Wrist injuries are scaphoid fractures till proven otherwise
McPherson v. Catholic Health Systems et al., Niagara County, NY, Supreme Court, Index #136647 Facts: An adult male falls on his outstretched hand (FOOSH). He seeks care in the ED where he is seen by a PA who documents pain, swelling, decreased mobility/range of motion and ecchymosis of the wrist. “Snuff box” tenderness is not addressed. An x-ray is reported as normal. The PA diagnoses a wrist sprain, the wrist is wrapped with an Ace bandage and he is advised to follow up with his PCP if not improving. He does so but no further action is taken. He continues to have pain and is eventually diagnosed with a scaphoid fracture and non-union requiring surgery, resulting in permanent decreased range of motion. The only evidence of involvement of the PA’s supervising physician was a mouse click creating a macro supporting the PA’s care.
Plaintiff: You didn’t document how I hurt my wrist. You should have checked me for “snuff-box” tenderness. FOOSH injuries are high-risk for scaphoid fractures, even when the x-ray is negative. You told me nothing about that possibility. You should have put me in a splint and recommend a repeat x-ray if I did not improve. You never consulted your supervising physician, who should have informed me that I needed closer follow-up.
Defense: We told you to seek follow-up. You did. If you thought you weren’t improving quickly enough, you should have returned to the ED or sought further care on your own in a more timely fashion. Immobilization does not guarantee that the fracture will heal.
Result: Defense verdict.
Takeaway: Scaphoid fractures are often occult, only appearing on x-ray 10-14 days later. Non-union is common, more often in the distal 2/3 of the scaphoid. Snuff-box tenderness is an important clue. If absent, that should be documented. Even if absent, immobilization in a thumb spica splint and follow-up is the best approach. Always tell the patient of the possibility of an occult fracture and recommend a follow-up x-ray if not improving. Nice review ->
Let the patient tell their story. Then believe them.
Chest pain complaints deserve your attention
Hallmark v. Shipman et al. - Walker County, AL Facts: A 40 yo male develops nausea after breakfast, continues to feel ill for 2 days and presents to the ED when he also developed some chest pain, thinking that he might be having a heart attack. Nurses document the chest pain. The doctor does not. An EKG is not mentioned in the case report. No cardiac enzymes are done. He is discharged about 4 hours later with a diagnosis of a stomach virus, but with continuing complaints suggesting heart problems. Two days later he develops severe chest pain, collapses and his wife calls 911. He is pronounced dead at the hospital after a failed resuscitation.
Plaintiff: You told me my heart attack was just a stomach virus. You should have at least considered the possibility that I was having a heart attack. You didn’t even check my cardiac enzymes.
Defense: You really did have a stomach virus. The heart attack came later. I met the standard of care.
Result: Jury verdict for $4 million
Takeaway: Listen to the patient’s history. Read the chief complaint, triage note and nurses’ notes. If you see or hear the words “chest pain,” either work up the patient or document why you chose not to. Ditto if you disagree with the nurses' notes. “Critical thinking” is what physicians get paid to do. Don’t anchor on your first impression.
[Editor's Note: Oddly, Alabama law allows only punitive damages, allegedly "to punish the wrongdoer and deter others from committing the same or similar errors." Unless we physicians actually learn something from these cases, the goal of both Alabama law and most plaintiffs will never be met. Thus, the origin of "Medical Malpractice Insights."]
Transfer expeditiously when indicated. Communicate plans and progress
9 yo dies of ruptured AV malformation
Quinde et al v. Clara Maass Medical Center et al. - Essex County Superior Court, New Jersey No. ESX-L-6760-09 Facts: A 9 yo girl is taken by ambulance to the local ER after a sudden loss of feeling in her face, weakness in her legs, and a headache. She begins seizing on arrival but remains able to localize pain. Evaluation by an emergency physician and pediatrician reveals the presence of an intracerebral hemorrhage with increased intracranial pressure on CT scan. She has a cardiac arrest about 3 hours after onset, is resuscitated and transferred to a peds neurosurgery hospital a bit over 4 hours after onset. On arrival there she has fixed, dilated pupils. Brain death is confirmed. Autopsy reveals a ruptured AV malformation. All but the emergency physician either settle or are dismissed before trial.
Plaintiff: The CT scan clearly showed a condition which you and your hospital were not equipped to treat. You failed to treat me appropriately after the CT scan. For over 2 hours you delayed transfer to a hospital that could treat me.
Defense: Your death was the result of a pre-existing condition. My care was appropriate and consistent with the standard. The pediatrician [who settled before trial] was in charge of the transfer, not me. The transfer was delayed because the receiving hospital at first refused to accept you. And the ambulance with whom our hospital contracts was delayed.
Result: After a 9 day trial and 2 days of deliberation, a jury awarded $497,686 in damages. That award was reduced by half to $248,843 because the death was 50 percent attributable to a pre-existing condition.
Takeaway: When you and your hospital are unable to treat a problem, expeditious transfer is key. Even more important is good communication with the patient and family about the gravity of the situation and the steps you are taking to arrange appropriate care.
[Editor's Note: That the defense was unable to mitigate this case on “causation” is rather shocking, especially when arguing over a delay of 1-2 hours in a critically ill patient with a catastrophic condition. Also, given that the case involves the death of a 9 yo girl, the award seems small. Maybe this indicates some jury sympathy for the physician.]Source ->:
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Charles A. Pilcher MD FACEP, Editor Medical Malpractice Insights
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