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Welcome to medmalreviewer.com! The purpose of this site is to improve doctor’s medical knowledge and documentation by reviewing real-life malpractice cases. These cases are presented in long form, deep dive fashion, published monthly. Each case is broken down into several posts. To see more info about the website, here are links to the About Page and FAQs. Another helpful overview post is the 3 Goals of Documentation. I’ve created a Documentation Template to help doctors write notes that are easy to defend, and a Documentation Rubric to grade notes from malpractice cases.
This case is about a 48 year old man who was driving his car on a county road during rainy conditions. He lost control of his car, drove off the road, and hit an embankment. 911 was called, and both police and EMS responded to the scene. At the scene, the patient seemed confused, and was felt to possibly be under the influence of illicit substances. Relevant portion of the EMS report is shown below:
The narrative portion of the EMS documentation mentions that he denies using illicit drugs or alcohol. It does note that he has been sick for the last 4 days, with symptoms including nausea, vomiting, and diarrhea. He was confused, and did not know where he was, where he was driving, nor how fast he was going. He denied any injuries or pain, but was taken to the nearest Emergency Department for treatment.
Looking for more content on bad medical outcomes? Check out the review of Bouncebacks!
The sheriff’s department responded to the scene. A lengthy crash report was generated. The relevant parts are shown below. In the narrative section, “DR#1” is the driver, who ultimately becomes the patient at the center of this case.
The police report notes that he crossed the center line, left the road, and struck the front driver’s side of the vehicle. The vehicle did not roll. The description of the patient’s condition matches that of the EMS report; he was confused and unable to state what road he was on or where he was traveling. They were suspicious that the driver was under the influence of “some type of drug or medication”.
Continue to the next page (red button below) to see what happens next once the patient is in the Emergency Department!