WhiteCoat

Death On The ER Floor – Coming To A Hospital Near You

Esmin Green’s cause of death was just announced this weekend – a pulmonary embolism, also known as a blood clot to the lungs.

There are a lot of things that bother me about Esmin Green’s death on the floor of Kings County Hospital. See video here.

It bothers me that the media has focused on only one aspect of this case – Esmin Green was “ignored.”
This was an incredibly busy psych ward. This Huffington Post article quotes a lawsuit Esmin Green’s daughter filed against the hospital as saying that “Sometimes the unit runs out of chairs, … forcing people to wait on foam mats or on the waiting room floor.” According to the article, the lawsuit also admits that the emergency ward “is so poorly staffed that patients are often marooned there for days while they wait to be evaluated.”
Laying on the floor may not be such an uncommon occurrence at Kings County Hospital. Although not what most of us would expect, is it reasonable for the staff at Kings County Hospital to think that the woman just laid on the floor to sleep after waiting for 24 hours?
The Huffington Post article also quotes NYC Mayor Michael Bloomberg as saying “I think what [the hospital employees] said is, ‘Oh well, people sleep on the floor all the time, and I didn’t pay any attention,’” “They shouldn’t be sleeping on the floor … and you should pay attention.” [emphasis added]

You’re absolutely right, Mayor Bloomberg. If people should be “paying attention” as you state, what are YOU, as New York’s exalted mayor, doing to improve the staffing so that more of New York’s downtrodden are able to receive necessary services at King’s County Hospital? Are you donating some of your $11.5 billion in personal assets to the system to make it better? Adding additional funding from city coffers? Taking half the staff from your plush office and reassigning them to Kings County Hospital to help? Don’t make me laugh.
You just as much to blame for Ms. Green’s death as the hospital and the administrators. Don’t cut hospital funding then cut bait and run when there is a bad outcome. Put your white halo to the side for a minute and take your licks like a man. A kick in the crotch to you, sir.

It really bothers me that some of the hospital staff tried to cover up Ms. Green’s death. According to the surveillance cameras, she fell from her chair onto the floor at 5:32 AM. Other patients in the same waiting room just sat there and didn’t pay much attention to her. Security guards strained their necks to look at her from around the corner and did nothing. At 6:35 AM, a staff member nudged her with a foot to see if she would move. By then, she was already dead.
King’s County medical records showed that “at 6 a.m., [Ms. Green] was ‘awake, up and about’ and had just used the restroom.” Another entry showed that at 6:20 a.m., [Ms. Green] was “sitting quietly in the waiting room, and had a normal blood pressure.”
The people who wrote these untrue entries and anyone who prompted them to do so should be prosecuted to the fullest extent of the law. There is no excuse for lying on medical records like this and doing so gives the whole house of medicine a big black eye.

What bothers me most about Esmin Green’s death is attorney Sanford Rubenstein who is the latest attorney trying to turn a horrible situation into an instant personal retirement account.
Ms. Green’s daughter, Tecia Harrison filed a $25 million lawsuit against Kings County Hospital in connection with her mother’s death. Ms. Harrison can be seen sitting with her mother in the video … right … er … um … well … actually Ms. Harrison is nowhere to be found in the video. In fact, Ms. Harrison, according to this article, had not seen her mother in eight years. Now the emotional distress Ms. Harrison suffered over the death of someone she hasn’t seen in eight years is suddenly worth more money than Ms. Harrison would have made in many lifetimes.

My mommy was so loving and protecting of her kids, that if she was even there (in the hospital) she would not tell us,” she said. “She’d know we would be so worried and anxious.” Maybe if you bothered to see “your mommy” once or twice in the past 2920 days, you might have known a little bit more about the woman who gave birth to you. Family members state that they called Ms. Green “constantly” — even though Ms. Green didn’t have a phone of her own. From what I can see so far, the family members are about as truthful as the people making the entries in Ms. Green’s medical records. The smell of money can do strange things to people. See other articles about Ms. Harrison’s lawsuit here, here, and here.

