By Angela

Mistakes Made by ER/Urgent Care Doctors

Angela was at home now, waiting for her insurance agent to call her back. When Marie, her sister, walked into the family room, she knew something wasn’t right. Karyn, a friend of Angela’s, was sitting on the couch, and Angela appeared very distraught about something. “Is everything all right?” Marie asked.

“Well, I went to get cat litter. It was a good day. I’m waiting for him to call me back, and it’s been 40 minutes. I think I need to go to Urgent Care. I found a lot of conferences to present at, until I looked in my rear-view mirror. I watched him coming at me in the mirror, until he didn’t stop and he hit me,” Angela answered in a shaky voice. Confused by her sister’s response, Marie glanced at Karyn and said, “What’s going on? Someone hit you?”

Translating Angela’s scattered thoughts, Karyn said, “A young kid hit Angela’s car while she was stopped in traffic and caused a lot of damage to her car. They had to tow it. Angela’s neck and shoulder are hurting pretty bad now and she wants to go to Urgent Care, but can’t until her insurance agent returns her call. It started out as a good day until all of that happened.” Marie and never heard her sister sound so ditzy. Half jokingly Marie told her, “Sounds like he knocked a few marbles loose, too. You’re not making a whole lot of sense. It probably is a good idea to get yourself checked out.”

“I’m going to call the company’s 800 number. I’ve got a horrible headache from this whole ordeal, and I want to go to Urgent Care because my shoulder blade and neck are hurting so bad! I don’t get it,” said Angela, as she reached for the Tylenol.

************

“So we’re seeing you today because you were in a car accident?” the nurse asked. “Yes,” Angela said and then recounted the accident to the nurse.

“Can you tell me your name? (Angela Cramer) Where you are right now? (Urgent Care) What day is it? (The 16th) Did you hit your head? (No) Did you lose consciousness? (No). “Oriented x3. No LOC,” the nurse wrote on her chart. “Are you feeling any pain? (Yes) Tell me about it.”

“My neck is hurting really bad, and my right shoulder blade. I don’t know why my shoulder blade is hurting. It doesn’t make sense. And there’s this burning sensation that went from my right shoulder blade across to my left shoulder blade,” Angela told the nurse, perplexed by both the location and the burning sensation. X-rays were taken, and Angela waited in the exam room for the doctor to return with some answers.

“Good news,” he said. “Nothing’s broken. It’s probably just soft tissue damage. I’m going to write you a prescription. Take these pills and use a heating pad for the pain.”

——————————————

Mistakes in the ER and Urgent Care:
Faulty Diagnostic Procedures

According to the CDC, ER departments treat and release 1.1 million out of the 1.4 million people who sustain a TBI in the US each year. Roughly 28% of these brain injuries result from falls, 20% from car accidents, 11% from assaults and 19% result from being struck by something. Yet as I think about my own experience, I wonder how many people are misdiagnosed by ER doctors.

Problem 1: ER doctors fail to educate patient about potential for MTBI and symptoms to monitor.

Traumatic brain injury is a process. While some patients present with clear signs and symptoms from the onset, such as loss of consciousness or coma, other patients may have more subtle signs and symptoms of TBI which can take days or even weeks to appear. They may look fine to others and they, themselves, may only have a vague feeling that they don’t quite feel right but can’t really put their thoughts into words. As I pointed out in the opening section, 75 – 90% of brain injuries will be concussions or mild traumatic brain injury (MTBI). And while these symptoms appear mild, they can lead to life-long disabilities.

Knowing this information, one would think that ER and Urgent Care doctors would understand this about a condition that occurs on such epidemic levels and treat patients accordingly. They should be well informed about: 1) events which are likely to produce head injuries, 2) the various ways in which brain injury can present, and 3) the progression of a brain injury. It makes sense that since these doctors are among the first people to whom potential TBI victims turn, they should be responsible for saying to the patient something like:

“You experienced a situation which can produce a brain injury. I don’t see any signs of that right now, however, brain injury can take several days or weeks to progress. Here are some signs and symptoms of concussion that you or the people you live with should know. If you have problems with any of these, you should follow up by making an appointment with your primary care physician.”

When I look back on my own experience and the experiences of others with mild traumatic brain injury (MTBI), or post-concussive syndrome, this did not happen. ER and Urgent Care doctors seem to treat patients based upon the question: “Is this person likely to die on my watch or in the next 3 days?” If not, the doctors do what is needed to quickly ship the patient out of the ER. In my case, I was told that nothing was broken and that I probably only had some soft tissue damage, leading me to believe that I was fine.

