Navigating Between Occam’s Razor and Hickam’s Dictum

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Should EPs be liable for initial CT interpretation?
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Click here閱讀Pregerson博士的分析:偏頭痛與大紅旗


Q. Was the patient’s care within the scope of reasonable practice?

Outcome: The case proceeded to trial. In addition to the above arguments, the defense also argued that earlier treatment would have been unlikely to have made a difference in the patient’s outcome. However, the extent of the delay and the multiple alleged errors in care seemed to have inflamed the jury. The parties agreed to a confidential settlement prior to jury deliberations. See graph below for the EPM survey results.


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Navigating Between Occam’s Razor and Hickam’s Dictum

Basilar artery strokes are devastating with a mortality rate greater than 70%. Adding to the high morbidity and mortality is the fact that strokes involving the posterior circulation tend to cause atypical symptoms. It is uncommon for ischemic strokes involving the anterior circulation to cause headaches, yet 40% of ischemic strokes involving the posterior circulation cause headaches. Vertigo, nausea, and/or vomiting are uncommon in anterior strokes, but occur in 50-70% of posterior circulation strokes. Posterior strokes are also more likely to cause facial paresis/pain, visual disturbances, and hearing loss. Unfortunately, there is a large overlap between migraine symptoms and posterior stroke symptoms. The International Headache Society is in its third iteration of headache classifications [1].在這些分類下,定義的偏頭痛頭痛必須與惡心和嘔吐或嘔吐物/陰影有關。此外,根據定義,具有光子的偏頭痛包括局灶性CNS功能障礙的可逆症狀,如眩暈,聽力變化,討厭,視力變化或減少的意識水平。偏頭痛與基底光環(以前稱為“基底偏頭痛”)可能存在與基底行程相同的症狀。


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A review of literature shows that there are literally dozens of clinical findings that might suggest need for further workup of headache. ACEP guidelines [2]建議在頭痛患者神經影像bnormal neurologic findings, altered mental status, change in the pattern of previous migraines, headache waking patients from sleep, and headache associated with syncope, nausea or sensory distortion. A Medscape article by Chawla [3]建議為第一或最差的頭痛表明神經影像觀點;與發燒,癲癇發作或異常的神經學檢查有關;這是新的和持續的;50歲以下的患者有新的發病;位於後麵;或者代表以前頭痛的模式的變化。Detsky等人。[4],suggested neuroimaging when chronic headaches are associated with “high-risk” features such as cluster headache or undefined headache, abnormal findings on neurologic examination, headache with aura, headache aggravated by exertion or Valsalva-like maneuver, and headache with vomiting. In clinical practice, it would be difficult to find a headache thatdoesn’t符合這些標準中的至少一個。

該患者呈現出疼痛,典型的偏頭痛頭痛,但她還有其他症狀,這些症狀不是典型的偏頭痛。雖然新的症狀不是診斷不同的過程,但它們可以提出懷疑,即可能涉及頭痛的另一種病因。此時,臨床醫生麵臨著決定患者的症狀是否代表常見疾病的罕見呈遞或症狀是否代表罕見的疾病的常見呈現。換句話說,人們必須在冬天的剃刀和赫克薩姆的詭計之間進行選擇。一方麵,我同意原告的論點,即新的暈厥,演講變化,聽力變化和麵部麻木的新發起的術語並不典型的偏頭痛頭痛。另一方麵,我也對待許多患有與典型偏頭痛不同的症狀的偏頭痛,並且迅速響應典型的偏頭痛治療。Although medical literature may suggest that the patient’s initial management may not have been optimal, I think it is reasonable to initially treat a patient with prior migraine symptoms and a headache that was typical of those prior migraines as having a migraine with aura rather than rushing the patient to neuroimaging. However, lack of improvement in symptoms after receiving medications for the headache may also suggest a need to reconsider the diagnosis. The fact that this patient’s discharge orders were written and then canceled after the patient was reevaluated suggests that the patient had not been thoroughly reevaluated prior to being discharged. The defense argued that the patient’s symptoms were likely due to hyperventilation. While hyperventilation may result in circumoral numbness, it typically does not cause numbness of the entire face, nor does it cause persistent speech changes or hearing difficulties. If the patient’s symptoms were due to hyperventilation, they should have resolved once the hyperventilation stopped. A reasonable re-evaluation of the patient would have picked up on the absence or persistence of the patient’s symptoms. The defense’s use of hyperventilation as an explanation for the patient’s new symptoms seemed uncompelling.