Attorney Rubenstein’s lawsuit against Kings County Hospital has a huge problem, though.
Wrongful death? How did the hospital cause Ms. Green’s death? Don’t even try to raise the silly argument that just because Ms. Green died in the hospital, the hospital was responsible for her death. What if a friend died in your living room? Would YOU be responsible for your friend’s death?
Medical malpractice? First, if Ms. Green collapsed from a pulmonary embolism, she was going to die. There is no way that they could save her life in a trauma center ED, much less a psychiatric ED — even if they diagnosed her PE as soon as she hit the floor. Regardless of what you read anywhere else, remember this: Ms. Green’s die was cast as soon as she hit the floor of that waiting room. Not even Michael Debakey could have saved her.
Second, one of the things that a medical malpractice plaintiff must prove in order to be successful against a medical provider is causation. Sure, it is heartwrenching to watch Ms. Green lay on the hospital floor while everyone casts her aside like a dead animal. Every lawyer knows that emotional outrage is the thing that megaverdicts are made of. But Attorney Rubenstein knows that if he cannot prove Ms. Green’s pulmonary embolism was caused by some negligence at Kings County Hospital, his med mal case will never make it to the jury.

Without causation, Rubenstein’s gravy train will slip right through his fingers. So what kind of pablum is Rubenstein feeding to the media? Here are some quotes:

“The length of time that Ms. Green spent in the emergency room … very well may have contributed to her death,” he said. “Physical inactivity was obviously a significant contributing factor.”
“Rubenstein said that had Green been carefully attended to when she arrived at the emergency room, doctors might have noticed swelling in her legs and taken action.”

He hasn’t used the word “causation” yet, but he will. Right now he just had to plant the seed. Later he will cultivate it. Come to papa, baby.
Rubenstein is playing the media like a fiddle and the media is sopping it up like hungry feed hogs. In the coming weeks and months, look for more selected comments to the media from Attorney Rubenstein to try to bolster his case. Soon the words “contributed to” will change to “caused.” Also look for some eunuch expert witness to get paid tens or even hundreds of thousands of dollars to give an expert opinion that Ms. Green’s wait in the hospital was the sole cause of the blood clot that killed her and that making patients wait for 24 hours to be seen is negligent.

No. On second thought, look for Kings County Hospital to try to settle this out of court as soon as possible to get out of the national spotlight. That way the case can encourage more plaintiffs and attorneys to file multimillion dollar lawsuits for bad events that occur beyond people’s control.

Should Kings County Hospital and the staff be held accountable for trying to cover up the death of Esmin Green? Absolutely.

Should a daughter estranged from her mother for eight years and some loquacious plaintiff’s attorney be given a windfall anywhere near $16 million and $8 million respectively for Kings County Hospital’s cover up? Never.

If the money is going to go anywhere, put it into providing better funding for the care of New York City’s indigent psychiatric population. Kings County Hospital is the only option for most of the low income Black residents who live near the facility in communities like Bedford-Stuyvesant, Brownsville and East New York. After all, Ms. Harrison stated that she only wants “justice” for what happened to her mother, right? What better way to make something good out of her mother’s death than to improve the system that let her mother down in her time of need?

My crystal ball says this won’t happen. Ms. Harrison will soon be the proud owner of a house in the Hamptons.

Just like the Medicare cuts, part of me hopes that Kings County Hospital goes to trial, gets hit with the full $25 million judgment, and goes bankrupt. Close down Kings County Hospital so that the mentally ill people in these poor areas will be forced to percolate into more affluent hospitals in lower Brooklyn, Queens, and Nassau County. Between the decreased psychiatric patient access and the Medicare payment cuts, the ED overcrowding in surrounding NYC Burroughs will kill more affluent people who have to wait for care like everyone else. Once the rich folk start dying, things will change a lot faster. ED overcrowding is an equal opportunity killer.

I have a better idea. Why doesn’t Kings County transport some of the patients in its waiting room to Mayor Bloomberg’s front door and give them tents to camp out for the few days until they get care? Then someone can sue Hizzoner when the next victim dies.

Think you can run a facility on a shoestring budget and then expect that everyone’s going to receive perfect, timely care? Ain’t going to happen. Not in New York City. Not anywhere in the United States. Not even at your hospital.

Quality care, quick care, free care – pick any two.

Scalpel made a rather poignant point on Kevin’s blog regarding this quote — some people only get to pick one.

Esmin Green was the latest unfortunate example.

She definitely won’t be the last.

P.S. Think that last statement is me blowing smoke? Read this, courtesy of MDOD.

39 Responses to “Death On The ER Floor – Coming To A Hospital Near You”

  1. Tex says:

    Wow!!
    Amen, brother, amen!

  2. Pink says:

    Excellent post, Whitecoat. This is one of the best yet. Bravo!

