The High Cost of Losing Your Cool

by Ann S. Lofsky, M.D., Anesthesia Consultant and Governor Emeritus

Physicians are, of course, human, and despite all attempts at maintaining professional demeanors, there will be those patients who bring out our emotional sides—often unexpectedly. When that helps us to empathize with what they are experiencing, it can be a mutually positive experience. But medicine is also one of the few professions for which the admission “I’m only human” is rarely an acceptable excuse. The doctor involved in the following case discovered that becoming emotional on the job carried a very unusual risk.

A 62-year-old woman, whose physician was a member of a large East Coast internal medicine group, phoned their exchange late on a Friday night complaining of several hours of unrelenting chest pain. Our insured internist was on call for that group. She told the patient to go immediately to the emergency room for evaluation. A cardiologist was consulted when EKG changes were suspicious for myocardial infarction. Nitroglycerine therapy was effective in relieving the pain, and arrangements were made for cardiac catheterization.

The patient was admitted to the ICU under the care of the insured internist. When the cardiologist who was to perform the angiography arrived at the hospital, he discovered that the patient’s INR was quite elevated due to chronic Coumadin therapy for her prosthetic heart valve. He decided that the risk of bleeding was too high, and as the patient remained stable, he elected to allow the clotting studies to normalize before proceeding. The patient became quite upset with the insured when told that the catheterization would not be done at that time, accusing the internist of calling the wrong cardiologist or of postponing the procedure only because it was a weekend. The internist spent almost an hour with the patient and her husband trying to explain the medical rationale but finally left the room stating, “There is nothing more I can do now.”

How Could the Internist Have Helped This Situation?

In retrospect, the reviewers felt that there was already a problem developing in terms of the trust and rapport between the patient and the insured. Some possibilities to help this situation might have included a group meeting between the patient, husband, cardiologist, and internist or an attempt to contact the patient’s own internist, with whom she had had a long-term relationship. Alternatively, there could have been an attempt to get another cardiologist to render a second opinion. This situation was made more difficult by the fact that it was a holiday weekend with limited availability of the physicians.

On Saturday, the insured was off duty, but there was a communication problem in signing the patient out to the on-call internist so that the patient was not seen by anyone for the medical group on that day. The cardiologist came to see the patient in the evening, writing a note in the chart that the INR still remained too high for an invasive procedure. The patient was apparently sleeping at the time and was not awakened.

By Sunday afternoon, the patient was demanding to know why she hadn’t seen “one single physician in two whole days.” The insured was again on call and, when phoned by the ICU nurse, came immediately into the hospital. She found a note in the patient’s chart written by the cardiologist that morning, stating that if the INR result was near normal, the patient should be started on heparin to prevent her valve from clotting while awaiting the cardiac catheterization. The catheterization had been scheduled for Monday morning.

The patient and her husband were both very hostile toward the insured as soon as she entered the room. She tried to explain that the labs had been followed closely and that there was now a need for heparin. The patient’s husband told her he thought all of the doctors on the case were “idiots” and that he was not going to allow his wife to take heparin since they had been repeatedly told that she was already over-anticoagulated. The patient also insisted she was going to refuse the drug. A heated discussion lasting several minutes ensued as the insured raised her own voice in an attempt to be heard over the husband. Finally, wagging her finger at the patient, she explained, “If you refuse this drug, your valve could clot, and you would die. It’s suicide, but I can’t do anything to stop you.”

A patient has a right to refuse medical therapy. The physician has a responsibility to make it an informed refusal, wherever possible, so that a patient understands the risks of making a decision against medical advice. Although not articulated in the most eloquent manner, reviewers felt that the internist had attempted to inform the patient of the risks of refusing treatment.

While the insured was at the nursing desk writing a progress note in the chart, an alarm sounded in the patient’s room. The woman had suddenly gone into ventricular fibrillation. A code was run according to ACLS protocol by a cardiologist who happened to be in the ICU, but it was unsuccessful. The patient was pronounced dead 45 minutes later. The patient’s husband began screaming at the insured, “You killed her. You did this!”

Could the Internist Be Held Responsible for This Death?

At autopsy, a rupture was identified in the patient’s right ventricle. The heart was significantly enlarged and had 70 to 80 percent blockages in three coronary arteries. Defense expert cardiologists opined that the rupture was inevitable and was not caused by the heated argument between the patient and the internist. Such a rupture typically occurs four to seven days after an MI and would not likely have been predicted or prevented even if the coronary catheterization had not been delayed.

It was felt by the plaintiff’s experts that the delay in the heart catheterization was below the standard of care, but that decision did not involve the internist. The main concerns regarding the insured centered around the patient’s not being seen in the hospital the day before the arrest and the confrontation that had occurred immediately prior to it. While it could be argued from a medical standpoint that neither of these facts altered the ultimate outcome of this case, it was not clear how sympathetic they would make the insured appear before a jury.

Most damaging was the testimony of the ICU nurse who was in the room at the time of the discussion between the insured and the patient. She stated she had called her supervisor immediately after the incident because she thought that the internist’s behavior had been inappropriate. This nurse had been told to document the entire conversation, which she had, after the patient’s death. She recalled the insured as being hurried and arrogant, failing to completely explain the function of the heparin to the patient and her husband. “She just didn’t show them any respect.” The nurse claimed she had heard the internist call the patient and her husband “fools” before leaving the room.

After the deposition of the nurse, the insured agreed to settle the case rather than take it to trial. The Doctors Company and the insured’s attorney were able to settle this case on her behalf.

The nursing supervisor who arrived in the ICU immediately after the code had also been irritated by the insured’s demeanor. She stated in deposition that she had questioned the internist as to why she had become so upset with the woman and her husband. The internist’s response was that she was having a really bad day. The nursing supervisor pointed out that it was not nearly as bad a day as the patient was having. “It would have been nice if she had apologized, but I don’t think she ever did.”