1

Outcome

• Child returned to ED 14 mos later

• C/o vomiting and headaches

• Head CT - large tumor, ependymoma

(small tumor noted on 1st CT)

• He died few years later

Lawsuit- $5 million settlement

Communication

Teaching Points

• Radiology must communicate with ED

• ED must have system to react to new findings, lab tests, reports

• “Incidental” findings are important

Case• 6 week old with fever, NY ED

• Initial labs unremarkable

• Pediatrician was called –advised discharge from ED

• Seen in office next day

• Blood culture + PCP, parents unaware

• Meningitis developed, dx 5 days later

• $750,000 verdict- lots of ‘finger pointing’

Selbst SM PEM Legal Briefs, Ped Em Care 29 (6), 2013

2

“What we have is a failure to communicate..”

• We do not work in isolation

• We are all in this together

• We must communicate with other staff

Medical Record

• Your best defense

or

• Plaintiff’s best witness

Documentation EssentialsCarefully document• History of illness / injury• Physical exam & vital signs• Time of exam, orders, procedures• Patient change or improvement

–“Tell the chart”–Timed re-assessment notes Yu KT, Green RA Critical aspects of ED documentation

and communication Emerg Med Clin NA 27(4); 2009

3

Recommendations for Documentation

Carefully document• Conversations with consultants• Reports of procedures, tests• Diagnostic impression,

thought process• Discharge instructions• Disposition

Case• 4 yr old boy abd pain, vomiting

• To PCP, then to ED in Massachusetts

• Alert, pale, dehydrated

• Diffuse abd tenderness

• X-rays- dilated loops, air-fluid levels (“clinical correlation recommended”)

• High WBC, left shift

• IVF and observed in ED, 4 hours

• Nurses notes indicated intermittent abdpain, awoke patient from sleep

• Doctor reevaluated- exam, VS not recorded

• Discharged- unresponsive at home 12 hours later

• Autopsy: volvulus, bowel necrosis

• Settlement $825,000

• Poor communication

• Poor documentation

4

Recommendations for Documentation

• Show a concerned, professional note

• Avoid inflammatory remarks

• Carefully note correctbody part

• Documents injuries with diagrams

Additional Recommendations for the Medical Record

Do Not:

• Black out or erase

• Engage in “battles” on paper

• Use insensitive terms

• Use unnecessary terms

• Alter the chart later

Altering Medical RecordsCase

– 5 week old brought to Alabama ED

– Fever noted, blood tests obtained, no LP

– Discharged, “return if not improved”

– Diagnosed with meningitis, severe complications

– Doctor testified he changed records (2 days after presentation), added info about why a full w/o not done

– $20 million verdictSelbst SM PEM Legal Briefs Ped Em Care 20 (11), 2004

5

Electronic Medical Records• Impact on malpractice still unclear

–Provides more discoverable evidence

–Copy & paste may perpetuate errors

–Clicking templates quickly may lead to inaccuracies (not right for patient)

–Drop down lists can lead to error

– Information overload- skip piecesMangalmurti SS, et al. Medical malpractice liability in the

age of electronic health records. NEJM 363; 2010.

Troublesome Chief Complaints

Cases for Discussion

13 Year Old Male

cc: Abdominal pain

Allergy - none

Medications -Acetaminophen

Exposure - none

PMH - none

6

History (Nurse)

RLQ pain since last AM

Nausea, vomiting

Walks with obvious pain

NPO, no BM 2 1/2 days

Fever to 102°

Resp easy, awake, guarding abdomen

Ambulates, off stretcher, no difficulty

History (Physician)

Began yesterday when woke

Nausea, vomiting

Pain mostly RLQ

Better with movement

Past history of pain with urination

Urine clear, no blood

Vital Signs

Temperature 103.9

Pulse 98

Respirations 24

Weight 44.6 kg

Blood pressure 122/82/70

7

Physical Exam

HEENT - Benign

Lungs - CTA

Heart - RRR

Abdomen - Positive BS, tender R and LLQ. Mild-moderate involuntary guarding. No rebound, no mass

