*With the exception of programs from the ACCEL series, each of which qualifies for up to 4 Category 1 CME credits.
Audio-Digest Emergency Medicine
Volume 30, Issue 03
February 7, 2013
Review of High-Risk Medical Cases Michael Jay Bresler, MD
Debate: Spine Immobilization in Penetrating Trauma Ali Salim, MD,
The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.
Emergency Medicine Program Info Accreditation InfoCultural & Linguistic Competency Resources
The goal of this program is to improve the delivery of care to high-risk patients in the emergency department (ED). After hearing and assimilating this program, the clinician will be better able to:
1. Ensure that results of laboratory tests are promptly reported to the appropriate physician and report documented and followed up with patient.
2. Distinguish unstable angina from other causes of chest pain.
3. Adhere to the legal regulations that govern the transfer and discharge of patients from the ED.
4. Distinguish between serious and benign causes of back pain.
5. Evaluate the appropriateness of spinal immobilization for patients with penetrating trauma.
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Review of High-Risk Medical Cases
Michael Jay Bresler, MD, Clinical Professor of Surgery, Division of Emergency Medicine, Stanford University School of Medicine, Palo Alto, CA
Case 1: male patient aged 39 yr with fever, anorexia, and weakness for past week; physical examination did not reveal cause of symptoms; patient febrile upon arrival at emergency department (ED); elevated white blood cell (WBC) count; hemoglobin 9.5 g/dL; hematocrit 28%; patient’s fever subsided after receiving antipyretic drugs and intravenous (IV) fluids; patient ambulatory and reported feeling well; patient discharged from ED; patient returned to ED 3 days later with dyspnea, dizziness, hypotension (75/40 mm Hg), pulse 125 beats/min, and fever; physical examination did not reveal cause of illness; patient admitted to intensive care unit and died after multiorgan failure; litigation — note in patient’s chart dated between his visits to ED revealed blood culture positive for Streptococcus pneumoniae; patient’s chart indicated that culture result presented to attending physician (Dr. Night); when deposed, Dr. Night said culture report relayed to colleague (Dr. Day) during shift change; Dr. Day reported that she unsuccessfully tried to contact patient and instructed nurses to keep trying to contact patient; nurse said she had no knowledge of culture report; patient’s file did not indicate attempted communication from hospital about blood culture; lesson — delayed reporting of laboratory test results and failure to document them may lead to lawsuits; miscommunication during shift changes may also contribute to legal action
Case 2: female patient aged 65 yr; reports feeling weak and dizzy;
answers negatively to all questions during review of systems; electrocardiography (ECG) reveals nonspecific ST segment changes; negative results for troponin test and all other usual laboratory tests; physician tells patient that all diagnostic tests negative; patient asks doctor about her “chest ache”; doctor perplexed at this response because he specifically asked about chest pain earlier; patient answered negatively when previously asked about chest pain because she viewed chest pain and chest ache as distinct entities; patient says chest ache present all day; physician repeats ECG and diagnostic tests but no change in results; physician concludes that chest ache not due to acute myocardial infarction (MI) and recommends follow-up with primary care provider “next week”; pearl — speaker recommends avoiding ambiguous statements such as “next week” when completing patient’s chart; use specific dates instead; result — patient died several days after visit; lawsuit claimed failure to diagnose acute MI; issues — distinguishing acute MI from unstable angina (UA); gastrointestinal (GI) cocktail useful for diagnosis of UA (should work within 1 to 2 min of administration if pain has GI etiology); patient history most important tool for diagnosing UA; speaker reminds physicians to use care when choosing language used with patients (ask about “chest symptoms” rather than “chest pain”); questions to ask when UA suspected — when did symptoms begin? when did specific episode of symptoms begin (constant or intermittent symptoms)? last time with no symptoms in chest? longest and shortest episodes of symptoms? cardiac etiology ruled out if longest episode very short (30 sec) or very long (8 hr); intermittent chest pain for 8 hr with episodes lasting ≈20 min may have cardiac etiology; in UA, pain resolves between episodes, ECG nondiagnostic, and markers normal
Case 3: male patient aged 48 yr; came to ED complaining of pelvic pain after being thrown off horse; refused to lie in supine position during examination; vital signs, physical examination, and diagnostic tests normal; pelvic x-ray normal (performed in lateral decubitus position); patient given analgesic to allow for supine x-ray; imaging revealed pelvic fracture dislocation; no legal issues in this case, and patient recovered; lesson — pay attention to unusual findings and behavior (refuses to lie supine); trust clinical intuition
Case 4: intoxicated male patient aged 21 yr brought to ED with open tibia fracture after motorcycle accident; patient stable; on-call orthopedist refuses to see patient due to lack of insurance and requests that patient be sent to county hospital; limb cleaned and splinted; patient given antibiotics and transferred to county hospital; patient recovered from injuries; ED physician accused of violation of Emergency Medical Treatment and Active Labor Act (EMTALA); information on EMTALA — applies regardless of outcome of patient or malpractice; formally on-call physicians held liable; nurses may perform screening examinations in accordance with hospital protocol, provided nurse trained and certified in that protocol; patients in active labor cannot be transferred; EMTALA applies to transfer and discharge from hospital; medically stable patients may be transferred for economic reasons; unstable patients may be transferred to another facility if current hospital cannot provide adequate level of care; name of physician responsible for transfer or discharge decision must be noted on chart and transfer forms; ED physician immune from EMTALA penalties if on-call specialist refuses to see patient or if hospital administration denies patient admission; outcome of case — EMTALA not violated; orthopedist not at fault because patient medically stable at time of transfer
Case 5: male patient sustains head injury by hitting head on sink during fall; patient had repetitive speech and abnormal behavior; no physical signs of trauma; receiving methadone for drug addiction; computed tomography (CT) of head negative for injury; toxicology screening shows narcotic and alcohol use; patient “admitted” to trauma service; patient given sedative and allowed to sleep; patient reported feeling well in morning and requests discharge; patient has normal behavior and speech; patient discharged against medical advice; patient brought back to ED several hours later after being found wandering along side of road; patient now has subdural hematoma and bilateral ankle fractures; patient survived injuries but had incomplete neurologic recovery; hospital and physicians sued; legal issue in case centered around determining when patients can leave hospital against medical advice; criteria for leaving against medical advice — patient must be mentally competent to evaluate decision; hospital staff must explain potential consequences of leaving hospital to patient; must give patients option of returning to ED if they change their decision; arrange for appropriate medical follow-up; physician must document entire interaction; hospital cannot restrain mentally competent patients against their will; attempt to get patient to sign Against Medical Advice (AMA) form (make note in chart if patient refuses to sign AMA form); AMA form does not give ED physician total legal protection
Case 6: man aged 56 yr; brought to ED after being hit by train; massive trauma and no signs of life upon arrival to ED; no attempt to resuscitate; pronounced dead on arrival; hospital accused of allowing man to die without providing medical care; speaker called as expert witness to review case; expert witness concluded that hospital staff not at fault; lawsuit never filed; lesson — reviewing cases for plaintiff’s attorneys may add to physician’s credibility and does no harm to fellow physicians
Case 7: man aged 32 yr submits to rectal examinations and sigmoidoscopy in ED due to language and cultural barriers; physician did not understand what patient said and did not get interpreter; patient undocumented immigrant and submitted to procedures because he did not want to defy authority figures; patient had no medical complaint (asking to use restroom); translation in ED — hospital staff responsible for providing interpreters for patients who do not speak English; new Joint Commission regulations require use of formally certified interpreters (may be certified by hospital); telephone translation services also acceptable; regulations state that uncertified staff or family members should not be used as translators; presence of some family members inappropriate in certain socially sensitive situations (eg, father of teenaged patient with possible pregnancy should not be present when patient speaks with physician)
Other issues in ED litigation: choose words carefully when speaking in front of families; explicitly outline reasoning for clinical decisions on template charts or electronic records; staff member competent to respond to medical emergency should always accompany patient during transport for imaging; ensure that patient understands aftercare instructions (patient should be able to repeat instructions) and ask patient if they have other questions; have nurse explain instructions again; reconsider original assumptions for patients who unexpectedly return to ED; abdominal pain — always consider appendicitis; patients with abdominal pain should be informed that severity of symptoms may progress; these patients should be scheduled for follow-up; appendicitis commonly missed in adults and children (two-thirds of adult patients with appendicitis not diagnosed until second visit ); appendicitis has continuum of symptoms (disease becomes apparent as it progresses); appendicitis may cause pyuria; ruptured abdominal aortic aneurysm can cause hematuria; abdominal pain in elderly patients should be taken seriously; mesenteric ischemia may explain pain out of proportion to abdominal examination in elderly patient (check amylase and bicarbonate levels, and perform stool guaiac ); back pain — evaluate autonomic nervous system; ask patient about bowel function and urination; explain symptoms of cauda equina syndrome to patients with low-back pain (may develop over time); IV drug users (or any patient with portal of entry for infection) with thoracic back pain may have epidural abscess; abdominal aortic aneurysm likely in patients (particularly older men) with back pain localized to left side of body; headache — physician must rule out subarachnoid hemorrhage (SAH) in patients with severe, sudden-onset headache (perform lumbar puncture first); 2% to 10% of CT fails to identify SAH; CT angiography and magnetic resonance angiography sensitive for SAH but few supporting studies
Advice on lawsuits: best prevention good medical practice and communication; few emergency physicians escape being sued at least once; physician should not take it personally; American College of Emergency Physicians (ACEP) has review board; sued physicians who believe expert witness has given unscientific, biased, or unethical testimony, should immediately submit testimony to ACEP review board; physicians should obtain supportive counseling
Debate: Spine Immobilization in Penetrating Trauma
Pro: Don’t take any chances: immobilize and protect
Ali Salim, MD, Associate Professor of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
Introduction: current edition of Advanced Trauma Life Support (ATLS) states that spinal stabilization equipment should be left in place on trauma patient until injury excluded (no distinction between penetrating and blunt trauma)
University of Miami study: assessed incidence of spinal injury in patients with penetrating torso injury; studied patients with single gunshot wounds not suspected of having injury to spine; found spinal injury in 10% of patients; >50% of injured patients had significant injury (defined as injuries involving spinal cord); all injured patients required intervention for spinal injury (eg, surgery, prolonged immobilization); found association between anatomic location of wound and incidence of spinal injury; concluded spine injuries common and often require medical intervention; study recommended evaluation of spine after gunshot wound
Ground-level falls: falls associated with gunshot wound provide potential source of blunt trauma in addition to penetrating trauma; study found spinal injuries in ≤5% of patients who fall; another study found significant injury due to ground-level fall in patients after assault; do not dismiss “insignificant” mechanism of injury
Con: A useless and potentially dangerous practice
Carlos V.R. Brown, MD, Associate Professor of Surgery, University of Texas Southwestern Medical School, and Trauma Medical Director, University Medical Center at Brackenridge, Austin, TX
Stance: patients with penetrating trauma do not require routine spinal immobilization; purpose of cervical spine immobilization to prevent neurologic deterioration secondary to unrecognized spinal instability following trauma; speaker states that neurologic injury uncommon in penetrating trauma; neurologic injury in penetrating trauma declares itself at presentation; University of Southern California study — spinal injury rare in patients with penetrating or blunt trauma due to assault; all patients with spinal injury had neurologic deficit at time of presentation; preventive measures like immobilization of cervical spine unnecessary because spinal injury presents itself immediately in these patients; Prehospital Trauma Life Support (PHTLS) recommendations — no data supporting routine spinal immobilization in patients with penetrating trauma to neck, torso, or cranium; spinal immobilization should never be performed at expense of accurate physical examination or identification and correction of life-threatening conditions; spinal immobilization may be performed after penetrating injury when focal neurologic deficit present, however little evidence of benefit
Dangers of spinal immobilization: time spent immobilizing spine could interfere with delivery of life-saving care; supine position detrimental to many patients with penetrating trauma (may prevent self-maintenance of airway); collar used for spine immobilization may hide injuries (eg, tracheal deviation, jugular venous distention); cervical collar may block access to patient’s airway
Cardin F et al: Clinical correlation of mesenteric vascular disease in older patients. Aging Clin Exp Res 2012 Jun;24(3 Suppl):43-6; Cornwell EE 3rd et al: Thoracolumbar immobilization for trauma patients with torso gunshot wounds: is it necessary? Arch Surg 2001 Mar;136(3):324-7; Haut ER et al: Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010 Jan;68(1):115-20; Klein Y et al: Spine injuries are common among asymptomatic patients after gunshot wounds. J Trauma 2005 Apr;58(4):833-6; Ramasamy A et al: Learning the lessons from conflict: pre-hospital cervical spine stabilisation following ballistic neck trauma. Injury 2009 Dec;40(12):1342-5; Rhee P et al: Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. J Trauma 2006 Nov;61(5):1166-70; Robinson WP et al: Derivation and validation of a practical risk score for prediction of mortality after open repair of ruptured abdominal aortic aneurysms in a US. regional cohort and comparison to existing scoring systems. J Vasc Surg 2012 Nov 20. pii: S0741-5214(12)01942-8; Spector LR et al: Cauda equina syndrome. J Am Acad Orthop Surg 2008 Aug;16(8):471-9; Stuke LE et al: Prehospital spine immobilization for penetrating trauma — review and recommendations from the Prehospital Trauma Life Support Executive Committee. J Trauma 2011 Sep;71(3):763-9; Velmahos GC et al: “Insignificant” mechanism of injury: not to be taken lightly. J Am Coll Surg 2001 Feb;192(2):147-52.
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