  3. eds says:

    As far as causation and wrongful death, if you look at the video, you see Ms. Green’s waiting quietly until her collapse, despite having been involuntarily admitted for agitation. She was almost certainly given an antipsychotic, and according to this BBC article from a few years ago, some antipsychotics can cause… deep vein thrombosis(http://news.bbc.co.uk/2/hi/health/957182.stm). No doubt the hospital was underfunded and understaffed, but nonetheless the staff’s actions probably did, yes, cause her death. And whether or not her children (who live in Jamaica and probably couldn’t afford to visit their mom regularly, let alone immediately fly up to be at her side in the emergency room) deserve a windfall on her death, litigation will at least shine a light on what actually happens to people like Ms. Green.

    Assuming facts not in evidence, counselor.
    There are a million and one possible reasons for the PE. Maybe she had a pre-existing clot, took an overdose of methadone before she got to the hospital, passed out from the methadone, and then the fall caused a DVT to break loose and kill her. Why is your scenario any more likely than mine?
    My bet is that litigation will NOT shine a light on what happened. The case will be settled out of court in a matter of weeks and there will be a non-disclosure agreement in place. No one will find out anything and the same thing will just happen again with the next underfunded hospital.

  4. Nurse K says:

    The ultimate irony would be if Esmin was at the psych hospital for depression due to not seeing her daughter/troubled family relationships.

    Of course, not to be the devil’s advocate, but we don’t know if a timely intervention could have saved her…tubes and heparin and more tubes and time go a long way…

    A psychiatrist is going to check a patient’s legs for DVTs? Is that right after he gets done with the gyne exam? We both know that doesn’t happen. Maybe she had a red hot leg. Who knows? Even then, heparin isn’t going to dissolve the clot in one day. She still would have flipped the clot – just wouldn’t have been on the ED floor. Instead she would have died in her sleep and no one would have given it a second thought.
    Once the PE caused her to lose consciousness, she wasn’t coming back. I have never seen a code run where they treat for presumptive PE and I have been to a lot of codes.

  5. one who knows says:

    I haven’t read anything that indicates Ms. Green was estranged from her family.

    She was a native of Jamaica but had been living in the United States. Her daughter was living in Jamaica.

    It’s not at all unusual for immigrant families to be split up like this, especially once the kids reach adulthood. And if they’re poor, they can’t really afford the airfare to travel back and forth.

    It’s fine for you to vent your outrage, but you would have more credibility if you would avoid jumping to conclusions that aren’t warranted by the facts. You don’t know squat about this family’s dynamics.

  6. HyperAl says:

    Eds Says “Litigation will at least shine a light on what actually happens to people like Ms. Green.”

    Like you I want to believe in that, but in Malpractice Lawsuits, that is hardly the case. It is hardly about the truth.

    Most plaintiff lawyer will tell you, they don’t want to go to trial because it is more work for them and at the end they may lose the case and make nothing. The less merit the case has the more they resort to trial in the court of public opinion. Scare tactics to force a settlement and an easy buck.

    Exactly. The shame factor will cause the hospital to fold like a house of cards.

  7. Amazing blog. Thank you and I am linking this on my blog in hopes it gets even more readers!!!

  8. eds says:

    Fair enough, Al, but on the other hand, the only reason the video of Ms. Green’s death came to light in the first place was because of a suit by the Mental Hygiene Legal Services against the hospital. Moreover, as I said in my first comment, it looks extremely likely to me that her death was directly caused by her forced treatment. I have no doubt that there are a lot of ridiculous, damaging malpractice lawsuits out there. I wouldn’t even be surprised if most malpractice lawsuits were purely cynical money ploys. I just don’t think Esmin Green’s case is one of those.

    There are a lot of legitimate lawsuits. The problem with this one is that it is using the “shock” value of the video to essentially extort money from the hospital.
    If we assume that Esmin Green was seen immediately, was admitted, and was instead waiting in the inpatient psych wards or the lunchroom when she threw her PE, it wouldn’t have made national news.
    The $25 million damages could be used to improve the services provided to other indigent psychiatric patients and keep this scene from repeating itself. Instead, the money will go to one attorney and to several of Esmin Green’s family members who don’t even live in the US.
    How does that improve the care that patients receive?

  9. Family Med Resident says:

    Excellent post. There are so many things wrong with this story that didn’t come out in the mainstream media coverage. Thank you for going over the many issues that are brought up by this event. And I agree with you that it’s unlikely the PE would have been detected or that she would have been saved even in the best of circumstances. Which of course, as you point out, does not take away from all the other problems with the system in evidence.

  10. Kelly says:

    Bravo! Great post!

