The next day, before seeing his PCP, the patient suffered an ischemic stroke with right-sided hemiparesis. The case went to trial, and the jury found in favor of the plaintiff.
Discussion
Unfortunately, multiple opportunities were lost in obtaining the correct care at the right time for this patient. Lack of communication and poor communication are frequently cited as causes in medical malpractice cases, and this case perfectly illustrates this problem.
First, the PCP should have called the ED and spoken to the EP directly. This would have provided the PCP the opportunity to express his concerns directly to the treating physician. This kind of one-on-one communication between physicians will always be superior to a hand-written note.
Second, it is unclear why the triage nurse changed the initial nurse’s correct assessment. It is also unclear what happened to the PCP’s note—it was never seen again. Clearly there was miscommunication at this point between the triage nurse and the patient. This case further illustrates the importance of good triage. Once a patient is directed down the wrong pathway (ie, to minor care rather than the main treatment area), the situation becomes much more difficult to correct.
Next, the EP in the low-acuity area was probably falsely assured this patient had only a “minor” problem problem, and not something serious. Emergency physicians must be vigilant to the possibility that the patient can have something seriously wrong even if he or she has been triaged to a low-acuity area. A minor sore throat can turn out to be epiglottitis and a viral stomachache can turn out to be appendicitis. These patients deserve the same quality of history, physical examination, and differential diagnosis as any other patient in the ED.
Finally, while we are not responsible for hospitalists or consultants, we do have a responsibility to our patients. We need to ensure that the care they receive is the appropriate care. Possible alternatives to discharging this patient would have been to call another hospitalist for admission or to seek the input of the chief of the medical staff or the on-call hospital administrator. As EPs, we are frequently required to serve as the primary advocate for our patients.
There is the possibility that even if the patient had been admitted to the hospital, the outcome would have been the same. However, since he might have been a candidate for tissue plasminogen activator or interventional radiology if he had suffered the cerebrovascular accident as an inpatient, he lost his best chance for a good outcome.