Problem 2: ER doctors often rely on the injured person’s report.

Does it honestly make any sense that a doctor would ask a patient: “Did you lose consciousness?” If someone who was alone during the accident lost consciousness, would they really be aware of it? Unless someone who was there at the scene of the injury told the injured person that they lost consciousness, how would s/he really know? They may have been sitting in their car for 20 minutes waiting for the police to show up and think that only 5 minutes passed; if asked, this person would not be aware that anything was out of the norm.

In situations like these, medical staff needs to question other individuals who may have come along with the injured person. With a potential brain injury, the patient is not the most reliable source of information. A friend or family member will also have better insight as to whether the patient is behaving normally or not.

Problem 3: ER doctors fail to do adequate assessments.

Doctors administer little more than the Glasgow Coma Scale, which assesses a person’s level of consciousness. While this is useful for more severe injuries, it is not intended as a tool to distinguish between other milder types of brain injury. Yet these “milder” types of brain injury are actually responsible for some very serious, long-term consequences.

In situations which are likely to produce a head injury, ER doctors should also be assessing for concussion and other forms of brain injury. Instead of only responding to what the patient is reporting, they should realize that this person may be disoriented and not thinking clearly and should ask questions and make observations which relate to symptoms of concussion:

Do you have a headache?

Are you experiencing any dizziness or nausea?

If a friend or family member who was familiar with the patient was not present to ask about their observations of the patient’s behavior which may be abnormal, an information sheet should be sent home telling them what to observe.

For more information about MTBI and an example of the kinds of things ER physicians should also be assessing, click on one of the highlighted links below.

Click here for Heads Up – Facts for Physicians booklet

Click here for Heads Up – Acute Concussion Evaluation (ACE) form


Problem 4: ER doctors fail to assess whether the patient may have post traumatic amnesia or if the patient is in a confusional state.

Patients with brain injury may experience holes or gaps in their memory for events immediately before the accident (retrograde amnesia) or for events after the accident (anterograde amnesia). Some patients who can’t remember or are fuzzy on certain details, compensate by making up answers to fill in the blanks of their faulty memory. Evidence of amnesia is critical since the length of amnesia may be a better predictor of brain injury severity rather than whether or not a person lost consciousness.

With this in mind, ER doctors need to ask a few more detailed questions of the patient and any other pertinent individuals (i.e., ambulance driver, EMTs, friend, family member) to determine any evidence of amnesia or confusion.

—————————–

Consider Angela’s interview with a neuropsychologist and some very different information he was able to get from the questions he asked. This kind of questioning and information, provides a very different assessment of just how serious her head injury may have been. A much different perspective than the Urgent Care doctor who did not consider that this was even a possibility.

Q: Tell me about the accident. Did you hit your head?

A: No.

Q: Did you lose consciousness?

A: No.

Q: Did you experience any amnesia?

A: (This was a different question. No one had asked her that before.) No, I didn’t experience any amnesia. I had problems remembering what people were saying to me and what I said to other people, but I remember everything about the accident quite well. Watching him come at me in my rear-view mirror. Sitting in the police car talking to him.

Q: How did you get in the police car?

A: Uh, well. (She had to think about this question.) I remember we were sitting on the other side of the road waiting…umm, waiting for something.

Q: Did you walk over to it from your car? Were you standing in the road waiting for the police? Did you both get in at the same time—or did you get in first?

A: Well, I remember going back to my car after yelling at him. I was sitting in my car waiting for the police to show up. And then I was sitting in the back of the police cruiser, apologizing to him for yelling at him. The policeman must have pulled up to my car and then I got in from my car.

Q: Do you remember doing that or are you guessing?

A: Oh, ummm. Well, I don’t remember how I got into his car. I was just there.

Q: Where did you go after the accident?

A: Home.

Q: How did you get there?

A: My friend, Karyn, picked me up.

Q: How did Karyn know where to pick you up?

A: I called her. No, I couldn’t have called her because I didn’t have a cell phone at that time. The policeman must have called her.

Q: Do you remember him calling her or are you guessing?

A: Well, he must have since I didn’t have a phone.

Q: You said that you went to Urgent Care a few hours after the accident. How did you get there?

