Hospitalist expert witness opines on intubation protocols for patient who died from pneumonia

A hospitalist expert witness discusses the treatment given to a patient who died from pneumonia prior to being transferred to a tertiary care center. This case involves a thirty-seven-year-old male patient with no significant past medical history. The patient developed flu like symptoms. His condition progressively worsened over the course of the day and his wife called for an ambulance when he developed trouble breathing with minimal exertion. He was admitted to the emergency room of a local hospital for complaining of cough, fever, chest pain and shortness of breath. On physical examination the patient was tachypneic and appeared constitutionally unwell. The initial chest x-ray performed on admission showed clear lung fields while a chest x-ray performed one hour after his presentation showed bilateral pulmonary pneumonia and superimposed congestive changes. The dramatic change in findings on the chest x-rays was indicative of the patient’s rapidly declining condition. A CT scan was ordered which demonstrated a consolidation on the left lower lobe with pleural fluid and air bronchograms. The decision was made to transfer the patient to a tertiary care center, given the severity of his condition. The patient was to be intubated prior to transportation to stabilize. During the intubation procedure the patient’s condition deteriorated further. The patient died within a few hours of his presentation to the hospital. The postmortem examination documented extensive and severe bronchopneumonia involving all lung lobes as the cause of death.

Question(s) For Expert Witness

1. Should this patient have been intubated sooner to avoid such a decompensation?

2. Knowing how sick the patient was shortly after admission was the treatment instituted timely and was it aggressive enough?

Expert Witness Response E-005297

Yes, this patient may have needed to intubated sooner. This decision relies heavily upon the data available to the treating medical staff e.g. labs and physiology etc., at the time. What were the patient’s arterial blood gases? What were the patient’s oxygen saturations? The patient is young, therefore it seems that he likely did not have any existing lung disease. I would also want to know if he was placed in a step down unit, on a monitor. Was he sick enough to warrant an intensive care admission? All of these factors would be critical information to decide if the initial care given to this patient was aggressive enough. Lastly transfer to a higher level care center also depends on the data and information available. Some situations are appropriate for 24 hour monitoring but require intensive monitoring if the support for more intensive care is not available. This patient appears to have developed and died from pneumonia and likely related sepsis based on the provided summary. Early initiation of antibiotic therapy and early assessment and stabilization of respiratory and circulatory compromise can have a major impact on mortality. This requires prompt recognition of the sepsis syndrome.