Hospital personnel have no choice.  Physicians and nurses are required by law to report all suspected domestic violence and child abuse to law enforcement authorities.  The flip side is that such reports are privileged and cannot be the basis of a civil lawsuit against the reporting healthcare provider.  COURT OF APPEALS OF OHIO June 3, 2013

  The husband dropped his wife off at the E.R. for treatment of a scalp laceration and then left the hospital.  Hospital personnel suspected the wife was a victim of domestic violence.  They called the local police who came to the hospital and arrested the husband when he returned to pick her up.  Charges of domestic battery were filed against the husband but were later dropped by the prosecutor. The husband sued the hospital for defamation and invasion of privacy.

  According to the Court, the fact that the patient's own obstetrician's recommendation led to her discharge from the E.R. without the hospital's standard procedures being followed did not diminish the hospital's liability to this patient for violation of the EMTALA. Cruz-Vasquez v. Hosp., __ F. 3d __, 2013 WL 2322016 (1st Cir., May 29, 2013).

  The patient was brought to the E.R. by paramedics at 11:45 p.m. with life-threatening gunshot wounds.   The E.R. physician phoned the on-call vascular surgeon.  The vascular surgeon's arrival was delayed and the patient did not go into surgery until 2:45 a.m.  He died in surgery at 7:00 a.m.

  The Court, however, was swayed in the patient's favor by the patient's expert's opinion that the patient should have been assisted in person by the hospital staff until she was safely out of the hospital and had met up with her family member.  The hospital nurses should have taken into account the known side effects of the medications the patient was administered in the emergency department as well as those she had taken at home which were noted in her chart at the time of her initial assessment.  These medications are known to cause dizziness and drowsiness and can have potentiated side effects with an elderly individual, according to the patient's expert witness. Heit v. Med. Ctr., __ N.Y.S.2d __, 2012 WL 3204526 (N.Y. App., August 8, 2012).

  The patient came to the emergency department at 5:47 p.m. and was seen by the triage nurse at 5:55 p.m.   The triage nurse asked him about the onset and severity of his chest pain, whether he had attempted self-treatment and whether he was a victim of domestic violence.   She obtained a pulse oximeter value and documented that the patient had taken an aspirin before coming to the hospital.   The nurse also began documenting the patient's cardiac risk factors including his BP, tobacco use and personal and family history of heart disease.   Then the nurse ordered an EKG which was done by an E.R. tech at 6:27 p.m.  The EKG was not abnormal.  The nurse had blood drawn at 6:40 p.m. for a cardiac enzyme work-up and sent him for a chest x-ray at 6:43 p.m.   At 7:50 p.m. the blood work came back positive for a possible cardiac event.  The nurse promptly reported the lab results to the E.R. physician who immediately came in and evaluated the patient and talked with a cardiologist.

  The US District Court for the Eastern District of Pennsylvania dismissed the patient's suit alleging violation of the US Emergency Medical Treatment and Active Labor Act (EMTALA).   The hospital's standing nursing protocol for E.R. patients with chest pain was to assess the patient with a physical examination, question the patient about his or her symptoms, screen the patient for domestic violence and create a record of risk factors.   Following the assessment, if a cardiac event was suspected, the nurse was expected to obtain a pulse oximeter reading, assign the patient the appropriate triage classification and alert other E.R. personnel to the patient's need for immediate treatment.  The nurse was then permitted to give aspirin, obtain an EKG, start O2, order blood drawn for a cardiac work-up and obtain a chest x-ray.

  If the hospital determines that the individual has an emergency medical condition, the hospital must provide either -

(A) Within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or

  (B) For appropriate transfer of the individual to another medical facility in accordance with the requirements of this section.

  A hospital stabilizes a patient by providing sufficient treatment that the patient's condition is not likely to materially deteriorate during or as a result of transfer or, where the emergency medical condition is a pregnant woman having contractions, by delivering the child.

