Legal Review and Commentary: Restrained victim dies: Confidential settlements
Legal Review and Commentary: Restrained victim dies: Confidential settlements
News: An automobile accident victim was taken to a community hospital emergency department (ED). Once it had been determined that the victim sustained a fracture to his neck, the patient was transferred to a trauma center hospital. In the midst of the transfer, information regarding the victim’s blood alcohol level was mistakenly transcribed. Following the transfer, the patient became extremely agitated and was restrained. Several days after admission, the patient died, and his family brought suit against the health care providers. The family alleged that the providers’ treatment was based on a misdiagnosis related to the blood alcohol test, which led to the patient having been overrestrained and subsequently led to the patient’s death from aspiration pneumonia. Several providers, including the trauma center hospital, settled for confidential amounts prior to trial.
Background: A 69-year-old man was in an automobile accident. He was taken from the scene of the accident to a community hospital by ambulance. Multiple diagnostic tests were performed, and it was determined that his neck had been broken in the accident. In addition, a blood test revealed that his blood alcohol level was slightly elevated. The attending ED physician decided that it was in the patient’s best interest for him to be transferred to a trauma center, where more sophisticated services were available to treat the patient’s neck fracture. In the course of arranging for the transfer, the results of the blood test were transcribed into the trauma center’s chart as "300" and/or "0.300" with no units attached seemingly due to a miscommunication between the transferring physician and one of the admitting residents at the trauma center.
Once the patient arrived at the trauma center facility, he was fitted with a halo support brace to protect his broken neck. He became extremely agitated and incoherent, attempting to pull the halo brace and IV lines. The attending resident sedated the patient with Ativan and recommended that the patient be restrained to prevent further injury. Then, based on the notation in the chart indicating an elevated blood alcohol level, one of the attending residents on call at the time suspected that the patient might have been suffering from acute alcohol withdrawal and he consulted with a neuropsychiatrist who specialized in the treatment of agitated patients and in particular patients suffering from acute alcohol withdrawal. Because of the severity of the patient’s agitation, the neuropsychiatrist agreed with the resident’s assessment and included acute alcohol withdrawal in the patient’s differential diagnosis and continued with the previous orders for sedation and restraint.
Approximately 24 hours later, the neuropsychiatrist was able to determine that, if alcohol ever played a part in causing this patient’s agitation, it was no longer a factor because of the lapse of time and the fact that any alcohol in the patient’s blood stream would have completely metabolized. The neuropsychiatrist signed off the patient’s care and recommended that the attending physicians pursue a more definitive diagnosis for the patient’s extreme agitation. The plaintiff argued that it was not clear from the medical record what the neuropsychiatrist’s role was — whether the specialist had signed off the chart and resigned from the patient’s care or, as a consultant, if he had assumed the leading role as the attending physician.
Two days later, the patient died. The cause of death was disputed. The plaintiff claimed that the patient had died from aspiration pneumonia, and that his sedation and restraints had prevented him from being able to clear his throat. The plaintiff also alleged that all of the physicians had misdiagnosed and were, in fact, misguidedly treating the patient as an alcoholic, allowing his pneumonia to go untreated. They further alleged that the hospital nurses failed to monitor the patient closely enough and failed to loosen his restraints as necessary to allow him to breathe. In addition, the plaintiff claimed the nurses further failed to perform or recommend the respiratory therapy needed to allow the patient to clear his chest.
Prior to trial, the trauma center, the attending physician, and medical resident settled at mediation for confidential amounts. The trial proceeded against the only remaining defendant, the neuropsychiatrist, who contended that the inclusion of acute alcohol withdrawal in the patient’s differential diagnosis was entirely appropriate, given the patient’s severe agitation. Further, the neuropsychiatrist testified that he consciously ignored the "300" blood alcohol recorded level because without any units of measure associated with the number, it was clinically insignificant and indecipherable. Instead, the neuropsychiatrist maintained that the mild sedation and restraints were ordered and were procedurally necessary and mandated to prevent the patient from injuring himself.
Finally, the physician entered pathology slides into evidence that revealed that the patient had died from a heart attack, which was completely unrelated to the pneumonia alleged by the plaintiff. Whether the patient coughed at all during his hospital stay was hotly debated at trial, as coughing is a necessary symptom for the diagnosis of pneumonia. According to the verdict report, the jury found no negligence against any of the defendants except the hospital. However, all damages were predicated on the finding of liability against the neuropsychiatrist; therefore, the plaintiff was awarded nothing at trial.
What this means to you: "This case in large part is based on the inexperience and poor medical judgment of the attending resident physician. Although the facts do not indicate the time line from the accident to admission to Hospital No. 1 to admission to the trauma center, it is probable that the time line is anywhere from six to 12 hours. This amount of time is not sufficient for someone to suffer from acute alcohol withdrawal. The focus should have been appropriately working up the differential diagnosis of acute delirium,’ regardless of the blood alcohol level instead of allowing the blood alcohol level to dictate treatment. Calling in the neuropsychiatrist was not inappropriate; however, when he signed off the case, the resident and attending physicians should have broadened their approach to diagnosis," notes Ellen Barton, JD, CPCU, a Phoenix, MD-based risk management consultant.
"In addition, it is important for all medical personnel — particularly those in training — to be sensitive to allowing their judgment to be inappropriately influenced by stereotyping patients as drunks, bums, or other equally negative categories. Formal or informal inservice educational sessions should be held for physicians and nursing personnel on how to deal with difficult, hard-to-handle patients. By providing the necessary emotional tools for dealing with these types of patients, health care providers will be able to refrain from acting on their automatic reactions before they have had a chance to thoroughly review and access the medical facts of the case," adds Barton.
"Finally, the hospital’s policies and procedures on restraints, particularly the provisions on the monitoring of patients who are restrained, needs to be carefully reviewed. Such policies and procedures should provide criteria for respiratory therapy for restrained patients who may have compromised airways. Regardless of the errors of the medical staff, which may or may not have been covered under the liability provisions of the hospital, the trauma center hospital’s need to contribute to the settlement was likely predicated on its failure to monitor a patient that had been clearly deemed as one who required additional attention," concluded Barton.
Reference
- Frank Millis, Individually and as Executor of the Estate of Robert Lee Mills Sr. vs. Geraldine Difford Hicklin, Memorial Hermann Healthcare System d/b/a Memorial Hermann Hospital, Christine Cocanour, MD, Billy Gill, MD, and Kenneth Reed, MD, Montgomery County (TX) District Court, Case No. 99-0402070-CV.
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