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A 21-year-old college student arrived at a New York ED complaining of severe chest pain radiating to her arms. The patient’s respiration was impaired, and she was experiencing nausea and vomiting. The ECG was normal.
The young woman was sent home with a diagnosis of GI illness and anxiety, but the worrisome symptoms persisted. Several hours later, she called an ambulance and was brought back to the same ED. An ECG taken on the way to the ED showed severe abnormalities. The patient was evaluated by a cardiovascular nurse practitioner, who contacted the on-call cardiologist. “The patient had an MI and suffered severe heart damage necessitating a heart transplant,” says Paul D. Squire, JD, an attorney at Kaufman Borgeest & Ryan.
The physician assistant (PA) who performed the initial assessment was sued. The central focus of the lawsuit, which settled out of court, was that the PA did not consult with a cardiologist during the first ED visit.
“There was a long delay until that happened, and then it was too late,” Squire says. To mitigate risk of missed STEMI in the ED, Squire says two things are needed: “Better training to symptoms and early involvement with specialists.”
Involving cardiology in the STEMI decision-making process can be legally protective for EPs. “What ED practitioners need to be wary of is doing it halfway,” warns Frederick M. Cummings, JD, an attorney in the Phoenix office of Dickinson Wright.
Sometimes, EPs forgo formality and ask a cardiologist colleague if they can run something by him or her. The consultant does not see the patient or the medical records and hears only a verbal rundown from the EP. In this case, says Cummings, “you are probably getting an incomplete assessment that you probably cannot reasonably rely on.”
Additionally, the EP likely subjects the cardiologist to legal exposure. Depending on state law, the consultant engaging in an informal consult can be construed as assuming a duty of care. This is problematic since the consultant is making recommendations based on limited information, something plaintiff attorneys will point out quickly. If a formal consult including evaluation by the consultant does not happen, the consultant then points the finger at the EP. “When the case goes south, you can bet that there is something in the ED chart where the cardiologist says, ‘If I had only known that, my advice would have been different,’” Cummings offers.
The EP is vulnerable to a persuasive legal argument. “The plaintiff can say, ‘You did know enough to get somebody else involved, but didn’t know enough to get them involved like they should have been. You withheld vital information, maybe unknowingly,’” Cummings explains.
The EP defendant now faces two parties to the litigation placing blame: the patient or family and the codefendant cardiologist. “When the EP testifies about all the information conveyed to the cardiologist, the obvious question becomes, ‘Why didn’t you just ask the cardiologist to see the patient?’” Cummings says.
The plaintiff attorney also can ask the cardiologist a simple question to which he or she already knows the answer: “Would you agree that a bedside evaluation would have told you more than just a verbal report?”
“Every time, the cardiologist will tell you, ‘You bet,’” Cummings says. “There are no shortcuts.”
Financial Disclosure: Kay Ball, PhD, RN, CNOR, FAAN (Nurse Planner) is a consultant for Ethicon USA and Mobile Instrument Service and Repair. The following individuals disclose that they have no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study: Arthur R. Derse, MD, JD, FACEP (Physician Editor), Stacey Kusterbeck (Author), Jonathan Springston (Editor), Jesse Saffron (Editor), and Terrey L. Hatcher (Editorial Group Manager).