A woman presented to urgent care following a t-bone car accident with complaints of intense left side body pain—specifically neck, shoulder, and rib pain—as well as nausea. The patient was referred for radiology by the attending physician, and her x-rays were examined by the radiologist. The scan of her cervical spine showed no abnormalities and the x-ray of her left shoulder displayed superior elevation of the clavicle with no fracture. The patient was diagnosed with left acromioclavicular (AC) joint separation and nausea. The attending physician prescribed anti-nausea and pain medications for her discomfort and was referred to an orthopedic surgeon.
After being discharged from the hospital, the patient collapsed at home where her husband attempted CPR and called 911. The patient was transported to an emergency medical center and was coded by staff for forty minutes until she was stabilized. She underwent several tests and examinations, including x-rays, CT scans, and a FAST examination. The tests revealed she had rib fractures, liver lacerations, stroke-like symptoms, and spleen injuries. The patient was immediately rushed into surgery for a laparotomy and splenectomy.
After surgery, the patient was moved into the surgical intensive care unit (SICU), where a post-op CT revealed a subdural hematoma with herniation. At this point, she had gone into organ failure and was pronounced brain dead later that day.
Despite what the decedent described as a 10/10 pain level on the left side of her body, neither the attending physician nor the radiologist treated her as a trauma patient. No total body CT scan was ordered and no FAST (Focused Assessment with Sonography in Trauma) examination was taken. Furthermore, the now-deceased patient was not transferred to an acute hospital that would have the proper equipment to treat her undiagnosed injuries. All of these missed protocols and lack of care led to the patient’s untimely death.
It is clear that liability rests with the defendants for failing to properly examine, diagnose, and treat the decedent. Any reasonably sensible doctor would have categorized the decedent as a trauma patient based on her exhibited symptoms, to which they would have immediately transferred her to a trauma hospital. Considering the patient reported directly from a scene of a motor vehicle accident, the attending physician should have been on high alert of the probability that she sustained splenic injury or head trauma.
The medical records alone prove the substandard level of care performed by the attending physician, leaving no defenses for their negligent actions. The patient put her trust in the medical team at the urgent care, who essentially sent her home with a bandage over an open wound.