Methodist Hospital case involve nurse conclusions
Methodist Hospital v. German is a Texas malpractice case that questioned whether nurses should be expected to draw medical conclusions from their observations, in addition to passing them on to physicians.
John German, then a 32-year-old mechanic, was admitted to The Methodist Hospital in Houston, TX, for surgery to correct a congenital heart defect. During the surgery, Mahesh Ramchandani, MD, committed a serious error by puncturing German’s healthy mitral valve, according to the court’s written opinion. The puncture resulted in a condition known as acute mitral valve regurgitation, which caused blood to flow backward through the heart and which would have been fatal if left untreated.
Ramchandani attempted to repair the valve during this surgery by suturing it, but a variety of serious medical conditions over the following two days indicated that the attempted repair was not successful. Over eight days beginning with his original surgery, German experienced, among other things, cardiac distress, multi-system organ failure, life-threatening bleeding, and low blood pressure. He required multiple blood transfusions, prompting the doctors to artificially elevate his blood pressure through the use of drugs known as vasopressors. German also experienced a significant decline in his blood platelet count, weak pulses, and other signs of blood clotting in his extremities.
At trial, German’s expert witness testified that these symptoms could indicate a rare adverse reaction to heparin called heparin-induced thrombocytopenia (HIT). But German’s expert conceded that these symptoms were also consistent with the numerous surgical interventions and medications that had been administered, and some of German’s doctors testified that at the time of treatment they believed the symptoms were caused by factors other than HIT.
The treating doctors testified without contradiction at trial that German would have died without these surgical interventions. Unfortunately, the doctors could not restore circulation to his extremities, and German later underwent surgery to amputate his left leg above the knee, all of his fingers, and part of his right foot, along with the toes.
German filed a medical malpractice lawsuit against his treating physicians and Methodist. He settled all of his claims against the doctors, and he proceeded to trial solely against Methodist on a theory that he had HIT, that it was preventable, and that the negligent failure to prevent it resulted in his amputations. German alleged that Methodist was liable for the negligence of its cardiovascular ICU nurses who failed to recognize the signs and symptoms of HIT and failed to alert the doctors to these conditions. In addition, German alleged that Methodist negligently failed to train its cardiovascular ICU nurses about HIT.
The jury found that Methodist was negligent and acted with malice, and it awarded $7.1 million to German on his claims against Methodist.
Texas Court of Appeal Justice Michael Massengale, JD, determined that the award was incorrect, saying "we find no evidence that the nurses failed to fully discharge their duties to accurately and completely document the patient’s signs, symptoms, and responses. Accordingly, the only possible remaining theories upon which the jury could have concluded that the nurses failed to satisfy the nursing standard of care are the possibilities that the nurses’ duty to report information included the duty to identify trends in that information or to verbally communicate particular information at a particular time."
The opinion goes on to state that "the proposed standard of care effectively required the nurses to engage in the unauthorized practice of medicine by making a medical diagnosis. Anything that could be characterized as the practice of medicine is expressly excluded from the scope of professional nursing in Texas as defined by the Nursing Practice Act. ... The nurses had no legal duty to draw any conclusion from their observations about the patient’s signs, symptoms, and responses that would have required a medical diagnosis."
The judge makes clear that the ruling does not mean that a nurse has no duty to recognize and appropriately report or otherwise act on the signs and symptoms of a dangerous allergic reaction. However, "Texas law specifies that it is the doctor, not the nurse, who draws medical conclusions from the information observed and reported by the nurse."
The full court opinion can be found online at http://tinyurl.com/k36co5s.