Dr. Barry Gustin - Medical-Legal Expert Services

Sometimes diseases are so rare and case presentations so atypical that it is difficult to blame a physician for failure to diagnose, and this should not lead to a medical malpractice action, no matter what the field: emergency medicine, primary care, or medical specialty care.  Here is a case in point:

A 61-year-old man presents to the emergency department (ED) with fever, dyspnea and a productive cough for 1 week that has failed to respond to outpatient antibiotics (levofloxacin). He also complains of worsening arthralgias in both lower extremities, particularly in his knees and ankles, as well as a 10-lb (4.54-kg) weight loss over the preceding 2 months. He is a former smoker with an 80-pack-year history, but there is no other significant medical history. He denies any recent travel, sick contacts, or occupational exposure to asbestos or mineral dust.  His only medications include over-the-counter analgesics for joint pains, and he denies having any drug allergies.

The following excerpt on EMTALA (Emergency Medical Treatment and Active Labor Act) is taken from a paper written by Dr. Damon Dietrich and Dr. Michael Crapanzano. The paper is entitled, "Emergency Department Diversion and Overcrowding: A Public Health Crisis." The paper discusses EMTALA in the context of ED diversion (EDD) and ED overcrowding (EDO).

In the U.S. today with increasing ER patient burden EMTALA violations have increased. This has resulted in increased litigation as well.

EDO and EDD are two of the most critical public health issues facing our nation's healthcare system today.[3,4,5]

• ED visits in 2003 rose to 114 million, up from 97 million in 1997.
• While visits increased by 17% over six years, 1128 EDs closed between 1988 and 1998, thus resulting in a dramatic increase in patient volumes and waiting times.
• US hospitals over the past ten years have closed more than 103,000 inpatient medical/surgical beds and 7800 ICU beds in an effort to control costs.
• The majority of the nation's 4000 hospitals and EDs report operating at or above critical capacity.
• In 2001, two out of every three hospitals reported diverting ambulances to other hospitals.
• EDO is reported to be most severe in areas with larger populations, higher population growth and higher than average uninsured patient volumes.

EDs represent the most critical access path to the nation's health delivery system, as the "guaranteed access point for all who need care regardless of ability to pay."[2] EDO exists when the ED has more patients than bed capacity or is over-saturated; this is a warning sign of capacity constraints under normal conditions. The March 2003 General Accounting Office Report indicated that EDO has many negative implications with regard to quality of care including prolonged patient wait times and suffering for acute problems while other patients are "boarded" in the ED, higher physician and staff stress, less confidentiality when patients are evaluated in nontraditional locations such as a hallway or on the EMS stretcher and increased transport times for ambulance patients due to diversion.[5] Contrary to public misconception, the gridlock in the ED is not in the waiting room, but rather occurs in the hallways of the ED with admitted patients waiting for beds upstairs for hours to days! The purpose of EDD was an innovative solution for EDO intended to "divert" stable patients transported by ambulance away from the hospital, thereby allowing the scarce beds remaining in the ED to be used for critical or unstable patients. EDD has been defined by The Lewin Group.[2]

 

Hypothetical Case Study:

A 39-year-old woman presents to the emergency department (ED) with a non-productive cough, non-pleuritic chest pain, and shortness of breath (dyspnea). She is a smoker currently using Estrogen for hormonal abnormalities, but has no other significant past medical history. Her physical examination is unremarkable except her pulse which is mildly elevated, including clear lung auscultation and a non-tender chest wall. Although you contemplate the diagnosis of pulmonary embolism, her well appearance and normal vital signs notwithstanding pulse including normal oxygen saturation argue for bronchitis-related symptoms. You consider and then order a D-dimer study to rule in or rule out a pulmonary embolus (clot in the pulmonary arteries).

Clinical Question

Can a subset of patients with sufficiently low risk for pulmonary embolism be identified who require no diagnostic testing or should all patients that have a clinical picture to some degree consistent with pulmonary emboli be fully evaluated?

A superb analysis of ruptured brain aneurysm and subarachnoid hemorrhage (SAH) was written by Edlow et al and was published in the Journal of Emergency Medicine, volume 34 (3), 2008. The article is reprinted and shared with you in its entirety below. References are include.

