Emergency Room Waiting Debacle is Alive and Well

This case involves a 10-year-old female patient that presented to her family doctor’s office with nonspecific chest pain. According to reports from the parents, the doctor performed a very brief physical exam and diagnosed the patient with a viral upper respiratory tract infection with associated chest irritation. The patient was sent home without any medications or desire by the physician for further workup. Within a few hours of returning home, the patient experienced a syncopal episode and was transported via ambulance to a major medical center in NY. At the time of her presentation to the emergency department at 14:21 the patient was lethargic, complained of chest pain, her blood pressure was 65/45 and heart rate was 184. The patient was triaged at 14:24 and despite these alarming symptoms, the patient and family were instructed by the triage nurse to take a seat in the waiting room. The attending emergency room (ER) physician at the time of the incident had a shift that ended at 15:00. This doctor left the emergency department at the end of his shift without seeing the critically ill patient. The next ER doctors shift commenced at 15:00. The patient had been in the waiting area for thirty-nine minutes and was not taken back to an examination room until 15:30. At this point, the patient had a documented decreased level of consciousness along with diffuse abdominal tenderness, a heart rate of 170-180 and a thready pulse. Cardiac monitoring revealed wide complex ventricular tachycardia. Blood gas studies revealed a pH 7.22, pC0 49, BE 7.8 and elevated cardiac enzymes. The patient experienced seizure activity at 16:08 followed by cardiac arrest. CPR was initiated, the patient was intubated but efforts were futile, as the time of death was reported at 16:50. Upon autopsy, the cause of death was determined to be lymphocytic myocarditis.

Question(s) For Expert Witness

1. What is the standard operating procedure for working up a young patient with chest pain?

Expert Witness Response E-001149

My initial thoughts are that this child had some rapidly progressive illness which presented initially with non-specific signs and findings, but which progressed rapidly to acidosis, possibly due to cardiac failure, and death, all within a matter of several hours. Chest pain is a relatively common finding in acute pediatric viral illness, along with generalized muscle ache and tenderness. The nature of the history can sometimes point a doctor towards or away from significant illness, but the vast majority of chest pain in otherwise healthy children is musculoskeletal in nature. Without greater detail, which includes the records of the initial doctor's visit, there is not much I can comment on.