Hot Seat #162: Denouement

Posted on: December 22, 2020, by :

Discussion: There was a lot of discussion regarding disclosing adverse events to patients. All participants agreed that being forthcoming with families and patients is paramount. However, the nature of this patient’s situation (a possible error occurred outside of the emergency department, but while the patient was still under the care of an ED physician), is challenging. Ultimately, participants felt that the individual most directly involved in the patient’s care at the time of an error should disclose, but in the event that this person is unable to disclose, the responsibility belongs to the attending physician.

A note on medical management: After discussing the ethical challenges of this case, discussion shifted to the medical management, specifically identifying mandibular fractures. The case alluded to difficulty biting down on a tongue depressor (officially known as the “tongue blade test (TBT).”). A publication in 2013 investigated the accuracy of this test, finding that the TBT had a sensitivity of 95% and NPV of 92% for detecting mandibular fractures (as compared to CT). In terms of radiographic diagnosis, a few participants brought of the possibility of using panorex given the family’s hesitation to undergo a second CT. Historically, panorex had been the imaging modality of choice, but recent literature in adults has shown CT to have better sensitivity in comparison to panorex. In children, who tend to fracture the condylar region (>50% of facial fractures), CT has been shown to have significantly better sensitivity (92% vs 70%) and specificity (87% vs 77%), when compared to panorex.

In conclusion, my takeaways from this case were: 1.) errors happen, but it is our job to disclose them to patients and families as soon as possible, 2.) the ‘tongue blade test’ (something many of our patients do without us even asking) has excellent NPV when used to evaluate for a mandibular fracture, and 3.) if you want to evaluate for mandibular fractures, choose a CT.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Brian Lee
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