An ED patient was so terribly anxious that he could not lie still for a CT scan. The patient was given a benzodiazepine, but the true problem was discovered minutes later when the patient went into cardiac arrest.

“Psychiatric” patients may present with an underlying medical condition that’s causing a mental status change. “This is a frequent medical/legal problem that comes up,” says Bruce Janiak, MD, a professor in the department of emergency medicine at Medical College of Georgia at Augusta University.

Once EPs conclude that a patient’s behavior is psychiatric, they may miss underlying medical conditions that are the real cause of the symptoms. This is less likely if a patient is behaving bizarrely, presents with a psychiatric history, and is taking psychiatric medications. “Otherwise, you need to look at the medical things first,” Janiak offers. “Get a good history before you decide it’s psychiatric.”

In one case, paramedics said the patient refused to walk because he was under a great deal of stress. The EP didn’t conduct a careful neurological exam, put the patient on an involuntary psychiatric hold, and missed a stroke. In another case, a patient did have a psychiatric history, but the ED missed an underlying medical condition. EMS brought the man to an ED after a violent altercation.

“EMS said only that the man was acting crazy and fell on his head,” Janiak reports. “It turned out that they tasered him, and he fell off the porch, landing on his head.”

 

 

The patient spent the next 18 hours in the ED waiting to be transferred.

“Once the individual was in jail, they found out they missed a neck fracture. The man ended up being quadriplegic,” Janiak says.

The subsequent malpractice lawsuit alleged the EP ignored the patient’s neurological symptoms. For instance, the man wanted something to drink, but would not use his dominant arm to pick it up.

“Instead of saying, ‘Maybe he has a neurological injury,’ they thought he was just being uncooperative,” Janiak explains.

Do What’s Reasonable

Alan Gelb, MD, clinical professor in the department of emergency medicine at the University of California San Francisco School of Medicine, is aware of multiple malpractice cases in which the EP failed to rule out a medical condition that was causing psychiatric symptoms. “Someone comes in, and they look psychotic,” he says. “You assume it’s schizophrenia or depression or manic depression.”

A typical fact pattern in these cases: During the ED visit, the patient’s symptoms are controlled with sedatives or antipsychotics. It later turns out that the patient has a medical condition such as encephalitis or meningitis.

“There are a lot of medical conditions that can cause a psychosis, and may appear to be psychiatric in origin,” Gelb cautions. Infections, stroke, head trauma, and drugs can mimic psychiatric conditions. Uncommonly, a brain tumor can present as a psychiatric disorder.

The difficulty of obtaining a good history and conducting a thorough evaluation is a complicating factor. For instance, if a patient is experiencing an aortic dissection, the EP would expect to see severe back pain and high blood pressure. “But if the patient is completely out of it, and yelling about Martians, and is not saying anything about any back pain, the high blood pressure would probably be attributed to their agitation,” Gelb notes.

In one case, a charge nurse told an EP to clear a patient for psychiatry. No one took the patient’s temperature, likely because he was yelling and acting bizarrely, but all other vital signs were normal. The patient was cleared to go to psychiatry, where it was discovered he had a temperature of 103. The patient was brought back to the ED for a spinal tap, which revealed meningitis.

This case reflects the pressures EPs are under to quickly place a patient in a psychiatric setting when they appear “psychiatric.” Crowding adds to the pressure. If there are no beds available at the transfer facility, keeping the patient in the ED could necessitate the ED going on diversion. “The on-call administrator is saying, ‘You’ve got to get these beds cleared out,’” Gelb says. “The mistakes you make are when you try to cut corners, for whatever reason.”

The patient with new onset of psychosis, with no previous history of psychiatric disorders, is a major red flag, Gelb warns. This is particularly true for older patients, since psychiatric disorders typically begin in late teens to early 30s.

“If you’re seeing somebody who is having a new psychosis at the age of 50, you have to be really worried that this is a medical problem,” Gelb notes.

Even in a younger patient, if there is no history of psychiatric disorder, seriously consider a head CT, Gelb offers. “That is something that if you don’t do it, and you miss something, you can just start writing the check.”

The duration of the behavior also is a clue. If it’s a true psychiatric disorder, family or friends typically report the patient has been acting strangely for weeks or months.

“If, over a couple of days, the patient goes nuts and has no history of acting strangely at all, then you need to be more worried about a medical problem,” Gelb says. Documentation of the EP’s thought process can help the defense. The ED chart should be clear as to why the EP didn’t order certain tests, why the EP didn’t think the patient had particular problems, and why the EP thought the patient was clearly psychiatric.

“When there is a problematic outcome, we can later point to the thinking behind the care plan. This protects physicians and their organizations, as it provides insight into the case as it unfolded in real-time,” says Scott L. Zeller, MD, vice president of acute psychiatric medicine at Emeryville, CA-based Vituity. Zeller also is a clinical assistant professor of psychiatry at University of California, Riverside.

In some cases, the EP made an obvious mistake by failing to order a test, such as a head CT scan in a patient who exhibits neurological symptoms.

“In others, there is no way they would have known what was going on,” Gelb says. Documentation of the EP’s medical decision-making can explain why it was not possible to identify the underlying medical condition at the time of the ED visit.

The EP’s legal obligation is to act reasonably based on the state’s definition of negligence. “It’s not ruling out every possible condition a person may have. It’s what’s reasonable,” Gelb stresses.

If nurses see something has changed, alerting the EP is legally protective for everyone involved in the patient’s care. “Otherwise, ED nurses will simply document the changes without telling you. That will kill you in a med/mal case,” Gelb cautions.

Failure to review nursing notes is a common complicating factor in these claims. EPs sometimes check the box stating that they’ve reviewed the nursing notes when they actually haven’t. Sometimes, EPs have read the notes up until that point in time, but don’t review the rest.

“I’ve seen those depositions,” Gelb recalls. Some EPs try to defend themselves by explaining that nursing notes are difficult to find because they’re on a different system, or are on a clipboard at the nursing station. “It can be more difficult in some places than others,” Gelb acknowledges. “But you can see the nursing notes.”

Before the patient leaves the ED, the EP must look at what other providers have documented in the chart. “If a psychiatric patient is in your ED for 12 or 24 hours, there’s going to be lots of nursing notes,” Gelb says. “Make sure there is nothing new going on. You also need to go look at the patient.”

This is difficult in a busy ED when the patient has already been accepted at another institution.

“The patient is finally getting out of your ED. The last thing you want to do is make more work for yourself,” Gelb says. “But you need to go reassess them.”