Quick Summary: Signs of cardiac tamponade were picked up by the staff nurse as she began to assess a patient who had just had a central venous pressure catheter inserted into the right internal jugular vein after gastric bypass surgery, before coming to the intensive care unit. Although not known at the time, the catheter had punctured and become embedded in the heart muscle, according to the court record. His heart rate had quickly risen to 120 from a baseline in the 70’s which was charted right after the CVP devise was inserted. The nurse was also concerned about rising CVP readings, and by the marginal output of urine. A pulse monitor, set at 140, went off several times in twenty minutes.

   The nurse promptly reported her concerns to the charge nurse. The staff nurse explicitly stated she believed there were early signs of cardiac tamponade.

   The charge nurse dismissed the patient’s rising pulse rate as a sign of "restlessness" and refused to call the physician. After an hour, the staff nurse got the physician’s phone number and tried to call him herself, but was stopped by the charge nurse, who told her to return to her station and said she herself would make the judgment when to call the physician. The charge nurse called a resident an hour later. The resident got a cardiologist there in five minutes. Surgery was too late to save the patient from permanent brain damage.