Underestimating symptoms in the ED - legal and professional consequences

As a doctor with many years of experience in emergency medicine, having been on duty in both the largest hospital east of the Vistula River and in smaller county hospitals, I understand very well the realities of working in the Hospital Emergency Department. I know the time pressure, the constant flow of patients, the chronic shortage of staff, and the situations in which decisions must be made instantly, often under tremendous stress. I know how easy it is to overlook subtle signs of illness when priority is given to patients with sudden cardiac arrest, extensive trauma or septic shock.

I also realize that an ED physician cannot know every disease entity as well as a specialist in the field. It is impossible to expect every on-call ED physician to be an expert in Addison's disease or secondary adrenal insufficiency. What can - and should - be expected, however, is that he or she should be able to recognize life-threatening conditions and follow basic principles of emergency management.

A few months ago, I had the honor of becoming the honorary patron of the Association for People with Addison's Disease and Adrenal Hyperfunction. Because of the trust placed in me, patients share their concerns and problems with me. Unfortunately, I surprisingly often receive complaints about ED staff downplaying the symptoms of adrenal insufficiency that patients present to hospitals with.

Disturbing accounts show a recurring pattern - a patient presents to the Hospital Emergency Department with clear symptoms of adrenal breakthrough, but his complaints are downplayed and the administration of hydrocortisone is delayed or skipped altogether. In extreme cases, the patient is sent home with the recommendation of rest and hydration. Unfortunately, the consequence of such treatment can have a tragic end - deterioration of the patient's condition, irreversible complications and even death.

Therefore, I have decided to discuss this problem more extensively - not only to increase patient safety, but also to warn less experienced colleagues against unwittingly breaking the law. It is not my goal to threaten sanctions or accuse doctors - I realize how demanding the work in the ED is. Instead, I want to draw attention to the fact that in the flurry of duties it is easy to overlook a patient whose life may depend on a single ampule of hydrocortisone.

Awareness of this risk and knowledge of the management of adrenal breakthrough will not only allow for effective medical intervention, but will also protect doctors from unnecessary legal risks. Because, after all, each of us wants - and should - act in such a way that we can look in the mirror with a sense of a job well done and the knowledge that we did everything necessary to save a human life.

Adrenal insufficiency as an emergency condition

A patient with adrenal insufficiency in adrenal breakthrough is an emergency patient. It is not a patient who can wait.

The main symptoms of adrenal breakthrough:

• Hypotension (low blood pressure, often resistant to fluid therapy),
• Severe weakness, confusion, disorientation,
• Hypoglycemia (trembling hands, sweating, impaired consciousness, in severe cases coma),
• Hyponatremia (sodium deficiency),
• Hyperkalemia (elevated potassium levels that can lead to cardiac arrest),
• Nausea, vomiting, abdominal pain.

A patient with such symptoms must immediately receive hydrocortisone.

Do not postpone the decision to administer hydrocortisone until the results of the ordered tests are available! If the patient is in adrenal breakthrough, withholding the drug can be a death sentence for the patient.

Refusal or delay of hydrocortisone administration - when does a doctor act unlawfully?

- Violation of Article 4 of the Law on the Medical and Dental Profession:

Article 4 of the Law on the Medical and Dental Profession imposes an obligation on the doctor to act in accordance with current medical knowledge and due diligence.

Failure to immediately administer hydrocortisone to a patient in adrenal breakthrough is a blatant violation of this principle because:

• This is an emergency - the symptoms are clear indications for hydrocortisone administration,
• Hydrocortisone is the only effective treatment,
• Failure to administer hydrocortisone can lead to the death of the patient.

One cannot make excuses for lack of experience in treating NKN. Remember that ignorance of procedures does not absolve the doctor from responsibility.

Criminal liability - Article 160 of the Criminal Code.

Less experienced colleagues in the ED should remember that failing to help a patient in a life-threatening condition can be classified as a crime under Article 160 § 2 of the Penal Code:

"Whoever exposes a person to imminent danger of loss of life or grievous bodily harm shall be punished by imprisonment for up to 3 years. If the perpetrator of the act is a person obliged to take care of another person, he faces imprisonment for up to 5 years."

A doctor who fails to properly treat an adrenal breakthrough patient may face criminal liability.

Civil liability - claims by the patient and his family

A patient who has been harmed by an error in the ED may also pursue civil claims under Article 415 of the Civil Code:

"Whoever, through his fault, caused damage to another, is obliged to compensate for it."

The patient's family can demand:

• Health Damages,
• Reparations for pain and suffering,
• Compensation pension if the patient has become permanently incapacitated.

Professional liability - proceedings before the Medical Chamber

A doctor who has grossly violated the rules of the art of medicine can be held professionally liable.

Consequences may include:

• Admonition or reprimand,
• Suspension of the right to practice the profession,
• Total deprivation of the right to practice the profession.

How can we protect ourselves from unwittingly breaking the law?

Many doctors only realize during proceedings before the Medical Board or in a civil lawsuit that problems could have been avoided by following a few simple rules. Here are specific tips that will help any ED physician protect both the patient and himself.

Key principles for the management of suspected adrenal breakthrough

Assume that a patient with adrenal insufficiency requires hydrocortisone.

- In emergency situations, time plays a key role - hydrocortisone is a life-saving drug.

- Don't wait for full diagnostics - delay may result in worsening of the patient's condition.

- When in doubt, consult, but treatment must be implemented immediately.

Don't judge a patient based on appearance alone - adrenal breakthrough can take an insidious course.

- Often the patient "doesn't look too bad," but within minutes rapid deterioration can occur.

- If a patient comes in with an information sheet with a diagnosis of NKN on it - take it seriously.

Remember that the treatment of adrenal breakthrough is simple and effective.

- 100 mg of hydrocortisone i.v. or i.m. immediately after diagnosis (without waiting for test results).

Fluid therapy: 0.9% NaCl - minimum 1000 ml in the first 2 hours.

If in doubt - document your actions.

1. First of all, if you give hydrocortisone to a patient in adrenal breakthrough, but it turns out that adrenal breakthrough was not the main cause of symptoms - you will not be held liable!
2. If, on the other hand, you don't administer hydrocortisone and the patient dies or suffers serious injury, legal action may be inevitable.

In conclusion - Remember that downplaying a patient's symptoms can lead to situations that will expose not only the patient's health, but also the doctor to legal consequences.

No one wants to find themselves in a situation where they have to explain themselves to the court or the Medical Chamber.

And all it takes is one simple action: giving hydrocortisone to a patient in adrenal breakthrough.

Application of this principle can save the patient's life and protect the doctor from serious consequences. It is worth remembering - for the sake of patients and for your own professional safety.