TESTS
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.
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CONSULTS
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.
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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).