In October 2011, the Centers for Disease Control and Prevention reported a 60% increase in “emergency department visits for sports– and recreation–related traumatic brain injuries, including concussions, among children and adolescents” over the past decade. That’s good news: as the CDC’s press release said, they believe the increase was due in part to “growing awareness among parents and coaches, and the public as a whole, about the need for individuals with a suspected TBI to be seen by a health care professional.” Great improvements have been made in terms of sports head injuries among kids, like through the CDC’s Heads Up initiative.
That’s the good news, but it raises an important question for emergency physicians and primary care physicians: are you ready for all the minor head trauma cases coming your way?
Viewed through a narrow lens, the solution to a suspected brain injury is obvious: if a kid complains about anything relating to their head, give them a CT scan. But CT scans come with their own costs and risks, not least exposing a developing brain to a year’s worth of background radiation.
I’m not here to tell you where the CT / no-CT line should be drawn. I can tell you, however, how I would draw that line as a medical malpractice lawyer when a parent comes in and tells me their doctor didn’t order a CT scan after a minor head trauma and their child later developed serious sequelae.
“Failure to diagnose” is most medical malpractice lawyers’ bread and butter. When we investigate cases, we use our own version of a differential diagnosis, scratching off every way we can lose until the case looks solid. Think jurors don’t understand the incremental risk of CT scans? Consider this sentence: “one head CT scan has more radiation than 20,000 trips through the TSA scanner at the airport.” We trial lawyers know the defense expert will say some version of that in front of the jury. We have to be ready to explain why it’s worth the risk.
Over the past few years there have been several major studies attempting to determine the indications of clinically significant TBI, including the National Emergency X-Radiography Utilization Study II (NEXUS II), and the Pediatric Emergency Care Applied Research Network (PECARN). There wasn’t, however, any clear synthesis of those studies’ findings until now, in “Evaluation of Minor Head Trauma in Pediatric Patients” by Dr. Amira Munas Bass and Dr. N. Ewen Wang, published in the January 2012 issue of Critical Decisions in Emergency Medicine.
Malpractice lawyers tend not to dwell on any particular publications, but we always like to know the latest empirical research before we decide whether or not to take a case, and the clearer the guidance, the better, both in taking strong cases and in rejecting weak ones. We know there’s a lot of medical malpractice out there, but the majority of our potential cases should not be pursued.
Based on the Bass-Wang article, we know that, if a primary care physician doesn’t send a child to the ED, or the ED discharges a child without a CT, after the child showed an abnormal mental status, emesis, evidence of a skull fracture or scalp trauma, or was the victim of a severe mechanism or fall from a great height, and the child develops serious sequelae, both NEXUS II and PECARN indicate the child’s symptoms should have indicated a clinically significant TBI. In contrast, if the only indications of a clinically significant TBI are the presence of a seizure or amnesia, then we similarly know under NEXUS II and PECARN that these symptoms may not have the same predictive value as was once believed.
In short, if you come into contact with pediatric patients who suffer minor head trauma, it may be time to brush up on your decision rules. You might just spare yourself a malpractice suit — not to mention save a life.
Maxwell S. Kennerly is an attorney who blogs at Litigation & Trial.
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