Part 1: Criminal acts—These activities are so heinous to the fabric of society that society acts to protect itself.

Part 2: Civil law—This part basically consists of resolution of disputes in which the state acts as the forum for various parties to resolve conflicts.

• Ignoring the claim and pretending that it did not happen. Nothing good comes through registered mail. Physicians must notify their group and hospital whenever a legal summons is issued with regard to the question of malpractice. Physicians can be found guilty and can have monetary damages assessed against them under a default judgment if they do not respond in the proper time frame.

• Going into a panic and talking to colleagues about the facts of the case. A physician should not discuss a pending legal action except in the presence of the defense attorney or in the setting of a properly constituted quality assurance meeting. A physician must avoid the temptation to “try the case” with friends.

• Contacting the patient. Once a lawsuit has begun, it is absolutely forbidden for the physician to make any calls, write letters, or attempt to contact the patient who has brought the action. Once a specific legal action has been taken, all interaction between parties should be conducted through their attorneys.

• Failure to preserve the integrity of the chart. Once a legal action has commenced, the chart should be copied, and the original chart should be sealed and put in a secure place in hospital records. No physician should ever, in any way, alter a medical record after the fact.

• Failure to assist counsel. The physician’s input is absolutely required and is mandated in the malpractice policy. Total candor is necessary, and no lawyer likes a surprise. Failure to cooperate with the defense counsel may invalidate a physician’s insurance policy. It must be stressed that you should feel comfortable with the counsel who is assigned to you. If you feel that you are not being represented adequately, ask your insurer for a reassignment or review of the current counsel. Remember that it is your medical license that is on the line.

• Displaying an arrogant, hostile, or defensive attitude. Physicians must realize that they are in business. A lawsuit is a part of business. No juror wants to see a physician’s God complex expressed in a deposition or from the stand. A simple, calm, and caring explanation of what actually happened goes best in court. It is important for the physician to not let pride or a sense of injury stand in the way of an intelligent defense.

• Thinking the trial is a search for truth. A trial is a dispute resolution process. No truth finding is involved. Lawyers generally do not care about the truth; they care about winning and about the money. Cases are often settled because of the economic implications. Although a case should obtain a verdict for the defense, it may not merit the cost that will be incurred in taking it to trial. If the case does go to trial, everything in the trial matters: the dress and manner of the physician, the personality and politics of the judge, the quality of the lawyers, the degree of sympathy for the plaintiff and family, and the quality of the experts. In this situation, an intelligent physician is an active participant who helps obtain the best experts to help defend him or her in court.

• Assuming that the legal process will not affect you. Physicians should take the process seriously, even at a subconscious level. A physician should be prepared to seek emotional help, as well as legal help, when the strain of a lawsuit hits.

• Knowing when settlement is the right solution. The physician should not ask a mediocre complaint expert to salvage the case. Not listening to medical and legal experts is a mistake. Certain cases are losers. The person least able to decide whether a case needs to be settled is the physician involved in the case. Other physicians with experience in medical malpractice and who know what wins and loses in court need to be involved in assessing the case. The effect of losing a lawsuit on the group, the hospital, and the emergency contract should not be underestimated.

Remember to confirm that the settlement release lists your name specifically. If you believe that a case is being pushed toward trial and you are not in agreement, discuss this with your attorney and consider filing a “Bad Faith Claim” against the insurer. This will help secure your personal finances in the event that the case settles higher than your policy limits. The insurer will need to come up with additional funds to cover the verdict. In addition, always entertain discussion of the national databank reporting with your counsel and options regarding the language of the settlement.

• Casually blaming another provider. No physician should ever make casual, derogatory comments about anyone else’s care. Physicians are responsible for the care that they have provided, not for the care of other physicians’ patients. Physician infighting raises the cost of cases and does no one, including the patient, any good.

• Expecting a quick resolution. EPs, by nature, desire rapid resolution of a problem. Law moves in a time frame of its own. It often takes years to resolve a case. The physician needs to understand that such processes are not what a physician would want.

• Ownership of patients. Patients own doctors; doctors do not own patients. The legal relationship of parties is that the physician is “the retained agent and servant of the patient.” When a patient is in your department, he or she is your patient from a legal standpoint. The physician cannot abrogate responsibility by saying that the patient belongs to another physician.

• Combative patients. The ED has not only the right to restrain but also the duty to restrain when the patient constitutes a danger to self or others by virtue of a physical or mental condition (Box 3). Determination of competency is the key issue. Competent patients may refuse or accept any care that they so chose. Patients who lack such competency will depend on the substitute judgment of the EP. Belligerent patients who are competent require law enforcement to handle the situation.

• Civil commitment. In all 50 states, civil commitment is the act of the probate court. The role of the ED is again to secure the patient so that the patient does not cause harm to self or others and to fill out a first certification detailing the behavior and physical findings that justify civil commitment. The observations of the family and police, as well as events seen by the physician, should be documented and used in the decision-making process. Most states require a second certification process to be done in a specified time frame by a mental health professional. In the ED, ruling out organic causes of disease and arranging for the patient to be reevaluated by mental health professionals are the primary goals of evaluation therapy. The authority for civil commitment of a patient is given over to the court system. It is up to the judge to decide on the continued suspension of civil liberties. Proper documentation by the EP that the patient constitutes a danger to self or others by virtue of illness goes a long way toward helping the court system make such decisions.

• Transfers. EMTALA is the law of the land. A transfer log is a high-profile document that must be maintained by federal law. Informed refusal can allow patients to exempt themselves from EMTALA regulations. Refusal to be transferred should be noted carefully on the patient’s chart by the EP and the nurse involved in the case. The transferring institution has strict legal responsibilities under the law. Stabilization is not an absolute process; it is relative to the needs of the patient. The patient should be stabilized such that the acts of transfer and moving the patient to a higher level of care have a reasonable probability of providing a better outcome for the patient. The appropriateness of transfer is left in the hands of the physician. The transferring institution needs to be able to send laboratory results, radiographs, and any other material obtained from the patient. All such material can be transferred by means other than direct travel, and no unreasonable delays in transfer should take place while awaiting laboratory results. Similarly, records can be transferred by electronic means and should not delay transfer of a critically ill patient. The receiving institution also has obligations under EMTALA. A hospital that usually and customarily receives patients should accept these patients unless their capabilities, at that time, are overwhelmed and they are unable to find room. This fact should be noted on the records when trying to obtain transfer of a patient.

• Reportable illnesses. The legal system and the ED function together as essentially an officer of the court. Legal reporting duties are mandated by law in every state. Other parts of the hospital (e.g., laboratory) also have obligations to report certain findings to public health authorities. Reporting statutes vary from state to state. EPs should be aware of and know the reporting requirements in the state which they are practicing. In all 50 states, child abuse, elder abuse, and assaults are reportable illnesses. The EP also maintains a duty to third parties who may not be present in the ED. There is an obligation to protect third parties by reporting to the police. Therefore, when a patient has a gunshot or stab wound, other people may be at risk, and failure to report such injuries could place them in danger. The ED and EP have a clear obligation to see that such reporting takes place.

• Legal blood alcohol limits. Legal blood alcohol limits have always been an area of controversy. This is a common problem, but the rules vary from state to state. Determinants for drawing blood and reportable blood alcohol levels are covered in each state under statute. The U.S. Supreme Court has spoken on this issue multiple times. With a court order (i.e., a signed warrant from a judge), the state does have the right to obtain blood alcohol levels. In most states, police officers alone have no authority to force a patient to have a blood alcohol determination made without a warrant. This does, however, vary from state to state because some states have given the police warrant authority to obtain blood. The U.S. Supreme Court ruled against forceful removal of stomach contents with a nasogastric tube. The Court viewed the taking of blood as a usual and customary medical procedure. Passing of a nasogastric tube was considered aggressive and offended the sensibilities of the Court. In no state can the police require the EP to pass nasogastric tubes to obtain samples. However, once a patient has discarded body contents (e.g., vomitus, urine, feces), such material then passes into the public domain, and the police have a right to discarded body contents.

• Incident reports. Incident reports are a part of the quality assurance system. In most states, incident reports are protected from both discovery and judicial admissibility. The function of such reporting is to improve care, not to point fingers. The important aspects of incident reports should be clear. The EP should not reference an incident report in the patient’s chart. Medical information about a particular patient belongs in the patient’s records, not in an incident report. Questions concerning the system of care are the proper subject of incident reports. Incident reports should not be filed in a patient’s chart. They are part of a separate system. If they are filed in the chart, they may inadvertently be discoverable should legal action take place.

• Response to in-house emergencies. The exact response capability of EPs to sick patients in the rest of the hospital varies from place to place. In large hospitals, this is rarely an issue. In many smaller or rural hospitals, the EP may be the only physician present. General rules should be followed if such care is given. The physician’s contract with the hospital should not have the physician guarantee to be in two places at once. All contracts should be written such that the EP will respond if not required to remain in the ED by the acuity level of other patients. The hospital always has the alternative of placing patients on cots and bringing them to the ED. When the ED is extremely busy, this may be the only reasonable way of handling the situation. When an EP is called to see a sick patient in another part of the hospital, the attending physician should also be called. Someone will be required to rewrite the orders, and someone will be required to speak to the family. The EP should not be viewed as taking over continuing care of the patient. In many states, response to in-house emergencies is considered part of an in-house Good Samaritan statute. This again varies from state to state and should not be assumed.

• Writing orders for admitted patients. This area is controversial and difficult. Without question, writing orders can potentially extend the liability of the EP to the in-house setting. Most EPs do not have in-hospital privileges, and therefore writing orders may not be justified. The EP’s medical liability carrier may also have questions regarding orders written on already hospitalized patients. This issue should be explored and settled explicitly with the malpractice carrier. If in-house orders are to be written, specific parameters about when an EP’s responsibility begins and ends should be determined between the ED and the medical staff through the medical executive committee. The best ways to limit exposure on the writing of inpatient orders are as follows:

• Prescriptions from the ED. Most medications written by EPs are for up to 10 days of antibiotics and usually for 4 to 5 days of pain medication. This type of prescription constitutes more than 90% of those written. For the EP to renew long-term prescriptions is generally considered inappropriate. Patients who are receiving medications for hypertension or seizures, for example, should be given only enough medication until they can see their own doctor. No long-term doctor-patient relationship is established in the ED, such patients are not monitored for side effects of drugs, and such monitoring is not expected to be done through the ED. Any prescription requiring a Drug Enforcement Agency prescription number should have proper warnings documented on the discharge instructions, along with a copy in the chart. Writing medications for third parties (i.e., enough medication to treat sexual contacts of patients with sexually transmitted diseases) is not a good idea until state laws change to cover EPs for any potential harm that may occur.

• Doctor-to-doctor conflict resolution. Conflicts on points of medical care are common in medicine: two doctors, two opinions. When an attending physician and an EP differ on certain issues, the problem must be resolved. Everyone’s story changes in deposition. EPs can be left in a precariously dangerous situation if they have not followed their own instincts. It should be clear on the chart when patient care is managed by another physician. The ED requires a policy on conflict resolution. The ideal policy contains a reference to joint responsibility, obligations of the attending physician to see his or her patients, the ability to refer a case to a neutral third party, and review of all such cases by the executive committee. The EP should beware of powerful, “big admitter” physicians who have unusual control of the executive committee. Such situations can lead to unhappy outcomes for both the patient and the physicians.

• Patients who leave before examination, who elope, and who leave against medical advice. Patients who leave before examination are always problematic. Someone must have seen them to register them in the ED. Capacity is everything. The question of whether the patient had the mental capability to decide to go home is an issue. The last health care professional to see the patient should write a note about why the patient left and attest that the patient had the mental capacity to make such a decision at that time. Elopement is a similar process in which the patient disappears in the middle of a work-up. In patients in whom we expect elopement, it is a good idea to take precautions. Placing armbands on these patients so that they will be recognized by security, placing them in visible locations in the ED, and assigning a family member to watch them are all useful techniques. If a patient does elope from the ED, the following should be done:

Informed consent in emergency medicine is rarely an issue or a problem. Informed refusal is, however. Patients who leave against medical advice are using a form of informed refusal. Lawsuits involving patients who leave against medical advice have a very stereotypic formula. It is claimed that the patient was not properly educated about the issues and therefore could not make an appropriate decision. Patients and families can claim that the patient’s mental status was worse than initially presented or that the patient was, in some way, discouraged from seeking medical care. The largest mistake that the EP can make is to believe that signing a piece of paper (i.e., the against-medical-advice form) is the same as following the legal process. It is not. The legal process contains the following:

• Return visits. In emergency medicine, “bounce-back patients” are always difficult. Frequently, prejudice against such patients exists because they are perceived as not following orders or as doctor shopping. In general, such patients have misunderstood instructions, or the disease entity has changed. Return visits have something that is always potentially dangerous—a diagnosis. The assumption is that the first physician was correct. Unscheduled revisits need to be evaluated, as for any other new patient, to ensure that some obvious change or intellectual blockade in understanding the patient’s health care condition has not occurred. In general, multiple bounce-backs constitute a serious problem. Some believe that third visits to the ED should result in admission until proved otherwise, although there is clearly no consensus. The possibility of misdiagnosis or mismanagement increases with each revisit.

• House staff, physician assistants, and medical students in the ED. The functioning of house staff members can be problematic for many reasons. The actual care given to patients may not be at the same level as care given by attending physicians. The expected standard of care under the law, however, is the same as would be given by a mature physician by virtue of attending-level supervision. All resident work must be supervised if it is to be billed under any federal program. Violations of this mandate are considered criminal violations of the federal law, and the current act has no exemptions. All training programs must follow the guidelines initially promulgated in 1969 and reestablished in 1995. What constitutes supervision has been defined for each specialty and is available and on public record. Ignorance of the law is no excuse. No EP should believe that merely signing the chart actually constitutes supervision of care. Unless the EP has been intimately involved in examination and management of the patient, such care has not happened. The attending physician ultimately bears the responsibility for the acts and omissions of the resident. Off-service residents (i.e., residents called down from another service) are also under the supervision of their attending physicians. When conflict arises regarding what needs to be done with a patient, it should not be resolved among residents, but rather among attending physicians of the various services. The law expects this, and patients deserve it. Physician assistants constitute a different problem. Their payment depends on the level of supervision. Online direct supervision is generally reimbursed at 100% of professional charges. Off-site or added-distance supervision in many states constitutes a lower payment for the services rendered. EPs should be well aware of the laws within their states with regard to the amount of supervision required to bill for such cases.

• Change of shift. There are two potentially dangerous times in an ED: July 1, with inexperienced incoming trainees in new roles, and anytime that a shift change occurs. At the change in shift the patient’s care must be transferred from one doctor to another. Continuity of information or insight into the underlying problem is always difficult under these circumstances, and thus a change of shift should be documented on the chart. A note should be made in the chart that the patient’s care was transferred to another physician at a particular time and that discussion was held with this other physician such that he or she is properly engaged in continuing care of the patient. The discharging doctor—the second physician to see the patient—generally assumes the duty to make certain that the patient’s care is complete.

• Laboratory studies, radiographs, and electrocardiograms. A general rule is that physicians should not ask a question to which they really do not want to know the answer. If you are going to order a test, you must follow up on the results in some way. A system is required to detect what has been ordered and to account for the results received. Laboratory tests, radiographs, and electrocardiograms must all be interpreted with regard to the specific patient. Follow-up on these issues should be guaranteed. A system is needed in which each variance in laboratory or radiographic test should be handled within the ED. A general rule is that you should not order tests for which you have no follow-up system. Patients who are admitted are not generally a problem. If tests are going to be ordered that must be followed up by an outside physician, however, this system needs to be guaranteed.

• Release of information. The doctor-patient relationship and patient records are protected under federal law. The information within the records is owned by the patient. The actual physical pieces of paper or material on which the record is written is owned by the hospital, and the hospital has a duty to maintain such records. Release of information requires the expressed consent of the patient. A wife, contrary to popular belief, has no implied right to her husband’s medical records. A parent, in the role of legal guardian, has a right to a child’s records but no right when that child is emancipated or has reached the age of adulthood. Casual release of information over the telephone should be discouraged. An individual patient’s right to protection of his or her record is part of the duty of the EP.

• Duty to a third party. Duty to a third party is always a difficult question in an ED. Various therapies may render a patient incapacitated in some way and thereby place the patient and others in danger. The very act of issuing a prescription requiring a Drug Enforcement Agency number means that the EP is accepting some responsibility to inform the patient about use of the drug. Patients who drive a car under the influence of heavy medication may injure themselves and others. Without proper warnings, the EP may be involved in litigation. Other devices that make a patient incapable of normal functioning (e.g., the use of crutches, eye patches, and various splints) may also place the patient and others at risk. Discussion of this situation on the chart is useful should the need to provide defense arise.

• Minors. State law varies to some extent regarding what constitutes a minor, particularly with regard to emancipation. Emancipated minors are those who live outside the home, provide their own financial support, and make their own life decisions. True emancipation of a minor is the act of a probate court. Nonetheless, minors have rights. In most states, laws exempt certain disease entities from the purview of parents. Also in most states, children who arrive for treatment and are older than 12 years may have questions of child abuse, substance abuse, sexually transmitted disease, and pregnancy treated without parental consent. However, adolescents rarely know these legal rights.

• Telephone orders and telephone advice. In general, the ED should not give telephone advice. Telephone advice is not provided in any structured or competent way in most cases, and the EP is frequently unaware that such advice is given. In most cases, patient inquiries and calls for medical advice should be routed away from the EP and nursing staff. Answering machine devices that advise the patient to come to the ED or to call 911 are often the most useful.

• Orthopedics. This field is still the most frequent area of lawsuit in emergency medicine, but it is relatively low as a cost-per-case situation (Box 4). The wrist and thumb are areas of higher dollar loss. Missed navicular fractures and gamekeeper’s thumbs are still problematic, only because they are frequently negative radiographically. Long bone fractures are rarely a problem. Smaller (i.e., radiographically negative) injuries are the major orthopedic problems in emergency medicine. The follow-up radiographic system should be airtight. If a reading is returned to the ED in which a fracture is discovered, proper notification of the patient should be guaranteed by the system. The total picture is what is important in emergency medicine. Certain fractures indicate that other actions should be taken. Examples are presented in Box 4.

• High-risk eyes, ear, nose, and throat or airway. Airway, in emergency medicine, is everything. Cases involving the airway are major problems because of the serious neurologic injuries that can result. As the disease spectrum in the country has shifted as a result of changes in immunization, the incidence of severe conditions such as epiglottitis has markedly changed. However, because the disease is rare, it does not mean that it does not exist. The decision to control the airway is clinical and is not based on oxygen saturation or blood gas measurements. Proper management of the airway is a core skill required by EPs. Intubation is not necessarily the answer, however. Proper use of a laryngeal mask airway or bag-valve-mask apparatus can frequently control and provide adequate ventilation for patients. The need for minute-to-minute intubation can be modified by other such airway controls. A much rarer, but still recognized complication in emergency medicine is nasal injury. The only condition for which emergency intervention is required is septal hematoma. It should be a quality assurance standard that every patient with a nasal injury have a comment in the chart about the presence or absence of septal hematoma. Radiographs are rarely required for nasal injuries.

When evaluating eye problems, the greatest concern is visual impairment, breach of the globe, or corneal disruption. The infection that occurs may result in blindness. Any impairment in vision or trauma involving the globe should prompt an ophthalmology consultation. Patients with corneal abrasions need to have the potential foreign body removed. Patients need to be educated to not wear contact lenses. They should be discharged with antibiotics and close ophthalmology follow-up to ensure appropriate healing. All patients with only one functioning eye should be referred to ophthalmology for all eye concerns.

• Wounds. All wounds seen in the ED are potentially contaminated and have foreign material almost by definition (Box 5). Lawsuits involving wound management by emergency medicine are based on three things: foreign body, foreign body, and foreign body. The cosmetic appearance of a wound is rarely an issue in emergency medicine unless a foreign body has been retained or infection has occurred.

• Tendon injuries. Tendons, in the relevant area of a wound, should be tested independently to arrive at the most precise diagnosis possible. Deep wounds should be observed through a range of motion to make certain that the tendon injury is not hidden by soft tissue. There is essentially no reason to explore a tendon sheath in the ED. Repair of tendons is rarely an emergency procedure. These wounds can be properly irrigated and closed loosely, and tendon repair can be performed later, within a reasonable period.

• Nerve injuries. Nerve injuries are like tendon injuries. There is essentially no reason for emergency repair of an injured nerve. It is very difficult to assess early in the injury whether a nerve has actually been severed or merely has a functional contusion. The need for proper follow-up is obvious, but immediate intervention is rarely, if ever required.

• Wound infections. It is important to let the patient know that the wound has been cleaned. The sink is your ally. Once a wound is disinfected, it is perfectly reasonable to have patients wash out their own wounds. No evidence suggests that sterile saline is any better wound irrigant than tap water.

• Bite wounds. Bite wounds are at higher risk for infection, but it depends on the organism involved. Dog bites tend to be less infective than most. Cat bites are highly infective. Human bites are even worse. The physician’s judgment is crucial in all these specific wounds. For a wound that you suspect will become infected, treat it as though you would on the patient’s next visit. Immobilization, intravenous antibiotics, elevation, and short-term interval follow-up are essential.

• Style points in wound management. Style points in wound management are essential for patient satisfaction. Pain management is often key. Topical anesthetics placed on the wound are appreciated by patients who have to wait before being evaluated. Long-acting “caine” derivatives are now the anesthetic agents of choice. Sedation may be needed, particularly in children. In view of their safety profile, sedatives should be used on a regular basis.

• Follow-up and suture removal. Arranging for follow-up and suture removal is important. Having the wound rechecked and arranging for proper interventions will essentially go a long way in preventing any legal actions concerning wound infections or retained foreign bodies.

• Poisoning. Poisoning falls into two general groups. The first group consists of cases of accidental poisoning, mostly involving children. Whenever an EP evaluates a child who has been seen more than once with “accidental poisoning,” the possibility of child abuse or neglect should come to mind. It is not only reasonable but also required that action be taken for the defense of the child. The second group in poisoning is overdose, which involves teens and adults. The science of treating poisoning has changed rapidly. It is generally wise for the physician to consult the poison control center or some other poison authority and to document such contact to make certain that current, acceptable treatments are being used. It is just as important to tell the family that you are seeking such outside expertise in management of the problem.

• Psychiatry. In emergency medicine, the major issue with psychiatry is that the physician must be able to delineate organic disease manifested as abnormal behavior (Box 6). All psychiatric patients eventually die of some organic process, and thinking that it is easy to decide what is causing abnormal behavior is often wrong. It is certainly possible to have both a psychiatric diagnosis and an organic problem at the same time. Psychiatric consultation services are often not ideal. It is important to identify who is involved in the evaluation of a patient. Only another physician can truly relieve the EP of liability on the issue. A psychiatric worker from some community program can certainly be helpful and may give an opinion, but if the EP disagrees with that opinion, the EP has an obligation to protect the patient first. The largest single burden on the practice of emergency medicine is patients who are mentally ill or who have altered mental status secondary to drugs or alcohol. There is really no way to dispute that these patients constitute a difficult and common part of emergency practice. When in doubt, the EP should wait until the proper resources are available. The need to restrain and reevaluate patients is a known part of the profession, and it frequently falls to the EP to perform these duties. Clearing patients for psychiatric admission is also wrought with danger. The EP cannot say that a patient is free of organic disease, only that the patient is capable of being evaluated by a psychiatric service. The rule, however, should be that if any doubt exists, the patient should be handled initially by a medical service. Abnormal vital signs should not be ascribed to psychiatric disease. No psychiatric diagnosis causes tachycardia, hyperthermia, or a decreased pulse oximetry measurement. Clues to organic disease include unexplained abnormal vital signs, tremors, and abnormal speech patterns.

• Chest pain. This condition is still the largest risk issue in emergency medicine. Between 20% and 25% of malpractice funds expended for emergency medicine are related to the complaint of chest pain. The groups of diseases that constitute most of these cases are acute coronary syndromes, aortic dissection, and pulmonary embolism. The reason that these entities are such large medical-legal problems is that they tend to attack patients in their most financially productive years and can be manifested by diverse and complex symptoms. Coronary artery disease is a common but mysterious disease. Unfortunately, sudden death is often the next manifestation of this disease. No current systems can totally rule out coronary artery disease, but we can at least place the patient in a lower risk category. Pain is highly subjective. Many people describe this pain as a sensation of pressure, or they may have no acute chest pain whatsoever but instead report pain in the neck, jaw, or arms. Patients frequently refer to their pain as heartburn. Physical examination in most patients with chest pain usually reveals nothing (Box 7). Only very unusual cases of nontraumatic chest pain have prominent physical findings. The electrocardiogram is important when it is positive and indecisive when it is negative. Cardiac markers are similar. An initial cardiac enzyme result, if positive, can prompt immediate therapeutic action. A negative enzyme result is just that. It is often too early in the process to know the direction in which the patient is heading.

• Pulmonary embolism. Pulmonary embolism is also a difficult diagnosis in many cases. It can commonly be misdiagnosed as pleuritis, pneumonia, or unknown syncope. A psychiatric diagnosis, such as hyperventilation syndrome, is very difficult to defend in court when the patient has died of pulmonary embolism. Work-up of pulmonary embolism has changed markedly in the last few years because of the use of D-dimer testing, Doppler testing of the extremities, and computed tomography (CT) scanning. The age of ventilation-perfusion scanning has essentially come and gone.

• Aortic dissection. Aortic dissection is a relatively rare disease. There may be 300 to 500 times more myocardial infarctions than aortic dissections in the United States each year. The symptoms can overlap and may be difficult to diagnose. The EP may consider obtaining a chest radiograph before thrombolytic agents are given. The use of thrombolytic agents for aortic dissection should be discouraged.

• Abdominal pain. Lawsuits related to abdominal pain in emergency medicine are highly age and sex dependent because of difficulties in diagnosis. Excellent evidence suggests that up to 50% of the time, a patient with a complaint of abdominal pain leaves the ED without a specific diagnosis proved by testing. Short-term follow-up is the key because examination is merely a snapshot of a moving picture. Gastroenteritis is a frequent diagnosis on lawsuit charts. Entities such as missed appendicitis, arterial disease, and in children, missed meningitis can often be ascribed to gastroenteritis. In the ED it is best to divide abdominal pain into either surgical or medical as general groupings to guide reexamination and therapies. Frequently, we do not have the exact explanation, and this is perfectly acceptable if the patient has been properly instructed and short-term interval follow-up care has been arranged. Abdominal CT scanning is useful, particularly in elderly patients with diffuse disease, but it is not infallible. If a patient’s examination shows peritonitis, remember that CT has a 5% to 8% error rate for appendicitis. Clinical judgment should rule (Box 8).

• Urologic issues. In emergency medicine, urologic emergencies are few. With the advent of newer catheter types, the need for an EP to call a urologic specialist into the ED has become rare. However, some issues have caused considerable medical-legal consternation. Testicular pain needs a diagnosis. A 10-year-old boy with testicular pain has torsion until proved otherwise. Even in a sexually active male patient, the possibility of torsion should not be underestimated. In general, painful testes are best treated after examination and testing with a call or referral to a urologist. A young male patient with testicular pain needs intervention in a timely manner. Overtesting can be a problem. Nuclear scans are not 100% accurate, nor are Doppler ultrasound scans. A young male patient with a painful testicle deserves the insight of a urologist. Sexually transmitted disease can also have long-term sociologic and medical-legal implications. A patient who is being treated for possible sexually transmitted diseases should be asked about partners and should be informed that these partners will also require evaluation and treatment. It is also fair to warn the patient that the public health department will be involved if cultures are positive. The health department has a duty to third parties who have been involved with the patient to seek them out and provide therapy. It may be best for the patient to understand the need to inform contacts and to advise them that they may be at some risk.

• Elevated blood pressure. Elevated blood pressure is found frequently in the ED. Most commonly it is a function of the pain or stress that is related to the chief complaint. It is not the standard to lower all elevated blood pressure. It is recommended that the EP document that no end-organ dysfunction is present and that the patient understands the sequelae of elevated blood pressure. Outpatient follow-up should be recommended to all patients.

• Headache emergencies. Headache is one of the most common chief complaints in emergency medicine (Box 9). The ED must consider the possibility of subarachnoid hemorrhage, meningitis, or carbon monoxide poisoning in every patient with headache. Although subarachnoid hemorrhage is relatively rare in the United States (≈50,000 per year), it carries high morbidity and mortality. The most important part of the patient’s history in deciding the possibility of subarachnoid hemorrhage is the rate of onset of the pain. In all long-term studies, this is the key factor in headache pain history. A CT scan is, by itself, not an adequate screen for subarachnoid hemorrhage. A positive CT scan is a positive indicator, but a negative CT scan is indeterminate. Meningitis is rarely confused with subarachnoid hemorrhage. In a patient in whom meningitis is a serious possibility, the timing of antibiotics is generally the issue at the time of a lawsuit. The EP should feel comfortable about starting therapy early.

• Spinal cord injury. Spinal cord injuries are relatively rare, but they are associated with devastating societal and financial cost. Maintaining a quadriplegic patient costs enormous amounts of money. The ED should properly document immobilization, and there should be no hurry to remove such immobilization. The EP should document an appropriate neurologic examination. Adequate films in patients seriously suspected of suffering cervical spine injury are important. Plain radiographs are becoming less useful, and more and more physicians are advocating an immediate move toward CT of the neck to delineate fractures clearly. The other end of the spectrum is also true. If a patient is awake, has no specific neck complaints, and has no obvious discomfort during examination of the neck, clinically clearing the cervical spine meets the standard of care. The various clinical trials looking at this study clearly point to the uselessness of radiologically pursuing patients whose findings are normal. If there is evidence of bowel, bladder, or motor dysfunction, magnetic resonance imaging should be performed.

• Seizures and syncope. Seizures and syncope can be lethal from multiple perspectives. Injury to the patient is a real potential problem, particularly in patients with seizures. Warnings about driving and the operation of machinery are important for protection of the public in general. Such warnings should be indicated in some way on the patient’s chart.

• Transient ischemic attacks and stroke. Transient ischemic attacks and stroke are becoming larger issues. The American College of Emergency Physicians has gone on record as specifically stating that tissue-type plasminogen activator is not the standard of care for stroke. Lack of rapid evaluation of patients with transient ischemic attacks and initial use of aspirin therapy have been the source of many ED lawsuits. Patients with transient ischemic attacks represent a high-risk group and require timely intervention.

• Trauma. The biggest issue in patients with trauma is too little, too late. Each ED should know what they can and cannot do and should move quickly to ensure that the patient receives the actual help needed. It is useless for a critically ill patient to be maintained in an ED and not be moved toward needed surgical rescue. If necessary, the EP in a smaller hospital needs to hold the ambulance or other transfer service to await rapid movement toward the facility of choice. Replacement of fluids and transfusion of blood should not wait for the results of any particular laboratory study. Administration of blood and treatment of shock are critical. Hemoglobin takes time to equilibrate, and patients in shock have no specific abnormal laboratory finding early in the course of the illness. In general, smaller hospitals should understand their capabilities. Excessive radiography is generally useless. Most limb injuries can be splinted, and radiographs can be performed at the receiving institution. The results of laboratory and radiographic studies can be sent after a patient has been transferred. The EP should beware of admitting patients to a hospital that cannot care for these problems. Head-injured patients should not merely be admitted for observation but be sent to a center where intervention can take place if it is actually required.

• Obstetric and gynecologic issues. With regard to obstetric and gynecologic issues, it is important for the EP to realize that there may be two patients and not one. The right questions need to be asked. Patients can be inaccurate about the exact dates of their menstrual periods. A urine pregnancy test is an excellent screen, and if it is positive, it is correct at the 99% level. If any question exists, a pregnancy test should be performed. Missed ectopic pregnancies have decreased dramatically in the United States as a medical-legal problem since the widespread use of β-human chorionic gonadotropin testing and ultrasound scanning. Sudden loss of consciousness or shock in a young female patient should raise the possibility of a ruptured ectopic pregnancy until proved otherwise. Eclampsia is the second most common obstetric and gynecologic emergency. Believe the patient’s blood pressure and monitor it carefully. Protein in urine, along with elevated blood pressure, means calling in an obstetrician to become involved in management of the case. In postpartum febrile female patients, ultrasound scans to check for retained products of conception and infection within the uterus are as important as checking the urine. Women who are 5 months into gestation and who have sustained trauma to the abdomen should undergo a period of fetal monitoring. Some legitimate debates exist regarding the length of this monitoring, but most authorities agree that a single reading of the fetal heart rate is not adequate. If a patient is hooked to a fetal monitor over a period of approximately 4 hours, most authorities would consider this a reasonable test to see whether fetal irritability is present.

• Pediatrics. The number of pediatric medical-legal cases in emergency medicine has actually decreased as rates of immunization and the various diseases that can be immunized against have increased. The keys to pediatrics are examination and early reexamination. The major issues around febrile children have not changed. The ED needs a protocol for the work-up of children at various ages to rule out infection. No single test can determine whether a child is ill. Important examinations on the chart should refer to the child’s level of consciousness, playfulness, hydration, and activity. A term such as “lethargic child” should prompt reexamination to see whether this is correct. It is true that most adults are more anxious about their children than they are about themselves. The EP frequently needs to convince parents that the child will do well at home. In most well-appearing children, testing is generally useless. Very little evidence indicates that complete blood counts and blood cultures are of use. In particularly young children who are febrile, urinalysis has proved to be a more important screening laboratory study. Feeding of children is important. Offer popsicles or a balanced salt solution of some kind so the parents can actually observe the child eating and keeping food down. The ability to retain fluid is often the reason that children are either admitted or discharged home. Finally, child abuse is a serious social problem seen in EDs. In general, never accuse anyone of abusing his or her child. You merely state that an investigative process is required because of the findings. It is important to emphasize that “they” make us do this type of investigation in these situations. Abuse and neglect are often difficult to separate in the ED, and such distinction needs to be made through social services. When in doubt, however, the child’s safety is paramount, and admitting a child for observation can certainly be a reasonable use of the hospital facility. Certain specific disease entities, such as sudden infant death syndrome, unusual burns, vaginal infections, certain types of fractures, and repeated toxic ingestions, should always be considered suggestive of child abuse until further information is obtained.