Presentation and physician action
At 8:30 a.m., a patient’s wife called her husband’s family physician and requested an appointment because her husband was experiencing chest pain that began the previous evening. The wife reported that her husband refused to go to the emergency department (ED).
The patient was a 61-year-old man. His medical history included low back pain, hypercholesterolemia, hypertension, and he had been a smoker for 40 years.
The patient’s wife was instructed by the physician’s staff to take her husband directly to the ED, yet the patient insisted on being seen by the physician. The wife was instructed to bring her husband to the office for an evaluation.
The patient arrived at the office a few minutes later and the family physician examined the patient. The patient’s blood pressure was low at 95/65 mm Hg and his pulse rate was 57 bpm. The family physician noted bilateral wheezing in the patient’s lungs. EKG results indicated ST elevation along with some disturbance in the inferior leads. The physician interpreted the EKG results as abnormal and noted “probably acute inferior infarction” on the EKG printout. He wanted to send the patient to the ED for cardiac evaluation. The physician called the ED and spoke to the on-call cardiologist advising him of the patient’s symptoms and EKG results. He asked the cardiologist to meet the patient in the ED.
The physician spoke to the patient’s wife advising her that the patient needed to go to the ED to have cardiac enzymes drawn to determine if the patient was having a myocardial infarction. The physician handed them a copy of the EKG printout and offered the couple the option of traveling to the ED by ambulance or private car. They declined the ambulance service and chose to travel by private car, believing that it would be faster. This discussion was not documented in the patient’s chart. On the way to the hospital, the patient experienced a cardiac arrest and died.
A lawsuit was filed against the family physician. The allegations included failure to call EMS to transport the patient to the hospital and to take measures to prevent the cardiac arrest. The plaintiffs alleged that the patient might have survived the cardiac arrest if he had been transported to the hospital by ambulance.
TMLT consultants who reviewed this case were not supportive of the family physician’s decision to allow the patient to go by car to the hospital. He should have insisted on EMS transportation, which would have been safer for the patient. It would have been in the patient’s best interest to have medical supervision at all times.
Consultants also had concerns about the phone call documentation in the patient’s chart. The notes documenting the wife’s initial call to the office appeared to have been written after the office was notified of the patient’s death. The physician encounter notes and instructions to the patient appeared to have been added at a later time as well.
Also affecting the outcome of this case was the patient’s noncompliance and poor judgment. His decision not to go to the ED after experiencing severe chest pain the night before and then refusing to go the ED as initially instructed by the family physician’s staff contributed to the poor outcome.
This case was settled on behalf of the family physician.
Risk management considerations
TMLT consultants who reviewed this case believed the family physician should have insisted upon EMS transportation. They felt the patient should not have been given a choice in the matter. The physician allowed the pressure exerted by the patient to dictate the treatment plan, although it proved to contradict good professional judgment. Based on the patient’s symptoms and cardiac risk factors, he should have been firmly directed to go to the ED.
The wife’s phone call and the physician’s instructions to the patient did not appear to be recorded contemporaneously. They were written as a late entry and were not identified as such. As a result, the entry was perceived as an alteration to the medical record. Medical records should never be altered. When making late entries, always annotate the entries with the time and date of the new entry along with the reason for the late entry. Altering the medical record jeopardizes a physician’s credibility and is often detrimental to the defense of the case. Remember that it is important to document all discussions with family members, including informed consent and refusal.
Although the patient was appropriately referred to the ED, it is recommended that well-defined telephone triage protocols be developed and followed by staff. Physicians and staff should document actions to demonstrate that protocols are followed. In addition, emergency protocols should be developed and included in the policy and procedure manual. Make sure that staff members are aware of all policies and procedures and have them sign and date their acknowledgement and understanding of these policies.