Summary:

Aneurysmal subarachnoid hemorrhage (SAH) is a serious cause of stroke that affects 30,000 patients in North America annually. Due to a wide spectrum of presentations, misdiagnosis of SAH has been reported to occur in a significant proportion of cases. Headache, the most common chief complaint, may be an isolated finding; the neurological examination may be normal and neck stiffness absent. Emergency physicians must decide which patients to evaluate beyond history and physical examination. This evaluation–computed tomography (CT) scanning and lumbar puncture (LP)–is straightforward, but each test has important limitations. CT sensitivity falls with time from onset of symptoms and is lower in mildly affected patients. Traumatic LP must be distinguished from true SAH. Cerebrospinal fluid analysis centers on measuring xanthochromia. Debate exists about the best method to measure it–visual inspection or spectrophotometry. An LP-first strategy is also discussed. If SAH is diagnosed, the priority shifts to specialist consultation and cerebrovascular imaging to define the offending vascular lesion. The sensitivity of CT and magnetic resonance angiography are approaching that of conventional catheter angiography. Emergency physicians must also address various management issues to treat or prevent early complications. Endovascular therapy is being increasingly used, and disposition to neurovascular centers that offer the full range of treatments leads to better patient outcomes. Emergency physicians must be expert in the diagnosis and initial stabilization of patients with SAH. Treatment in a hospital with both neurosurgical and endovascular capability is becoming the norm.

Background

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A 41-year-old cognitively impaired man who lives in a home for the mentally impaired is presented to the emergency department (ED) by his caregivers. His caregivers at the home noticed that, after washing the patient, 1 of 2 shaving blades present in the morning was missing. Although they hadn't witnessed it, they suspected that the patient had ingested the missing shaving blade. The caregivers, however, haven't noticed anything abnormal with the patient; he does not have any shortness of breath, stridor, wheezing, hemoptysis, vomiting, or upper gastrointestinal (GI) bleeding. At no point have the caregivers noticed the patient coughing or choking; however, they are still worried about the possibility that he might have ingested or aspirated the blade.

At baseline, the patient has unintelligible speech and, therefore, cannot be directly interviewed. The patient has been living in a residence for the mentally impaired for the past 31 years, and he is dependent on his caregivers for all of the activities of daily living. Apart from his mental underdevelopment, the patient suffers from epilepsy and has been previously investigated for Raynaud's disease; in addition, the patient's history is significant for an ejection systolic murmur. The murmur was first detected by echocardiography, which revealed normal left ventricular function and a slightly thickened mitral valve, with minimal regurgitation. He takes multiple medications, including dipyridamole 100 mg TID, phenytoin 100 mg TID, doxepin 25 mg BID, nitrazepam 5 mg nocte, carbamazepine 20 mg BID, nifedipine 10 mg BID, nortriptyline 25 mg TID, and risperidone 1 mg nocte.

On physical examination, the patient is not in any distress. His oral temperature is 98.6°F (37.0°C). His pulse is regular at 82 bpm and his blood pressure is 140/90 mm Hg. His oxygen saturation is 99% while breathing room air. A visual inspection of the oropharynx does not reveal the presence of a foreign body, and there is no evidence of any recent trauma, bleeding, or swelling. There is normal range of motion in the neck, and no evidence of stridor or respiratory difficulty is noted. On chest auscultation, there is good air entry bilaterally, and normal vesicular breathing is heard. His heart sounds reveal a 2/6 ejection systolic murmur. His abdomen is soft and nontender. Additionally, no distention or rebound is noted on the abdominal examination.

Background

Figure 1. (Click to enlarge)

A 46-year-old woman presents to the emergency department (ED) with a history of worsening, constant right upper quadrant pain that radiates to her back and side. She has had nausea and has vomited twice in the past several hours. The intake triage nurse considers that she may have ingested something toxic, and turns immediately to her Emergency Physician who is also a well known toxicology expert consultant.  But he learns upon questioning that she underwent a laparoscopic cholecystectomy 2 weeks ago, without complications, and returned to her normal diet. She has not had any bowel movements or flatulence since the pain began. She denies having any fever, chills, or rigors. Her medical history is significant only for high blood pressure, high cholesterol levels, and gallbladder disease. She takes lisinopril, aspirin, multivitamins, and ginseng. She denies smoking or drinking alcohol.

On physical examination, the patient is awake, alert, and oriented. Her vital signs are within the normal range, with a heart rate of 84 bpm and a blood pressure of 124/76 mm Hg. She appears to be in mild distress. The cardiorespiratory examination yields normal findings, with clear lungs and a regular heart rhythm. Her abdomen is soft, but her bowel sounds are decreased, and she has marked tenderness in the right upper quadrant. The rest of her abdomen is minimally tender, with no evidence of guarding or rebound and no palpable masses. The other physical findings are normal.

The laboratory investigation reveals an elevated WBC count of 14.0 × 109/L (14.0 × 103/µL), with a left shift of 87% neutrophils. Her liver function tests, lipase level, and basic chemistry panel are unremarkable.

Contrast-enhanced computed tomography (CT) scans of the abdomen and pelvis are ordered. Figure 1A shows an anteroposterior (AP) scout image, and Figure 1B shows a selected axial section. The appearance of the xrays is that of bean-like substances.

The diagnosis is Cecal Volvulus.

