ER Wait Leads to Amputation

By ThinkReliability Staff

In some cases, it’s easy to equate “cause” with “blame”.  Sadly that seems to be the case for the family of a 2-year old triple amputee from Sacramento, where a near-certain malpractice suit looms.  The fundamental question in this story is whether or not Malyia Jeffers would have come so close to death had she been diagnosed and treated sooner, upon arriving at the emergency room.

Malyia, bruised, feverish and weak, waited with her family in her local hospital’s emergency room for five hours.  Originally assessed as sick with only a virus and a rash, her parents suspected something more.  Once again a triage nurse reassessed Malyia as non-urgent, with just a virus and rash.  Finally as her small body went limp, her frantic father barged past the ER nurses’ station to demand a second opinion.  That move is probably what saved her life, as blood tests soon confirmed liver failure due to group A streptococcus (GAS).  Two hospital transfers later, Malyia was on life support and blood pressure medication which kept her heart beating and ultimately saved her life.  The lack of oxygen to her limbs however forced doctors to amputate her left hand, fingers on her right hand and both of her lower legs three weeks after her initial infection.

According to the Center for Disease Control, “severe, sometimes life-threatening, GAS disease may occur when bacteria get into parts of the body where bacteria usually are not found, such as the blood, muscle, or the lungs…Streptococcal toxic shock syndrome (STSS) results in a rapid drop in blood pressure and organs (e.g., kidney, liver, lungs) to fail. While 10%-15% of patients with invasive group A streptococcal disease die from their infection, more than 35% with STSS die.”  Doctors know that early diagnosis and treatment are critical with aggressive bacteria such as GAS.  Would Malyia have fared better had she been seen sooner?

Emergency room waiting times have exploded in recent years.  If you were to ask someone on the street why, you might guess that the biggest contributing factor is the growing number of uninsured patients.  Not so, according to an extensive 2009 government report.  Long wait times are actually a symptom of a complex problem.  Vacant hospital beds, specialist availability and access to primary care all play a part in why emergency rooms, especially metropolitan ones, are constantly full.  Using a Cause Map, it is easier to see exactly why.

While Cause Mapping might help us see why ER wait times are a complex issue, it doesn’t alleviate the suffering the Jeffers family has and will face in the months and years to come.   Unfortunately it is tempting to point fingers and place blame.  Yet the reasons behind this tragic cause are not so simple.  Hopefully, process improvements will alleviate the suffering of those stuck waiting in the ER.

More information on the story can be found in the Sacramento Bee.  A 2009 GAO report also provided helpful information on the nation-wide issue of emergency room waiting times.