Case # 2

The patient was a 21 year old male who was involved in a one car accident. He was thrown twenty feet. The patient was intoxicated when he was taken to the emergency department of Oconee Memorial Hospital by paramedics. The paramedics recorded that the plaintiff had good movement in his extremities.

The emergency department physician, Dr. N (a general surgeon) removed the cervical collar and other immobilizing devices in order to take X-rays. The physician took the plaintiff's arm and holding the back of the plaintiff's neck lifted him into a sitting position. The patient yelled out that his neck was in pain. He subsequently became quadriplegic.

The plaintiff contended that the defendant had mistreated patients who are intoxicated, that the defendant regularly removed cervical collars from emergency room patients, that the defendant improperly lifted the plaintiff into a sitting position, that the patient's paralysis resulted from the treatment received in the emergency department.

The defendant contended that the plaintiff was injured in the automobile accident and there was no relationship between the emergency department treatment and the plaintiff's injuries.

The jury returned a $5 million award for the plaintiff.

Case Commentary

The alcohol impaired patient may have a serious traumatic injury with no complaint of pain. The EP should assume that the intoxicated patient brought in from the scene of an accident has suffered traumatic injury until proven otherwise. A review of alcohol related lawsuits suggests that, at times, the EP’s feelings about the intoxicated patient get in the way of clinical decision making. The EP must recognize that the intoxicated patient is at high risk group for serious injury, and make these patients a priority.

Case # 3

The patient presented to the emergency department of the McGuire Veterans Administration Medical Center requiring assistance to walk and under the influence of alcohol. He complained of tingling in his arms and weakness in his legs. He also complained of severe pain in his neck and shoulders. He was initially combative and verbally abusive but calmed down later. The patient cooperated with the medical examination in the emergency department by allowing his blood to be taken and his upper motor strength to be tested.

When asked to move his legs, however, he indicated that they were sluggish to move. The patient had a history of a C-spine injury sixteen years earlier in a helicopter crash. The diagnosis was possible cervical spine injury, but the physician felt that a repeat exam would be necessary when the plaintiff was sober.

The patient/plaintiff claimed that no cervical MRI or X-ray studies were performed for sixteen hours. The MRI studies revealed an acute herniated disc at the C6-7 level causing his neurologic symptoms. The plaintiff claimed that surgery was performed nineteen hours after admission, which resulted in his becoming a C-7 quadriplegic.

According to accounts, a settlement with a present cash value of $1 million was reached.

Case Commentary

Once again, the EP must aggressively work-up all potential life or limb threats in the patient 'under the influence.

The inebriated patient who has blunt head trauma is in intracranial bleed until proven otherwise. The inebriated patient with neck pain is an unstable cervical fracture until proven otherwise. This patient should have been completely immobilized and a hard collar and backboard applied pending further diagnostic evaluation.

If the physician felt the need to repeat the exam prior to radiographic evaluation, complete immobilization in the interim may have avoided this lawsuit. The plaintiff would claim that movement during the sixteen hour delay caused or aggravated the injury. Optimally this patient would have been sent immediately for CT or MRI if available. If the physician felt strongly that repeat exam was indicated, further testing should not have been delayed beyond the suggested 3 to 6 hours. If for any reason the diagnostic evaluation had to be delayed, complete immobilization or transfer to a facility that could carry out the evaluation was indicated.

Case # 4

The patient was a sixteen year old boy who was taken to the defendant Emergency Care Center after his friends found him abandoned in a parking lot. He was disoriented, lethargic, semi-comatose and unresponsive, except to painful stimuli. His blood alcohol level was 53 mg/dl. The patient exhibited poor verbal skills, sluggish pupils, contusions on the back of his skull, upper back abrasions and an inability to communicate rationally.

The defendant emergency physician examined the patient at midnight. The primary diagnosis was alcohol abuse with possible head injuries. The emergency staff checked on the patient periodically through the night. The patient's condition deteriorated between five o'clock and six o'clock a.m. and he was transferred to another Medical Center. In route, the patient died as a result of a massive intracranial epidural bleed.

The plaintiff claimed that the defendant should have immediately transferred the decedent to the medical center for a CT scan for further evaluation that was not available at the emergency clinic. The defendants contended that the decedent had been treated appropriately given his conditions and symptoms. They also maintained that immediate transfer of a patient in the decedent's condition for a CT scan was not within the standard of care.

