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Emergency Room/ER Expert Witness

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The emergency room of a hospital or healthcare facility is the department whose physicians perform emergency medical treatments on patients with urgent conditions. Due to the unplanned nature of patient attendance, an emergency room must be well stocked and manned in order to handle any emergency patient.

One of AME's emergency room expert witnesses has written an exclusive medical malpractice article that we have provided, for your interest, below.

Emergency Room - Medical Malpractice

The usual problem with emergency medicine is a missed diagnosis and the failure to call in a consultant. A patient with chest pain should have an electrocardiogram. If there is an index of suspicion of heart attack and even if the electrocardiogram is normal, the patient should be admitted to the hospital and observed in the coronary care unit with electrocardiogram monitoring. Under those circumstances, eighty percent of patients who arrive in a hospital with a heart attack leave alive. The major cause of death, in these cases, is an irregular beating action of the heart, an arrhythmia called ventricular fibrillation, which is treatable with drugs and electric shock.

A small percentage of patients will develop a rupture of the heart muscle wall from scar tissue weakening, after a severe heart attack, or total heart failure because the entire heart muscle has been turned to gangrene flesh due to lack of blood flow through a blocked main coronary artery. The controlling muscle struts of the heart valves can be damaged from the effects of the heart attack. Most patients, however, leave the hospital alive if their condition is immediately recognized and properly treated. Heart attack misdiagnosis is not an uncommon emergency room cause of action.

Were the consultants called timely? Did the nurses intervene on their own when they saw problems? Was the patient hooked up to a monitor? Was the patient left alone? Was a proper history taken?

We see the headache question. If the patient has an acute headache and high blood pressure, the blood pressure must be treated and a neurosurgeon called in if there are signs or symptoms of brain damage. One of those emergency conditions is an aneurysm, a weakening of a blood vessel at the base of the brain, supplying blood to the brain. If timely recognized, and if the blood pressure is reduced and anticlotting medication like the drug Amicar (also called epsilon or amino-caproic acid) is given, they can help prevent or limit the degree of hemorrhage into the brain substance. Blood pressure can be reduced rapidly with medications. Emergency surgery can be done. If the patient is stable, surgery can be delayed up to two weeks until the scarring around the blood vessel is thicker, making surgery safer. The decision to operate depends upon which blood vessels are involved and the clinical circumstances. Recognition is the key.

The emergency room doctor must have an index of suspicion, and he must take a proper history. Did this patient have chronic headaches? Was this a severe and new headache, localized differently, which he never had before? High blood pressure or not, either way the patient should be observed. Consultants should be called. The purpose of an emergency room doctor is to treat emergencies, to have a high index of suspicion, to consider all differential diagnoses, and to call in consultants.

Other than skin wounds, hand injuries and deep wounds should never be sutured in the emergency room. A hand surgeon, general surgeon, orthopedic surgeon or plastic surgeon should be called. The patient should be taken to an operating room where the wound is again cleansed thoroughly and the tendons are examined with the patient’s physical movements. The entire area of the tendon should be checked for complete or partial severance. The inside of the cut must be examined to be sure those structures weren't injured, all foreign substances such as dirt and glass were removed, and appropriate x-rays taken. Suturing up the wound and leaving dirt behind, with gas gangrene infection setting in, is usually provable negligence in an emergency room situation, depending upon the circumstances.

Human and animal bite wounds should never be sutured. They are highly contaminated and cannot be totally "sterilized". If a patient had a dirty wound from falling down in their backyard, which the dog or cats use as a bathroom, we never suture that up because the patient can get gas gangrene from the germs that are present. We have to cleanse out the wound thoroughly, give antibiotics, and usually admit the patient to the hospital. Never close the skin primarily, including "old” cuts present for more than eight hours; the risk of infection developing is too great. Depending upon their condition and who is going to see the patient, sometimes they can be sent home. The point is, a consultant should be called and proper hospital care and follow up care given. All follow up instructions must be in writing and given to the patient or to a responsible person who can understand the instructions.

Emergency room doctors recognize and respond to emergency situations; they must call in consultants immediately so that they can triage the patient to the proper person at the right time. Stab wounds, gun shot wounds, that's obvious: he should call someone. In chest wounds, fractured ribs can pierce or collapse a lung. He must get a chest x-ray. Did they perform all the x-ray studies, take all the appropriate blood tests for the condition? Did they take the medical history properly? Did they give instructions for follow up care for head trauma? If the patient has a head injury, but no loss of consciousness, the x-ray is negative, and they are neurologically intact, they can be sent home. The family must be told to awaken the patient every hour. If there is a change in the neurologic condition, and confusion, lethargy, developing paralysis or vomiting occur, they are to bring him back immediately. A CAT scan should be taken at that point. (Perhaps a CAT scan before, depending upon the condition and the nature of the injury.) Follow up instructions are critical in emergency rooms. If they fail to provide these instructions, then they're negligent.

Emergency room doctors also see neck injury patients. With patients in automobile accidents, is there a fractured neck? What difference does it make? Well, if the neck is fractured and the bones are unstable, the spinal cord can be squashed, causing paralysis, paraplegia or quadriplegia. There has to be an index of suspicion. The patient has to be stabilized with the understanding that these conditions may exist until ruled out. The patient is stabilized, protected against himself when they're drunk, and taken to x-ray with supervision, where x-rays of the neck are taken. X-rays of the whole neck should be taken, (not just of the first four cervical vertebrae, but of all seven) to look for a fracture, dislocation, to see stability, and to call a consultant in when necessary. Hospital personnel have a duty to have a high index of suspicion, and to use the tests that are available to them.

Most emergency room doctors today are certified in Emergency Medicine, and every doctor working in an emergency room is held up to that standard of care. The moonlighting eye doctor taking care of a baby is held up to an emergency room standard of care. They must call the appropriate consultants.



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