Clear Documentation is Your Best Defense
When working in the Emergency Department, certain subsets of patients should heighten your risk management awareness. Below we will outline four categories of patients who can present risk management challenges.
1. Patients you do not like.
As physicians, along with providing quality medical care, we have been taught empathy. We should approach all patients the same and do our best to try and understand why they are in the Emergency Department. It is inevitable you will come across patients you simply do not want to spend time with. They are either unfriendly, appear condescending, or for whatever reason, the two of you don't “hit it off”. This subset represents a true risk management challenge as we all tend to minimize their complaints and work to expedite their discharge or admission out of the Emergency Department. Not to belabor the point, but the take home message here is to step back from your initial impression and difficult interaction and ensure your differential diagnosis and work-up are complete. Patients who are unfriendly and difficult to deal with can have subarachnoid hemorrhages, thoracic dissections, and other life threatening emergencies which are easily overlooked.
2. Patients you do not understand.
EMTALA mandated care ensures the Emergency physician, by Federal law, must provide a medical screening exam and stabilization procedures for all patients. At some point, you will encounter patients who do not speak English, whether in the middle of the night, on a holiday, or when the hospital interpreters are unavailable. Therefore, we find ourselves trying to communicate in ways which are simply nonproductive. This subset of patients represents a risk management encounter as without the appropriate ability to communicate, pertinent history and physical examination can be limited due to the inability to answer questions and follow commands. The advice in this case: do your best to call family members, or hospital administrators who may have options for interpreters. If push comes to shove, admit these patients to the hospital after you have elicited the assistance and understanding of your primary care physician colleagues. Your medical-legal responsibilities are not waived because you missed appendicitis in someone who speaks a different language than you.
3. The intoxicated patient.
It is amazing the amount of intoxicated patients who are discharged or admitted to the hospital with acute medical conditions or injuries which go undiagnosed. We are not suggesting that every intoxicated trauma patient receive the “whole body scan”, however, those intoxicated patients, from whatever chemical they have ingested, deserve the red flag approach. Each of us should step back and strongly consider injuries and/or diagnoses which would be more obvious in sober patients. A piece of advice on this subgroup: ensure you completely undress them and provide a complete exam as you will be amazed at what you will find.
4. Patients who return to the Emergency Department shortly after being discharged.
Of the four subsets of patients discussed, this, in our opinion, represents the one which we should most aggressively approach. Whether a significant injury or medical condition is found on the second visit or not, these patients deserve “the next step in the evaluation process” approach. For example, the young person with chest pain discharged the night before who returns the next night with similar complaints, may have the uncommon disease i.e. thoracic dissection vs. pulmonary embolism. The abdominal pain from twelve hours prior who returns following a negative work up may need a CAT scan for appendicitis or a spinal tap to rule out meningitis or subarachnoid hemorrhage. Finally, the geriatric patient who returns weak and dizzy and continues to fall, may have a dysrhythmia, subdural hematoma, or septic focus. In summary, return visits should prompt the emergency physician to consider serious diagnoses and mandate a more aggressive evaluation.
In conclusion, risk management is part of our everyday duties in the Emergency Department and many textbooks are available for reference. The timing of this article may be relevant as senior residents prepare for graduation. All the book/medical knowledge in the world cannot prepare you for the types of situations you will encounter in the ED. There is no doubt understanding medicine and the associated academics are important, however, being street wise and learning form your mistakes and those of your colleagues, should hopefully minimize your risk management exposure. Remember: “those who do not learn from the past, are condemned to repeat it."
