Medical Malpractice in the ER: Maintaining a "High Index of Suspicion"

When it comes to medical malpractice in the emergency medicine department, the usual problem is a missed diagnosis and the failure to either admit the patient or call in a consultant. Bad outcomes occur when emergency physicians fail to maintain a high index of suspicion.

Take for example, a patient who presents with chest pain. He or she should have an electrocardiogram. If there is a reasonable index of suspicion of heart attack and even if the electrocardiogram is normal, the patient should be admitted to the hospital and observed in the coronary care unit with serial electrocardiogram monitoring and additional testing.  Under those circumstances studies show that eighty percent of patients who arrive in a hospital with a heart attack leave alive. The major cause of death, in these cases, is an irregular beating action of the heart, an arrhythmia called ventricular fibrillation, which is treatable with drugs and electric shock when given in a timely manner.

A small percentage of patients will develop a rupture of the heart muscle wall from scar tissue weakening, after a severe heart attack, or total heart failure because the entire heart muscle has been permanently injured due to lack of blood flow through a blocked main coronary artery. 

Other causes of acute chest pain merit hospitalization and intervention as well.  A pulmonary embolus, for instance, is a blood clot to the lung.  Patients with clots in their legs or chronic cardiac arrythmias like atrial fibrillation are at risk for this.  Untreated pulmonary embolus has a high mortality rate.  The take home lesson is that patients presenting with a chief complaint of chest pain often merit admission for additional work-up and treatment. Inappropriate discharge often results in adverse outcomes that inevitably lead to lawsuits.

Headaches are another area of potential malpractice.  Is the headache just a benign tension or migraine headache, or is it due to something more serious, like a ruptured aneursym, a brain tumor, or an infection. Untreated, brain conditions can lead to disability or death.  Timely treatment on the other hand usually has a very good prognosis.  Suspicion of the diagnosis is key.  Indicated evaluation will then follow naturally. 

Hand injuries involving tendon injury should be definitely diagnosed and referred to a hand surgeon. Missing hand tendon lacerations are common causes for medical malpractice lawsuits. They tendon lacerations are not uncommonly missed by the emergency physician. The entire area of the tendon should be checked for complete or partial severance. The inside of the cut must be examined to be sure those structures weren't injured, all foreign substances such as dirt and glass were removed, and appropriate x-rays taken. The wound should be thoroughly irrigated and loosely sutured pending definitive treatment within a few days.

Human and animal bite wounds should never thoroughly irrigated and sutured only if there is no risk for deep space infection. These wounds are highly contaminated and often cannot be totally "sterilized". These patients must always take antibiotics, and 24 hour follow-up is mandatory. 

Head Injuries:  If the patient has a head injury, but no loss of consciousness, the CT of the head is negative, and they are neurologically intact, they can be sent home for follow-up with their primary care physician.

Neck Injuries: the neck must be protected and stabilized while x-rays are obtained.  If there is a fracture or dislocation that is unstable, any neck movement could result in injury to the spinal cord leading to paralysis.

Emergency room physicians recognize conditions, stabilize and treat them, and call consultants for admission or timely out-patient follow-up. But the successful practice of emergency medicine is largely dependent on maintaining a high index of suspicion and acting accordingly.  A well-trained and experienced emergency physician will consider a broad range of potential differential diagnoses for any given presenting problem and will methodically work to rule-in or rule-out the most likely diagnoses.

Copyright © 2020 - & Dr. Barry Gustin