Whining radiologist and “fake news” neuro consult
- Jan 17th, 2019
- 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
Whining radiologist and “fake news” neuro consult
Case 1: Radiologist asks to delay exam (reader submission)
Facts: An elderly female presents to the ED with low back pain, believing she strained her back lifting a grandchild. Exam shows no evidence of cord compression. Plain films of the L-spine are negative. She next sees her PCP and is continued on a course of conservative treatment. Two weeks later she develops L leg radicular pain and returns to the ED with positive straight-leg-raise and loss of L knee and ankle reflexes. Further questioning elicits a Hx of breast cancer 3 years prior. The ED physician suspects evolving cord compression and orders an urgent MRI. He receives a phone call from the radiologist.
Radiologist: “My MRI tech just left for the night. I don’t want to call her back in. Can’t you just defer this till morning?”
ED Physician: “No. Call her back in. This patient needs an MRI now.”
Result: The MRI revealed L3 osteomyelitis, a secondary compression fracture, an epidural abscess from T12-L5, and bilateral psoas abscesses. Patient had emergency surgery, recovered, and remained independent in her ADL’s. The surgeon felt that a 12 hour delay would likely have left her paraplegic. A bad outcome and likely lawsuit were avoided.
- Despite a 50 year history of emergency medicine as a specialty, ED physicians still encounter bullying. It may be a reluctant admitting physician, an obstinate consultant, or sometimes our own lack of self-confidence.
- Do what’s right for the patient. Not the consultant. Not the radiologist. Not the MRI tech.
- Ask yourself what YOU would want YOUR doctor to do if YOU were the patient.
- Had the MRI been postponed and a lawsuit filed, the radiologist would have the most valid defense: “The ED physician never told me she was THAT sick. I asked a question. He made the decision. He delayed the test. I would have called the tech back if he only told me why he was concerned.”
- Arguing with a consultant, e.g. a senior neurosurgeon, who tells you by phone at 2 AM to send your patient to the office in the morning can be difficult. Don’t give in. You’re at the bedside. He or she is not.
Case 2: Speaking of neurosurgeons… Incomplete neuro consult and inappropriate discharge
Facts: An adult male is brought to the ED after an MVC. He is seen by an ED physician and trauma surgeon and describes pain in his neck and L shoulder with weakness in his R arm and hand. A cervical CT shows a C-6 fracture of the pedicle and transverse process. Callus formation suggests the fracture may be old. The trauma surgeon’s request for a neuro consult is answered by a neurology resident. The “consultant” tells the trauma surgeon “I’ve discussed the patient with my attending, and the patient can go home if he is ‘at baseline.’” A nurse decides the patient is “close to baseline” despite needing assistance to walk, so he is discharged. The next morning, he awakens with no sensation or movement below his chest. An MRI shows the fracture and an associated large herniated disc have now caused cord compression. The patient is left with partial paraplegia, and a lawsuit is filed.
Plaintiff: Hospital policy states that a neurosurgeon must examine any patient with a spinal fracture. A neurology resident saw me. The neurosurgeon on-call that night recalls nothing of the event, the resident documented nothing in the EHR, and the audit trail shows no one other than the radiologist viewed the CT scan.
Defense: We did an adequate evaluation and made a reasonable decision to discharge you.
Result: $3.5 million verdict against multiple defendants after 5 years of litigation and a 12 day trial.
- An MRI is better than a CT at discerning acute vs. old vertebral fractures.
- Document patient encounters and consultations, with names, times, and dates.
- Assure that you have well-defined relationships among emergency physicians and consultants. Know who’s making the decisions. If delegating care to another physician, make it clear with a “handoff note” – especially for discharge.
- The ED physician remains the “captain of the ship,” at least sufficiently so that he/she will be a named defendant in almost any ED-related lawsuit.
- Nurses are valuable resources, but do not delegate discharge decisions to them. Instead, develop relationships that assure that they feel comfortable challenging a physician’s plan of action – or inaction.