Medical errors committed by emergency room health care providers including physician’s, nurses, and physician’s assistants can result in loss of life or serious personal injury. To prevail in malpractice cases the attorney must understand the medical rules, the diagnostic pitfalls, how the emergency rooms operate, and how cases are defended.
The cardinal rule in the emergency room, “the worst first rule”, is that life and limb threatening problems must be ruled our first and failing to follow this rule may result in missed or delayed treatment with catastrophic consequences for the patient. This is a form of differential diagnosis where the attending physician must look at all possible potential problems and rule out the worst first. For example, failure to properly evaluate a patient who has symptoms of a cardiac condition – such as heart attack or stroke – can result in death or life altering injuries. While hospitals often mandate the approach, their ER teams must use for patients with signs or symptoms of a cardiac condition, by way of specific hospital policies and procedures, these may deviate from generally accepted guidelines such as those found by the advance cardiovascular life support manual from the American Heart Association.
One of the best recourses in evaluating whether a hospitals emergency room care meets the minimum standards is the advanced trauma life support manual from the American College of Surgeons. The manual is accepted as the standard of care in the immediate post-trauma period. Emergency room doctors, nurses, and physicians assistants are commonly ACLS and ATLS certified, so utilizing these resources for questioning can be extremely valuable.
Another valuable source and one of the most frequently overlooked tools available is the emergency medical treatment and active labor act also known as (EMTALA) or the antidumping law. The act requires that any patient who arrives at the hospital for an emergency room evaluation must be given an adequate medical screening and may not be discharged in an unstable condition once it is determined that an emergency medical condition exists.
A common mistake made in emergency rooms is one of diagnostic errors. A missed diagnosis is common when a patient doesn’t have what is considered a classic presentation. The attorney must be familiar with the medical condition in question and able to identify the classic and atypical signs and symptoms the emergency room team should have been aware of. For example, more than fifty percent of pulmonary embolisms are mis-diagnosed with pneumonia, chronic lung disease or another element. The emergency room miss rate for ruptured abdominal aortic aneurisms is thirty percent. Up to twenty-five percent of bacterial meningitis is initially missed in the emergency room because the classic triage of symptoms (fever, neck stiffness, and altered mental status) is not present, and the emergency room fails to appreciate its variable clinical manifestations.
Also, fourteen percent of strokes are initially mis-diagnosed for various reasons such as failure to adhere to the AAJ and American Stroke Associations’ established stroke management guidelines.
Atypical presentations for a subarachnoid hemorrhage are between twenty-five and fifty percent and five percent of subarachnoid hemorrhages are missed in the emergency room due to failure to consider the full spectrum of possible symptoms, follow algorithmic workup, and understand the limitations of testing. This condition can be missed because the patient doesn’t have the “worst headache of his or her life”.
