This case involves a child who presented on to the emergency room with low blood pressure and a high-grade fever. Flu was suspected and a rapid influenza test was administered. The test came back negative, and the patient was sent home. Several days later, the patient returned to the emergency room with significantly lower blood pressure. A second rapid influenza test came back positive for flu. The patient was treated for the flu but developed pneumonia shortly after and passed away. An expert physician’s assistant was sought to discuss whether or not there was a failure to timely and appropriately treat the influenza symptoms that led to the patient’s death.
Question(s) For Expert Witness
- 1. How routinely see patients with a similar presentation?
- 2. What are the best practices for when a patient like this presents to the ER?
- 3. Should the patient have been admitted to the ER on the first visit and treated for influenza and heart failure?
Expert Witness Response E-006207
I have 17 years of experience as a physician’s assistant, with most of those including urgent care and emergency medicine work. I also have hospital medicine experience taking care of a variety of cardiac conditions. I have also been a full-time physician’s assistant educator for the last 9 years. I teach medicine topics, including cardiology. I see patients with flu symptoms all the time during the flu season. I am concerned about the patient’s low blood pressure, regardless of what the cause is. I wouldn’t discharge a person with that low of a blood pressure, unless I had a good reason why it was low and I improved the blood pressure with IV fluids, etc. If the low blood pressure wasn’t explained well (as in poor oral fluid intake, vomiting, nausea, etc.), this patient should be admitted for further workup. The patient would need labs, including a CBC to make sure anemia wasn’t the cause of the low BP. I would also do an ECG to make sure that the low BP wasn’t caused by something cardiac. Troponin would also be indicated. I would also like to know this person’s cardiac risk factors and co-morbidities. As I said, I would admit a patient with that low of a blood pressure if it wasn’t explained well and improved. That would require a significant workup in the ER and probably hospital admission. If the patient had heart failure, they needed to be admitted.
Expert Witness Response E-106647
I am a professional registered nurse with 20 years experience in multiple hospital settings including Level I trauma environments and physicians’ offices. Throughout my career, I have seen several patients present with similar symptoms. Patients that present to the ER with tachycardia and Hypotension should automatically trigger the possibility of extreme dehydration and sepsis should be ruled out. This patient would immediately be placed on a cardiac monitor and blood pressure should be cycled to take BP every 15 mins. An IV would be established and labs would be drawn (CBC, CMP, and Cardiac Markers if a known heart patient) including a set of blood cultures. I would anticipate orders for IV fluids (Normal Saline 0.9% 1 Liter bolus) if not a heart failure patient or any other contradictions. I would also anticipate the order for a flu test, knowing that even a negative test result doesn’t necessarily mean the patient doesn’t have the flu. Depending on the brand and sensitivity of the test, Rapid Flu tests can range from 10%-70% accuracy in detecting the H1N1 strain of Influenza. Meaning the possibility of these patients having a negative flu test is high. Admission would then be determined based on the findings of the labs and the patient response to the IV fluids, which would be no longer tachycardia or hypotensive. The patient’s age and history would also be a determining factor.