A Lesson Learned

Everyone knows emergency departments (ED) are busy and often chaotic places. The medical and nursing staff have multiple and conflicting demands on their time, attention and resources. The challenges can be daunting at times.

One such challenging case involved Casey, a 36 year old gentleman brought in by paramedics for being incoherent with difficulty speaking and walking. The patient was initially evaluated by the ED physician at 1:45 AM; however the physician found the patient to be too intoxicated to get a meaningful history. The physician noted the patient was having trouble focusing and at times was belligerent and combative.

As the ED physician was completing his initial evaluation, he was called away urgently to attend to several trauma patients brought in from a serious motor vehicle accident nearby. Casey was placed on a stretcher in a holding area between the waiting room and exam rooms.

When the ED physician returned at 2:30 AM to check on Casey he found Casey to be unresponsive, not breathing, cyanotic and with fixed dilated pupils. Despite aggressive resuscitation efforts, the ED staff was unable to save Casey. The cause of death was determined to be respiratory failure, secondary to aspiration.

In reviewing this case as a Legal Nurse Consultant there are several important points to consider.

Because the ED physician had been called away urgently to attend to the trauma cases, he neglected to document taking Casey’s vital signs and physical exam prior to leaving him in the holding area. When the ED physician was questioned during deposition, he was unsure if he in fact, he did check the vital signs given Casey’s mental state or if he had and merely forgotten to write them down.

The ED physician was also unable to answer in deposition, as to whether he had checked on Casey at any point between 1:45 and 2:30 AM. The standard of care as well as the hospital policy stated clearly that patients in the ED should have their vital signs checked every 15 minutes.

The lessons learned in this case were straightforward. It is the same thing everyone was taught in nursing and medical school–document, document, document!! If it’s not there it didn’t happen/you didn’t do it!

Given that the hospital policy clearly stated how frequently patients were to be assessed during their stay in the ED, it was determined that the failure to adequately monitor Casey was a breach in the standard of care.

Plaintiff counsel would certainly argue that the ED physician knew or should have known that alcohol consumption may cause significant respiratory depression.

Furthermore not only would the ED physician be liable in a case such as this but also the hospital by extension.

The take home message is that written medical documentation always provides greater credibility than personal recall of events.

If you have a case you would like reviewed, please contact me directly.