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
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
1] Myocardial infarction
The spectrum of ACS also includes UA [unstable
angina]
DO NOT trust your office ECG’s computer
interpretation!
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!
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?”
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