First doctor to treat NSW teenager who died from infection admits he should have taken vital signs
The first doctor to treat a limping teenager, whose sudden death from a fastacting infection is under coronial investigation, says in retrospect he should have taken a full set of basic readings such as blood pressure.
Alex Braes, 18, died at Sydney’s Royal Prince Alfred hospital nearly 46 hours after limping into Broken Hill Base hospital at 3am on 20 September 2017.
His inquest has heard a full set of vital signs – including blood pressure, heart rate and temperature – weren’t taken until his fourth presentation about 11am on 21 September.
An internal hospital policy at the time stated it wasn’t mandatory to take all six vital signs for patients deemed non-urgent, as Braes was considered in his first three presentations.
Dr Devinda Arangala was asked on Tuesday if he now thought taking five minutes to take vital signs would have added to the “clinical picture” of Braes.
“In retrospect, I think it would have been useful,” he told the NSW coroners court. “[At that time] I’d decide on which obs were most clinically relevant.”
The inquest has heard it appears Braes’s presentation was unusual for an already unusual condition.
In lieu of an autopsy, a panel of experts determined the teenager had invasive group A streptococcal, an infection that can be fast-acting, cause devastating complications such as toxic shock syndrome and sometimes develop into necrotising fasciitis or flesheating disease.
The death rate can be as high as 50%, even with early and aggressive intervention.
The expert panel said it was possible an infected toenail was the source of the infection.
Arangala said he believed Braes was in a “moderate” amount of pain and appeared to have a knee ligament injury.
“He certainly looked in discomfort but he could walk which, to me, was a reassuring sign,” he said. “But, otherwise, he looked well.”
There was no sign of extreme unbearable pain, a symptom of necrotising fasciitis, or any other clear sign of infection, the doctor said.
“I considered infection but it was low down on my list of differentials,” he said.
“I wanted to confirm or exclude my first diagnosis.”
No blood tests were ordered at that time.
Braes was recorded as having no fever, which the court heard came from a nurse’s check with a thermometer.
The nurse also recorded his pain score as “five out of 10” at rest and during movement, and his pulse rate as “regular”.
Patients at Broken Hill were now getting vital signs taken “left, right and centre”, the nurse said.
“We’ve had a lot of upgrades since … all this has happened,” Caroline Anderson told the court on Tuesday.
She triaged Braes as non-urgent after he presented with a “light” limp and found it impossible to get comfortable in the waiting room.
“An injured knee, I would not have thought it was life-threatening,” she said.
The nurse was asked on Tuesday if it was best practice to record the actual temperature in degrees Celsius or simply that there was no fever.
“If I was at triage, I would write a number … but I know a lot of doctors and nurses will just write afebrile,” she said.
The inquest continues.