Medical Malpractice Insights: Take a history. Do an exam. Don’t jump to conclusions.

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

This month’s case illustrates basic clinical medicine. Take a history. Do an exam. The patient will tell us all we need to know (most of the time). Doing it right the first time means we don’t have to do it over – or spend 5 years in litigation.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

“But why does my leg hurt so bad, Doc?”

Take a history. Do an exam. Don’t jump to conclusions.

Facts: A male truck driver in his early 40’s is struck in the medial left calf while playing semi-pro football. About a week later, he experiences increasing pain, swelling, bruising, heat, redness and tenderness from his knee to his ankle. The pain worsens over the next week to the point that he is unable to walk. He seeks relief by soaking in a warm tub. His wife hears him screaming in pain, finds him on his hands and knees in the bathtub, and takes him to the ED. He requires a wheelchair from the car to the triage area. In addition to the above symptoms, his wife reports that he had a fever of 102 degrees 2 days earlier. The triage nurse records only “Ankle injury. Injury to L calf 2 weeks ago.” An electronic T-chart for “ankle injury” is begun. Before even seeing the patient, the EP orders an ankle x-ray – based on the triage note. The radiologist reports significant medial calf swelling and a small accessory ossicle on the medial malleolus. The EP then sees the patient and documents nothing about the calf injury 2 weeks earlier. His exam records only lateral ankle tenderness and nothing in the T-chart box for “calf exam.” Oddly, a normal HEENT exam IS documented. The EP informs the patient that he has a “chip fracture” of the (non-tender) medial ankle, applies an air splint and discharges him with instructions regarding ankle injuries. Four days later he is hospitalized and undergoes surgery for an extensive medial calf abscess. An attorney is consulted and a lawsuit filed.

Plaintiff: I was in so much pain I couldn’t even think. I told the triage nurse about my football injury and how the pain developed gradually. You never asked me how it happened. I got hit with a football helmet on my calf. I never twisted my ankle. It was really more of a bruise and a scrape. If you had examined me, you would not have missed my swollen calf because I was wearing shorts. You misinterpreted a medial malleolar accessory ossicle as a chip fracture, and that wasn’t even where I hurt. I couldn’t walk, I needed a wheelchair, you never checked my gait, and I left in a wheelchair. You made up your mind when you saw the x-ray report, before you even met me. You didn’t take a history or do a decent exam. I had a calf abscess. You missed it. Because of that I spent nearly a week in the hospital and was out of work for months.

Defense: I took a history; I just didn’t record it. If you were wearing shorts, there was no way I could have missed that. I didn’t think the calf was the problem. Your history, symptoms, and exam were consistent with an ankle injury. My care was appropriate. Other ED staff all deny seeing any calf abnormalities.

Result: After 5 years of litigation and a 6 day trial, the jury sided with the defense, believing that if the leg was as bad as the plaintiff claimed, someone would have noticed.

Takeaways:

• Read triage and nursing notes but be aware that they can be wrong, incomplete, and/or misleading. Both the calf and the ankle were mentioned at triage in this case.
• Take your own history from the patient – and any other source in the room.
• Examine the patient.
• If your history and/or exam differ from that of a nurse, address the differences in your documentation.
• Don’t make up your mind before seeing the patient or base decisions on previous assumptions. That’s “anchoring bias” (i.e., “I know what you have before I see you.”)
• Don’t let lab or imaging reports overly influence your own judgement. When you’re already latched on to an ankle sprain, an abnormal x-ray, even in the wrong location, does not mean you’re right. “Confirmation bias” makes us think we’re smarter than we really are.
• “Anchoring bias” plus “confirmation bias” leads to “premature closure.” That’s “making a diagnosis before you have all the facts.”
• Don’t be misled by radiology “hedges” but pay attention to incidental findings. Put them in context and inform the patient.