Legal Pearls: Multiple Errors Lead to Tragic Death

Many medical malpractice stories have tragic endings, but few have the number of errors that took place in this sad tale.

Clinical Scenario

The patient was a 19-year-old college sophomore. She had graduated with honors from high school and had been an athlete.  By her sophomore year in college she had a serious boyfriend. She and her boyfriend visited her family for the weekend late in September, and then returned to her dorm.

After returning to the dorm, she began experiencing chest pains and shortness of breath. “I can’t breathe,” she told her boyfriend, before passing out. He called 911 and the paramedics came and took her to the hospital. The paramedic who treated her noted that she had fainted, was short of breath, and had chest pain, low oxygen saturation, rapid heart rate, and rapid breathing. The paramedic radioed the hospital on the way and told the nurse that she believed the patient had a pulmonary embolism and would need a CT scan.

The only medical provider in the emergency department that night was a family nurse practitioner (NP). Although the NP had not had training in acute care or emergency medicine, 8 months earlier the hospital had granted her privileges to provide care to critically ill patients in the emergency department.

When the patient arrived at the hospital, the NP initially ordered a CT scan of the chest as well as a urinalysis. While in the bathroom for the urine sample, the patient passed out again. When the urine sample came back, it was positive for methamphetamine, however it was negative for amphetamine, which was unusual. When the NP mentioned the positive drug test, the patient, her mother, and her boyfriend all protested that she was an athlete and did not do drugs. At the request of the patient’s mother, the NP ordered another urinalysis, which came back negative for methamphetamine. Despite this, the NP cancelled the chest CT scan, diagnosed the young woman with methamphetamine use, and admitted her overnight.

At some point over the next several hours, the NP consulted her supervising physician by phone, who told her to order the CT scan, which she did at 12:22 AM, 8 hours after the patient had arrived in the emergency department. However, the clinician failed to specify that the scan be performed and reported on an urgent basis. Thus, the radiologist did not read and report the results back until nearly 2 hours after the CT was ordered. The results showed pulmonary emboli in both lungs of the patient. The patient was immediately transferred to another hospital where she was given clot-busting drugs, but she died within 2 hours of arrival. The patient had been in the original hospital for 11 hours with pulmonary emboli and had not been treated. An autopsy confirmed that she had not taken any drugs.

The Case

The patient’s mother sued the hospital (and many other defendants, including the nurse practitioner’s supervising physician), based on the fact that a nurse practitioner was the only provider in the emergency department, and had not been trained or credentialled in emergency medicine or acute medicine.

Even more shocking, during the trial, evidence came out showing that the nurse practitioner had actually been fired by the hospital for “quality/safety concerns” 27 days prior to treating the patient. Her employment contract specified that she get a 30-day notice of termination, and so the hospital had continued to have her work since she was going to have to be paid during that 30-day period.

The paramedic testified that she had radioed the hospital with the belief that the patient had a pulmonary embolism and recommended a CT scan. Experts for the plaintiff testified that the patient had all the classic symptoms of a pulmonary embolism, plus she was on hormonal birth control pills which increased the risk. The experts concluded that had she been diagnosed and treated within the first 8 hours of presenting at the emergency department she would have survived. Instead, she spent 11 hours in the hospital without treatment for her pulmonary emboli.

Other experts testified as to the lack of knowledge of the NP, and the failure of her supervising physician to actually supervise. The NP was admonished for her diagnosis of methamphetamine use. Several nurses who were working that night testified that the patient did not exhibit behavior of someone who had taken methamphetamine.

Testimony about the patient by her family and friends was especially gut-wrenching for the jury. After a short deliberation, they found the hospital liable and awarded the patient’s family close to $6.2 million for the teenager’s wrongful death.

What’s the Take Home?

So many things went wrong in this case. The paramedic suggested the right diagnosis but was ignored. The family nurse practitioner was unqualified to be providing care in emergency situations and was clearly out of her element. The initial diagnosis of methamphetamine use was incorrect: one test didn’t show it at all, and the other showed methamphetamine, but not amphetamine–a discrepancy. Plus, the patient, her mother, and her boyfriend all denied that she used drugs and stressed that she was an athlete who was concerned with her health. Another grave mistake was the NP cancelling the CT scan after making the wrong methamphetamine use diagnosis. When the NP finally consulted her supervisor and got the advice to order the scan, she neglected to specify that it was urgent, resulting in yet another delay. Hours were ticking by in an emergency situation, while the NP never did a proper differential diagnosis to rule out the most dangerous possibility–pulmonary embolism.

Finally, the hospital’s decision to have the NP be the sole medical provider in the emergency department knowing that she both wasn’t qualified and that she had already been terminated for “quality and safety concerns” (and was only working because they had to pay her anyway) was clearly negligent.

Bottom Line—Always rule out the most dangerous diagnosis first, and if you are unsure or are practicing in an area in which you are not completely comfortable, ask for help.