Rectal - Vault empty, no stool

Abdominal X-Ray

Small calcified mass - pelvis

Possible appendicolith vs renal stone

Repeat exam

Less pain

No peritoneal signs

Abdominal X-Ray

Official Reading

Multiple radiopaque densities-RLQ

Possibly retained contrast material

Appendicolith cannot be ruled out

8

CBC

WBC 9.76 Segs 83

Hgb 14.7 Bands 14

Hct 41.6 Lymph 2

Plts 233 Baso 1

UA

Sg < 1.005

PH 6.0

Protein, glucose Negative

Bili, blood Negative

Nitrates Negative

Ketones Trace

Impression

Probable renal lithiasis

Plan

Repeat UA

Acetaminophen

IV NS

9

Re-evaluation

PO taken well

Pain free

Mild abdominal tenderness

Impression: renal colic vs AGE

Discharge Instructions

Ibuprofen

Encourage oral fluids

Strain urine

Save any stones

Appendicitis

Teaching Points

• Review any study ordered• Consider CT scan,

abdominal ultrasound, MRI • Re-examine patient• Document carefully

10

Appendicitis

Teaching PointsTextbook case is unusualAdmit for two of three

• Classic history• Impressive Exam• Abnormal labsConsider follow-up in 12-24 hours

History

• 9 year old girl with diffuse abdominal pain

• Began today; no dysuria

• + nausea, vomiting, diarrhea

• Felt warm to touch

• Took ibuprofen

Physical Exam

• T-99.8, P-104, R-18, BP- 95/68

• Comfortable, no acute distress

• Mild tenderness RLQ, no mass, no distention

• “No peritoneal signs”

• Exam otherwise unremarkable

11

ED Course• Ultrasound obtained

• Nurse took report- “normal US” (appendix not visualized)

• Diagnosis: gastroenteritis

• Discharge to home

• Return next evening- very tender RLQ

• Perforated appendix found

Case Progression

• Complicated course

• 50 days in hospital

• Lawsuit: Defense verdict

–Family did not follow instructions to return sooner

CASE9 yr old boy went to Utah Urgent Care Center with abd pain, vomiting, diarrhea. DX: “flu”. Next day, family called, reported pain now shifted to L side, green emesis. Family not told to return. Next day, ruptured appendicitis complications followed. Settled for $18,000.

12

15 1/2 year old male• CC: Chest pain for one week• Football injury, hit over right ribs• 4 days later, neck stiff & painful• Chest pain with walking• Achy, stabbing pain• Pain increasing, worse

with exertion

Further History

• Mild dizziness with standing

• Unable to run, climb stairs

• Shortness of breath at night, diaphoretic

• Intermittent headache

Further History

• No URI, or hemoptysis• No head trauma, diarrhea• No photophobia• No fever• No arm or jaw pain• PMH- pneumonia age 3

13

Vital Signs

• Temp 38.3 oral

• Pulse 78 106 standing

• Resp 24

• BP 128/84 124/92 standing

Physical Exam

• General-alert, talkative, obese male• HEENT- normal• Neck- Mild tenderness,

ROM limited• Torso- Tender sternum

–No CVA tenderness–No rib tenderness

Physical Exam

• Lungs-clear• Heart- Regular, normal split S2• Abdomen- soft, not tender,

no mass• Extremities-no edema• Skin- normal• Neuro- alert, oriented x 3

14

Laboratory Studies

• EKG- Normal sinus rhythm, rate 99

–Left axis, possible RVH–ST elevation inferolateral leads–Borderline prolonged qT

• CXR-top normal heart, lungs clear

ED Course• IV fluids- no change VS• Cardiology consult by phone• Impression: Musculoskeletal pain

