Mr M is a 57-year-old man who was brought into the emergency department (ED) at 12:30 pm by ambulance after calling 911 with complaints of vomiting and chest pain that radiated down his left arm. Emergency medical technicians confirmed to Ms B, a nurse, that Mr M complained of chest pain and reported vomiting. When Ms B questioned the patient about whether he was currently experiencing chest pain, he denied being in pain.

Ms B assessed Mr M and documented a medical history of high cholesterol and chronic obstructive pulmonary disease and a family history of coronary artery disease, diabetes, and hypertension. She ordered an electrocardiogram (ECG) and a troponin level blood test.

The electrocardiogram (ECG) results were read by the technician as borderline with a note that stated “MD must review STAT.” [It is not clear whether the technician noted what aspect of the ECG was borderline.] The blood test results came back at approximately 1:30 pm and revealed that Mr M’s troponin level was elevated at 0.09 ng/mL (normal range, 0-0.08 ng/mL).

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The hospital has a policy pertaining to patients who come into the ED with chest pain to ensure that they are assessed for heart attack and get a proper diagnosis. The policy requires a physician, nurse practitioner, or physician assistant to assign the patients to 1 of 4 tracks. Tracks 1 through 3 are for patients with “chest pain of certain or probably cardiac origin” and require, among other things, serial ECGs and troponin testing. Track 4 is for patients with chest pain of “probable noncardiac origin” and does not require serial testing. Nurses are to follow orders based on the assigned tracks; if a physician doesn’t assign a track, the nurse should ask the physician to assign one.

Ms B triaged the patient as a probable track 3 and wrote in the patient’s chart “track 3?” The ED physician, Dr S reviewed the patient’s ECG result and interpreted it as showing “no ischemic changes.” At 1:50 pm, he evaluated the patient. When asked about symptoms, the patient denied nausea and vomiting. Mr M told the physician that he had recently undergone a stress test, which was negative.

Dr S was not concerned with the slight elevation in the patient’s troponin level and considered it clinically unremarkable. The patient’s vital signs were also unremarkable. Rather than assign the patient to a track, the doctor ordered that the patient be discharged.

Dr S entered the discharge instructions and had Ms B go over them with the patient.

The discharge paperwork advised the patient that, based on his examination, the exact cause of his chest pain was unknown but his condition did not appear to be serious and the pain did not appear to be coming from his heart. Mr M was discharged from the ED at 2:45 pm after receiving a single ECG and a single troponin level test.

The patient passed away the next day at his home from an acute myocardial infarction. His widow hired a plaintiff’s attorney and brought a lawsuit against Dr S and Ms B. The case proceeded through the discovery phase, and depositions of all the parties and experts were taken. In his deposition, Dr S testified that he had decided to discharge Mr M because the patient was asymptomatic while at the hospital, received a negative stress test, and had unremarkable vital signs and test results.

The doctor testified that in practice, “initiating a formal track is optional — physicians use it or don’t as they see fit.” If he had assigned a track to Mr M, it would have been track 4 for probable noncardiac origin chest pain, which wouldn’t have required serial ECGs or troponin testing.

Prior to trial, Dr S settled out of court with the plaintiff leaving only the claims against Ms B. Ms B’s defense attorney made a motion for summary judgment, asking the court to dismiss the case. The court granted the motion, concluding that any alleged negligence by Ms B was not the proximate cause of the patient’s premature discharge because there was undisputed evidence that the physician would have discharged Mr M even if Ms B had questioned his decision. The case against Ms B was dismissed.

Plaintiff Appeals

The plaintiff appealed this decision, arguing that the lower court had erred in granting summary judgment. Summary judgment, the plaintiff pointed out, may only be granted when there are no issues of facts in contention, only law. A court can decide the law if there are no issues of material fact in dispute.

The plaintiff argued that the court erred when it granted summary judgment to Ms B because the totality of the evidence surrounding Mr M’s discharge created a fact issue as to whether Ms B’s alleged negligence proximately caused the patient’s death. Issues of causation, noted the plaintiff, are questions for a jury, except in clear, plain, and undisputed cases.

In this case, the Court of Appeals stated there were issues of fact that needed to be decided by a jury. The court noted that the plaintiff had presented expert witness testimony during depositions by experts who criticized Ms B’s handling of the case and argued that she should have triaged Mr M as more urgent and should have advocated to have him placed on a formal track or given more testing. The expert noted that the doctor was unaware of the patient’s complaint of vomiting and Ms B should have brought it to his attention. The expert noted that if Dr S refused to listen to Ms B, she could have taken it up the chain of command to advocate for her patient.

The Court of Appeals reversed the lower court’s decision and remanded the case back to the trial court for a jury trial.

Protecting Yourself

While we don’t know whether Ms B will ultimately be found liable in this case, both she and Dr S could have reduced their chances of a lawsuit by following the protocols of their employer hospital. Ms B should have asked Dr S to put the patient on a formal clinical track and perform repeat testing. If Ms B’s actions are found to have caused or contributed to Mr M’s premature discharge from the hospital, then she may be found liable.

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