Approximately 12 hours after discharge, the patient presented back to the ED via ambulance. At that time, she was hypotensive and tachypneic, with a thready palpable pulse. On repeat examination, she no longer had pulses present in her feet. An arteriogram found complete occlusion of her arterial circulation at the level of the knees bilaterally, requiring bilateral belowthe- knee amputation.
The patient sued both the emergency medicine physician and the PA for failure to provide her with the necessary care during her initial ED visit, resulting in loss of limbs. The defendants claimed the patient could not prove gross negligence by clear and convincing evidence, as required by state law. Following the ensuing trial, the jury returned a $5 million verdict in favor of the plaintiff.
Discussion
First, it is important to remember that just because a patient has been triaged to a low-acuity area does not mean she or he must have a minor problem. The provider still must maintain a high level of vigilance— regardless of the location of the patient in the ED.
Second, was this patient in atrial fibrillation, which is responsible in approximately 65% of all peripheral emboli? The abrupt onset of this patient’s symptoms is much more compatible with an embolic origin of her symptoms rather than a thrombus (ie, symptoms of claudication).
Lastly, a diagnosis of cellulitis is inconsistent with the physical findings of the PA, as well as those of the triage nurse and paramedics. This patient’s feet were cool to the touch whereas cellulitis presents with erythema and increased warmth. While the presence of pulses was somewhat reassuring, the cool temperature of the feet and complaint of pain were indicators of the need to evaluate for a possible arterial origin of these findings. However, if this were an embolic phenomenon, peripheral arterial ultrasound would have probably been normal, and the outcome unchanged.
Case 3: Failure to Communicate
A 59-year-old man presented to his primary care physician (PCP) for intermittent right-hand weakness and numbness and tingling in his right arm during the previous 24 hours. As the PCP was concerned that the patient might be experiencing a transient ischemic attack (TIA), the patient and his wife were instructed to go directly to the ED of the local hospital. The PCP wrote a note stating that the patient needed “a stroke work up,” gave the note to the patient, and told him to give it to the ED staff.
The patient went directly to the ED and was immediately seen by a “rapid triage nurse.” He gave the note to the nurse and told her of the PCP’s concerns. The nurse documented on the hospital assessment form that the patient was high priority and needed to be seen immediately. She attached the PCP’s note to the front of the form.
The patient was then seen by the traditional triage nurse. After evaluation, she changed the priority from high to low acuity. The triage nurse later stated later that she never saw the PCP’s note, nor did she obtain any history regarding the concerns of the PCP.
The patient was then evaluated by an EP in the low-acuity (or minor-care) area of the ED. The EP later stated that he never saw the note from the PCP, and had not received any information regarding a suspected TIA or stroke. The EP ordered a right wrist X-ray, diagnosed carpel tunnel syndrome, and prescribed an anti-inflammatory medication as well as follow-up with a hand surgeon.
The initial (rapid triage) nurse saw the patient leaving the ED at the time of discharge and thought he had not been in the ED long enough to have undergone a stroke work up. She reviewed his paperwork and saw the patient had not received the indicated work up. The nurse called the patient’s house and left a message on the answering machine notifying him of the need to return to the ED. The patient arrived back to the ED approximately 2 hours later.
On the second ED presentation that day, the patient was evaluated by a different EP. The patient had blood drawn, an electrocardiogram, and a noncontrast computed tomography scan of the brain, the results of which were all normal. The EP concluded the patient required admission to the hospital for additional work up (eg, carotid Doppler ultrasound). The hospitalist was paged, and told the EP he would be there “as soon as possible.” However, after several hours delay, and no hospitalist, the patient became impatient and expressed the desire to go home. The EP urged the patient to follow up with his PCP in the morning to complete the evaluation.