The jury returned a verdict for the defendants.

Case Commentary

This was a gift. It appears there was a delay in diagnostic evaluation. However, remember that the jury is asked to measure the physicians conduct not against the highest quality practitioner, but against the reasonably trained practitioner. Here, the jury believed that it was reasonable to observe rather than aggressively evaluate.

Although this was a defense verdict, the case demonstrates a critical element regarding management of this patient group. The alcohol level of 53 milligrams percent does not explain the long list of neurologic signs and symptoms. Alcohol levels in this range may begin to cause problems with judgment, but would not cause obvious neurologic changes. If the alcohol level is not consistent with the patient’s presentation, the EP must dismiss alcohol as the cause and aggressively pursue the diagnostic evaluation.

Case # 5

The patient was a 23 year old named Shawn Davis. He was a laborer. Mr. Davis went to a concert, and had been drinking beer. Leaving the concert, the patient was struck by an automobile and knocked to the ground. He was taken to an emergency department, where the defendant emergency physician, Dr. W, examined him and noted that he was unsteady on his feet. Dr. W. did not obtain a blood alcohol level, nor did he pursue any other diagnostic evaluation. Mr. Davis was sent home with head injury instructions.

Several hours after arriving home, Mr. Davis aspirated and was revived by his parents. An X-ray revealed a skull fracture with a subdural hematoma. The plaintiff underwent an emergency craniotomy and evacuation of the hematoma. As a result of the delay, Mr. Davis is blind in one eye, and has a loss of peripheral vision in the other eye.

The plaintiff alleged that the defendant was negligent in attributing his symptoms to alcohol and in failing to diagnose the skull fracture and subdural hematoma. The defendant contended that he conformed to the standard of care in sending the plaintiff home with head injury instructions. The parties reached a structured settlement of $120,000 cash plus $1000 a month for life.30

Case Commentary

As you can see, this is a commonly recurring theme in alcohol related emergency malpractice lawsuits. Intracranial injuries get missed in intoxicated patients who present to the emergency department. The emergency physician documented that the patient was not steady on his feet. Unless proven otherwise, this represents a focal neurologic deficit. This case required more aggressive management, probably CT and continuing observation until the patient was no longer intoxicated.

Case # 6

The patient had consumed several beers and some whiskey at the apartment of a woman, not his wife, over the course of an hour. Shortly after he left the woman heard "a little boom, boom sound". She saw the man lying face down on the cement patio at the bottom of a flight of stairs leading up to her apartment. She helped him up, placed a pillow under his head and told him to sleep it off. The woman's daughter discovered the man when she returned home several hours later. She told the man to leave. In response he said that he "couldn't move" or did not want to move because of pain in his arm and neck and numbness in his neck.

An ambulance was called and EMT's responded within minutes. Although the man smelled of alcohol and appeared intoxicated, he was coherent and answered questions. The EMTs apparently checked only his blood pressure and checked his pupils by shining a flashlight into his eyes. They urged him to go to a hospital.

When he continued to refuse and the woman and the daughter continued to insist that he leave the stairs a police officer called a paddiwagon and he was taken to a detoxification center. The officers found that he was "dead weight" so they carried him by his arms and belt to the vehicle and placed him face down on the floor. A doctor at the detoxification center immediately recognized signs of spinal injury and had him transported to a hospital.

The patient went into cardiac arrest upon arrival, subsequently became comatose and died two days later. His treating physician concluded that the cause of death was a fractured neck with spinal cord contusion and that the fracture took place at the initial impact. The plaintiff's expert faulted the EMTs for failing to recognize the broken neck and failing to immobilize the patient.

The jury returned a verdict in favor of the plaintiff for $676,548. 31

Case Commentary

The pre-hospital setting further complicates the management of this difficult group of patients. Pre-hospital providers must maintain a low threshold for suspecting serious trauma in alcohol impaired patients. This was an intoxicated individual, complaining of pain in his neck. The EMTs should have recognized and acting upon the high risk of cervical injury.

An EP taking ‘medical control’ by radio communication could have authorized restraint, immobilization and transfer to the hospital. If this intoxicated patient had refused care, the refusal should appropriately be denied. The ED must work in close cooperation with pre-hospital providers in order to provide optimal patient care.