Here's my thoughts.....
I would consider the following....
Did the provider have a duty to act
Did the provider act inappropriately, or fail to act
Was the patients condition was worsened by the act, or failure to act.
The most basic steps of pretty much any healthcare provider course (nurse, emt, or even a CPR course for laymen) teach the first thing you do is assess the "ABC's" of your patient, Airway, Breathing & Circulation.
Any time there is a change in patient condition, you immediately go back and re-assess your ABC's.
The fact that the nurse did or did not tell the physician about the bleeding is irrelevant to the patients condition. Clearly, the nurse admits that she noticed blood coming from the trach site, (i.e. the patients airway). This should have warranted an immediate and substantial "red flag" in the nurses mind, as ANY blood from ANY airway is not normal, and the fact that the patient had a trach indicates that the patient obviously was having difficulty managing her airway on a good day, yet alone now that there's some amount of blood coming from it. The fact that it is being splattered on her gown indicates that either it's arterial (very bad) or being forcefully expelled from the tube via coughing (indicates difficulty clearing) or may have had some other underlying condition causing her to cough.
The nurse should know enough about anatomy and physiology to know that the carotid arteries and jugular veins run immediately adjacent and on both sides of the trach, so there is always potential to rupture one of these vessels, of the tube is inserted incorrectly.
The nurse, when she noticed blood on the patients gown splattered from the tube, should have assessed the patients airway (for patency), respiratory rate, pattern, work of breathing and breath sounds, and should have assessed the patients heart rate, strength and rhythm. Was any of this done? Was the patients SP02 (Pulse Ox) checked? Skin color, temp?
The nurse is trained to properly assess a patient, independent of the doctor. The nurse should have assessed this patient correctly, frequently re-assessed the patient, and implemented care based on her assessment. The patient did not just suddenly and without warning, drown in her own blood. This took time, probably 15-30 minutes time for the patient to drown at minimum, and potentially hours, depending on how fast/slow she was bleeding. Did the nurse notice she was bleeding and then just not check on her again? Did the nurse notice there was a significant bleed (shock or airway compromise) and just not worry about re-telling the doctor? Even if the nurse had told the doctor the patient is drowning in her own blood, does this relieve the nurse of the situation? She's a nurse! A skilled healthcare provider! She should have reacted to the patients condition and called the Doctor, called the ER, called 911, called somebody and got this patient some help!
The defendants response that the nurse was not required to tell the doctor for 12 hours is ridiculous. In other words I see you bleeding into your airway, and I'm not required to do anything or concern myself with it for 12 hours?
The defendants response that zero percent of patients survive this injury anyway is incredibly calloused!!!! You'd better have some major stats to back up that claim!
Just my two cents
GA PI PDE046367
----- Original Message -----
To: email@example.com ; firstname.lastname@example.org
Cc: email@example.com ; firstname.lastname@example.org
Sent: Monday, June 08, 2009 6:29 PM
Subject: [infoguys-list] could she have been saved?
Need your opinion on this case. $10 donated to the Schiff Liver Center.
thanks in advance for your opinions. As always they are extremely valuable.
Patient had a tracheotomy tube that was downsized in the morning because
she was getting ready to be released from the hospital in a couple of days.
Four hours later, the patient coughed blood out of the trach tube that
nurse’s records note was spattered on her gown and sheets.
Nurses did not tell the doctor in charge about this blood. Ninety minut
es later, the patient bled out from the trach site into her lungs and drown
in her own blood.
Plaintiff alleges that the nurses’ failure to tell the doctor within an
hour of the initial episode of coughing up blood was negligence that caused
patient’s death. Plaintiff further alleges that, if the doctor had been
told within one hour of the first bleeding episode and appropriate surgical
intervention had been given, patient more likely than not would have
Defendant alleges that, even though nurses’ notes created the day of the
event say the nurse did not tell the doctor about the first bleeding episode
for 90 minutes, that she actually did tell the doctor an hour earlier and
just forgot to write it in the records. Nurse created a “late entry”
record three days after patient died to add that information. Defendant
alleges “late entry” notes are common in medical records to add information that
gets left out.
Defendant further alleges that, although the standard of care did not
require the nurse to tell the doctor of the first bleeding episode for 12
hours, even if nurse had told the doctor as soon as it happened, it would not
have made a difference because zero-percent of patients who have this type
of bleed can be saved even if the doctor is notified immediately.
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