    I work for a psychiatrist in one of the largest cities in America. I am amazed at the number of phone calls I get from people desperate for an appointment for themselves or a loved one. The wait for an appointment is currently 3 weeks…almost 4 weeks. What is more amazing is that the doctor I work for does not take insurance at this location. It is his private practice. (He does, however, take insurance and medicare at his other 2 offices). When I tell people that it will be at least 3 weeks before they can be seen…they almost always tell me how frustrated they are that they cannot seem to make an appointment with any doctor – they all have a 2-3 week wait. The lack of competent psychiatric care (especially for children) is almost non-existent. It’s sad.

    Thanks. From my experiences in the ED, it is only going to get worse.

  11. mottsapplesauce says:

    Wow–hell hath no fury than a WhiteCoat rant! Excellent post.
    I’m curious though, based on the comment from ‘One Who Knows’, if the daughter was really too poor to be in contact with her mother. It’s not like Jamaica is light years away, don’t they have mail service? I remember seeing this when it first aired & some of my co-workers thought the same thing I did. Why didn’t someone in that very room notify the staff? Then I got to thinking, they were probably in fear of litigation. I know I wouldn’t have ignored her, but not everyone in today’s sue-happy society is willing to lend a hand. What a shame.
    I totally agree with you WhiteCoat that nothing will improve until it starts affecting people with clout.

    My guess is that people laying on the floor in the building was not so uncommon an occurrence. The daughter’s lawsuit says so. If someone is laying on the floor in a restaurant, everyone will notice. If someone is laying in bed, no one thinks twice. If someone is laying in an airport, whether it arouses concern depends on the situation – in the middle of an aisle would cause concern, against the corner laying on luggage might not.

  12. name says:

    Dr. Debakey died three days ago.

  13. kristen says:

    Mottsapplesauce: “nothing will improve until it starts affecting people with clout.”

    The problem is that people who have mental illnesses do not have “clout.” When I was first diagnosed as bipolar, I was hospitalized twice in less than a year. One of those was involuntary after a suicide attempt. I had very good private insurance. I still spent two weeks of my life in Psych ward dumps. The “better” psych ward was actually worse. In Psych ward you can understand that “normal” common things may be absent. Like pens, TP holders, plastic garbage bags, toothpaste tubs. Everything that could possily hurt someone. But the dirt, the mold, the dirty rooms…are just gross. Not to mention the screaming and the yelling (by both the staff and the patients). Psych wards are dismal places.

    It would not take much to make these places better. A coat of paint, a cleaned bathroom, a dvd player for the ward? When you think that people have their own phone and TV in the medical wards, and a whole ward shares a TV in a common room, you would think they would at least have a nice tv.

    It is very upsetting to have many of your rights taken away, and then live in a situation that is worse than the local spca. AT least the dogs have beds to sleep on.

  14. Rogue Medic says:

    Eds,

    The study you mention was on outpatients. They found that PE (Pulmonary Embolus) was possibly more common, especially in the first 3 months of treatment. The lower potency drugs carried the greatest risk. If this patient was medicated acutely, I would expect a higher potency drug, but I do not know anything about what is used in this facility. You make a pretty definite leap from a review of outpatient studies to a single inpatient episode. This is the kind of thing we can expect from the lawyer, but we should be more skeptical.

    Treatment with antipsychotic drugs is important. If we keep eliminating the drugs available for use, how will that help anyone, but the trial lawyers?

    Physical inactivity may have contributed to the development of clots, but she does not appear to be an active healthy person to begin with. Blaming her “inactivity” on a 24 hour period in the waiting room is misleading. Sitting in a chair for an extended period of time is something that caused Vice President Dan Quayle to develop blood clots in his legs while flying around doing what a VP does. His flights were much shorter than 24 hours.

    If she developed a saddle embolus, there is little that can be done for her. By the time she arrives at the equipment to place a line to deliver heparin straight to the clot (not likely to dissolve it while her brain is still functioning), or to advance a catheter to the clot and break it up directly (I’ve only read about this, never seen it done), or both – the benefit from treatment is gone.

    All of this is assuming that they immediately reach the correct conclusion about the cause of cardiac arrest and treat her appropriately and immediately. To read Eds’s posts, you would think that heparin injections are being given at the door, just to keep the deaths down to a few a day.

