Ress v. Abbott Northwestern Hosp., Inc., C8-88-2208

• Decision Date: 08 December 1989
• Docket Number: No. C8-88-2208,C8-88-2208
• Parties: Randy W. RESS, Respondent, v. ABBOTT NORTHWESTERN HOSPITAL, INC., Petitioner, Appellant, Commissioner of Jobs and Training, Respondent.
• Court: Minnesota Supreme Court

Page 519

448 N.W.2d 519

Randy W. RESS, Respondent, v. ABBOTT NORTHWESTERN HOSPITAL, INC., Petitioner, Appellant, Commissioner of Jobs and Training, Respondent.

No. C8-88-2208.

Supreme Court of Minnesota.

Dec. 8, 1989.

Syllabus by the Court

Registered nurse committed misconduct within the meaning of Minn.Stat. Sec. 268.09, subd. 1(b) (1988) by initiating an unauthorized, unaccepted and dangerous procedure and refusing to follow a physician's directions.

Robert S. Halagan, Minneapolis, for appellant.

Phillip I. Finkelstein, St. Paul, for Randy Ress.

Donald Notvik, Asst. Atty. Gen., St. Paul, for Com'r of Jobs & Training.

Heard, considered and decided by the court en banc.

YETKA, Justice.

Randy Ress was fired as a registered nurse by Abbott Northwestern Hospital for allegedly exceeding the bounds of his nursing authority and for refusing to follow the orders of a physician. He was disqualified for unemployment benefits by the Department of Jobs and Training. On appeal, a referee reversed the department and awarded benefits. The commissioner reversed the referee, denying benefits; the court of appeals reversed the commissioner and awarded benefits. We reverse the Minnesota Court of Appeals, 438 N.W.2d 727, and reinstate the commissioner's order denying benefits.

The facts in this case are as follows. Randy Ress worked as a nurse at Abbott from May 5, 1980, until Abbott discharged him on February 5, 1988. His final position at Abbott was as a registered nurse in intensive cardiac care. At that time, Sandi Martin, head nurse of intensive cardiac care, was Nurse Ress's immediate supervisor and had been so for approximately 3 years. She terminated Nurse Ress because he acted outside the scope of medical and nursing practice and refused to follow doctor's orders in an emergency situation with a patient on January 21, 1988.

The patient involved in this incident was a very sick, elderly woman suffering from numerous lung problems. She was on a ventilator and required high concentrations of oxygen. A ventilator mechanically assists the patient to breathe. The patient was on "do not resuscitate" (DNR) status. DNR status means, generally, that the primary objective is to keep the patient comfortable.

Dr. John Mielke, her primary attending physician, described the patient's condition in his statement. She suffered from severe restrictive lung disease secondary to kyphoscoliosis. Kyphoscoliosis is a deformity of the spine in which the spine is S-shaped and humped. 2 J. Schmidt, Attorneys' Dictionary of Medicine and Word Finder K-20 (1981). She entered the hospital with pneumonia in both lungs and numerous complications. Pneumonia causes congestion in the lungs which hinders or stops the exchange of oxygen and carbon dioxide.

An endotracheal tube (ET tube) placed in the patient's airway through her mouth connected her to the ventilator. She was also monitored by a Swan Ganz catheter, a catheter with a little balloon on the tip placed directly into the heart through a vein for monitoring blood pressures. Ideally, the catheter should be in the pulmonary artery. Critical care nurses must watch to make sure the catheter does not become permanently "wedged" in the pulmonary artery so as to close it off and possibly cause the vessels to rupture. They do this by watching the "wave forms" on the monitor; if they are "dampened or lost," the catheter may be wedged.

Nurse Ress was responsible for the patient's care on January 21, 1988. Three other nurses assisted him. At approximately 10:40 p.m., the instrument monitoring the patient's heart showed that she had lost the "wave form" indicating proper placement of the Swan Ganz catheter. Following this, the patient suffered "gross hemoptysis" from the ET tube. Hemoptysis means bleeding from the lungs or the airway. 2 J. Schmidt, Attorneys' Dictionary of Medicine and Word Finder H-45 (1981). In other words, Nurse Ress testified, blood forcefully shot out of the ET tube.

Nurse Ress called for help. He then began suctioning the ET tube in accordance with established protocol; that is, he opened the little cap on the end of the ET tube and suctioned the blood through the opening. That way, the patient remains attached to the ventilator.

