NUHS Symposium

High Risk Encounters and High Risk

Phrases in the Acute Family Practice

Setting

A/Prof Peter Manning

Emeritus Consultant

Emergency Medicine Department

National University Hospital

Singapore

We will discuss…

• High risk clinical scenarios

• High risk phrases

• Documentation

High risk clinical scenarios

The risk of law suit is increasing.

John Davenport, MD, JD

Fam Pract Manag. 2000 Oct; 7(9):33-36

There follows a major disruption to the

physician’s practice.

“…….extracts a tremendous price in emotional

distress, loss of self-esteem and sometimes,

public regard……..”

High risk clinical scenarios

2 approaches to addressing this problem : -

Ignore the legal issues, try to do a good job

clinically and hope to avoid a lawsuit

Develop an approach to lower your risk of a law suit,

and, make your case defensible if you are sued

Know your risk!

There are 5 conditions that characterized by

high incidence, extensive publicity and

heightened public expectations for early

prevention and cure…..?

Know your risk!

In descending order of lawsuit prevalence…..

+ myocardial infarction

+ breast cancer

+ appendicitis

+ lung cancer

+ colon cancer

Know your risk!

A mnemonic might help…….

“Listen to BACH”

Lung, Breast, Appendix, Colon, Heart

1] Myocardial infarction

The spectrum of ACS also includes UA [unstable

angina]

DO NOT trust your office ECG’s computer

interpretation!

1] Myocardial infarction

38-year-old man presented to EMD with anterior chest pain.

1] Myocardial infarction

This is not a benign tracing

1] Myocardial infarction

Common pitfalls…..?

Poor documentation of

+ characteristics

+ precipitating factors

+ associated symptoms

Failure

+ of advice for follow up of apparently ‘atypical pain’

+ to compare current with old ECGs

+ failure to follow up on “abnormal”

2. Breast cancer

Almost equal to AMI in litigation prevalence

Jolie's aunt dies of breast cancer

BBC News - 2 hours ago [Monday, 27th May 2013]

“…….Angelina Jolie's aunt has died of breast cancer, nearly

two weeks after the Hollywood star said she had had a

double mastectomy to avoid such ...”

2. Breast cancer

Perceived actions or lack of action � delayed

diagnosis � injury to patient

Most complaints filed by women < 50 years who

had discovered breast masses and received the

diagnosis of “fibrocystic disease of the breast”

2. Breast cancer

Majority of breast lumps are benign, however…..

Pitfalls involve :

+ no clear follow up plan for monitoring changes

in a ‘benign lump’

+ failure to order an appropriate test in the first place

+ failure to follow up on abnormal mammograms

Systems issue : you must have an office system to

prevent mismanagement of tests i.e., tests that are ordered

are performed and that the results are made available to you

3. Appendicitis

Ranks # 3 in prevalence even though ‘appy’ accounts for only 5%

cases of abdominal pain

Common pitfalls :

+ failure to document an adequate examination

+ failure to provide clear follow up plan if symptoms

change or if patient’s presumed condition does

not improves in a reasonable period

High risk phrase - “It’s not your appendix - it’s just stomach flu ”

3. Appendicitis

Commonest misdiagnosis is ?........

Acute gastroenteritis

[AGE]

Labs are generally unhelpful,

but one physical sign is useful

……….?

Scoring systems [Alvarado & RIPASA]

Alvarado : [6 clinical & 2 lab]

[Mnemonic = MANTRELS]

M - migratory pain 1 point

A - anorexia 1

N - nausea /vomiting 1

T - tenderness in RIF 2

R - rebound 1

E - elevated temp 1

L - leucocytosis 2

S - shift to left 1

1-4 – ‘appy’ very unlikely

5-6 – moderately likely

7-10 – highly likely

Studies ruling out appendicitis (Alvarado < 3-4) have a

sensitivity of 96%; studies ruling in appendicitis (Alvarado > 6-7)

have a sensitivity of 58-88%, depending on the study and score cut

offs used. The 2007 McKay study recommends CT scan for

Alvarado 4-6, surgical consultation for Alvarado ≥ 7.

Scoring systems [Alvarado & RIPASA]

RIPASA : 15 parameters [12 clinical, 2 lab and 1 social]

•age : < 40 years 1 point & > 40 years 0.5

•gender : male 1 & female 0.5

•RIF pain : 0.5

•migration of pain to RIF : 0.5

•nausea and vomiting : 1

•anorexia : 1

•duration of symptoms < 48 hours 1 & > 48 hours 0.5

•RIF tenderness 1

•guarding 2

•rebound tenderness 1

•Rovsing's sign 2

•fever 1

•raised white cell count 1

•negative urinalysis 1

•foreign national registration identity card 1

The optimal cut-off threshold

score from the ROC was 7.5, with

a sensitivity of 88 percent, a

specificity of 67 percent,

a PPV of 93 percent and an NPV

of 53 percent.

