Pediatric Emergency Medicine: Legal Briefs

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A California boy with asthma developed respiratory distress and was brought by paramedics to a local emergency department (ED) at 12:52 AM on March 27, 2013.1 In the ED, he was noted to be in severe respiratory distress and he was obtunded. The emergency medicine physician placed him on a bilevel positive airway pressure (BiPAP) machine and gave him methylprednisolone, epinephrine, and magnesium sulfate. After this treatment, the patient improved, although he remained tachypneic with shallow, irregular respirations. His pulse trended up from 118 per minute at 1:25 AM to 127 per minute at 5:30 AM, and his respirations went from 30 per minute to 38 per minute. The emergency medicine physician reevaluated the patient, determined that he was still in severe respiratory distress, and arranged for transfer to a university hospital. While waiting for the transport team, the emergency medicine physician reevaluated the patient's arterial blood gas and noted that the pC02 level had improved from 140 mmHg to the 80s. When the transport team arrived at approximately 5:40 AM, the patient's pC02 level had improved to the 60s. He was consequently disconnected from the hospital's BiPAP machine and connected to the transport team's BiPAP machine. While still in the ED, the respiratory therapist on the transport team was allegedly advised that the BiPAP mask from the hospital did not have an exhalation port on the circuit. Consequently, the patient would rebreathe his own carbon dioxide if the mask was not changed. However, the transport team did not change the boy's mask at any point before, during, or after transport. During transport, the patient's condition began to deteriorate. The respiratory therapist ventilated the boy with a bag-mask device in the ambulance. The boy was noted to have head bobbing and increased tracheal tugging. The transport team also noted subcostal retractions and a decrease in his Glasgow Coma Scale score. Upon arrival at the university hospital, the patient developed respiratory failure and his trachea was immediately intubated. During endotracheal intubation, he apparently aspirated and developed cardiac arrest. He was resuscitated and admitted to the pediatric intensive care unit. The patient remained intubated from March 28 to March 30, 2013. He had a computed tomography (CT) scan that showed no evidence of a hypoxic brain injury.
The patient's respiratory condition improved. However, before being weaned off the ventilator, he had seizure -like activity. On March 30, 2013, a continuous electroencephalogam (EEG) was performed. The EEG leads were attached to the patient's head with a collodion adhesive. The patient immediately deteriorated, he went into respiratory failure, then cardiac arrest, and was declared dead shortly afterwards.
The boy's mother sued the 2 hospitals and several physicians, but the case ultimately continued only against the emergency medicine physician who first treated the patient. The mother contended that the standard of care required this physician to intubate the patient's trachea upon his arrival to the ED and that his failure to do so resulted in cardiopulmonary arrest when he arrived at the university hospital. The cardiopulmonary arrest necessitated further treatment, including the EEG. The defendant emergency medicine physician countered that endotracheal intubation was not required by the standard of care and that the asthma exacerbation was appropriately treated with BiPAP and medications. The physician further noted that the patient's vital signs had improved during his time in the ED and that medical records show that he tolerated his BiPAP and other treatment without incident.
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