My Most Memorable CLNC® Case: My First Major Case Gave Me the Confidence to Offer My Expertise to Attorneys

My most Memorable CLNC® Case involved a 35-year-old female who was 3 days postpartum following a delivery due to eclampsia. The patient presented to the emergency department (ED) one hour after being discharged from the OB unit for shortness of breath and hypertension.

Upon arrival her initial vital signs (VS) were: BP-157/90, HR-108, RR-24, T-97.9, Sa02-95% and Pain-10/10. She stated, “I got released from upstairs and my blood pressure is high. I took it earlier and it was 190/111. I feel short of breath also.” Repeat VS were: BP-175/111, HR-117, RR-24, Sa02-94% and Pain-10/10. She was assigned the Emergency Severity Index (ESI) 3.

16 minutes after arriving to the ED, the patient was ambulated to the room and placed in a gown. The nurse documented that ABCs were normal and the patient was awake, alert, and cooperative with calm affect. The nurse also documented that the patient was positive for chest pain, diaphoresis and shortness of breath.

Seven minutes later the patient was up and dressed and refused to stay to see the physician. It was documented that the patient “will rest for one hour and will return if symptoms continue.” The nurse documented that she encouraged the patient to stay, but the patient refused.

85 minutes later the patient returned to the ED. VS were: BP-164/89, HR-112, RR-24, T-97.6, Sa02-92% and Pain-10/10. She was taken to the room via wheelchair and placed in a gown. An EKG was completed. Documentation indicated normal ABCs, and the patient was calm, appropriate and speaking coherently. The nurse documented sharp chest pain with radiation to the left arm and complaints of shortness of breath. Documentation reflected a vaginal delivery 3 days prior and stated that symptoms started one hour prior. She also noticed swelling in her feet and ankles. Non-pitting edema in both legs was documented.

20 minutes after arrival VS were: HR-113, RR-21 and Sa02-87%. It was documented that 02 was started 2L/NC with continuous pulse oximetry. Repeat VS five minutes later were: BP-163/109, HR-109, RR-26 and Sa02 92%. Ten minutes later an IV was placed. The patient was sent to radiology for a CT.

20 minutes later the patient returned from CT. VS were: BP-163/109, HR-122, RR-36 and Sa02-82% on 2L. The patient was noted to be extremely anxious and stated, “I want to go home.” She was coughing up large amounts of pink frothy sputum and had complaints of nausea.

Two minutes later Zofran was administered. It was noted that the patient continued to be very anxious. A non-rebreather mask was initiated at 15L. Cyanosis and increased shortness of breath were noted. The staff prepared to intubate.

Five minutes later, etomidate 30 mg and succinylcholine 150 mg were administered. VS were: BP-163/109, HR-38, RR-20 and Sa02-74%. Two minutes later CPR was started. The patient progressed from pulseless electrical activity to asystole. 22 minutes later she was pronounced dead. Sa02 never improved post intubation or during CPR.

I was hired by the plaintiff attorney to provide a chronological timeline with opinions regarding nursing standards and deposition questions for defense witnesses.

Deviations from the standards included:

1. Inappropriate documentation related to triage and care of the patient. The Emergency Severity Index was inadequate. The patient was not identified as at risk related to pain > 6/10, abnormal VS, chest pain and shortness of breath.
2. Failed to monitor the patient appropriately while in the ED.
3. Failed to obtain an EKG within 10 minutes of complaint of chest pain.
4. Failed to identify the patient was declining in status related to blood pressure, heart rate and oxygen saturation.
5. Failed to have a nurse accompany the patient to CT.
6. Failed to be more assertive about the patient leaving. Allowed the patient to leave with chest pain and shortness of breath. The Emergency Medical Treatment and Labor Act (EMTALA) requires an emergency medical screening to rule out an emergency medical condition. The patient did not get that screening. The question is, should the nurse have notified the physician that the patient wanted to leave? Did she have enough information prior to the patient leaving?
7. Failed to notify the providers of the patient leaving.

This case was my most memorial because it was my first major case. I brought my nursing experience to the case. I have strong opinions when it comes to nursing standards and the care or lack of care given to the patient. This case affected the family left behind.

Lessons I learned started with being prepared. More importantly, don’t just do the job requested – also offer additional information and insights. The attorney wants to hear your thoughts. I have received multiple cases from this attorney. It has made me a stronger CLNC and more confident to offer my expertise to attorneys.

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Carol Fridal, MS, RN, CEN, CLNC owner of C Fridal Legal Nurse Consulting has more than 30 years’ nursing experience in emergency and trauma. Carol consults on medical malpractice and personal injury cases for plaintiff and defense attorneys.

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