Emergency Medicine Claims/Risk Reduction Workshop

In a claims review for The Doctors Company, the panel found three elements crucial to delivering quality emergency medicine: common sense, a keen index of suspicion, and follow-through.

An expert panel of physicians, attorneys, and claims representatives reviewed 14 cases involving emergency physicians. Six key observations emerged from the case review:

• The severity of injury in cases involving emergency physicians tends to be high.
• Suits frequently allege both inadequate diagnosis and inadequate therapy in a specialty that demands quick clinical judgments and therapeutic action.
• Collaboration and cooperation with other hospital departments and physicians are critical.
• Good record keeping is as important in the emergency room (ER) as it is in all other areas of medicine.
• Well-organized trauma programs have set extremely high standards, leading to increased expectations and to mandatory adherence to strict protocols.
• An emergency physician may be involved in a suit that represents an adverse outcome considerably removed from the patient’s initial ER care. Suits alleging delayed diagnosis (nine of the 14 cases) were the most common source of litigation in this study.

The following case reviews summarize specific problems found in several of the cases.

Posterior Shoulder Dislocation

A 45-year-old patient went to the ER after falling on his left arm during a syncopal episode. An insulin reaction was diagnosed and treated. Both the emergency physician and the radiologist read x-rays of the left humerus as negative. The patient’s arm was placed in a sling, and he was discharged with instructions to be rechecked by his physician. Although the emergency physician did not diagnose a posterior shoulder dislocation, the patient ultimately required an open reduction.

Posterior shoulder dislocation is a difficult diagnosis to make. Posterior dislocations, however, are frequent sequelae of seizure disorders. Clinicians should suspect such a dislocation if physical examination shows the patient has a limited range of motion in the absence of a fracture. An axillary x-ray view of the shoulder is the sine qua non required to diagnose a dislocation. If there is any disagreement about the diagnosis, an axillary x-ray is the easiest to read and should be requested even if it is difficult to obtain.

Toxic Shock Syndrome

A 37-year-old woman came to the ER complaining of five days of nausea, vomiting, and hematuria accompanied by lower abdominal and flank pain. An intrauterine device was present. A physical examination showed moderate left-sided costovertebral angle tenderness and a benign abdomen. A pelvic examination was not performed. After two hours in the ER, the patient’s temperature rose to 103.4 degrees and her pulse increased to 134.

Urinalysis showed four to six white cells with five to six red cells. Epithelial cells and mucous threads appeared in the specimen, and only 1+ bacteria were seen. The patient was treated with two grams of ampicillin intravenously and was discharged with instructions to take oral ampicillin. She was re-admitted two days later with a generalized rash and septic shock. Ultimately, she required mitral valve replacement and sustained significant ototoxicity.

Evidence for pyelonephritis in this case was relatively weak. Even if the diagnosis had been correct, the temperature of 103.4 degrees and the pulse of 134 made hospital admission much more prudent than discharge from the ER. In addition, ampicillin does not cover a sufficiently broad spectrum to be used as monotherapy in a patient with pyelonephritis. A pelvic examination should have been performed on this patient. The exam would have revealed a moderate vaginal discharge due to a staph endometritis.

The problem in this case was not the failure to diagnose toxic shock syndrome, because it was not present when the patient was in the ER (the patient was not in shock and did not have the characteristic rash). The problem was that the workup of an obviously sick patient was not adequate and that the disposition home was not wise.

Delayed Diagnosis of Myocardial Infarction

A 39-year-old man presented to the ER on Christmas Day with chest pain radiating to his left arm, diaphoresis, and dyspnea. An electrocardiogram showed tall peaked T-waves, and there was a slight elevation of the creatine phosphokinase. The patient’s chest pain was relieved by an antacid and Lidocaine cocktail. The ER physician phoned the on-call cardiologist, who indicated it was unlikely that the patient had experienced a myocardial infarction. He requested that the patient be sent home from the ER and that he have a treadmill scheduled for the following day. The patient failed to keep his appointment and suffered an acute myocardial infarction five weeks later.

The ER physician’s diagnostic impressions were appropriate, but the disposition of the patient was not. Evidence of myocardial pathology was very strong in this case, and the ER physician should have insisted on the cardiologist’s personal attendance, hospitalized the patient, or consulted with a second cardiologist.

Subdural Hematoma

A 60-year-old woman was placed in custody by the sheriff’s department after she was found lying in a parking lot. She had vomited, her speech was slurred, and she had epistaxis. The arresting officer thought she was under the influence of alcohol. Seventeen hours after being taken into custody, she was transferred to an ER. The emergency physician found no signs of trauma. His neurologic examination showed the patient was slow to verbalize, though she was oriented to name and place. Laboratory studies showed normal electrolytes, normal glucose, and a blood alcohol level of 0. The impression was that the patient had a hangover. She was discharged home alone, by taxi. Three days later, her family brought her back to the hospital, at which time she was found to have a left temporal skull fracture and a hematoma.

