A morbidly obese patient’s body fat may not allow an ED physician to accurately palpate for a mass or other condition; some patients cannot undergo some radiological studies due to their size. This doesn’t equate to malpractice — even if a bad outcome occurs, according to Linda M. Stimmel, JD, an attorney at Wilson Elser Moskowitz Edelman & Dicker in Dallas.
“As an ED physician, you may not be able to complete the assessment you need. That is not malpractice,” Stimmel says. “You can only accomplish what is reasonable in the situation.”
However, Stimmel notes, it is imperative to chart the decisions or lack of treatment that may be associated with a particular obese patient. “Detail why a certain test was not performed. Chart your analysis, and the restrictions you are faced with regarding this obese patient,” Stimmel advises.
The Doctor’s Company, a Napa, CA-based medical malpractice insurer, recently analyzed 332 emergency medicine claims that closed from 2007 to 2013. In 8% of claims, obesity was a factor in the outcome; 76% of cases involving obesity had a diagnostic-related allegation. (The complete study is available at www.thedoctors.com/emergencymedicinestudy.)
Here are some examples of obesity-related ED claims:
- A patient who presented with shortness of breath and an oxygen saturation level of 92% waited in the waiting room for five hours. The patient died of a pulmonary embolus.
- A patient presented complaining of knee pain after a long plane trip and left with a diagnosis of knee ligament strain. The patient died shortly thereafter from a pulmonary embolus.
- Doctors treated a patient with intense pain due to kidney stones with opioids and discharged her home where she died in her sleep, due to the effects of opioid suppression of the respiratory center and undiagnosed sleep apnea.
“We code obesity as a comorbidity only when we see a link between the outcome of care and their obesity,” says Darrell Ranum, JD, CPHRM, vice president of patient safety and risk management at The Doctor’s Company.
Many of the cases in which obesity was coded as a comorbidity involved risk factors that increased due to obesity, but were not adequately addressed. This was seen in cases of hyperlipidemia, hypertension, diabetes, and increased risk of deep venous thrombosis, myocardial infarction, and stroke.
“It appears from reviewing these cases that physicians must factor the risks of obesity into their differential diagnosis, because it does increase risk of having one of these clinical problems,” Ranum says. Most of the cases in which diagnosis was alleged to be incorrect were due to physicians not addressing the increased risk that obesity represents for conditions like pulmonary embolism or cardiac damage, he adds.
Stimmel has defended healthcare providers in medical malpractice cases in which the patient was morbidly obese. Here are some common allegations in these claims:
- The ED physician didn’t do a thorough history and examination.
“Be detailed in your initial examination and in triage,” Stimmel says. “The history of such a patient is critical.” The morbidly obese patient, many times, will have several co-morbid conditions that may affect the ED assessment and treatment. “The ED physician can be at risk by not asking the right questions that may disclose a risk that could impede the treatment,” Stimmel says.
- The ED didn’t have appropriate equipment.
Stimmel says EDs should be equipped with “reasonable” equipment for the general patient population. If there is not an appropriate bed or MRI in your ED for a morbidly obese patient, Stimmel suggests taking these two steps:
-Research other facilities that may be better equipped to handle this type of patient. “So there will be no EMTALA [Emergency Medical Treatment and Labor Act] concerns, have your administration work with other back-up facilities for a transfer agreement,” Stimmel says.
-If there are no such back-up facilities in your area, alert the police or paramedics of your ED’s limitations regarding morbidly obese patients.
If the ED equipment is reasonable for the general population and the ED can document efforts to have other facilities serve as back up, Stimmel says, “an ED physician should not be held liable for lack of sufficient equipment to take care of morbidly obese patients.”
- The ED physician failed to complete a thorough skin assessment.
If a patient’s decubitus ulcer is not described in the chart, plaintiff attorneys may use this as evidence that the ED physician did not complete a thorough examination. “If the skin assessment is relevant to the patient’s condition, make sure it is well-documented,” Stimmel says. “This is a greater liability risk in areas of long-term care than in the ED. But it needs to be noted in the ED exam if it is relevant.”
- That appropriate tests weren’t obtained due to the patient’s size.
Michael Blaivas, MD, FACEP, professor of emergency medicine at University of South Carolina Medical School and an ED physician at St. Francis Hospital in Columbus, GA, has seen EPs forego lumbar punctures or lower extremity ultrasounds to rule out a deep vein thrombosis on obese patients.
In some cases, EPs convince the patients to decline such testing. “However, if a family member or the patient recall such a discussion and can elaborate that they were steered away or scared off by the EP, this can be very challenging to deal with,” Blaivas says.
Blaivas is aware of cases involving over-sedation of obese patients. “As we know, some meds are specifically absorbed into fat and then redistribute. This can mean unexpected prolonged sedation in obese individuals,” he says. Additionally, the incidence of sleep apnea is very high. “When you combine the two, you are at risk for over-sedation and airway loss. That is exactly what happens from time to time,” Blaivas says, noting the best practice is for EPs to know the effect of medications in obese patients. “Be aware of more likely diseases such as heart disease and sleep apnea,” Blaivas adds.
Obese patients often have comorbidities such as diabetes, hypertension, cardiac and circulatory issues, pulmonary issues, and face greater risk when intubation is necessary in the ED, says Leilani Kicklighter, RN, ARM, MBA, CHSP, CPHRM, LHRM, principal of the Tamarac, FL-based Kicklighter Group. “Providing an IV line can be particularly difficult,” she says.
In an emergent situation, obtaining the weight of a morbidly obese patient can be very difficult as normal scales cannot be utilized; weight-based medical dosages may need to be estimates. “Detailed documentation of the ER physician’s thought process and circumstances of the patient’s injury or condition is very important, should allegations of negligence be asserted,” Kicklighter says.
A general risk-reducing practice is to simply treat obese patients as well as you treat other patients. EPs might tell patients, for instance, “We may not be able to see this as well as we would like,” or “This may be a little harder due to your size.”
“Many obese patients realize their weight brings limitations,” Blaivas says. “In a polite way, discuss the challenges with the patient. Let them know you are trying, that you care, and that you and the hospital will do their best.”
- Michael Blaivas, MD, FACEP. E-mail: firstname.lastname@example.org.
- Leilani Kicklighter, RN, ARM, MBA, CHSP, CPHRM, LHRM, The Kicklighter Group, Tamarac, FL. Phone: (954) 294-8821. Fax: (954) 665-2863. E-mail: email@example.com.
- Linda M. Stimmel, JD, Attorney at Law, Wilson Elser Moskowitz Edelman & Dicker LLP, Dallas. Phone: (214) 698-8014. Fax: (214) 698-1101. E-mail: firstname.lastname@example.org.