Medicolegal Briefs - The Case of the Wrist Injury

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Brian S. -

I am a relatively new Nurse Practitioner practicing in Urgent Care and E.R. I understand the theory behind being specific in detail with the patient's follow up instructions. However, has it been studied or considered that in some/many circumstances that if we are too specific in detail (if your.....continues for 14 days please follow up with.....) and there is a bad outcome at 7,10,12 days then we are then more responsible for that patient's outcome than if we simply suggest "if your...continues please follow up with...."?

Mike W. -

Hi Brian
Thx for the question and your thoughts! My recommendation is to be as specific as possible and have a short timeline. There is a lot of subtlety, but briefly, the timeline needs to be consisted with the disease process which is being evaluated. For example, for the unlikely RLQ eval where no testing is necessary, a timeline of 72 hours is too long as the risk of rupture is too high before this time. On the other hand, the 2018 ACEP position statement on low risk chest pain recommends a 1-2 week timeline for follow up. Interestingly, just this morning I recorded a whole medical legal briefs with an attorney focusing on d/c instructions... stay tuned to em rap!!!

gm -

The pricing data you mentioned seems low to me (perhaps it's the cost to hospital, not charge seen by patient?). I encourage you to look up your hospital's chargemaster (publicly available, google "hospital X chargemaster") and see what the pricing is for a wrist MRI at your hospital. Does this change your decision to order an MRI?

I looked at a local hospital's charges, upper extremity joint MRI was $`1,670. On top of a wrist x-ray of $449. Plus the reality is that, while it is might be possible to get an MRI quickly first thing in the morning, best case scenario it still adds another hour or two to this patient's stay to the detriment of whoever is in the lobby waiting for a chair. or a bed. Later in the day, it might delay the MR on the posterior CVA patient or the spinal epidural abscess patient in the bed/chair right next to the wrist patient. If you have ever been frustrated waiting for an emergent MRI because there's someone else on the table, wrist MRIs will only compound the issue, plus add to whatever charges the patient sees from the hospital. My vote is thumb spica and close followup!

Mike W. -

Thx gm, for the comments - yes, the pricing is wildly variable and will vary based on what the insurance will pay or if the patient even has insurance. Agree that unnecessary MRIs may cause a delay, so this certainly depends on ED volume and ability of MRI to do the scan quickly. Though a bit cliche, if MRI is an option, this is a perfect situation for shared decision making. For me as the patient, I would like the MRI, but I certainly would be comfortable as the doctor treating a patient who wants to just have splinting and a repeat XR. Thx for the thoughts!

Jesse I. -

Long time listener/first time commenter, and a big fan of both EM:RAP and your medicolegal segments specifically Mike. My reply is shaped in part by a year working in a small resource-limited community hospital in NZ (which has an MRI scanner), but this after 10 years in busy community EDs.

Your MRI-now recommendation (based on a perhaps incomplete cost analysis as the prior commenter suggests) to me seems short sighted. Outside of the NBA power forward or a manual laborer living paycheck to paycheck, who needs to know now? And please don't say ED physicians... we can ask for help. :) MRI in very select patients maybe... But to apply this recommendation to a large cohort of patients, and to a large audience of providers of variable physical exam skills and abilities, seems silly to me and wrought with unintended consequences, cost being one of many.

Who would you like to field the call from this patient when their insurance carrier denies coverage for the MRI? Or the ED referral from the urgent care provider or community ED doc requesting an MRI for the 8 y/o boy with a negative x-ray and a sore wrist?

What exactly is the harm of placing this patient with a clinical fracture in a splint or short arm cast and getting a repeat exam in one week by an orthopedic surgeon? For the office workers, school-age kids, and retirees that make up the majority of our ED wrist injury patients?

Thank you again for your continuing contributions to EM:RAP. We all benefit from hearing about these cases and understanding our risk.

Mike W. -

Hi Jesse, and thx for the comments! It has been my opinion for quite awhile that we under utilize MRI scans and in all honesty, my nonemergent use of them has been mainly for brain imaging and rarely to r/o scaphoid fxs. But I do believe this is a good opportunity for SDM and I agree most patients will opt for splinting and recheck w PCP, but that it should be offered, pending volume in the ED, etc. Your points are VERY well made and appreciated! On a side note, great to hear from New Zealand - I have spent quite a bit of time there and even worked picking boysenberries on a farm outside of Nelson - thx again for the comments and cheers!

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