Law and Medicine: November

By Dainius A. Drukteinis, M.D., J.D.

“The only real mistake is the one from which we learn nothing.”
– John Powell

Timing in the Emergency Department

From a patient care standpoint, as well as a liability standpoint, the timing of interventions in the Emergency Department is often crucial. In medical malpractice cases, plaintiff’s attorneys highlight unduly long periods of time for critical treatment, and juries may be unsympathetic to prolonged delays. In an Emergency Department bursting with patients, the allocation of time is one of the greatest challenges for the emergency medicine physician.

In O’Shea v. State of New York, 2007 N.Y. Misc. LEXIS 386, a patient presented to an Emergency Department having cut off two fingers with a table saw. The injury occurred at 6:30 p.m. The patient was triaged at 7:19 p.m. The emergency medicine physician saw the patient at 7:42 p.m. X-rays were performed at 11:33 p.m. Orthopedics was finally consulted at 1:00 a.m., more than five-and-a-half hours after the patient presented to the Emergency Department. Orthopedics arrived at 1:30 a.m. The wounds were stitched closed by orthopedics at 2:00 a.m. Reimplantation of the saved digits could not be performed within eight hours from the time of injury as an operating room would not have been available that quickly.

An expert witness in the malpractice case testified that eight hours for reimplantation of digits is

…about the upper limit without trying to break records

The emergency medicine physician was found negligent for not contacting orthopedics sooner. Due to this prolonged period of time, among other negligent acts by orthopedics, the patient and his wife were awarded $525,000.00.

In retrospect, it is easy to see how five-and-a-half hours seems too long when we focus all of our attention on one patient, especially in the courtroom. When that time is broken down, however, we see how easily it can occur. Registration of the patient may prevent ordering studies. There are bottlenecks in radiology due to limited resources. The same patient may require other interventions such as labs, antibiotics, and pain medications. Sicker patients in the Emergency Department may divert our attention and require more of our time. This problem is compounded when consults pressure us to “package” patients before they are consulted, i.e. with all of their labs, studies, and radiographs completed.

In the Emergency Department, it is important to recognize system failures and distractions that will undermine timely interventions and consultations. Perhaps “packaging” every patient before contacting the consulting service is unwise. Finally, whatever the systems failure or distraction, it must be remembered that it is the emergency medicine physician who is ultimately accountable for those delays in time. We are responsible for making it happen.

Dainius A. Drukteinis, M.D., J.D. is an Attending Physician at MetroWest Medical Center in Framingham, Massachusettes. He may be contacted at ddrukteinis@gmail.com

Law and Medicine Vol 1.1

By Dainius A. Drukteinis, M.D., J.D.

“The only real mistake is the one from which we learn nothing.”
– John Powell

Radiology Hearsay in the Emergency Department

How often have you spoken with radiology on the phone before an official report has been dictated?

An emergency medicine physician in Louisiana recently found his understanding of radiology findings at odds with the dictated radiology report. See Spillman v. Southwest Louisiana Hospital Association, 2007 U.S. Dist. LEXIS 25547 (April 4, 2007).

In Spillman, a child was brought to an emergency department and a CT scan was obtained to rule out appendicitis. Radiology called an emergency department nurse with the result. The nurse then relayed the result to the attending physician

…appendix area looks o.k., no mass or inflammation noted.

Once the patient was discharged, radiology dictated a report which stated,

…possible fluid-filled dilated appendix seen in the right lower abdomen.  The possibility of appendicitis cannot be excluded or confirmed.

It was later determined that the child had a ruptured appendix.

Whether or not you believe the radiologist changed the findings, this miscommunication could have been further compounded had the nurse told a resident, who then told the attending, who then signed out the patient to the oncoming team.

The scenario quickly begins to look like the childhood game of telephone. It is for this reason that courts frown upon hearsay evidence, and that written communication tends to be given more weight than oral communication. That is not to say we should never rely on oral communications by radiology or other services in the hospital. However, we must be wary that in our desperate need to disposition patients quickly, there are many ways that essential communication can break down and harm our patients.

This case was ultimately decided in favor of the doctor on different grounds.

Dainius A. Drukteinis, M.D., J.D. is an Attending Physician at MetroWest Medical Center in Framingham, Massachusettes. He may be contacted at ddrukteinis@gmail.com