    This is not an easy diagnosis in a patient with no apparent risk factors. Of the “potentially reversible causes” of cardiac arrest, PE is one of the least likely to respond to treatment, in part because of the difficulty of diagnosing it correctly. ED doctors will tell you that the most difficult diagnosis is PE. And that is in an awake patient with chest pain or difficulty breathing, not an unresponsive, pulseless patient. There is no test that will guarantee that you do not have a PE – none.

    One of the articles linked to states, “Green, a patient at KCHC, was allowed to writhe on the floor of its psychiatric emergency ward for a full 24-hours before a nurse realized Green was in distress; by then, Green had died.”

    “writhe on the floor . . . for a full 24-hours”? Not in the video I saw.

    Dr. WhiteCoat,

    Excellent post. You point out many things that we do not find elsewhere.

  15. Gabriel... says:

    I’m not sure where there could be a reasonable case for causation when the woman was admitted for “agitation and psychosis”, then was left in the psychiatric ward waiting room where she later died from a pulmonary embolism. This case has the definite feel of various groups trying to manufacture a martyr after the fact… she didn’t die Because of neglect or Because the American system of health care is overly stretched or broken. If she had been admitted straight away to the psychiatric unit for overnight observation she would have died in a bed or in the admissions office.

    Speaking of forcing martyrdom where it doesn’t belong, there’s very little to no chance her death was caused by any immediate dosing of anti-psychotics. In the October, 2000, BBC article “Ed/eds1980″ references it was written “if this association is true, and this paper seems to strongly suggest that there is a link, the overall risk is still small.” The numbers I found say the chance is less than 0.01%, and that’s over the long term. I’m pretty sure there’s a greater chance she was mistakenly injected with a massive overdose of NovoSeven by a sociopathic hemophiliac.

    Esmin Green is dead and the health care system needs to be better… the two don’t have to have anything to do with each other, but both are unfortunately true.

    The more news articles I read, the more that I see Esmin Green was a wonderful lady who was failed by the health care system where she sought help. I agree with you that it is unlikely that her ultimate outcome would have differed. The system failed her by its cover-ups. The system failed her and everyone else by creating an atmosphere where 24 hours waits for “emergency” care are the norm – even if this aspect of the system did not directly contribute to Esmin Green’s death.
    More and more of us are going to become victims.

  16. AA says:

    There are so many comments I want to make but I will respond to this quote:

    “She definitely won’t be the last.”

    I agree but for probably different reasons from what the commentator intended. As a person who is tapering off of all psych meds due to horrific side effects, including a hearing loss, when you have a psych med history, everything is viewed through the lens of that label. You know longer cease to be a person who may have a medical problem in addition to psych issues.

    I know someone who was always very compliant on psych meds in spite of devastating side effects. But when this person complained one day to her psychiatrist that a med was causing nausea, he attributed her complaint to her mental illness. When she admittedly became belligerent that he wouldn’t listen, he involuntarily hospitalized her which induced trauma. She finally got her medication changed but it should have never gotten to that point.

    Another blogger with a psych med history was diagnosed myasthenia gravis by a neurologist in an ER. She had ended up there because her previous doctor refused to consider that something was seriously wrong and suggested she go back on her antipsychotic.

    So when Esmin Green toppled over, the same camera angle was used. As a result, the issue isn’t whether quick treatment could have saved or not or whether the daughter really cares for her mother or not. Those are smoke screen issues that are diverting us away from what the real issue is which is when you became a psych patient, you cease to be a human being who has possible other medical problems. Until the attitudes of the medical profession change, which include comments on this blog, we will have future Esmin Greens.

    Your point is unclear to me.
    If you’re saying that psych issues may overshadow medical problems, I agree to a point. On the other hand, no competent physician is going to ignore a psych patient’s chest pain and say “it’s all in your head.”
    How do the attitudes change for the better? Empathy? The sheer volume of patients makes empathy difficult. Failure of doctors to consider other diagnoses? How exactly does one verify psychosis in a patient on medications? Should we go performing thousands of dollars in extra testing on each patient to be *sure* we have the right diagnosis? If so, who’s going to pay for the testing?
    You can’t demand the best health care someone else can pay for and then complain when someone else isn’t willing to pay for it any more.

  17. eds says:

    Rogue Medic,

    Thanks for the medical context– you’re right, I did make a pretty big leap there, and the things you’ve pointed out do convince me that it would have been unreasonable to expect the staff to have seen Ms. Green as being at risk or to catch her problem in time. (And I see by the “Eds1980″ that you know I’ve been looking anywhere I could for people discussing this incident… as you can tell, this story really upset me.) Gabriel’s probably also right that it’s tempting to see Ms. Green as a martyr. You’re also right that treatment with antipsychotic drugs is important. I don’t at all think these drugs should be off-limits– but I do think that they should be used very carefully and that the harm they sometimes cause shouldn’t be immediately dismissed. Kristen’s and AA’s points about the tendency to write off the valid concerns of people with a psych diagnosis are right on, and I think that problem is not solely a result of underfunding and understaffing.

