The Verdict is In
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What's Your Approach to Supervision?

A 52-year-old-male presented to the ER for R leg weakness starting 30 minutes prior to arrival. This patient had been previously seen in the ED multiple times for different complaints related to altered mental status, seizures, substance abuse, and being immunocompromised secondary to HIV. He was seen by the resident and a stroke alert was activated. He was afebrile with normal vital signs. His labs showed a leukocytosis of 13 and elevated INR of 2.0. After the CT brain was negative for any acute intracranial process, a lumbar puncture was attempted multiple times by the resident (and presumably the supervising physician) due to his persistent altered state to rule out meningitis. After several attempts were unsuccessful, there was an order for IR to perform the LP. Upon that attempt, the interventional radiologist immediately detected blood in the intradural space.

Two days later the patient was able to move all four extremities but had a significant strength decrease and limited movement of his right leg. An MRI brain showed bilateral subarachnoid hemorrhage. Days passed and the patient remained in the hospital. Two weeks after the onset of symptoms he developed complete inability to move both his lower extremities and had bowel incontinence. After a T and L-spine MRI, he was diagnosed with a thoracolumbar epidural abscess and hematoma and underwent laminectomy for evacuation. Eventually he was discharged to a rehab unit with the discharge diagnoses of bilateral lower extremity weakness, urinary retention, and probable clumping of the lumbar nerves. The patient alleges he continues to have significant disabilities and the physicians were sued.

Multiple defense experts were critical of the ED care. One opined it was not reasonable to do a lumbar puncture on a patient with an INR of 2.0. This expert felt an MRI of the brain should have been performed before deciding to proceed with a lumbar puncture; and, in the meantime, the patient could have been treated with antibiotics and antivirals (if meningitis was their concern) while methods were used to bring down the INR. Another expert explained there are no rules regarding a maximum INR for performing a spinal tap. Consideration of the INR in conjunction with the spinal tap is based on the physician’s clinical judgement. Yet, if the patient is anticoagulated for an "important condition," it may be reasonable to perform the LP without reversing the INR. An informed consent of the risks involved would need to be discussed. Discussion of risks were not documented anywhere in the record. This expert also said under this condition the LP should have been performed only by experienced physicians and, in this case, it would have been better to only attempt under fluoroscopic guidance. A third expert felt the LP was indicated because viral meningitis is in the differential when a patient is HIV-positive. But, this expert said she would have reversed the INR first. This expert also opined on causation stating it is likely the multiple blind LP attempts in the ED were the underlying cause of blood in the patient’s dura.

The Verdict Image

When strategizing the defense for the ED attending, there were a few points of discussion in addition to the statements mentioned by the experts above. Was there negligent supervision? The attending reported he has no recollection of this case and has no explanation as to how the events could have occurred. There was no documentation of the indications for the procedure, no documentation of informed consent for the procedure, and no documentation of a procedure itself. It was determined for patients of this complexity more documentation from the attending reflecting supervision was indicated. Even if minimally involved, the attending could be on the hook for 50% of the liability for negligent supervision.

Survey Questions

1. True or False: As an ED attending, if you supervise advanced providers or residents, you should take time to review test orders and results. You should have clear supervision guidelines in place.

  1. True
  2. False

2. LP is a relatively safe procedure, but minor and major complications can occur even when good technique is used. These include:

  1. Post-LP headache
  2. Infection
  3. Bleeding
  4. Spinal hematoma
  5. Cerebral herniation
  6. Neurologic symptoms such as radicular pain or numbness
  7. Back Pain
  8. All the above

3. True or False: When a patient has mental capacity, an informed consent discussion of the risks, benefits, and alternatives related to an invasive procedure needs to be documented in the patient’s medical record.

  1. True
  2. False

4. We are unaware of any significant clinical studies that have systematically examined interventions to reduce the risk of bleeding following an LP based upon the degree of thrombocytopenia or clotting study abnormalities. Therefore:

  1. It is not within the standard of care to perform an LP on patients with abnormal platelets or an elevated INR
  2. The guidepost is "clinical judgement." In all cases, the relative risk of the procedure must be weighed against the potential benefit. In cases where the LP is considered necessary, but the risk of bleeding is high, one should then determine the safest means possible to perform the procedure

5. Why is supervision important?

  1. You don't know what you don't know, until you know it
  2. Sometimes two sets of eyes are better than one
  3. It is important for patient safety
  4. Liability varies according to state law, but in general, a supervising physician should consider all healthcare providers they supervise as extensions of themselves. Supervising physicians have an obligation to ensure patient care is within the standard of care when delegating care to others
  5. All the above


Relias Media: TNever even saw the patient? You still might be liable, if supervising
UpToDate: Lumbar puncture: Technique, indications, contraindications, and complications in adults