Medical Malpractice Insights: A short walk can prevent a long trial

Author: Chuck Pilcher, MD FACEP (Editor, Med Mal Insights) // Editors: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Welcome to this month’s case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

 


A short walk can prevent a long trial

“Road test” every at-risk patient before discharge

Facts: A 34-year-old financial manager with a 17 year history of back pain presents with back pain, leg numbness, and weakness. A brief exam is done with the patient supine on the gurney. A CT scan of the lumbar spine reveals a minor disc bulge and mild stenosis. He is discharged by the ED physician to follow up with his PCP. The nurse documents that the patient needs a 2 person assist to get off the gurney and is unable to walk. He is discharged by wheelchair.  The CT scan is over-read the next day and an MRI recommended. Two days later the patient presents to another hospital with overflow incontinence, bilateral leg pain, and numbness. An MRI shows a large herniated lumbar disc. He is diagnosed with cauda equina syndrome (CES). Despite surgery, he is left with incontinence and leg weakness. A lawsuit is filed claiming his initial ED discharge was negligent.

Plaintiff: You never got me off the gurney. You didn’t ask me if I could walk, or even re-examine me when the nurse told you I couldn’t. You didn’t do a rectal exam or a simple gait check. You even have a slang term for this simple neuro exam: ED staff call it a “road test.” I could still pee when you saw me and got worse. Earlier surgery would have prevented my paralysis. A CT scan is a poor test for a patient with leg weakness. You should have had a wider differential in mind and ordered an MRI or done a rectal exam. I was just another back pain patient to you.

Defense: I did a CT scan. It was negative. You didn’t tell the triage nurse that you couldn’t walk. I found nothing suggesting CES. I told you to return if you got worse, but you waited 2 days. And once you have CES, there’s no good evidence that earlier surgery is better than later surgery.

Result: Trial with jury verdict for $1.9 million against first ED physician.

 

Takeaways:

  • A “road test” is probably our single best screening neuro exam. It is quick, easy, and comprehensive, testing a patient’s strength, proprioception, coordination, and balance – and can even help diagnose appendicitis. (Recall that observing the patient is often a key step on the EM oral boards.)
  • Adding heel-toe tandem walking and/or ability to stand on tiptoes or heels provides additional information on nerve function.
  • In busy ED’s, too many patients are still being discharged without ever leaving the wheelchair or gurney on which they arrive.
  • Keep CES on the top of your differential (and spinal epidural abscess), and walk every at-risk patient. (This includes patients with hip, ankle, or knee complaints as well as those with generalized weakness, dizziness, or symptoms of TIA or stroke.)
  • A patient who “can’t” walk (as opposed to “won’t” walk) should make one very nervous.
  • A short walk can avoid a long trial.

 

References:

http://www.emdocs.net/em3am-cauda-equina-syndrome/

http://www.emdocs.net/cauda-equina-syndrome/

http://www.emdocs.net/em-cases-lower-back-pain-emergencies/

Leave a Reply

Your email address will not be published.