News: A man presented to a physician several times for the treatment of pain in both shoulders. He received medications that failed to alleviate his pain. One morning, the patient called the health center that prescribed the medications and informed the receptionist that he was experiencing shoulder pain and requested an appointment, which was scheduled for 45 minutes thereafter.

While being driven to the health center, the patient experienced shortness of breath and suffered a heart attack. Fortunately, his nephew was driving and was able to pull over and call 911. The patient passed away shortly thereafter. His sister brought suit on behalf of the man’s estate against the physician and the hospital. The plaintiff and the physician settled, but the case against the hospital proceeded to trial, where the jury found in favor of the hospital.

Background: In May 2014, a 52-year-old security guard presented to a family medicine physician at a health center for treatment of bilateral shoulder pain. The physician performed a normal examination, diagnosed musculoskeletal pain, and prescribed pain medications. A few days later, the patient returned to the health center with continued pain and increased pain in his left shoulder. The patient told the physician that the medications failed to reduce the pain, and the physician prescribed different pain medication. The physician also told the patient to apply heat to his left shoulder and to return if needed.

Three days later, the patient called the health center and requested an appointment for further treatment of shoulder pain; an appointment was scheduled for 45 minutes later. As the man felt he was unable to drive safely, his nephew drove him to the medical center. During the drive, the patient experienced shortness of breath and chest pain, and the nephew pulled over to call 911. The patient lost consciousness and was transported by ambulance to a hospital. Resuscitation efforts were unsuccessful, and he was pronounced dead as a result of a myocardial infarction.

The man’s estate, represented by his sister, sued the physician, alleging that he failed to diagnose a cardiac-related issue when he saw the patient. The estate also sued the health center, claiming that the receptionist failed to refer the patient to emergency services. The patient’s nephew also filed suit against the physician, alleging negligent infliction of emotional distress. The plaintiffs settled with the physician, and the case against the health center proceeded to trial.

At trial, the estate’s expert in family medicine opined that when a patient calls a medical practice complaining of unexplained arm pain, even if the symptom is generic, the staff taking the call has a responsibility to elicit additional information. The estate argued that the receptionist should have inquired as to which arm was painful and if he had other symptoms. If she was uncertain whether he needed to be seen by a health center physician or present to an ED, she should have transferred the call to a nurse qualified to make that determination. The expert concluded that the receptionist’s failure to ask follow-up questions, or in the alternative direct the man to call 911, breached the standard of care.

Defense counsel maintained that the receptionist did not breach the standard of care. The receptionist, who had worked in previous hospital and medical settings, testified that if she had sensed the man was in distress or was experiencing a medical emergency, she would have directed him to call 911. She further testified that it was her usual practice to type into the office telephone log a patient’s complaints, which in this case simply read “arm pain.” The receptionist testified that the man’s demeanor and the symptoms he described led her to believe it was appropriate to schedule an appointment with a health center physician.

The defense’s internal medicine expert opined that the receptionist’s conduct, without knowing the patient’s background other than his arm pain, did not fall below the standard of care. The defense also cited the patient’s 2009 records that indicated that he was a heavy, longtime cigarette smoker, and that the physician instructed him to stop smoking. In 2014, he was still smoking; moreover, he had not undergone any medical evaluations during that five-year period.

The jury returned a verdict in favor of the defense after a four-day trial.

What this means to you: This case illustrates the importance of providing adequate training for nonmedical personnel in healthcare facilities. To the extent an employee has contact with a patient, that employee must have basic training to evaluate the urgency of a patient’s symptoms. As the receptionist testified in this case, if she had sensed the man was in distress or was experiencing a medical emergency, she would have directed him to call 911. In part, her experience with hospitals and medical settings helped prevent liability for the health center.

Hospitals and other healthcare facilities should similarly be trained to be wary of patient conditions and symptoms so as to avoid unnecessary malpractice suits. The patient’s estate here argued that the receptionist should have inquired further as to the patient’s status, given his stated arm pain. Most physicians’ offices, urgent care centers, and even hospital EDs are staffed with medical assistants who have basic training in simple procedures. These staff members may also function as receptionists greeting patients, answering phones, and scheduling appointments.

What is essential is that individuals can recognize what they do not know and when to elevate the patient’s concerns to a nurse, physician, or another individual better qualified to assist. No matter who is interacting with the patient, the critical question that must be asked of all callers is whether he or she is experiencing an emergency.

A safe response is to tell callers to call 911 or go to the nearest ED if they need to be seen right away. Another option is to ask the caller to speak to a licensed nurse if one is readily available. In general, diagnosing a patient over the phone is problematic, even for a physician. Nevertheless, patients do call and may express concerns about their symptoms, so care providers must be prepared for this eventuality and be able to calmly respond and advise patients to seek emergency care when appropriate.

Similarly, healthcare facilities without EDs should implement procedures to deal with patient emergencies. The foundation of such procedures should include a duty to inquire into patients’ symptoms. In a situation where a patient appears to require emergency medical attention, staff members should be instructed to contact 911 promptly and prepare for an immediate transfer to a nearby hospital. Coordination with hospitals is essential for smooth patient transitions. Healthcare facilities should foster relationships with nearby hospitals and train medical personnel accordingly.

The patient in this case suffered from a myocardial infarction, which is a common and well-understood urgent medical condition. With a condition such as this, the symptoms (chest tightness, shortness of breath, chest or arm pain, etc.) are generally known, and care providers must be trained to recognize them — and to promptly act. Once diagnosed, treatment of myocardial infarctions commonly involves an angioplasty, which breaks up the blockage preventing adequate blood flow.

Other treatments may include the use of stents or coronary artery bypass grafts. Medications also can be used to assist with treatment of heart attacks, including blood thinners, thrombolytics, antiplatelet drugs, nitroglycerin, beta-blockers, ACE inhibitors, and pain relievers.

While the man in this case did suffer from a serious and emergent condition, the jury determined that the care provider was not liable based on the limited information provided by the patient and the provider’s appropriate response.

REFERENCE

Decided on May 29, 2018, in the Lancaster County Court of Common Pleas; case number CI-15-398.