July 20, 2021

The Court of Appeals of Georgia (“Georgia Appellate Court”) held in its Opinion filed on June 16, 2021: “there is evidence suggesting that the patient warranted care his treating physician did not provide to him. Experts testified that Moss should have been placed on the Level II track order and that his troponin levels should have been monitored over several hours before he was discharged. Further, a cardiologist who reviewed Moss’s ECG testified that it had significant abnormalities, in contrast to Dr. Stokes’s interpretation of the test as unremarkable. To the extent Nurse Stelmachers failed to perform actions – such as calling Dr. Stokes’s attention to Moss’s troubling symptoms, including his nausea and vomiting, or advocating for Moss to be placed on a treatment order track – that would have made it more likely for Moss to be provided with the care that was warranted, this situation is distinguishable fromthat in Reeves, where the missed diagnosis would have triggered a consult with a urologist but would not have resulted in any change in the patient’s treatment. Consequently, we do not find Reeves to be controlling, and, for the reasons stated above, we conclude that genuine issues of material fact remain as to whether Stelmachers’s negligence proximately caused Moss’s death and that the trial court therefore erred by granting summary judgment.”

The Underlying Facts

On July 26, 2014, 57-year-old Ralph Moss was transported by ambulance to Medical Center of Central Georgia’s (“MCCG”) Emergency Department after he complained of vomiting and chest pain that radiated to his left arm. Moss arrived at the Emergency Department at 12:28 p.m., and he was not experiencing chest pain at that time. Briana Stelmachers, a nurse in the Emergency Department, assessed Moss and, based on standing orders, performed an electrocardiagram (“ECG”) and troponin level blood test. Moss’s ECG was initially read as “Borderline ECG – Preliminary – MD Must Review STAT,” and emergency room physician Dr. Nathan Stokes subsequently interpreted the ECG as showing “no ischemic changes.” A troponin test was performed at 1:24 p.m., and it revealed that Moss’s troponin level was elevated at 0.09ng/mL, above the normal range of 0-0.08ng/mL.

To assure that each patient presenting to the emergency department with chest pain receives the proper diagnosis and that heart attack core measures are addressed, MCCG’s internal policy requires a physician, nurse practitioner, or physician assistant to assign patients to one of four order set tracks. Nurses are to follow orders on the assigned track, so if a patient has not been assigned a track, the policy provides that the nurse should ask the physician for track orders. Tracks 1–3 are for patients with chest pain of certain or probable cardiac origin and require, among other things, serial ECGs and serial troponin testing. Track 4 is for patients with chest pain of probable non-cardiac origin and does not require serial testing. Stelmachers initially triaged Moss as “Level III,” but Dr. Stokes did not assign Moss to a track, and Stelmachers did not approach Dr. Stokes about placing Moss on one.

Dr. Stokes evaluated Moss at 1:50 p.m. Moss told Dr. Stokes that he had recently undergone a stress test and the results were negative. Based on Moss’s physical exam and history, Dr. Stokes documented several risk factors for heart attack, including a history of high cholesterol and COPD and a family history of coronary artery disease, hypertension, and diabetes. Moss told Dr. Stokesthat he had no nausea or vomiting. Although Moss had complained of those symptoms to EMS and Nurse Stelmachers, Dr. Stokes could not recall whether he saw the report documenting Moss’s complaints of those symptoms before he decided to discharge Moss.

Moss was discharged from the Emergency Department at 2:42 p.m, having received a single ECG and single troponin test. Dr. Stokes entered the discharge instructions and Stelmachers went over them with Moss. The discharge paperwork advised Mossthat, based on his exam, the exact cause of his chest pain was unknown but his condition did not appear to be serious and the pain did not appear to be coming from his heart. Moss died the next day, at his home, of an acute myocardial infarction.

Georgia Appellate Court Opinion

The Georgia Appellate Court stated: “We conclude from this record that there is a genuine fact issue as to whether Nurse Stelmachers’s actions were a proximate cause of Moss’s death. We first note that, in this case, Evans presented expert testimony that Moss’s premature discharge “almost certainly led to his death.” And although it was Dr. Stokes who made the decision to discharge Moss, that does not absolve Nurse Stelmachers from liability … There was also evidence that, even if Dr. Stokes had not been receptive to Stelmachers’s advocacy, she could have reached out to a charge nurse or other physician. This testimony creates a question for the jury as to whether Nurse Stelmachers’s breaches in the standard of care were a proximate cause of Moss’s premature discharge, which led to his death … there is evidence in the record establishing that it was the premature discharge that caused Moss’sinjury. And, as discussed above, there was evidence that Stelmachers’s breaches in the standard of care contributed to that premature discharge.”

Source Evans v. The Medical Center of Central Georgia, A21A0256.

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