The initial history given to the ER physician included misinformation that the patient had been arrested the day before for public intoxication. The physician was sufficiently conscientious to call the jail to see if additional information was available, but he found no one who knew the patient. In retrospect, the physician understood the unfortunate events that led to the wrong conclusions. He indicated in his affidavit that if the patient had presented with a history of an unwitnessed syncope, his approach would have been quite different.

The problem of erroneous or inadequate history is frequent in emergency wards. For this reason, diagnostic conclusions must be conservative and potentially more severe diagnoses must be formally excluded before patients are discharged.

Ketoacidosis

A 24-year-old man came to the ER with dry heaves, myalgias, and headaches. His temperature was 99.3 degrees, but otherwise his vital signs were normal. His physical examination was benign, and the diagnosis was viral syndrome. The patient was hydrated with 1,000cc of D5/normal saline and was given 5mg of Compazine IV. He was sent home on Tylenol and Compazine and was told to follow up with his personal physician. He was admitted to the hospital the next day with florid ketoacidosis and acute rhabdomyolysis.

The panelists regarded this as a difficult case because, even in retrospect, the signs of ketoacidosis were not obvious when the patient was in the ER. Although this case would have been properly diagnosed if routine urinalysis and blood studies had been performed, panelists found it hard to fault the ER physician specifically, given the nature of the patient’s presentation. Ordering laboratory studies without specific indication would have been difficult, although a more detailed history might have revealed polydipsia and polyuria. Nonetheless, the panel noted that serious underlying pathology should be considered in any patient presenting to the ER—it is a risky place to practice cost containment.

Thrombocytopenia

A two-year-old patient was brought to the ER after more than 12 hours of uncontrolled epistaxis. The patient had an ecchymosis over the left eye and hemorrhagic skin lesions involving the entire body. The platelet count was 5,000, with a hematocrit of 32.9. The patient’s physician, a pediatric hematologist, was contacted by telephone. He advised that the patient was being treated for idiopathic thrombocytopenic purpura with prednisone and that he could be discharged with outpatient follow up. The patient returned five hours later, semiconscious, with a fever of 101 degrees and blood pressure of 55/30. He died the next morning. The death certificate listed the cause of death as intracranial bleeding.

This is another case in which the advice of the attending or consulting physician was inappropriate, and follow-through by the ER physician was inadequate. Patients with a hemorrhagic diathesis and a platelet count as low as 5,000 cannot be followed at home, even if the diagnosis has previously been established. The ER physician should have insisted on personal attendance by the patient’s doctor or alternatively arranged for admission to another service.

Cervical Fracture

This unusual case involved a 30-year-old trauma patient who was life-flighted to the ER following a motor-vehicle accident. The patient had a lacerated spleen and liver, a fractured pelvis and ribs, and a hemopneumothorax. A cervical collar had been placed, and a C-spine x-ray was ordered. The resident reviewed a set of films with the radiologist, who found no fracture. The attending physician ordered the collar removed. Unfortunately, the patient became paraplegic four days later. The normal films were later determined not to be those of this patient.

The lesson here is obvious and dire. Institutional procedures must be impeccable, especially in the supercharged atmosphere of a busy hospital trauma center where patients and films are initially labeled by number rather than by name.

Tendon Laceration

A 24-year-old woman presented to the ER with a two-centimeter laceration of the distal fifth finger. The emergency physician conducted a careful examination and specifically noted that distal tendon function was intact. Nearly one month later, the patient had lost the function of the flexor digitorum profundus tendon, and surgical repair was necessary. Because the emergency physician carefully documented his examination, including the pertinent rule-outs, there should have been no liability in this case. The tendon rupture undoubtedly occurred subsequent to ER evaluation.

A Difficult Patient

The panel reviewed one case involving a difficult patient who was also an attorney. The patient was seen in the ER for complaints of a dislocated right shoulder. The emergency physician administered Fentanyl to reduce the dislocation. Before the physician could perform the reduction, however, the patient informed him that she had reduced the dislocation herself. After learning that the patient had driven herself to the hospital, the physician attempted to administer Narcan to reverse effects of the narcotic so that she could drive home. The patient refused the Narcan and became physically abusive. Security was summoned, and the Narcan was then administered. The patient alleged that the Narcan was administered contrary to her wishes.

Conclusion

Emergency physicians have a difficult role. They must often make a whole series of potentially critical diagnostic and therapeutic decisions in very short order. The ER atmosphere is also frequently chaotic, with numerous patients requiring evaluation and treatment simultaneously, and adequate histories may be impossible to obtain. Be sure, however, to document your efforts to obtain an adequate history. Workups on numerous complex patients must be kept straight and dispositions made promptly. In addition, ER clientele may not be the easiest patients to care for. Finally, the ER physician has the responsibility of making sure that attending and consulting physicians respond appropriately when they are needed.

On a more positive note, although the severity of the suits reviewed by the panel was high, the care provided by ER physicians met or exceeded appropriate standards in the vast majority of cases. Records were surprisingly good, and the majority of these suits were strongly defensible.

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