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Headache, abdominal pain pose liability risk
(Editor’s note: This is the second of a three-part series covering the top five issues that lead to malpractice claims in the ED and how you can address them. The January 2004 issue of ED Management addressed chest pain, and this month’s installment involves headache and abdominal pain. Next month, the last installment will address head injury and stroke.)
Though it is impossible to eliminate the malpractice risk in the ED, you can greatly reduce the risk by better addressing headache and abdominal pain, said Diane M. Sixsmith, MD, MPH, FACEP, chairman of emergency medicine at New York Hospital Medical Center of Queens in Flushing.
Sixsmith’s insight comes from 25 years as an expert witness and malpractice consultant, in addition to her years in the ED. She spoke on the topic at the recent meeting of the American Society for Healthcare Risk Management in Nashville, TN, along with Andrew S. Kaufman, JD, a partner with Kaufman Borgeest & Ryan in New York City, a prominent law firm defending health care malpractice claims.
The patient presenting with a terrible headache is a clinical challenge and a huge liability risk, Sixsmith explained. Does the patient have only a routine headache or a subarachnoid hemorrhage that could kill suddenly? The temptation is great to assume that the patient only has a normal headache, but that assumption could have terrible consequences, not only for the patient but also in terms of your liability.
Likewise, the patient with abdominal pain could have bad case of gas or an aortic dissection. The huge difference in outcomes, and the limited time and background available to the ED physician, creates a tremendous liability risk, Kaufman said.
"ED physicians are at a distinct disadvantage," he explained. "They’re expected to catch every case of aortic dissection without overreacting and practicing too much defensive medicine every time someone says they have a stomachache. We’re asking a lot of them."
A CT scan and lumbar puncture (LP) often are necessary to properly diagnose the cause of headache, but Sixsmith said ED physicians often perform only the CT scan and don’t proceed on to the LP when the CT is negative. That’s a big mistake clinically and in terms of risk management, she added.
"If the patient needs a particular procedure, you can’t say he doesn’t need it because it’s difficult. Either he needs it or he doesn’t," she continued. "A standard policy in the ED should be If you think of it, do it.’"
Sixsmith said that, from her experience in working with ED lawsuits, abdominal pain is the most frequent condition leading to malpractice suits.
It is difficult to diagnose because the symptoms often are nonspecific. She explained that incorrectly diagnosed ischemic bowel, perforated viscous, and appendicitis often lead to prolonged hospitalization, significant complications, infertility, and not infrequently, death.
"The ED provider is well-advised to pay attention to the abdominal exam and do it well," she added. "Patients with tenderness usually have pathology; but not infrequently, they will have completely normal blood tests and plain X-rays."
CT scans have completely changed the management of abdominal pain, Sixsmith said. The standard is no longer "admit and observe" or "discharge and hope," she explained. "A CT is now the standard of care for abdominal pain, and I will stake my professional reputation on it," she said. "It’s no longer just observation. Make sure your institution makes it easy for ED docs to get a CT scan."
Because surgeons are regarded as the experts in evaluating abdominal pain, it is difficult to defend not calling in a surgical consult, Sixsmith noted. Many abdominal conditions present atypically, especially in elderly patients, she said, so this common complaint must prompt a thorough examination.
All patients complaining of abdominal pain should undergo a rectal exam, Sixsmith added, and a normal blood test does not rule out an abnormal process. Heed other red flags, such as low blood pressure, fever, or tachycardia.
She also cautioned that, more so than many others, abdominal pain is a condition in which the patient’s personal behavior can get in the way of a proper diagnosis.
Sixsmith recounted an elderly patient in her own ED who complained of severe epigastric pain but was uncooperative and kept insisting he only needed an enema. He eventually received an enema and was discharged soon after with a diagnosis of abdominal pain. The patient returned to the ED hours later and was diagnosed with a perforated peptic ulcer. The patient died after several weeks of postoperative complications. Sixsmith said the patient’s unpleasant attitude may have gotten in the way of a good diagnosis on the first visit.
"Don’t let a patient’s behavior, insurance status, substance abuse, hairstyle, or personality affect your diagnosis," she advised. "Stick to what you know are the right steps toward a diagnosis."
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