This case involves a ten-year-old child who presented to an emergency room with complaints of a three-day history of vomiting and severe headaches. The patient was almost immediately discharged following minimal examination with a presumed case of gastroenteritis diagnosis. The characteristics of the headaches & vomiting were not explored by the treating physician. The patient brought back to an ER by her parents a week later complaining of a 10-day history of vomiting. This represented the second ER visit within 7 days for the same complaints. The patient’s mother told the ER physician that the child was having persistent migraines that precipitated the vomiting episodes. Blood work was ordered which revealed that the patient was severely dehydrated and showed signs of ketonuria. Yet again, the headaches were not explored further and the relationship between the headaches and vomiting was not investigated further. Instead, the patient was again released with a presumed diagnosis of UTI, without any investigation as to the etiology of her recurrent vomiting. The patient presented a third time with complaints of vomiting for 21 days. She was admitted for a gastrointestinal workup. During diagnostic testing, the patient was given IV Morphine as analgesia for the severe headaches. The headaches were not relieved by the Morphine, prompting an order for IV Toradol and head CT scan. The patient’s mother alerted nurses when she noticed that her daughter’s breathing had become “noisy”. The patient was non-responsive and subsequently became apneic. The patient was immediately intubated. The CT scan ordered prior to the respiratory distress revealed transtentorial, cerebellar, and subfalcine herniation related to an obstructing mass within the right lateral ventricle, extending into the foramen of Monro. External ventricular drains were emergently placed. On arrival to the OR, the patient remained unresponsive with fixed and dilated pupils. She never regained consciousness and brain death was confirmed shortly thereafter.
Question(s) For Expert Witness
1. Did the chronic history of vomiting warrant admission on the first or second ER visit?
2. Could an earlier intervention have altered this patient's outcome?
Expert Witness Response E-000534
There are several 'red flags' in the presentation, evident from the history given here. Firstly, the diagnosis of gastroenteritis typically requires the triad of nausea, vomiting, and diarrhea. There are only two of these reported to be present on the initial visit. Further investigation should have been carried out before discharging the patient. Secondly, the details of the neurologic exam would be useful, as given how precipitous the outcome was, one could expect to see some other neurologic findings on examination of such a patient. Third, the diagnosis of migraines in the ED setting in a 12-year-old is problematic and certainly should not be taken lightly. Finally, a UTI in this age group can be associated with a headache, but it is less likely to cause such severe headaches over this duration of time and the patient's past medical history did not fit such a diagnosis. In summary, if the diagnosis of an intracranial problem was entertained, neuroimaging could have been performed earlier, leading to a more timely neurosurgical intervention. This could have potentially changed the outcome for this patient.
About the author
Dr. Faiza Jibril
Dr. Faiza Jibril has extensive clinical experience ranging from primary care in the United Kingdom, to pediatrics and child abuse prevention at Mount Sinai Hospital, to obstetrics in Cape Town, South Africa. Her post-graduate education centered on clinical research and medical ethics. Dr. Jibril is currently Head of Sales in the US and Canada for Chambers and Partners - a world leading legal ranking and insights intelligence company.
