Medical Malpractice Bulletin – December, 2012

Perspective: Must physicians do a lumbar puncture on every suspected subarachnoid hemorrhage?
Charles A. Pilcher MD FACEP

Classic medical training has been to do a lumbar puncture (LP) on every patient with a new, sudden onset headache if a CT scan does not show a suspected subarachnoid hemorrhage (SAH), usually from a ruptured cerebral aneurysm. That wisdom has been challenged by a presentation at the 2012 ACEP Scientific Assembly, by Dr. Ashley Shreves and Dr. David Newman. They found that for every  SAH one might find on LP, one would have to do 700 such procedures, with the risks accompanying those procedures. Continued ->

Whiplash: To treat or not to treat, that is the question.
What interventions help patients with acute cervical strain? The condition, commonly referred to as “whiplash,” is most often the result of a rear end motor vehicle crash The question has been debated for years. Chiropractors and physical therapists insist that frequent, and often prolonged, treatment is helpful. Others are more skeptical. In a recent review of 3851 patients published online in Lancet, Dr. Sarah Lamb and colleagues found that “active management” was no different than “usual care” in shortening the course or reducing the disability from such injuries. “Active management” included multiple sessions with a physical therapist. “Usual care” included one session of advice from a PT, then simple home care with NSAIDS, rest and time. The outcomes were not significantly different between the two groups. This is in line with an earlier study by Kongstad et al. “The extra and more costly treatments do not speed recovery” says Dr. Lamb. “What is more, although additional physiotherapy, beyond a single advice session, did offer a modest short-term benefit, it was not cost-effective.” A summary of Dr. Lamb’s recent study is available on Health Day.

The cost of defensive medicine
Jackson Health Care recently published a paper on the costs of defensive medicine. The authors goals for the study were: 1) To voice physicians’ growing concerns over the negative impacts of defensive medicine, and the way it is affecting their relationships with their patients, and 2) to encourage physicians, patients, attorneys and state and federal representatives to work together to find a solution that eliminates defensive medicine practices, protects physicians from frivolous lawsuits, penalizes true malpractice and compensates patients for negligent care. To view the entire report, click here. In 2011 ACEP surveyed over 20,000 emergency physicians. Nearly 10% responded and of those, 53% believed see Question #12 that “defensive medicine” was the main reason emergency physicians order the number of tests that they do. [Editor’s Note: My personal experience over 35+ years of practice is consistent with most studies that place the average cost of defensive medicine at somewhere in excess of 25% of our health care costs. However, if a doctor **truly** ordered an unnecessary test, such practice would fall below the standard of care, be unethical, and lead to a valid claim of medical malpractice.]

On being an expert
One of the honors of being an expert witness is the opportunity to learn from the mistakes of others rather than from my own. Over the years I have compiled my own short list of “rules of the road” for the practice of emergency medicine. A few of these were learned the hard way in my own “school of hard knocks,” the rest from a variety of cases I have reviewed, or from the experiences of colleagues. Here’s the short list:
* All chest pain is a PE or AAA/Dissection until proven otherwise.
* C-spines CAN be cleared clinically and reliably, but document it.
* Missing an appy is OK if you evaluate for it and give good discharge instructions.
* Back pain evaluations should always r/o an epidural abscess
* If on Coumadin, patients with any blunt head trauma deserve a CT scan
* NEVER send a patient out in a wheelchair if you haven’t watched them walk.
* All vertigo is a posterior stroke till proven otherwise.
* Youth is no barrier to a heart attack, stroke, pulmonary embolus or aortic dissection
* A battery of tests will never compensate for a poor history (or failure to read the nurse’s notes)
* Every wrist sprain is an occult navicular fracture and should be treated as such.
* Shoulder trauma with legitimate severe pain and a negative x-ray must still have a posterior dislocation ruled out.
* Every patient with a both-bone fracture of the lower leg must be warned about compartment syndrome symptoms.

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