Emergency physicians (EPs) make decisions based on patient history, assessment, diagnostic tests, and other factors. Equally important are data conveyed by EMS — information physicians cannot obtain anywhere else. “EMS has experienced something that the ED providers have never experienced, which is the scene,” says Christopher B. Colwell, MD, FACEP, chief of emergency medicine at Zuckerberg San Francisco General Hospital and Trauma Center.
EMS may report something concerning they observed or a comment the patient made during transport. “The transition from EMS to the ED is a critical communication point,” Colwell argues. “If we don’t do it well, we can lose important information that can make a difference in patient care.”
A recent malpractice case alleged ED providers missed a significant injury from a knee dislocation. The patient was discharged home, but returned the next day with a compartment syndrome from an arterial injury. This led to leg amputation. The patient sued the ED providers, the hospital, and the EMS providers.
“EMS testified that based on what the patient told them and how he was acting, they were concerned he might have dislocated his knee,” Colwell reports. A key point of contention was whether EMS had reported the concern about the dislocation to ED providers. The concern was included in the EMS written report. EMS providers testified the information also was given verbally to an ED nurse. However, this nurse’s documentation did not include the statement from EMS about a possible dislocation.
During the EP’s deposition, an attorney showed the EMS report. The EP testified that had the EP seen the report, the patient’s workup might have been different. The parties ended up settling out of court.
When EMS has documented a specific concern, and the ED did not act on that concern, “it’s hard to say that the information would not have been helpful. Then, it’s really a matter of which provider is going to take responsibility or be held liable,” Colwell explains.
EDs need a good system to ensure information from EMS is transmitted effectively. Some patients report only vague symptoms, such as fatigue, upon arrival to the ED. “Sometimes, we are not finding anything that requires admission,” Colwell says. “But it can all come down to what information is available and what isn’t.”
EMS might contribute an insight that changes the disposition. For instance, EMS might tell the ED the patient should not be discharged home without an Adult Protective Services evaluation. One elderly woman was brought by ambulance to an ED and complained of generalized weakness. The ED found nothing specific that would warrant hospital admission. EMS reported the fire department was in the process of condemning the patient’s house, which was completely filled with newspapers and clutter. “Obviously, that was key information, and it was an unsafe home environment,” Colwell says.
Instead of going home, this patient was admitted for “failure to thrive,” and social services became involved.
If valuable information from EMS is missed, and EMS and EPs end up as co-defendants in a lawsuit, “nobody wins,” Colwell argues. “It will be a he said/she said situation.”
The EP has no way to prove the EMS did not convey a piece of information. In malpractice cases, says Colwell, “it’s not uncommon for this to be an issue.”
Plaintiff attorneys will want to know what was conveyed by EMS, and what someone did with that information. “Any plaintiff lawyer who knows what they are doing will start with the EMS record. It’s the beginning of the medical component of the patient’s care,” Colwell says.
Plaintiff attorneys will scrutinize the medical record, looking for anything EMS reported that was not addressed during the ED visit. “There are a number of ways the process can break down,” Colwell says. Sometimes, the written report from EMS is never entered into the ED medical record. Even if it is, it can take hours or a day. That does not help during the ED visit. Generally, someone in the ED takes a verbal report when EMS arrives. “That then gets translated in a variety of ways to the care team,” Colwell explains. “If you don’t get that verbal report, it’s a missed opportunity and a big risk for lost information.”
Colwell describes this as the ideal system: The EP and ED nurse take the report together when EMS arrives. Listen to what EMS found at the scene, what they did in terms of treatment, and what the response to that treatment was. Together, decide on the next steps. “That often doesn’t happen in busy EDs,” Colwell admits.
Malpractice attorneys will claim ED providers should have been aware of everything contained in the EMS documentation, says Ashley Dobbin Calkins, JD, an attorney in the Richmond, VA, office of Hancock Daniel. Failure to note anything potentially relevant could be problematic for an EP defendant. For example, EMS may chart a history, allergies, or vital signs that contradict the ED chart. EMS might chart relevant home or environmental factors that are not included in the ED chart. “If EMS documentation is readily available to providers, the expectation that it will be reviewed would be higher,” Calkins notes.
An expert could testify it is below the standard of care not to review potentially relevant documentation, especially if anything is missed that could have made a difference in the patient’s outcome.
“Relevant information in EMS records that is not reviewed by a provider creates a damaging story for a plaintiff to tell at trial,” Calkins concludes.
The emergency physician and ED nurse should take the report together when EMS arrives. Listen to what EMS found at the scene, what they did in terms of treatment, and what the response to that treatment was. Together, decide on the next steps.
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