Duties and responsibilities
Trauma care in the emergency department — Early diagnosis a key factor in improving patient outcomes
Originally published April 2012
Emergency department physicians are often faced with trauma patients who have sustained potentially life-threatening injuries. When time is of the essence, early diagnosis and treatment are essential to optimize patient outcomes. However, numerous factors may impede urgent diagnostic and therapeutic measures.
The CMPA reviewed medico-legal cases involving trauma patients with multi-system or life-threatening single-system injuries, or both, between 2005 and 2011. A total of 237 cases were identified, of which 195 are closed. Falls were the most frequent mechanism of injury, followed by motor vehicle collisions (MVC) and assaults with blunt objects. The most common types of injuries were vertebral fractures, intracranial injuries, rib fractures, lung injuries (e.g. hemopneumothoraces and contusions), and splenic injuries. In the cases analyzed, trauma patients with multi-system injuries had better clinical outcomes than patients with single-system trauma. A considerable number of cases involved non-tertiary centres.
Delay in diagnosis was the most frequent shortcoming identified, followed by communication issues among healthcare professionals, and administrative concerns (e.g. inadequate documentation and resource problems).
This article describes diagnostic problems encountered by CMPA members caring for trauma patients and identifies factors that interfered with the diagnostic process.
Common diagnostic problems
In this analysis, the deficiencies identified most often related to history taking or general evaluation.
Key factors in the patient's trauma history or medical history were overlooked and important clinical symptoms were not taken into account. Diagnostic investigations were not always ordered or performed when indicated, in particular, imaging for establishing potential head, spinal, extremity, or chest injuries; pertinent blood work (e.g. International Normalized Ratio [INR] on anticoagulated patients); neurological assessments; and serial assessments. Misreading of X-rays and CT scans and failure to read pre-hospital personnel and nursing notes also contributed to delays in diagnosis. At times, the physician delayed performing required therapeutic procedures despite arriving at the correct diagnosis.
Factors that affected the diagnostic process
Factors in this analysis that contributed to difficulties in the diagnostic process may be considered in three broad categories: patient-related, physician-related, and system-related.
Patient-related factors included:
- multiple injuries
- co-morbid conditions (e.g. ankylosing spondylitis, degenerative disc disease, chronic pain, anticoagulation, dementia, psychiatric disorders, obesity)
- alcohol or drug intoxication
- aggressive or combative behaviour, often in the context of head injuries or intoxicants
- limited availability of the health history
- inability or failure to communicate all painful areas
- language barrier
- non-compliance with medical instructions (e.g. leaving the hospital against medical advice, not complying with recommended follow up or investigations, failure to return to the initial treating hospital if the patient's condition worsened)
- incorrect contact information interfering with follow-up
- in police custody
Physician-related factors included:
- under-appreciation of the mechanism of injury (e.g. due to lack of verbal communication or failure to read the notes of pre-hospital personnel and nursing staff)
- failure to adequately expose and thoroughly examine the patient
- inability to examine the patient due to such factors as lack of patient cooperation
- lack of familiarity with trauma care protocols, relevant guidelines, and transport policies
- a perceived lack of time to perform a thorough assessment
- difficulties in the interpretation of diagnostic imaging
- false reassurance from early negative findings of newer bedside technologies such as focused assessment with sonography for trauma (FAST) studies
- premature diagnostic closure and anchoring on a diagnosis
- premature or inadequate discharge and follow-up instructions
System-related factors included:
- concurrent assessment and treatment of multiple trauma victims
- multiple physicians caring for a patient, which creates an increased need for communication
- sub-optimal technology, including off-site interpretation of diagnostic imaging
- non-adherence to established trauma protocols by other healthcare professionals
- lack or unavailability of resources or trained personnel, such as access to imaging, transfer resources, and specialists
- difficulties in contacting recently discharged patients when further investigation or treatment may be needed (e.g. a significant missed radiological finding)
Insufficient observation period for a patient involved in a high-speed motor vehicle collision
A 20-year-old woman presented to the emergency department (ED) of a tertiary hospital by ambulance after being involved in a head-on, high-speed MVC.
She experienced a brief loss of consciousness at the scene. Pre-hospital personnel noted seat belt usage, air bag deployment, and significant intrusion into the passenger compartment. Upon arrival, she was agitated and complained of left chest and left upper quadrant (LUQ) abdominal pain. The ED physician obtained the trauma history from the patient and her mother. Relevant physical findings included normal vital signs, a Glasgow Coma Score (GCS) of 15, a soft abdomen, and mild tenderness on palpation of the left chest and LUQ. An upright chest X-ray was normal as was her hemoglobin. The ED physician, who was accredited in ultrasound, performed a FAST study which he interpreted as negative. Over the ensuing two hours, the patient was observed. Her vital signs, including her GCS, remained stable and serial abdominal examinations were unchanged. The patient was instructed to return to the ED if her abdominal pain worsened or if she developed any neurological deficits.
