By Damian D. Capozzola, Esq.
The Law Offices of Damian D. Capozzola
Jamie Terrence, RN
President and Founder, Healthcare Risk Services
Former Director of Risk Management Services
California Hospital Medical Center
News: A 12-year-old girl was taken by ambulance to a hospital. She exhibited symptoms of hyperglycemia, abnormal respiration, and an accelerated heart rate. The physician in the emergency department treated her with insulin. Ten minutes later, the physician noted that the patient had acidemia (significant amounts of acid in the blood). He responded by placing the patient on an insulin drip. About 10 minutes after that, the blood test results indicated that the patient had high blood sugar, abnormally low sodium and chloride, and a high white blood cell count. The patient began to exhibit signs that fluid was collecting in a lung. The physician responded by having the patient prepped for insertion of a breathing tube. A CT scan indicated swelling and herniation of the patient’s brain, and her blood pressure abruptly dropped. The patient was taken by helicopter to the pediatric intensive care unit at a different hospital. As a result of her diabetic ketoacidosis (DKA), the patient remained in a coma until her parents decided to have her taken off life support. The girl’s parents sued the hospital and the treating physician. They argued that the treating physician had administered too much insulin, which they alleged caused the brain swelling. They also argued that the treating physician had failed to administer mannitol, which they claimed would have reduced the patient’s brain swelling. After a trial, the jury members found in favor of the physician and the hospital, and they concluded that the physician had not violated the standard of care.
Background: In 2008, a 12-year-old girl started complaining of nausea and vomiting. The girl’s mother contacted the girl’s pediatrician. The pediatrician believed that it was merely the stomach flu and told her to come in for an in-person evaluation if the symptoms grew worse. The girl was suffering from DKA. The girl had not exhibited signs of diabetes before, so she had not been undergoing any treatment for diabetes at the time. The next day, the girl exhibited severe symptoms, and the girl’s mother called for an ambulance. The girl was noted to have hyperglycemia (elevated blood sugar), abnormal respiration, and an accelerated heart rate.
At the hospital, the treating physician attempted to treat the hyperglycemia with insulin. Ten minutes later, the physician noted the presence of acidemia. He placed her on an insulin drip. About 20 minutes after the patient arrived at the hospital, blood tests indicated that the patient had high blood sugar, abnormally low sodium and chloride, and a high white blood cell count. The patient began to exhibit signs that fluid was collecting in a lung. The treating physician responded by having the patient prepped for insertion of a breathing tube. A CT scan indicated swelling and herniation of the patient’s brain, and her blood pressure abruptly dropped.
The decision then was made to have the patient taken by helicopter to the pediatric intensive care unit at a different hospital. At this time, the patient was not showing signs of headache, vomiting, incoherence, incontinence, or lethargy, which are symptoms that would have indicated brain swelling.
After arriving at the pediatric intensive care unit, the patient became comatose. She remained in a coma for two days, after which her parents decided to have her taken off life support.
In 2010, the girl’s parents sued the hospital and the treating physician. They argued that the treating physician negligently administered too much insulin, which they alleged caused the patient’s brain swelling. They also claimed that the hospital did not have hard copies of the appropriate resources that the physician needed to consult while treating the patient. The parents said that, as a result, the physician needed to consult the internet to look up options for treating the patient. Finally, the girl’s parents argued that the treating physician had failed to administer mannitol, which they claimed would have reduced the patient’s brain swelling.
The lawyers for the hospital and treating physician argued that the physician did provide the appropriate level of care, but that the patient’s DKA already had progressed too far for the physician to be able to save the patient. The lawyers for the hospital and treating physician also argued that the patient did not exhibit symptoms of brain swelling that would have put the treating physician on notice that he should administer mannitol. The lawyers for the defense thus argued that the treating physician fully complied with the standard of care applicable to a treating physician in an emergency department.
After a trial, the jury found in favor of the hospital and the treating physician. The jury concluded that the physician had not violated the standard of care in treating the patient.
