There are two broad categories of things that kill trauma patients. No, I’m not talking about violent penetrating injury, falls, car crashes, or any other specific mechanisms. I am referring to the end events (on a macro scale) that take their lives.
These two basic killers are: hemorrhage and brain injury. The vast majority of the time, a dying trauma patient has either suffered a catastrophic brain injury, or has ongoing and uncontrolled bleeding.
Here’s the law:
Your trauma patient is bleeding to death until you prove otherwise.
Bottom line: Since there is little we can do above and beyond the basics in the ED for severe brain injury, your focus must be on hemorrhage. There are lots of things we can do about that, and the majority involve an operating room. Always assume that there is a source of hemorrhage somewhere, and it just hasn’t shown itself yet. There can be no rest until you prove that the source does not exist. And hopefully, you do that very, very quickly.
Other Laws of Trauma:
Time for some more philosophy! After doing anything for an extended period, one begins to see the common threads and underlying principles of their area of expertise. I’ve been trying to crystallize these for years, and today I’m going to share one of the most basic laws of trauma care.
The First Law of Trauma: Any anomaly in your trauma patient is due to trauma, no matter how unlikely it may seem.
- An elderly patient who crashes his car and presents with arrhythmias and chest pain is not having a heart attack. Nor does he need a cardiologist or a trip to the cath lab.
- A spot in the liver after blunt trauma is not a cyst or hemangioma; it is a laceration until proven otherwise.
- A patient found at the bottom of a flight of stairs with blood in their head did not have a stroke and then fall down.
Bottom line: The possibility of trauma always comes first! It is your job to rule it out. Only consider non-traumatic problems as a last resort. Don’t let your non-trauma colleagues try to steer you down the wrong path, only to have your patient suffer.
Other Laws of Trauma:
What are common sources of malpractice complaints against nurses? The most common event is medication error. Most people worry about common errors like wrong dose, wrong drug, and wrong route of administration. But one less commonly considered drug-related responsibility is assessment for side effects and toxicity of medications administered.
Other common reasons include failure to adequately monitor and assess the patient, and failure to supervise a patient that results in harm. Significant changes in patient condition must be reported to the responsible physician. However, doing so does not necessarily get the nurse off the hook. If the physician’s response leads the nurse to believe that they have misdiagnosed the problem or are prescribing an incorrect drug or course of action, the nurse is obligated to follow the chain of command to notify a nursing supervisor or other physician of the event.
And finally, one of the most common issues complicating malpractice cases of any kind is documentation. Lawsuits must typically be filed within two years of the event that caused harm. Once that occurs though, several more years may pass before significant action occurs. Collection and review of documentation, identification of experts, and collection of depositions takes time. And unfortunately, our memories are imperfect after many years go by. Good documentation is paramount! “Work not documented is work not done,” I always say. And poor documentation allows attorneys to make your good work look as bad as they want and need it to.
Reference: Examining Nursing Malpractice: A Defense Attorney’s Perspective. Critical Care Nursing 23(2):104-107, 2003.
Back in the old, old days, there was really no such thing as nursing malpractice. Nurses had little true responsibility, and liability largely fell to the treating physicians. But as nursing responsibilities have grown, they have become an integral part of the assessment, planning, and management of their patients.
As all trauma professionals know, our work is very complex. And unfortunately, our understanding of how the human body works and responds to injury is still incomplete. So unfortunately, undesirable things happen from time to time.
But does every little adverse event or complication mean that someone is at fault? Or that they can/should be sued? Fortunately, the answer is no.
The law is complex, at least to professionals outside the legal field. Following are the basics of malpractice as it relates to nurses.
There are four elements that must be present for a malpractice case to be brought forward:
- The nurse must have established a nurse-patient relationship. Documentation provided by the nurse or other providers in the medical record must demonstrate that they were in some way involved in care of the patient.
- A scope of duty must be established within the relationship. For example, an ICU nurse will have duties relating to examining the patient, recording vital signs, reporting significant events to physicians, etc. The exact duties may vary somewhat geographically and even between individual hospitals. Written policies help to clarify some of these duties, but often, experts are required to testify to what the usual standards of care are when not covered by policy.
- There must be a departure from what is called “good and accepted practice.” The definition of this leaves a lot of wiggle room. It is defined as the care that an ordinarily prudent nurse would have provided in the given situation. It does not need to be the optimum or best care. And if there is more than one approved choice, a nurse is not negligent if they choose either of them, even if it later turns out to be a poorer choice.
- Finally, there must be a cause-effect relationship between the nurse’s action and the patient’s alleged injury. This linkage must be more than a possibility, it must be highly probable. For example, wound infections occur after a given percentage of operations, and it varies based on the wound classification. It’s a tough sell to bring suit for improper dressing care in a grossly contaminated wound that is likely to become infected anyway. Typically, expert witnesses must attest to the fact that the patient was, more likely than not, harmed by the nurse’s action or inaction.
Stay tuned tomorrow (Monday) for part 2!
We know that in-hospital trauma professionals are at risk for litigation. But what about prehospital providers? Unfortunately, there is painfully little literature for us to go on. In this case, I was only able to dig up a single 20 year old paper to help provide a little guidance.
A retrospective review was conducted of data from a computerized database (note that I did not say online; this was from the birth of the internet) of court cases filed against EMS agencies nationwide. It specifically looked at ambulance collisions and patient care incidents.
Here are the factoids:
- Only 76 cases were identified over a 6 year period (!!)
- Collision and patient care suits were divided nearly 50:50
- In ambulance collisions, the other motorist was likely to sue (78% of cases)
- With patient care issues, 93% of the plaintiffs were the patient (who were the other 7%??)
- The most common collision occurred in an intersection, or was a rear-end accident
- The most common patient care issues were arrival delay, inadequate assessment, inadequate treatment, patient transport delay, or failure to transport
- About half named an EMT or paramedic as codefendant
- 41% of suits were closed without any payment to plaintiff, but there were 5 cases with awards greater than $1M US (and this was in 1994!)
Bottom line: Yes, EMS providers do occasionally get sued. It is probably more likely today than it used to be given the legal climate in the US. Providers need to be familiar with the common reasons for lawsuits involving them, and always practice within their scope and in compliance with protocols and medical direction. Whether specific individual liability insurance is needed is a local and regional thing, and should be negotiated with your particular employer.
Reference: Emergency medical services liability litigation in the United States: 1987 to 1992. Prehosp Disaster Med 9(4):214-220, 1994.