An orthopedic surgeon at a small community hospital contacted an emergency department (ED) physician at a large academic medical center about a patient transfer. At this hospital, standard procedure called for all transfers from outside hospitals to be seen and evaluated in the ED. The orthopedic surgeon briefly described a 92-year-old woman with a history of dementia who had a left hip fracture. They had taken her to the operating room, but she developed low blood pressure before the case and the anesthesiologists were not comfortable managing her care at the community hospital. The referring orthopedic surgeon also spoke with the on-call orthopedic surgery resident at the tertiary care center and conveyed the same brief history. Minimal other clinical details were discussed.
The patient was transferred to the tertiary care center and was clinically stable on arrival to the ED. None of the notes or clinical documentation from the referring hospital arrived with the patient other than her demographic data. She was quickly admitted by the orthopedic surgery resident and prepped for surgery the following morning.
Early the next day, the patient was taken to the operating room for surgical repair of her hip fracture. During induction of anesthesia, the patient rapidly became hypotensive and required vasopressors. The surgical team proceeded, but the case was complicated by significant hemodynamic instability. The patient survived the surgery, but experienced persistent postoperative hypotension (shock) of unclear cause and could not be weaned from the ventilator. Ultimately, care was withdrawn and she died a few days after surgery.
Notably, following her operation on hospital day 2, medical records arrived from the referring hospital and the anesthesia notes were reviewed. They were handwritten and difficult to read but described "profound hypotension" at the start of the case and that the patient had actually suffered a full cardiac arrest (written as "unable to obtain BP...no palpable pulse...arterial access...case cancelled, to PACU."). There were few other details in any of the notes about the cardiac arrest.
Although it was not completely clear to the orthopedic team or anesthesiologists what happened, all agreed that her case would have been managed much differently had they known more about the events at the referring hospital and that such knowledge could have potentially prevented her death.
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