Plaintiff attorneys commonly claim that the emergency physician (EP) did not perform an appropriate workup or respond to diagnostic test results in a timely manner, and that this delay significantly contributed to a poor outcome, says Jonathan M. Fanaroff, MD, JD, associate professor of pediatrics at Case Western Reserve University School of Medicine in Cleveland.
“This can be seen in a variety of conditions, from appendicitis to stroke,” he adds.
Fanaroff says it is far easier to defend these cases when the EP appropriately documents that he or she considered the diagnosis in question, initiated and responded to diagnostic testing results without delay, and obtained appropriate consults, such as a surgical consult for suspected appendicitis, in a timely fashion.
“Poor documentation can make these cases very difficult to defend,” Fanaroff says. If the electronic medical record (EMR) shows that no one checked abnormal laboratory or X-ray results, he adds, “the case will likely need to settle.”
A recent malpractice lawsuit highlights several pitfalls an EP can encounter when treating a patient with a time-sensitive diagnosis. The case involved a patient who injured his knee in a water skiing accident. The EP’s physical evaluation was very limited, due to the patient’s intense pain.
“The physician took a history and ordered X-rays of the injured knee, with no indication that they should be performed ‘stat,’” says Keith C. Volpi, JD, an attorney at Polsinelli in Kansas City, MO, who defended the EP in the resulting lawsuit. The X-rays showed a spontaneously reduced dislocation. The EP consulted with the on-call orthopedic surgeon, who requested a CT angiogram of the knee to evaluate potential vascular injury. This showed an occluded popliteal artery.
The EP advised the on-call orthopedic surgeon of the results. The orthopedic surgeon and a vascular surgeon operated shortly thereafter.
“The patient alleged that he sustained permanent vascular injury in his knee due to the delayed diagnosis and resultant compartment syndrome,” Volpi says.
Here are three factors that became central issues in the decision to settle the malpractice suit:
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The EP failed to recognize the potential for a time-sensitive injury.
“It goes without saying that the most common pitfall in diagnosing a time-sensitive injury is recognizing the potential for a time-sensitive injury,” Volpi says.
The defendant EP failed to appreciate that the most common knee injury associated with water skiing is dislocation, that dislocation very commonly causes vascular injury, and that vascular injury in the knee must be treated within approximately six hours of acute injury to avoid permanent damage.
“Had he appreciated these facts, he most certainly would have acted with a greater sense of urgency,” Volpi says. “Plaintiffs’ counsel hammered this home during the EP’s deposition.”
The defendant EP was very well-prepared for the deposition.
“But great deposition testimony can’t change the fact that the records showed no sense of urgency in his care and treatment,” Volpi notes.
Volpi counsels his ED clients to ask specialists for details regarding the most common time-sensitive injuries.
“Then create a flow chart of symptoms and acute events that one can walk down, to quickly rule in or out this type of injury,” he advises.
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The EP failed to designate orders as “stat.”
Nearly an hour passed before the patient was taken for X-rays of his injured knee, because the X-ray order was not denoted “stat.”
“Many ED physicians have told me that they expect that every order from the ED is treated as a ‘stat’ order. But I’ve not seen this play out regularly,” Volpi says, adding that ED orders, particularly for labs and imaging, should always be denoted “stat.”
“This gives the ED physician the best chance of timely diagnosing a time-sensitive injury,” Volpi says.
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The EP waited too long to obtain specialist consultation.
The orthopedic surgeon ordered the CT angiogram to explore vascular injury as soon as he learned of the nature of the injury. The problem was that the EP waited more than an hour after the patient arrived in the ED to contact the orthopedic surgeon.
“In the eyes of the general public, this is simply too much time for an ED physician to diagnose a dislocated knee and the need for specialty care,” Volpi says.
SOURCES
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Jonathan M. Fanaroff, MD, JD, Associate Professor of Pediatrics, Case Western Reserve School of Medicine, Cleveland. Phone: (216) 844-3387. Fax: (216) 844-3380. Email: [email protected].
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Keith C. Volpi, JD, Polsinelli, Kansas City, MO. Phone: (816) 395-0663. Fax: (816) 817-0210. Email: [email protected].
