Failure to Perform ECG as Part of Triage Protocol Leads to Death

This case involves a 10-year-old female patient that presented to her family doctors 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 New York Hospital. 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 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. Patient experienced seizure activity at 16:08 followed by cardiac arrest. CPR was initiated and the patient was intubated but efforts were futile as the time of death was reported at 16:50. Upon autopsy 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 and was the standard of care breached in this case?

Expert Witness Response E-000534

This case was mismanaged and terribly so. If they had correctly understood the nature and scope of her cardiac compromise, this girl could have been given intensive care and after days to weeks her viral carditis likely would have resolved and she'd be otherwise healthy. The first physician who saw her failed to get an ECG, she did not get an ECG at triage, and despite the tachycardia in triage, she was send to wait for what was a deadly delay. This kind of case is exactly why there are triage protocols in place to catch patients with extremely abnormal vital signs or concerning complaints such as chest pain.