EXECUTIVE SUMMARY

Plaintiff attorneys can link a bad outcome with failure to review EMS findings. Some risk-reducing tactics for EDs:

  • Create and follow a clearly defined process for how EMS gives information to ED personnel;
  • Ensure that ED personnel receive complete information from field EMS providers;
  • EPs should review any EMS records available and consult with others who received verbal reports.

Did a neighbor tell paramedics that a patient saw a cardiologist regularly? Did a bystander observe the patient lose consciousness briefly before someone called 911? Did the patient’s daughter mention that her mother fell a few days ago?

Any of these pieces of information could be pivotal in correctly diagnosing the problem and crafting a timely treatment plan — unless, of course, EPs never know about that useful information.

“By failing to review EMS records, the emergency physician caring for the patient could potentially miss an opportunity for early diagnosis or treatment,” says Katharine C. Koob, JD, an associate at Post & Schell in Philadelphia.

It may be easy for a family member to jump to the conclusion that a terrible outcome is related to poor communication between EMS providers and EPs.

“Whether that perception is true or not, [family members] will be more likely to consider litigation,” Koob warns.

Without the full story, ED providers are forced to make decisions based on incomplete facts. “Witnesses at the scene often possess valuable information that can be used in the ED to provide treatment immediately upon the patient’s arrival,” Koob notes. Discovery during delayed diagnosis litigation reveals the bombshell: All the answers were in the EMS report all along. There are a few examples of how failure to review EMS records could result in litigation, including:

  • Failure to learn about loss of consciousness at the scene. This could delay recognition that a patient is suffering from a lethal heart arrhythmia rather than a benign episode.
  • Not knowing the time of onset for stroke symptoms. This means ED providers are unable to administer tissue plasminogen activator since it is unknown if the patient was within the treatment window.
  • Failure to identify recent medical procedures. For example, knowing about the patient’s colonoscopy could help EPs make the correct diagnosis of bowel perforation.
  • Failure to be aware of a recent fall injury. This could delay the diagnosis of an epidural abscess, causing spinal cord compression and permanent neurologic deficits or other injuries.

In virtually any case where ED personnel failed to review information gathered by EMS with the potential to speed up diagnosis and treatment, litigation can be triggered. The plaintiff attorney links the patient’s bad outcome to the lack of information.

“Such allegations can be made even if the medicine and statistics suggest that the poor outcome was inevitable,” Koob underscores.

It is no easy task for ED providers to defend themselves against an assertion that additional, overlooked information would have affected a patient’s outcome. “No one can know this with 100% certainty,” Koob notes.

Some EDs have not instituted a set process regarding how EMS providers give information to ED personnel. Legally speaking, this can be a “minefield” for EDs, says Paul C. Kuhnel, JD, an attorney in the Roanoke, VA, office of LeClairRyan. Factors such as whether the patient lost consciousness at the scene can become focal points during malpractice litigation. “If EMS leaves their record in the ED, then the ED personnel need to review it during the treatment of the patient,” Kuhnel advises.

It is critically important for ED personnel to receive complete information from field EMS providers, says W. Ann Maggiore, JD, an attorney at Butt Thornton & Baehr in Albuquerque, NM.

“Paramedics are now sophisticated prehospital medical providers who are capable of administering numerous medications and performing complex procedures,” says Maggiore, a practicing paramedic and a faculty member in the University of New Mexico’s department of emergency medicine. The “handoff” of the patient from field providers to the ED is an important time for information to be exchanged and documented. “Failure to do so can expose the ED physician to liability for negligence,” Maggiore warns. “A ‘reasonable’ physician would want to know what care had been rendered previously.”

For example, if a paramedic treated a patient with cardiac problems and administered medications, ED personnel need to know the patient’s condition when the 911 call was made and what EMS found at the scene. Failure to find out what medications were administered (and in what doses) and why could result in duplicate medications administered to the patient’s detriment, Maggiore notes. Before electronic medical records, a physical copy of the EMS chart usually was left with the ED and was included in the patient’s medical chart. Today, it is not always possible for field providers to do that electronically. “Even if a verbal handoff is done, the ED provider should include a statement in the patient’s chart,” Maggiore says.

For instance, such documentation might state: “Per EMS, patient found supine on the kitchen floor with a heart rate of 40 and a blood pressure of 68/42; atropine 1.0 mg administered, and patient’s heart rate came up to 64 with a blood pressure of 76/80.”

Ideally, each ED would create and follow a clearly defined handoff procedure, helping to ensure smooth transitions. However, following a specific process for communicating findings may not always be possible in hectic ED settings. “This is not always feasible based upon changes in staffing and other factors,” Koob acknowledges.

A sudden emergency can interrupt communication between EMS and ED providers. Koob recommends ED physicians review any EMS records available and/or designate another provider, such as a resident, to review them where helpful and appropriate. Another option for ED physicians is to ask personnel who may have received a verbal report from EMS, such as a triage nurse, for information.

The key is for EPs to take ownership of getting information for each patient from EMS. This way, says Koob, “ED physicians are more likely to maximize their knowledge of all available material to evaluate and treat their patients.”