    But, look– blaming her children is pretty disgusting. And if this hospital really was a place where it was reasonable for the staff to leave Ms. Green writhing on the floor in death throes for an hour since “laying on the floor may not such be such an uncommon occurence”, was that hospital the best place for her to be?

  18. IVF-MD says:

    Although my readers tend to be a very specialized audience, I felt inspired to link to this excellent post of yours, if for nothing other than to remind people just how much information is held back by the mainstream media.

    Thanks!

  19. Rogue Medic says:

    Eds,

    I did not get the impression that Dr. White Coat was blaming the children. He was criticizing the “hit the jackpot” approach that her family appears to be taking. The staff of this facility has spent more time with Ms. Green than her family has. Why? I have no way of knowing. Maybe she has a long term psychiatric condition that has driven her family from her. I could come up with dozens of theories. I think that it is a good idea to cover all of this in a post on her death. I think that this was very well done, here.

    Yes, psychiatric drugs have huge problems. I am not in favor of just handing out medication. Some people do not seem to be able to manage without medication. In acute situations, antipsychotics can mean the difference between the patient being heavily sedated or being tied up and making any underlying medical condition worse with an increased heart rate, increased blood pressure, increased respiratory rate – people die while restrained, too.

    Many of the drugs to treat psychological/neurological conditions have such severe side effects, that the patients will stop taking them. The medical condition seems less of a problem than the treatment.

    I may have jumped the gun on the family dynamics based on the information available at the time I wrote the post. I don’t “blame” the children, but I find it ironic that just because she is Ms. Green’s daughter, many people seem to accept (even expect) that Ms. Harrison is entitled to a large sum of money just because her mother was featured on the video.
    Got all kinds of thoughts about antipsychotic meds. This just isn’t the forum right now. Maybe worthy of a post in the future.

  20. AA says:

    Hi,

    You said,

    “Your point is unclear to me.
    If you’re saying that psych issues may overshadow medical problems, I agree to a point. On the other hand, no competent physician is going to ignore a psych patient’s chest pain and say “it’s all in your head.””

    But that is exactly what is occurring. I know you find that hard to believe but the examples I just gave you are proof of that. I can give you plenty more if you want.

    There was also a survey of physicians that showed that they take the complaints of people with psych histories less seriously than if patients don’t have them.

    Sorry, I don’t mean to sound rude but you guys truly don’t seem to understand what is going on or you don’t want to know what is going on.

    <>

    Huh? What does the sheer volume of patients have to do with the fact that 4 to 6 employees saw Ms. Green on the floor and did nothing?

    Attitudes will change for the better when you start viewing patients with psych histories as human beings.

    Sorry, as one who worked in special ed for $11.00 per hour and dealt with many students, I am not buying that excuse. If you can’t have empathy, why are you in the helping profession?

    <>

    This has nothing to do with cost. Again, the issue is because those staffers saw Esmin Green as a psych patient and not someone who was medically in trouble, she was ignored.

    I don’t understand your point about verifying psychosis in a patient in meds. That has nothing to do with what I said.

    But since you bought up cost, it is better to get the diagnosis right initially than pay money in lawsuits. You get what you pay for which is the argument you were using on me although I still don’t understand why. But I will throw it back at you.

    Regarding your point about Ms. Green’s daughter being entitled to money, again, that is not the point. Sometimes, lawsuits are the only way to get someone’s attention regarding poor treatment.

    Even if other places could care less about people with psych histories, the fact that they may pay out huge amounts of money in lawsuits might convince them to change their ways.

  21. AA says:

    Hi,

    I totally messed up my previous post. Sorry about that. Hopefully, you can figure out what I was responding to.

    I am too tired to resurrect it but will visit later in case you have questions.

  22. Nurse K says:

    A psychiatrist is going to check a patient’s legs for DVTs?

