Riches

I.

BACKGROUND

A. Emergency Room Visit Riches arrived at the emergency room at San Gorgonio Memorial Hospital at 12:59 p.m. on February 11, 2019, with a complaint of abdominal pain that radiated to her left leg and back. She had a history of diabetes, hyperlipidemia, hypertension, and atrial fibrillation, and had taken anticoagulants in the past. Within 20 minutes of Riches’s arrival, the emergency room physician, Eugene S. Kim, M.D., examined Riches and noticed her left leg was cooler and paler than her right leg. He ordered a venous ultrasound of her left leg to evaluate for possible deep vein thrombosis and a computed tomography angiogram of the abdomen and pelvis to evaluate for possible aortic dissection. The ultrasound was performed at Riches’s bedside at 2:00 p.m., and she was taken for the angiogram at 3:00 p.m. and returned to the emergency room 20 minutes later. Sohn read the ultrasound, found no evidence of deep vein thrombosis, and reported his findings at 2:07 p.m. He read the angiogram, found no aortic aneurysm or dissection but did find complete occlusion of the left common iliac artery with distal reconstitution, and reported his findings at 3:24 p.m. At 4:00…