getting better when they had the energy to fight.”

    During the evening, the little girl fell from a rocking recliner. The mother had not witnessed the event, but both children reported it to her. The child cried immediately after the fall, but soon resumed playing and the mother thought nothing more about the episode until she noticed that her daughter was limping. She contacted her pediatrician only to find that her office was inundated with ill children. Because the child's symptoms were related to an injury and radiographs might be needed, the office nurse recommended that she go to an emergency department.

    When triaged at the minor emergency center, the child had a temperature of 38.3°C. The rest of her vital signs were as expected for a mildly febrile 3-year old. She was alert, active, and noted to have a significant limp with decreased weight-bearing on her right leg. While the little girl was still in triage, an obviously stressed physician looked into the triage booth. “I've never seen it this busy,” she complained to the triage nurse. “Everyone in town must be sick.”

    “This little girl has a fever and pain in her knee after a fall,” the triage nurse told her, pointing to the child.

    Without stopping to examine the child or to even acknowledge her presence, the doctor responded, “Just order an x-ray and some routine pediatric labs, and I'll get to her when I can.” She hurried off before the nurse or the child's mother could respond.

    The little girl went to x-ray, and after a struggle, had her blood drawn. After waiting several hours, though, she still had not been examined by the physician. Finally, the child's mother told the nursing staff that she had to leave. She explained that her husband was away, and neighbors had volunteered to watch her son, but she simply could not impose on their kindness any longer. “Besides,” she said, “she seems to be getting better. I'm sure her leg isn't broken.” When asked by the nursing staff, she signed the paperwork indicating that she was leaving against medical advice, and left the minor emergency center.

    The next day, the little girl refused to bear weight on her right leg, and she continued to have a fever. Her mother contacted her pediatrician's office, and was again told that the doctor was extremely busy. Nonetheless, when she described her long wait in the minor emergency clinic, she was advised to bring the child to the office. Secondly, among the “routine labs” that were sent at the minor emergency center was a blood culture. The emergency physician never intended to order a blood culture, but the triage nurse assumed that one would be included in “routine pediatric labs.” Late on the day after the visit, the minor emergency clinic received a call from their laboratory provider that the blood culture was positive. Eventually, someone tried to call the family at home, but because the mother was already out seeking care for her daughter, there was no answer. The result was put into a pile of others, which would be sent to the patient by certified letter.

    Meanwhile at the pediatrician's office, the little girl was seen and examined first by a nurse practitioner, who immediately sent for the doctor. Both were concerned about the child's right leg. On examination, the little girl cried and complained of pain when her hip was manipulated. The nurse practitioner suggested that they get the results from the minor emergency center, but when they tried to do so, they were told that the results could only be sent once the child's mother faxed a release-of-information form. The pediatrician turned to the mother, and said, “Look, we could wait all night for those results, and I don't think it would help us very much. Your daughter might have an infected hip, and based on your description, it sounds like they didn't x-ray her hip. Even if they had, the film probably would have been normal. She needs to be seen at a children's hospital, anyway. There is one downtown. Why don't you just take her there?” So the child and her mother embarked upon their third medical evaluation.

    The emergency department at the children's hospital was just as busy as every other place they'd been, and it was nearly midnight by the time they were actually seen by a resident. The resident told them that they were “lucky” that she was able to see them before midnight because the girl needed an ultrasound of her hip and “the techs leave at midnight.”

    With the ultrasound complete, the child and her mother returned to the emergency department to await the results. It took a considerable amount of time for the resident to return, and tell them the “good” news. The ultrasound did not identify a large fluid collection in the child's hip joint, a finding that made a septic arthritis less likely. The resident strongly suggested, however, that the little girl be seen by the orthopedic surgery resident before any further testing was conducted. Almost an hour later, the orthopedic surgery resident arrived, and after a few preliminaries, declared, “Your daughter doesn't have a septic hip joint. She needs a bone scan.”

    “OK,” the mother said. “We've been here all night. We might as well get it done.” Her frustration was obvious in her tone.

    “I wish it were that simple,” the orthopedic resident said. “We won't have techs to do the test until morning. But,” he added quickly, seeing the mother's face flush, “she'll be the first patient done tomorrow.”

    “No!” the mother said. “No, we've been to three doctors, and had plenty of tests. If you can't tell me what is wrong with her,” she said, now crying, “then please do something you can do tonight.”

    “OK, OK,” the resident said. “I don't know if it will add anything, but we can do a CT scan.” And with that, the patient was off for a CT scan.

    The orthopedic resident was back in the room a few minutes after the scan was completed. He seemed a bit deflated. “Ma'am,” he said to the little girl's mother, “your daughter has an infection in the bottom part of her spine. We can see it clearly on the CT scan. I think we would have ultimately found it, after the bone scan, but we would have still done a CT scan. I'm very glad that you insisted that we do something tonight.”

    And he went on to explain the treatment of pyogenic sacroiliitis.

    The child was admitted to the children's hospital. A blood culture done prior to the initiation of antibiotic therapy grew Staphylococcus aureus. The child eventually recovered without significant sequelae, but the mother ultimately sued the minor emergency center and the physician involved. Due to the circumstances, neither suit was successful.

    To be sure, this child ultimately proved to have a very rare condition. Most patients with pyogenic sacroiliitis receive several medical evaluations before a diagnosis is made, and as in this case, it is often ultimately made by happenstance while the physician is trying to rule out a more common condition such as septic arthritis. This case demonstrates, however, how some of the current ills of our so-called health care system can conspire to create suboptimal care. Crowded emergency centers and offices, disconnected providers, multiple medical records, and poor systems of follow-up can make adequate and appropriate care seem negligent. In fact, few if any of the problems this poor mother and child encountered were examples of medical error, but try telling that to the mother!

    Suggested Readings:

    1. Sasson M, Shvartzman P. Hypodermoclysis: An Alternative Infusion Technique. Am Fam Physician 2001;64(9):1575.
    2. Wu MS, et al. Pyogenic Sacroiliitis: A Comparison Between Paediatric and Adult Patients. Rheumatology 2007;46(11):1684.
    © 2009 Lippincott Williams & Wilkins, Inc.