The negative appendicectomy

rate decreased significantly from

16.3 percent to 6.9 percent,

which was a 9.4 percent reduction

(p is 0.0007).

4. Lung cancerCommon allegation ?

“…the physician did not recognise the importance of a symptom

in enough time for early diagnosis and curative therapy….”

Common pitfalls :

Failure to order a CXR in patients whose symptoms might

arguably indicate lung cancer

Then, once the diagnosis of lung cancer is made….

…attorneys often point to otherwise nonspecific chest symptoms in the past as

evidence of existing lung cancer and the need for earlier and potentially curative

interventions….

5. Colon cancer

Typical claim is that the doctor did not intervene with

diagnostic tests when symptoms demanded it, or failed

to properly manage relevant tests.

If a patient refuses colonoscopy, do you document an

informed refusal?

High risk phrases

Several areas of the body are famous for

harbouring ‘occult’ fractures…………….?

• carpal bones

• elbow

• femoral neck

• pubic rami

• mid-foot

“It’s not broken”

High risk phrases

Do NOT forget rib fractures

“It’s not broken”

CXR

•is the initial study of choice

may miss up to 50% of undisplaced rib fractures and is

not sensitive for costal cartilage or stress fracture - but is

still useful but add oblique views

Can you rely on the radiology report? Unfortunately not!

High risk phrases

Do NOT forget the Lisfranc fracture-dislocation

“It’s just a sprain”

High risk phrases “It’s just a bruise”

Do NOT forget the Boutonniere lesion

Boutonniere lesion

Sequel to a missed boutonniere injury

Infectious disease - MERS-CoV

Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

MERS-CoV Status Update from MOH dated 20 May 2013

There is limited human-to-human transmission suggested in a UK family cluster, and a

French hospital cluster, and two suspected clusters in Saudi Arabia and one suspected

cluster in Jordan.

Occurrence of 22 cases linked to a Saudi Arabia healthcare facility indicated some

human-to-human transmission. Among the cluster of 22 cases, three were family

members of cases in the hospital while two were healthcare workers whose source of

infection is unknown.

The evidence does not point to widespread community infection nor sustained human

to human transmission. However, there has been evidence of nosocomial infection.

Infectious disease - MERS-CoV

Ask “Have you visited the Middle East in the last 10 days?”

Check 3 more things

“Have you visited

any healthcare

facility there?”

Does the patient

have fever?

Does the patient

display respiratory

symptoms?

• isolate patient

• transfer according to your choice

Proceed as

per normal

NoYes

Dengue feverRecent death

Red flags i.e., risk stratification

• hypotension

• flushing

• finger oedema

• abdominal symptoms

• haemoconcentration [be wary < 48%]

• hyponatraemia

• rapid platelet dips

• multiorgan involvement e.g., transaminitis

Otherwise daily platelet counts available and not everyone needs dengue serology

High risk phrases

Although these injuries may seem minor, wounds with neglected

foreign bodies are a common cause of malpractice claims

“What glass?”

Vukmir RB. Medical malpractice: managing the risk.

Med Law. 2004;23:495–513

The authors of one study involving patients injured by

broken glass found retained glass in 15 % of wounds

High risk phrases

Caveat : If the patient says “I think there is something

in there…….believe them

The positive predictive value of patient sensation was 31 percent;

negative predictive value was 89 percent.

Although the negative predictive value was high, 57 % of retained

glass foreign bodies would have been missed without radiography

“What glass?”

Steele MT, Tran LV, Watson WA, Muelleman RL. Retained glass foreign bodies

in wounds: predictive value of wound characteristics, patient perception, and

wound exploration.

Am J Emerg Med. 1998;16:627–30

High risk phrases

Caveat : always image for suspected glass FBs….

Glass fragments as small as 1 – 3 mm will show

on underpenetrated films i.e., soft tissue technique

Inform the radiographer what you are looking for!

……the technique for soft tissue and bone differs – a

glass FB might be missed in the latter

“What glass?”

High risk phrases “Just a bump on the head”

Bridging veins

Documentation

A fully documented medical record can forestall a suit.

Full documentation includes :

•patient’s medical history

•physical findings

•your diagnosis

•the treatment plan

•the care rendered

•*** the advice given to the patient with clear follow up plans

Documentation

“How much is enough documentation?

How much documentation is realistic?

At least consider full documentation for any

of the high-risk areas

Is it true that….”if you didn’t record it, you

didn’t do it”?....

In summary………..

Know your high risk areas………Pareto principle

Avoid high risk phrases

Document better

Thank you for your time

and attention