2) if truly that fast(over 70) and long transport, consider intubation prior to transfer, and 3) agree would have requested higher transport skills is possible at all. This child likely would have died regardless but give the care you can.
in regards to intubating, interesting thought, perhaps correct, but if there was a degree of right heart failure too, (which certainly might be the case with , say, myocarditis), positive intrathoracic pressure from the vent might cause complete cardiovascular collapse.
I'm just a simple ED doc at a large rural community hospital (merced, calif); I might have considered and like to see my own bedside US heart lungs, ecg, trop, labs, lactate.
what was BP? pressers? dobutamine? lasix? is it possibly cardiac stress secondary to sepsis?
again , retrospection is easy , so I apologize, but that is one of the important points of this format... to discuss, and perhaps learn form each other. the child was in the first ER for hours, and some or all of this might have been obtained, done.
Several thoughts from decades in EM and from flight medicine:
1. EBRs (Electronic Billing Records) let you make make very accurate errors. I have had EBRs happily accept a temp of 37.1F in a live patient, one not in the morgue. The software that accepts this type of data without an incredulous challenge to the entering person ("WTF?!? Emoji/emoji") and an override key requiring entry of the email from the King of Nigeria declaring that you have won USD3000000$ upon receipt of your credit card numbers complete with security code... Well, you get the idea; the system is designed to fail the patient and the physician.
2. It is an attractive fallacy to presume air is better than ground:
* Assume the aeromedical asset (helicopter) comes from the receiving hospital. Assume ground speed = 120 MPH. Assume a reasonably equipped ground ambulance (they have the data on the patient to know what's needed) can travel 60 MPH.
* Assume time to launch = 15 min for aeromedical and 5 min for ground ambulance from referring.
* Assume time to unload-to-ER-bed is 15 min for aeromedical vs 5 min for ground ambulance.
It's 20 minutes faster for ground transport.
I think it's useful to examine our assumptions. I tend to feel stupider afterwards.
It’s always easy to review a case through the retrospectoscope, and find fault (it’s what plaintiff attorneys and plaintiff experts do all the time). Realistically, though, prospectively it is hard to manage a suddenly deteriorating kid, especially with no pre-existing related history. If you receiving hospital has a team, utilize them. They almost certainly have considerable experience managing sick kids. Abnormal vital signs should ALWAYS be rechecked, and commented upon. Altering a record after the fact is the kiss of death for one’s credibility. While the pediatric PA might have been the only resource available, this kid warranted someone experienced with pediatric training in sick kids for evaluation. Finally, the autopsy report should have been commented upon; it might have helped exonerate the defendants.
I wonder what the discussion was with the receiving hospital, in terms of advice and support in management. Intubating a child in such a condition is high risk procedure in itself and requires good preparation and experience.
In the UK where I work there are regional paediatric critical care advice and retrieval services, that are linked to a tertiary hospital. When a local hospital requires escalation in care for a critically ill paediatric patient they liaise with these services to ensure safe management until the arrival of the retrieval team.
I would encourage carefully evaluating using the receiving teams pediatric team versus a local team. In many areas the receiving transport team will take 3-4 hours one-way to arrive, and then take another 3-4 hours back. This can create a substantial delay, and with a sick patient may not be standard practice. I would suggest working within your system to identify rapid, and safe transport of these types of patients before you receive a sick patient.
I also agree with a previous comment that flight may not always be faster. As a previous poster indicated, there may actually more time to transport the the patient if they are within 30-45 minutes from the receiving facility. Additionally, they sometimes have to cancel as weather changes, creating potential for additional delays.
There are not only potential harms to the patient with delays to receiving care, there is potential medical/legal risk, as well as potential regulatory implications (EMTALA). All these different elements should be carefully considered when making decision about transport.
terribly tragic... Peds cases always worry me. prob a myocardititis. retrospectively (which is often 20/20) stat air might have been better, preferably Peds team
I’m curious about the lack of labs. Surely while waiting for transport they could’ve checked some labs. I also wonder how good of a job the paramedics were doing monitoring this patient. Would be quite the coincidence if she really only de compensated the second the transport was completed.
And yes the “expert” opinion is terrible, it contains no actual medical information or critique, and it’s so bad that I would go so far as to say that person should not be a program director and they’re basically a hack.
While it may not be the clinicians doing the transport fault, however it would be interesting to see the run report for this transfer and see if anything happened during transport that should of been acted on sooner. Granted, it is the sending facility responsibility to stabilize the patient within their capabilities. It would also be helpful to see the protocols of the agency doing the transfer to see if the problems presented to them during transport, would even allow them to treat adequately, or at the very least divert to the nearest ED for immediate stabilization.
