In January of 1996, as opening day for "Rent" approached, Larson felt unusually tired. He went to the emergency room at St. Vincent Hospital‘s complaining of a fever and chest pain. St. Vincent‘s staff concluded the patient was suffering from a viral syndrome, and sent him home. The next day Larson again went to an emergency room, this time at Cabrini Medical Center. On this visit he complained of severe chest pain and dizziness. After conducting some tests and speaking with Larson, Cabrini staff sent him home with a diagnosis of food poisoning. He died at home that night of a dissecting aortic aneurism.

     

    The success of the show, the media coverage of Larson's work and death, and the investigation by the New York Department of Health followed. St. Vincent Hospital was fined $6,000 as a result of the investigation. The Department of Health was particularly critical of nursing involvement. The Department noted that nursing staff initially assessed Larson's situation as "urgent" based on his complaints of severe chest pain and his abnormal blood pressure readings. The Department was critical that, contrary to hospital policy that urgent patients be seen within an hour, Larson Waited an hour and 40 minutes for a second evaluation by a physician. There was no record of vital signs being measured in the interim or at any time prior to his discharge. Again, hospital protocol called for these follow-up measurements.

     

    Cabrini Medical Center was fined $10,000 after the investigation by the Department of Health. The Department felt Cabrini staffs diagnosis of food poisoning was unsupported by the medical evidence. Investigators couldn't find documentation in the record that any other possible causes of chest pain were considered or eliminated. They believed the emergency department's responses were inappropriate, questioning the insertion of a nasogastric tube, the administration of an analgesic, Toradol, and the patient‘s discharge before chest X-rays were interpreted. The Department acknowledged that other care might have actually been given. But it criticized the lack of nursing documentation- again noting that Larson's vital signs were not recorded.  New York Department of Health Commissioner, Dr. Barbara DeBuono, conceded that correctly diagnosing the tear in the lining of Larson‘s aorta “would have been extremely difficult” for either hospital. The Department was most concerned, however, that the chest pain was not aggressively pursued. 

     

    This case is a reminder of some basic principles. The New York Department of Health clearly wanted to send a message to providers to aggressively investigate complaints of chest pain. Cardiologist Thomas Graboys is Director of the Lown Cardiovascular Center in the Harvard system. Dr. Graboys notes:”You can make certain assumptions about people. For example, it used to be we were less concerned if a woman came in, particularly if she was premenopausal, and complaining of chest pain. You'd say, ’Well, she's young. The likelihood of having heart disease is low.’ We’ve realized that’s not true.... so you can't have a gender bias about this. You can't have a bias about risk factors just because someone comes in and seemingly, doesn't have risk factors. It doesn't mean that that person can't be in the midst of a heart attack... And then location... You assume that because someone has belly discomfort that that's not related to the heart, when in fact it may be.” 

     

    Another lesson from this case is that clinicians need to document patient assessments, differential diagnoses, and treatment rationales. This kind of documentation does not have to be exhaustive or long. But thoughtful, concise entries can demonstrate adherence to protocols, guidelines, and algorithms, or justifies deviation from them. Documentation can be key to the defense of a negligence claim or suit, and may take on increasing importance in physician contract negotiations with managed care organizations.  The Department of Health investigation was based on New York regulations under which the hospitals are licensed. Although they vary from state to state, these kinds of regulations often allow investigators to make unannounced inspections to ensure hospital compliance with a wide variety of rules. A finding of "lack of compliance" is not a finding of physician malpractice.  What it says is that the Departments rules were broken. The documentation issue is a good example. The Department clearly requires documentation of patient care and the hospital providers did not record at an appropriate level. However, even the Department of Health recognized that no documentation does not necessarily mean that care was not provided.

     

    The fines do not conclude this matter. Larson‘s family is suing the providers for malpractice. The Department of Health's findings are not a determination of malpractice. The findings certainly highlight some of the challenges the providers will face in defending the lawsuit. Without a detailed medical record, the clinicians will have to rely on their memories to reconstruct the events and thought processes of that evening in January of 1996. Ironically, Larson's posthumous fame has focused a spotlight on the care he received. But his relative anonymity at the time he was seen will undoubtedly make that evening blend in memory with so many others for these providers.


    Hospitals Fined When Celebrities Die

    by Attorney Frank E. Reardon

    February 1997

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