Tuesday, May 8, 2007

Law and Medicine Rounds

By Dainius A. Drukteinis, M.D., J.D.

“The only real mistake is the one from which we learn nothing.”
- John Powell

Radiology Hearsay in the Emergency Department

How often have you spoken with radiology on the phone before an official report has been dictated? An emergency medicine physician in Louisiana recently found his understanding of radiology findings at odds with the dictated radiology report. See Spillman v. Southwest Louisiana Hospital Association, 2007 U.S. Dist. LEXIS 25547 (April 4, 2007).

In Spillman, a child was brought to an emergency department and a CT scan was obtained to rule out appendicitis. Radiology called an emergency department nurse with the result. The nurse then relayed the result to the attending physician,
“...appendix area looks okay. No mass or inflammation noted.”
Once the patient was discharged, radiology dictated a report which stated,
It was later determined that the child had a ruptured appendix.

Whether or not you believe the radiologist changed the findings, this miscommunication could have been further compounded had the nurse told a resident, who then told the attending, who then signed out the patient to the oncoming team.

The scenario quickly begins to look like the childhood game of telephone. It is for this reason that courts frown upon hearsay evidence, and that written communication tends to be given more weight than oral communication. That is not to say we should never rely on oral communications by radiology or other services in the hospital. However, we must be wary that in our desperate need to disposition patients quickly, there are many ways that essential communication can break down and harm our patients.

This case was ultimately decided in favor of the doctor on different grounds.

Dainius A. Drukteinis, M.D., J.D. is a fourth year Emergency Medicine Resident at NYU/Bellevue Hospital. He may be contacted at ddrukteinis@gmail.com


EM Rez said...

Interesting case. ED physicians often take verbal reads from the radiologist in one form or another, often to maintain throughput of the ED. "Official" reports often are much delayed and waiting for the report to appear in the pacs would surely add to congestion. I have personally discussed cases with radiologists, only to find an addendum that had been added later which in some cases would affect my management of the patient. Are there any solutions that are offered? Does ACEP have an opinion on this? By the way, which doctor won the case, I assume you mean the ED doctor.

Dainius said...

This is a problem that we face every day. As you have noted, some institutions do not transcribe the "official" report until much later. For instance, some hospitals have residents read films overnight and the attending radiologist might not dictate the "official" report until the following afternoon. It might be too late by the time the patient is called back. I am not aware of an ACEP guideline on this issue. Certainly, understanding the limitations of your own hospital's system is important, and should be factored into your final decision, with the clinical picture weighing more heavily when the gravity of the entertained diagnosis is severe.

scalpel said...

Our radiology dictations are transcribed pretty quickly (almost immediately) so I will usually wait to read the written report before dispositioning my patients. I've been burned before with an added "incidentaloma" that wasn't mentioned in the verbal report, but it certainly was dictated as "discussed with Dr. Scalpel."

When the dictation is occasionally delayed, I will document my conversation with the Radiologist and note his impression in the chart.

Dainius said...

That is another great example of how oral communication can break down, creating potential liability. It is not necessarily ill intentions, but true miscommunication between hospital departments. This is not limited to radiology and the emergency room. This can happen between any two services. You are lucky that most of your dictations are done almost immediately. Documenting your conversation in the chart, as you understood it, is required as a bare minimum. Unfortunately, it will never be as good as waiting for the final read.