The ambulance pulled up to the emergency department at a rural medical center, and the paramedics rushed in. “16-year old male, involved in a car accident,” one of them announced. “Reports minor chest pain and slight trouble breathing.”

Dr. T, 52, and his physician assistant Mr. E, 36, launched into action. The patient, Tim, was lucid and had no obvious major injuries. Mr. E noted a chest abrasion, most likely from the seat belt Tim had been wearing. The PA checked Tim’s vital signs, ordered lab work, and began a detailed physical exam. Dr. T also noted the chest abrasion as the only sign of injury and the complaint of slight chest pain. He ordered a chest x-ray and a CT scan of the patient’s head and neck. Both were negative.

Over the course of the next two hours, Mr. E and Dr. T repeatedly observed the patient and examined him six times. At the end of that time, based on the normal lab results, vital signs, and lack of visible injuries, pain, or tenderness, Dr. T released Tim to his father, who took him home. 

That evening, father and son chatted and watched TV. Eventually, Tim fell asleep on the couch, but when he woke up in the middle of the night, he went upstairs to his bedroom. The next morning, the father walked in to find Tim dead, lying half on and half off the bed.

An autopsy revealed a significant laceration of the liver, a smaller one of the spleen, and almost two liters of blood in the abdominal cavity. Determined to hold someone accountable, the parents sued Mr. E, Dr. T, and the medical center.

The two clinicians spent a great deal of time second-guessing themselves as they agonized over the unexpected death of such a young person. Ultimately, they concluded that they had done all they could—and their attorney agreed.