Original Contribution
Analysis of lawsuits filed against emergency physicians for point-of-care emergency ultrasound examination performance and interpretation over a 20-year period

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Abstract

Objective

The study aims to define extent of lawsuits filed against emergency physicians (EPs) over point-of-care emergency ultrasound (US) during the last 20 years.

Methods

We performed a nationwide search of the WESTLAW legal database for filed lawsuits involving EPs and US. WESTLAW covers all state and federal lawsuits dating back to 1939. Using an electronic search feature, all states were searched using emergency and US as key words. The database automatically accounts for different variants on US such as sonography. An attorney who is also boarded in and practices emergency medicine, as well as an emergency US expert, reviewed returned cases. Descriptive statistics were used to evaluate the data.

Results

Using the search criteria and excluding obvious radiology suits, 659 cases were returned and reviewed. There were no cases of EPs being sued for performance or interpretation of point-of-care US. There was one case alleging EP failure to perform point-of-care US and diagnose an ectopic before it ruptured. This case was won by the defense. There were no cases against EPs for common causes of radiology and obstetric litigation including sexual assault during endovaginal US. Cases of missed testicular torsion on US were frequent in the emergency setting but none linked EP US.

Conclusions

Only one case filed against EPs over the last 2 decades was identified, it was over failure to perform US. Most frequent litigations against radiologists and obstetricians are unlikely to be duplicated in the emergency department, and future litigations may also come from EP failure to perform point-of-care US.

Introduction

Recent years have seen a tremendous increase in ultrasound (US) use by emergency physicians (EPs) [1], [2], [3], [4], [5], [6]. What was more of an academic interest 2 decades ago has now reached common topic status. Over the last 15 years, the American College of Emergency Physicians (ACEP) has created multiple documents on US guidelines, performance standards, and billing [1], [2], [3], [4]. Concomitantly, developments outside emergency medicine, including the AHRQ report from 2001, which mandated US guidance for central line placement, are pushing emergency US to many community emergency medicine practices [7]. Residency training now mandates US education, and US is regularly tested on residency in-service examinations as well as both written and oral boards. Table 1 lists the US applications described in the 2008 ACEP US guidelines [3]. The 2 categories distinguish between core applications and those that are more advanced and less frequently performed. However, many EPs already in community practice did not receive US training in residency and are left to catch up [5].

Unlike adopting new practice mandates such as goal-directed resuscitation for sepsis or the change to rapid sequence intubation many years ago, becoming proficient in US is more time and work intensive. In addition, there is a specter of liability for possible missed diagnoses or incorrect treatment. Several groups have encouraged this fear by speaking out against EPs' use of US in clinical practice [8]. Even recently, editorials have been directed at large audiences speaking out against point-of-care US and raising more fears about liability [9]. Various e-mail list discussions and blogs for emergency US groups periodically discuss alleged litigation generated by EP US misses but never seem to actually amount to identifiable cases.

Although considerable angst has been generated about liability encountered by EPs when using US and anecdotal urban tales exist about critical misses leading to poor outcome, no objective data have been published on the topic. It is logical to expect multiple lawsuits against EPs for US use just as for other types of cases. In addition, if concerns are valid, there should be a large body of litigation making it clear that EPs are at risk when using US in their practice. Lastly, it would be helpful to establish the pattern of lawsuits to date to increase practice safety. We sought to define the extent of lawsuits filed against EPs over point-of-care emergency US performance and interpretation during the last 20 years by searching a nationwide legal database.

Section snippets

Study design

This was an observational retrospective cohort study design, approved by the institutional review board with waiver of written informed consent because no patient data would be collected from the legal database.

Study protocol

We performed a nationwide search of the WESTLAW legal database for filed law suits involving EPs and US. WESTLAW covers all state and federal lawsuits dating back to 1939. We chose to focus on the previous 20 years because there are no documented cases of routine point-of-care US use by

Results

All federal and state cases were searched focusing on the last 20 years. Using the search criteria and excluding obvious radiology suits, 659 cases were returned and individually reviewed. Each of these cases were individually reviewed. Table 2 lists the categories of US types returned among the initial 659 cases shown by our search. Cases in which the EP and radiologists were being sued, but the EP did not perform the US, as in all of the testicular US cases we found, were excluded. There were

Discussion

The question of liability is an important one and can affect not only how clinicians may use point-of-care US but also how quickly its use spreads through emergency medicine [10]. As most academic facilities are now considered saturated with point-of-care US, the remaining growth will occur in the community practice setting [3]. This is also the setting most sensitive to the perception of liability and risk because there is no sense of protection from a university or a teaching setting.

The

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Presented at the 2007 ACEP Scientific Assembly in Seattle, Washington.

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