But all in all, from what is described this patient more than likely should of been intubated from what is initially described.
As the receiving PEM doc at the children's hospital, I would have activated ECMO if I had this patient arrest in front of me. I'm surprised the children's hospital called time of death after a less than 20 minute pediatric code with a witnessed in-hospital arrest...did this children's hospital not have ECMO available to activate for an apparently previously healthy child with a witnessed cardiac arrest? Seems like this is one of the few cases where ECMO activation would have made a real difference.
This is a though case. Probably the doc felt his duty was fulfilled once patient was accepted by the other hospital. Performing and documenting frequent reevaluations or a reassuring blood gas could have help justify not intubating patient before transport. I'm also surprised HFNC wasn't started if kiddo was working so hard to breathe. Adding stuff to the chart looks always very defensive.
18mo c respiratory distress is common (e.g. bronchiolitis) and most of them do well, however most of them don't have cardiomegaly. The fact that the doctor got a CXR had the potential to be fortuitous - maybe it was his usual practice, or maybe the clinical picture was worrisome. He spoke with a large pediatric medical center so there may have been an opportunity for advice to support the patient's hemodynamics - that's the primary etiology of deterioration. It's possible that the accepting physician was also not all that familiar with how rapidly these kids can deteriorate. As for airway support, you need to have them on an inotrope first. That alone might reduce some of the respiratory distress. In any case, even though PPV will probably help, you need to have an inotrope (e.g. dobutamine) to support BP prior to starting PPV.
I felt that intubating should be done here , even if its high risk but i think if patient deteriorates while intubating , with proper pre-procedural explanation a lawsuit could probably be avoided , but hey a dead child with crying parents make a good court case and high winning chances
Would the pediatric transfer team have been any faster? In my experience not, but in a sick kid does it make sense to wait longer for the preferred transport team or get them where they need to be. Somewhat analgous to a concerning trauma at a low level or no trauma facility (ABCs, cxr, pelvis xray, good? okay transfer to a higher level trauma facility).
I would have electively intubated her prior to transport and placed her on a ventilator with adequate sedation. That would have at least allowed safe transfer.
Has anyone considered croup in this child? Croup tent? Airway aspiration? Not enough information was given as far as what was done while waiting for transport. If no improvement I'd have taken child to OR and intubated with ENT standby.
1) make sure vital signs are correct
2) if truly that fast(over 70) and long transport, consider intubation prior to transfer, and 3) agree would have requested higher transport skills is possible at all. This child likely would have died regardless but give the care you can.
in regards to intubating, interesting thought, perhaps correct, but if there was a degree of right heart failure too, (which certainly might be the case with , say, myocarditis), positive intrathoracic pressure from the vent might cause complete cardiovascular collapse.
I'm just a simple ED doc at a large rural community hospital (merced, calif); I might have considered and like to see my own bedside US heart lungs, ecg, trop, labs, lactate.
what was BP? pressers? dobutamine? lasix? is it possibly cardiac stress secondary to sepsis?
again , retrospection is easy , so I apologize, but that is one of the important points of this format... to discuss, and perhaps learn form each other. the child was in the first ER for hours, and some or all of this might have been obtained, done.
Several thoughts from decades in EM and from flight medicine:
1. EBRs (Electronic Billing Records) let you make make very accurate errors. I have had EBRs happily accept a temp of 37.1F in a live patient, one not in the morgue. The software that accepts this type of data without an incredulous challenge to the entering person ("WTF?!? Emoji/emoji") and an override key requiring entry of the email from the King of Nigeria declaring that you have won USD3000000$ upon receipt of your credit card numbers complete with security code... Well, you get the idea; the system is designed to fail the patient and the physician.
2. It is an attractive fallacy to presume air is better than ground:
* Assume the aeromedical asset (helicopter) comes from the receiving hospital. Assume ground speed = 120 MPH. Assume a reasonably equipped ground ambulance (they have the data on the patient to know what's needed) can travel 60 MPH.
* Assume time to launch = 15 min for aeromedical and 5 min for ground ambulance from referring.
* Assume time to unload-to-ER-bed is 15 min for aeromedical vs 5 min for ground ambulance.
It's 20 minutes faster for ground transport.
I think it's useful to examine our assumptions. I tend to feel stupider afterwards.
It’s always easy to review a case through the retrospectoscope, and find fault (it’s what plaintiff attorneys and plaintiff experts do all the time). Realistically, though, prospectively it is hard to manage a suddenly deteriorating kid, especially with no pre-existing related history. If you receiving hospital has a team, utilize them. They almost certainly have considerable experience managing sick kids. Abnormal vital signs should ALWAYS be rechecked, and commented upon. Altering a record after the fact is the kiss of death for one’s credibility. While the pediatric PA might have been the only resource available, this kid warranted someone experienced with pediatric training in sick kids for evaluation. Finally, the autopsy report should have been commented upon; it might have helped exonerate the defendants.
