Discussion

This case highlights the essential role that communication plays in the care of all patients. The disconnect in the patient’s referral at the first ED visit nearly led to a disaster. Awareness of his prior hypotension certainly would have led to a higher level of concern—though not necessarily the correct diagnosis; given his benign workup and vital signs in the emergency department, he may have been discharged home regardless. That the doctor did not realize the patient was referred to the emergency department from an outside facility illustrates the concept of “holes in the Swiss cheese” remarkably well. The clinic did not call the emergency department to notify them of a referred patient, there were no processes in place requiring the triage nurse to ask patients if they had been referred to the emergency department by an outside facility, the patient did not volunteer this information, and the doctor did not think to ask.

This case provides an excellent opportunity to refine our understanding of EMTALA. Just because a medical screening exam does not arrive at the correct diagnosis does not mean there was an EMTALA violation. The hospital and emergency physicians involved seem to have prevailed in the legal proceedings, but caution must be taken given the complexity of EMTALA litigation. Specialized attorneys may spend large swaths of their careers dealing with these cases, and even the most well-intentioned emergency physicians are unlikely to have read, let alone understand, its complexities. Just as in medicine, nuanced interpretations are best left to the experts.

See the Records

Visit www.medmalreviewer.com/case-7-ankle-injury/ to review the full medical records or send Dr. Funk an email with your thoughts on the case at admin@medmalreviewer.com.

Dr. Funk is a practicing emergency medicine physician in Springfield, Missouri, and owner of Med Mal Reviewer, LLC. He writes about medical malpractice at www.medmalreviewer.com.