SPECIAL REPORT
Common Mistakes in the ED
By Geetika Gupta, MD, FACEP, VP Risk Management EPMG, PC, Clinical Faculty at the University of Michigan and St. Joseph Mercy Hospital Emergency Medicine Residency Program; and Charles Grassie, MD, MS, JD, FACEP, President and CEO of EPMG, Ann Arbor, MI.
In an age of high patient volumes, overcrowding, and prolonged patient stays in emergency departments (EDs), the clinician is challenged to be both efficient and effective on a daily basis.
In the ED, clinicians are required to apply a careful, diligent approach to each patient that still may sometimes lead to a missed diagnosis. In this article, we discuss certain common mistakes that may cause clinicians to overlook devastating disease processes or consequences. Avoiding these omissions may help protect against both misdiagnosis and the potential for subsequent civil action.
CASE 1, Patient with back and neck pain. A 51-year-old male presented to Hospital A (a free-standing ED facility) with complaints of back and neck pain.1 He arrived via EMS on a backboard, had no past medical history, and was medicated en route with fentanyl. Cervical-thoracic-lumbar plain films of the spine were negative and he was transferred to Hospital B due to continuation of his pain.
At Hospital B, he arrived with his family and reported that three days prior to presentation he was lifting a sofa and felt some back pain. Then on the day of presentation, he woke up with severe back and neck pain, left knee discomfort, and right shoulder discomfort. Review of systems was negative for gastrointestinal or genitourinary symptoms, chest pain, and shortness of breath. He also denied any upper respiratory symptoms or other injuries.
He had no relevant past medical or surgical history. On arrival, he was febrile with a temperature of 102.6 degrees F. His pulse was 116, blood pressure was 130/82, and respiratory rate was 16.
Pertinent negatives on physical exam included a normal cardiac and pulmonary exam, and his abdomen was soft, non-tender/non-distended with appropriate bowel sounds. Examination of his neck and spine showed right paracervical tenderness with bilateral diffuse lumbar pain. Neurological exam showed normal strength, sensation, and reflexes, but he was unable to ambulate without experiencing intense pain in his neck and lumbar spine.
The differential opined by the evaluating provider included back spasms, meningitis, or a viral syndrome. The work-up included CT scan of the brain and cervical spine, urinalysis, and lumbar puncture. All were normal except for the lumbar puncture, which had an opening pressure of 38 mmHg. The patient was given pain medication and was asked to ambulate, which he did with moderate pain. He reported that his neck hurt with ambulation and he was given a soft cervical collar and discharged to home. Prior to discharge, the patient's wife voiced concerns about her husband's inability to walk, stating "My husband has never taken a day off in his life. He is in good shape and is a hard worker. He doesn't complain and this is not like him." In response to the wife's concerns, the evaluating resident relayed a story about her uncle who had back spasms that were accompanied by back and neck pain. The wife responded that she did not care to hear about the resident's family history and that her only concern was for her husband as "something is clearly wrong with him." Despite this, the patient was discharged and advised to follow-up with his primary care physician (PCP) and neurologist within 2-3 days.
The patient presented to his PCP three days later and was sent immediately to the ED for neurological changes. Emergent MRI revealed a 5cm abscess in the cervical epidural region and he was taken urgently to the OR for decompression.
CASE 2, right lower quadrant pain. A 43-year-old registered nurse arrived in triage at 23:55 with complaints of right lower quadrant pain for eight hours prior.2 She had a recent history of ovarian cysts and also had been experiencing nausea, decreased appetite, and urinary frequency/dysuria. She stated "I had a D&C in September and my period is late, so I don't know if my ovaries are twisted or if it is my appendix." She was seen by the ED physician who noted the history above. In addition, the patient stated her pain began suddenly at 12 p.m. on the day of presentation. Her review of systems was negative, and her exam showed a temperature of 97.8 degrees F, pulse of 70, respiratory rate of 20, and a blood pressure of 107/66. She rated her pain as a 10/10.
