Do you think he won the case? Find the outcome here:
. . . a patient presented to an Emergency Department having cut off two fingers with a table saw. The injury occurred at 6:30 p.m. The patient was triaged at 7:19 p.m. The emergency medicine physician saw the patient at 7:42 p.m. X-rays were performed at 11:33 p.m. Orthopedics was finally consulted at 1:00 a.m., more than five-and-a-half hours after the patient presented to the Emergency Department. Orthopedics arrived at 1:30 a.m. The wounds were stitched closed by orthopedics at 2:00 a.m. Reimplantation of the saved digits could not be performed within eight hours from the time of injury as an operating room would not have been available that quickly.
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{ 17 comments }
I’d love to see Kevin offer an opinion rather than just aggregate.
It seems rather unquestionable that 8 hours was too long. The only real question is whether the conditions in the ER justified the triage and the wait.
I don’t agree completely with the argument that registration/labs/etc could easily delay things.
ER’s get “notifications” and patients are often rushed in for trauma, etc. So these mechanisms CAN be bypassed. No one would let a chest pain linger in the waiting room if it sounded like the real deal.
So if there’s a window of 8 hours,and ER docs knew this, then that should have triggered just such a situation.
And since it sounds like a trauma (i.e. severed fingers), I’m surprised he waited. I mean, was someone just walking around in the waiting room carrying a couple of sevred digits in a jar? Gross.
The 8-hour delay was absurd and could only be justified by an ER packed with worse cases. I think the jury got it right.
This is one of those cases that is bizarre due to the lack of explanatory information. I suppose it’s POSSIBLE that the EM guy just decided to sit on Mr. 3 Fingers for 4 hours before calling ortho, but it seems a little… unlikely. Even in the county EDs I’ve been in, bringing in your own fingers will usually draw some attention.
great. he was awarded 535,000$. he could have possibly had the digits reimplanted if it was done earlier. im a doctor and though i abhor mal practice. this is a clear case where proper care was not delivered.. if the ER is so busy that a guy with fingers cut off cant be seen and worked on in a timely fashion, you need to hire more doctors. 535,000 dollars could hire 2-3 more doctors full time for a year. if i was the guy who had the digits amputated and i went to the ER at a decent hospital, i think i woudl expect better care. im not for malpractice. but in this case it is a necessary component of society.
i think we have a right to expect better care in 2007. unless you go to a very minor ER in a very small town. if you are treated in any city with a population greater than 500,000 i think you shoudl expect better service in any ER.
I’m confused. Why the delay in consulting orthopedics? That seems to be the crux of the malpractice case.
The delay between seeing the doctor at 7:42 PM, and calling orthopedics at 1:00 AM.
One would think amputated fingers would trigger the call to ortho right on the spot. Did the ER doc need an X-ray for that?
The comments about breaking down the delay for various interventions, labs, X-ray, and, yes, paperwork…..it still doesn’t make sense. The doc saw the patient and clinically saw trauma.
Fingers cut off.
No subtlety here. Call orthopedics first. Then get studies to see if there may be more work needed than a “simple” (relatively speaking) reimplantation. Maybe there’s more occult trauma in the hand….fine.
And yes, maybe the patient has a cardiac history that may need to be addressed as best one can in a short time. Fine. Get the studies.
But it seems the first call is to ortho.
Something doesn’t seem right in the whole picture.
I can understand wanting to get all the facts through a package of lab work before making a diagnosis, but it was immediately obvious that the guy had two fingers cut off. Not much question about that diagnosis.
I don’t understand it. They will wait 5 hours on labs and Xrays to call ortho on an obvious emergency like this. When my ER department calls me after 5 minutes with a 95 year old with a hip fracture without a single lab.
Who says the ED is responsible for reattaching this guy’s fingers?
EMTALA says the patient has to be stable, he doenst have to be “fixed”
Nothing pisses off surgeons, anesthesiologists and all affiliated people who work late into the night than hand-off delays.
Many injuries or conditions have so called ‘golden windows’ of opportunity. Six hours to close a compound fracture, but the medical system has pissed away 5.5 hours and suddenly at 1 am it is a crisis that they can punt to us. In a timely manner the case would have been done and we’d all be in bed, and the patient would have a better chance at successful repair (earlier in the golden window is better than late in the golden window).
This case just doesn’t make sense. Given the pressure on ERs to rapidly obtain a disposition on patients and the relative simplicty of finding a home for this one (in the OR) that a quick call to ortho would have been just the ticket. I wonder if there is more than is admitted to however. Were ortho consultants difficult to find (did the patient have insurance?) and what other factors might have played a role that the hospital is not admitting.
Read the whole thing.
O’Shea v. State of NY
I have a hard time following it from the legal summary.
Was there delay in consulting orthopedics? Or was the delay because the orthopedists thaought reimplantation was not indicated, so they took their time getting around to a simple repair because there was no hurry?
SarahW gave us the summary of the case. It seems that the pivotal question was not the referral time to orthopedics, but rather the decision of ortho to not attempt replant.
The orthopedist has the role of consultant to determine the likelihood of technical success and the risks of replant versus simple closure of the wound.
Further, as a private individual, he has the right to choose whether or not to enter into a contract of service with a patient. Even if he concludes that replant might be in the patient’s interest risk/benefit wise, he is not under any servitude to provide this task for the patient. Like any businessman in america, the doc can choose any work he wishes, and turn down any he wishes so long as it is not because of membership in a protected group (sex, race, religion, etc.)
But the Emergency Physician was found negligent?
If the orthopedic surgeon chose not to reimplant because the person was a poor risk for surgery because of general medical condition, then the whole thing does not make sense. No negligence as far as I can tell.
If the orthopedic surgeon chose not to reimplant because too much time had passed since the injury, then I could see the argument for negligence if there was a delay consulting orthopedics.
Although not this case, I was asked whether other circumstances in the Emergency Department could theoretically affect the outcome, and whether liability could be transferred to the hospital, rather than the physician, for inadequate staffing if there were too many critical patients to handle.
The standard of care for the physician is not “perfect” or “ideal” care. The standard of care is what a reasonable physician would have done under the circumstances. This takes into account the circumstances of the Emergency Department at the time, such as the number of critical patients present. In some instances the physician-in-charge may have control over those circumstances and sometimes the circumstances will be out of the physician’s control.
If, for instance, a physician during a natural disaster or large-scale terrorist attack is faced with an unexpectedly high number of critical patients, the physician would be required to use the disaster guidelines to triage those patients. Patients whose lives are at stake, and have a reasonable chance of recovery, may take priority over patients whose limbs are at stake. In such a case, the reasonable physician may be required to attend to life-threatening injuries over strictly limb-threatening injuries. On the other hand, if the circumstances are not so dire and there are mechanisms in place to contact backup physicians or divert patients to other hospitals, it may be the physician-in-charge who is liable.
The question of transfer of liability to the hospital is more difficult. In general, an employer is liable for an employee’s negligence or carelessness under the doctrine of respondeat superior. This doctrine assigns ultimate liability to an employer for damage caused by an employee’s carelessness. The relationship between doctors and hospitals, however, does not always fit so easily into the employer-employee relationship. Depending on the situation, the doctor may be considered more of an independent contractor to the hospital. Nevertheless, a hospital may be accountable for circumstances that lead to patient injury outside of the physician’s control, such as inadequate staffing, inadequate supply of medications, or carelessness of ancillary staff hired by the hospital, such as technicians.
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