ED malpractice claims involving aortic aneurysm generated higher average indemnity ($369,872) than any other medical condition, according to a recent analysis.1

“Failure to timely diagnose is the most common allegation in malpractice actions, followed closely by poor communication between providers,” says Amy Evans, JD, executive vice president of business development and liability claims division at Intercare Insurance Services in Bellevue, WA.

Evans says the following included in documentation can refute allegations of failure to timely diagnose abdominal aortic aneurysm (AAA): a current, negative CT; a note indicating AAA was a part of the differential; and the specific reasons the EP believed the diagnosis was unlikely. Consider the following AAA cases involving these scenarios:

• Patients with sudden abdominal pain that waxes and wanes with a GI cocktail. “We see several cases every year where that patient later ruptures and dies,” Evans reports.

In those cases, plaintiffs’ counsel seized on the fact the GI cocktail masked the symptoms of the deadly AAA. The attorneys argued the EP treated a life-threatening condition as nothing more than a “belly ache.” Ideally, the EP noted that AAA was considered, but not likely due to low BMI, no history of hypertension or smoking, and lack of any corroborating symptoms. “If the symptoms wax and wane, EPs can consider monitoring the patient long enough to see if the symptoms truly resolved or are just in the waning part of the symptom cycle,” Evans says.

• AAA was missed without documentation of provider-to-provider discussions. “This is especially pertinent if the patient is being discharged or admitted to a specialist who did not see the patient in the ED,” Evans says. The plaintiff attorney focuses on whether the EP covered the size of the aneurysm, the patient’s vitals, lab results, and symptoms.

Sometimes, the patient told the EP he is aware of the AAA, which another physician is following. In those malpractice cases, the EP called the other provider who confirmed awareness of the AAA. The second provider agrees the patient can be discharged for later office follow-up. Then, shortly after discharge, the patient ruptures and dies. “At deposition, the other provider often testifies that they were not told the size of the AAA and/or they did not approve of discharge,” Evans explains.

For successfully defended cases, documentation includes specific information conveyed by the EP and the specific instructions provided by the treatment provider.

• Some lawsuits involve dissections that happen after admission from the ED. The admitting or consulting specialist does not round on the patient immediately, and later testifies the EP never told them the patient was acute or unstable.

Evans gives this example of a documentation note that can help refute this: “Surgeon Dr. Johns confirmed she will see the patient within an hour to determine whether emergent surgery is necessary. Ordered NPO status just in case.”

“If urgency is conveyed verbally, it should be documented in the chart, along with exactly when the consulting said they would see the patient,” Evans says.

Stephen Colucciello, MD, FACEP, has reviewed multiple claims involving missed or delayed diagnosis of leaking AAAs. In one case of an elderly woman with sudden, severe back pain, a lumbar film showed degenerative disease. She was discharged without anyone evaluating the aorta.

“The plaintiffs later argued that the wrong test was ordered — a lumbar film instead of an abdominal CT with contrast,” Colucciello says.

Based on the allegations in lawsuits, Colucciello says EPs can make successful claims less likely with these specific practices:

  • Remember that in older patients with back, flank, or abdominal pain, normal distal pulses and normal abdominal exam does not rule out the diagnosis. “Hypotension is an especially ominous sign, but is not always present,” says Colucciello, a professor of emergency medicine at Wake Forest School of Medicine.
  • Set a low threshold for performing bedside ultrasound of the aorta (or, if the patient is stable, for obtaining an abdominal CT).
  • Check the medical record to see if the patient has undergone an abdominal CT in the past several years. “Since abdominal aortic aneurysms grow at the rate of about 1 cm per year, a normal aortic diameter in the past several years on CT makes a new AAA unlikely,” Colucciello says.
  • Consider AAA in the older patient with apparent renal colic. “In one study, up to 87% of patients with leaking AAA had hematuria,” says Colucciello.2
  • Follow current guidelines for management of AAA. These suggest avoiding aggressive fluid resuscitation (as long as the systolic blood pressure is between 70 mmHg and 90mmHg, and the patient demonstrates a normal mental status).3 “Do not over-resuscitate, especially with crystalloids,” Colucciello says. “If the patient is in frank shock, resuscitate with blood and get the patient to the OR as soon as possible.”
  • If the hospital does not offer vascular surgery, establish a transfer protocol, such as “Code Rupture,” with a center that routinely handles AAA repair. “Time to operation is key in the management of ruptured AAA, preferably less than 90 minutes, and sooner if possible,” Colucciello offers.
  • Instead of sending a hemodynamically unstable patient to CT scan for suspected AAA, perform bedside ultrasound, and call the vascular surgeon. “If the surgeon insists upon CT first, document this in the medical record,” Colucciello says. The EP might chart, “Suspected AAA. Case discussed with vascular surgery, who asked for a CT scan for operative planning. Aware that BP systolic was 70 mmHg at the time of consult.” 

REFERENCES

  1. Wong KE, Parikh PD, Miller KC, Zonfrillo MR. Emergency department and urgent care medical malpractice claims 2001-15. West J Emerg Med 2021;22:333-338.
  2. Pomper SR, Fiorillo MA, Anderson CW, Kopatsis A. Hematuria associated with ruptured abdominal aortic aneurysms. Int Surg 1995;80:261-263.
  3. Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018;67:2-77.e2.