Headache case illustrates the risks of poor ED care

To explain how EDs often leave themselves open for liability when treating headaches, Diane M. Sixsmith, MD, MPH, FACEP, chairman of emergency medicine at New York Hospital Medical Center of Queens in Flushing, tells a story, based on a real incident, in which everything went wrong.

Sixsmith told this story at the recent meeting of the American Society for Healthcare Risk Management in Nashville, TN:

A 25-year-old mother of two presented at the ED with a two-day history of fever, headache, and confusion. A resident and attending examined the woman, and when there were no focal findings on the neurological exam, their differential diagnosis was encephalitis and meningitis. They decided to do a lumbar puncture (LP), which a resident attempted three times with no success.

With no active supervision of the LP by the attending ED physician, the two physicians decided the patient didn’t really need an LP after all because the resident was having too much difficulty doing it. She left with a diagnosis of reaction to amoxicillin. The next day, her husband called the family doctor and told him that he thought his wife was having a nervous breakdown. The family doctor referred the wife to the local outpatient psychiatric facility. The psychiatrist there spent five minutes with her, felt strongly she had an organic process, not a psychiatric one, and referred her back to the ED.

In the ED, the differential again was encephalitis, but also acute depressive psychosis. The plan was to do a computed tomography (CT) and an LP. But then there was a shift change. The oncoming physician, without examining the patient, decided she was really a psychiatric problem and requested a psychiatric consult. No psychiatrist was available at 3 a.m., so the patient was discharged and told to return in the morning. That day, the patient had a grand mal seizure and was hospitalized, in a coma, from which she gradually improved over several weeks. The diagnosis was herpes encephalitis. The patient ended up with residual cognitive deficits and sued for malpractice.

So what went wrong in that case? Just about everything, Sixsmith said. These are some of the lessons:

  • The standard of care for new onset headache is a careful history and a complete and documented neurological exam.
  • A CT scan and LP should be done sooner rather than later; and in many cases, a neurological consult is helpful.
  • Unsupervised care provided by residents often results in mistakes. "When the resident could not do the LP, there was no reason for the attending not to step in or for an alternative, more expert provider to do the LP," she explained. "Deciding that the LP was no longer necessary defies logic."
  • Regarding the second ED visit, Sixsmith advised you should always "look twice as hard to find the cause of the patient’s symptoms on the second visit."
  • It is equally important that the off-going and incoming doctor are crystal clear about what the plan is about the patient, "so that the second doctor doesn’t cavalierly dismiss a patient whom he or she didn’t initially evaluate," she added.