Could This Be You? Medical-Legal Case Studies Michael Jay Bresler, M.D., FACEP

Transcription

1 Could This Be You? Medical-Legal Case Studies Michael Jay Bresler, M.D., FACEP Clinical Professor Division of Emergency Medicine Stanford University School of M di i

2 MEDICAL - LEGAL CASE WISDOM We (Should) Hold These Truths to be Self-Evident To slide 162

3 Doctors and Plaintiff s Lawyers Do Not Share Love

4 If you re sued You re screwed

5 So Don t Get Sued!!

6 A Few Important Reminders In no way can we summarize all the medical-legal risks we face. These are just a few of the more frequent problems leading to Emergency Medicine litigation.

7 Communication is crucial. Let the patient talk. Let the family talk. Remember: Only lawyers know what the dead really said...

8 Communication is crucial. Lack of English is no excuse for you! Use a medical translator, the ATT language line, or similar service Be wary of using family members, especially in socially sensitive situations

9 CHARTING DOCUMENT DOCUMENT DOCUMENT DOCUMENT DOCUMENT AND ONE MORE THING --->

10 DOCUMENT!

11 Template Charts Useful Save time Lots of information May jog your memory Great for billing But can be dangerous Place check marks carefully Write or dictate additional supporting evidence

12 Template Charts As we convert to electronic medical records, the urge to just check off the boxes or use smart phrases will be even more tempting. The same principles apply

13 Read the Nursing Notes Same for Paramedic Notes Even though neither is written for your benefit!

14 Beware!! Beware of notes written After you have completed your charts After the patient has left the E.D. If the Paramedic notes are not available to you - document that.

15 Death Ray Don t t lose your patient in X-Ray! X Don t t forget they re there Send a nurse if unstable Send a monitor (and a nurse!) if appropriate

16 After-Care Instructions are Crucial Both in writing - and in reality Make sure the patient understands Ideally, have the patient repeat the instructions back to you preferably in a language you understand! The nurse can hand over the written instructions, while repeating what you have already told the patient yourself.

17 After-Care Instructions are Crucial Lack English is no excuse - for you! The law says it s s your fault if the patient does not speak your language - really! You can use the AT&T or similar language service or a medical translator. Family members may be OK, but beware of socially sensitive situations, as well as deficient translation skills.

18 Leaving Against Medical Advice The patient must be mentally competent Potential consequences of the AMA decision should be explained The option of returning to the ED should be offered Appropriate follow up options should be given The chart should document all of this!

19 Temporary Admission (Holding) Orders Communication is Critical Between you and the admitting M.D. Between you and the floor nurses Between the floor nurses and the admitting M.D.

20 Temporary Admission (Holding) Orders Who will be in charge? Who knows that? What is the life span Of the data you have collected? Of your orders? What should be done when there s s a question or problem?

21 EMTALA (COBRA) Screening exam before $ inquiry Can be performed by RN but must be per protocol with prior training Patient must be stabilized within the capability of the hospital Whatever stabilization means!

22 EMTALA (COBRA) Discharge from E.D. counts Transfer to another facility counts Not in active labor means no reason to suspect delivery prior to arrival at receiving facility

23 EMTALA (COBRA) Stable patients may be transferred for economic reasons Unstable patients may be transferred for medical reason Appropriate documents/records must accompany transferred patient

24 EMTALA (COBRA) EMTALA violation may be found Without malpractice Without a bad result Finger the bad guy if there is one If you have to transfer an unstable patient, state the reason

25 EMTALA (COBRA) The best protection and the best defense: DO THE RIGHT THING!

26 Follow up Lab & X-ray X Reports Tell the patient & family that x-ray x results are preliminary. Have a formal protocol in place Make sure the follow-up is completed DOCUMENT!!!

27 Change of Shift Make no assumptions Re-evaluate evaluate if conditions change Make sure you BOTH feel comfortable DOCUMENT!!!

28 Return Visits Unscheduled return visits may be ominous. Reconsider all assumptions Think of reasons NOT to admit rather than the opposite.

29 Medical Clearance for Psych Organic vs.. Non-Organic Is there Cognitive Dysfunction? Mental Status Exam for Cognition Level of Consciousness Orientation Memory Attention Fund of Information

30 Medical Clearance for Psych No one can be medically cleared in the E.D. They can be judged medically non- emergent at a given point in time.

