Failure to Diagnose Myocarditis Leads to Infant Death

Case Summary

This case involves a 10-month-old baby girl that was seen by a Physician Assistant in pediatrician’s office for weakness, decreased nutritional intake, vomiting, and no urine output. The baby was given Pedialyte and sent home. She was never seen by the pediatrician. The baby had previously been seen by the same PA one week prior due to decreased fluid intake and was sent home without physician interaction at this visit as well. On the same day of the second visit, the baby’s condition deteriorated, and she was taken to the Emergency Room. Upon admission, heart rate was 164, respiratory rate was 32 and temperature was 98.8. She had a poor capillary refill of 3.5 seconds. The baby was vomiting and had had no wet diapers for 24 hours. CBC, basic metabolic panel, and urinalysis were abnormal. Blood culture was negative. No chest x-ray or EKG were performed. Upon review of systems, the baby was listless, had poor muscle extremity strength, and had decreased responsiveness. The baby was given normal saline and discharged after 4 hours with a heart rate of 152 and respiratory rate of 32. She had no wet diapers noted. After discharge, the child’s condition deteriorated, and she was taken to a second ER in cardiac arrest. Resuscitation failed, and the child passed away. The autopsy determined the cause of death was myocarditis.

Case Theory

There is no specific test for myocarditis. it is largely a clinical diagnosis. The doctor must rely on the history provided by the family and a physical examination. There are numerous tests that can be performed that help with make a diagnosis of myocarditis. The most common test is a chest x-ray. The heart size is often enlarged, the blood vessels of the lungs are bigger, and there may be fluid in the lungs. An EKG can also give helpful clues if the diagnosis is suspected; however, the findings may be non-specific. Abnormal heart beats can be identified that are frequently present with myocarditis. An echocardiogram or heart ultrasound is useful in measuring heart size and function and helps confirm the clinical diagnosis whilst ruling out the presence of blood clots in the heart. Lastly, the most precise way to make the diagnosis of myocarditis is by performing a cardiac catheterization heart biopsy. The diagnosis of myocarditis is clinically accurate 65 percent of the time. In this case the failure of the PA to alert the pediatrician to examine the baby, and the negligence of the ER to appropriate test this patient were below the standard of care and contributed to the baby’s death.

Expert Witness Q&A

1. In general, what aspects of a patient’s care are important in determining whether a pediatric patient should be admitted or not?
2. What is the pediatric PA standard of care for requiring physician involvement in a patient with unresolved symptoms?
3. Was it negligent to discharge the baby from the ER with no improvement of urine output and high heart and respiratory rates?
4. Should the ER have performed additional testing prior to discharge?

Expert Witness Involvement

Specialty Description: Pediatric Emergency Room Nurse. A pediatric ER nurse can opine on the standard of care for evaluation and discharge of a baby with similar symptoms.

Specialty Description: Pediatric PA. A Pediatric PA can opine on whether the physician should have been alerted to continuing symptoms and examined this baby.

About the author

Erin O'Brien

Erin O'Brien is a senior medico-legal writer and editor, with 25 years of experience authoring healthcare deliverables. Previously, Erin authored an award-winning column in the health and wellness sector, guest hosted a wellness radio show, and received an FMA Charlie Award for Excellence in Writing.

Erin has reviewed and completed case studies for thousands of medical malpractice cases, both plaintiff and defense nationwide, and was presented the US Chamber of Commerce Best Small Business Blue Ribbon designation.  Erin is an experienced Medical Risk Consultant and device start-up project manager. She has consulted for numerous successful healthcare and bio-tech start-ups. After completing a Bachelor of Science degree at the University Of Wisconsin, Erin pursued an educational background in Healthcare Risk Management at the University of South Florida. Erin crafts her work with attention to detail, readability, healthcare marketing regulations, and medical standard of care.

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