Malpractice occurrence in emergency medicine: does residency training make a difference?

We evaluated the effects of Emergency Medicine (EM) residency training, EM board certification, and physician experience on the occurrence of malpractice claims and indemnity payments. This was a retrospective review of closed malpractice claims from a single insurer. Outcome measures included the occurrence of claims resulting in indemnity, indemnity amounts, and defense costs. Differences in the outcome measures were compared based on: EM residency training, EM board certification, EM residency training versus other residency training, and physician experience using both univariate and multivariate analyses. There were 428 closed EM claims with indemnity paid in 81 (18.9%). Indemnity was paid in 22. 4% of closed claims against non-EM residency-trained physicians, and in only 13.3% against EM residency-trained physicians (p = 0.04). The total indemnity was $6,214,475. Non-EM trained physicians accounted for $4,440,951 (71.5%), EM residency-trained physicians accounted for $1,773,524 (28.5%). The average indemnity was $76,721 and the average defense cost was $17,775. There were no significant differences in the mean indemnity paid per closed claim or the mean cost to defend a closed claim when comparing EM-trained and non-EM residency-trained physicians. The total cost (indemnity + defense costs) per physician-year of malpractice coverage was $4,905 for non-EM residency-trained physicians and $2,212 for EM residency-trained physicians. EM residency-trained physicians account for significantly less malpractice indemnity than non-EM residency-trained physicians. This difference is not due to differences in the average indemnity but is due to significantly fewer closed claims against EM residency-trained physicians with indemnity paid. This results in a cost per physician-year of malpractice coverage for non-EM residency-trained physicians that is over twice that of EM residency-trained physicians.

Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center.

BACKGROUND: Despite numerous studies, no clear consensus exists for the optimal use of emergency department thoracotomy (EDT). As such, we have continued to critically review our experience with EDT during the last 23 years to clarify indications for EDT and evaluate its cost-effectiveness. METHODS: This was a retrospective review of 950 EDTs performed at our regional Level I trauma center during the last 23 years. Cost-benefit ratios were calculated using standardized models. RESULTS: In 23 years, 950 patients underwent postinjury thoracotomy. We were able to obtain the complete medical records for 868 patients (91%). Overall survival was 4.4%, with 3.9% surviving functionally intact. All survivors of blunt trauma had either palpable pulse or recorded blood pressure in the field. Blunt trauma functional survival when field vital signs were present was 2.5%. Of note, 26.5% of our functional survivors sustained penetrating injuries and had no pulse or blood pressure in the field. Stab wounds to the chest and gunshot wounds to the abdomen were the two mechanisms of injury most likely to be survived. The benefit-charge ratio was strongly in favor of performing EDT at 5.6:1; it was 1.8:1 if adjusted for the cost of maintaining all neurologically injured survivors throughout their lifetime. CONCLUSION: EDT is efficacious and cost-effective for select patient populations. We suggest a key clinical pathway for the use of EDT that would reduce the number of procedures by at least 32% without changing the number of neurologically intact survivors.

Ultrasound based key clinical pathway reduces the use of hospital resources for the evaluation of blunt abdominal trauma.

BACKGROUND: Evaluating blunt abdominal trauma remains a resource intensive aspect of trauma care. Recently, emergency department ultrasound has been promulgated as a noninvasive diagnostic alternative. Consequently, we hypothesized that an ultrasound based key clinical pathway (KCP) would reduce the number of diagnostic peritoneal lavage (DPL) and computed tomographic (CT) scans required to evaluate blunt abdominal trauma without increased risk to the patient. METHODS: This study was a prospective analysis of patients evaluated for blunt abdominal trauma during a 3-month period using this KCP compared with a 3-month historical cohort. RESULTS: Data were collected for 486 KCP patients and were compared with 516 patients in the study cohort. No differences were noted regarding demographics, number of laparotomies, or type of injuries. Using the KCP, DPL was reduced from 17 to 4%, and computed tomography from 56 to 26%. Furthermore, the injury severity score increased from 11.6 to 21.5 for DPL patients and from 4.6 to 8.3 for computed tomography patients. Ultrasound exams were used exclusively in 65% of patients. CONCLUSIONS: An ultrasound based KCP resulted in significant reductions in the use of invasive DPL and costly CT scanning in the evaluation of blunt abdominal trauma without risk to the patient.

Blind nasotracheal intubation in the presence of facial trauma.

Blind nasotracheal intubation (BNTI) is an effective procedure for the intubation of trauma patients. The presence of major facial trauma has been considered a relative contraindication due to the perceived risk of intracranial placement. The purpose of the present study was to assess the risk of intracranial placement in patients with facial fractures who undergo BNTI. The records of 311 patients with facial fractures were reviewed for methods of intubation and complications. Eighty-two patients underwent BNTI. There were no cases of intracranial placement, significant epistaxis requiring nasal packing, esophageal intubation, or osteomyelitis. Three patients (4%) developed sinusitis and eight (10%) developed aspiration pneumonia. We conclude that the presence of facial trauma does not appear to be a contraindication to BNTI.

The efficacy of intravenous droperidol in the prehospital setting.

Droperidol is used for sedating combative patients in the emergency department (ED). We performed a randomized, prospective, double-blind study to evaluate the efficacy of droperidol in the management of combative patients in the prehospital setting. Forty-six patients intravenously received the contents of 2-cc vials of saline or droperidol (5 mg). Paramedics used a 5-point scale to quantify agitation levels prior to and 5 and 10 min after administration of the vials. Twenty-three patients received droperidol and 23 received saline. At 5 min, patients in the droperidol group were significantly less agitated than were patients in the saline group. At 10 min, this difference was highly significant. Eleven patients in the saline group (48%) required more sedation after arrival in the ED versus 3 patients (13%) in the droperidol group. We conclude that droperidol is effective in sedating combative patients in the prehospital setting.

Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid.

The minimum volume of intraperitoneal fluid that is detectable in Morison's pouch with ultrasound in the trauma setting is not well defined. To evaluate this question, we used diagnostic peritoneal lavage (DPL) as a model for intraperitoneal hemorrhage and undertook a blinded prospective study of the sensitivity of ultrasound in detecting intraperitoneal fluid. Participants included attending physicians and residents in emergency medicine, radiology, and surgery. During the infusion of the DPL fluid, participants continuously scanned Morison's pouch until they detected fluid. All participants were blinded to the rate of infusion and the volume infused. One hundred patients were entered into the study. The mean volume of fluid detected was 619 mL. Only 10% of participants detected fluid volumes less than 400 mL and the overall sensitivity at one liter was 97%. We conclude that reliable detection of intraperitoneal fluid in Morison's pouch requires a greater volume than has been previously described.