    No, I meant if they’d pulled her off the floor right away, could she have lived? It’s not 100% obvious when she actually died, although the initial collapse doesn’t look really promising. The main question that will be asked in this lawsuit is if a timely intervention after she fell could have saved her. Generally in a medical negligence-type lawsuit you have to prove that something done was wrong or negligent(however that was defined) and that negligence caused harm to the patient, in this case, a preventable death. Technically, it would seem that if the PE was massive enough to kill her right away or nearly right away and no amount of help could have caused her to ventilate properly, the negligence of “failure to monitor” would be null and void. That’s my Medilegal 101 there, but, of course, the hospital will pay no matter what.

    I don’t know about antipsychotic meds in this hospital, but we never give them in the lobby without a physician eval first.

  23. Teresa says:

    One thing that bothers me that has only been briefly touched–is it reasonable to expect a patient to wait for long periods of time, like 24 hours, without providing at least a cot to lie down on? This is one reason I probably would never go to the ED unless I really could not delay medical treatment–I couldn’t stand the wait conditions. Not providing at least a cot to lie on seems inhumane to me. But it’s not worth millions in a lawsuit, for sure.

    I’m not suggesting, by the way, that a cot would have prevented this tragic death. This is a total red herring, I know; it’s just a sidebar question that occurred to me.

  24. Rogue Medic says:

    My first comment I mentioned heparin to dissolve the clot. That would not be the appropriate drug, tPA would be the appropriate drug. A bit of brain flatulence there. It would still be unlikely to work.

    When reading that her daughter is in Jamaica, I thought “it is only across the river in Queens,” but that is a different Jamaica. :-)

  25. Stacie Mc says:

    Rouge Medic,

    Thanks for your last post. Too many people think that giving heparin dissolves clots. Even Whitecoat makes this statement in a reply to a comment above: “Even then, heparin isn’t going to dissolve the clot in one day.”.

    The goal of heparin therapy is NOT to dissolve the clot. It does not do that. It is given to prevent the clot from getting bigger.

    After the clot has stabilized (in size), patients go home from the hospital with the clot still in their body. The body may or may not reabsorb the clot in time.

    Going into the vein to remove the clot actually carries a higher risk that pieces will break off and cause trouble than leaving it alone does.

    If it is felt the clot is at risk for breaking loose and is in the lower extremities, a filter may be placed in the vein leading back to the heart to capture stray pieces and prevent them from getting to the heart or lungs.

    Just a FYI to everyone.

  26. rogue medic says:

    Stacie Mc,

    I was just referring to immediately life threatening PEs. If you go to the 2005 ACLS guidelines, in Part 7.2: Management of Cardiac Arrest, under Potentially Beneficial Therapies they describe the very limited succes with tPA.

    The last link will take you directly to the section. The first link will take you to the issue of circulation that contains the free full text of the ACLS guidelines.

    There are some places that are using a wire to break up the clot and/or a longer catheter to directly introduce the tPA into the clot – but this is only for the patient in cardiac arrest. If the patient has enough cardiac output to produce some kind of blood pressure, more conservative treatment is used. I wouldn’t be surprised if these treatments become more common for less critical patients. With strokes, catheters are bing advanced to the site of injury to deliver a much smaller dose directly to the area, rather than expose the patient to the risk of systemic administration of drugs with dramatic side effects.

    Thanks for the links.
    I still think the chances of Ms. Green being brought back under the best of conditions were small and that the chances of her being brought back in a psychiatric hospital were nil.

  27. EE says:

    Teresa,

    Providing cots for a patient to lay down on in the waiting room is a bad idea. First, that would mean more cleaning. Second, more of the homeless would come in and sleep on them. Third, this would create arguments in the waiting room “why you be laying on my cot, thas mah cot,” etc. If you’re waiting in the ER for that long, chances are you shouldn’t be in the ER in the first place. The ED is a place for emergencies, comfort isn’t exactly a priority (with the exception of a few instances, burns for ex.)

  28. Lady says:

    Interesting, post.

    Now, imagine that the woman was white! Do you still have the same comments? :(

    I don’t see how race plays any part in what happened to Ms. Green.
    Would I be upset if the same thing happened to a Hispanic, Anglo, Chinese, Muslim? Absolutely.
    Do I think that anyone deserves a $16 million windfall because a family member seeks healthcare services and there aren’t enough services available to care for the patient? Never.
    The only potentially good thing about this case is that it brought to light the consequences of inadequate healthcare funding. Unfortunately, the media and Ms. Green’s attorney are twisting it into an issue of blaming the hospital for not doing more on a shoestring budget.
    Sad on several levels.

