Six days later, the man was found dead at home. An autopsy revealed aortic dissection as the cause of death.
Plaintiff for the decedent claimed that Dr. M. failed to perform a proper history and physical examination, which would have revealed the signs and symptoms described by the decedent’s co-workers. It was undisputed that the co-workers’ description of the decedent’s condition at work was suggestive of aortic dissection. The plaintiff claimed that CT should have been ordered, with results indicating surgery; this would likely have prevented the man’s death. The plaintiff also claimed that the decedent’s abnormal ECG results should have prompted hospital admission and an inpatient cardiac work-up.
The defendant claimed that the decedent never reported the severe and dramatic symptoms described by his co-workers, to the paramedics, the triage nurse, or the emergency physician. Dr. M. further maintained that a proper history and physical examination were performed, that proper studies were conducted and appropriate medications provided, and that the decedent was properly discharged in an improved condition.
OUTCOME
The defendant hospital settled for $75,000 before trial. According to a published account, a defense verdict was returned, although an earlier trial in the case had ended in a $3.7 million verdict.
COMMENT
A history of abdominal pain and hypertension makes aortic dissection a diagnostic possibility, but it is unclear whether aortic dissection was considered as part of the differential diagnosis. The sudden onset and severe nature of the pain were clues, but controversy arose over whether this presentation was conveyed to the prehospital responders, the triage nurse, and/or the emergency physician.
This case was apparently retried following a substantial $3.7 million verdict, with the second result being quite different: a $75,000 settlement from the hospital and a defense verdict. It is unclear why the case was retried.
There are a few noteworthy points in this case. First, there was a disconnect between the description of the patient’s presentation given by his co-workers and the content of the EMS, nursing, and physician notes. The co-workers described sudden onset of severe pain, resulting in the patient crying and writhing on the floor; the triage nurse characterized the pain as abdominal “cramping” in quality, with the physician noting the patient’s description as “moderate” in intensity—a substantial difference. Whenever possible, attempt to elicit history from different sources and document each source of the information. In this case, more than likely the patient’s original presentation was not clearly communicated by the patient or by his co-workers to any of the treatment providers—the EMTs, the triage nurses and other hospital personnel, and the emergency physician.
Second, use of a “GI cocktail” as a diagnostic test to distinguish between gastrointestinal (GI) and non-GI causes of abdominal or chest pain can be problematic. The composition of the GI cocktail is generally antacid, viscous lidocaine, and an anticholinergic agent. Here, after consuming the GI cocktail, the patient said he felt better—perhaps falsely suggesting a gastrointestinal source of pain. While the use of a GI cocktail may provide symptomatic relief in certain circumstances, there is inadequate evidence to support making diagnostic decisions based on a patient’s response to it. So don’t.
Third, EDs are often overcrowded and chaotically busy. Such conditions can result in an overburdened staff, with clinicians feeling they did the best they could in an extremely difficult environment. Some clinicians have remarked they would like the jury to see “how the ED was that day”—to explain the pressure, the pace, and the other dire and pressing patient needs. But the malpractice plaintiff wants the jury to see “how the ED was that day,” too—to support the conclusion that the patient was not given the proper time, attention, and care that his or her condition warranted. Here, the plaintiff’s co-workers were willing to testify that the patient was “kept in the hallway,” that the department was “very busy,” and the personnel did not “pay much attention” to the patient—all to support the conclusion that the care was substandard.
While I can’t offer any breakthrough suggestions to cure the problem of ED overcrowding, I can recommend that clinicians do their best to make sure patients roomed in unconventional locations (such as the hallway) receive full attention and requisite concern so that they do not feel (or are not perceived as) neglected. A patient who has been placed in the hallway is still a patient in the hospital under your care. It goes without saying that a clinician should never form diagnostic or treatment impressions by virtue of where a patient is being examined: When a patient in the hallway is discovered to be acutely ill, immediate steps must be taken to re-room that patient. —DML