By Keri Gardner, M.D., MPH, FACEP
National Director of Quality & Patient Safety, Regional Medical Director
As we closed out 2014, we looked back on our medical malpractice lawsuit experiences and saw that there were definitely some common themes. Troponins and TPA have definitely been prominent in this year’s malpractice claims. I will share three practice pearls with you so that this knowledge may help you as avoid one of these distressing events in the new year.
- Evaluation of chest pain
- Stroke treatment and TPA
- Imaging of injuries
Evaluation of Chest Pain
With the advent of the ultrasensitive troponin, our evaluation of patients with chest pain is changing—but the literature is way behind practice, and let’s face it, coronary artery disease is still a major disease in the American population. A full-time emergency physician is seeing hundreds of patients with chest pain a year, so even if the rate of missed MI is 1% or less, you have tremendous exposure on this complaint. A risk proof practice of medicine in this regards means understanding which troponin your lab is using, and partnering with your local cardiology group to establish which rule out protocol they are using and then following it. What if you don’t have a local cardiologist to work with? No problem. Develop your own protocol for your group in conjunction with your hospitalist group and other admitting physicians.
We see so many patients with chest pain and studies show some of them are going to infarct and die in the next 48 hours. Whether you are doing 2-hour delta troponins, or 6-hour repeat troponins, or a troponin 8 hours after their pain started, make sure that you are following some protocol you can reference—and ensure that their EKGs have no changes from normal or from their prior ECG. When you send them home, consider starting a daily aspirin and recommend follow up within 1-2 days.
Stroke Treatment and TPA
Any controversial element of medicine is a gift to attorneys that keeps on giving because no matter what you do, someone will argue that you are wrong and have literature to back them up. Does this mean that we throw up our hands and say that it is hopeless? No! We just have to be at least as clever and savvy as the attorneys that are going to look at the case long after the medical record leaves our hands.
Let’s consider the case of ischemic stroke. Since stroke can be a devastating disease, make sure that you evaluate any neurologic complaints completely and document a thorough neurologic exam. When stroke is suspected, cover all your bases. First: Get the labs and head CT done immediately. Second: establish a time of onset with the patient and family and document it. Third: Count the number of hours since onset, see if you are in a 3 or 6 hour window, and do all the currently recommended therapy for stroke that is not controversial (aspirin, etc.) Home: discuss the TPA options with the patient and family. Share your recommendations with them and share the opinion of whomever is the closest neurologist that you get on the phone—and then document the decision and why.
Imaging of Injuries
My last pearl of 2014 is regarding imaging studies of injuries. Just when everyone is telling us to do fewer studies, I am going to recommend that you may need to do more. Have a low threshold for imaging lacerations. If it was a kitchen knife that sliced the pad of a finger, then an X-ray is unlikely to be helpful. But a chainsaw tearing into a hand may have caused a bony injury or a jagged laceration to the leg from falling in the woods may contain a foreign body—both are examples of good injuries to X-ray. And when you finish suturing, make sure you pick up all your sharps, lest you find yourself in the position of having a patient show up a few days later with a suture needle that mysteriously appeared in the wound.
In this Winter season of giving gifts, I hope that you will give one to your future self by having your charts reflect the excellent care and decision-making that go into each of your patient encounters. Doing so doesn’t just help you defend your care before a jury, it stops attorneys from being willing to take the case at all.