Case Archive
 
Osteopathy, Emergency Medicine
Ref. # 42197

A 19 year old Missouri college student presented to the ER of a regional medical center at 1233 complaining of shaking, chills since the prior night, headaches, dizziness, and pain in his ankles, feet, shins and hands. His temperature was 101.2, pulse 158, respiratory rate 18, blood pressure 96/55. The nurse initiated lab studies including CBC, chemistry, coagulants, UA, strep screen, and blood culture, as well as chest X-ray and an IV of 0.9% NaCl. The ER physician, a D.O., performed a physical exam and noted errythematous tympanic membranes, mild errythema of the pharynx and purpura on the skin of the shins, ankles, feet and hands, 1-5 mm in size. The patient was admitted with a diagnosis of Idiopathic Thrombocytopenic Purpura (ITP). A second D.O. took over his care and noted purpura on the hands up to the elbows and on the feet and legs up to the knees. He confirmed the diagnosis of ITP and added via dictation a diagnosis of vasculitis, possible polyarteritis nodosum, thrombocytopenia, renal insufficiency, hyponatremia and pyrexia. The patient was medicated with Demerol and Vistaril and, after an hour and fifteen minutes, transferred to the CCU. Over the next two hours his fever worsened to 106.7. He remained tachycardic and tachypneic. He became confused and the purpura became twice as extensive according to nursing records. Another hour later he was transferred to a major medical center via ambulance and was admitted with a diagnosis of sepsis and disseminated intravascular coagulation. Preliminary blood cultures showed gram negative diplococci and the diagnosis of meningococcemia was made. Treatment consisted of 14 full days of ceftriaxione. The patient suffered renal failure, underwent hemodialysis, and ultimately lost both legs below the knees and several fingers on each hand. A medQuest ER physician, also a D.O., found multiple breaches of the standard of care. This was a "textbook case" of meningococcemia, a life threatening diagnosis. The purpuric rashes with fever are pathognomonic findings for this infectious disease, which could not have been more obvious. Both D.O.'s failed to recognize the patient was in septic shock at the time of admittance, as evidenced by tachycardia, hypotension, tachypneia and fever, and supported by the lab tests, which were never interpreted. Furthermore, there was a negligent delay of more than 5 hours in treating the patient with antibiotics and even Tylenol for the fever. The patient was negligently given Solumedrol 125 mg IV, as steroids have no place in the treatment of septic shock because they increase morbidity and mortality. The rate of IV fluid administration, 125 cc/hour, was inadequate. Had the patient's condition been recognized, diagnosed and aggressively treated, there would have been a greater chance of a better outcome.




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