Case history shows how head injury is easily mistreated

To illustrate how EDs set themselves up for malpractice liability when treating head injuries, Diane M. Sixsmith, MD, MPH, FACEP, chairman of emergency medicine at New York Hospital Medical Center of Queens in Flushing, tells the story of a 22-year-old boxer who was knocked out in a training session.

The boxer regained consciousness and was transported to the ED. His examination was unremarkable except for amnesia for the event and somewhat slowed mentation.

A computed tomography (CT) scan was ordered, but 90 minutes later the patient was found unresponsive, with a Glasgow coma score of 4.

The CT was done and showed an acute subdural bleed. He was intubated, and the ED physician spent the next 70 minutes on the phone trying to arrange for neurosurgical care. The patient was accepted for transfer to another hospital, but the ambulance didn’t arrive for two hours later. He survived surgery but remains severely disabled.

Sixsmith notes that patients with head injury often will have a period of normality after their injury and then rapidly deteriorate, so "it is important not to be fooled into thinking that the normal-appearing patient is fine.

"Careful nursing observation at 15 minutes intervals and nurses who are trained to observe subtle changes in neurological status can alert the physician to a patient who is going downhill before that process is irreversible," she adds.

Sixsmith also stresses the need to evaluate each patient "with a sense of urgency" and to obtain a diagnostic CT of the head as soon as possible.

"Even more than in patients with major trauma, patients with head injury have the golden hour to be stabilized," she says.

Prompt neurosurgical response is crucial, adds Sixsmith. "Every head injury malpractice case will hinge on how quickly the diagnosis was made and how quickly the neurosurgeon intervened," she continues. "Transfers to tertiary care facilities must be done stat, since every minute delay increases the liability of the transferring hospital."