A: I drove myself. No, that’s not right. My car was towed. Maybe it was my sister….no, she probably had to wait for my nephew to get home from school. No, I mean, um….it was July so he wasn’t in school. Karyn probably took me there, because my nephew would have been home with my sister.

Q: Do you remember riding in her car or going into Urgent Care with you?

A: Well, not really, but I’m sure it must have been Karyn who took me there.

That’s when Angela finally understood the statement, “Sometimes you don’t know what you don’t know.”

————————————————–

Points to Consider:

1) If you know someone who has suffered a jolt or blow to the head, make sure someone accompanies the person to the ER or Urgent Care. This person’s role should be to:

a) communicate to medical staff the events surrounding the injury,

b) share observations of the injured person, such as any abnormal changes in the person’s behavior or functioning,

c) ask questions or clarify information, and

d) remember what was done or said during the visit.

2) Ask the doctor:

a) Is there a possibility of a concussion?

b) What kind of problems or symptoms should necessitate a follow-up visit with the patient’s PCP?

3) Don’t just trust that the doctor will tell you what you need to know. Educate yourself and the injured person on signs of a concussion by reading the following fact sheet for patients put out by the CDC.

Click here for Heads Up – Fact Sheet for Patients. Scroll down to page 2 to find “When to Call the Doctor: Signs and Symptoms of Concussion.”

4) Don’t trust that the injured person’s PCP will be knowledgeable regarding concussion. Educate yourself about concussion by reading the pamphlet put out by the CDC called “Heads Up – Facts for Physicians about Mild Traumatic Brain Injury.”

Click here for Heads Up – Facts for Physicians about Mild Traumatic Brain Injury.

© Angela Cramer, 2008

Photos and clipart are the property of Jupiterimages made available through subscription:
© Jupiterimages Corporation, 2008 www.clipart.com


———————–

Sources:

G. Gioia & M. Collins. “Heads Up: Acute Concussion Evaluation (ACE) form.” Heads Up: Brain Injury in Your Practice – A Tool Kit for Physicians. 2006. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. 13 Oct 2008. <http://www.cdc.gov/ncipc/tbi/ACE.pdf&gt;

Heads Up: Brain Injury in Your Practice – A Tool Kit for Physicians. 14 June 2007. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. 13 Oct 2008. <http://www.cdc.gov/ncipc/tbi/physicians_tool_kit.htm&gt;

“Heads Up: Fact Sheet for Patients.” Heads Up: Brain Injury in Your Practice – A Tool Kit for Physicians. U.S. Department of Health and Human ServicesCenters for Disease Control and Prevention, National Center for Injury Prevention and Control. 13 Oct 2008. <http://www.cdc.gov/ncipc/tbi/Heads_Up_factsheet_english.pdf&gt;

“Heads Up: Facts for Physicians about Mild Traumatic Brain Injury.” Heads Up: Brain Injury in Your Practice – A Tool Kit for Physicians. U.S. Department of Health and Human ServicesCenters for Disease Control and Prevention, National Center for Injury Prevention and Control. 13 Oct 2008. <http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf&gt;

Johnson, Gordon. “Amnesia and Brain Injury.” 25 Mar 2008. Brain Damage Blog – Attorney Gordon Johnson. 16 Oct 2008. <http://tbilaw.blogspot.com/2008/03/amesia-and-brain-injury.html&gt;

Johnson, Gordon. “CDC Acute Concussion Evaluation – Improved Process.” 03 Apr 2008. Brain Damage Blog – Attorney Gordon Johnson. 16 Oct 2008. <http://tbilaw.blogspot.com/2008/04/cdc-acute-concussion-evaluation.html&gt;

Johnson, Gordon. “The Need for Periodic Followups after a Concussion.” 04 Apr 2008. Brain Damage Blog – Attorney Gordon Johnson. 16 Oct 2008. <http://tbilaw.blogspot.com/2008/04/need-for-periodic-followups-after.html&gt;

TBI Home page. 23 Sept 2008. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. 13 Oct 2008. <http://www.cdc.gov/ncipc/tbi/TBI.htm&gt;

Thurman D, Alverson C, Dunn K, Guerrero J, Sniezek J. Traumatic brain injury in the United States: a public health perspective. Journal of Head Trauma and Rehabilitation 1999; 14(6): 602-15.

Go Back to When Doctors Hurt, Instead of Help


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