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Tests and Consults in Emergency Medicine

Related to: Cures Act: Opening Notes, Emergency Medicine


A typical ED malpractice case pivots on the clinicians missing a key opportunity to gather or share one more bit of knowledge. At these junctures, the practitioner must balance clinical judgment and production pressures. Relying too much on “seeing” a pattern before it is fully filled in, or allowing frustration with test/imaging access, turnaround times, and accuracy to hinder appropriate orders leaves you vulnerable to an incomplete problem list or a differential diagnosis not considered.

A standardized approach to diagnostic testing is often appropriate, but patients are safest when their ED team orders tests or images judiciously, rather than perfunctorily. This minimizes the risk of assumption and maximizes the value of results as an essential part of the diagnostic process. This also diminishes any tendency to treat counter-intuitive results as anomalies.


Claims that point to a mismanaged consult reflect numerous challenges in ascertaining expert input in the ED. In community hospitals, Emergency Medicine physicians often face a backed-up line for imagings and a prolonged wait for (sometimes reluctant) consultants to arrive. In academic facilities, residents serving as consultants present varying degrees of expertise; and curbside consults—although appealing in a crisis—can unsettle some of your colleagues.

In all settings you'll find patients who bridge changing shifts. Maintaining breadth in the differential diagnosis, and continuity in the synthesis of data through those handoffs is paramount. EDs that structure team communication—and train their staff to use those structures—minimize the risk of losing valuable information, and decrease the propensity of diagnostic fixation and premature discharge.

Case Example: Tests and Consults

A 53-year-old female presented to the ED at 5:30 a.m., complaining of sudden pain in her left axilla. Initial assessment revealed elevated blood pressure and heart rate, a low-grade temperature, and an elevated WBC (17,000) with left shift. No mass was palpable in the left axilla, her chest X-ray and CT scan were normal. After an undocumented (curbside) consult, the attending physician documented his decision not to start the patient on antibiotics. He diagnosed left arm strain and discharged the patient with pain medication. Her vital signs at discharge were not documented. 

The patient returned to the ED the next morning complaining of severe pain, fever, chills, vomiting, and shortness of breath. She had a 103.3 fever, elevated heart and respiratory rates, decreased O2 sats, and her WBC was 14,000. Three hours later, the patient was noted to look “very ill.” She was started on antibiotics and an ultrasound revealed a small fluid collection in the left axilla.

A “stat” surgical consult was ordered, but two hours passed before the patient was seen by the consulting surgeon. She was admitted with a diagnosis of sepsis and possible left axilla abscess, with plans to rule out necrotizing fasciitis. She was taken to the OR for exploration of the left axilla mass, which revealed edematous, conglomerated lymph nodes, and venous thrombosis. Cultures confirmed Group A strep.

After an arrest and CPR in the OR, the patient was transferred to the ICU. She died the next day, following multi-organ failure, hypo-tension, and hypoxia. Her cause of death was streptococcal toxemia/toxic shock. (Case settled: $1.5M).

July 25, 2012
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