  29. Family Med Resident says:

    OK EE (#28), you completely missed the point (unless you were being facetious and I missed it). The patient NEEDED to be there. It was an EMERGENCY. A psych emergency is still an emergency and requires treatment. Most of the patients are not there for fun, they are there to get the medical care they need.

    The point is that there is such a shortage of psych beds that people routinely wait 24-48 hours in the ED before being placed. Would you seriously begrudge a psychotic patient who is in the ED for over a day a cot to lie down on?

    I also see no need to make fun of how certain patients talk.

  30. EE says:

    Yes, I don’t think we should be putting cots in the waiting room. Transfer the patient out if you need to, thanks to the fact that there aren’t psych beds, or, stick them on a cot in the hall. I’m not arguing that she didn’t need to be there (I actually don’t know if she did or not, she wasn’t my patient so I’m not going to comment on it) but, I stand firmly by my point that cots shouldn’t be in the waiting room. A good percentage of patients in ED waiting rooms for long amounts of time really DON’T need to be there. We shouldn’t encourage they’re behavior by providing them a place to sleep.

  31. EE says:

    I also wasn’t making fun of the way they talk, that’s just how it is. I’m dead serious.

  32. MQ says:

    PE that causes collapse isn’t always fatal. It’s often but not always. I was involved in one case in northern Europe. About 20 years old boy collapsed on the street. He called taxi, not ambulance, and came to our ER. In ER he was painfull and tachycardic about 160/min. He lost consciousness again, and we gave thrombolytic i.v. We had to give even CPR for a while. Later in nearby university hospital they made him embolectomia. One month later the boy walked to our ER and brought us chocolate.

  33. Teresa says:

    EE: Providing cots for a patient to lay down on in the waiting room is a bad idea.

    From the article: a woman in a hospital gown in the waiting area of the psychiatric emergency room

    She was already a patient. It was a psych emergency room. You are knee-jerking about abuse of regular emergency rooms.

    Did you read the article (DB Medical Rants; Happy Hospitalist) about long tails? You would benefit enormously from learning to examine details before you come to the same conclusion every time you see something familiar.

    From the article: who had been waiting for a bed when she collapsed, had been involuntarily admitted the previous day for “agitation and psychosis,”

    What is a patient who has been admitted involuntarily supposed to do if there isn’t a bed for them?

    Your attitude is disturbing. You don’t seem to have much compassion for the struggles of people who have a disease they can’t control:

    EE: We shouldn’t encourage they’re behavior by providing them a place to sleep.

    Well there you go. Malingering psychotics shouldn’t have their behavior encouraged by providing them with a place to sleep when they’ve been involuntarily committed. Let them eat cake and sit up in chairs or pace the floors, but they will not be given a comfortable place to sleep lest, God forbid, they are encouraged to continue to be psychotic.

    A bit of sarcasm, but I think having to wait 24 hours for a place to sleep where one had zero choice about the accommodations would make a lot of rational people nearly psychotic.

  34. EE says:

    Great, I don’t care about the details. Put them in a hallway, cots in a waiting room is a bad idea.

  35. sonya lazarevic md says:

    I really enjoyed your post! I wanted to comment in particular on the family dynamics portion of this case….

    It is true that people who immigrate to the US may not ‘see’ their family for long periods of time, its unusual, however, for them to not be in touch at all. I find people in NYC Caribbean communities to maintain very close family ties, but then again, exceptions occur…. Its my brief experience as a Psych resident, that people with chronic mental illness lose contact with their families. its my observation that the more chronically disorganized and psychotic a patient becomes, the less family support they have. Its understandable. Family often do not have the understanding or resources to manage mental illness.

    I do all my calls in the CPEP, which is a specialized psych ED, any my hospital. Comments about cots being available for psych patients as bad thing is uninformed. If my attending or I need to move people out of the CPEP because the pt doesnt belong there or needs to be admitted, they are moved. You get your share of malingerers, but in genreal most people come because they need to be there. Cots are needed and well utilized. Sometimes patients must rest or are sedated and therefor must be reclined.

    I agree with the previous comment, if the pt was white (even of moderate income), this attention would have different meaning to it.

  36. [...] is it just a coincidence that a hospital New York was in the news for some bad patient outcome not too long [...]

  37. [...] it’s Beatrice Vance Then it’s Esmin Green Just today, Kevin MD linked to another story about Brian Sinclair who died in Winnipeg after [...]

  38. [...] recent blogs have discussed or linked to articles about patients who have died in ED waiting rooms. Thanks to SymTym for some other examples – from Sacramento, and more evidence of problems with ER [...]

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