Constellation

By Elia Petzierides

Six hours after 19-year-old Adam Fabre presented to the emergency department with fever, neck pain and vomiting, his mother voiced her objection as the doctor tried to discharge him home. Soon after, Mr Fabre became unconscious, began to convulse, and died the next day. How did the medical team fail to identify the severity of his illness and what can be done to prevent a re-occurrence?

What happened?

At 3:34am on July 14, 2006 Mr Fabre presented with his mother to the emergency department of a public hospital in Melbourne, Victoria, Australia. He was first seen and triaged by a senior triage nurse.

The process of triage involves prioritising patients by assigning a category of one to five which correlates with the maximum time a patient should wait for assessment and treatment. According to the Australasian Triage Scale a Category 1 patient (highest priority) is to be seen by a doctor immediately and at the other end of the Scale a Category 5 patient (lowest priority) is to be seen within 120 minutes.

The triage nurse documented Mr Fabre’s complaint as “2/7 days of temps headache and vomiting, non-petichial rash. Reports pain at the back of neck. Reluctant to touch chin to chest, otherwise good neck movement. Nil photophobia. Skin warm and dry. Feels muscles are saw (sic).” Observations at triage were: a temperature of 38.5 degrees Celcius (101.3 Farenheit) and a heart rate of 120 beats per minute.

Mr Faber was assigned a triage Category 5 before being taken into a cubicle and assessed by a nurse of 18 years’ experience. This cubicle nurse found Mr Faber to have muscle soreness, vomiting, photophobia (visual sensitivity to light), neck stiffness, a blanching rash (one that becomes pale with gentle pressure), chills, tachycardia (fast heart rate), a normal blood pressure and severe pain which Mr Fabre rated at an intensity of 10 out of 10.

With the emergency department not being very busy, Mr Fabre was seen by a junior resident doctor six minutes after being triaged. The junior doctor – who commenced working in the emergency department 11 days earlier – was present while the cubicle nurse was completing the assessment detailed above. The junior doctor then completed her own assessment of Mr Fabre before consulting with the senior doctor in the department who did not see Mr Fabre. Of note, the junior doctor described Mr Fabre as looking “unwell” and documented a three day history of runny/blocked nose, cold and headache, fever and chills, muscle ache everywhere, vomiting, tachycardia, nasal discharge, “(+) difficulty/pain doing chin-chest touch” and “Kernigs sign negative”. Both of these final two assessments aim to identify meningeal (membranes that cover the brain and spinal cord) irritation. Kernigs sign is a test that involves flexing the hip then straightening the knee.

The junior doctor made a provisional diagnosis of viral Upper Respiratory Tract Infection (URTI) and Mr Fabre was given paracetamol and codeine which he vomited shortly after. An intravenous line was inserted and blood samples were taken for testing. The hospital did not have any on-site pathology service and as such the blood samples were to be sent to a laboratory for testing at 8:30am. A venous blood gas was also taken and was found to be normal using an onsite blood gas analyser. He was then given an anti-emetic (metoclopramide – to stop vomiting) and paracetamol per rectum. Later he was given two litres of normal saline intravenously over 75 minutes.

Prior to the conclusion of her shift, the cubicle nurse was concerned about Mr Fabre’s pain and – in accordance with the nursing responsibility of being a patient advocate – raised her concern with the senior doctor. She asked him twice to review Mr Fabre, which he did not.

The cubicle nurse also expressed her concern at the junior doctor’s inexperience. Presumably not satisfied with the response from the senior doctor, she also notified the nurse-in-charge. To the on-coming day shift nurse she voiced her opinion that the medical team were not “on top of” Mr Fabre’s condition.

Being of the belief that Mr Fabre was suffering from a viral URTI – and with the support of the department’s senior doctor – the junior doctor attempted to discharge Mr Fabre home. Mr Fabre’s mother adamantly objected and insisted he remain in hospital.

At 9:00am Mr Fabre was observed to be acting strange according to his mother and moments later became rigid and unresponsive. He was then intubated (insertion of a breathing tube into his airway), ventilated, given antibiotic and antiviral therapy and transferred to the Intensive Care Unit (ICU) of a nearby larger public hospital.

Prior to transfer, both of Mr Fabre’s parents recall being told by a nurse and doctor that their son was young and strong and as such had an 80% chance of survival. The ICU staff provided the parents with a different prognosis, giving Mr Fabre nil chance of survival. He was pronounced deceased at 1:35pm the following day.

What went wrong?

The cause of death was listed by the forensic pathologist as “acute bacterial meningitis with secondary cerebritis (meningococcus)”.

An independent medical expert was requested to provide an opinion on the clinical management afforded to Mr Fabre. He provided a definition of meningitis from this reference.

