The lumbar puncture (LP) procedure is commonly performed in the Emergency Department (ED). While minor complications of LP such as post-procedure headache or back pain occur somewhat regularly, significant complications such as post-procedural spinal hematomas, are rare.1 Despite their low incidence, these spinal hematomas are associated with a significant amount of morbidity for the patient and increased medicolegal risk for the provider.
There are many pitfalls the practicing Emergency Medicine practitioner can encounter, but hopefully avoid during their time in the ED. Bounceback patients, the ones who come back the next day, usually worse off than the day before, are definitely dreaded events that most would like to avoid. Of course, the ideal goal would be to never have that happen to you or your patients, but that is just not realistic. That’s why Bouncebacks! can be integral to anyone’s reading list.
In the emergency department (ED), failure to comply with discharge instructions has been associated with an increased rate of adverse outcomes for patients. 1,2 There is tremendous variability in the information that is provided to patients in discharge paperwork. In some EDs, a simple handwritten discharge note is given to the patient, while in others, extensive, diagnosis specific pre-created instructions are provided to patients at time of discharge. To improve patient outcomes and reduce their medicolegal risk, providers must recognize pitfalls associated with discharge instructions and include two key elements as a part of all discharge paperwork.
Cauda equina syndrome (CES), which occurs due to compression of the distal lumbar and sacral nerve roots, is a potentially devastating cause of back pain. CES is often missed on the patient’s initial visit which can lead to significant neurologic compromise in a matter of hours . To improve patient outcomes and minimize medicolegal risk, providers need to understand the limitations of the history and physical and carefully consider the diagnosis of CES in any patient with back pain.
Fluoroquinolones are a widely used class of antibiotic that are effective in treating a wide variety of infections. Despite their popularity there is increasing concern regarding to the potential complications associated with these agents. In 2008, the U.S. Food and Drug Administration (FDA) issued a black box warning involving fluoroquinolone use and an increased risk of tendon rupture. More recently in 2013 the FDA released another warning regarding the risk of peripheral neuropathy and required additional warnings to be added to the drug labels .
There is significant practice variability when providers are asked to determine if a patient is intoxicated. Some providers will evaluate a patient to determine if a patient is “clinically sober”, while other providers will rely on a patient’s blood alcohol concentration (BAC) to evaluate a patient’s level of intoxication. There is very little data to suggest that either approach is superior; however, both practice patterns have significant limitations and carry a certain degree of medicolegal risk.
Patients who leave the emergency department against medical advice (AMA) are at an increased risk of having a bad medical outcome, and can be a source of significant medicolegal risk to providers. Earlier we reviewed eight elements to address when signing a patient out AMA. There are two common myths regarding patients who leave AMA that can complicate an already difficult situation.