Lawsuit for a Misread of ED Ultrasound? Not Likely
Lawsuit for a Misread of ED Ultrasound? Not Likely
No lawsuits to date for missed findings
Given the fact that most emergency medicine residencies now include ultrasound in their training, and the use of ultrasound in EDs is clearly increasing, one obvious liability risk involves misreads of ultrasound examinations performed in the ED.
"People are really afraid of this, but should not be, for several reasons." says Michael Blaivas, MD, RDMS, vice president of Bear, DE-based Emergency Ultrasound Consultants and director of emergency ultrasound at Northside Hospital in Atlanta, GA.
Blaivas notes that everyone misreads imaging studies occasionally. "Radiologists are sued for misreading X-rays, MRIs, CTs and ultrasounds all the time," says Blaivas. "I have been an expert in about ten cases now where radiology misread very simple ultrasound examinations with very obvious findings. It will happen to clinicians also, one day."
However, according to the latest published study on the topic, there were no lawsuits filed against ED physicians for missing something on ultrasound as of 2007 in state or federal courts.1
"There were however, three known lawsuits filed alleging emergency physicians should have performed a point-of-care ultrasound to catch something," says Blaivas. These involved two abdominal aortic aneurysms (AAAs), with one case lost by the ED physician and one that wasn't resolved, and an ectopic pregnancy case that settled out of court.
Focused use of ultrasound "leads to very safe practice," says Blaivas. "[ED physicians] find with some experience, they are better than radiologists at the narrow applications they are performing. This is because most radiologists now get very little training in residency in ultrasound, and often have no interest in it."
Examples include point-of-care AAA evaluation, a pelvic ultrasound to determine if an intrauterine pregnancy is present, and a simple focused assessment with sonography in trauma (FAST) examination to see if there is fluid present in the abdomen of an unstable patient.
"Other procedures, such as thoracentesis and paracentesis, should be done with ultrasound assistance," says Blaivas. "When ultrasound is used, the chances of complications go down."
Blaivas notes that the series of questions on some plaintiff's attorney websites include whether the prospective plaintiff or a loved one have been injured during the placement of a central line, and if the answer is yes, whether ultrasound was used. "This will be more of a problem, as word gets out among plaintiff's groups," says Blaivas.
Different Legal Standard
Leonard Bunting, MD, FACEP, is assistant professor of emergency ultrasound at Wayne State University and emergency ultrasound director at St. John Hospital & Medical Center, both located in Detroit, MI. He says that he is unaware of any successfully litigated suits involving ED ultrasound, but that current risk comes from misinterpreting an exam.
"The gray area we are anxious about is what standard we will be accountable to. We are not radiologists," says Bunting. "Our bedside ultrasound training is focused on answering specific clinical questions that impact the patient's emergent condition."
The question is, what exposure will ED physicians face if they perform a limited exam of a trauma patient's spleen and fail to diagnose an adjacent renal mass? "We shield ourselves by limiting our training, but is this a defensible position? Time will tell," says Bunting.
Robert B. Takla, MD, FACEP, chief of the Emergency Center at St. John Hospital and Medical Center in Detroit, MI, says, "We will be held to the standard of care for ER physicians and not radiologists or any other specialty. Once we acknowledge and recognize our limit, then our obligation is to peruse further diagnostic testing as clinically appropriate."
In other words, if the ED physician cannot tell from a FAST exam with a reasonable degree of medical certainty that the patient has no intraabdominal injuries, then he or she has an obligation to utilize other modalities, such as a CT scan or observation with serial examinations.
According to Takla, "it is pretty close to standard of care, especially at tertiary care institutions and teaching institutions, that ER physicians have this skill set. Smaller community hospitals have yet to make that same progress."
However, Takla says that it is even more important for ED physicians in those smaller community hospitals to be skilled at ultrasound, since resources and diagnostic testing at those facilities are more limited.
Standard of Care?
"If the growth of the field continues on its current trajectory, we will likely see a time when ER physicians will be at risk for not using this tool," says Bunting. "Although many of us hardcore ultrasonographers would like to believe ED ultrasound is the standard of care, I don't think we are there yet."
Blaivas says that point-of-care ultrasound "is definitely rapidly on its way to becoming standard of care," and that ultrasound guidance for central lines, trauma evaluation, and AAA evaluation already is standard of care.
"Anyone not using ultrasound in this fashion is definitely at risk," Blaivas says. "Other applications are also becoming the standard, but are not quite there. The worst thing for an ED is if others in the region, or worst of all a competition in town, has ultrasound available and you don't. It is very easy for a plaintiff's attorney to point a finger and say, 'They have it.' The worst part is, juries will agree."
Bunting says that once it is fully implemented, bedside ultrasound "has the potential to greatly reduce exposure." Studies have demonstrated that use of emergency medicine ultrasound can decrease the time to diagnose and treat several life-threatening conditions.2-6
Blaivas says to consider some of the more subtle ways in which ultrasound can reduce risk. This is because of the information it can rapidly deliver at the bedside, and its screening potential.
For instance, at the same time an ultrasound can rapidly rule out an AAA, it can also help the ED physician to determine whether someone has a pneumothorax, so that the patient doesn't end up waiting too long for a chest X-ray in a busy ED.
Similarly, using ultrasound with nerve blocks allows the ED physician to avoid conscious sedation in some cases. "This will avoid the occasional sedation complication, and take less nurse time away from other patients," says Blaivas.
Blaivas adds that other applications, such as gallbladder and focused cardiac evaluation and ruling out deep venous thrombosis, can avoid delays and improve care.
For example, patients sitting for hours in the ED waiting to get a lower extremity ultrasound can be diagnosed or ruled out quickly, and placed on anticoagulants if needed. Likewise, a patient with shortness of breath may be discovered to have a pericardial effusion and be admitted instead of sent home, or perhaps even drained to avoid a sudden decompensation and arrest later.
"Simply catching it early and notifying a cardiologist of a moderate size effusion may avoid a disaster, if it remains unknown until much too late," says Blaivas.
References
1. Blaivas M, Pawl R. Analysis of lawsuits filed against emergency physicians over bedside emergency ultrasound examination performance or interpretation over a 20-year period. Ann Emerg Med 2007;50:S85.
2. Plummer D, Brunette D, Asinger R, et al. Emergency department echocardiography improves outcome in penetrating cardiac injury. Ann Emerg Med 1992; 21:709-712.
3. Theodoro D, Blaivas M, Duggal S, et al. Real-time B-mode ultrasound in the ED saves time in the diagnosis of deep vein thrombosis (DVT). Am J Emerg Med 2004; 22:197-200.
4. Jones AE, Craddock PA, Tayal VS, et al. Diagnostic accuracy of left ventricular function for identifying sepsis among emergency department patients with nontraumatic symptomatic undifferentiated hypotension. Shock 2005;24:513-517.
5. Sierzenski PR, Leech SJ, Dickman E, et al. Emergency physician ultrasound decreases time to diagnosis, time to CT scan, and time to operative repair in patients with ruptured aortic aneurysms. Acad Emerg Med 2004;11:580a.
6. Sierzenski PR, Leech SJ, Gukhool J, et al. Emergency physician echocardiography decreases time to diagnosis of pericardial effusions. Acad Emerg Med 2003;10:561.
Given the fact that most emergency medicine residencies now include ultrasound in their training, and the use of ultrasound in EDs is clearly increasing, one obvious liability risk involves misreads of ultrasound examinations performed in the ED.Subscribe Now for Access
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