Dr. Stevens, the first-year resident physician, arrived. He recalled that the patient had bled from her ET tube a few days earlier probably because, in light of the patient's abnormal posture, the rigid ET tube had caused irritation. Thus, when he observed the bleeding again, he suggested that Nurse Ress move the ET tube slightly to relieve any possible irritation. Nurse Ress refused, commenting on how difficult it was to place the ET tube in this patient. Nurse Ress suggested instilling epinephrine into the ET tube as an alternative. Dr. Stevens answered that he wanted to use vasopressin. Nurse Ress stated that vasopressin was not available at the nursing unit and ordered one of the nurses to get some epinephrine. Dr. Stevens eventually agreed to use the epinephrine.

According to Abbott's established protocol, when a nurse notices blood in the ET tube, the nurse should suction the airway with a suction catheter to open it. Head Nurse Martin testified that Nurse Ress should have continued to follow this protocol. If that failed, he should have contacted an attending physician or an anesthesiologist. Instead, Nurse Ress created and initiated a procedure outside any established protocol: he poured saline over ice, rendering it non-sterile, and lavaged ¹ the ET tube for approximately 15 to 20 minutes in an attempt to stop the bleeding. During these 15 to 20 minutes, the patient was not connected to the ventilator.

While protocol allows that it is appropriate in some circumstances to instill small amounts, not exceeding 3 to 5 cubic centimeters, of sterile saline into the ET tube in order to break up thick secretions and facilitate suctioning out the tube, it does not call for iced saline. It is not clear how much saline solution Nurse Ress used. The record does support that, a number of times over a period of about 15 to 20 minutes, Nurse Ress instilled at least 5 cubic centimeters of non-sterile iced saline into the patient's ET tube and then suctioned. Nurses use a 5 cc saline lavage capsule when following the proper protocol. The capsule works better than a syringe because, with a syringe, the nurse will probably have to remove the patient from the ventilator as Nurse Ress did in this action.

Dr. Stevens did not order nor comment on the lavage. He left to consult with a more experienced resident for about 10 minutes, during which time Nurse Ress continued to lavage the ET tube. Dr. Stevens returned and ordered Nurse Ress to discontinue the lavage because the iced saline could cause a blood clot. In his statement, Dr. Stevens stated that Nurse Ress answered, "I'm just about done anyway, the bleeding seems to be slowing down."

Iced lavage of the tracheal tube is not an accepted medical or nursing procedure. The non-sterile solution could have caused infection in an already gravely ill patient. Further, pushing liquid into a patient's lungs would decrease the patient's oxygen level, creating a state, in Head Nurse Martin's words, similar to drowning.

Dr. Mielke, the attending physician for the patient involved in this action, expressed concern to Martin about Nurse Ress's conduct. He submitted a letter stating:

It is my professional opinion that several of the actions, of the nurse in question, were dangerous and may have contributed to the speed at which this patient died. ² At this point in the patient's course she was quite ill but we had not limited our current measures in hopes that she may regain her ability to oxygenate. Certainly the installation of 30-40 cc of saline into the tracheal bronchial tree on several occasions was absolutely contraindicated and could have only worsened the patient's situation. No physician would have ordered this treatment had the question been raised by the nurse. In addition, it is well known that people on high doses of PEEP [positive and expiratory pressure] are very susceptible to profound hypoxia [a deficiency of oxygen reaching the tissues of the body] when disconnected from the respirator. This might have precipitated life threatening arrhythmias[,] exacerbated the patient's shock and certainly have caused significant discomfort to the patient.

(Emphasis added.)

In a letter to Head Nurse Martin, Dr. Hale, chairperson of the Critical Care Committee and a pulmonologist on staff at Abbott, stated: "Iced saline lavage for patients with hemoptysis is not an acceptable mode of therapy. The practice could be dangerous and life threatening in any patient." A pulmonary clinic nurse specialist at Abbott, Ruth Sohl-Krueger, elaborated on the nurse's responsibility in this situation, stating that lavage with large quantities of iced saline

is not a safe independent nursing intervention for the following reasons:

1. large volumes of fluid are a physical obstruction

2. you do not want to clot the blood in the airway since this will cause obstruction

3. this process would require long periods off of the ventilator--dangerous to someone who is so marginally oxygenated[.]

(Emphasis in original.)

Shortly after the bleeding incident, Dr. Stevens ordered a chest x-ray. Nurse Ress refused, arguing that the patient was comfortable and he did not want to disturb her until the family had visited. Nurse Ress said that he would order the x-ray after the family had seen her in 5 to 10 minutes. Dr. Stevens came back twice, insisting that the patient needed an immediate x-ray to diagnose the cause of the bleeding for appropriate treatment. Dr. Stevens told Nurse Ress that the family could see her after the x-ray. Nurse Ress told Dr. Stevens that he would ask the third-year resident about the x-ray. Dr. Stevens said that Nurse Ress should talk with him about the x-ray; in response, Nurse Ress walked away. The chest...