Ms. U was a newly graduated nurse practitioner who was just finishing her sixth month working in a hospital emergency department (ED). While many of the physicians she worked with were pleasant and helpful, others could be brusque and intimidating. Unfortunately, the acting chief of the ED, Dr. O, was among the latter group.

Paramedics brought Mr. M to the ED one evening while Ms. U was on duty. He had sustained injuries to his left leg after losing control of his motorcycle and crashing into a guardrail. Mr. M had been pinned under his motorcycle until help arrived. He reported severe pain and numbness in his leg. When Ms. U examined him, she noted tenderness and swelling in the knee area. She was unable to detect a pulse in the injured leg. Concerned, she went to one of the more experienced clinicians on the nursing staff, Ms. Y.

Ms. Y was also unable to detect a pulse and advised Ms. U to try using a Doppler ultrasound, but that method also proved unsuccessful. Ms. U noted this in the patient’s file and called in the supervising physician, Dr. O.

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The physician noted the same pain, swelling, and tenderness that Ms. U had, but he wrote in his examination notes that he was able to detect a pulse in the leg.

Ms. U was perplexed and approached the physician as he was leaving the examination room. “Doctor,” she began, “I was wondering how you were able to detect a pulse in the patient’s leg when, even with the help of the Doppler, we could not?”

“I am too busy right now,” replied the physician, and walked off. Ms. U described the incident to Ms. Y, who also tried but failed to get a satisfactory reponse to the question from Dr. O.

Dr. O attributed the patient’s pain to a severe sprain. He discharged the patient with instructions to go home and rest and elevate the leg, apply ice to keep the swelling down, and follow up with an orthopedic physician after a few days.

Before the patient left the hospital, Ms. U and Ms. Y informed him of the fact that they had been unable to locate a pulse in his leg, possibly because of the swelling. “That might indicate a problem,” said Ms. U. “My advice is to call the hospital or come back if the pain does not go away or gets worse.”

Mr. M’s pain continued to intensify, and the swelling of the knee increased. He went to the ED of a different hospital the next day, where he was diagnosed with a dislocated knee and lacerated popliteal artery. The severity was such that amputation was considered; however, the leg was saved by emergency surgery. The patient spent 35 days in the hospital following the surgery and never fully regained function of his leg. After returning home, he sought the counsel of a plaintiff’s attorney, who filed suit against the original hospital, Dr. O, and the nursing staff on duty that evening, including Ms. U.

Legal paperwork, motions, and depositions took almost one year to complete. Just prior to trial, Dr. O settled out of court for $275,000. The case against the hospital and the nurses, however, proceeded to trial.

The plaintiff’s attorney used witness testimony and the patient’s records to show that the nurses had been unable to locate a pulse in Mr. M’s leg, despite Dr. O’s statement to the contrary.

The plaintiff testified how the nurses had alerted him to the situation but did not follow up. He explained to the jury how the injury impacted his work as a construction worker. “My leg is permanently damaged,” he stated. “I can’t get jobs that require climbing ladders or doing anything very physical.” He also testified about ongoing pain and discomfort.

When it was the defense’s turn to testify, Ms. U explained that she had to rely on the more experienced Dr. O’s findings. On cross-examination, however, she was forced to admit her doubts.

“Did you ask Dr. O how he managed to get a pulse when neither you nor the other nurse was able to do so?” asked the plaintiff’s attorney.

“Yes,” Ms. U answered, “but Dr. O did not respond. He told me he was too busy.”

“But the fact that you asked indicated that you were concerned. You were, in fact, concerned that the patient’s circulation might have been impaired, weren’t you?”

“Yes, I was concerned,” Ms. U replied.

“Yet you did not notify a supervisor,” the plaintiff’s attorney pointed out.

“I asked my colleague, who also questioned Dr. O, but she did not get an answer either,” stated Ms. U, who was beginning to feel uncomfortable.

“After neither you nor your coworker got a satisfactory response from Dr. O, did you go to his supervisor or another physician to raise your concerns?”

“No,” said Ms. U, hesitantly.

The plaintiff’s attorney then brought out a copy of the hospital’s ED policies-and-procedures manual and had Ms. U read aloud the portion stating that if a nurse believed appropriate care was not being given to a patient, a hospital supervisor must be notified. If on notification the situation were not resolved, the next in the chain of command must be made aware until the situation was resolved.

“I’ll ask you again,” said the attorney. “Did you raise yor concerns about the patient to a hospital supervisor?”

“No,” Ms. U admitted quietly.

The same scenario was played out with the other nurse. After closing arguments, the jury deliberated for five hours before announcing a verdict for the plaintiff in the amount of $880,000.

Legal background

This case might have played out differently if it took place in a physician’s office or small practice. In that case, it would have been unlikely that procedures were in place to prevent this sort of situation, and it would have been easier to argue that the ultimate course of action when treating any patient is up to the physician in charge. However, based on the hospital’s policy, Ms. U and her colleague should have voiced their concerns to a supervisor rather than let Dr. O ignore them. By not following the policies, the nurses opened themselves and the hospital to liability. A written document is very powerful evidence and difficult for a jury to ignore.

Protecting yourself

Always read the employment manual when starting a new job and familiarize yourself with the content. Dr. O intimidated Ms. U, but this should not interfere with the quality of care that a patient receives. Just as a nurse has a duty to question an inappropriate medication order, a nurse also has a duty to question a potentially incorrect or missed diagnosis. If the physician will not listen or discuss it with you, find someone who will.