August 2023

Volume 17, Number 8                                                                                                              August 2023

Guest Commentator:

Michael Ritter, MD, is an EP who has been on RMM in the past and who practices at Providence Mission Community Hospital in Mission Viejo, California.  He has a particular interest in the legal aspects of EM with wrongful credentialing being of special interest.  He has no conflicts of interest to declare.

E-Mails

Rural Airways

  • For rural hospitals without 24/7 specialist calls, how often are emergency physicians asked to manage inpatient codes or airways on the floor? What are the risks to the patient and physician?
    • Many small hospital EDs are staffed by only one provider.  In this setting it may be totally unrealistic to have more than one.   In a situation like this you must do your best.  It’s unlike that two airways or arrests would need care simultaneously in settings like this.  But remember the case in Texas complained that only having one provider was a safety issue.  He was fired by his contract management group, and he sued and won $26M.
  • I hear there is a growing trend to utilize respiratory therapists or even paramedics for definitive airway management; would this meet the standard of care if the hospitalist is not proficient in airway management?
    • It seems perfectly appropriate in settings of only one provider to have RTs trained and credentialed to manage airways in emergent situations when the EP is otherwise involved with a critical patient.
  • Can you do a review of failed inpatient airways and the risks around them?
    • Unfortunately, we’re unaware of a database of this type of case.

Cases

Splint Too Tight?

  • 7 YO had a forearm fracture.
  • Orthopedist applied splint wrapped with an ACE bandage and a Coban self-adhesive (elastic) wrap.  Child said it was too tight at the time of splinting.
  • Coban edited out of notes (claims it was not an alteration of the record
  • Multiple surgeries required, PT/OT, still dysfunctional.
  • $2M settlement offer declined.
  • Six-day jury trial / two days of deliberation — $9M
  • Key Points:
    • Don’t put on a splint with a wrapping that can’t expand.
    • The splint should not be causing pain on discharge.
    • Advise the patient / parent to return if new or increasing discomfort (document)
    • Check nerve and circ before discharge (document)

Not Another One?

  • A 66-year-old female patient in a home for Alzheimer’s was declared dead by the staff.
  • On arrival at the Funeral Home, when the body bag was opened, she was awake and gasping for air. Her drug treatment had been lorazepam and morphine.
  • The doctor in charge had ordered an increase in the morphine because of an activity decline.
  • Despite a DNR directive, the patient was transported to the ED and subsequently returned to her care home where she died two days later.  If corrections were not made a fine of $10,000 was to be assessed by the state.
  • Key Points:
    • Be familiar with the signs of death — mistakes can’t be made here.
    • Be aware of the concept of “wrongful life” — resuscitating a DNR patient and causing that patient additional pain and anxiety.

And One More

  • An 82-year-old woman was pronounced dead at a nursing home in Ohio.
  • She was found breathing in the Funeral Home three hours later.  She was transported to an ED. Outcome is unknown.  The case was referred to the New York attorney general.
  • Key Points:
    • More of the same.  Although these cases are rare, they get a lot of press.

No Smoking

  • WKRN TV Nashville, Brittany Baird, May
  • A 64 YO man hospitalized with multiple chronic medical problems arrested while on an oxygen non-rebreathing mask.
  • On using a defibrillator, a spark was generated, and the patient sustained significant burns and died later that night.
  • The lawsuit alleges that electrode pads were not properly placed and that the flow of oxygen was not discontinued and allowed to dissipate per hospital policy.
  • The wife saw flames cover her husband’s body.
  • “He got burned in the throat, the face, the head, the chest, and his hands. And he got burnt really bad, he was on fire, and I said he’s on fire, put him out,” the wife recalled saying.
  • No outcome available yet
  • Key Points:
    • Does your hospital have a policy about this?  If so, you may want to remind providers.
    • Should you not have a policy and leave it up to the providers given this is a super rare condition and more harm may result than benefit?

Signs of a Stroke Missed

  • An EP and two physician groups are being sued for $2.4M for allegedly missing the signs of a stroke.
  • The suit claims the patient went to the ED in 2020 with complaints of slurred speech, weakness of his left side, headache and trouble breathing.
  • After a CXR and EKG, several hours later the patient was diagnosed with reactive airway disease or lingering flu symptoms.
  • The patient went to a different physician and a CT was consistent with a stroke.
  • The patient was hospitalized for 12 days.
  • Suit = failure to diagnose (no CT, incomplete exam)
  • Key Points:
    • We don’t always know enough details about these cases but based on what’s presented it appears that the neuro symptoms were overshadowed by the respiratory symptoms — blinders on?
    • Were any of the non-respiratory symptoms addressed in the nurses or clinicians’ notes?

Missed Aneurysm – $29M.

