Rachel A. Lindor

Introduction: Shoulder dislocations comprise approximately half of all major joint dislocations evaluated in the emergency department. Despite often being considered a simple injury, diagnosing a dislocation can be difficult, especially when accompanied by a fracture associated with unusual mechanism, or when the physical examination is limited. Missed and delayed diagnoses can result in poor patient outcomes and legal risks for clinicians, necessitating a high level of vigilance. Case Series: We review three medical malpractice cases centered on the failure to recognize shoulder dislocations. Key issues included missed diagnosis, limited physical examination documentation, and inadequate discharge instructions. Conclusion: Shoulder dislocations can be challenging to identify, and missed diagnoses give rise to subsequent clinical and legal risks. Emergency physicians must maintain a high index of suspicion for this injury, recognize the limitations of standard imaging, and thoroughly document clinical decision-making during both initial evaluation and patient discharge.

Introduction: Prolonged emergency department (ED) wait times pose problems for both patients and ED staff. Poor patient outcomes can result in litigation that could have been prevented by faster access to care. Case Series: We present 10 lawsuits involving patients who experienced poor outcomes allegedly due to inappropriate management in the waiting room. These cases involved allegations of violations of the Emergency Medical Treatment and Labor Act (EMTALA) or general negligence and were levied against both the physicians and hospitals involved. Conclusion: Both common law and EMTALA’s medical screening exam requirements impose significant obligations on physicians and hospitals to proactively manage patients in the waiting room. Being familiar with these requirements may help minimize legal risks

Objectives: We describe the types of emergency department (ED) visits managed by non‐physician providers (NPPs), including physician assistants and nurse practitioners, and emergency medicine (EM) physicians, assessing shifts in care patterns over time.Methods: We used data from the National Hospital Ambulatory Medical Care Survey collected from 2009 to 2021. We classified visits by provider type: physician only, physician with resident, physician with NPP, and NPP only. We described characteristics of visits by provider type, including patient demographics, triage urgency, imaging, length of stay, and disposition, and analyzed using Poisson regression. We described the change in type of provider seen over this study period and further analyzed by triage urgency and hospital location.Results: Of 1.684 billion estimated ED visits from 2009 to 2021, 1.171 billion were managed by physicians without residents or NPPs (physicians only), 136.3 million by physicians with residents, 209.1 million by physicians with NPPs, and 167.4 million by NPPs only. Patients seen by physicians only were older, were triaged as having more urgent needs, had a longer ED length of stay, and were more likely to be admitted compared to those seen by NPPs only. Physician‐only visits decreased from 77% to 62%, while NPP‐only visits increased from 6% to 11%. The physician with the NPP group similarly grew from 9% to 17%. For visits assigned a triage urgency level of 2 (“emergent”), physician‐only visits decreased by 20%, physician with NPP visits increased by 13%, and NPP‐only visits increased by 3%. In metropolitan areas, physician‐only visits dropped 14%, with a 5% increase in NPP‐only visits. In non‐metropolitan areas, physician‐only visits decreased 17%, with a 9% increase in NPP‐only visits.Conclusions: The EM workforce has shifted, with NPPs seeing a higher percentage of patients, including both lower‐ and higher‐acuity patients. This shift is particularly prominent in rural areas but is evident across all regions.

Objective: We sought to characterize patients presenting to emergency departments (EDs) with abdominal pain and to validate risk categories defined by the Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE‐2) for low‐risk recurrent abdominal pain. Methods: We conducted a retrospective cohort study of patients presenting with abdominal pain between November 2019 and November 2023 across 21 EDs in Arizona, the Midwest, and Florida. Patients were categorized per GRACE‐2 into recurrent and non‐recurrent pain as well as low‐ and high‐risk groups. Primary outcomes included 72‐h returns and mortality at 30 and 90 days. Results: The study included 162,494 visits (112,896 unique patients; median age 46 years; 61.2% female). Among these, 4.3% had low‐risk recurrent abdominal pain. Patients with recurrent and non‐recurrent low‐risk pain had similar ED length of stay and discharge rates to each other, compared to patients with high‐risk pain who had longer length of stay and lower discharge rates. At 30 days after the ED encounter, patients with low‐risk recurrent abdominal pain had similar mortality to patients with low‐risk non‐recurrent pain (0.4% vs. 0.3%; adjusted RR = 1.31, 95% CI: 0.85–2.03), while they had significantly lower mortality than patients with high‐risk recurrent abdominal pain (0.4% vs. 2.3; adjusted RR = 3.14, 95% CI: 2.02–4.89). Conclusions: This study highlights the heterogeneity in patients presenting to the ED with abdominal pain. Among these patients, those with low‐risk recurrent pain demonstrated similar lengths of stay, discharges, and mortality rates to those with low‐risk non‐recurrent pain and less favorable lengths of stay, discharges, and mortality rates compared to those with any high‐risk features. These findings suggest that low‐ and high‐risk features may be more useful than recurrent or non‐recurrent pain in identifying patients who could benefit from more robust ED evaluations.

Pregnancy induces significant physiologic changes that impact the cardiovascular system, potentially exacerbating pre-existing cardiac conditions or precipitating new illnesses. Pregnant patients with cardiac emergencies pose unique challenges, as standard interventions may pose risks to the developing fetus. This article aims to enhance emergency physicians’ confidence in managing pregnancy-related cardiac emergencies by providing a structured approach to initial evaluation and stabilization. We review eight common categories of pregnancy-associated cardiac illness: gestational hypertension and pre-eclampsia, cardiomyopathy, arrhythmias, valvular disease, aortopathies, congenital heart disease and pulmonary hypertension, coronary disease, and anticoagulation-related complications. For each condition, we summarize relevant pregnancy-specific pathophysiology and outline evidence-based, personalized emergency management strategies.

Introduction: Bell palsy, an idiopathic dysfunction of the seventh cranial nerve, is the leading cause of unilateral facial paralysis, although other more serious entities such as stroke, infection, and tumor may present similarly, leading to both medical and legal risks in cases of misdiagnosis. Case Series: We present four malpractice cases revolving around misdiagnosis of Bell palsy. These cases alleged failure to diagnose, failure to obtain informed consent, and failure to provide appropriate discharge instructions. Outcomes ranged from a jury verdict in favor of the physician, to an out-of-court settlment for $400,000, to a jury verdict in favor of the patieint for over $3.1 million. Conclusion: Bell palsy is the most common cause of unilateral facial paralysis. While the diagnosis can be made at the bedside without advanced testing, doing so requires a clear understanding of the pathophysiology of the disease, an appreciation for the role of advanced diagnostics, and thorough documentation of a supportive history and physical exam. Misdiagnosis or mismanagement confers both clinical and legal risks.

While congenital heart disease historically was a pathology primarily restricted to specialized pediatric centers, advances in technology have dramatically increased the number of people living into adulthood, the number of complications faced by these patients, and the number of patients visiting non-specialized emergency departments for these concerns. Clinicians need to be aware of the issues specific to patients’ individual congenital defects but also have an understanding of how typical cardiac pathology may manifest in this special group of patients. This manuscript attempts to provide an overview of this diverse but increasingly common group of adult patients with congenital heart diseases, including a review of their anatomical variants, the complications they face at the highest rates, and ways that emergency physicians may need to manage these patients differently to avoid causing harm.