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Unexpected Results of Needless Tests Can Cause Legal Problems
If you don't believe a diagnostic test is truly necessary but you order it anyway, you must be prepared for results to come back unexpectedly abnormal, even if these "incedentalomas" have nothing to do with what brought the patient to the ED, warns Bruce Janiak, MD, professor of emergency medicine at Medical College of Georgia in Augusta.
Janiak gives the example of a possible pneumonia patient who gets a chest X-ray that shows a dot on the other side of the lung. "So you get a CT scan, which comes back inconclusive, and you get a PET scan," he says. "You now have $10,000 invested in the case, and the patient didn't need the chest X-ray in the first place. That is a problem."
Similarly, says Janiak, you don't want to find yourself ordering a complete blood count, which is intended to look for secondary signs of infection, that comes back with an elevated white count that you dismiss as having nothing to do with the patient's presenting symptoms.
"You will find yourself on the stand, trying to explain why you ignored the result," Janiak says. "Imagine yourself having to tell a jury why you order tests you don't need, and when they come back abnormal, you don't do anything about it."
John Burton, MD, chair of the Department of Emergency Medicine at Carilion Clinic in Roanoke, VA, reviewed a case of an EP sued by a patient who came in with abdominal pain. As part of the workup, the EP decided to do an abdominal series X-ray that included a single-view chest X-ray.
"It turned out that the patient died from an aortic dissection," says Burton. The plaintiff argued that this could have been visualized on the chest X-ray, which was part of the abdominal X-ray series that the EP ordered.
"If you think you should order some tests to protect yourself, you should be careful which tests you order," warns Burton. "Some of those tests may bring information into the medical record that you really don't want in there, because you weren't considering those things to begin with."
In the case of the patient with abdominal pain, the EP had never contemplated aortic dissection, says Burton. "The plaintiff had him in a tricky spot. He had ordered a test, but had not thoroughly interpreted that test on behalf of the patient," he says. "He was only looking at the belly, but the chest X-ray was clearly done."
Be Very Strategic
Since delayed-diagnosis lawsuits often involve the EP's failure to act appropriately on a test that was ordered, says Burton, "you may get into more trouble by ordering a bunch of tests. You've got to be very strategic about what you order."
Look at each individual patient, he recommends, and consider whether you can defend ordering a test, based on the patient's presenting signs and symptoms. If you have every reason to believe a patient has a certain diagnosis based on their signs and symptoms as charted in the medical record, says Burton, then you should be ordering a test to pursue that diagnosis.
Some ED medical records reviewed by Burton have indicated that a patient presented with signs and symptoms consistent with subarachnoid hemorrhage, but the EP didn't order a CT scan and may not have even done a lumbar puncture.
In one case, the EP documented that a patient's headache symptoms were consistent with prior migraine headaches, but the patient actually did have a subarachnoid hemorrhage and a lawsuit ensued. During discovery, it was noted that the triage notes conflicted with the EP's assessment, and stated that the presenting symptoms were, in fact, very different from the patient's previous headaches.
"The EP never addressed that conflict in the medical record," says Burton, adding that the case settled out of court. In addition, the patient had no apparent history of migraines, which conflicted with the EP's charting.
"This suggested that the EP was documenting this purely as a defensive move, and was clearly positioning themselves in the medical record to say that this was not consistent with the diagnosis for subarachnoid hemorrhage," says Burton.
For more information, contact:
John Burton, MD, Chair, Department of Emergency Medicine, Carilion Clinic, Roanoke, VA. Phone: (540) 266-6331. E-mail: JHBurton@carilionclinic.org.