 

Near-Syncope in a 24-Year-Old Man

Background

Figure 1. (Click to enlarge)

A 24-year-old man with no significant past medical history presents to the emergency department (ED) with a complaint of several episodes of a sensation of nearly blacking out. The episodes have occurred about 3-4 times over the 3 days before presentation. The duration of each episode has ranged from a few minutes to over an hour. The patient notes that he has felt his "heart beating really fast," with associated light-headedness. He denies having any chest pain, shortness of breath, or nausea associated with these events. He cannot identify exacerbating or alleviating factors; specifically, he denies exertion as an inciting factor. The remainder of his review of systems is negative except for some mild chronic shortness of breath. The patient takes no medications at home and has no active medical conditions. He smokes 2-4 packs of cigarettes per day and has done so for 5-6 years. He denies any illicit drug use or recent use of over-the-counter medications or herbal remedies. He has no history of any significant cardiac disease or sudden cardiac death in his family.

On physical examination, the patient is afebrile, with a pulse of 65 bpm, a blood pressure of 120/84 mm Hg, and a respiratory rate of 15 breaths/min. His room air saturation reading is 100%. In general, he is well-appearing and in no acute distress. The patient's neck examination shows no jugular venous distention. The heart sounds, including S1and S2, reveal no audible murmurs, rubs, or gallops. The apical impulse is nondisplaced and of normal impact. The lung sounds are diminished throughout, but there are no wheezes, rales, or rhonchi. He has no edema of the lower extremities, and the distal pulses are easily palpable. All other exam findings, including a neurologic examination, are unremarkable.

The patient is placed on a cardiac monitor, and an 18-gauge intravenous (IV) catheter is inserted into the antecubital fossa. Laboratory tests consisting of a complete blood count (CBC) and serum electrolytes are ordered. A portable chest radiograph reveals slight hyperinflation and hyperlucency of the lung fields, with a flattened diaphragm and central pulmonary artery enlargement. An electrocardiogram (ECG) is obtained (see Figure 1).

A 46-year-old man presents to the emergency department (ED) with a 4-day history of dry cough, fever, chills, night sweats, a 13-lb (5.9-kg) weight loss, (over a 2-week period), shortness of breath, and easy fatigability. Two weeks before presentation, he went with a friend to clean an abandoned house in Kentucky. The house was very dusty and had a lot of bird droppings. His friend developed a fever with cough and could not continue working after 4 days. Our patient, however, continued to work until the job was done (a total of 7 days). He has not had any hemoptysis, chest pain, or any other symptoms, except as noted above. He has mild asthma, uses an albuterol inhaler once every 3-4 months, has smoked half of a pack of cigarettes per day for the last 30 years, does not drink alcohol, and does not use any illicit drugs. He has no significant family history and is not allergic to any medications.

On physical examination, his oral temperature is 98.9°F (37.2°C). His pulse is regular, with a rate of 98 bpm, and his blood pressure is 137/91 mm Hg. He is mildly tachypneic, with a respiratory rate of 22 breaths/min. The patient is thin but not emaciated, and he has poor dentition; his head and neck examination is otherwise normal, with no palpable lymph nodes. He has normal S1 and S2 heart sounds. Chest auscultation reveals fine rales in the mid and lower zones of both lungs. His abdomen is soft and nontender, with normal bowel sounds. He does not have any lower limb edema, and he has normal peripheral pulses.

Background

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A paramedic call is received in the emergency department (ED) reporting a 10-min estimated time of arrival for a 17-year-old male who was found in cardiac arrest following a blow to the chest. The patient has regained spontaneous circulation, and is currently stable and maintaining his own airway. A rhythm strip faxed to the ED prior to the patient's arrival shows ventricular fibrillation, with subsequent conversion to a normal sinus rhythm after defibrillation with 200 joules (see Figure 1). Further questioning of the prehospital personnel reveals a history of witnesses reporting that the patient, a center outfielder for a local baseball team, was trying to catch a baseball when one of his teammates accidentally ran into him, elbowing him in the middle of his chest. The patient immediately dropped to the ground and was unresponsive. Cardiopulmonary resuscitation (CPR) was initiated by his coach after no pulses were palpated. The paramedics arrived 5 minutes later and, as noted on the rhythm strip, found the patient to be in ventricular fibrillation. One 200 joule countershock was administered, converting the ventricular fibrillation to a normal sinus rhythm, and the patient was noted to regain consciousness.

Upon arrival at the ED, the patient reports only mild anterior chest wall pain and denies any substernal chest pain, shortness of breath, palpitations, weakness, or confusion. He states that he has never before fainted. The patient and his mother deny any significant past medical or family history, including any arrhythmias, unexplained sudden deaths, or cardiac structural diseases. He denies having a lower exercise tolerance than his teammates and also denies any smoking, drinking, use of medications, illicit substance abuse, or doping practices.