Case description Type 1 diabetes
07-09-2022 -by Mathilda Boer – case manager Regional Investigative Committee
On a Saturday, the mother of an 11-year-old patient calls with concerns about persistent vomiting for a day. He doesn’t keep the ORS inside either. His mother indicates that he has deep-set eyes with circles. He is limp, doesn’t keep anything down and vomits 2 times an hour. He has no diarrhea and no fever. She had also had mild symptoms of vomiting and diarrhoea the day before. Her request for help is to get something against the spitting. Triage takes place and ends up with a U2, but in consultation with the directing physician this is scaled down to a U3 because of the stable image of the boy. After consultation with the directing physician about whether a consultation or medication is appropriate, a consultation is offered anyway – scheduled three quarters of an hour after the telephone contact.
Upon arrival, the patient is placed in the emergency room due to his unstable condition. When examined by the GP, he was clear and alert, but tired. His blood pressure and pulse checks were within normal range, and he had no fever. His mucous membranes were moist and his skin turgor was normal. The abdominal examination was normal except for slight pressure pain in the stomach area. After examination, the GP will conclude that DD gastroenteritis is present. For this, the patient is given Ondansetron and a safety net: start drinking small amounts, start ORS, if vomiting continues despite Ondansetron, contact in case of watery diarrhoea, 300 ml of ORS at a time.
Mother calls again on Sunday morning. She says she is anxious because of her son’s deterioration. He didn’t sleep last night, looks grey, is drowsy and can’t stand on his own. Last night he didn’t sleep because he was thirsty. His mother notices that he has a strange voice and hollow eyes. During the conversation, she notices his blue lips, knees and toes. During the interview, the triage nurse calls in the ambulance for an A1.
Afterwards, the patient turned out to have severe hyperglycemia in type 1 diabetes de novo; glucose 43 was measured in the ER. He was in the ICU for a few days, but fortunately has now recovered well.
The above case has led to a number of points that we would like to share with you in order to prevent a recurrence:
- Scaling down is only permitted after consultation with the directing or consulting doctor, under substantive arguments and no more than one urgency code. In this case, this was partly done well, but we note that scaling down can also have serious consequences. Our patient came in as U3 and was placed in the first aid room. If this had not been done, the patient would have been in the waiting room and all U2s would have been given priority. This could have caused a delay, which would not have been desirable in this case. In principle, he was assessed as a U2 (within the hour) so there was no need to scale down. Scaling down increased the risk that the patient would have had to wait longer unnecessarily. So be aware of the consequences of scaling down.
- Given the fact that he had an increased risk of dehydration given the frequent vomiting, a more concrete safety net could have been given in which the mother contacts the GP post after 4 hours to report how things are going.
Unfortunately, there are no standards or guidelines to deal with this incident. However, gastroenteritis usually also involves diarrhea. Especially if it lasts a little longer. Attention is quickly drawn to vulnerable target groups such as the elderly or children up to 2 years of age, but in an older child with persistent vomiting, this picture does not correspond to the epidemiology that we often encounter. Be alert if there is persistent vomiting without diarrhoea and broaden the examination to include a glucose measurement, neurological examination and the question of possible intoxications.
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