Do ER docs face unfair legal risk, given ER chaos and the urgency of patient decisions?
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“The most important thing is that there’s a neurological exam right away. Even if you’re neurologically intact and it’s a severe injury, [you] get a CT scan right away. This is the trauma protocol. [But] in the ER, there are a million other things happening. Unfortunately, things can be overlooked.” — Neel Anand, MD, MCh Orth, a board-certified orthopedic spine surgeon
“Even for the most seasoned among us … it is sometimes difficult to catch everything. In those moments, we can only hope that we have a robust training to fall back on and make the right decisions for each patient that walks through the door of the ER.” — Ken Perry, MD, FACEP, emergency physician
After a patient’s chiropractic neck adjustment led to a brainstem stroke, ultimately resulting in locked-in syndrome, a Georgia court awarded the plaintiff $75 million in damages—the largest medical malpractice verdict in the state’s history. []
When the 32-year-old patient collapsed at his chiropractor’s office, he was brought to the emergency room, where physicians failed to urgently and appropriately diagnose and treat him, the patient’s attorneys alleged.
Court documents say the ER physician failed to tell the neurologist that a CT angiogram of the neck had been performed and that the patient had seen a chiropractor. []
“His attorneys argued that the care team failed to reach a definitive diagnosis until the patient’s second day in the hospital. During the protracted wait, Buckelew’s brain was so severely damaged that he is now permanently stricken with ‘locked-in syndrome,’ rendering him unable to feel or control any voluntary muscle groups except those of his eyes,” Radiology Business reports.
The case has spurred dialogue across the medical industry, with physicians turning to Reddit forums to discuss.
As one hospitalist with the username “lilbelleandsebastian” wrote on a forum in the Medicine Reddit, “I don't know the details of the OP's case, seems an awful shame that a chiropractor paralyzed someone and two downstream physicians took the hit. These are just some of the other real-world factors that I didn't really consider in training but think a lot more about now as a community attending.”
Physician perspectives on properly diagnosing patients amid ER chaos
So, how do ER physicians make quick and accurate patient decisions—especially with neck injuries like this one—with the ER being so chaotic?
According to Neel Anand, MD, MCh Orth, a board-certified orthopedic spine surgeon and Director of the Cedars-Sinai Spine Center in Los Angeles, when patients present with a neck injury in the ER, there isn’t room for error.
“The most important thing is that there’s a neurological exam right away," Dr. Anand says. "Even if you’re neurologically intact and it’s a severe injury, [you] get a CT scan right away. This is the trauma protocol.”
But in the ER, mistakes can happen. “In the ER, a million other things are happening. Unfortunately, things can be overlooked. It’s not common, but I can see that happening,” Dr. Anand says. Ryan Marino, MD, an emergency physician and associate professor at Case Western Reserve University School of Medicine, agrees.
“Because it can be so busy and so chaotic, and because patients can present differently, outside of the typical patterns, it does remain a constant challenge,” Dr. Marino says.
The ER life, says Ken Perry, MD, FACEP, an emergency physician, simply isn’t for the faint of heart. “The ER is a comfortable place for a small subset of physicians. Those of us who find a sense of zen when the world is seemingly out of control gravitate toward the ER," he says. Even for the most seasoned among us, however, it is sometimes difficult to catch everything.
"In those moments, we can only hope that we have a robust training to fall back on and make the right decisions for each patient that walks through the door of the ER,” Dr. Perry says, noting that he doesn’t know all the particulars involved in this case.
Stacy Lee, JD, Professor of Practice in Law & Ethics at Johns Hopkins Carey Business School, says that courts need to take greater account of emergency department realities when evaluating malpractice claims.
"The fundamental issue lies in how the ‘standard of care’ is interpreted in emergency settings. While the legal standard—what a reasonable, prudent physician would do under similar circumstances—remains appropriate, judges and juries often lack understanding of what ‘similar circumstances’ truly entail in emergency medicine,” Dr. Lee says.
Related: Malpractice premiums are rising: Here’s why, and what you can do