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ACEP Now: Vol 39 – No 06 – June 2020

Figure 2: The physician’s warfarin and Lovenox order.

After the patient’s return, the ultrasound results were finalized and were negative for DVT. The patient was placed in a knee immobilizer and discharged to follow up with orthopedics. He was offered a wheelchair but declined in favor of using his crutches. While he was making his way out of the front of the hospital, the patient lost his balance, fell, and hit his head on the ground. A nurse witnessed this, and he was brought back into the emergency department and evaluated by the same physician who had discharged him only minutes earlier.

The patient denied loss of consciousness, and his vitals were again unremarkable. An abrasion to the head was noted, but otherwise he had a normal exam and no complaints. He was discharged home without any further workup.

The patient made it back to his apartment. The next morning, a friend was unable to contact him and went to check on his well-being. Unfortunately, he was found dead. An autopsy was performed, and a large subdural hematoma was discovered (see Figure 3).

Figure 3: The patient’s autopsy report.

Legal Blowback

The patient’s family filed lawsuits against the nurses involved as well as the physician who discharged him. The lawsuit was filed in federal court because the emergency department was a Veterans Affairs facility. Ultimately, the federal case was dismissed without trial. The case against the physician was then refiled in state court, and an undisclosed settlement was reached prior to trial.

This case illustrates several key points. Although some emergency physicians comfortably perform DVT exams at the bedside, many are not in the practice of doing so or were trained before point-of-care ultrasound was in wide use. Performing a DVT study at the bedside could have been completed in just a few minutes, negating the need to transfer this patient. The argument can be made that he would not have required empiric anticoagulation while waiting for transfer and there would also not have been a handoff of his care.

The patient presented back to the emergency department only several minutes after having been discharged. Every ED physician knows the frustration of a rapid bounceback. After a patient has a long ED stay with a complicated workup, it can be difficult to start over again with an entirely new workup for a new chief complaint. However, it is important to avoid early mental closure in these situations and not brush off a subtle but life-threatening presentation. Working quickly toward a rapid disposition is an important skill in emergency medicine, but it must be balanced against the risks of causing harm.

In hindsight, it is obvious the patient needed a CT scan of his head. He was an elderly patient on warfarin, and due to his subtherapeutic INR, he had been given additional anticoagulation hours before his head injury. There are no clinical decision rules that would suggest this patient could safely be discharged without obtaining a head CT.

Another possible contributing factor to his fall was the fact he was placed in a knee immobilizer. An elderly man on anticoagulation with limited mobility is an obvious fall risk. There is no indication for using a knee immobilizer in this case given that he did not have any fractures or injury to the extensor mechanism of his knee. Simple compression with an ACE bandage would have been appropriate and allowed for safer mobility.