Chest wall injury• Plan: Ibuprofen• Return to ED if pain worse,

passes out• Follow BP with pediatrician

15

Subsequent Course

• 8 hours later• Rescue squad transport• Expired in another ED• Lawsuit filed• Settlement -several hundred

thousand dollars

Myocarditis

• Chest pain for one week• Respiratory distress later• Chest pain with exertion• Abnormal exam- resting tachycardia,

orthostatic changes, pallor, rales, rhonchi, muffled heart sounds, gallop rhythm

• Dyspnea, shock, arrhythmia

Myocarditis

Teaching Points• Consider if:

–Chest pain with fever–Chest pain with exertion

• Obtain CXR, EKG• Consultation requires examination• Think about the vital signs

16

Case• 3 mo old girl brought to PA ED, 2007

• Temp 103 F

• Dx ear infection, given amox

• No documentation of which ear, no description

• Next day- ill appearing- diagnosis pneumoccocal meningitis - died 2009, from complications

• Verdict $1.7 millionSelbst SM Legal Briefs Ped Emerg Care 30(6), 2014

Triage 2000Age 16

Trouble breathing 45 minutes

PMH asthma

Alert, dyspnea

Numbness hands, feet

Lungs clear

T- 39.2

P- 112

RR- 40

BP- 112/90

Physician HX at 2020

• C/O Left shoulder, LUQ pain• Began while driving• Numbness, tingling fingers• Difficulty breathing resolved• Now C/O pain everywhere• Saw psychologist in past

17

Exam• Alert, anxious, appears upset• Skin warm, dry• Neck supple• Heart, lungs normal• Abdomen soft, LUQ tenderness• Extrems 2+ pulses, FROM

Course 2130• “Feels fine, wants to go”• “Histrionic patient”• Abdomen soft• Joints FROM, no swelling• CXR negative• Assessment- Viral Syndrome• Plan- Recheck 3-4 days

Course

• 11 PM -home (via wheelchair)• PCP called ED- parents unhappy• In AM, unable to stand• Called 911 BP 90/64, P 120• To local ED- purpuric rash• Initial DX- HSP• Final DX- Meningococcemia• Bilateral below knee amputations

18

Lawsuit

• Was CBC indicated?

• Was diagnosis reasonable?

• Was discharge appropriate?

• Was outcome altered?

MeningococcemiaTeaching Points• Difficult to diagnose• May present without

petechial rash• 16% present with bone, back pain• Avoid DX of flu, if no URI• Do not D/C child in severe pain

Sepsis/ BacteremiaTeaching Points

• Difficult to diagnose• Document general description of

baby, feeding• Consider admission to Observation

Unit

19

Triage- 1207

• 22 month old• Irritable, fever• Vomiting since

last night• Lips, oral

mucosa dry

T- 103.8

P- 120

RR- 32

BP- 102/78

Physician

• Exposed to sibling with virus

• Shaking movements of arms

• PE: irritable, looks around

–No rash

–Chest clear

Labs

• WBC 10.8, segs 42, bands 43

• UA normal

• Lytes normal

• LP WBC 1, Gluc 81

20

Course

• IV saline given

• Spoke to PCP

• Admit for observation at 1815

Course

• Inpatient resident saw patient twice

• 1845 Drank eagerly on ward

• 0530 Seizure

• 0845 Code blue -death

Lawsuit

Who is responsible once patient leaves ED?

21

Discharged Patients

Teaching Points

• All involved share responsibility

• Care given by others

affects ED staff

Teenager with sudden abdominal pain and groin pain

• To Urgent Care Center ED

• After triage, to waiting room

• Seen by physician 3 hours later

• Swollen scrotum, epididymitis considered

• Doppler study, blood flow

Course

• Urology consulted

• Arrived to ED 30 minutes later

• Testicular torsion diagnosed

• To OR 1 hour later,

• Necrotic testicle removed

• Lawsuit - settlement for $200,000Selbst SM. PEM Legal Briefs. Ped Emerg Care 26(4):2010.