Refer to: Phillips LA: Skull radiography and professional liability (Information). West J Med 131:82-83, Jul 1979
Skull Radiography and Professional Liability LEON A. PHILLIPS, MD, Seattle IT IS WIDELY ASSUMED by emergency physicians that skull roentgenograms provide a measure of protection against malpractice actions. This belief is at least partly responsible for the 6 to 8 million radiographic examinations of the skull done every year, which cost an average of $50 each. The following two cases suggest that allowing normal findings on x-ray films of the skull- to influence clinical decisions is perhaps more dangerous than failing to request skull radiography.
Reports of Cases CASE 1. An 11-year-old boy was injured in a schoolyard fight. He was taken to hospital where radiographic examination of the boy's skull was carried out and he was seen by at least two resident physicians and an attending physician. No abnormalities were noted on the x-ray films of the skull and a complete clinical evaluation was not made, no provision was made for further careful observation and no head trauma instruction sheet was given to the boy's father. Approximately two hours after release the boy was brought back to the hospital by his father. Another physician immediately recognized an epidural hematoma and contacted a neurosurgeon, who responded belatedly due to an automobile accident en route to the hospital. An epidural hematoma was removed too late to prevent quadriplegia with aphasia. A skull fracture was identified at operation and a record $4,025,000 award was made in the professional liability suit that
followed."12 The author is Associate Professor of Radiology, University of Washington School of Medicine and University Hospital, Seattle. Reprint requests to: Leon A. Phillips, MD, Dept. of Radiology, SB-O5, University of Washington School of Medicine, Seattle, WA 98195.
JULY 1979 * 131
CASE 2. A 24-year-old man came into the emergency facility at a university hospital. He said that he had been struck above the right ear by the tip of an umbrella which had been thrown at him. The umbrella had stuck in his head and it was necessary for his brother to pull it out. The patient was seen by two physicians, one a neurosurgical resident. Both noted a 1 cm laceration above the right ear and some numbness over the nose, upper lip and roof of the mouth. Good quality x-ray films of the skull were made and interpreted as normal. The chief neurosurgical resident was telephoned and he advised having the patient return to the clinic nine days later. On the following day the patient visited the outpatient department of another hospital. A physician there, impressed with the man's story, ordered additional x-ray studies and tomography, which showed fragments of bone about 2 cm inside the skull. Craniotomy was carried out and the fragments were removed. After release from hospital the man consulted an attorney about bringing suit against the university hospital. Apparently he was advised against legal action because there was no physical impairment or permanent damage.
Discussion In both cases x-ray films of the skull showed no abnormalities, and for this reason careful clinical evaluation and observation were neglected. Searches of the medical and legal literature, and information from professional liability insurers, have suggested that physicians are much more likely to be sued for missing a fracture on x-ray films of the skull than for not requesting the films.3'4 As a matter of fact, the author has been unable to document a single case in which a physician was sued for malpractice for nQt obtaining x-ray films of the skull after careful clinical evaluation and observation. During the past several years we have reviewed all skull roentgenograms requested from the emergency facility of the University of Washington Hospital, and have completed two projects for the Bureau of Radiological Health and the Washington State Professional Standards Review Organization involving the evaluation of more than 3,600 skull radiographic examinations done at Harborview Medical Center.5 6 Results of these studies have suggested that at least 80 percent of all emergency facility skull radiography is un-
necessary or misleading and probably increases malpractice jeopardy because of inevitable false negative reports. Skull radiography simply does not rule out skull fracture or brain damage. Our recommendation for the faculty of the University Hospital emergency facility is that no x-ray films of the skull be made immediately when patients present with head trauma. If after careful clinical evaluation and observation one of the following "high yield criteria" is present, cranial computerized tomography should be requested: * Unconsciousness (including cases of alcoholic patients who cannot be aroused) or a documented decreasing level of consciousness at the time of arrival at the emergency facility after metabolic and seizure disorders are excluded as the cause of unconsciousness. * Skull depression palpable or identified by probe through laceration or puncture wound. * Unexplained focal neurological signs.
Skull radiography should be requested only when indicated to confirm findings from computerized tomography. REFERENCES 1. Martin M: That record malpractice award-Why $4,025,000? Med Economics, Jul 23, 1973, pp 120-148 2. Niles vs Mt. Zion Hospital and the City of San Rafael. 42 Cal App 3 ed, 116 Cal Rptr 733, 1974 3. Summary of Malpractice Closed Claims. National Association of Insurance Commissioners (Milwaukee, WI) Vol 1: No 4, May 1977 4. Malpractice Digest. Sep/Oct 1978, p 5 5. Phillips LA: A Study of the Effect of High Yield Criteria for Emergency Room Skull Radiography, DHEW Publication No. 78-8069. US Dept of Health, Education, and Welfare, FDA, Jul
1978 6. Phillips LA: Emergency Facility Skull Radiography. Report submitted to DHEW/Public Health Service, Bureau of Radiological Health and Health Care Financing Administration (Washington State PSRO), Aug 1978
Refer to: Southern Medical Association meeting in Las Vegas (Information). West J Med 131:83, Jul 1979
Southern Medical Association Meeting in Las Vegas FOR THE FIRST TIME the American Medical Association's Council on Continuing Physician Education will be presenting a series of 22 postgraduate courses in conjunction with the Southern Medical Association at its annual Scientific Assembly, November 4 through 7, 1979, in Las Vegas. The courses as well as the total scientific program are planned to offer a variety of subjects for all major specialties. The Southern Medical Association presents an outstanding convention with 21 section programs in the various specialties, more than 200 exhibits, social and educational events for spouses, a president's reception and dance, and other activities. This is the first assembly that the Southern Medical Association has planned outside the southeastern area. Physicians may request literature on the courses from the AMA Department of Meeting Services, 535 North Dearborn Street, Chicago, IL 60610, or on the total convention from the Southern
Medical Association, 2601 Highland Avenue, Birmingham, AL 35205.
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