Medical Malpractice Insights: Inappropriate discharge leads to paraplegia
- Sep 17th, 2019
- Chuck Pilcher
Here’s another 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
Inappropriate discharge leads to paraplegia
There’s a policy – follow it.
A consult is required – get it.
If it happened – document it.
Facts: A 64-year-old male involved in a major MVC is found by EMT’s complaining of weakness in his R arm and pain in his L shoulder. On ED arrival, he reports R hand weakness and neck pain that increases with movement. A “trauma alert” is called, and a trauma surgeon joins the emergency physician (EP) in the patient’s care. A CT scan shows a fracture of the pedicle and transverse process of C6 with a fragment extending inferiorly. However, the radiologist also notes possible callus formation suggesting a pre-existing injury. Therefore, the trauma surgeon requests a neurosurgical evaluation. A neuro resident responds and evaluates the patient. He then tellsthe trauma surgeon that he has discussed the case with his attending neurosurgeon who advises that the patient can be discharged “if at baseline.” A nurse decides that the patient is “close to baseline”, and he is discharged, despite needing assistance to walk. On arrival at home, he cannot walk and needs to be carried inside. He awakens the next morning with no sensation or movement below his chest. At another ED, an MRI shows the fracture and a large herniated disc with cord compression.
Plaintiff: You never called the neurosurgeon. You never documented that you called him. According to the audit trail, he never accessed the EMR or viewed the CT scan. He recalls nothing of the event. He never saw me. There’s no documentation that you even spoke to him. Your hospital has a policy that requires a neurosurgeon to examine any patient with a spinal fracture. You didn’t follow that policy.
- Neuro Resident: I spoke with the neurosurgeon and told the trauma surgeon his recommendation.
- Neurosurgeon: I recall nothing of the event. I would have looked at the CT scan if I had been consulted.
- Trauma Surgeon: I did an adequate evaluation, got the CT scan, and requested the consult.
- Emergency Physician: I made a reasonable decision to discharge you based on the nurse’s observation and my understanding of the trauma surgeon’s recommendation.
Result: $3.5 million verdict after 12 day trial 5 years following the injury.
- Road test your patients before discharge. How often does a patient arrive, spend 4 hours on a gurney, have tests, and leave without their gait ever being visualized? Too often. Sending a patient home without a “road test” is a recipe for disaster.
- Assure that you have clear relationships between EP’s, the ED nursing staff, and consultants. Who is responsible to whom, when, and under what circumstances?
- The EP remains the “captain of the ship” unless a clear handoff delegating care (especially discharge and follow-up) has occurred and is documented.
- If your hospital or residency program has a policy requiring certain procedures, such as mandatory consultations, follow it.
- The ED nursing staff is responsible primarily to the patient and the ED physician unless a handoff to a consultant (including the trauma surgeon) has clearly taken place.
- Accepting second-hand advice from a consultant via a nurse or resident is a poor practice. If you need a consult, you deserve a conversation with the ultimate consultant, in this case the on-call neurosurgeon.
- This patient’s “baseline” was never established. One can’t assumea baseline when none is documented, especially when the nurse is assuming the baseline without consulting either involved physician.
- Assure that your own ED nursing staff is comfortable with the disposition. Our nurses are our best defense. Intervene and “stop the line” if you sense something might be amiss.
From Dr. Katy Hanson at Hanson’s Anatomy:
Reference: Canadian C-Spine Rule Infographic. Ian Stiel. The Ottawa Rules. (online)