Four hours later, following a syncopal episode, the patient returned with increased abdominal pain and distention, nausea and vomiting, bilateral shoulder discomfort, and confusion. An urgent abdominal CT scan revealed a lacerated spleen. The patient underwent an emergency splenectomy. A closed head injury and post-concussion syndrome were also diagnosed. The patient fully recovered.
The mother lodged a complaint with a medical regulatory authority (College) alleging inadequate assessment and premature discharge from hospital.
The College was of the opinion that in the context of a suspected head injury and possible intra-abdominal injury it would have been prudent to hold the patient for a longer period of observation to determine the need for further investigations. While not questioning the physician's competency in performing and interpreting the ultrasound, the College concluded that the ED physician was falsely reassured by the negative FAST. The College cautioned the ED physician about the importance of an appropriate period of observation and directed him to prepare a report about the ED assessment of patients presenting with significant mechanisms of injury.
Cervical spine X-rays not ordered for an elderly patient involved in a rollover
A 73-year-old male driver was injured in a rollover MVC. He did not lose consciousness and was able to extricate himself from the car.
On arrival to a community hospital emergency department, physical examination was remarkable for a GCS of 15, absence of midline cervical spine tenderness, and a small scalp laceration which was sutured. Based on the absence of neck tenderness in an alert patient without significant distracting injuries, the ED physician did not order cervical spine (C-spine) films as per the National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria. Approximately three hours after arrival, the patient complained of a headache and stiff neck. On re-examination, the C-spine remained non-tender. The patient was discharged with standard head injury precautions.
Approximately six hours later, a family member brought the patient to a different ED due to concerns about neck pain, headache, confusion, and ataxia. Despite normal neck range of motion, the patient now exhibited midline cervical tenderness. X-rays revealed a fracture of the second cervical vertebra. A non-contrast head CT showed no other anomalies.
The family initiated a College complaint alleging the first ED physician should have ordered imaging.
The College expressed the view that the record reflected that the patient did not exhibit symptoms or physical findings of significant neck injury throughout his stay in the first ED. The College maintained that although the emergency department physician's management of the patient was not in accordance with the Canadian C-spine Rule, which would have mandated imaging on the basis of age and mechanism of injury, he did correctly apply the NEXUS Low-Risk Criteria. As both clinical decision-making tools are commonly used, the College concluded the ED physician met the standard of care. However, the College was critical that the ED physician did not document the specific follow-up advice given to the patient.
Imaging and INR not ordered for an anticoagulated patient who fell and struck her head
A 60-year-old woman presented to a rural ED after striking her head in a fall.
She had a history of a mechanical mitral valve and previous stroke for which she was being treated with warfarin and an antiplatelet agent. On admission, she was noted to be alert but vomiting, and complaining of a headache and neck discomfort. A truncated neurological examination was normal. C-spine films were normal. The patient was observed overnight in the ED. She remained alert and oriented but had ongoing complaints of headache, neck pain, dizziness, and nausea. At the nurses' request the ED physician prescribed an antiemetic and acetaminophen twice, and discharged the patient the following morning on the basis of the nurse's telephone report that the patient remained alert. The physician did not personally reassess the patient prior to discharge.
The patient was found unresponsive at home the following morning. A CT scan of the head at another hospital revealed massive subdural and intracerebral hematomas. The patient's INR was elevated. Despite rapid reversal of anticoagulation and surgical intervention, the patient failed to improve, and life support was withdrawn. The family began legal proceedings.
Peer experts opined that the ED physician did not consider a diagnosis of head injury despite the presence of significant warning signs in a high risk patient. They expressed the view that although the patient may not have met the criteria for an immediate CT scan of the head, INR levels should have been performed in addition to the overnight monitoring. The experts further maintained that, in light of the patient's anticoagulated status and persistent nausea and headache, a CT scan should have been performed before discharge. They were also critical that the ED physician did not personally reassess the patient despite the persistent headache and nausea. Lastly, the discharge plan and instructions were believed to be inadequate. Without expert support, the CMPA, on behalf of the member ED physician, and the hospital contributed to a shared settlement paid to the patient's family.
Managing medico-legal risks
The following risk management considerations are based on the expert opinions in the analyzed cases:
- Obtain an appropriate history to establish the mechanism of injury and possible injury patterns.
- Use a systematic approach during physical examinations to decrease the possibility of overlooking an injury.
- When appropriate, provide an adequate observation period. Perform serial physical examinations and investigations when indicated.
- In the context of trauma, routinely consider a patient's coagulation status.
- Consider using credible clinical decision rules.
- If bedside diagnostic technologies (e.g. FAST ultrasound) are available in your workplace, ensure you receive appropriate training to perform the investigation and interpret the findings, and that quality assurance mechanisms are in place.
- Provide and document discharge instructions. Consider whether the discharge plan is adequate. Are individuals available at home to monitor the patient?