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****************************************************** This Case Review May Be Cited As: Lopez, Andrew M. October 22, 2000. Trauma Patient, In Shock And In Decline, ER Physician Does Not Transfer. Clinical Case of The Week. Retrieved (insert date) from the World Wide Web: http://www.nursefriendly.com/nursing/clinical.cases/2000/102200.htm ******************************************************
Summary: When a patient from a trauma scene arrives at the hospital, initial assessments and evaluations are critical. In this case, a patient involved in a Motor Vehicle Accident was brought in with symptoms indicative of Shock. On evaluation the decision was made to treat the patient on site. The patient then would die soon after admission. Should the ER physician have transferred her? The female patient was transported to the hospital via ambulance following a motor vehicle accident. "Motor vehicles accidents account for more deaths than all natural disasters combined. In fact in the United States your chances of being injured in an motor vehicle accident is better than one in a thousand, in any one year. If you are a male, than you are twice as likely to die in a motor vehicle accident than if you are a female. Yet, if you are a female you are slightly more likely to be injured. The ages of 16 and 24 are the most dangerous for both sexes."2 The facility she was brought to was a Rural Hospital and not well equipped to deal with trauma emergencies. The attending ER physician was a second year Pediatric resident, perhaps not the most desirable candidate to handle this type of patient. Her initial physical symptoms of cold/clammy skin and falling blood pressure 95/55 on arrival were later opined to be highly indicative of shock. "Shock is caused by any condition that dangerously reduces blood flow, including heart problems (such as acute MI or heart failure ), changes in blood vessels, changes in blood volume, and injuries. Related factors include bleeding , vomiting , diarrhea , inadequate fluid intake ( fluid imbalance ), and kidney disorders. Types of shock include anaphylactic shock (caused by allergic reaction ), bacteremia or septic shock (associated with infections), cardiogenic shock (associated with heart disorders), diabetic shock ( diabetic hyperglycemic hyperosmolar coma ), electric shock , hypovolemic shock (caused by inadequate blood volume), and neurogenic shock (caused by damage to the nervous system). Shock is a life-threatening condition that requires immediate medical treatment. Some degree of shock can accompany any medical emergency. Shock can get worse very rapidly. Be prepared to begin rescue breathing or CPR as needed."3 The attending physician ordered intravenous fluids at a rate of 200/cc per hour, X-rays were ordered and performed and attempts to stabilize the patient initiated. Despite the efforts of the ER Physician and Nursing Staff, the patient would code three hours following her admission, attempts to resuscitate the patient were not successful. An autopsy on the patient’s body identified "Treatable Shock" as the most likely cause of death. The family would bring suit against the driver of the other vehicle involved, the ER physician and the Hospital/Nursing Staff. The court found for the plaintiff and ruled that the attending physician was not, in fact qualified to treat a patient in the condition the patient had been in. A ruling was handed down and responsibility assigned at 10% to the physician and 90% to the Hospital/Nursing Staff. An award of $900,000 was reduced to $500,000 pursuant to a statutory cap. The hospital would appeal. Questions to be answered.
Expert witnesess testifying at the trial would examine the documentation including initial assessments by both the Medical/Nursing staff and the test results from the labs/x-ray performed. They stated that the initial presentation of the woman was strongly indicative of shock and would require treatment that the Rural facility simply was not equipped to offer. Upon completion of the initial assessments, immediate arrangements for transfer to a Trauma Center would have been justified and prudent. The evidence to justify the patient’s transfer was overwhelming when examined by an Emergency Medicine Physician/Expert Witness. It was then revealed that the hospital had no policies or procedures in place for transfers to larger facilities. Trauma patients such as the young woman in question were not frequent, common or expected at this facility. The decision to transfer the patient would have been based on the patient’s presentation which was strongly indicative of a trauma case the physician/facility could not safely handle. The decision to transfer the patient was laid squarely in the lap of the attending physician who did not give the order. Testimony and documentation from the chart would reveal that the nursing staff discussed transferring the patient with the physician at the time. The nursing staff in addition to the symptomatology indicating shock, told the physician the patient had active vaginal bleeding of unknown origin. The expert testimony both Nursing/Physician indicated that the decision to transfer was for the physician to make. It should be noted here that a healthcare or medical professional owes a clearly defined duty to the patients they accept into their responsibility. Standards of Care dictate the level of services that will be provided. This is clearly defined in Nurse Practice Acts and Medical Licensure guidelines. If, as in this case, safe and competent care cannot be given, that duty mandates that care of the patient be transferred to a more qualified practitioner or facility that can give adequate care. If this is not done, the applicable standards of care are then breached and possible claims of negligence may result. If the physician in this situation would not arrange for the transfer of the patient, it was the responsibility of the Hospital/Nursing Staff to inform the on duty supervisors and administrators of the situation. Had this been done, and had the record shown that the Administrative/Nursing/Hospital staff were aware and recommended that the patient be transferred, the assignment of responsibility would have shifted from the hospital to the individual physician. Based on the testimony of the Nursing staff documenting the need for transfer and it’s discussion of same with the physician, the appeals court shifted responsibility from 90% of hospital to 75% and increased the physician’s liability from 10% to 25% based on the evidence. It would be interesting to examine in more detail the results of the X-rays and test performed at the time. They may have given a better picture of what was happening at the time and were not available at the time of this review. Related Link Sections: Cardiopulmonary Resuscitation, CPR Clinical Charting and Documentation, Nurses Notes: http://www.nursefriendly.com/nursing/directpatientcare/clinical.documentation.nurses.notes.htm Courtroom Directory (National): http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/courtrooms.online.htm Direct Patient Care Links on: The Nurse Friendly: http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm Emergency Department Humor: http://www.nursefriendly.com/nursing/humor/erhumor.htm Ethics: http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm Medical Legal Consulting Nurse Entrepreneurs: http://www.legalnursingconsultant.org Related Cases: February 16, 2000 Nurse Advises "Reconsider Choice of Physicians" An Nurse's Ethical Dilemma. In this case the nurse providing patient care noted a decline in the patient's condition, evidenced by weight loss, hallucinations, psychiatric symptoms, and acute distress. The findings were documented and attempts were made to contact the attending physician. The attending physician, however, failed to return any of telephone messages. Deerman v. Beverly California Corp., 518 S.E.2d 804 - NC (1999) http://www.nursefriendly.com/nursing/clinical.cases/2000/021600.htm October 3, 1999: Grand Mal Seizure Follows Cervical Myelogram, Anticipated Risk or Nursing Negligence? Cascio v. St. Joseph Hosp., 734 So.2d 1099 - FL (1999) Summary: With a proper Informed Consent obtained, it is accepted that a patient is aware of potential risks & complications prior to a procedure. In this case, following a cervical myelogram, a patient developed seizures and suffered an injury. The physician would blame the nursing staff for causing an "increased risk" by not following procedures. http://www.nursefriendly.com/nursing/clinical.cases/100399.htm August 29, 1999: Surgeon "Loses Clamp" Behind Patient's Heart During Bypass. Nurse's Responsibility To Pick Up? Summary: During any surgical operation, there is an inherent "duty" owed to the patient that the operation will be carried out competently. This includes carrying out specified procedures and taking measures to prevent "foreign" objects from being left in the body cavity. In this case, during a coronary artery bypass grafting, a clamp slipped from the surgeon's sight. It would be found on x-ray later sitting behind the patient's heart. http://www.nursefriendly.com/nursing/clinical.cases/082999.htm Sources:
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Last updated by Andrew Lopez, RN on March 23, 2017
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