I wonder what the discussion was with the receiving hospital, in terms of advice and support in management. Intubating a child in such a condition is high risk procedure in itself and requires good preparation and experience.
In the UK where I work there are regional paediatric critical care advice and retrieval services, that are linked to a tertiary hospital. When a local hospital requires escalation in care for a critically ill paediatric patient they liaise with these services to ensure safe management until the arrival of the retrieval team.
I would encourage carefully evaluating using the receiving teams pediatric team versus a local team. In many areas the receiving transport team will take 3-4 hours one-way to arrive, and then take another 3-4 hours back. This can create a substantial delay, and with a sick patient may not be standard practice. I would suggest working within your system to identify rapid, and safe transport of these types of patients before you receive a sick patient.
I also agree with a previous comment that flight may not always be faster. As a previous poster indicated, there may actually more time to transport the the patient if they are within 30-45 minutes from the receiving facility. Additionally, they sometimes have to cancel as weather changes, creating potential for additional delays.
There are not only potential harms to the patient with delays to receiving care, there is potential medical/legal risk, as well as potential regulatory implications (EMTALA). All these different elements should be carefully considered when making decision about transport.
terribly tragic... Peds cases always worry me. prob a myocardititis. retrospectively (which is often 20/20) stat air might have been better, preferably Peds team
I’m curious about the lack of labs. Surely while waiting for transport they could’ve checked some labs. I also wonder how good of a job the paramedics were doing monitoring this patient. Would be quite the coincidence if she really only de compensated the second the transport was completed.
And yes the “expert” opinion is terrible, it contains no actual medical information or critique, and it’s so bad that I would go so far as to say that person should not be a program director and they’re basically a hack.
While it may not be the clinicians doing the transport fault, however it would be interesting to see the run report for this transfer and see if anything happened during transport that should of been acted on sooner. Granted, it is the sending facility responsibility to stabilize the patient within their capabilities. It would also be helpful to see the protocols of the agency doing the transfer to see if the problems presented to them during transport, would even allow them to treat adequately, or at the very least divert to the nearest ED for immediate stabilization.
But all in all, from what is described this patient more than likely should of been intubated from what is initially described.
As the receiving PEM doc at the children's hospital, I would have activated ECMO if I had this patient arrest in front of me. I'm surprised the children's hospital called time of death after a less than 20 minute pediatric code with a witnessed in-hospital arrest...did this children's hospital not have ECMO available to activate for an apparently previously healthy child with a witnessed cardiac arrest? Seems like this is one of the few cases where ECMO activation would have made a real difference.
This is a though case. Probably the doc felt his duty was fulfilled once patient was accepted by the other hospital. Performing and documenting frequent reevaluations or a reassuring blood gas could have help justify not intubating patient before transport. I'm also surprised HFNC wasn't started if kiddo was working so hard to breathe. Adding stuff to the chart looks always very defensive.
18mo c respiratory distress is common (e.g. bronchiolitis) and most of them do well, however most of them don't have cardiomegaly. The fact that the doctor got a CXR had the potential to be fortuitous - maybe it was his usual practice, or maybe the clinical picture was worrisome. He spoke with a large pediatric medical center so there may have been an opportunity for advice to support the patient's hemodynamics - that's the primary etiology of deterioration. It's possible that the accepting physician was also not all that familiar with how rapidly these kids can deteriorate. As for airway support, you need to have them on an inotrope first. That alone might reduce some of the respiratory distress. In any case, even though PPV will probably help, you need to have an inotrope (e.g. dobutamine) to support BP prior to starting PPV.
I felt that intubating should be done here , even if its high risk but i think if patient deteriorates while intubating , with proper pre-procedural explanation a lawsuit could probably be avoided , but hey a dead child with crying parents make a good court case and high winning chances
Would the pediatric transfer team have been any faster? In my experience not, but in a sick kid does it make sense to wait longer for the preferred transport team or get them where they need to be. Somewhat analgous to a concerning trauma at a low level or no trauma facility (ABCs, cxr, pelvis xray, good? okay transfer to a higher level trauma facility).
I would have electively intubated her prior to transport and placed her on a ventilator with adequate sedation. That would have at least allowed safe transfer.
Has anyone considered croup in this child? Croup tent? Airway aspiration? Not enough information was given as far as what was done while waiting for transport. If no improvement I'd have taken child to OR and intubated with ENT standby.