Confusing RSD injuries can pose special challenge to managers
Chameleon disease’ leads to malpractice cases
Risk managers may find themselves in a seemingly impossible situation when a patient claims that a simple bump on the elbow or a standard examination by a physician has caused a crippling, painful condition called Reflex Sympathetic Dystrophy (RSD).
When many of your highly qualified physicians have not even heard of this strange disorder, how do you refute claims that it is all your fault?
This quandary is far more frustrating than other types of malpractice charges, says risk manager Doug Jaquez, MHA, of Merle West Medical Center in Klamath Falls, OR. Jaquez is preparing to defend a malpractice case in which a patient claims that an emergency physician’s routine range-of-motion exam led to the RSD that the woman now says has her in constant pain and unable to work.
The very nature of RSD makes the claim nebulous and difficult to defend. The symptoms often seem minor to observers, and the diagnosis can be difficult if the physician has even heard of it. But the disorder is far from rare. About 200,000 people are diagnosed with RSD each year. RSD can occur from a minor trauma such as bumping your elbow, and it also can occur after surgery, broken bones, and sprains. Some researchers believe RSD is caused by abnormal actions or reflexes of the sympathetic nervous system, while others consider it to be an exaggerated nervous response in the affected limb. There also is some evidence that stress plays a role. (For more on what RSD is, see story, p. 28.)
Jaquez’s RSD nightmare began on Christmas Eve 1996, when the woman sought emergency care for bumping her elbow. The initial diagnosis was a simple contusion, but RSD was diagnosed within two weeks of her hospital visit. She is now suing the emergency physician and the hospital, alleging that the emergency physician caused the disorder by performing a range-of-motion test. (For details on the incident, see story, p. 29.)
The emergency physician adamantly denies the charge, and there is little evidence to show that the hospital or physician is at fault. Nevertheless, Jaquez sees it as a difficult case to defend because RSD is such a nebulous diagnosis and so poorly understood.
"This disease is so tricky," Jaquez says. "We know it’s not our fault, but this whole disease is so strange that I’m not sure how we’re going to prove it’s not our fault. The ER physician had never heard of it until I brought it to his attention."
Hard feelings contributed to claim
And the hospital’s position is made worse by a few circumstances that complicate any malpractice suit. A hospital-employed physical therapist told the woman that the RSD probably was caused by the physician’s exam, and the physician was brusque with the patient when she sought help in the busy emergency department on Christmas Eve. The doctor questioned why the woman came to the hospital with such a minor problem, and the animosity apparently contributed to the woman’s filing the claim later on.
"We don’t know what the outcome of this case is going to be," the risk manager notes. "We usually know ahead of time how a case will turn out, but I really don’t where we’ll end up with this one."
For those unfamiliar with RSD, the patient’s complaints often seem like a blatant case of malingering or symptom magnification. After all, how could a simple bump on the elbow cause such debilitating pain? But in fact, RSD is a legitimate diagnosis, not a loosely defined disorder on the fringes of medicine.
Nelson Hendler, MD, MS, clinical director of the Mensana Clinic in Stevenson, MD, is a nationally recognized expert on RSD. He tells Healthcare Risk Management that the disorder is perfectly legitimate but difficult to understand.
Symptoms can change
"It’s sometimes called the chameleon disease," says Hendler, who also is president and director of clinical research for the RSD Syndrome Association of America, a nonprofit organization based in Haddonfield, NJ. "You think you’ve got one set of symptoms, and then they change to something completely different. That makes it easy to attribute to malingering. But in fact, the disease changes over time. What you saw last month is going to be different from what you see next month. Usually."
A risk manager’s approach to RSD will be far more difficult if the health providers involved are not familiar with the disorder. Two liability hazards are posed by a poor understanding of the disorder, suggests Graham Whitfield, MD, PhD, FICS, an orthopedic surgeon in West Palm Beach, FL, and a clinical assistant professor of surgery at Nova Southeastern University in Ft. Lauderdale, FL. Whitfield is experienced in treating RSD patients and has consulted on lawsuits involving RSD.
