Incorrect triage caused critical delay
Incorrect triage caused critical delay
Ms. Q was a nurse working in the emergency department (ED) of a regional medical center. She'd been employed at the medical center for about five years, and, although she liked the work in general, she was not thrilled about having to work nights and weekends. However, she liked her coworkers and found her job interesting.
One of the most challenging aspects of the job was the initial assessment of patients coming into the ED. After a brief examination and history, Ms. Q would decide how the case should be triaged. That decision is extremely important, as it affects how quickly each patient will be treated.
Ms. Q was on duty one night when Mrs. B, aged 61 years, came in. Mrs. B said that she suddenly began experiencing chest pain earlier in the day. She came into the ED at about 8:15 pm, and was seen by Ms. Q at 8:20 pm.
Mrs. B reported a history of smoking and hypertension, and told Ms. Q that the chest pain she was experiencing was severe and radiated down her arm, back, and neck. Mrs. B rated her pain as "10," the highest possible level. Ms. Q took Mrs. B's BP, which was elevated at 228/104 mm Hg. Based on these factors, Ms. Q placed the patient in the triage category of "urgent," which was second only to the most severe category of "emergent."
Dr. R, the attending physician, came to see the patient 15 minutes after initial assessment. Dr. R reviewed Ms. Q's notes and performed a physical exam. At about 8:30 pm, Dr. R ordered a diagnostic panel, chest x-ray, placement on a monitor, sublingual nitroglycerin, and GI medications for the patient. Because Mrs. B was not in the most severe triage category, these orders were not carried out immediately; it took about one hour for Mrs. B to be placed on a monitor and given medications.
The results of the diagnostic tests indicated that Mrs. B's vital signs and cardiac enzymes were normal, her chest x-ray was negative, and an ECG did not show any acute ischemic changes. Her BP had decreased to 154/88.
Late that night, Dr. R contacted Mrs. B's regular physician, Dr. C, and advised him about the situation. Dr. C had the patient admitted for observation and testing, and he ordered that she be put on a blood-thinner. Dr. C also scheduled a stress test to rule out ischemic heart disease. However, by that evening Mrs. B was still doing very poorly. A second ECG was performed and the attending physician diagnosed an acute inferior-wall MI.
Because the medical center did not have the capability for heart surgery, Mrs. B was transferred to another hospital for a cardiac catheterization at 1:00 am. The catheterization revealed that Mrs. B had an aortic dissection — a tear in the ascending aorta above her heart — requiring emergency surgery.
During surgery, a large hemorrhage and a hematoma were discovered, with excessive bleeding into the tissue around the right coronary artery and in the right ventricle. The surgeon believed that Mrs. B had less than a 1% chance of surviving surgery and decided not to proceed.
Over the next week, Mrs. B had progressive deterioration of multiple organ systems since her heart was not able to pump enough blood throughout her body. She died about a week after going to the ED.
Once Mrs. B's husband recovered from the shock, he consulted with an attorney. After reviewing Mrs. B's medical records with an expert, the attorney decided to take the case.
"Unfortunately, many things went wrong in your wife's situation," he told the widower. "It started right away when she wasn't categorized as an emergency in the ED. That slowed down her treatment from the start. Then, the ED physician made the wrong diagnosis, and he didn't order a CT scan. Your wife's personal physician made things worse by prescribing blood-thinners."
Mr. B's attorney explained that his expert witness said an aortic dissection should have been suspected from the start, as Mrs. B was exhibiting all the typical signs — sudden continuous chest pain, back pain, and hypertension. That, along with Mrs. B's age and the fact that she was a smoker, required Dr. R to consider aortic dissection as a differential diagnosis. Yet, he merely ordered a chest x-ray, which does not rule out aortic dissection.
"Had your wife's triage been properly categorized, she would have been given a CT scan, and the tear would have been discovered. Immediate surgery could have saved her life," the attorney said.
A lawsuit was filed against Dr. R, Dr. C, and the medical center, alleging that the nursing staff had incorrectly triaged the patient, leading to a delay in diagnosis and treatment, and ultimately, to Mrs. B's death.
Ms. Q consulted with the medical center's team of attorneys, who asked questions about her triage procedure. Had Mrs. B been a man, Ms. Q admitted, she probably would have rated the triage category "emergent," but female patients with similar symptoms were generally considered "urgent," since such patients were less likely to be having a heart attack.
The defense attorneys eventually filed a motion to dismiss the case against the medical center, but the court refused, on the grounds that there was enough evidence for a trial based on whether the treatment delay contributed to the patient's death.
The case was settled out of court with Dr. R, Dr. C, and the medical center each contributing an undisclosed amount to the plaintiff.
Ms. Q was sued through the medical center, not individually. This is quite common in cases involving clinicians who are not physicians, for two reasons. First, the medical center is ultimately liable for Ms. Q's actions as an institutional employee. Second, the medical center has deeper pockets than an individual clinician does, so the plaintiff goes after the bigger target. Sometimes a plaintiff will sue both the medical center and the clinician.
When it comes to cardiovascular issues, research has shown that women may not be diagnosed or treated as aggressively as men. Studies have also shown that women are more likely than men to experience delays in emergency care for cardiac symptoms. It is important for clinicians to assess each patient without regard to gender stereotypes. Any delay in treatment, as this case demonstrated, can be the difference between life and death.Ann W. Latner, JD, is a former criminal defense attorney and freelance medical writer in Port Washington, N.Y.