The Expert: Dr. Ronnie Fuerst, a pediatric emergency medicine physician based in South Carolina.
In a 2016 Florida medical malpractice trial, Dr. Ronnie Fuerst, a pediatric emergency medicine physician from South Carolina testifies for the defense in a case involving alleged negligence leading to the death of a 12-year-old girl due to complications of new-onset diabetes with diabetic ketoacidosis. The plaintiff claimed that the treating physician failed to treat the girl properly and delivered too much fluid, causing fatal brain swelling and brainstem herniation.
Dr. Fuerst examines the standard of care for the treatment of diabetic ketoacidosis (DKA) by the emergency room doctor through his forthright answers to rapid-fire questioning from the defense attorney. The initial treatment with an insulin bolus followed by an insulin drip did not seem to help much with the patient’s high blood sugar, and this was an indication that there was something complicating the diabetes, such as an infection. The combination of diabetes and this complicating factor ultimately led to DKA, a very serious, life-threatening condition. One percent of these patients with DKA will develop significant cerebral edema (brain swelling), and of those, 25-30% will die from this pathology. In this case, the vital signs were initially stable, and a chest X-ray was taken to search for the infection.
The treating physician, Dr. Dudley Teel, began preparing the patient for transfer to a facility that would be more appropriate for treating this condition. Fuerst explains it is the standard of care to send the patient to the receiving facility with a hospital chart/detailed summary of what was done at the original facility. As this was being prepared, with 10 minutes left before the helicopter would arrive for the transfer, the documented examination of this patient by both Teel and the triaging nurse showed no signs of an acute neurologic problem, and no indications for giving mannitol, a diuretic, to lower the pressure of her cerebral spinal fluid.
Then the patient’s status changed suddenly. She complained of a headache, her breathing changed, and she had a sudden sense that she was dying. A code was called, Dr. Teel was at the bedside, mannitol was ordered, and she was sent for a CT scan of her brain. These actions were all demanded by and complied with the standard of care in this situation, according to Fuerst. The expert explains further the mantra of stabilization in emergency medical care, “ABC”—Airway, Breathing, Circulation. Since this patient had a sudden critical change in her respiratory status, the “Airway” and “Breathing” parts of this plan were instituted by placing a breathing tube down the patient’s throat and breathing for her with an “Ambu bag,” or bag valve mask.
Most patients with DKA have some degree of cerebral edema, but it is usually not clinically significant and generally does not present this quickly when it is clinically significant. The expert explains that the CT scan in this case demonstrated intracerebral hemorrhage accompanying the DKA. This could be related to the DKA process itself and in this case appeared to be a subarachnoid hemorrhage accompanying diffuse brain swelling and brain herniation. This hemorrhage can be a slow leakage or a sudden event. This would be expressed clinically as a severe headache, a change in mental status, and a change in breathing.
While mannitol can be given to help lower the pressure in the brain in a case like this, it was not present at the patient’s bedside. The expert was asked to address the fact that, in this case, mannitol was not immediately available despite being called for in the “Milwaukee Protocol,” a protocol for treatment of DKA. Fuerst explains mannitol is mixed in the pharmacy as needed, instead of being mixed by the nurse in the ER as it has been in the past. He feels that guidance protocols, such as the “Milwaukee Protocol” are often presented to physicians as an ideal, but this is not how an emergency room is run in practice. Not everything can be immediately available to everybody at all times. Unlimited resources do not exist in real emergency rooms, Fuerst explains, concluding that a hospital does not breach the standard of care by not having mannitol available at every bedside.
The plaintiff’s allegation of a breach when oxygen was not administered to the patient is also cast aside by the testifying expert because her oxygen saturations never fell. He disagrees as well with the claim that it was a breach to estimate the patient’s weight: “Estimating her weight was exactly the right thing to do,” he concludes. Further, he states plainly that the total fluid administration—including an insulin bolus, a fluid bolus, an insulin drip, and additional fluids—was within the standard and was not considered reckless, as the plaintiff’s legal team alleged.
Dr. Fuerst offered testimony that completely refuted the plaintiff’s allegations. His conclusions and their presentation were instrumental in the jury’s verdict for the defense.
Gary Gansar, MD, is residency-trained in general surgery. He served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Touro Infirmary and Mercy Hospital in New Orleans, LA. Dr. Gansar was Board Certified in general surgery while in active practice. He joined AMFS in 2015 as a Physician Medical Director.
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