This case involves a male patient who presented to a walk-in clinic complaining of respiratory symptoms that were diagnosed as bronchitis. He was given azithromycin as well as cough syrup and sent home without instructions for additional follow up. Less than two days later, the patient was found unconscious by his girlfriend and was immediately rushed to the hospital. The patient was diagnosed with bilateral pneumonia, as well as swine flu, and was admitted to the hospital. While in the hospital, the patient was given vasopressors in order to maintain his blood pressure, which caused his feet to become ischemic and, eventually, necessitated a double amputation. It was claimed that the initial work-up at the walk-in clinic should have been more comprehensive, including the administration of a chest x-ray.
Question(s) For Expert Witness
- 1. Please explain your experience treating patients who present with similar symptoms.
- 2. Do you have specific experience with Vasopressors?
Expert Witness Response E-000299
This case is extraordinary to say the least. Obviously, seeing someone with a bad cold or virus is an everyday experience. What is key here is whether or not there were symptoms that suggested either a more severe situation from H1N1 directly, or the presence of a secondary bacterial infection such as streptococcus or MRSA. I am amazed that there was loss of consciousness less than 2 days later. Usually, the person would have been having symptoms of near fainting from fluid loss, dehydration, or shock that would have forewarned the patient to seek help before loss of consciousness. Pneumonias that are life threatening are common to all lung specialists. Vascular ischemia is a known side effect of vasopressors. Avoiding high doses is always a key consideration, and fluid management is the main therapy to help limit the risk of ischemia. However, there may have been issues with acute respiratory distress syndrome, or some other medical concern, that may have forced the physician to limit fluids.
Expert Witness Response E-008605
The initial management at urgent care is reasonable if the patient complained of upper respiratory infection symptoms only. Depending on the time of year, a rapid flu test should have been performed. However, H1N1 can progress quickly, so it is uncertain if knowing the patient had influenza would have prevented their rapid progression. Vasopressors can cause tissue ischemia if used in high doses, and I have seen necrosis of digits due to vasopressors. That being said, I have never seen limb amputations due to vasopressor use, but it could happen. I am a pulmonary critical care physician who has cared for patients in the ICU with H1N1 flu during the epidemic in 2009.