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)
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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.
- 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.