Is the EP Qualified to Give Clearance?
Concussion laws often require evaluation to be done by a particular class of health care provider — one trained in the evaluation and management of a concussion, says William M. McDonnell, MD, JD, an associate professor of pediatrics in the Division of Pediatric Emergency Medicine at University of Utah in Salt Lake City.
“Concussion laws may inject a degree of uncertainty as to whether particular physicians can, or should, evaluate patients with concussions,” he says.
There is no widely accepted medical consensus on which professionals are trained in the evaluation and management of a concussion, notes McDonnell. “Education related to traumatic brain injuries is a component of every medical school curriculum. Thus, arguably all physicians have such training,” he says.
Since neurologists are highly trained in long-term management of neurologic injuries, some might interpret concussion laws as requiring evaluation of every child with a concussion by a neurologist, says McDonnell, while others might argue that specific training in acute traumatic injuries, including concussion, is most extensively addressed in emergency medicine and trauma training programs, and, therefore, ED evaluation is required for all such patients.
“As a result of this lack of clarity regarding physicians who are qualified to perform the evaluation, schools and other organizations justifiably may be concerned about potential liability under concussion laws, and may err on the side of caution,” says McDonnell.
Accordingly, sports organizations may insist that all children with concussions receive ED or neurology specialist evaluations, when less costly medical evaluations in many cases might be more appropriate, says McDonnell.
“Uncertainty regarding which medical professionals must provide the medical evaluation may increase ED referrals, as schools and community organizations seek to comply with the law,” he says.
Written Clearance
Concussion laws often require that a health care provider provide “written clearance” before the child may resume participation in a sporting event, notes McDonnell. “However, ‘written clearance’ has no uniformly accepted definition in the medical or legal literature,” he says.
It is possible that despite appropriate medical evaluations and treatment, courts and/or juries in medical malpractice cases will interpret such “written clearances” as guarantees that the child will suffer no future adverse events related to the head injury, says McDonnell.
By directing health care providers to provide “written clearance,” concussion laws may effectively make those providers responsible for choices more properly delegated to parents, and may imply that the health care providers can guarantee outcomes.
McDonnell says that ED physicians might reduce their potential liabilities by taking the following steps:
• Establish and follow a clear institutional “concussion protocol,” with evidence-based processes for return-to-play clearance and clear discharge instructions;
• Clarify in the chart, and in conversations with the parents, what “clearance” to return to play means — that reasonable medical standards indicate that the child may return to play, but that the parents must consider the child’s individual risks and benefits of returning to play, and that clearance is not a guarantee against adverse outcomes;
• Firmly resist pressure from parents and coaches to “clear” a child to return to play when relevant medical evidence and practice guidelines indicate that additional treatment or evaluations are indicated;
• Facilitate outpatient follow-up with appropriate specialty providers for patients who cannot be cleared under the institution’s concussion protocol.
Sources
For more information, contact:
- Douglas S. Diekema, MD, MPH, Treuman Katz Center for Pediatric Bioethics, Seattle (WA) Children’s Research Institute. Phone: (206)-987-4346. E-mail: [email protected].
- Roger J. Lewis, MD, PhD, Department of Emergency Medicine, Harbor, UCLA Medical Center, Torrance. Phone: (310) 222-6741. E-mail: [email protected].
- William M. McDonnell, MD, JD, Associate Professor of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City. Phone: (801) 587-7456. E-mail: [email protected].
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