Legal Review & Commentary

Plaintiff Alleges Failure to Diagnose Cardiac Complication; Jury Verdict in Tennessee

by: Radha V. Bachman, Esq.

Buchanan, Ingersoll & Rooney, P.C.

Tampa, FL

NEWS: A man who had been out in his garden working complained to his wife of pain in his left arm. However, the pain did not subside after the man soaked his arm in warm water and applied an ice pack, and his wife drove him to the emergency department (ED) at a local hospital. The man was seen by a paramedic and a nurse practitioner and was diagnosed with a sprain due to overuse. The man was never seen by a physician while at the hospital. Less than two hours after leaving the hospital, the man collapsed and was found by his wife on the bathroom floor of their home. After arriving at the hospital, the man was pronounced dead of a myocardial infarction and sudden cardiac death. A jury verdict was entered against the hospital and was upheld on appeal.

BACKGROUND: After utilizing an ax and other large garden tools in his garden, a man who was obese and a heavy smoker began experiencing pain in his left arm. In an effort to alleviate the discomfort, the man applied an ice pack and soaked his arm in warm water. When the pain did not subside, the man's wife drove him to the ED for treatment. Upon arriving at the hospital, the man rested, while the woman filled out the necessary paperwork. The man was initially seen by a hospital paramedic, who took the man's vital signs. The man's wife claims to have informed this paramedic that the man was experiencing stomach discomfort, along with the pain in his left arm and wrist. The man's blood pressure was documented as 130/70, his pulse was 100, and his respiratory rate was 20. Following the triage evaluation, the man was seen by a hospital nurse practitioner, who ultimately diagnosed the man with a sprain due to overuse. Since no other cardiac-related symptoms were readily apparent, the nurse practitioner did not pursue a cardiac workup. No further questions regarding the man's medical history were asked by the nurse practitioner.

The man's presentation and symptoms were discussed with the ED physician, who concurred with the nurse practitioner's findings and signed the discharge order. The man was discharged with instructions to take an over-the-counter pain reliever, to ice his arm, and to rest his arm. He was never seen or evaluated by a physician.

Less than two hours later, the man's wife found the man unconscious on the floor of their bathroom. He was rushed to the hospital, and after several failed attempts, was pronounced dead of a myocardial infarction and sudden cardiac death. The man's wife brought a wrongful death action against the hospital and several other individual defendants.

The plaintiff alleged that the treatment provided in the emergency room fell below the standard of care in light of the fact that the man was never seen by a physician. The plaintiff contended that had the man been seen by both the nurse practitioner and a physician, the proper inquiries would have been made regarding the man's background and symptoms. Likewise, a physician would have noticed that the man was obese and was a heavy smoker with high cholesterol. The experts who testified on behalf of the plaintiff almost unilaterally agreed that the hospital failed to follow its own policy, which required that a physician see and examine every patient who presented at the ED. A jury found the hospital 100% liable for the death of the man.

WHAT THIS MEANS TO YOU: This patient presented to the emergency department (ED) with recognized cardiac risk factors, a history of smoking and obesity, and one of the classic signs of a myocardial infarction, i.e., radiating left arm pain. This left arm pain was not relieved by heat or cold, with an onset after heavy physical exertion. Another symptom, stomach discomfort, was allegedly communicated by the wife to the triage paramedic upon arrival at the hospital, but not documented or relayed to the ED staff.

Several issues come to the forefront that the risk manager should investigate, evaluate, and address. Upon this first visit, the established policy that all patients presenting to the ED be seen by a physician before discharge was not followed. It does not appear that the nurse practitioner or the paramedic even considered the potential that this patient, obviously obese and with a history of heavy smoking, two cardiac risk factors, was suffering an MI or other cardiac emergency. No EKG or blood work was drawn as part of the evaluation to rule out a cardiac diagnosis. The nurse practitioner discussed the patient with the physician, but there is no evidence regarding the content of the conversation. Other pertinent information in this regard would be whether the conversation was in person, so the physician could review the record, or a phone conversation. How distracted the physician was during this conversation may have played a role in the physician's response or lack of response. However, in view of the policy that the patient should have been seen by the physician before discharge, these questions are non-issues. Enforcement of established polices needs to be re-emphasized to all medical and nursing staff. A final review of the record by the discharging nurse to verify the patient has been seen by a physician can assist in compliance with this policy.

This patient was readmitted to the same hospital, where he ultimately expired. This event should have been called to the risk manager as an incident report written and sent to risk management. Since the patient had been working in his garden, it can be presumed it was during the day, and the risk manager was still in the hospital if it was not a weekend — or was available by phone, if not on site. In addition to having a copy of the medical records of both admissions to the ED made and sent to risk management, statements of the staff involved should be taken or obtained immediately by risk management. The original record should be sequestered according to the risk management policy. Depending on the state laws and claim management/handling procedures in this state and hospital, how the initial statements are obtained should follow those guidelines.

Misdiagnosis or missed diagnosis of myocardial infarction (MI) is a known emergency medicine risk. A great deal of focus has been put on this issue, and many hospital EDs have implemented the standards, applied for, and received recognition as a Cardiac Center of Excellence. Protocols have been developed for evaluating patients who present with signs and symptoms of impending MI.

The risk manager should initiate a root cause analysis (RCA) to determine the deviations from accepted practice and why they happened. After determining both the root cause and the derivative issues, risk management should collaborate with staff to develop policies, procedures, protocols, and education to facilitate practices to comply. Practice should follow policy and procedures, and policies and procedures should reflect practices. Failure to comply with established policy, procedures, and protocols should be addressed by risk management.

In this case, the information given by the wife to the triage paramedic regarding the stomach upset may have been important additional information that — taken into context with the other signs and symptoms — may have caused the nurse practitioner or the physician to make a different diagnosis, or at least look more at the cardiac potential than just a sprain. This symptom was not documented on the triage record nor in the ED record, so there is no way to know if it was communicated to the nurse practitioner. This raises the issue of full documentation of all signs and symptoms, no matter how insignificant they may seem at the time.

The practice of utilizing a paramedic as the triage person should be revisited. The usual practice is to have this function performed by an RN. The nurse practice act in many states does not allow a Licensed Practical Nurse (LPN/LVN) to do patient assessments. Paramedics in the field may do physical assessments and follow doctor's orders or protocols for emergency treatment. Depending on the state, paramedics may not be allowed to do patient assessments as a staff member of an ED. This should be researched and addressed based on state laws and regulations.

A review of all ED triage and other standing protocols should be undertaken to verify that they meet current medical and emergency medicine standards.

In addition, as a part of the annual staff competency evaluations, the risk manager should work with the ED nursing management and medical staff to develop competency assessment tools that address signs and symptoms of common and high-risk conditions and differential diagnoses that frequently present to an ED — and in particular this hospital's ED. Part of the competency evaluation of the ED nursing staff is appraisal of physical assessment as well.


Supreme Court of Tennessee, No. M2006-01214-SC-R11-CV.