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High‐risk Cases in Emergency Medicine: Part 1

Kevin M. Klauer, DO, EJD, FACEP

Chief Medical Officer, EMP, Ltd.

Medical Editor‐in‐Chief, ACEP Now

Speaker, ACEP Council

Asst. Clinical Professor, MSU College of Osteopathic Medicine

The information provided in AHC Media Webinars does not, and is not intended to constitute medical or legal advice. Opinions, references and links provided by our speakers are provided for your convenience and do not represent our endorsement of such opinions, products or services.

Thursday, November 6th, 2014

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SpeakerDr. Kevin Klauer is the Director of the Center for Emergency Medical Education and the Chief Medical Officer for Emergency Medicine Physicians, Ltd., based in Canton, Ohio.  He also is the Director of EMP’s Patient Safety Organization.  He serves on the Board of Directors for Physicians Specialty Limited Risk Retention Group. He is an Assistant Clinical Professor at Michigan State University College of Osteopathic Medicine.   He has received the EMRA Robert Dougherty ACEP/EMF Teaching Fellowship and also the ACEP's National Emergency Medicine Faculty Teaching Award. He was most recently recognized by the Ohio Chapter ACEP with the Bill Hall Award for service.  Dr. Klauer is the co‐author of two risk management books: Emergency Medicine Bouncebacks: Medical and Legal and Risk Management and the Emergency Department: Executive Leadership for Protecting Patients and Hospitals.

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1. Discuss strategies to identify high-risk features of clinical entities in emergency medicine.

2. Develop strategies to improve patient safety.

3. Review ways to reduce professional liability in the practice of emergency medicine.

Learning Objectives

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Diederich Healthcare

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The Current Malpractice Climate

• Claims Frequency

• 1/26,800 ED visits

• Indemnity

2002:  $80,000

2013:  $163,000

2013 ASHRM Hospital ProfessionalLiability Benchmark Analysis 

Future claim severity expected to increase 4% annuallyLoss Rate for 2014: $6.16

The Genesis of Risk

Unhappy PatientsUnhappy Patients

Bad Outcomes

Bad Outcomes

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Important Tools

• Stop Diagnosing

• Scheduled ED re‐evaluations

• Discuss testing limitations

• Testing responsibility

• No Fly Zone

• Atypical Chest Pain

• Anxiety

• Constipation

• Gastroenteritis

• Atypical Migraine

• Teething?

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Important Tools

• Stop Diagnosing

• Scheduled ED re‐evaluations

• Discuss testing limitations

• Testing responsibility

• No Fly Zone

• Atypical Chest Pain

• Anxiety

• Constipation

• Gastroenteritis

• Atypical Migraine

• Teething?

High Risk Entities

• Pulmonary Embolism

• TIA

• tPA for Stroke and Consent 

• Appendicitis

• Intussusception

• Thoracic Aortic Dissection

• Interruptions

Pulmonary Embolism

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Case History

• CC: “Chest Pain”• HPI: 34 y/o female presents to the ED

complaining of right sided chest pain which began 3 hours prior to arrival. No trauma.

• PMHx: None• Meds: None• No cough. No SOB. Pain is pleuritic

Exam

• VS: BP: 118/78, RR: 20, HR: 76, T: 98.7, Pox: 97%

• LS: Clear to auscultation“Right Inframammary tenderness”

• Legs: No clubbing, cyanosis or edema

• Neuro: Normal

ED Course

• Chest radiograph: Normal

• ECG: Normal

• Ibuprofen 600 mg PO

• Oxycodone/Acet PO

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Impression/Plan

• Dx: Musculoskeletal chest pain

• Rx: Ibuprofen and Oxycodone/Acet

• 7 day follow up with PCP

• Discharge

Outcome

• PCP follow up in 7 daysNo change in treatment

• Consult 3 days later

Outcome

• PCP follow up in 7 daysNo change in treatment

• Consult 3 days later

Pathology

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Outcome of Claim

• Emergency Physician released

• Hospital and PCP remain

THE PULMONARY EMBOLISM RULE‐OUT CRITERIA (PERC) RULE DOES NOT SAFELY EXCLUDE PULMONARY EMBOLISM Hugli, O., 

et al, J Thromb Haemost 9(2):300, February 2011

• 1,675 Pts (outpts) being evaluated for PE

• 13.2%:  PERC Negative

• 85.1%:  Low pretest probability per Geneva

• PE:  21.3%

• 5.4% of the PERC Negative Group

• 6.4% of PERC Negative and Low probability

Incidence, Timing & Vulnerability of Pregnancy

• VTE:  0.76‐1.72 per 1,000 pregnancies

• 4X risk of non pregnant population

• 2/3rd DVT:  Antepartum (evenly distributed)

• 43‐60% of pregnancy related PE occur in puerperium

• PE is the leading cause of maternal death in developed nations

1.1‐1.5 per 100,000 deliveries

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Incidence, Timing & Vulnerability of Pregnancy

• VTE:  0.76‐1.72 per 1,000 pregnancies

• 4X risk of non pregnant population

• 2/3rd DVT:  Antepartum (evenly distributed)

• 43‐60% of pregnancy related PE occur in puerperium

• PE is the leading cause of maternal death in developed nations

1.1‐1.5 per 100,000 deliveries

50% of events occur in 

the first 20 weeks

Puerperium 

RR = 20

PERC

• < 50 years

• HR < 100 beats per minute

• Room air oxygen saturations greater than 94%

• No prior deep venous thrombosis [DVT] or PE

• No recent surgery or hemoptysis

• No exogenous estrogen

• No clinical signs suggestive of DVT

No D‐dimer!

Pregnant Patients Were Excluded From Their Derivation Study

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Clinical Features of Patients With PulmonaryEmbolism and a Negative PERC Rule ResultJ. Kline, D. Slattery1880 with PE:  All 8 (parameters) Neg in 6%None of these died at 30 days (v. 108)3 Factors Associated with PERC Neg PE

Pleuritic CP, Pregnancy, Post Partum

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TIAs

Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA.

2000 Dec 13;284(22):2901-6.

• Patients discharged with Dx of TIA

• At 90 days 10.5% returned with a stroke

• 50% of those were within the first 48 hours

• Predictive factors

Age > 60 DM

Speech Sx > 10 minutes

Weakness

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Uchiyama S. Brain Nerve. 2009 Sep;61(9):1013‐22.Transient ischemic attack, a medical emergency

• “A medical emergency”

• Acute Cerebrovascular Syndrome (ACVS)

Stead, L.G., et al. An Assessment of The Incremental Value of The ABCD2Score In The Emergency Department Evaluation of Transient IschemicAttack, Ann Emerg Med 57(1):46, January 2011.

• 637 TIA Pts

• ECG, CT, Labs and Carotid Doppler, Observation Unit

• ABCD2 Score

• 2.4% at 90 days

• 7 days:   1.1,% 0.3%, 2.7%

• 90 days: 2.1%, 2.1%, 3.6%

Mullins et al. CT and Conventional and Diffusion‐weighted MR Imaging in Acute Stroke:Study in 691 Patients at Presentation to the Emergency Department Radiology August2002

• Imaging < 6 hrs after ED Presentation

• CT:  40% Sens

• DW MRI:  97% Sens

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The National Jury Verdict Review and Analysis (48725) Massachusetts

20-year-old plaintiff to suffer permanent and severe cognitive dysfunctions.Series of TIAsAphasia/Difficulty understanding/Difficulty in movingED in BostonCT and LP NormalNeurologist: Consulted by phoneDx: Atypical Migraine2 days later: Primary care physician Dx Migraines2 days later: Aphasia and Rt sided hemiplegia1 day later: Massive strokeDx: Carotid dissectionLawsuit: Neurologist and Primary care physician

The National Jury Verdict Review and Analysis (48725) Massachusetts

20-year-old plaintiff to suffer permanent and severe cognitive dysfunctions.Series of TIAsAphasia/Difficulty understanding/Difficulty in movingED in BostonCT and LP NormalNeurologist: Consulted by phoneDx: Atypical Migraine2 days later: Primary care physician Dx Migraines2 days later: Aphasia and Rt sided hemiplegia1 day later: Massive strokeDx: Carotid dissectionLawsuit: Neurologist and Primary care physician

$1,000,000 Judgment

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Standard of Care ArgumentIs Informed Consent Required?

Incapacitated Patients

Likelihood of Litigation

• 95%:  Lawsuits from not giving tPA or not diagnosing stroke

• 5%:  From complications

• Just as likely to get sued for giving it as you are for not giving it

Many more are not given the drug 

Much larger pool

% tPA = % no tPA will result in lawsuits

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Community Hospital/EP/Hospital

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Appendicitis

Case History

• 5 yr old male with 3 hours of generalized abd pain since 1 hour after dinner tonight, V x 2 twice, no fever, no diarrhea. No assocsymptoms.

• VS‐ 99.1/110/24  BP‐ 101/58

• PE‐Abd‐ +BS, mild epigastric tenderness, no rebound

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Case History

• Diagnosis: Gastroenteritis

• Instructions: 

Vomiting Sheet

Flu sheet

Follow up with PMD tomorrow

Case History

• Day 2‐ To the PMD’s office

• “Pt with abd pain for 15 hours, V X 2, seen in the ED last night diagnosed with the flu”

• No vitals at PMD office

• Exam‐ “abd slightly tender, pt appears ill”

• Plan‐ CBC, 3 way abdominal films

Case #9

• Day 2‐ To the PMD’s office

• “Pt with abd pain for 15 hours, V X 2, seen in the ED last night diagnosed with the flu”

• No vitals at PMD office

• Exam‐ “abd slightly tender, pt appears ill”

• Plan‐ CBC, 3 way abdominal films

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Case History

• Day 2 evening‐ Back to the ED

• Resident exam‐ pt here last night, PMD today, abd pain for 24 hours, x‐rays and labs done today, V X 3 today, felt warm today, taking sips of fluid, no BM today, points to belly button as area of tenderness.

• VS‐ 100.5/130/28/ 105/51

Case History

• Resident exam

• Pt sitting on bed, appears tired, but in no distress

• Abd‐ some tenderness in epigastrium, no HSM, no masses, dec BS noted, no CVA tenderness

• Attending note‐ “Agree with above”

Case History

• Disposition

• Diagnosis‐ Gastroenteritis

• Plan‐ vomiting sheet, clear fluids for 24 hours, F/U PMD 3 days

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Case History

• The next AM

• Pt has a restless night, c/o pain all night, at 11am the pt is unable to be aroused, parents call 911, the pt codes on the way to the ED

• Autopsy shows perforated appendix and blood CXs grew Strep

• Case settles after depositions, but before trial

Rothrock & Pagane ACUTE APPENDICITIS IN CHILDRENANNALS OF EMERGENCY MEDICINE 36:1 JULY 2000

• The most common non‐traumatic surgical disorder in children > 2 yrs

• Dx:  1‐8% of children presenting to pediatric EDs with CC of Abd pain

• Perforation:  <15% in adolescents, but nearly 100% in children < 3 yrs

• 11% more:  May‐August:  Association with enteric infections

Rothrock & Pagane ACUTE APPENDICITIS IN CHILDRENANNALS OF EMERGENCY MEDICINE 36:1 JULY 2000

• Genetic Predisposition (1st degree):  RR 3.5‐10.0

• 50th percentile for fiber intake = 30% reduction in likelihood

• 10%‐36%:  Report prior similar symptoms

• Diarrhea:  9‐16%

• Constipation:  5‐28%

• Dysuria:  4‐20%

Pain with Movement1. Cough sign 95% 2. Cat’s eye sign 80%3. Heel drop sign 93%

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Rothrock & Pagane ACUTE APPENDICITIS IN CHILDRENANNALS OF EMERGENCY MEDICINE 36:1 JULY 2000

• Increased Incidence

Viral outbreaks (Mumps, Coxsackie and Adenovirus)

Amebiasis

Bacterial enteritis

• Infectious etiology for appendicitis?

• Extended Breast Feedings

Milk‐induced alteration of the immune response

Lymphoid tissue at the base of the appendix less reactive

May limit exposure to other dietary risks

Rothrock & Pagane ACUTE APPENDICITIS IN CHILDRENANNALS OF EMERGENCY MEDICINE 36:1 JULY 2000

• Initial misdiagnosis rates range from 28% to 57% for children 12 years old or younger

• Nearly 100% for those 2 years or younger

Table 1.Initial misdiagnoses in childhood appendicitis.Misdiagnosis % of CasesGastroenteritis  42 Upper respiratory tract infection*  18 Pneumonia  4 Sepsis 4 Urinary tract infection 4Encephalitis/encephalopathy  2 Febrile seizure  2 Blunt abdominal trauma  2 Unknown  22*Includes diagnoses of otitis media, sinusitis, pharyngitis, and upper respiratory tract infection. From Rothrock SG, Skeoch G, Rush JJ, et al. Clinical features of 

misdiagnosed appendicitis in children. Ann Emerg Med. 1991;20:45‐50.

Gastroenteritis?!

• McKerzie v. Barnes Hospital 1995 MO• Wozniuk v. Kitchin 1997 GA• Klug v. Ramirez 1992 TX• Birkett v. Kasulke 1983 NY• Green v. Dupre 1987 LA• Granbury Minor Emergency Clinic v. Thiel

2009 LA

• Stringer v. Trapp 2010 MS

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Medical MythA digital rectal examination should be performed on all individuals withpossible appendicitis West J Med. 2000 September; 173(3): 207–208.

• Children:  1/3 Severe Discomfort

“Major crying and screaming”

Another 1/3:  “Mild discomfort” Facial grimacing or crying

• 1979 (Bonello):  46% False – and 53% False +

• 1991 (Dixon, largest study)

1204:  85% rectal examinations

No difference in management

Intussusception

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Case History

• HPI

15‐yr‐old male

Lower abdominal pain, cramps and vomiting for 3 hours

• Physical examination

BP:  120/64; HR:  122; RR:  24; T:  100.1

Abdominal:  Soft, right mid abdominal tenderness, hyperactive bowel sounds

Case History

• DiagnosticsLaboratory:  WBC 12.5, BMP, Lipase, UA all normal

• ED CourseIV fluids

Phenergan 12.5 mg IVP

Morphine sulfate 4 mg

Condition improved but not abd reassessment

Discharged after 4 hours

Dx:  Gastroenteritis and Dehydration

Case History

• Outcome

Return visit at 1130 pm (approx 18 hours after discharge)

Cardiopulmonary arrest and pronounced at 1145 

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Case #11

• Outcome

Return visit at 1130 pm (approx 18 hours after discharge)

Cardiopulmonary arrest and pronounced at 1145 

Intussusception

• Leading cause of intestinal obstruction in infants

3 – 12 mo

• Ileocolic is most common

Small bowel:  ileoileal via the ileocecal valve and continues into the colon (poss rectum)

Sausage shaped mass in Rt Abd 2/3

• Colocolic:  Rare

• Infants:  Hypertrophied Peyer’s Patches

Lead Point

Intussusception• > 2 yrs:  Alternative lead point

Meckel’s, Polyp, Duplication or Tumor

• Frequently preceded by daysDiarrheal illnessViral Syndrome/URIHenoch‐Schönlein Purpura

• Classic triad (20%)1. Colicky abd pain 2. Vomiting3.  Rectal bleeding

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Intussusception

• Colicky/Episodic abdominal pain

• Gradual irritability, anorexia and may vomit

• May appear well 

• May be lethargic/listless

• Partial or complete SBO with gen distension

• Mass may be noted in RUQ

• 50%‐75%:  occult blood

• Lack of blood does not exclude the Dx

• Four classic x‐ray findings / target sign, crescent sign, absent liver edge sign, bowel obstruction

Currant Jelly Stool 50%• Mesenteric vein compression

• Arterial supply preserved

• Increased pressure = Currant jelly stoolSpontaneous; or

Rectal exam

• Increased pressure = Arterial compromise

• Bleeding reduces

• Bowel ischemia occursPerforation

Intussusception 

Med‐Challenger • EM

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CT Scan -- Intussusception

US Study -- Intussusception

Sensitivity for ileocolic intussusception = 98% / Specificity, 98%

Management

Diagnosis: plain x-ray, ultrasound, barium enema (“coiled spring” sign)Treatment: air contrast enema, surgery

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Thoracic Aortic Dissection

Case #12Aortic Dissection Mimicking SAH

Nohe Anesth Analg 2005

• Case report 63 y.o. female with sudden onset excruciating headache, severe arterial hypertension, syncope, and coma.

• Initial head CT and angiography normal

• Intubated, ICU, neurology consult, anticoagulation

• 8 hrs later, 2nd CXR showed widening of the mediastinum

• Immediate surgical aneurysm repair with good recovery without sequelae.  

Neurological

Gaul C, et al. Neurological symptoms in aortic dissection: a challenge for neurologists. Cerebrovasc Dis. 2008;26(1):1‐8. 

• Neuro Sxs at Onset:  17%‐40%• Pain Free Dissection:  5%‐15%Stroke. 2007 Feb;38(2):292‐7.• Type A• 102 Consecutive Pts• 29% had Neurological Sxs• Only 2/3s had Chest Pain

Neuro Sxs?+ Diastolic Murmur = Dissection

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Hansen M, et al. Frequency of and inappropriate treatment of misdiagnosis of acute aortic dissection. Am J Cardiol. 2007 Mar 15;99(6):852‐6.

• 66 Consecutive Cases

• Misdiagnosis:  39%

• ACS Most Common MisdiagnosisASA 100%

Plavix 4%

Heparin 85%

Thrombolytics 12%

• Major Bleeding:   38% v. 13%

• Mortality:   27% v. 13%

INTERRUPTIONS

Chisholm CD, Collison EK, Nelson DR, Cordell WH Emergency department workplace interruptions: are emergency physicians "interrupt‐driven" and "multitasking"? Acad Emerg Med. 2000 Nov;7(11):1239‐43.  30.9 & 20.7 

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Case History

• 48 year old white female

• CC:  Left upper back pain

• HPI:  3 hours, acute onset, non‐reproducible to palpation but slightly worsened by ROM

• Assoc:  Pleuritic

• PSHx:  No ETOH, ½ ppd Tobacco history

Case History

• CBC, Urinalysis, BMP, Troponin I negative

• ECG SR without ectopy or ischemic changes

• CT Pulmonary angiogram:  Negative 

Case History

• Disposition

• Discharged 

• 3‐5 Day follow up

• Rx:  Ibuprofen and Vicodin

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Case History

• Died 26 hours after discharge

Case History

• Claim Filed

• Settlement on behalf of the physician

• $750,000

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This presentation is intended solely to provide general information and does not constitute legal advice. Attendance at the presentation or later review of these printed materials does not create an attorney‐client relationship with the presenter(s). You should not take any 

action based upon any information in this presentation without first consulting legal counsel familiar with your particular circumstances.

Thank you for attending!

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