A 40-year-old female who was a frequent ED visitor presented with a chief complaint of vague pain. After a focused workup, the EP came to discuss the findings and discharge plan with the patient. The patient reported the pain had worsened — something the EP viewed with skepticism. Nevertheless, the EP ordered an abdominal X-ray. When it came back normal, the EP reassured the patient and sent her home.

“The patient was later found down at home, and was determined to have died from sepsis secondary to abdominal/pelvic pathology, which would have required surgical intervention,” says Michael Blaivas, MD, FACEP, professor of medicine at the University of South Carolina Medical School and an ED physician at St. Francis Hospital in Columbus, GA.

The EP presented her case to peer review to state the reasons why abdominal films were ordered and considered to be adequate.

“But she could not justify relying on them for a differential, which, at that time, included appendicitis, abscess, pelvic inflammatory disease, diverticulitis, and other significant pathology,” Blaivas says, adding the plaintiff prevailed in subsequent malpractice litigation against the EP.

Although X-rays cannot rule out many life-threatening conditions, Blaivas is aware of multiple cases in which EPs have ordered them for abdominal pain and missed pathology.

“I saw a case once of an abdominal X-ray ordered to rule out intestinal perforation,” Blaivas recalls. “When negative, the patient was sent home with strong pain medications.” The patient decided to go to another ED several hours later, where he underwent an abdominal CT after several more hours. “The CT showed a small amount of free air — not caught by the abdominal X-rays — and bowel perforation,” Blaivas says. The patient became septic, but eventually recovered after a prolonged stay.

“Unfortunately, abdominal X-rays are very limited in diagnostic capability and in their disease rule-out scope, in comparison to CT,” he says.

Blaivas has reviewed several other malpractice cases in which EPs could not justify ordering X-rays for undefined abdominal pain, and could not answer what the test might have ruled out or identified.

“By the time they get to deposition, they have studied the topic and know,” Blaivas notes. “But they are hampered in their defense by lack of prospective documentation and available literature to support their position.”

Susan Martin, Esq., executive vice president of litigation management and loss control in the Plano, TX, offce of AMS Management Group, names failure to order a CT scan as a top allegation in cases involving a failure to recognize or diagnose an acute abdominal surgical condition.

“Many cases are now geared toward whether a CT should have been done with or without contrast,” she adds. “This is a clinical decision dependent on many factors.”

Martin offers this example: A missed appendicitis case in which a young woman presents with acute abdominal pain. She does not have the “classic” symptoms of an appendicitis, but the EP orders a CT without contrast. The appendix is obscured and cannot be visualized, so the patient receives discharge instructions to return if pain worsens.

The next day, the patient returns with a ruptured appendix and is taken to the operating room. The patient sues the radiologist and EP for malpractice, with the plaintiff attorney alleging that the EP failed to diagnose appendicitis, and failed to consult a surgeon while the patient was in the ED.

“EPs should develop valued and trusted relationships with radiology staff in order to better communicate the critical findings and make further recommendations,” Martin recommends.

To protect themselves legally from allegations of a missed acute abdominal surgical condition, Blaivas suggests the following for EPs.

  • Know the limitations of any tests ordered, and address this in the chart.

“Like so many things in emergency medicine legal cases, it comes down to documentation,” Blaivas says. The reason the EP ordered abdominal films instead of a CT scan could turn out to be a pivotal factor in defense of a malpractice lawsuit. “Perhaps there was a history of ileus or small bowel obstruction recurrently, and that was the only thing on the EP’s differential — and justifiably so, based on the physical examination,” Blaivas adds.

  • Explain the reason why the EP does not think a particular test is indicated.

“This is where one must have some knowledge of indications, statistics about outcomes, and also any national recommendations,” Blaivas says.

EPs might document: “Based on the following guidelines ...” or “Given the sensitivity and specificity of the test, I felt ...”

Blaivas says this helpful documentation usually is missing from ED charts. “The really egregious cases had no medical decision making at all,” he says. Tests simply were ordered, with a brief note stating “severe abdominal pain.”

“A solid case has to be laid out as to why a test is not indicated,” Blaivas stresses. “Simply saying so only takes you part way.”

  • Discuss why a particular diagnostic test was ordered with the patient and family.

“Document that you answered questions after explaining everything,” Blaivas advises. “Also, state what the patient or family decided on, and what their questions were.”

SOURCES

  • Michael Blaivas, MD, FACEP, Professor of Medicine, University of South Carolina Medical School; ED Physician, St. Francis Hospital, Columbus, GA. Email: mike@blaivas.org.
  • Susan Martin, Esq., Executive Vice President, Litigation Management/Loss Control, AMS Management Group, Fort Lauderdale, FL. Phone: (866) 520-6896. Fax: (817) 704-4291. Email: smartin@amsmanagementgroup.com.