Legal Review & Commentary

Improper IV leads to amputation

By Mark K. Delegal, Esq., and Jan Gorrie, Esq.
Pennington, Moore, Wilkinson, Bell & Dunbar, PA
Tallahassee, FL

News: A woman came to a Texas emergency room (ER) with an accelerated heart rate. An IV line to her right hand was placed into an artery rather than vein. Though the patient complained of discomfort, the IV remained improperly placed for long enough to cut off the arterial blood flow to her hand, ultimately resulting in the loss of her thumb and index finger. Prior to trial, the case was settled for an undisclosed amount.

Background: When the 56-year-old woman came to the emergency room for evaluation and treatment of a rapid heartbeat, ER personnel determined that she was suffering from supra ventricular tachycardia, and started her on Adenocard. The Adenocard was administered through an IV catheter placed in the patient’s left wrist near the base of her thumb. The IV site used was the treating nurse’s position of first choice for placing all IV’s regardless of the medication being administered.

Following the initial administration of the Adenocard, the patient complained of a burning sensation where the IV catheter had been placed and moved distally into her hand. Despite her complaints, emergency room personnel continued to use the IV catheter to administer additional intravenous medications, including another dose of Adenocard, as well as Nubain and Phenergan.

The nurse who inserted the IV used a tourniquet. However, it appears that she never palpated the site to determine if the vessel was a vein or artery, and it seems as though the nurse had placed the patient’s IV catheter into the dorsal branch of the radial artery instead of a vein. Later that day, the patient was discharged with pain medications for her hand.

By the next morning her thumb and index finger had turned black and blue. She returned to the same emergency room. In her evaluation, the ER nurse noted that it appeared as though the woman had dyed her two fingers. An ER physician sent her home without further treatment.

The following day, her condition had not changed and she went to another hospital’s emergency room. The hospital was larger and operated a trauma center. The ER nurse suspected that medications had been improperly administered. Both Nubain and particularly Phenergan are known to cause pain, severe chemical irritation, and significant spasm of distal arterial vessels, which can result in gangrene. The patient had developed gangrene in her thumb and index finger, which necessitated amputation of those two digits.

The plaintiff patient alleged negligence on the part of the emergency room personnel with respect to the initial placement of the IV catheter and more particularly the treating physicians’ and nurses’ failure to move the catheter after the patient repeatedly complained of pain at the site and distal radiating pain. The plaintiff also maintained that the hospital was negligent in simply discharging her with pain medications for her sore hand without first seeking an appropriate consultation to diagnose and treat the condition.

The defendant physicians, hospital, and hospital personnel denied that the injury was caused by administering Nubain or Phenergan, claiming instead that the loss of blood flow was caused by an unrelated blood clot or embolus. Under that scenario, the defendant physicians felt that they were not negligent in failing to diagnose that event or failing to undertake treatment for that condition.

Prior to trial, the case was settled with all defendants for a confidential amount. The second ER physician, though he was named in the case, did not have to pay anything based on testimony that while he failed to diagnose the condition, it was not reversible, and therefore his oversight did not cause additional harm.

What this means to you: "While those of us who work in health care recognize how busy an emergency department care be and are aware of the dynamics of that department, we must not forget that we are dealing with people, each with unique pain thresholds. Again, it seems that the patient’s self-reported pain was ignored. Listening to and evaluating what the patient has to say is important and should not be dismissed," says Leilani Kicklighter, assistant administrator, safety and risk management, North Broward Hospital District, Fort Lauderdale, FL.

Once again, the facts of this case lead to the need for proactive and, hopefully, preventive education and training.

"Specifically, the differentiation between a vein and an artery, the effect that certain medications have on the blood vessels, and how that impacts the decision of where to place an IV, as well as a review of the anatomy of the sites most usually selected to be used for IV insertion, are all essential components of an IV education course. For instance, in this case it may have been better to have placed the line at her elbow given the medications being administered," adds Kicklighter.

In addition to reviewing the role the nursing staff played in this case, the actions or inactions on the part of the emergency department physicians should be examined.

"Presumably, the continuing hand pain was brought to the attention of and evaluated by the emergency department physician prior to discharge on the day of the first admission. In view of the description of the fingers upon the return visit to the emergency department, it raises the question of the adequacy of not only the physical evaluation at triage but that of the physician. If the nurse determined and documented that there was a compromise to circulation or pulse it would seem that the situation would be more emergent.

"The nursing staff would have an obligation to question the treating physician as to the lack of treatment in the face of such apparent obvious compromise. If the response from the physician was not receptive, the nurse would have had an obligation to contact both the nursing supervisor and hospital risk management. In any event, an incident report should have been made out by the triage nurse who initially recognized the state of the fingers just 24 hours after discharge from the emergency department. The fact that the patient went to another emergency department the following day with a potentially emergent condition that had not been evaluated and stabilized is a potential EMTALA violation. This is another reason for an incident report to risk management." notes Kicklighter.

Another note on the emergency physicians is whether they were hospital employees or contract providers.

"If the emergency department physicians were contract providers, the risk manager should revisit the agreement to evaluate quality of care clauses, verify that the emergency department consent language reflects the contractual relationship, and make sure that there are signs in various locations throughout the emergency department that indicate the contractual relationship. In addition, the track record’ of the two physicians involved in this patient’s care should be examined in light of incident," Kicklighter says.

Zelma Shannon v. Martin G. Guerroero, MD, Carmelito Arkangel, Jr., MD; Judy White, RN; and Methodist Healthcare System of San Antonio, Ltd.; d/b/a San Antonio Community Hospital, Bexar County (TX) District Court, Case No. 98-CI-14760.