When Personal Telephone Calls Are Best

Taking physician orders for patient care is a primary function for a hospital nurse. When physicians ask nurses to arrange for another physician’s consultation, however, many things can go wrong.

Dr. OS, an orthopedic surgeon, admitted his 77-year-old patient for a total replacement of her left knee. After an uneventful surgery on December 9, Dr. OS ordered Lovenox (a low molecular-weight heparin), to prevent deep-vein thrombosis. The patient’s pre-operative platelet count was 189,000; after a drop in her count to 144,000 on December 13, the patient received a unit of her own blood, which brought her platelet count back up. Because of the episode, Dr. OS noted “we will have to watch the platelet count,” but he continued her on the Lovenox for six more days.

On December 15, the patient was transferred to the transitional care unit for occupational therapy. She appeared to do well until early December 26, when the nurse noted at 0120 the patient’s complaint that her right leg is numb, painful, heavy, and cold and that she couldn’t wiggle her toes. The nurses gave the patient a previously prescribed Darvocet and told her it would take some time for the pain to stop. The patient, not satisfied with her care, called her daughter to complain that she was not getting assistance and that her call light was not being answered. At 2 a.m., nursing notes show a strong pedal pulse using a Doppler. The patient was able to move her leg and toes, though the leg was cool to the touch. Around this time, Dr. OS’s on-call partner called in asking why the patient and her family were calling him. When the nurses advised Dr. OS’s on-call partner of the patient’s complaints, he ordered more Darvocet.

At 11 that morning, nursing notes show the patient still complaining of right foot numbness and coldness. A nurse called Dr. OS, who was performing surgery elsewhere. Dr. OS ordered the nurse to call Dr. IM, the patient’s long-time internist who had previously seen the patient one day after surgery. The notes for December 26 show that Dr. IM called back to order a K-pad for the right leg. Though Dr. IM recalled visiting the patient that day, neither the hospital nor his office records reflect any such visit.

Dr. OS saw the patient on December 27. He noted that she complained of pain in her right leg and foot weakness. Dr. OS ordered an MRI to rule out stroke. Though Dr. OS wrote “evaluate vascular,” there is no indication he ordered any tests or vascular consult.

When the patient could not complete the MRI the next day, Dr. OS evaluated her again and, now suspecting a vascular embolism, called a vascular surgeon for a consultation. When CBC that day revealed a platelet count of 48,000, the vascular surgeon formed the opinion that the patient had developed heparin-induced thrombocytopenia.

Several days later, the patient required an amputation above the knee.

At deposition in the patient’s lawsuit against her health care providers, the patient’s attorney spent time questioning Dr. OS on his telephone calls with the nursing staff on the morning of December 26.

Dr. OS testified that because he was in surgery when he received the call informing him of the patient’s foot drop, he instructed the caller to contact Dr. IM to ask him to see the patient. Dr. OS did not ask the caller for any information on the condition of the leg. And though he testified that at that point he was concerned with a possible herniated disk or stroke, he did not instruct the caller to ask Dr. IM to evaluate the patient for a herniated disk or stroke.

Dr. OS testified that he did not personally call Dr. IM to ask him to see the patient and never followed up with anybody at the hospital to confirm that Dr. IM did see the patient.

The parties in the patient’s lawsuit resolved the matter prior to arbitration.

Should physicians rely on a nurse’s telephone call when one doctor wants another to examine a patient? Given the absence of any record of Dr. IM visiting the hospital that day, the failure of Dr. OS to make a personal call to Dr. IM makes an impression of poor communication.

Not only would a personal telephone call from Dr. OS to Dr. IM look more defensible, such a call would have given Dr. IM the benefit of the surgeon’s thoughts on what to look for in this complaining patient and what to rule out.

In these kinds of situations, a physician’s personal telephone call is best.

Gordon Ownby is general counsel at CAP-MPT.Comments on Case of the Month should be directed to gownby@cap-mpt.com