Ms. V disliked working the night shift in the busy emergency department (ED) of a regional medical center, but the policy was that shifts had to be varied. The nurse practitioner found the nights to be either very slow and boring or unbelievably busy. As soon as she walked in at 8:00 pm on that April evening to start her 14-hour shift, Ms. V knew it was going to be one of the busy nights.
Ms. V saw five patients in the first hour before she was assigned to Mrs. J’s case. Mrs. J was a 39-year-old mother of two who had been in the middle of a family vacation when she became ill. The family was on a car trip from another state when Mrs. J began feeling increasingly nauseated and started experiencing chills. She took acetaminophen, thinking it was a fever, but she did not improve. After another hour in the car, the family decided it was time to find a hospital.
The triage nurse in the ED noted that Mrs. J’s BP was 111/68 mm Hg, her heart rate was 163 beats per minute, her temperature was 102°F, and she reported her pain as being a 9 out of 10. Mrs. J’s medical history included thyroid disease, Hodgkin disease, and migraine headaches. Her surgical history included an appendectomy, a lumpectomy, and exploratory spleen removal.
Ms. V was assigned to the case and went in to see the patient for the first time at 9:00 pm. She reviewed the triage nurse’s report and then spoke to the patient.
“Your heart rate is quite high,” said Ms. V.
“Yes,” replied Mrs. J, “It usually runs high when I’m sick. Do you think I will be here long? We are on our vacation, and I hate to spend any part of it in the hospital. My children will be very disappointed.”
Ms. V chatted with the patient about her two young children—a boy and a girl—until the emergency physician, Dr. P, arrived. He ordered routine lab work, including blood and urine samples, blood cultures, a chest x-ray, and an ECG. The blood work was initially negative for bacteria, but Mrs. J’s WBC count was 14,000 cells/µL.
Dr. P, concerned that the patient might have meningitis, conducted a lumbar puncture, which revealed clear spinal fluid. The physician ruled out bacterial meningitis.
Over the next several hours, Ms. V attended to the patient, who was given ibuprofen to reduce her fever, ondansetron (Zofran, Zuplenz) for nausea, and meperidine (Demerol) and lorazepam (Ativan) for pain. At 1:30 am, Dr. P noted a differential diagnosis of viral infection, bacterial infection, upper respiratory infection, urinary tract infection, and viral meningitis, and ordered that the patient be discharged.
An hour later, Ms. V noticed that Mrs. J’s heart rate was up to 155 and BP was 115/75. She mentioned the elevated heart rate to the patient’s husband and Dr. P but did not note it on the chart. Dr. P ordered metoprolol (Lopressor, Toprol) to lower the heart rate. By 3:00 am, Mrs. J’s heart rate was down to 133 and her BP was 87/52, and Dr. P finalized her discharge from the hospital. Mrs. J and her husband were instructed to return to the ED if symptoms worsened or didn’t improve. Ms. V wished her patient well, and advised her to enjoy the rest of her vacation.
By 9:00 am the next day, Ms. V was looking forward to going home and getting some sleep. Her thoughts of sleep evaporated, however, when an ambulance pulled up bearing Mrs. J, who was in obvious distress. As the physician began intubating her, Ms. V quickly got a history from the patient’s husband. According to Mr. J, when they returned to the hotel, Mrs. J was tired and groggy and fell asleep. But a few hours later she woke up not feeling well and suffering from stomach cramps and chills. Her husband thought she had a fever and gave her ibuprofen, which had worked earlier. He fell asleep, and was awakened later by his wife moaning in pain. He noticed that her bottom lip was discolored and he called 911.
Later, despite the best efforts of emergency personnel, Mrs. J coded and was pronounced dead. The cause of death was later determined to be septic shock due to acute bilateral adrenal hemorrhage.
Ms. V was informed that she and Dr. P were being sued for medical malpractice.
At trial, the plaintiffs alleged that Dr. P did not meet the standard of care because although he ordered metoprolol to lower Mrs. J’s heart rate prior to discharge, he did not address the cause of the tachycardia, which was indicative of sepsis. The plaintiffs argued that Ms. V was negligent for failing to document the elevated heart rate on discharge, for failing to voice concerns or advocate for the patient, and for failing to point out to Dr. P that the plaintiff had had her spleen removed, thus putting her at higher risk for sepsis.
During testimony, Dr. P admitted that he failed to determine that Mrs. J did not have a spleen, and that an untreated bacterial infection in a patient with no spleen could be catastrophic. On cross examination, he testified that had he known about the splenectomy, he would have admitted Mrs. J and immediately administered antibiotics. After several days of testimony by experts on both sides, the jury deliberated for three hours and returned a verdict for the plaintiffs in the amount of $1.2 million. The jury found Dr. P 60% at fault and Ms. V 40% at fault.
To convict a clinician of medical malpractice, a jury must find a breach of standard of care, and that the breach was the cause of the harm. In this case, the defense’s argument was that the patient’s death was not caused by the clinicians’ breach of duty, but rather that the patient’s chances of survival were so poor by the time she came in that she likely would have died regardless.
Because the defendants were arguing that their breach was not the cause of death, they both admitted the breach in duty, which was not advocating for the patient or reading the patient’s chart well enough to know that she did not have a spleen. When their lack-of-causation argument failed to move the jury, their defense fell apart.
Ms. V did not act as an advocate for her patient. Taking notes, especially in a case where there are abnormal vital readings at the time of discharge, is essential. But even more essential than chart notating is making sure that all practitioners involved are aware of anything that might impact the patient’s care.
In this case, Ms. V should have pointed out to the physician that Mrs. J had no spleen and thus was at risk for sepsis. Had this been brought to the forefront, the patient’s abnormal heart rate and fever would have been understood in context, and might have led to the proper diagnosis.
Being an advocate means being familiar with everything in the patient’s chart, and being willing to voice concerns when necessary. Ms. V did not point out to the physician that the patient had had a splenectomy. Dr. P did not read the chart thoroughly enough to see that information himself. And because of those oversights, Mrs. V did not receive the antibiotics that might have saved her life.
Ann Latner, JD, is a former criminal defense attorney and a freelance medical writer based in Port Washington, N.Y.