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Use Case:
Emergency Department

Other Use Cases

Scenario

8:30 pm: It's a busy Saturday night at A&E (Accident and Emergency), an outreach extension of a regional public hospital [name withheld]. 

An elderly grandmother presents with her four-year-old granddaughter, who apparently has been, "Hot, coughing, crying, and got stiff and jerky for a few seconds." The grandmother said, "That's when I brought her in."

After waiting in the queue for an extended time, grandmother is confused when asked by the non-medical front desk attendant about any details other than above. Apparently, the child's parents have been overseas at a conference for the past week. She is asked to sit down and fill out the standard paperwork, after which she is requested to return to the queue for processing.

9:15 pm: The grandmother fills in the paperwork and again makes her way through the queue, which has increased in length since her arrival with her grandchild. She presents the finished paperwork and is told to now sit down and wait for the nurse to come and see the child.

Case4 1

9:45 pm:  A tired and harried nurse arrives to review the child's condition and, after lifting the child's blouse and removing her socks, notes:

  1. A few small, flat, slightly purple spots (petechiae) located on tops of feet, but mainly "viral rash" on trunk (retiform/morbilliform).
  2. Moderate fever (38.8 °C).
  3. Sleepy.
  4. Uncomfortable.
  5. Cough.

The nurse triages the patient as "Viral URI with typical viral exanthem", and asks additional questions of grandmother, discovering that the child did have an apparent cough and mild fever earlier in the week reported first by day-care personnel where she attends three days a week. The grandmother gave the authorisation to use Panadol (acetaminophen) liquid over the telephone, which apparently "helped" with the child's symptoms.

Case4 2

10:20 pm: A tired young GP attending the clinic that evening shift appears and takes the now lethargic/unresponsive child back to the examining room to discover A "Semi-lethargic, warm, uncomfortable" four-year-old female child with:

  1. Multiple medium-sized (1 to 3 centimetres) non-blanchable purple macules extending over the legs,
  2. Net-like erythematous exanthem noted extending over truncal area,
  3. 39.5 °C temperature,
  4. BP 100/60, and
  5. Pain with movement of limbs.

She again asks the grandmother if this had been progressing, but the grandmother is flustered, a little confused, and is noted to be a poor historian. The GP then requests that the hospital ED is contacted for consultation.

10:45 pm: The GP explains the situation to the busy on-call ED Reg (third-year trainee), who requests a better description of the skin findings be provided, as it sounded like the paediatrics on-call registrar would need to be involved. 

Case4 3

11:30 pm: The ED finally contacts the busy paediatric on-call person, who then contacts the GP. In-depth verbal descriptions of the "rash" are given to the Registrar who begins to start "putting it together", but still partially tracking with the predisposing initial triage diagnosis of acute URI with a viral exanthem.

11:35 pm: The GP's conversation is interrupted by a frantic med-tech who states that the child in exam room four is seizing.

11:36 pm: An ambulance is called, and the child is prepared for transport to ED. Valium is given to try and extinguish the recurring seizure.

Case4 4

11:55 pm: An "Unresponsive four-year-old female child" is received in the ED, with skin findings noted by the attending physician and paediatric registrar as:

  1. Wide-spread petechial macules and purpuric patches,
  2. Some palpability and vesiculation noted,
  3. A temperature of 41 °C,
  4. BP 78/50, tachycardic, in status epilepticus".

A stat lumbar puncture and blood culture are ordered. 

12:15 am: Proactive IV antibiotics are begun after protracted attempts by nursing staff, (ultimately requiring the on-call anaesthetist) to establish IV access, (small vessels, severe hypotension, noted in the chart).

12:45 am: Returning stat labs (PCR-based) indicate the pathogen to be Neisseria Meningitidis (child has been since transferred to the NICU in the interval).

04:52 am: Despite full efforts of NICU team, child expires from presumptive septicemia/DIC and multi-organ failure.

Outcome

Everyone involved was understandably distraught. The parents were informed over the telephone 12 hours later, once they were located in Thailand. The grandmother subsequently required hospitalization for presumed hypertension/diabetic-related mild CVA.

The case ultimately went to court, where the plaintiffs' (parental) expert witnesses all testified that the child might well have been salvaged had the medical response been more timely, informed, focussed, and proactive.

Defense's Argument

The defence team argued via their experts that:

  1. The GP's performance met Standard of Care, emphasising extenuating circumstances of Grandmother's confused historical account of the child's illness, overcrowded A&E, atypical presentation, etc.
  2. The diagnosis and treatment process was timely, they argued, given these extenuating circumstances.
  3. They further argued that "the typical case" of meningococcal septicemia involves a male (3:1 male versus female), age 6-12 months-old or adolescent, demonstrating full-blown Purpura Fulminans, high-grade fevers & chills, and meningitic signs, etc.
  4. Defence specifically cited the history of previous URI provided by Grandmother, and the atypical clinical presentation (emphasising minimal skin findings on initial exam, etc.), as supporting "a reasonable" preliminary triage diagnosis of "Viral URI with Exanthem."

Plaintiff's Argument

The Plaintiff's experts countered the above arguments by simply stating that any fully-qualified paediatrician or dermatologist looking at the child in the A&E would have considered the possibilities of an "atypical case", and expedited diagnosis/treatment accordingly.

Result

The conclusion was that, although the mortality rate in such cases of meningococcal septicemia is approximately 25% to 35%, this particular patient might well have survived had the delivery of medical care been more appropriate and expeditious.

Conclusion

We are left asking how might the circumstances have been altered, at each stage of healthcare delivery, to result in improved chances of this child's survival? The answer is quite maddeningly simple - either of photographs one or two (above) of the child's "rash" to the smartphone of a qualified paediatrician/dermatologist, requesting their opinion(s). The outcome might have been very different for this four-year-old girl, had this been done in the A&E.

Doctors are in an unenviable position. One one hand, if they use their phone to take a clinical photo using the standard camera app, they are likely to breach patient privacy regulations, and thus they are discouraged from doing so. On the other hand, if doctors don't take a photo in situations like described above, patients lives are lost. We feel it is incumbent upon hospitals to provide its doctors with a compliant and easy-to-use method for capturing and sharing clinical photos — this is what PicSafe® does, and this is why we created PicSafe®.

When doctors face the dilemma of whether they should take clinical photos on their phone, the lesser of evils is commonly accepted. Doctors have been enduring the increased risk of breaching patient privacy regulations, and as such, using ones smartphone to take clinical photos has become the standard of care. If a hospital does not provide an environment in which doctors can deliver the standard of care, they risk losing lives, losing staff, and they are potentially liable.

Note: The above scenario happened and was witnessed by a founder of PicSafe®. The photos are not from the real case because, unfortunately, photos were not taken. The images used are done so with the requisite permission, and they depict what was witnessed in the case presented.

Grief