This case involves an otherwise healthy teenager who came into an ER in Nebraska with a fever and stomach ache. Following a brief examination, he was given an over the counter pain medication and discharged home. Several days later, he returned to the ER complaining of ongoing bloody stool. Stool cultures were ordered in the ER and he was discharged home. He returned to the ER later that day as the bloody stool was continuing and was now diarrhea. Despite these symptoms, the teenager was, once again, discharged home from the emergency room. The patient was eventually brought to the emergency room by ambulance, where he was finally diagnosed with an infectious kidney disease. The child required a number of dialysis treatments, and will eventually require a kidney transplant.
Question(s) For Expert Witness
- 1. How many patients are under your care/have been under your care with this syndrome?
- 2. Have you ever lectured or published on this disease?
Expert Witness Response E-050867
I am a board certified Pediatrician and Pediatric Nephrologist at a large university children’s hospital where I am the Program Leader of Pediatric Kidney Injury & Disease Stewardship Program. I treat approximately 30 children per year with this disorder. I routinely give lectures on the diseasse and was also the first author on a recent publication evaluating the use of eculizumab in atypical hemolytic uremic syndrome. I am able to speak to the causality issues here in terms of how the performance of the emergency room providers impacted the prognosis of this patient. Particularly, the use of the pain medication with its deleterious effect of the kidney and the inadequate treatment of this patient’s volume depletion from bloody diarrhea likely contributed to the poor outcome here. I led a root cause analysis of a similar case at my home institution.
Expert Witness Response E-005880
I have been a pediatric nephrologist for 30 years. I have seen hundreds of cases of patients with this syndrome and various complications. I published a review article on this syndrome as well. I think what happened between the second and third ER visits is important. There is clinical evidence that severity may be reduced if you maintain good fluid and electrolyte balance and good volume status. Patients who are allowed to become dehydrated may have a more severe course. A very reasonable question that will be asked is why did the parents wait so long to come back. Did they receive proper counseling from the ER about returning if the patient was dehydrated or showed evidence of becoming more ill?