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Vermont – Emergency Medicine – Suspected Ventricular Tachycardia Not Addressed In A Patient With Respiratory Distress, Fever, And An Elevated Heart Rate
On 2/6/2013 a patient’s father contacted EMS (emergency medical services) because his son had respiratory distress, fever, and an elevated heart rate.
EMS documented a heart rate of 278 and performed a pre-hospital EKG because ventricular tachycardia (VTach) was a concern. EMS contacted the hospital to report vital signs and their impression of VTach.
The patient presented to the emergency department at 11:29 p.m. The patient was triaged at 11:42 p.m. and a pulse of 245, blood pressure of 53/39, and a temperature of 101.02 were recorded. An EKG was performed at 11:43 p.m. The results were shown to the ED physician at 11:47 p.m.
The ED physician’s notes state that at 12:13 a.m. the patient was examined. It was documented that the ED physician suspected the patient was in VTach, but no therapy was administered.
The ED physician then contacted the on-call cardiologist, who advised the ED physician to treat the patient for probable sepsis with fluids and Tylenol. The ED physician then ordered IV antibiotics and spoke to a critical care physician about transfer of the patient.
At 12:29 a.m. the patient had a ventricular fibrillation cardiac arrest. He was treated with various medications but no shock was given. At 12:45 a.m. the patient was pronounced dead.
The Board concluded that the ED physician be reprimanded, complete 15 hours of continuing education on Advanced Cardiac Life Support, and pay a fine of $1000.
Date: September 2017
Diagnosis: Cardiac Arrhythmia
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
A patient was treated by a family practitioner from May 2012 to September 2012.
On the first office visit, the patient presented with symptoms and behaviors that met the DSM-IV criteria of anorexia nervosa, as well as the National Institute for Mental Health criteria of Pediatric Acute Neuropsychiatric Syndrome (PANS). The patient’s medical records from the patient’s prior primary care physician included a diagnosis of anorexia nervosa and a prior recommendation for inpatient mental health treatment for anorexia.
The family practitioner made the following diagnoses: systemic inflammatory syndrome with multi-systemic symptoms and marked neuropsychiatric dysfunction with probable underlying infectious triggers; PANS (Pediatric Acute Neuropsychiatric Syndrome); and probable PITANDs (Pediatric Infection-Triggered Autoimmune Neuropsychiatric Disorders). Anorexia nervosa was not documented as a primary or differential diagnosis. The family practitioner indicated that he considered the possibility of a purely behavioral syndrome like anorexia nervosa, but felt that the patient’s anorexia was “part of a more complex multi-system picture.”
The family practitioner based his diagnosis on the patient’s history and symptoms meeting the diagnostic criteria for PANS, testing positive to three infectious agents, and an initial response positive response to PITANDs treatment, in addition to a lack of positive response to anorexia nervosa focused management with the patient’s prior primary care physician and other consultants.
The family practitioner saw the patient on three occasions over a four month period, which the Board believes is inadequate for management of anorexia for an adolescent. The family practitioner relied on his nurse to call the patient on weekly updates and weight checks.
In addition to three office visits, the family practitioner’s treatment included ordering numerous blood tests, and the prescribing of medications, antibiotics, herbal supplements, and vitamins for the infection etiologies and the inflammatory conditions. However, he did not prescribe any medications for the treatment of anorexia nervosa. While the family practitioner believed that the patient was being treated by his primary care physician, this was not confirmed with any other provider, and the family practitioner did not communicate directly with any other provider beyond sending his initial office visit note and lab results to the patient’s primary care physician.
The Board judged the family practitioner’s medical records and communication with the patient’s primary care physician concerning his treatment of the patient were inadequate. The family practitioner’s office notes did not document past surgical and family history, temperature, height, BMI calculation, and growth curve charting.
Based on review of the family practitioner’s medical records concerning his treatment of the patient and the documentation of his communication with the patient’s parents, it appears that the family practitioner did not clearly explain his role in the patient’s care to the patient’s parents until the end of his treatment. Is it possible that the patient’s parents believed that the family practitioner had taken over the role as the primary care physician and was actively managing the patient’s care.
The family practitioner’s position was that he believed that he was participating in the care of the patient in the role as a consultant to his primary care physician and that the patient’s primary care physician was concurrently monitoring the patient. With the exception of the provision of his initial office note and lab results, the family practitioner did not communicate with the patient’s primary care provider during the course of his treatment. After sending his initial note and lab results, the family practitioner did not communicate with the patient’s primary care provider or any other medical professionals until the patient had an acute worsening of the condition on 9/13/2012.
The Board judged that the family practitioner failed to appropriately monitor, manage, and maintain comprehensive medical records on a juvenile patient with a severe eating disorder.
The Board ordered that the family practitioner be reprimanded, complete one hour of continuing medical education on cognitive bias, and that he shall only practice medicine in a structured, group setting for a period of three years.
Date: September 2017
Symptom: Weight Loss
Diagnosis: Psychiatric Disorder
Medical Error: Improper treatment, Failure of communication with other providers, Failure of communication with patient or patient relations, Failure to properly monitor patient, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF