Medical malpractice: managing the risk.

STUDY OBJECTIVE: This is an attempt to present an analysis of the literature examining objective information concerning the likelihood of medicolegal errors as it applies to current medical practice. Hopefully this information will be synthesized to generate a cogent approach to manage risk in emergency medicine. METHODS: Articles were obtained by an English language search of MEDLINE from January 1976 to July 2003. This computerized search was supplemented with literature from the author's personal medicolegal collection of peer review articles. This information was presented in a qualitative fashion. RESULTS: There was a steady increase in both the incidence and the recovery amount of verdicts involving general malpractice litigation. There are clearly high-risk emergency medicine categories responsible for most malpractice events, involving such commonly encountered conditions such as chest pain, abdominal pain, pediatric fever, central nervous system (CNS) bleeding, and abdominal aortic aneurysm (AAA). Interestingly, there is a second peak of more minor emergencies, specifically wounds with neglected foreign bodies and missed fractures. Clearly, the largest dollar amount recovery still involves chest pain with subsequent missed transmural myocardial infarction (MI). Interestingly, there does not appear to be a strong correlation between adverse events, outcome and medicolegal risk. Likewise, there does not appear to be a strong correlation between socioeconomic status and a propensity to sue, but there were some defined links with physician profiles involving past malpractice history, as well as prior adverse relationships or communication skills to subsequent claims. Interestingly, a significant association appears to be advertising placed by local law offices seeking to provide services. Lastly in the emergency medical services (EMS) realm, the single strongest correlate to malpractice was the likelihood of an ambulance accident and not related to care delivered itself. CONCLUSION: The current emergency medicine medicolegal dilemmas are a complex interaction of both patient and physician factors specifically targeting several disease categories and damage claims. Awareness of these issues can help to minimize subsequent medicolegal risk and improve patient care.

Witnessed arrest, but not delayed bystander cardiopulmonary resuscitation improves prehospital cardiac arrest survival.

INTRODUCTION: This study correlated the effect of witnessing a cardiac arrest and instituting bystander CPR (ByCPR), as a secondary end point in a study evaluating the effect of bicarbonate on survival. METHODS: This prospective, randomised, double blinded clinical intervention trial enrolled 874 prehospital cardiopulmonary arrest patients encountered in a prehospital urban, suburban, and rural regional emergency medical service (EMS) area. This group underwent conventional advanced cardiac life support intervention followed by empiric early administration of sodium bicarbonate (1 mEq/l), monitoring conventional resuscitation parameters. Survival was measured as presence of vital signs on emergency department (ED) arrival. Data were analysed using chi(2) with Pearson correlation and odds ratio where appropriate. RESULTS: The overall survival rate was 13.9% (110 of 792) of prehospital cardiac arrest patients. The mean (SD) time until provision of bystander cardiopulmonary resuscitation (ByCPR) by laymen was 2.08 (2.77) minutes, and basic life support (BLS) by emergency medical technicians was 6.62 (5.73) minutes. There was improved survival noted with witnessed cardiac arrest-a 2.2-fold increase in survival, 18.9% (76 of 402) versus 8.6% (27 of 315) compared with unwitnessed arrests (p<0.001) with a decreased risk ratio of mortality of 0.4534 (95% CI, 0.0857 to 0.1891). The presence of ByCPR occurred in 32% (228 of 716) of patients, but interestingly did not correlate with survival. The survival rate was 18.2% (33 of 181) if ByCPR was performed within two minutes and 12.8% (6 of 47), if performed >two minutes (p = 0.3752). CONCLUSIONS: Survival after prehospital cardiac arrest is more likely when witnessed, but not necessarily when ByCPR was performed by laymen.

Prehospital cardiac arrest outcome is adversely associated with antiarrythmic agent use, but not associated with presenting complaint or medical history.

STUDY OBJECTIVE: This study associated survival from prehospital cardiac arrest to patient historical variables including presenting complaint, medications used, and medical history as a secondary end point in a trial evaluating the effect of bicarbonate administration. This raises issues concerning extensive prehospital historical assessment that may potentially delay care and transport. METHODS: This prospective multicentre trial enrolled 874 prehospital cardiac arrest patients encountered by urban, suburban, and rural emergency medical services. This group underwent conventional ACLS intervention followed by empiric early administration of sodium bicarbonate (1mEq/l). Survival was measured as the presence of vital signs on emergency department arrival. Data analysis used Student's t test, Fisher's exact test, chi2 with Pearson correlation, and logistic regression (p<0.05). Secondary end points were analysed including an association with common historical variables such as medical history, presenting complaint, or drugs used. RESULTS: The overall survival rate was 13.9% (110 of 793) of prehospital arrest patients. There was no correlation between historical factors, such as chief complaint or history of present illness (p = 0.277), medical history (p = 0.425), presence of specific disease conditions (p = 0.1125-0.956), or overall drug use (p = 0.002-0.9848). However, there was an adverse association between specific antiarrhythmic use (p = 0.003) and outcome. CONCLUSION: There is little relation of patient historical factors on the outcome from prehospital cardiac arrest raising issues of efficiency with history taking in prehospital care and transport.

Sodium bicarbonate in cardiac arrest: a reappraisal.

The routine use of sodium bicarbonate in patients with cardiac arrest has been discouraged, with the benefit of outcome evaluation. Current recommendations include an elaborate stratification of circumstances in which bicarbonate is to be used. The physiological and clinical aspects of bicarbonate administration during cardiopulmonary resuscitation in animal and human studies were reviewed. The onset of significant acidemia or alkalemia is associated with adverse system specific effects. The administration of bicarbonate may mitigate the adverse physiological effects of acidemia, improve response to exogenously administered vasopressor agents, or simply increase venous return due to an osmolar effect, resulting in increased coronary perfusion pressure. Likewise, bicarbonate may have adverse effects in each of these areas. The preponderance of evidence suggests that bicarbonate is not detrimental and may be helpful to outcome from cardiac arrest. An objective reappraisal of the empirical use of bicarbonate or other buffer agents in the appropriate "therapeutic window" for cardiac patients may be warranted.

Cardiac arrhythmia therapy.

Cardiac dysfunction is often manifested as arrhythmia, with disruption of the normal periodicity and regularity of electromechanical activity. The therapy for arrhythmia begins with proper diagnosis, since many pharmacological interventions are themselves arrhythmogenic. Intervention for acute arrhythmia involves correction of underlying systemic conditions by ensuring adequate oxygenation, ventilation, acid-base homeostasis, electrolyte balance, and fluid status. Classification of antiarrhythmic agents assists in a structured treatment approach that utilizes different agents based on the etiology of the arrhythmia and the drug's mechanism of action. A deliberate treatment strategy guided by the morphological criteria of the arrhythmia modified by the rate and duration of complexes, noting symptoms and hemodynamic stability, is desirable.

Sodium bicarbonate may improve outcome in dogs with brief or prolonged cardiac arrest.

OBJECTIVE: Despite the absence of outcome evaluation, the use of sodium bicarbonate in cardiac arrest has declined based on advanced cardiac life-support guidelines. The effects of bicarbonate therapy on outcome in a canine model of ventricular fibrillation cardiac arrest of brief (5-min) and prolonged (15-min) duration were examined. DESIGN: Prospective, randomized, controlled trial. SETTING: Experimental animal laboratory in a university medical center. SUBJECTS: Thirty-two adult dogs, weighing 10 to 17 kg. INTERVENTIONS: The animals were prepared with ketamine, nitrous oxide/oxygen, halothane, and pancuronium. Ventricular fibrillation was then electrically induced and maintained in arrest for 5 mins (n = 12) or 15 mins (n = 20). Canine advanced cardiac life-support protocols were instituted, including defibrillation, cardiopulmonary resuscitation (CPR), and the administration of epinephrine (0.1 mg/kg), atropine, and lidocaine. The bicarbonate group received 1 mmol/kg of sodium bicarbonate initially, and base deficit was corrected to -5 mmol/L with additional bicarbonate, whereas acidemia was untreated in the control group. Cardiopulmonary values were recorded at intervals between 5 mins and 24 hrs, and the neurologic deficit score was determined at 24 hrs after CPR. MEASUREMENTS AND MAIN RESULTS: The treatment group received an additional 2 to 3 mmol/kg of bicarbonate in the early postresuscitation phase. Compared with controls, the bicarbonate group demonstrated equivalent (with brief arrest) or improved (with prolonged arrest) return of spontaneous circulation and survival to 24 hrs, with lessened neurologic deficit. The acidosis of arrest was decreased in the prolonged arrest group without hypercarbia. Improved coronary and systemic perfusion pressures were noted in the bicarbonate group with prolonged arrest, and the epinephrine requirement for return of spontaneous circulation was decreased. CONCLUSIONS: The empirical administration of bicarbonate improves the survival rate and neurologic outcome in a canine model of cardiac arrest.

Cardiac arrhythmia diagnosis.

Cardiac dysfunction is often manifested as arrhythmia, with disruption of the normal periodicity and regularity of electromechanical activity. Cardiac arrhythmias, or abnormalities of cardiac rhythm, are associated with a diverse group of conditions, including congenital, metabolic, structural, physiological, and immunological, and infectious abnormalities. Dysarrhythmia may also be classified as primary because of endogenous electrical abnormalities, or secondary, because of exogenous influences such as ischemia or adrenergic stimuli. Clinical arrhythmia syndromes begin with a single asymptomatic abnormal complex that is benign, progressing to grouped, sustained complexes associated with worsened symptoms and outcome. Proper diagnosis of arrhythmia reflecting symptomology and outcome is essential in acute cardiac care.

Successful therapy for cerebral phaeohyphomycosis due to Dactylaria gallopava in a liver transplant recipient.

A 68-year-old liver transplant recipient who was being treated with FK 506 and immunosuppressive steroid therapy was admitted to our medical center because of a tonic-clonic seizure. Computed tomography of the head revealed multiple discrete cerebral abscesses, and culture of fluid drained intraoperatively yielded a dematiaceous fungus. The isolate was susceptible to amphotericin B and itraconazole but was resistant to flucytosine and fluconazole. The patient was successfully treated with a prolonged course of amphotericin B colloidal dispersion and itraconazole, as evidenced by both clinical and radiographic resolution of disease over a 2-year follow-up.

Acute adrenal insufficiency resulting from adrenal hemorrhage as indicated by post-operative hypotension.

We examined the incidence, diagnosis and therapy of acute adrenal insufficiency, secondary to adrenal hemorrhage. This insufficiency resulted in temperature irregularities. hemodynamic instability, and a large volume resuscitation requirement post-operatively. The case illustrates that a high level of suspicion should be maintained in a clinical scenario that mimics sepsis or myocardial insufficiency in the intensive care unit.

Compliance with emergency department referral: the effect of computerized discharge instructions.

STUDY OBJECTIVE: To examine the effect of computerized discharge instructions on emergency department patient referral recommendations. DESIGN: Prospective, descriptive analysis and clinical trial. SETTING: Emergency medicine residency-affiliated urban hospital with 568 beds and 29,000 annual visits. TYPE OF PARTICIPANTS: One thousand ED patients discharged to an outpatient referral network during a six-week period. INTERVENTION: Mandatory referral was provided in written or computerized (Logicare Corp, Eau Claire, Wisconsin) format for each 500-patient group. Demographic data and compliance, measured as appointment completion within 30 days, were analyzed using chi 2 with Yates' correction, Fisher's exact, and odds ratio comparisons (P < .05, 95% confidence interval). MEASUREMENTS AND MAIN RESULTS: The institution of computerized discharge instructions resulted in increased overall patient compliance from 26.2% to 36.2% (P < .0008) with odds ratio of 1.59 (1.2 to 2.1). Subset analysis showed increased compliance in patients who were more than 40 years old (32.5% to 61.1%), were female (28.7% to 39.7%) with a private physician (36.4% to 53.9%), established hospital relationship (26.1% to 38.9%), had nonurgent complaints (26.5% to 36.2%), were specifically diagnosed with strain or contusion (17.0% to 36.8%), or were referred to obstetrics/gynecology clinic (13.2% to 48.6%) (P < .001). CONCLUSION: Computerized discharge instructions were associated with improved compliance with ED referral recommendations, based on historic and contemporary controls.

Pyogenic hepatic abscess.

Pyogenic hepatic abscess is a rare condition associated with severe sequelae. The diagnosis may be obvious in patients with fever and leukocytosis who are clearly predisposed to this infectious complication. In patients without known risk factors, diagnosis and treatment are often delayed, usually until numerous health care resources have been consulted. The evaluation of occult hepatic abscess may be improved by a history directed at identifying predisposing conditions, by an appropriate physical examination and by the use of computed tomographic scanning. The standard treatment for pyogenic hepatic abscess is percutaneous or open drainage, accompanied by broad-spectrum antibiotic therapy.

Adult and pediatric pharyngitis: a review.

Acute pharyngitis is frequently encountered in the ambulatory care setting. Although usually of viral etiology, streptococcal disease is the focus of diagnostic efforts, in light of significant suppurative and nonsuppurative sequelae. The traditional symptoms of fever, adenopathy, and pharyngeal exudate are suggestive, but not diagnostic of streptococcal pharyngitis. Thus, the importance of diagnostic testing, including Group A beta hemolytic strep antigen screen and culture, is emphasized. Recent innovations in therapy include modification of antibiotic dosing regimens and use of cephalosporins to improve patient compliance.

Compliance with emergency department patient referral.

This study evaluated the nature and efficacy of compliance with emergency department (ED) patient referral recommendations. This was a prospective, nonrandomized, descriptive analysis of all ED patients referred mandatorily to an established urban hospital follow-up network. Compliance was measured by analysis of hospital records determined as appointment completion. Patient demographics, urgency of complaint, hospital relationship (new versus established), diagnosis (International Classification of Diseases-9CM), specialty, and method of payment, defined as clinic or private referral, were determined. Comparisons between groups used Fisher's exact test and chi 2 analysis (alpha = 0.05). There were 2,185 patients encountered with 1,443 (66%) discharged for referral, and an overall compliance rate of 27.8% (401 patients). Patients had a mean age of 36.9 years; 50.6% were male, 94.4% were established patients, 51.1% were clinic cases, and 96.7% had nonurgent complaints. Patients encountered had higher rates of compliance if female (33.9%), greater than 40 years of age (43.4%), with urgent complaints (46.8%), and if referred to private physicians (37.0%) (P less than .001). Compliance also correlated with the diagnosis of fracture (63.3%) or laceration (45.6%); and specialty referral to obstetrics-gynecology (28.4%) and general surgery (22.4%) consultants (P less than .01). Most patients demonstrate low compliance (28%) with follow-up recommendations, even with a directed ED referral system.

Aeromonas hydrophila: myofascial necrosis and sepsis.

An alcoholic patient with ascites was admitted to the intensive care unit for gastrointestinal bleeding. He subsequently developed spontaneous myonecrosis of the extremities culminating in sepsis syndrome. This was a unique, non-traumatic presentation of Aeromonas hydrophila soft tissue injury.

Confirmation of endotracheal tube placement: a miniaturized infrared qualitative CO2 detector.

STUDY OBJECTIVES: A miniaturized, infrared, solid-state, end-tidal CO2 detector was used to confirm emergency endotracheal tube (ETT) placement. DESIGN: This prospective, clinical study used a miniature, infrared, solid-state end-tidal CO2 detector to confirm ETT placement in an acute setting. SETTING: The ICU, emergency department, and hospital floor. TYPE OF PARTICIPANTS: There were 88 consecutive adult patients requiring 100 emergency intubations. MEASUREMENTS AND MAIN RESULTS: The indication for airway intervention was considered urgent in 79% and under arrest conditions in 21%. The mean number of intubation attempts was 1.83 (range, one to five) with difficulty of intubation of 6.48 and confirmation of 7.75, on a linear scale from 0 (lowest) to 10 (highest). Determination of ETT position revealed intratracheal intubation in 96% and esophageal intubation in 4%. Placement was confirmed by direct visualization or radiography in all cases. Sensitivity and specificity for ETT localization was 100% (P less than .0001). CONCLUSION: This hand-held infrared capnometer reliably confirms ETT placement under emergency conditions.

Low back pain: review of diagnosis and therapy.

Low back pain is a patient complaint frequently encountered in the emergency department setting. The disease entity is often a diagnostic challenge with a subtle presentation, but can be accompanied by significant neurovascular complications. Current topics of controversy include the utility of radiologic evaluation, pharmacologic and holistic treatment strategies, as well as guidelines for urgent referral of patients with lumbar pain.