This memorable case gave me the perfect opportunity to leverage my nursing experience and to educate the attorney, enabling him to understand why this case was meritorious and what he needed to know to win it.
How I Leveraged My Nursing Experience to Educate the Attorney About the Merits of an Emergency Case
by Peggy Hettick, RN, CLNC, NLCP
My most Memorable CLNC® Case involved a 57-year-old male patient who died unexpectedly in the emergency department (ED). When the attorney handed me the medical records, he said, “The defense claims they did everything they could to save this man’s life. I’ve reviewed the records and I tend to agree, but his wife insists that her husband’s death was preventable. Tell me what I’m missing.”
The patient presented to the ED just before midnight with complaints of difficulty breathing that had started earlier that day. Despite using an albuterol inhaler and nebulizer, he continued to experience shortness of breath. Upon admission to the ED, he was only able to speak in short 1-2 word responses.
The ED RN had almost 20 years’ experience, primarily in emergency. She documented initial vital signs as BP 129/77, HR 116, respirations 20, O2 saturation 96% on room air and temperature 97.6° F. The patient’s airway was unobstructed, and there were decreased lung sounds bilaterally. Alert and orientated with warm, dry skin, he was placed on 2 liters of 02 via nasal cannula and started on a nebulizer treatment. Documentation indicated that after the first treatment, the patient was breathing easier, lungs moved more air and heart rate was 114. Second and third nebulizer treatments were subsequently administered 20 minutes apart. Documentation indicated clear lungs, BP 107/65, HR 113, respirations 20, and O2 saturation 96%. The patient reported feeling better and declined hospital admission. He was discharged home at 0155 in good condition.
At 0300 (approximately 1 hour after discharge), the patient returned to the ED with shortness of breath, stating he couldn’t breathe. The ED nurse documented BP 115/75, HR 125, respirations 26, labored and tachypneic, temperature 98° F, O2 saturation 85% at room air, skin diaphoretic and diminished lung sounds. The ED nurse further documented that the patient was in respiratory distress and that he reported, “I just can’t breathe.” The RN started the patient on 4 liters of O2 via nasal cannula and documented HR 148 prior to starting him once again on nebulizer treatments, which were administered at 0310, 0345 and 0405.
At 0420 the ED nurse documented that the patient continued to deteriorate, which led to the decision to intubate. At 0434 the flight team was present, preparing for transfer to a larger hospital in an outlying area. Blood pressure was noted to be dropping to 81/62 at 0455. A 1000cc bolus of normal saline was started by the flight team. The patient was transferred with the air flight team at 0520 in stable condition.
The patient was returned to the rural hospital ED at 0610 with a code blue in progress. He had a loss of pulse as he was loaded into the plane, at which time resuscitative measures (CPR) were started and continued upon transfer. Resuscitative measures were continued in the ED until 0705, when CPR was discontinued and the patient was pronounced dead. An EKG, done shortly before CPR was discontinued, revealed ventricular tachycardia (V-tach) and ventricular fibrillation (V-fib).
The autopsy revealed the cause of death was due to congestive heart failure. The heart was markedly enlarged, and pleural effusions were present. The liver was intensely congested, consistent with the cause of death. Significant coronary artery atherosclerosis and early bronchopneumonia were also noted, possibly contributing to the death.
Documentation failed to support the defense’s claim that appropriate care had been administered. There was lack of documentation and in some instances no documentation at all. The ED nurse deviated from the standards of care. The ED nurse’s deposition confirms this opinion. She admitted, “I didn’t know what was going on. The alarms on the cardiac monitor and pulse oximetry kept ringing, so I turned everything off. The cardiac monitor showed a rhythm that was all squiggles, so I threw the strips away. The patient kept me so busy that I didn’t have time to document. I watched him from the doorway in the hall.”
The case was headed for trial, but due to COVID, it was settled out of court for an undisclosed amount of money. The patient’s death was preventable, just as his wife had insisted.
This memorable case gave me the perfect opportunity to leverage my nursing experience and to educate the attorney, enabling him to understand why this case was meritorious and what he needed to know to win it. The attorney praised my work, noting that I was good at what I did and knew what needed to be done. He also stated that through me, he could visualize not only what the client’s wife witnessed, but also how terrified the patient must have been in his final hours as he struggled to breathe.
The experience was mutually educational. The attorney taught me the importance of staying focused during depositions and not letting the opposing attorney sidetrack or rattle me. He taught me how to maintain credibility and avoid handing control over to the opposition.
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