Mr G, a physician assistant, was employed at a busy emergency department (ED) for more than a decade. The work was challenging, but Mr G liked the fact that he saw a variety of medical issues, met new people every day, and had some autonomy to make decisions. There were things he didn’t like, however. The ED could be understaffed at times and he often felt rushed and pressed to get patients in and out quickly.

On a busy day, Mr G was working in the ED with several nurses, another physician assistant, and a supervising physician. When new cases were triaged, the physician would be assigned anything life-threatening and Mr G would be assigned to the less serious cases (eg, minor injuries, skin conditions, and ear infections). As soon as 1 case was completed, he picked up the next folder and moved on to the next examination room.

Ms P, a 60-year-old executive, had been out for her regular slow jog in her neighborhood when a large piece of furniture flew off the back of a pickup truck and splintered on the street where she was walking. A large piece of wood struck Ms P in the shin, causing significant pain and bruising. In the examination room, Mr G introduced himself to the patient and took a history, making a note in the chart that Ms P was on warfarin 7 mg daily. He examined the large hematoma on Ms P’s leg. Ms P noted that the bruise was “much bigger than it was when it first happened.” Mr G ordered a radiograph to “make sure the leg is okay.”

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While Ms P was in radiology, Mr G saw another 3 patients, referring 1 to the supervising physician, and treating and releasing the other 2 patients. When Ms P returned from radiology, Mr G informed her that her leg was not broken or fractured, but that she had swelling that would take time to go down. He gave her a prescription for a pain reliever, told her to rest, and advised her to return to the ED if anything changed.

Because Mr G was not working the next day, he was not there when Ms P returned with a ruptured hematoma. The surgeon discovered actively bleeding at the site of the hematoma and a large blood clot. Ms P was taken into surgery to remove the clot as well as surrounding necrotic skin.

Over the next year, Ms P would require 2 additional surgeries, including a skin graft on her leg. Her leg was scarred and permanently damaged and she could no longer jog. She hid the disfigurement on her leg with clothes.

Ms P consulted with a plaintiff’s attorney to see if she might have a case against the hospital. The attorney questioned her at great length about her medical treatment by Mr G: “Did he know you were on warfarin? Did he advise you to stop taking warfarin, or to contact the prescribing doctor immediately? You said that the bruise was smaller when you arrived at the hospital and it got larger. Did the PA measure it that you know of? Or did he ask you to stay so it could be monitored?” Ms P answered no to all the questions.

The attorney took the case and filed a negligence lawsuit against the hospital, claiming that it was liable for Ms P’s “extraordinary medical expenses, pain and suffering, loss of enjoyment of life, and permanent impairment.”

When questioned by the defense attorney, Mr G relied on his notes that indicated that Ms P was on warfarin; that she had a hematoma from being struck with debris; that he prescribed a pain reliever; and released the patient with instructions to come back if anything changed.

Mr G did not have any more specific discharge instructions, and Ms P testified that she was only sent home with boilerplate information.

Expert medical witnesses called on behalf of Ms P also testified, stating that the hospital had failed to meet its duty of care in her treatment. Specifically, the experts faulted Mr G for not properly examining, marking, or monitoring the hematoma when Ms P initially arrived in the ED; for not advising the patient to discontinue warfarin or contacting the prescribing doctor; for discharging the patient with an expanding hematoma; and for failing to provide adequate instructions following her first visit to the hospital.

After deliberations, a jury returned a verdict for Ms P in the amount of $1.2 million.

Protecting Yourself

Because clinicians are busy, especially in a setting like an ED, it is crucial to take good notes. It’s not surprising that Mr G did not remember the interaction with this patient over a year later. But Mr G made several mistakes. He took very few notes. He failed to follow up on the fact that the patient was taking warfarin, a blood thinner that could exacerbate internal bleeding. He failed to track whether the hematoma was growing while she was in the ED. He failed to provide instructions for monitoring the hematoma once she left the hospital. In essence, it was treated like a bruise without looking at the underlying reason why the patient was taking warfarin and how that medication might affect her condition.

Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, New York.