Medical Malpractice Insights – You cleared me for jail; I died there 2 days later
- Nov 20th, 2018
- Chuck Pilcher
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
You cleared me for jail; I died there 2 days later.
Why that’s not malpractice…
Facts: An adult male in his 50’s is arrested on a domestic violence charge. Because he is only 10 days post brain surgery and still has sutures in his scalp, he is appropriately brought to the ED for medical clearance prior to being booked into jail. During the exam, he offers no complaints and does not mention that 5 years earlier he had a stent placed in his dominant RCA which was 90% occluded. His LAD at that time was completely occluded. The ED physician determines that he is recovering from his brain surgery as expected and is safe to be taken to jail. Two days later, he is noted by jail staff to be rubbing his chest but tells jail staff it is because of “anxiety”. He declines their offer of medical assistance. Thirty minutes later he is found in extremis on the floor of his cell. Resuscitation is unsuccessful. An autopsy finds a 600 gm heart (normal ~300 gm), an acute thrombus of the proximal R coronary artery, a completely occluded LAD, and a 50% occlusion of the circumflex artery. An attorney is contacted by the deceased’s family about filing a claim for an inadequate medical clearance exam.
Plaintiff: You cleared me to go to jail without checking my heart. I was on “heart medicines” (a statin and a basic anti-hypertensive). You didn’t check any of my old records. You should have admitted me to the hospital, not sent me to jail where the stress caused my heart attack and death. You did not do a thorough medical screening exam (MSE).
Defense: You were doing fine at home. You were only brought to the ED because you had a recent surgical wound on your scalp. Had you not been in custody, you would still be at home recovering. You had no other reason to be in the ED. You did not complain of chest pain, nor had you had any problems since your stent was placed 5 years ago. Your only “complaint” was that you were under arrest. An MSE is not a complete history and physical; it is a “screening” for acute medical problems. I had no reason to do any tests on your heart or check your old records. Even if I had done an EKG and/or troponin, there is no reason to expect that either test would be abnormal. Based on your arrest for DV, your home life was likely more stressful than jail. Based on your autopsy, you were a walking cardiac time bomb and were going to have a heart attack sooner or later. I met the standard of care, documented my findings and cleared you for jail. And by the way, the jail staff offered to get you help, and you declined their offer.
Result: After review by a plaintiff expert, the case was felt to be completely defensible; no case was filed.
- We are emergency physicians, not prophets. Even if we know you have disease, we cannot predict if or when you will die of that. We can only work with what we hear, see, smell, and feel.
- An MSE does not require tests in the absence of complaints.
- A prior history of disease is insufficient cause for admission.
- Good documentation is the best defense.
Source: Submitted by reviewing expert.
Reference: While EMTALA requirements were met in this case and an adequate though focused medical screening exam (MSE) was done, check out “Cops and docs: The challenges for ED physicians balancing the police, state laws, and EMTALA”by Malcolm et al. Several case law examples are succinctly reviewed. https://www.insleyrace.com/Cops-and-Docs.pdf