Findings on exam included a normal cardiac and pulmonary evaluation, and her abdomen was non-tender and non-distended with normal bowel sounds. Pelvic exam showed a normal perineum with blood tinged discharge in the vaginal vault and external cervical os. Her uterus was normal sized and her cervix was normal as well. On bimanual exam, she was noted to have severe adnexal pain, right greater than left.
Her labwork showed an elevated white cell count of 15.2, with a normal urinalysis and a negative serum pregnancy test. Her pelvic ultrasound showed a normal uterus and right adnexa, with two cysts (each 2cm in size) on the left ovary. Normal flow was noted to both ovaries and there was a trace amount of free fluid.
The patient was informed of her results, including the leukocytosis. She asked why it was elevated. The explanation given to her was the concept of white cells increasing in the blood stream as a result of stress, which can be painful. She was instructed to follow-up with her gynecologist in 2-4 days and the ED nurse caring for the patient requested that the patient receive acetaminophen and oxycodone hydrochloride since "she is one of us."
The patient took her pain medication and saw her gynecologist as instructed 3 days after her initial ED presentation. Her gynecologist immediately sent her back to the ED and a diagnosis of a perforated appendix was made. She was treated by interventional radiology for drainage of an appendiceal abscess and underwent appendectomy thereafter.
CASE 3, right lower leg pain. A 21-year-old male with a history of migraine headaches arrived to the ED with complaints of pain in the right lower leg.3 Per the triage note, the patient stated he injured his right lower leg while playing basketball the day prior. He complained of pain to the right shin that he described as 7 out of 10. The family reported he mentioned numbness in his lower leg and pain with movement; he was unable to ambulate unassisted into the ED.
He was afebrile with normal vital signs and his exam revealed minimal tenderness over the distal third of the anterior lateral tibial region with minimal swelling and slight muscular spasm. He was neurovascularly intact and an X-ray of the region was negative. He was discharged home with a diagnosis of shin splints.
The patient returned to the ED 12 hours later with worsening pain. On the second presentation, he reported constant pain and an inability to bear any weight on his right leg. His vital signs remained stable and an exam noted tenderness at the mid right tibial surface with a 4mm hard nodule. There was no fluctuance or drainage, and it was not warm or erythematous. He still had an intact neurovascular exam, but no reflexes were tested and there was no documentation of palpable distal pulses.
The patient was once again diagnosed with tendonitis and discharged with orthopedic referral and instructions to return to the ED with worsening symptoms. He was seen by the consultant orthopedic surgeon the next day and was diagnosed with acute anterior compartment syndrome and taken immediately to the operating room for fasciotomy.
Case Review. After careful review of these cases, through the benefit of hindsight, what common threads are woven through each one? Are assumptions made in dealing with difficult, puzzling cases that can be scrutinized for future learning? And, what important information can be picked up from an initial visit that can help to solidify the correct diagnosis at that time?
ABCs. We must be aware of the many facets that encompass the care we provide. It is imperative that the history given by the patient and family members or acquaintances is carefully noted and analyzed, as well as to the patient's presenting vital signs. The temptation to ignore or downplay patient complaints and presenting symptoms must be avoided, and a plausible, rational explanation for any abnormality in vital signs should be sought. These very crucial factors can play a significant role in the appropriate disposition of any patient.
Customer Service. On many occasions, patients who have experienced poor outcomes have been asked why they did not pursue legal action against the treating physician. Almost universally, the response centered on the individualized, compassionate care that the patient and family members perceived throughout their experience. As Sir William Osler once stated, "people do not care how much you know, as long as they know how much you care."
