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Diabetic w/.24 BAL treated in ER & discharged--dies in hosp.

CASE ON POINT: Dagner v. Anderson, 651 S.E.2d 640 (2007)--VA

CASE FACTS: On the evening of September 22, 2000, Caroline Dagner, a 52-year-old insulin-dependent diabetic, was transported to the ER at Southside Community Hospital after being found unconscious in her apartment by her adult daughter Keisha Dagner. It was undisputed that Dagner had taken her daily doses of insulin, had not eaten any solid food, and had consumed a considerable quantity of beer. While en route to the hospital, emergency medical personnel determined that Dagner was likely suffering from hypoglycemia, and gave her an injection of glucagon in an effort to stabilize her condition. Dagner responded positively to the glucagon treatment and began to regain consciousness. Upon arrival at the hospital's ER at 8:35 p.m., Dagner was evaluated by RN Kim Brown, a triage nurse. She was then examined by Dr. Charles Anderson. Nurse Brown and Dr. Anderson concurred that Dagner's condition was the result of diabetic hypoglycemia. They also detected a smell of alcohol on Dagner's person and suspected that she might be intoxicated, a factor which would interfere with her body's ability to recover from the hypoglycemic episode. Dr. Anderson ordered various lab tests including a blood alcohol level test. He directed that Dagner be given a meal, and that she receive 50 milligrams of dextrose. While Dagner ate the meal, Dr. Anderson spoke with her about her routine for managing her diabetes. During that conversation, Dagner, who then appeared to be fully alert and responding normally, conceded that she had in the past encountered complications in managing her blood sugar level when consuming alcoholic beverages. Dr. Anderson warned her that she "should never drink alcohol again." After receiving the lab test results, which, among other things, showed a blood alcohol level of .24, Dr. Anderson discussed a management plan with Dagner, directing her to return home, measure her blood sugar level, eat a snack, and rest. He then discharged Dagner from the ER shortly after 10:p.m. At Dagner's request, Nurse Brown called Keisha Dagner to advise her that her mother was being discharged and needed to be taken home. Keisha told Nurse Brown that she would be unable to leave work and come to the hospital until the next morning. Dr. Anderson was not advised that Dagner would not be able to return home and follow the management plan he laid out for her. Dagner remained in the waiting area of the ER, unattended for over eight hours. When hospital personnel next checked Dagner on the morning of September 23, she had a blood sugar level of 17 and was comatose and unresponsive. She was admitted to the hospital and died on December 20, 2000, without regaining consciousness. Keisha Dagner, in her capacity as administratrix of her mother's estate, brought suit for wrongful death against Dr. Anderson and the hospital. After a jury trial, the jury returned a verdict for Dr. Anderson. Keisha appealed.

COURT'S OPINION: The Supreme Court of Virginia reversed the judgment of the trial court and remanded the case for a new trial. The court concluded that the thrust of Dr. Anderson's defense was that his discharge of the patient from the ER did not violate the standard of care since it was not foreseeable that the patient would suffer an AWS seizure after her diabetes-induced hypoglycemia had been treated and stabilized. The court concluded that the improper admission of Dr. Shank's opinion testimony on behalf of Dr. Anderson, that the patient had suffered an AWS seizure, was the only evidence offered to rebut the estate's evidence to the contrary. The court ruled that this could have influenced the jury to find Dr. Anderson not negligent. The court reversed the judgment of the trial court and remanded the case for a new trial.

LEGAL COMMENTARY: The court rejected the estate's contention that the trial court erred in allowing the jury to consider evidence that the patient's brain injury and subsequent death were caused by an AWS seizure. The court perceived the issue before the jury to be whether Dr. Anderson's treatment of the patient, specifically his decision to discharge her from the ER, rather than to delay discharge for further observation, or to admit her to the hospital, fell within the applicable standard of care for a physician providing treatment to a patient suffering from diabetes-related hypoglycemia in an ER setting. In this context, evidence as to the actual cause of the patient's subsequent coma, brain injury, and death was clearly relevant in determining whether the standard of care was violated. The deceased patient's estate had the burden of showing that a reasonable emergency care physician, under the factual circumstances known to Dr. Anderson, would have recognized that the patient's condition might worsen with respect to the actual cause of her subsequent brain injury and death, whether from a diabetes-related trauma or some other cause. If the cause of her brain injury and death resulted from, or was contributed to by, an AWS seizure as the defense maintained, then the estate would have been required to show that Dr. Anderson should have foreseen that possibility prior to discharging the patient. Accordingly, the court held that the trial court did not err.

A. David Tammelleo JD Editor & Publisher

Meet the Editor & Publisher: A. David Tammelleo, JD, is a nationally recognized authority on health care law. Practicing law for over 40 years. he concentrates in health care law with the Rhode Island firm of A. David Tammelleo & Associates. He has presented seminars on medical, nursing and hospital law throughout the United States. In addition to his writings as Editor of Medical Law's, Nursing Law's & Hospital Law's Regan Reports, his legal articles have been published in the most prestigious health law journals. A prolific writer, his thousands of articles, as well as his achievements as an attorney and lecturer, have won him recognition in Martindale-Hubbell's Bar Register of Preeminent Lawyers, Marquis Who's Who in American Law, Who's Who in America and Who's Who in the World.
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Title Annotation:Medical Law Case on Point
Author:Tammelleo, A. David
Publication:Medical Law's Regan Report
Date:Feb 1, 2008
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