31 Medical Clearance for Psych Sample wording: At this time there is no evidence of a non-behavioral medical emergency which would preclude transfer of care to the psychiatric service or to another facility for further psychiatric as well as medical evaluation.

32 Chest Pain Cardiac or Non-Cardiac? Aortic Dissection? Esophageal reflux or spasm? G.I. Gas? Chest Wall? If Cardiac M.I. or Unstable Angina?

33 Chest Pain Remember - Cardiac pain can be burning Cardiac pain can be epigastric Cardiac pain can be pleuritic The crucial question - Is there pain between breaths? Beware of GI cocktail Beware of chest wall tenderness

34 Chest Pain If discharged Arrange for follow up. Both patient and family must understand that you cannot absolutely rule out a heart condition.

35 Abdominal Pain Can always be early appendicitis - Or anything else! If discharged, let patient and family know that a serious condition could develop over the next few hours or days Document that discussion.

36 Abdominal Pain Appendicitis can cause pyuria AAA can cause hematuria Abdominal pain in the elderly is serious until proven otherwise

37 Abdominal Pain Pain out of proportion to exam in older folks may be mesenteric ischemia. Check for Guaiac positive stool Elevated amylase Metabolic acidosis

38 Back Pain Don t t forget to evaluate the autonomic system, at least by history Cauda Equina Syndrome Bowel or Bladder Incontinence or incomplete evacuation

39 Back Pain Severe back pain in needle users Malingering? Real back pain - like any other patient? Epidural abscess? (especially thoracic - which may have no neurologic signs or symptoms!)

40 Back Pain Back pain in older patients, especially left sided - even with hematuria - is ruptured abdominal aortic aneurysim until proven otherwise

41 Headache Suspect Subarachnoid Hemorrhage (SAH) if Sudden onset of headache, maximizing in minutes Worst headache ever

42 Headache CT may miss 2-10% 2 of SAH, depending on the scanner While newer generation 64 detector CT scanners are much more sensitive, there are no reliable sensitivity data available yet

43 Headache If SAH is suspected, and the CT is negative, further investigation is required Traditionally, that means LP

44 Headache However, newer modalities may reveal hemorrhage, and importantly, may also reveal the suspected underlying aneurysm or AVM. CT angiography (CTA) MR imaging/angiography (MRI/MRA) It is not yet known if these modalities are sufficiently reliable to replace LP

45 Clearing the C-SpineC The neck may be cleared in an alert patient who can feel pain, has no major distracting injuries, and: Denies neck pain No tenderness on palpation No pain with rotation -> > flexion Remember SCIWORA Cord injury is not radio-opaque! opaque!

46 Serious Extremity Trauma May Not Be Obvious Ligament damage may be obscured by Pain, effusion, or muscle spasm Limb-threatening arterial injury may not impair circulation - at first Popliteal artery contusion may lead to delayed thrombosis

47 Serious Extremity Trauma May Not Be Obvious Always evaluate & document motor, sensory & vascular status Beware of compartment syndrome with continuing pain out of proportion to injury or exam Palpable pulses may be present!

48 Drug Addicts Are Often Sick Beware of occult infection Especially epidural abscess If addicts need pain meds, they usually need significant doses

49 Endotracheal Intubation CONFIRM & DOCUMENT Symmetric breath sounds No gastric sounds Vapor in the tube Good compliance Oxygen saturation Carbon dioxide variation Turkey baster Secure the tube

50 Conclusion The best prevention Good medical practice Good communication Good documentation

51 Conclusion If - really when! - it happens: Stay calm It really is just a game At least for the lawyers It s s only the word processor that says you shouldn t t have been born

52 You are not alone! We all get sued Conclusion Don t t suffer alone ACEP, county & state medical societies can provide support Don t t let it take over your life

53 Conclusion ACEP members can submit outrageous deposition testimony to the Standard of Care Review Board Their findings may be admissible in court.

54 Conclusion As Bob Dylan once said Everybody must get stoned But if you re a good doc, communicate with your patients, and document, You ll usually be O.K.