Helping a troubled patient
If you are an emergency nurse, you practice within the requirements of the Emergency Medical Treatment and Active Labor Act. However, the nurse in the following case made a patient care decision that may have violated EMTALA. (Munoz v. Watsonville Community Hospital, Case No. 15-cv-00932-BLF, United States District Court Northern District of California San Jose Division, Jan. 25, 2017) KH, a female, underwent gastric bypass surgery and was discharged without complications. About 15 months later, she had intermittent episodes of severe abdominal pain and went to an emergency department. The emergency room physician examined her and diagnosed KH with intermittent bowel obstruction. She was treated with IV medication and hydration. The obstruction seemed to have resolved at the time and she was discharged. Three months later, KH went to another ED complaining of abdominal pain. This ED had no records from her prior visits to the former ED and she was not able to communicate her history fully due to her limited ability to speak English. Laboratory results were normal, except for "very mild hypokalemia" and mild dehydration. An X-ray of the abdomen indicated a significant amount of stool with a few air-fluid levels. The ED physician gave KH an opioid analgesic, and when her pain level decreased to 0 on a scale of 1-10, she was discharged with a prescription for a laxative. Later on the same day, she returned to this same emergency department because the pain had resumed. The physician was aware of her history, determined that her pain level was 10 on a scale of 1 to 10, and found her condition to be a "certified medical emergency." After treating her with Ativan, Haldol and a soap suds enema, the ED physician discharged the patient. The discharge nursing note indicated the patient had a pain level of 8 out of 10 at the time of discharge. Upon returning to her home, KH's condition worsened. She went into cardiac arrest and was taken back to the ED from which she was discharged. She was resuscitated but died the next day after another cardiac arrest. The cause of death was peritonitis and septic shock due to an internal hernia.
The rationale behind the lawsuit
KH's former husband and father of her minor child filed a lawsuit alleging violations of EMTALA. The hospital in which the ED was located filed a Motion to Dismiss KH's complaint. The court stated the purpose of EMTALA is to provide an appropriate medical screening examination within the capability of the facility, and if an emergency medical condition exists, it must provide treatment to stabilize the condition. EMTALA also includes conditions under which a patient may be transferred. After reviewing the evidence in KH's case, the court held there was an appropriate medical screening and therefore granted the first part of the hospital's Motion to Dismiss. The court did not grant the hospital's second part of its Motion, however. It held that discharging KH with a pain level of 8 out of 10 violated the hospital's duty to stabilize KH and it also failed to transfer her to a facility for her high level of pain, which was the identified emergency medical condition. The court clearly pointed out that there was no duty to treat an undiagnosed condition (the hernia). Due to the court's rulings, the case continues in trial court and has not yet been concluded. However, the case highlights several important duties of an ED nurse. Regardless of a physician order to discharge a patient from an ED, an ED nurse has the legal and ethical obligation to question such an order when the patient's condition warrants it. In this case, the severe pain level was simply documented by the nurse. The nurse apparently did not question the ED physician about the order or notify her supervisor about the questionable order or take any other action to prevent the discharge. As a result, the hospital may have violated EMTALA. More importantly, the nurse appears not to have fulfilled her duties to KH grounded in standards of practice, the state nurse practice act and the Code of Ethics for Nurses with Interpretive Statements. At the very least, the patient's condition warranted compliance with these obligations. EMTALA also requires specific care, stabilization, and transfer requirements for women in active labor who present in an ED. EDITOR'S NOTE:
