Be Service Oriented

The key is to understand that as an emergency physician (EP), when you arrive at work, you check all your prejudices at the door. Remember that you may never be able to solve a patient’s chronic medical problem, but showing genuine concern and providing a positive patient experience will go a long way toward relieving the patient’s fears. Box 212.1 is a list of simple rules that should help facilitate the doctor-patient interaction.

Charting and the Medical Record

The only things that really go to court with a physician are the patient’s medical record and the physician’s credibility. The chart is the only document that the plaintiff attorney has to understand what happened and to be able to decide whether bringing legal action is worthwhile.

Multiple issues with regard to a chart accompany every lawsuit. Box 212.2 is a list of simple rules that should help facilitate the key points for a sound medical chart.

Discharge Instructions

Approximately half the lawsuits in emergency medicine revolve around discharge instructions and the discharge program given to patients. Box 212.3 gives a few paramount rules for discharge instructions.

Ownership of 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, and thus the physician cannot abrogate responsibility by saying that the patient belongs to another physician.

Combative Patients

The ED has the duty to restrain patients when they constitute a danger to self or others by virtue of a physical or mental condition (Box 212.4). Determination of mental and physical capacity is the key issue. Patients who lack capacity will depend on the substitute judgment of the EP. Belligerent patients who have capacity require law enforcement to handle the situation.

Civil Commitment

Again, the role of the ED is 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.

Reportable Illnesses

The legal system and the ED function together as essentially an officer of the court. In all 50 states, child abuse, elder abuse, and assaults are reportable conditions. The EP also maintains a duty to third parties who may not be present in the ED. Therefore, when a patient has a gunshot or stab wound, other people may be at risk, and failure to report such injuries could place the patient and institution in danger.

Legal Blood Draw for Alcohol Testing

This varies from state to state because some states have given the police warrant authority to obtain blood whereas in others a court order is required. It is the ED’s responsibility to comply with the law. The police have the right to discarded body contents (e.g., vomitus, urine, feces) once such material passes into the public domain. An EP is also obligated under the EMTALA to offer a medical screening examination to all individuals arriving for a blood draw.

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. Incident reports should not be filed in a patient’s chart.

Response to in-House Emergencies

All contracts should be written such that the EP will respond if not required to remain in the ED because of the acuity level of other patients. The hospital always has the alternative of putting a patient on a cot and bringing the patient to the ED. 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 be confirmed by EPs at each site where they are required to perform this duty.

Writing Orders for Admitted Patients

The EP’s medical liability carrier may have questions regarding orders written on already hospitalized patients. The best ways to limit exposure on the writing of inpatient orders are as follows:

Prescriptions from the Emergency Department

Any prescription requiring a Drug Enforcement Agency prescription number should have proper warnings documented, usually on the ED general discharge instructions. In addition, one should avoid writing prescriptions for nonregistered patients (i.e., the nurse or technician you are working with).There is no medical liability coverage for this practice.

Midlevel Providers, Residents, and Emergency Physician Supervision

Midlevel providers (MLPs) practice under the EP’s license. EPs should sign off on charts only after they have been reviewed by them. The EP is ultimately responsible for the actions of the MLP.

All resident work must be supervised if it is to be billed for under any federal program. All violations of this mandate are considered criminal violations of the federal law, and the current act has no exemptions.

Patients Who Leave before Examination or Against Medical Advice or Who Elope

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 (Box 212.6).

Elopement is a similar process in which the patient disappears in the middle of a work-up. Document what actions were taken to find the patient. For example:

Return Visits

In emergency medicine, “bounce-back patients” should often be reevaluated as new-visit patients. Disease processes may often become evident only after the second or third visit.

Change of Shift

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 so 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. Repeating the examination and evaluation of vital signs is recommended before discharge.

Laboratory Studies, Radiographs, and Electrocardiograms

The ED should have a process to detect what has been ordered and to account for the results received. A system is needed in which each variance in laboratory or radiographic test should be handled within the ED.

Health Insurance Portability and Accountability Act

The doctor-patient relationship and patient records are protected by federal law under the Health Insurance Portability and Accountability Act (HIPAA). Protection and release of this information are mandated by the HIPAA. Please refer to Chapter 211 for a more in-depth discussion.

Duty to a Third Party

Various therapies may render a patient incapacitated in some way and thereby place the patient and a third party in danger. 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. Other devices that make the patient incapable of normal functioning (e.g., the use of crutches, eye patches, 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

Emancipated minors are those who live outside the home, provide their own financial support, have borne a child, or make their own life decisions. Such emancipation is given through the act of a probate court. In most states, children who arrive for treatment and who are older than 12 years may have questions of child abuse, substance abuse, sexually transmitted disease, and pregnancy treated without parental consent.

Telephone Orders and Telephone Advice

In general, the ED should not give telephone advice. Answering machine devices that advise the patient to come into the ED or to call 911 are often the most useful.

Orthopedics

It is always wise for the EP to let patients know that this is the beginning of a process. Orthopedic management includes recognition, reduction, retention, and rehabilitation (Box 212.7). The ED is only the first part of what may be a long and complex process.

Eye, 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 (Box 212.8).

Wounds

All wounds seen in the ED are potentially contaminated and have foreign material almost by definition (Box 212.9). Lawsuits in emergency medicine wound management are based on three critical issues: foreign body, nerve injury, and tendon injury.

Poisoning

“Accidental poisoning” must be clearly reviewed and the potential for abuse or neglect considered. A patient with an intentional overdose should be placed under suicide precautions while actively treating the patient for the effects of the overdose. An EP may consult with poison control.

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 212.10).

Chest Pain

This condition is still the largest risk issue in emergency medicine. Between 20% and 25% of malpractice funds expended in 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 (Box 212.11).

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. If a patient’s examination shows peritonitis, remember that computed tomography has a 5% to 8% error rate for appendicitis. Clinical judgment should rule (Box 212.12).

Back Pain

Evaluation of back pain is a daily occurrence in the ED. More than 6 million annual visits have been reported. The evaluation should be systematic and consider the red flags to warrant imaging for ruling out diagnoses with high morbidity and mortality, including ectopic pregnancy, abdominal aortic aneurysm, aortic dissection, spinal cord compression syndrome, and inflammatory conditions (Box 212.13).

Urologic Issues

In emergency medicine, urologic emergencies are few. Diagnoses that require emergency intervention are testicular torsion and sexually transmitted diseases. 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 such contacts that they may be at some risk.

Elevated Blood Pressure

Elevated blood pressure is often found in the ED. Most commonly it is related to the stress or pain of the situation involving the chief complaint. It is not the standard to lower all elevated blood pressure. It is recommended that the absence of end-organ dysfunction be documented and that the patient understand the sequelae of elevated blood pressure. Timely follow-up is recommended to address this issue with the patient’s primary care physician.

Headache Emergencies

Headache is one of the most common chief complaints in emergency medicine (Box 212.14). The EP must consider the possibility of subarachnoid hemorrhage, meningitis, or carbon monoxide poisoning in every patient with headache.

Spinal Cord Injury

Spinal cord injuries are relatively rare, but they carry a devastating societal and financial cost. During the patient’s evaluation, the EP should properly document immobilization, and there should be no hurry to remove such immobilization. Document an appropriate neurologic examination on arrival of the patient. Obtain a magnetic resonance image for patients with evidence of motor, bowel, or bladder dysfunction.

Seizures and Syncope

Seizures and syncope can be lethal from multiple perspectives. Injury to the patient and reoccurrence are real potential problems. Precautions for safety should be initiated in the ED as soon as possible. If the patient is discharged, 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 a transient ischemic attack and the 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

All EPs should know what they can and cannot do and should move quickly to ensure that the patient receives the actual help needed (Box 212.15). Administration of blood and treatment of shock are critical.

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 (Box 212.16).

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. Child abuse is a serious social problem in EDs. In general, you should 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 fracture, and repeated toxic ingestions, should always be considered suggestive of child abuse until further information is obtained (Box 212.17).