Ms. P was a nurse practitioner in a busy clinic in a large urban area. The clinic employed more than 50 physicians, including specialists, and its motto was that it provided comprehensive medical care from “head to toe.” Ms. P’s job, along with the eight other NPs who worked at the clinic, was essentially to triage the cases. She would see the patients first and treat minor complaints. If further evaluation was warranted, Ms. P would call in a physician to see the patient. When necessary, the patient would be sent to the emergency department of the local hospital.

One afternoon, Mrs. D, age 45, came into the clinic and was seen by Ms. P. The patient complained that she had been experiencing diminished vision over the past few days and felt as if there were a foreign object in her right eye. She also reported impaired peripheral vision. Ms. P inquired about the patient’s medical history and discovered that she was HIV-positive and suffered from vasculitis. When asked if she was having any other problems, Mrs. D reported a mild headache but reiterated that her main concern was the problem with her right eye.

Ms. P tested the patient’s vision. Visual acuity measured 20/30 in the left eye and 20/200 in the right. The patient reported that she had never needed glasses or any other vision correction. After making notes in the patient’s chart, Ms. P called in Dr. E, the clinic’s ophthalmologist. Dr. E conducted a thorough examination of the patient’s eyes and found that Mrs. D was suffering from a hemifield defect in her right eye and some slight abnormalities of the right optic nerve. He concluded that the symptoms were the result of dry eye syndrome and optic neuropathy; prescribed eyedrops; and advised the patient to return the next day, when a technician would be available to perform a visual-field test.

After Mrs. D left the examination room, Dr. E told Ms. P that although he believed the patient was suffering from dry eye, it was possible that her symptoms were attributable to a tumor. “If the drops haven’t helped by tomorrow, I’ll send her for a CT when she returns for the visual-field test.”

Ms. P glanced toward the retreating figures of Mrs. D and her husband and asked the doctor, “Should we send her now?”

“There’s no rush,” replied Dr. E. “It’s not an emergency at this point.”

The physician, however, was mistaken. Mrs. D suffered a fatal ruptured aneurysm early the next morning before she was able to return to the clinic for her follow-up appointment. She died as the ambulance was en route to her house.

A few days later, a clinic receptionist received a call from Mrs. D’s angry and distraught husband. Although Ms. P did not speak directly to the husband, she understood that he was furious at the doctor for not diagnosing the aneurysm in time to treat it. Ms. P wondered whether she should have pressed Dr. E to call the patient back for a CT scan. Should she have recognized Mrs. D’s symptoms as an emergency? She felt bad about what had happened, but there was a waiting room full of patients to see. She immersed herself in her work and tried not to think about Mrs. D.

Several months later, Mrs. D’s family sued both Dr. E and Ms. P for medical malpractice.

Ms. P met with the defense attorney assigned by her insurance company. In explaining the events that led to the lawsuit, she included the fact that she had questioned Dr. E about whether to send the patient for a CT scan immediately. The attorney told Ms. P that while he believed she would be exonerated if the case went to trial, he would not want to be the attorney representing the physician.

At the trial, Mrs. D’s husband and daughter described the anger and sadness they lived with every day, knowing that their loved one might have been saved had she been given proper medical attention. The plaintiffs’ attorney then called an emergency medicine physician to the stand. The physician testified that Mrs. D’s symptoms (headache and loss of vision in one eye) were signs of an emergency situation warranting an immediate CT scan and should have been recognized by the clinicians as such. The next witness was an ophthalmologist who stated that Mrs. D’s hemifield loss was a significant symptom that suggested pressure on the optic nerve; this would be a most dangerous diagnosis and should have been treated as an emergency. The expert also testified that dry eye syndrome would not result in vision loss and that the patient had been misdiagnosed by her ophthalmologist.

In their turn on the witness stand, the defense experts said that an aneurysm is extremely difficult to diagnose and that a few days of blurred vision and peripheral vision loss were more indicative of a slow-growing tumor that would not necessitate an emergency CT scan. The defense also argued that Mrs. D’s symptoms could have been caused by her pre-existing conditions, i.e., the HIV infection and vasculitis.

After three days of deliberation, the jury found Dr. E liable but exonerated Ms. P. Mrs. D’s family was awarded $1,500,000.

Legal background

To be successful in a medical malpractice case, the plaintiff has to prove that the clinician deviated from the standard of care which a practitioner in the same situation would provide. In this case, the jury determined that Dr. E had diverged from the standard of care introduced by the plaintiffs’ ophthalmologist. The plaintiffs’ attorney did not, however, introduce any evidence showing that Ms. P did anything different than any other NP would have done in that situation. Therefore, the jury did not find Ms. P liable. Ms. P examined the patient, noted the symptoms, and referred the patient to a physician for further examination. When she questioned the physician about the CT scan, she was told that it was unnecessary. There was no reason for her to believe that the physician was wrong.

Protecting yourself

Discerning when an emergency situation exists can be challenging. While the need for urgent action is sometimes obvious, many symptoms can occur in both harmless and emergency situations. Headache and vision problems can be associated with minor issues, yet they can also be signs of something requiring immediate attention. To further complicate the matter, patients are often unaware if symptoms indicate an emergency and might not show up at a clinic or hospital until it’s too late. Mrs. D waited a few days after her vision suddenly diminished before seeking medical help because she did not realize that sudden vision loss required urgent attention.

To determine whether a situation might be an emergency, question the patient very thoroughly and look at the symptoms as a whole. While headache and vision problems manifesting separately may be relatively benign, together they are more likely to indicate a serious situation.

Ms. Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.