Meningococcal disease is a serious infection caused by a bacteria commonly known as meningococcus. According to the World Health Organisation it is fatal in 50% of cases if left untreated. The bacteria is relatively common and is carried in the throat of 1 in 4 people. For reasons not clearly understood, in a very small proportion of these carriers the bacteria becomes invasive and causes disease. The most common diseases caused are either meningitis, septicaemia or a combination of both.
– Meningitis is an inflammation of the meninges (the membranes that cover the brain and spinal cord).
– Septicaemia is an infection of the blood.

The presence of meningococcal bacteria in the blood is referred to as meningococcal septicaemia and in the early stages causes fever and rigors (involuntary shaking chill lasting 10-20 minutes associated with fever). These bacteria also cause damage to blood vessels in the first 24 hours. Once damaged, the blood vessels leak blood which generates the classic petichial (non-blanching) rash and in advanced cases – when combined with the general effects of severe infection on the body – can lead to loss of limbs.

An important point of distinction here is that Mr Fabre had Meningococcal Meningitis and did not have Meningococcal Septicaemia. That is, the infection was localised to his meninges and did not enter his blood stream.

While the allocation of a triage Category 5 by the triage nurse did not make a difference to Mr Fabre’s outcome the independent medical expert deemed that a more urgent triage category would have been more appropriate for someone with Mr Fabre’s presentation. The possible impact the Category 5 had on the clinical staff’s perception of Mr Fabre’s severity of illness was not discussed in the Coronial Inquest Finding summary, though ‘anchoring‘ errors are a recognised phenomenon involving a clinician retaining their initial impression despite evidence to the contrary.

The medical director of the emergency department attended the Inquest where he unequivocally acknowledged clinical staff should have been alerted by Mr Fabre’s signs and symptoms and that the senior doctor should have personally examined Mr Fabre. He added this failure was out of character for the senior doctor. On this matter the independent medical expert stated that it is “very difficult” for a senior doctor to obtain an accurate clinical picture via a verbal handover from a junior doctor, and this is especially so without any pathology test results that might help guide decision making.

The independent medical expert provided a firm view on the misdiagnosis of URTI, asserting that it failed to recognise the fact that Mr Fabre presented with a “serious illness” and failed to acknowledge the significance of “the constellation of symptoms and signs”. He clarified this by stating the central issue of this case was not that meningococcal meningitis was not identified, but that Mr Fabre was diagnosed with an URTI while displaying signs and symptoms of serious illness.

Let us take a closer look at each of the pertinent signs and symptoms – the ‘stars’ that make up the aforementioned “constellation” – and reflect upon their relevance. The independent medical expert credited this reference as the source.

– Blanching rash
Some of the staff were incorrectly reassured by the presence of the blanching rash. The independent medical expert believed this was ignorant of the possibility of meningococcal infection without a petichial rash. While the petichial (non-blanching) rash is commonly associated with meningococcal septicaemia, less commonly known is that early meningococcal rash may be a diffuse blanching rash, as it was with Mr Fabre. This either completely resolves or evolves into the petichial rash.

– Severe pain in extremities, neck, back or other location
The significance of Mr Fabre’s severe pain appears to have been neglected by most staff. Muscle pain may be an early sign of meningococcal meningitis even without apparent fever. Muscle pain occurs in both adults and children, and in children may present as an inability to walk. In short, be alert to any febrile patient with severe pain at any location.

– Vomiting associated with headache or abdominal pain
Seemingly innocuous, vomiting is actually an uncommon symptom in previously healthy individuals. When vomiting occurs without diarrhoea it should not simply be dismissed as a gastrointestinal infection. Importantly, vomiting should also be recognised as being a common symptom of central nervous system infection and occult sepsis.

– Concern of parents or relatives
Mr Fabre’s mother displayed significant concern for her son’s well-being. Parents are cited as being the best judges of the health of their children. Concern of relatives and friends should be seen as a warning sign. On this occasion it failed to generate the desired response.

– Neck stiffness
Given the conflicting reports of neck stiffness from the staff, the independent medical expert gave a précis of assessing for neck stiffness caused by meningeal irritation (meningism). When the neck is bent forward (moving chin-to-chest) in the presence of meningeal irritation there is a reflex (involuntary) spasm of the neck muscles giving the clinician a feeling of resistance to flexion. This resistance is known as nuchal rigidity. It occurs irrespective of the patient’s conscious state. Importantly, patients with viral illness may complain of neck stiffness but do not have nuchal rigidity upon examination.

The decision to discharge Mr Fabre was underpinned by the misdiagnosis of URTI. One important point the independent medical expert made was that when the initial treatment plan failed to generate the expected improvement in Mr Fabre’s condition, Mr Fabre should have been reviewed by the senior doctor and the diagnosis should also have been reviewed. This did not happen.