Fred Lee, author of "If Disney Ran Your Hospital, 9 ½ Things You Would Do Differently," states "compassion also creates loyalty to physicians."4 He also notes the strong relationship between physician communication and malpractice lawsuits. He has found that patients tend to become angry about something other than clinical outcomes. The most common thread of medical malpractice suits dealt with physicians not validating or empathizing with patients and not showing them warmth, compassion, and concern for their worrying. He also added that "family members need empathy too."4
Close Follow-up. One crucial piece of the complete evaluation is to make sure to arrange timely follow-up for a patient, especially for those diagnoses that are less certain or when the addition of 24-48 hours of time could aid in making the correct diagnosis. While it would be nice to insure every patient has timely follow-up with their PCP or the appropriate consultant specialist, sometimes the only option is to instruct the patient to follow-up in the ED. While some patients may express reluctance to do so due to inconvenience or ED wait times, it has been found that a careful explanation of why you are making the follow-up recommendation goes a long way in persuading a patient to come back. As always, documentation of this discussion and recommendation is paramount for the emergency care provider.
Outcomes. Case 1: Diagnosis Spinal Cord Compression Syndrome. A patient who presents with fever and midline vertebral tenderness and a diminished ability to ambulate should automatically raise a red flag in the mind of the provider. Although this patient did not have a history of high-risk behaviors, he was unable to ambulate in the ED secondary to significant cervical spine and neck pain. The "red herring" was the patient's own voluntary admission that he thought his pain was related to the sofa he had lifted prior to coming to the ED. While this sort of activity can produce significant musculoskeletal injury, this act alone does not explain his febrile condition or his inability to ambulate out of the ED.
Should an MRI of the cervical spine, looking for something beyond a musculoskeletal injury, have been ordered? In hindsight this seems obvious. In real time, an MRI would have allowed the clinician to investigate the potential for cervical spinal pathology that could account for a fever and a diminished ability to ambulate. Our goal is prevention of further neurological demise while intervention is still feasible and not to intervene after subsequent paraplegia and/or bowel and bladder dysfunction.
If we as clinicians do not know the exact diagnosis, it is imperative to acknowledge this fact. We are never going to diagnose every patient correctly the first time we evaluate them. "The biggest mistake is thinking that one visit is going to have all the answers," explains Greg Henry, MD, of Medical Practice Risk Assessment Inc. and past President of ACEP.5 However, this is where the reasonable physician can arrange for follow-up that is time and action specific, especially when an observation unit for serial exams is not available. In this case, one could argue that if a patient who normally is able to ambulate cannot walk out of the department without significant assistance, especially with an unknown etiology, he or she probably should not be discharged.
In this particular case, why did the family take legal action? One motivating factor was to recoup money from lost income related to the missed diagnosis. However, the patient regained almost full functionality and was not off of work for a lengthy recovery. During discovery, it became clear that this primarily hinged on the lack of customer service. The patient's wife stated that the resident physician was not empathetic to her and her husband. In addition, she commented that the doctor was flippant about her husband's case. In fact, the wife stated she was very upset that the resident physician tried to compare her husband's condition to her own family member. The wife held the resident responsible for the missed diagnosis. The patient filed a lawsuit,1 and after thousands of dollars spent in discovery the case was settled for $175,000.
Case 2: Diagnosis Appendicitis. Mrs. Jones, a health care professional herself, is aware that misdiagnosis can occur in caring for patients. In her case, her exam was consistent with right adnexal pain but the misdiagnosis hinged on the disconnect between two cysts with minimal pelvic fluid as the source for her "10 out of 10" pain. In addition, she did have an elevated white blood cell count. Although we know this does not diagnose acute appendicitis, this lab value must be strongly considered in the differential. An elevated total white blood count >10,000 cells/ mm3, while statistically associated with the presence of appendicitis, has very poor sensitivity and specificity and almost no clinical utility.6 In this scenario, the elevation in white cell count was reviewed with the patient and explained by demargination due to her level of pain. Anchoring onto this explanation led to a missed diagnosis. The key to this case was the need for close follow-up that was required to provide a plausible, reasonable diagnosis for her right lower quadrant abdominal pain. Patients with an unclear diagnosis that could include appendicitis should have follow-up in 12-24 hours, and they must be advised that appendicitis has not been ruled out and that is why the follow-up is critical. The provider must clearly document that this discussion took place with the patient as well as documenting any family members or nursing personnel who also may have been present at the discussion.