Another point of contention in this case was the emergency physician’s misread of the CT scan. Although a dense basilar artery sign is an uncommon finding, the consequences of missing this finding are potentially serious. Emergency medicine residency training has comparatively little formal training in CT interpretation. Without sufficient training or demonstration of competence in formally interpreting CT scans, a hospital may be called into question for credentialing a physician to perform such interpretations. Real-time radiology interpretations are ubiquitous in emergency medical practice and are available via teleradiology 24 hours a day to any location with an internet connection, so real-time readings by a radiologist would have been available in this case. If physicians practice outside of their specialty training when providing medical care, the law generally holds them to the standards of the specialist. Here, the emergency physician’s interpretation of the CT scan would be held to the standards of a radiologist – and a radiologist picked up on a critical finding that the emergency physician missed. Of course, the radiology interpretation did not occur until the following morning by which time the radiologist would have known the results of the MRI prior to interpreting the CT scan, giving the radiologist additional information that the emergency physician did not have at the time of the reading. While Brady argues that a determination whether this is a reasonable practice may depend on community or hospital practice patterns, few courts still accept the a “local” standard of care, instead recognizing a national standard to which all physicians are held.

為了成功的醫療事故lawsuit, a plaintiff must prove four elements: Duty to treat, breach of duty, causation, and damages. In this case, there was obviously a duty to treat and there were obviously significant damages since the patient suffered a debilitating stroke. Even if we assume that the treating emergency physician acted unreasonably, the plaintiff still must prove the that the physician’s negligent acts caused the patient’s injuries in order to be successful in a medical malpractice claim. Consider the timing of the events. The patient presented with a headache that had been present for four hours before she came to the emergency department. If a CT scan was ordered shortly after the patient was evaluated in the emergency department, a reading would ideally be returned within the first 30 minutes. If the basilar artery stroke was diagnosed at that time, the patient would already have been at least 4½ hours into the stroke process, putting her outside of the treatment window for thrombolytic therapy. Shortly thereafter, the patient became somnolent and had no improvement with Narcan.


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該方案中指出,病人接受了thrombectomy nine hours after she presented to the emergency department which was 13 hours after her symptoms began. The BASICS study [5]showed that of patients who developed “severe” symptoms (defined as coma, locked-in syndrome, or tetraplegia), only 39 of 347 patients were able to look after their own affairs without assistance (modified Rankin Scale of 2 or less) at one month. By the time this patient received treatment, her comatose condition would have classified her as “severe” symptoms and therefore, even though she needed a walker to ambulate, her outcome was better than 89% of patients presenting with a severe basilar artery stroke. A 2002 study by Devuyst [6]顯示100%的基底動脈撫摸和意識障礙患者具有較差的結果。金製造家的2009年研究[7]showed that a dense basilar artery sign on CT increased the likelihood of a poor outcome more than fivefold. This patient’s outcome was therefore better than would normally be predicted based on her symptoms and radiologic findings.

為了總結,最初將患有預先存在的偏頭痛和非典型症狀作為偏頭痛的患者可能不是最佳的護理,但我認為這是可觀的關懷。很難確定醫生是否在出院之前對患者進行任何重新檢查,但沒有記錄一個並在患有這些投訴的患者身上,這將越過線條進入不合理的護理。我也認為,在沒有專業培訓的情況下,醫院預計應急醫生可以解釋放射科學家的能力是不合理的。然而,盡管這個患者的關心的方麵似乎對我來說似乎是不合理的,但原告可能難以證明任何感知的疏忽護理導致患者的損害。


REFERENCES

  1. https://www.ichd-3.org.
  2. https://www.acep.org/clinical-practice-management/clinical-policy-critical -issuesue-in-the-evaluation-and-management-of- adult-patiants-presenting-the-the-the-hthe-emergency-department-急性頭痛
  3. http://emedicine.medscape.com/article/1142556-workup#c8
  4. Detsky M,McDonald D等人,這種患者是否有頭疼的患者有偏頭痛或需要神經影像動物?jama。2006年9月13日; 296(10):1274-83。
  5. Schonewille, et al., Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study (BASICS): a prospective registry study. The Lancet, Neurology, 2009 Aug. 8(8), p724–730
  6. Devuyst G, Bogousslavsky J, Meuli R, et al. Stroke or transient ischemic attacks with basilar artery stenosis or occlusion: clinical patterns and outcome. Arch Neurol. 2002 Apr. 59(4):567-73
  7. Goldmaker等人,Uncencaly CT上的Hyperdense Basilar動脈標誌預測急性後循環中風中的血栓和結果。中風。2009年1月40日(1)

關於作者

SENIOR EDITOR DR. SULLIVAN, an emergency physician and clinical assistant professor at Midwestern University in Illinois, is EPM’s resident legal expert. As a health law attorney, Dr. Sullivan represents medical providers and has published many articles on legal issues in medicine. He is a past president of the Illinois College of Emergency Physicians and a past chair and current member of the American College of Emergency Physicians’ Medical Legal Committee. He can be reached at his legal web sitehttp://sullivanlegal.us.

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