7-year-old girl was brought to the emergency department by her parents because she was complaining of abdominal pain, painful urination, and fever. (Med Malpract Verdicts Settl Exp 2004;20(6):17.) The emergency physician ordered abdominal x-rays and a urinalysis. The urinalysis indicated a urinary tract infection. The physician, based on his clinical evaluation and UA findings, diagnosed the patient with a urinary tract infection and discharged her.
The physician attempted to cancel the abdominal series after the UA came back. The x-rays were completed anyway, but because he thought they had been cancelled, he did not interpret them. A day and a half later, the patient was diagnosed with a ruptured appendix, and underwent surgery at a different hospital. She required hospitalization for two weeks secondary to complications.
The plaintiff's attorney claimed the diagnosis of impending rupture of the appendix could have been made if the x-rays had been read. The plaintiff also claimed that as a result of the delay in diagnosis, she suffered a disfiguring scar and intra-abdominal adhesions. According to reports, the case was settled for $385,000. (Queens County (NY) Supreme Court, Index No. 26447/99.)
Comments: While we don't have all the details of the case available, the emergency physician probably based his diagnosis on the presence of white blood cells in the urine, the painful urination, and presumably a negative abdominal exam. Numerous physicians have been misguided by the presence of pyuria or hematuria in missing the diagnosis of appendicitis. While the emergency physician's clinical gestalt was not unreasonable, the unfortunate outcome and chance of litigation could have been reduced significantly with adequate discharge instructions. He made a clinical decision that many of us would have made in the initial stages of the disease process.
In the face of abdominal pain with a benign abdominal examination and pyuria but no bacteriuria, however, arrangements for a mandatory re-evaluation within eight to 12 hours should have been made and the importance of this impressed upon the parents by the physician. Discharge instructions need to be “time specific” and “action specific.”
“See your doctor if not better” is not enough. The risk of litigation could have been reduced significantly had the patient received documented instructions of “You must see your doctor or come back to the ER within eight or 12 hours for a recheck without fail.” Almost 50 percent of all the lawsuits in emergency medicine can be prevented with adequate documentation and discharge instructions. (Massachusetts Emergency Medicine Closed Malpractice. Claims: 1988–90. Ann Emerg Med 1993;22(3):553.) Above and beyond any tort reform we need to comprehend the implications of this.
Pyuria is such a common finding in appendicitis, and not simply in the high percentage of patients with retrocecal appendicitis, that diagnosis of UTI based upon pyuria is fraught with problems. As for obtaining plain x-rays, unless the clinician suspects a foreign body, ingested or otherwise, perforated viscus, or bowel obstruction, it is not a helpful test to order in the ED, not to mention that it gives fodder to some plaintiff's attorney who can argue it was not “interpreted” in a correct or timely way.
PE Diagnosed as Bronchitis, Dyspnea
A 52-year-old man presented to the ED complaining of chest pain since that morning. (Med Malpract Verdicts Settl Exp 2004;20(5):16.) The pain was reproducible, in his left chest and radiating to his left arm and back. He also had some shortness of breath while on an airplane that same afternoon. He was seen by a first-year resident who formed a differential diagnosis of acute coronary syndrome (ACS), pneumonia, costochondritis, and pulmonary embolus. She obtained an EKG, cardiac enzymes, and a chest x-ray, all of which were normal. She gave the patient nitroglycerine and ibuprofen without effect.
The resident subsequently discussed the patient with her attending emergency physician who evaluated the patient and made the diagnosis of bronchitis, musculoskeletal pain, and dyspnea, and discharged him after placing him on antibiotics and a cough syrup. One week later, the patient collapsed in his home and died. Autopsy revealed an acute pulmonary embolus as the cause of death. Several older pulmonary emboli also were present that predated his presentation to the ED.
The decedent's wife brought wrongful death and malpractice actions against the two physicians and the state of New York, which operated the hospital. The plaintiff claimed that the attending physician's failure even to consider pulmonary embolism in the face of chest pain with a pulse oximetry of 93% and a normal CXR — a clear indication of pulmonary dysfunction — was extreme negligence and a clear violation of the standard of care. The plaintiff also contended that the resident physician clearly violated the standard of care because she considered pulmonary embolism in her differential diagnosis but undertook no diagnostic testing to disprove her suspicions.
The attending physician contended that when he evaluated the patient, his vital signs were normal and he had no reason to suspect pulmonary embolism given his presenting symptoms. The defendant's expert witness also contended that pulmonary embolism is a very a difficult diagnosis to make, that it can have many different presentations, and is commonly missed. The court ruled that both physicians were negligent and their inaction was the proximate cause of the patient's death. Damages in the amount of $1,664,730 were awarded. (Court of Claims (NY) Syracuse, Case No. 102377.)
Comments: Pulmonary embolism has humbled countless physicians, and will continue to confound and bewilder us. It can masquerade as an infiltrate consistent with pneumonitis, ACS, musculoskeletal pain, and numerous other entities with a very deceptive and vague presentation. Despite all the current advances and numerous clinical criteria (Wells, Wicki), it's not only a difficult diagnosis to make, it's even more difficult to exclude.
Some would have advocated admitting this patient on an ACS pretense, “transferring” diagnostic responsibility and medicolegal risk to someone else, a mistaken belief. If a specific diagnosis is not made in the ED, it is quite likely that it will not be made on the medical ward either. Making the diagnosis requires a high clinical suspicion, risk stratification, and most importantly, thorough history-taking. If when you walk out of the room you don't have a clear differential diagnostic impression in your mind, always go back and chat longer with the patient. Finally, if anyone — medical student, paramedic, nurse, resident, or physician assistant — entertains and documents a suspected diagnosis, the captain of the ship must rule it out or explain why not.
Expert Witness presents actual malpractice suits filed against emergency physicians. It provides general legal information to help readers understand emergency cases that result in legal action, but is not a substitute for personal legal advice from an attorney.