Ultimately, the patient sought legal counsel and sent a demand letter to the physician that indicated her dissatisfaction with her care.2 She stated "I told her I thought I had appendicitis but the doctor just wouldn't listen. She kept trying to tell me that it was my ovaries but I knew that wasn't the case. If someone had just addressed my concerns this would have been handled correctly from the start and I wouldn't have had to go through what I went through." She further stated that as a nurse she did not think an elevated white count correlated with a problematic ovarian cyst. The patient blamed the ED physician for ignoring the white count of 15,000 and not being told to follow-up sooner. In addition, she pointed out that the Percocet she was taking for her pain should have been recognized as an agent that could mask a fever and/or worsening pain. In the end, this patient settled with the physician for $25,000.
Case 3: Diagnosis Compartment Syndrome. The concept of anchor bias, meaning a situation in which a provider anchors onto a diagnosis, is used to describe a scenario in which the provider holds steadfast to a particular diagnosis while rationalizing its validity to the particular situation at hand. This case involves a young, healthy male, a demographic that generally doesn't tend to complain. He arrived to the ED to the presenting physician with the "red herring" of shin splints. In this situation, the physician anchored onto this diagnosis as a means of explaining this patient's condition. In evaluating this case retrospectively, there were many unusual factors that were overlooked. A patient with shin splints usually will not complain of an inability to feel parts of his foot and will usually be able to move his foot. A red flag should have been raised when it was noted that the patient could not ambulate into the ED the second time because of the severity of the pain. It can further be argued that the diagnosis of "shin splints" could have represented the earliest form of compartment syndrome. This layman's term is technically referred to as "medial tibial stress syndrome." Shin splints are almost always on the medial tibia. Compartment syndromes of the lower leg (which are actually uncommon), are typically along the lateral aspect of the lower leg. In the scope of medical practice, this nuance of medial versus lateral is often not differentiated. As a result, the term "shin splints" is often used as the name for overuse of muscles of the anterior lower leg. Taking a step back and looking at the presenting signs and symptoms and physical findings, a patient who is experiencing severe pain and neurological changes on exam should not be sent home with a diagnosis of shin splints. This patient returned to the ED again; the second treating physician anchored onto the initial diagnosis and failed to provide close follow-up that was time and action specific. This case was settled without formal litigation.3 During discussions, the patient and family expressed that "they were treated poorly in the ED and that on both visits they were not taken seriously by either physician." The patient's sister told the triage nurse and evaluating physician that she had never seen her brother in so much pain. In addition, he was an athletically active young man and he never should have been discharged if he could not ambulate out of the ED. The family filed suit and settled out of court for $250,000.
Summary. In conclusion, all of these scenarios depict the need for practitioners to use dynamic thought processes and to be aware of the various thinking errors that can occur.7 In many cases, he or she must decipher and diagnose. It is important that emergency physicians take the time to listen, to not rationalize, and more importantly to show compassion. Adhering to these principles may still result in a missed diagnosis, but the clinician will have established a bond of caring and empathy toward the patient and family that may diffuse the situation and avoid litigation.
References
1. Michigan Circuit Court, Case No. 01-223-NH, (2001)
2. Letter to settle a claim without formal litigation (2006).
3. Letter to settle a claim without formal litigation (2006).
4. Lee F. If Disney Ran Your Hospital, 91/2 Things You Would Do Differently. Second River Healthcare Press, 2004.
5. Personal communication, Dr. Gregory Henry.
6. Cardall T, Glasser J, Guss D. Clinical value of the total white blood cell count and temperature in the evaluation of patients with suspected appendicitis. Acad Emerg Med 2004;11:1021-1027.
7. Hubler JR. Errors and patient safety: a cognitive autopsy of thinking errors. Audio-Digest Emergency Medicine July 7, 2007, Vol. 24, Issue 13.
In an age of high patient volumes, overcrowding, and prolonged patient stays in emergency departments (EDs), the clinician is challenged to be both efficient and effective on a daily basis.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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