Whitfield sees serious liability hazards posed by the extremes of either overreacting or ignoring claims of RSD. In the first case, risk managers and clinicians may be so bewildered by a patient’s claim of RSD that they offer to settle a case that actually has no merit whatsoever. After all, just because RSD is a legitimate diagnosis does not mean that all patients claiming to have RSD actually do have it, and it certainly is not always true that your care caused or exacerbated the patient’s RSD.
Over-diagnosis is a problem, Hendler says. He estimates that 70% of all the patients referred to him with an RSD diagnosis do not actually have the disorder. Instead, they often have nerve entrapment syndrome or rediculopathy.
Although he certainly believes RSD exists, Hendler acknowledges that a lot of doctors and attorneys slap on an RSD diagnosis without good cause. That the defendant health care provider may not understand the disorder makes that tactic easier.
Can range-of-motion exam cause RSD?
Whitfield and Hendler both stress that the confusing nature of RSD does not mean that there are no clear-cut issues with the disorder. While even the RSD experts may not completely understand how RSD develops and what causes it, they know that certain activities cannot cause RSD. The most common cause is some type of trauma.
So what about the malpractice case facing Jaquez, the risk manager in Oregon? Could an emergency physician’s standard range-of-motion exam cause RSD or exacerbate an existing case of RSD?
"A claim like that is unilaterally not going to be true," Hendler says. "It is highly unlikely that any physician will precipitate a course of RSD just by examining a patient."
Whitfield agrees. Assuming the woman truly has RSD, Whitfield says the woman’s bump on the elbow in a department store, the reason she sought emergency care, is the far more likely cause of the disorder.
Ignoring patient’s claims also risks liability
Hendler and Whitfield both suggest that health care providers not be intimidated by claims of RSD. Even though the confusing nature of the disease may make you doubt your ability to defend the case, they say the claim should be viewed with the same skepticism and objectivity as any other malpractice claim.
Be willing to educate yourself about the disorder and gather the appropriate information for a defense, they say, rather than offering an inappropriate settlement because the case seems too difficult to defend. Your legal strategy could depend on your ability to teach your staff about RSD.
On the other hand, they also caution that health providers can be legitimately at fault if they overlook true cases of RSD. If clinicians do not adequately understand RSD, they may dismiss patient complaints or even accuse the patient of malingering. When the patient truly is in pain, that is a recipe for a malpractice lawsuit.
That is what Whitfield suspects happened at Jaquez’s facility. The woman appeared in a busy emergency department on Christmas Eve complaining of extreme pain from what appeared to be a simple contusion, and the doctor brushed her off.
"This can happen a lot with RSD, and that may be the biggest malpractice risk associated with the disorder," Whitfield says. "You have to keep in mind that the patient with exaggerated pain may not be a whiner. Even if you can’t do much more for her at that point, you can’t just blow [her] off."
Know the basics
The two RSD experts say it is not surprising that an emergency physician would not be an expert on RSD. The disorder is more commonly diagnosed and treated by orthopedic surgeons, neurologists, and anesthesiologists. But emergency physicians should at least be familiar with the basics of RSD, they say, so that the patient can be referred to appropriate specialists and complaints will not be ignored. (For more advice, see story, p. 29.)
"I see nothing negligent about an emergency doctor not noticing the RSD and sending the patient home with routine treatment," Whitfield says. "But the more you can do to show some compassion for the patient, the less likely you’re going to be sued by a patient with RSD. For that, you need someone in the ER who is not chronically overworked and has the time and patience to impart some sympathy."
[For more information, contact: Nelson Hendler, MD, MS, clinical director of the Mensana Clinic, 1718 Green Spring Valley Road, Stevenson, MD 21153. Telephone: (410) 653-2403.
RSD Syndrome Association of America, P.O. Box 821, Haddonfield, NJ 08033. Telephone: (609) 795-8845.
Graham Whitfield, MD, PhD, FICS, 2150 S. Congress Ave., West Palm Beach, FL 33406. Telephone: (561) 433-1749.]
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