Top 5 Mistakes in the Emergency Room

More and more Americans rely upon the care received at their local hospital emergency department. Across the country, emergency departments have reported increased patient traffic for years; the most recent available estimates from the Centers for Disease Control and Prevention show a rise of 10 percent from 2008 to 2009.

In a 2011 poll conducted by the American College of Emergency Physicians, 80 percent of respondents said patient volume had increased “somewhat” or “significantly” during the previous year. What follows is a short discussion of 5 of the most common (and avoidable) mistakes which occur in hospital emergency departments:

  1. Failing to diagnose a ruptured abdominal aortic aneurysm. Making the diagnosis of a ruptured abdominal aortic aneurysm (AAA) is a true emergency. The condition is so grave that an estimated 50% to 70% of patients with a ruptured AAA do not survive long enough to make it to the emergency room. The classic presentation of a ruptured AAA is hypotension (abnormally low blood pressure), a pulsatile abdominal mass and acute onset of severe back or flank pain. Patients in the emergency department with these symptoms should immediately be seen by a surgeon.
  2. Failing to order antibiotics for patients with an open fracture. Too many patients to count arrive at their local emergency room with broken bones. Fortunately, most fractures are non-displaced and closed. An “open fracture” is a broken bone that penetrates the skin, creating a real risk for infection. The open versus closed distinction is important because when a broken bone penetrates the skin there is a need for immediate treatment, and an operation is often required to clean the area of the fracture. Intravenous antibiotics should be given as soon as possible after the diagnosis of an open fracture and then continued for 24 hours, with an additional 24 hours of coverage after operative repair.
  3. Failing to diagnose compartment syndrome and/or popliteal artery injuries resulting from knee dislocations and leg injuries. Compartment syndrome occurs when the interstitial pressure in a closed fascial compartment rises to the extent that it compromises tissue profusion (blood flow) resulting in injury to soft tissues and nerves. The clinical signs and symptoms of compartment syndrome include pain out of proportion to the injury, pain on passive range of motion, pallor, loss of sensation, and loss of distal pulses. The injury is most associated with tibial fractures (the larger and stronger of the two bones in the leg below the knee). The popliteal artery, through numerous smaller branches, supplies blood to the knee joint and muscles in the thigh and calf. It can be injured in a way which restricts blood flow to the lower leg, creating a medical/surgical emergency. Patients in the emergency room with suspected popliteal artery injuries should immediately be evaluated by a surgeon, who most likely will order radiographic testing to determine the extent of the problem.
  4. Failing to order chest x-rays for patients suffering from blunt chest trauma. Think about the typical rear-end automobile accident where the driver is violently thrown into the steering wheel or chest restraint belt. How about falling from a ladder and landing on your side or stomach. Both of these common events can cause “blunt chest trauma” which can result in a multitude of injuries to vital structures including the heart, tracheobroncial tree, lungs, ribs, sternum, spine, and diaphragm. A supine (patient lying face up) anterior-posterior (AP) chest x-ray should be one of the first radiographic studies ordered by the emergency room doctor. This type of chest x-ray is effective in the diagnosis of thoracic aortic injuries, a serious and life-threatening condition. Chest x-rays can also aid in diagnosing pneumothorax (collapsed lung), diaphragmatic hernias, pulmonary contusions, sternal fractures, and rib fractures.
  5. Failing to diagnose heart attacks in diabetic patients. Coronary artery disease (CAD) is very prevalent in patients suffering from diabetes mellitus. Diabetes is a risk factor for myocardial infarct or heart attack. The problem for diabetics is that many (as high as 90%) do not experience the tell-tale sign of angina (chest pain or discomfort that occurs when an area of your heart muscle doesn’t get enough oxygen-rich blood) when they are experiencing a heart attack. This means that emergency room doctors need to be extra vigilant in diagnosing diabetic patients. The index of suspicion must be elevated for the less classic presentation of myocardial ischemia including dyspnea (shortness of breath), congestive heart failure, pulmonary edema, syncope, and arrhythmias. Standard workups should include an electrocardiogram, serial cardiac enzyme markers, chest x-rays, echocardiogram, and continuous telemetry monitoring.