Well-Meaning Staffers Must Know When It Is Time to Call the Doctor

Well-trained nurses and other staffers who take a personal interest in the well-being of patients are certainly a requirement for a successful medical practice. These individuals’ strong desire to help patients is likely a big reason that they were hired. It is also a trait that needs careful management by the physician.

Dr. O was the obstetrician for a 36-year-old patient who in late April was about eight weeks along in her fourth pregnancy. As the months progressed, fundal height of the fetus tracked consistently with gestational age. The mother’s weight gain averaged five pounds per month. Six urine tests through mid-October were always negative for protein.

In early November a fundal height was taken but not charted. Though the patient’s weight was 47 lbs over her pre-pregnancy weight, the pregnancy was considered uneventful.

On November 10, the patient called and then came into Dr. O’s office because she did not feel any fetal movement. Dr. O was in surgery, so the patient was seen by Dr. O’s licensed vocational nurse. The nurse listened to the fetal heart by Doppler and considered it within normal limits. The nurse sent the patient home with instructions to eat a good lunch, rest on her left side, and feel for three fetal movements in a two-hour period.

At 5 p.m. that same evening, the patient called the office. Dr. O’s LVN took the call as Dr. O was still out. The patient told the nurse that she had followed her instructions, but still did not feel any fetal movement. The nurse told the patient to eat a good dinner, have something sweet, drink a tall glass of cold water, and check for fetal movement over the next two hours. The nurse did not contact Dr. O.

The patient came in to see Dr. O at 10 a.m. the next morning and said that though she did feel some fetal movement the evening before, it was much less than usual. Instead of the usual kicking, the patient reported a light “rolling” movement and stomach “butterflies.” Dr. O put the patient on a fetal heart monitor, which he interpreted as non-reassuring because of lack of variability. Dr. sent the patient to the hospital but did not perform an ultrasound or order a crash C-section because he did not believe the problem was urgent.

The patient was admitted to the hospital’s labor and delivery floor at 11 a.m. At 11:45 a.m. a nurse called Dr. O regarding the fetal monitoring strip. Dr. O ordered an oxytocin challenge test and arrived at about 12:15 to evaluate the patient. By 12:40, Dr. O believed the strips showed the need for a C-section, which was performed at 1 p.m.

On delivery the infant weighted 4 lbs., 10 ounces with Apgar scores of 3, 8, and 8. He was immediately transferred to the NICU, where he was intubated for nine days. Cranial ultrasounds were normal, but the child suffered cerebral palsy and other abnormalities.

The patient sued Dr. O for her child’s resulting developmental difficulties.

In his deposition, Dr. O testified that his nurse violated his office protocol in handling the patient’s late afternoon call. Under that protocol, it was mandatory for her to contact him or send the patient to the hospital for further evaluation.

Office protocols are critical to the safe operation of any medical practice. Simply having a protocol, of course, is not enough. Regular training and discussions between physician and staff on the protocols will help avoid “refresher by injured patient” syndrome.

Comments on Case of the Month may be directed to Gordon Ownby, CAP-MPT’s general counsel, at gownby@cap-mpt.com