  • A 43-year-old patient awoke with SOB and upper abdominal pain that eventually spread to his back and chest.
  • The EP ordered tests that ruled out an MI and PE.  The WBC was elevated, and the patient was admitted with a suspected infection.
  • A CXR on the floor noted “mild hazy interstitial opacity that could represent a small airway inflammation or developing/early pneumonia.” 
  • The patient noted a foot puncture several days prior and this was considered possibly the source of the infection.
  • By the next morning the patient’s SOB and pain had worsened significantly at which time the on-duty physician order a CT of the chest that demonstrated  “a massive aneurysm at the beginning of [the patient’s] aorta and a dissection extending through most of his aorta.”
  • En route to a helicopter for a transfer, the aorta ruptured.
  • There was an 8-day trial, and the jury took three hours to come in with a plaintiff verdict.
  • $20M to be paid overtime, largely to the patient’s two children.  With interest almost $29M.
  • Plaintiff’s attorney “If you just treat people based on what the likelihood is, statistically, you’re going to miss a lot of life-threatening conditions. And that’s what happened in this case.”
  • Key Points:
    • The three killers that always need to be considered in patients getting a CXR and ECG are cardiac ischemia, PE, and dissection — always all three.  You can’t just play the odds.
    • Something in your note should indicate you considered dissection.  You’re not required to get a CT angiogram but consider noting findings that do not support this diagnosis but do indicate that you considered it.
    • Here’s another case in which a large variety of symptoms inconsistent with a foot infection or endocarditis were ignored in favor of a substantially less plausible diagnosis.

Missed Stroke – $38,614,587

  • This is a 2010 case but there are still lessons to be learned even though embolectomies were only experimental at the time.
  • A 19 YO male was herding cattle with his father when he suddenly slumped over and had difficulty speaking.
  • The EP noted the patient to be flaccid in all four extremities and unable to talk.
  • The radiologist noted a small thalamic stroke of indeterminate age on CT.
  • Routine blood tests were normal and apparently with this information the on-call hospitalist was called around midnight.
  • No neuro consult was requested (they had a teleneurology service — but the EP said no one returned the call) and the on-call physician, who was at home, elected to not come in.  Instead, admission orders were given over the phone, the patient was admitted to the neurology service with the diagnosis of a possible stroke.
  • A CT angiogram in the morning confirmed a basilar artery occlusion but in the meantime the patient had aspirated.  Worse than death the patient lived.
  • Everyone except the hospitalist settled (including the EP and her group).  At trial it was determined that the EP was responsible for 30% of the award, the hospitalist, 40% and 30% to the radiologist who read the first CT.
  • The patient suffered the “locked in” syndrome for three weeks that gradually evolved over a year to the partial use of one hand, spastic quadriparesis, loss of balance and severe speak impairment.
  • Key Points:
    • On the face of it, this is a horrible case!!  All these sudden-onset neuro finding, and the on-call doctor called in orders???
    • Could the outcome have been changed given clots weren’t being removed then and a transfer would have added many hours (and no procedure would have been done)?
    • Remember the responsibility of the EP.  If the on-call doctor won’t come in, call other doctors — chief of service, chief of staff.  Remind them of their EMTALA obligation. 

Misplaced Femoral Catheter – $4.7M

  • A 50 YO female OD’d on BP pills and on arrival in the ED was awake but with a low BP and pulse. 
  • An attempt by the EP to establish a jugular line so that epinephrine could be given centrally was unsuccessful. 
  • Approximately two hours later the patient was sedated and on a ventilator a femoral line was placed, and IV epinephrine given.
  • 15 minutes later the patient arrested and was resuscitated. 
  • On transfer to the ICU the intensivist continued the infusion of vasoconstrictors via the femoral line
  • The following morning a nurse noted that the lower right leg was cold, mottled and without a pulse.  A blood draw from the femoral line was noted to be bright red. 
  • The meds were stopped but the patient was not seen by the intensivist for another four hours and no vascular surgeon had been consulted.
  • Three-week trial / eight hours of deliberation
  • The EP was dismissed after it was determined that the plaintiff’s expert was a critical care specialist and not an emergency medicine specialist.  This was a Georgia case.
  • Key Points:
    • The catheter was misplaced right from the beginning and the EP was mistaken about its location and the consequences of giving IV adrenergics wasn’t appreciated by the EP or until the next day.
    • Write the check.

Is a CT Scan Need to Diagnose Diverticulitis? 

  • A 54 YO unemployed female presented to the ED with abdominal pain.
  • A UA was consistent with a UTI and the EP also felt diverticulitis may be present given a past history of diverticulosis.
  • Ciprofloxacin was prescribed.  No CT was performed.
  • The patient returned two days later and a CT revealed diverticulitis and one or more colon perforations.  She had surgery 11 days later and there were some post-op complications.
  • It was asserted that the patient should have been admitted at her first ED visit along with a CT and IV antibiotics and this treatment would have avoided the colon surgery and its complications.
  • The EP won at trial.
  • Key Points:
    • Is a CT the standard of care in a patient diagnosed with diverticulitis?  You’d have to say most places that have a CT scanner will have one ordered.  But this is not likely the case in rural settings where a CT scanner is unavailable.  Are there two standards of care?
    • Would having a CT changed the outcome — the surgery sounds semi-elective.
    • The use of IV antibiotics for routine cases of diverticulitis is not likely the standard of care — some studies show antibiotics don’t matter (although the community standard is likely to give oral antibiotics)
    • Did this woman really have a UTI as well — not likely.  Consider the diagnosis of asymptomatic pyuria.

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Rachel Lindor, MD                             Kevin Klauer, DO, EJD                                 Rick Bukata, MD

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