What this means for you: This case is an example of how an expert can explain the standard of care that physicians are expected to follow while treating a patient. In a trial for medical malpractice, it is common for both parties to present experts discussing the appropriate level of care that a physician must follow and whether the treating physician met that standard of care. The issue of the standard of care played a particularly important role in this case, in which the experts discussed the standard of care for an emergency department physician. In some states, the plaintiff in a medical malpractice lawsuit will need to prove a higher level of recklessness for emergency department physicians than for other physicians. Healthcare practitioners should consult with legal counsel to be aware of the legal standards guiding their areas of practice and determine whether any special standards of care apply in their state. Healthcare practitioners should take steps to ensure that they are complying with that standard of care.
This case also illustrates the importance of not only being aware of the appropriate standard of care, but also taking steps to make a record that the healthcare practitioner is complying with that standard of care. In this case, for example, the lawyers for the hospital and treating physician used the medical entries for two purposes:
- to demonstrate all of the steps that the treating physician took to administer treatment to the patient;
- to set forth all of the patient’s symptoms to explain the treatment that the physician decided to administer.
In particular, the lawyers for the hospital and treating physician introduced evidence of the treating physician’s medical entries, which showed an absence of symptoms of brain swelling (headache, vomiting, incoherence, incontinence, and lethargy). This evidence helped to establish that the appropriate standard of care did not require an administration of mannitol, because the patient’s symptoms did not include these telltale signs of brain edema. When administering healthcare, therefore, it is important for a practitioner to keep diligent and thorough records of patients’ symptoms. These records later may be useful to explain the conclusions reached by the healthcare practitioner, as well as the decisions about what treatment to provide. These diligent and thorough records also can be useful to explain why the healthcare practitioner did not reach other conclusions and decided not to administer other treatments.
It is also critical that emergency medicine physicians gather as much information about their patients as possible. Families, friends, or whoever presents with the patient should be listened to. Without the benefit of knowledge of the patient’s medical history, emergency department doctors often must rely on what they see now without understanding what may have been going on 24 hours ago or even five years ago. Asking the right questions is essential. No symptom or complaint should be minimized. No patient’s feeling or concern should be ignored. Patients live in their bodies, and they know when something is not right. It’s up to the physicians to unravel the mysteries, get to the source of the problem, and try to fix it. Physicians get in trouble when they jump to conclusions without taking the time to obtain information, which happens more often than one would think.
The handoff between shifts is another risk factor. The off-going physician gives information to his or her relief. The incoming physician often takes that information and continues care based on it. The problem is that if that information is based on a poor history from the patient or family and the treatment plan is incorrect, the liability for any errors falls on both physicians.
Physicians have a responsibility to complete a full assessment when assuming care of a patient. Documenting that assessment based on the physician’s interpretation, and not based on what was documented by the previous physician, is essential. This practice is the expectation and will provide protection from liability if thoroughly done and documented.
Finally, this case may reflect how a change in technology can lead to a change in what is required under the applicable standard of care. In this case, the lawyers for the patient argued that the hospital was required to maintain hard copies of medical resources that the physician could consult during his treatment, under the applicable standard of care. The jury members disagreed, however. They were not persuaded that the hospital was negligent by not having hard copies on site; nor did they conclude that the physician violated his duty of care by looking up treatment options on the internet. It is unclear whether this same result would have been reached by another jury in a different jurisdiction (or even another jury in the same jurisdiction).
In any event, this case does indicate that it may be possible to use new and developing technologies to meet the applicable standard of care in ways that were not available previously. Healthcare practitioners should consult with counsel regarding the standard of care in their jurisdiction. They then should ensure that they have the necessary resources available to provide the appropriate treatment for patients. It takes a confident physician to know when additional resources are needed. Patient recovery is the objective, and using all available resources to achieve it safely and without causing harm is the goal.
Indian River County Circuit Court, Florida, Case No. 2010-CA-073141 (April 5, 2016).