Very often patients are treated by a team of physicians and occasions arise when instructions or orders of two doctors will be at conflict with each other. What is the responsibility of the nurse?

Facts : On August 19, 1988, the plaintiff underwent a mid-lumbar osteotomy performed by Dr. Bernard Pfeifer, an orthopedic surgeon, and Dr. Stephen Freidberg, a neurosurgeon, to alleviate a debilitating spinal deformity. As part of this procedure, fixation hooks and rods were inserted into the plaintiff's spine.

Dr. Pfeifer's postoperative plan was to confine the plaintiff to his hospital bed for four to five days following the surgery. Contrary to this plan, at 10 A.M.. on August 21, 1988, Dr. Glen Seidman, a first-year orthopedic resident, ordered that the plaintiff be given "warm and form lumbar bandage" (a soft orthopedic support) and be moved "out of bed to chair today." Dr. Seidman wrote both of these orders in the "physician orders" section of the plaintiff's chart. However, in the "progress notes" section of the plaintiff's chart, Dr. Seidman only noted his order for the "warm and form bandage."

At approximately noon on August 21, 1988, Dr. Pfeifer acknowledged Dr. Seidman's "progress notes" concerning the "warm and form bandage" and added to the note that the plaintiff was to be x-rayed the next day and, "if okay," was to be moved out of bed to a "tilt table." Dr. Pfeifer apparently did not see the order to move the plaintiff which Dr. Seidman entered in the "physician orders" section of the plaintiff's chart. The "physician orders" and "progress notes" sections of the plaintiff's chart were not on the same page.

The orders of both Dr. Seidman and Dr. Pfeifer were noted by the charge nurse, Kristin Bartelson. Pursuant to Dr. Seidman's order, the nurse on duty in the early morning of August 22, 1988, encouraged the plaintiff to get out of bed and work. As the plaintiff stood up and took a step, he heard a loud snapping noise in his back and fell backward onto the bed screaming in pain. When Dr. Pfeifer arrived shortly thereafter, he yelled at the nurse, "You should never have moved him! Why in hell did you move him!"

As a result of the plaintiff's movement, the hooks and rods which had been inserted in his spine to hold it together "slipped out" of position. The corrective surgery which the plaintiff underwent to reposition this hardware was not successful.

Court Decision: Under the laws of Massachusetts, the medical malpractice tribunal must determine whether the plaintiff's offer of proof presents evidence which, if substantiated, raises a legitimate question of liability for judicial inquiry.

In order to raise such a question of liability, a medical malpractice plaintiff must show (1) the existence of a doctor or nurse-patient relationship, (2) that the performance of the doctor or nurse did not conform to good medical practice, and (3) that damage resulted there from.

With respect to his claim against Nurse Kristin Bartelson, the plaintiff presented to the medical malpractice tribunal the affidavit of an expert which stated that "As the R.N. giving written notation to Dr. Seidman's orders... Bartelson owed a duty of care to [the plaintiff] to either carry out the order or, if not assigned to direct care, to effectively communicate the orders to the assigned care giver. She should have been aware of [the plaintiff's] care plan and should have known of and reported the inconsistent intentions of Dr. Seidman and Dr. Pfeifer regarding [the plaintiff's] movement. In my opinion, it is reasonably certain that had Kristin Bartelson been aware of [the plaintiff's] care plan, effectively communicated orders to the assigned care givers, and been aware of and reported the inconsistent intentions of Dr. Seidman and Dr. Pfeifer regarding [the plaintiff's] movement, [the plaintiff] would not have suffered the injuries requiring his further surgery."

Because the plaintiff's offer of proof with respect to his claim against Nurse Bartelson contained evidence which, if substantiated, would reasonably support an inference that a nurse-patient relationship existed between Nurse Bartelson and the plaintiff, that Nurse Bartelson's performance did not conform to good medical practice, and that injury to the plaintiff resulted therefrom, the tribunal erred in determining that the plaintiff's offer of proof as to Nurse Bartelson did not raise a legitimate question of liability appropriate for judicial inquiry.

St. Germain v. Pfeifer 637 N.E. 2d 848 (Mass 1994)