Communication issues were also highlighted. At 8:00am during medical handover an opportunity arose for the oncoming senior doctor to review Mr Fabre. This was deemed to be a missed opportunity as the oncoming senior doctor was under the false impression Mr Fabre had already been personally reviewed by the previous senior doctor. One further communication issue was the lack of action that resulted from the cubicle nurse raising her concerns with the nurse-in-charge. The Inquest was unable to glean any clarity on the outcome of this issue.

The blood test results – described as a “useful adjunct” to clinical assessments by the independent medical expert – showed a raised White Cell Count and a grossly elevated inflammatory marker CRP (C-reactive protein) of 239. These results which were indicative of serious infection and not consistent with a viral URTI, were sent to the off-site pathology laboratory for testing at 8:31am. This was close to the time when Mr Fabre started convulsing and the opportunity for them to be of any diagnostic assistance was lost.

Regarding the administration of two litres of intravenous saline, the independent medical expert noted that this may have (unintentionally) contributed to Mr Fabre’s cerebral oedema (brain swelling) and subsequent deterioration.

The independent medical expert stated that treatment of suspected mengingococcal meningitis is with early antibiotics. Consistent with common practice, this should not be delayed by waiting for blood test or lumbar puncture results. It was agreed that it was not possible to say if any substantial difference in Mr Fabre’s outcome would have been possible if he was given antibiotics soon after arriving at hospital.

It should be noted that both the junior and senior doctors provided heartfelt apologies to Mr Fabre’s family and did not contest any evidence related to their respective shortcomings. The junior doctor – who was tearful throughout much of her evidence – also told the family she had “done her best”. Mr Fabre’s family generously thanked the doctors for their openness and honesty throughout the Inquest.

Will it happen again?

Policy changes were made at the hospital involved. These included protocols on recognition of serious illness, education on meningitis and a new on-site pathology service. Notably, a protocol for disagreement over diagnosis or treatment was implemented which empowers doctors and nurses to follow a process in the event of a perceived lack of response from a senior doctor. Upon notification the nurse-in-charge is able to contact the senior doctor on-call for a reassessment of the patient. Given the changes implemented by the hospital prior to the Inquest, the Coroner was sufficiently satisfied that no recommendations were required for the hospital.

In an attempt to share the information learnt about the complexities of diagnosing meningococcal disease the Coroner requested the Inquest Finding notes and the independent medical expert’s notes be publicly available on the Coroners Court website. It is this request that has inspired the writing of this article, albeit five years after the Inquest.

While it is acknowledged that there were failings at the hospital that contributed to Mr Fabre’s death, it is important to reflect upon what occurred and ask ourselves what we can do to prevent a re-occurrence? Below are some suggestions from the author’s perspective.

Healthcare professionals would no doubt benefit from the advice of the independent medical expert regarding identification of signs of serious illness, reading the journal article as a refresher on meningococcal disease, and investigating what mechanisms exist in their workplace for resolving disagreements with other clinicians.

Patients and their families would benefit from an awareness of the Australian Charter of Healthcare Rights which provides a series of seven rights for patients within Australia. The rights to safe and high quality health services, participation in decision making and the right to comment or complain about the care they receive are three pertinent rights that serve to empower anyone facing a similar situation.

In conclusion, the tragic death of Mr Fabre highlights the importance of delivering healthcare at a consistently high standard. The next time you are presented with a patient with a seemingly minor illness, zoom out and observe the constellation of signs and symptoms. It might just save a world of consternation.

The author Elia Petzierides is a Victorian based Advanced Life Support Paramedic and a Registered Nurse with a Graduate Diploma in Advanced Clinical Nursing.

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5 thoughts on “Constellation

  1. This is so unfortunate. A life lost cannot be replaced. I hope as nurses we learn from this mistake and not think just because we have seen “such presentations” before then we do not make extra efforts. I also hope as a team in ED we can improve on our practices.

    I had a similar experience, unfortunately I had to also force the Doctors to do extra checks to find out the problem. It turned out I had a life threatening bowel obstruction and needed to have emergency surgery. That was only found out after being turned back 4 times. Even the ambulance refused to take me to hospital the second time around so my family drove me to ED.

    I sympathise with the mother and the family because it is not easy.

    Like

  2. Great reminder to be thorough and think globally Elia. An old friend of mine, coincidentally an old triage nurse herself, came to work one day, she was somewhat angry. Her 17 yo had been burning the candle at both ends, too much partying, not enough studying, and she had to leave him at home that day, sick with a sore throat. She arrived home from her shift that night and he was tragically deceased, Meningococcal disease.

    Liked by 1 person

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