  The hospital may not transfer the individual unless -

  (A)(1) The individual (or a legally responsible person acting on the individual's behalf) after being informed of the hospital's obligations under this section and the risks of transfer, in writing requests transfer to another facility; and

  (ii) A physician has signed a certification that based on the information available at the time of the transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual, and in the case of labor, to the unborn child from effecting the transfer, or

  (B) The transfer is an appropriate transfer in which the receiving facility

  (i) Has space available and qualified personnel for the treatment of the individual, and

  (ii) Has agreed to accept transfer of the individual and to provide appropriate medical treatment.

  (C) In which the transferring hospital sends to the receiving hospital all medical records relating to the emergency condition and the informed consent.

  (D) In which the transfer is effected through qualified personnel and transportation equipment, including life support.

  If a hospital has screened an individual and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to the individual.  

  The important but somewhat circular definition of the term "inpatient" is an individual who is admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services with the expectation that he or she will remain at least overnight and occupy a bed even though the situation later develops that the individual can be discharged or transferred to another hospital and does not actually use a hospital bed overnight.

  The patient came to the hospital's E.R. complaining of abdominal pain.    He was seen by the triage nurse within minutes of arrival.   He reported his pain was 9/10 and the nurse obtained and charted a history of pancreatitis and peptic ulcer disease.   Soon after being led to an exam room to which he ambulated without assistance he was asked to put on a hospital gown.   He refused.   Over the course of the next few hours he remained hostile and combative.  Hospital security was called.   The E.R. physician got him to take off his shirt for an IV and a CT, but the CT had to be cancelled when the patient refused to swallow the oral contrast medium.  The nursing supervisor finally convinced him to change into the hospital gown, but he soon changed his mind, put his shirt and jacket back on and left AMA.

  The hospital's E.R. nurses did not follow the hospital's procedures for the assessment and treatment of chest pain and by not doing so they deviated from the accepted standard of care.  However, the nurses' errors and omissions, although negligent, did not rise to the level of willful or wanton negligence.  COURT OF APPEALS OF TEXAS October 13, 2011

  A $1.3 million jury verdict has been overturned which we reported in December 2010: Emergency Room: Nurses Blamed For Patient's Death From MI After Discharge Home, Legal Eagle Eye Newsletter for the Nursing Profession, (18)12, Dec. 10, p. 6.   The Court of Appeals of Texas was highly critical of the nursing care the patient received in the emergency room but nevertheless found no liability in the family's lawsuit against the hospital because the nursing care, although negligent, did not rise to the level of willful or wanton negligence, a wrinkle of Texas's medical malpractice law.

  The E.R. nurse's triage of this patient was a reasonable preliminary screening, given the symptoms he reported, the way he appeared and what else was going on in the emergency department at the time.  The standard of care depends upon the circumstances and the options that are available at the time to the patient's caregivers. SUPREME COURT OF MISSISSIPPI July 21, 2011

  The patient came to the E.R. with chest pains.  She was given two EKG's, one which was normal and one which showed a septal infarct whose age could not be determined.  A chest x-ray was read as normal.  She was seen by the physician and discharged after receiving a dose of oral captopril and an albuterol inhalation treatment in the E.R.  Early the next morning she was taken by ambulance from her home to another hospital where she was pronounced dead from a myocardial infarction. 

   The jury in the District Court, Jefferson County, Texas ruled the E.R. nurses were 80% and the E.R. physician 20% liable for the patient's death and awarded $1,315,275 from the hospital as the nurses' employer in addition to $162,112 the family had already received from the E.R. physician as a pre-trial settlement.  The family's nursing experts placed a heavy weight of responsibility directly on the nurses to orchestrate and ensure proper care for this cardiac patient in the E.R. Licatino v. Health, 2010 WL 4388956 (Dist. Ct. Jefferson Co., Texas, January 20, 2010).

  A nurse cannot reassure parents their infant will be all right without fully assessing the child's condition and obtaining a physician's examination.  Based on the nurse's reassurances, the parents did not wait to see the physician, and the child died.  The hospital was ordered to pay nearly two million dollars for negligence. COURT OF APPEALS OF GEORGIA, 1996.

  The court blamed the parents' leaving the hospital on the nurse's false reassurances and held the hospital liable for payment of substantial legal damages for the nurse's actions. The parents were not to blame for leaving against medical advice. Medical Center, Inc. vs. Poe, 480 S.E. 2d 40 (Ga. App., 1996).