ED staff over-rely on the radiology report, or give insufficient information to the radiologist. Anna Berent, JD, has seen these two issues come up repeatedly in ED malpractice claims. These are the fact patterns in actual cases:
• An EP treated a patient who reported hearing his foot make a “pop” sound after a fall. An X-ray report referenced a possibly old calcaneal fracture.
“Dismissing the significant findings of the physical exam and the history, the ED doctor attributed the pain to a soft tissue injury, and did not stabilize the foot upon discharge,” says Berent, claims counsel at Western Litigation in Houston.
Several days later, the fracture became displaced. Eventual surgical intervention was complicated by intractable infections and concerns over possible foot amputation. “The case assessment through outside experts revealed that had the ED physician heeded the physical exam, he would have at least stabilized the foot upon discharge or ordered a follow-up with an orthopedic specialist,” Berent reports.
• A young woman came to the ED with severe abdominal pain. The EP suspected a ruptured cyst, which was the only diagnosis on the differential. Once the ultrasound confirmed there was no ruptured cyst, the patient was discharged. She returned the next day with a diagnosis of a ruptured appendix. “While the radiologist is also named in the suit that stemmed from the incident, their role was quite limited, and they will likely be dismissed from the case,” Berent explains.
• An elderly man injured his knee when he shattered a flower pot. After cleaning the wound, the ED physician wanted to confirm there were no shards remaining in the wound, and ordered an X-ray. However, the physician told the radiologist only that the patient had fallen, without mentioning the broken flower pot. The co-defendant radiologist noted no fractures, but missed the presence of shards in the wound.
The patient sued the EP and radiologist. The lawsuit alleged a severe infection developed due to failure to remove the shards. The EP claimed he relied on the interpretation of the X-ray to confirm the wound did not need further cleaning. The radiologist claimed he would have noted the presence of the shards if the EP had indicated it. “Both physicians are locked in, and their adjusters recognize the potential for finger-pointing,” Berent notes.
• A routine chest X-ray revealed a widening mediastinum, suggestive of an aortic aneurysm. The radiologist defendant contended that a slightly widened mediastinum in an elderly patient is not unusual and often not mentioned in a radiology report.
However, the EP was using the chest X-ray as an initial screen for aortic aneurysm in addition to looking for other pulmonary pathology. “The patient’s aortic aneurysm was not diagnosed before death,” says Rodney K. Adams, JD, a visiting assistant professor at the University of Richmond (VA) School of Law.
• A young man presented to the ED with complaints of severe abdominal pain, and a CT scan was ordered. The patient stated he had been seen previously in other EDs several times over the past few weeks.
During litigation, it was discovered the patient had undergone several abdominal CT scans. “When all of the CT scans were collected and reviewed, they showed a clear progression of bowel dilation and fat stranding,” Adams says.
• A routine post-intubation X-ray revealed the endotracheal tube probably was positioned improperly. The radiology report was entered in the electronic medical record timely, but the patient was in the process of transferring from the ED to the ICU at that point.
The ICU physician assumed the EP had repositioned the tube. The EP did not review the report because the patient was already in the process of transferring. “She assumed the ICU physician would be reviewing the report,” Adams says.