Death in the ED: Heart attack after two-hour wait termed 'homicide'
Death in the ED: Heart attack after two-hour wait termed 'homicide'
Fingers point at hospital, staff, and overtaxed emergency system
The death of a 49-year-old woman from a heart attack after waiting two hours to be seen in the emergency room of a Waukegan, IL, hospital has been ruled a homicide following a grand jury inquest. The grand jury's finding in September against Vista Medical Center East is believed to be the first of its kind, and state prosecutors were still weighing the evidence and their options in late October.
The July 28 death of Beatrice Vance is viewed as a wakeup call on a number of fronts:
Was there a violation of the Emergency Medical Treatment and Active Labor Act (EMTALA), brought on by inadequate triage and/or failure to reassess her condition during such a lengthy wait?
Was there discrimination based on race? (Vance was black.)
Does blame lie with the triage nurse, emergency department physicians, hospital protocol, or, as many medical bloggers have suggested, an overtaxed emergency medicine system?
The hospital is not commenting on the case, and the state attorney's office was still mulling the complexities of the grand jury inquest decision at presstime.
"We are looking into it, trying to determine what happened and what the facts are, and we'll review that before deciding how to proceed," says Daniel Shanes, a Lake County state's attorney's office prosecutor.
The inquest results also go to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Illinois Department of Public Health.
Under Illinois law, a coroner's inquest is a legal public inquiry into the manner of death. The coroner and six jurors sit in a quasi-judicial fashion, and medical, investigative, and legal evidence is presented to determine the manner and circumstances surrounding a death, including foul play, hazardous conditions, or death due to an unknown cause. An inquest is not a criminal or civil court proceeding, but an investigative and recommendation process.
Lake County Deputy Coroner Robert Barrett stated that his finding, following investigation of Vance's death, was that she died of a heart attack caused by a blocked artery, but that "delayed and inadequate treatment" contributed to her death.
Illinois does not have a statute recognizing negligent homicide as a criminal offense, says Shanes. Reckless homicide is an offense reserved only for deaths caused by motor vehicle accidents. The choices as to cause of death considered by the jurors were homicide, suicide, accidental death, and death due to undetermined causes.
In reaching its decision, the jury ruled that Vance's death, while directly attributed to a heart attack, was also the result of "gross deviations from the standard of care that a reasonable person would have exercised in this situation."
According to the coroner's investigation, Vance had waited almost two hours for a doctor to see her after complaining of classic heart attack symptoms — chest pains, nausea, and shortness of breath. The coroner found that the hospital follows two protocols for patients suspected of having heart attacks, from the American Heart Association and the American College of Cardiology, and that Vance's symptoms clearly fell into both.
The inquest jury also heard evidence of protocols, including recommendations that patients apparently suffering from a heart attack should be put on cardiac monitoring immediately and have an electrocardiogram done within 10 minutes of arrival at the hospital, neither of which was done in Vance's case, the coroner reported.
Shanes said the coroner's report sates that Vance arrived at the emergency room at 10:15 p.m. July 28 and was seen by a triage nurse at 10:28 p.m., who classified her condition as semi-emergent. Her daughter, a licensed practical nurse, was with her, and tried at least twice to have her mother seen by a physician; at 12:25 a.m., two hours after triage, an emergency room nurse called for Vance to be seen, but got no response. Vance was unconscious and pulseless, and efforts to resuscitate her failed.
The Illinois State Medical Society in October had no official comment on the Vance case other than their director of media relations, Laurie Peacock, reaffirming the belief that "patients deserve the care they need."
"We'll be monitoring the situation surrounding Beatrice Vance's death," Peacock added.
ACEP: Learning opportunity
The American College of Emergency Physicians (ACEP) says the case elicits questions about what emergency patients should do if their condition worsens while they are in the waiting room.
"First, my heart also goes out to the family of Beatrice Vance," says ACEP President Rick Blum, MD, FACEP. "Emergency physicians and nurses are dedicated to saving lives, and we treat more than 110 million patients each year."
Though Blum refrained from speculating about the facts surrounding Vance's death, he said emergency physicians "have been sounding an alarm for years about the growing crisis in our nation's emergency departments."
"We issued a national report card on the state of emergency medicine earlier this year [The National Report Card on the State of Emergency Medicine, available at www.acep.org, click on National Report Card], and the Institute of Medicine released three major reports in June about the fragmentation and lack of capacity to deal with day-to-day emergencies, let alone an act of terrorism," he said.
Blum points out that while patients with chest pains, stroke symptoms, or other life-threatening emergency go to the front of the line in an emergency department's triage process, sometimes patients come in with mild symptoms that worsen during their wait and should not hesitate to seek help from a nurse. However, Vance's daughter told investigators she tried repeatedly to alert nurses about her mother's worsening condition.
Blum also commented on a concern voiced by health care providers concerned with the ripple effect the homicide finding might have.
"[E]mergency physicians and nurses go into emergency medicine to save lives," he says. "To criminalize their efforts would be a terrible mistake and have a severe chilling effect on people going into the medical field."
Sources
For more information, contact:
- Laurie Peacock, director, media relations and officer outreach, Illinois State Medical Society/ISMIE Mutual. Phone: (312) 580-6497. E-mail: [email protected].
- Daniel B. Shanes, JD, chief of felony review, Felony Review Division, Lake County State's Attorney Office, 20 S. County Street, Waukegan, IL 60085. Phone: (847) 377-3025.
- Frederick C. Blum, MD, FACEP, president, American College of Emergency Physicians, 1125 Executive Circle, Irving, TX 75038. Phone: (800) 798-1822. E-mail: [email protected].
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