Absolutely astonishing and horrifying to me that two physicians, who performed reasonable workups and were ambushed by an AAA they had no particular reason to suspect, are now liable for more money than they would likely make in their careers.
Yep, agree that its a big reason. Also... even if there was no liability, it's very crushing and demoralizing to take care of someone and miss something big and they die. You really take that personally, just on a human level, when it happens.
Very true. I think for most people though even worse than that is doing something that causes their death. In addition to "what if I miss something" there's a what if the patient has an unknown contrast allergy and the unnecessary CTA sends them into anaphylactic shock and they die? On the one hand, you would probably feel worse if that was the cause of death than a missed diagnosis, on the other hand, I think we all know the outcome of that malpractice trial would be totally different.
Absolutely right. And what is laughable is that academia still teaches with the thought that “we don’t teach defensive medicine”. That’s insane and ignorant. We must teach defensive medicine (with reasonable consideration of resources and work ups) and I do because I know how devastating a lawsuit is for one’s career, sleep, mental health and future decisions. Not to mention what genuine malpractice (I don’t this this case is substandard care) does to a patient and their family. This case is terrifying yet these cases are so educational and help me to be a better teacher, EM physician, and expert witness.
That's why the scans are not "unnecessary". In point of fact, they are profoundly necessary, for virtually every pt w/ even the remotest chance of dissection/aneurysm. There will never be a time, there has never been a time, in the whole history of medicine, in which a back seat jockey/expert in "retrospectoscopic" medicine, testified, "I would NEVER have ordered that scan. The EM physician was ENTIRELY justified in NOT ordering that scan". What they WILL testify to (needless is say), is something on the order of, "Of COURSE, the circumstances of THIS PARTICULAR CASE (and no other) warranted CTA C/A/P, and any minimally competent physician should have realized that. The EM physician was eminently at fault, and this poor, sweet innocent child/wife is absent her father/husband forever."
When the risks outweigh the benefits, it is indeed unnecessary. "The risks and benefits" should ideally not be driven by legal procedures but I know that is a pipe dream.
The standard of evidence for medical malpractice when it comes to rare conditions presenting in an unusual way should be much higher than that for common conditions presenting in an unusual way or rare conditions presenting in a typical way.
In Utah, by statute, for emergency medicine the burden of proof is "clear and convincing" (versus "preponderance of the evidence" for non-EM med mal cases).
It's a fairly new statute (enacted 2009) and I haven't seen any judicial interpretation yet--the law develops slowly in Utah. In practice, we've been treating it as applying to any case seen in the ER. The statute applies to "emergency care" (separately defined) "from the time that the person presents at the emergency department of a hospital and including any subsequent transfer to another hospital, until the condition has been stabilized and the patient is either discharged from the emergency department or admitted to another department of the hospital." (Utah Code 58-13-2.5(2)) I would think that, if challenged, the courts would be receptive to an argument that it applies to *any* care given in the ER, even if the doc isn't EM trained and even if, in hindsight, it wasn't an "emergency medical condition".
As a side note, the definition of "emergency medical condition" is:
(54) "Emergency medical condition" means a medical condition that:
(a) manifests itself by acute symptoms, including severe pain; and
(b) would cause a prudent layperson possessing an average knowledge of medicine and health to reasonably expect the absence of immediate medical attention through a hospital emergency department to result in:
(i) placing the layperson's health or the layperson's unborn child's health in serious jeopardy;
(ii) serious impairment to bodily functions; or
(iii) serious dysfunction of any bodily organ or part.
Yeah that seems like it would apply to any care in the ER, by any type of doctor. I haven't done much looking at cases from Utah, I'll have to check it out. Thanks for sharing, that was very informative!
My pleasure! Thanks for your newsletter, I really enjoy reading it. (I assume you're familiar with Dr. Chuck Pilcher's newsletters? If not, check them out, I think you'd appreciate them)
This seems like a crazy verdict for a presentation that was most suggestive of an infectious process and a CXR that was read as consistent with pneumonia.
Other than inappropriate/insufficient antibiotic choice, I don't see how this represents negligence. Both hospitalist and ER doc appear to follow standard of care.
Most of the money went to the 2 young daughters. My heart really goes out to them but it seems like the jury was probably swayed by their emotions and pity for the girls and translated this into "the docs need to pay".
Terrifying they ended up getting successfully sued for $20 million dollars. I do agree that source control of the foot and broad spectrum ABX with MRSA coverage should have been started, but endocarditis was a very reasonable differential in light of the evidence.
Outstanding summary of the case and how things evolved, and what the witnesses testified, etc. Also, excellent teaching points by the reviewer. I agree with everything he said, and would add that the apparent infection/sepsis/possible endocarditis findings clearly led the physicians down one path for diagnostic and therapeutic intervention. This kind of situation can lead to "anchoring" bias, where the working diagnosis tends to prevent perception of or more serious consideration of other possible diagnoses. Having said that, the extreme pain (especially to the upper and lower back) and cardiovascular "equivalent" symptoms such as paleness, sweating, and shortness of breath were probably CLUES that there was SOMETHING ELSE going on IN ADDITION to infection and endocarditis. Retrospectively, that is easy to say. But in real-time ED practice, not necessarily easy to recognize and/or act on. Clearly, this was a case where a very good start was made at arriving at and treating a reasonable working diagnosis. And I am certain neither physician had the mindset at the time of admission ... "We know everything about what is causing ALL of the patient's signs and symptoms and our workup, assessment, and treatment plan is finalized." NO, in real time, they appreciated that there were still unanswered questions and possible other coexisting acute diagnoses involved in this case. I am certain that, given enough time for the tests to be done, etc., all relevant diagnoses would have been made and appropriately acted upon. It is so unfortunate that "time ran out" for this patient and these poor doctors -- who both seem to have done their best under the circumstances. This was NOT a case of a patient being admitted with an unreasonable working diagnosis and treatment plan and then languishing or being ignored on the ward. They recognized things were changing and escalated his level of care appropriately (ICU transfer, more tests and consults ordered, etc). I do feel that the jury just felt sorry for the wife and daughters, and that is what led to their verdict -- more than a true assessment of "malpractice." One other point -- a cringer -- Kiss of death giving Toradol, right? Again, you cringe in hindsight, not necessarily in real time. But I am sure the prosecuting attorney had a field day with that. The whole thing is so sad. I practiced for 40 years in the ER, and I don't think I would necessarily have done anything different. Probably, a Chest CT would have been a saving factor if it had been done in the ED. That is the only thing that may have saved the day -- and not necessarily the patient, mind you. It would only have been ordered if the ED doctor had a nagging feeling that "something else might be going on, and I just want to be thorough before I call for the hospitalist to admit." Also, even if the aneurysm was diagnosed in the ED and an operation was done upon urgent transfer elsewhere, the patient may still have ruptured and died before making it to the OR. Or he could have also died after the operation. Many of them do. I suspect the aneurysm was, in fact, dissecting before rupture. So this was not a good prognosis under any circumstances. OK, I have gone on too long. Just a very heart-wrenching case. To the doctors involved: Brush yourselves off and don't beat yourself up too badly over this. You are both excellent physicians, and I am certain you have saved many, many lives to your credit. This case was extremely challenging, and it was difficult to account for the entire clinical picture on the basis of an AA alone. Your initial working diagnosis and treatment plan was reasonable. I believe you both CARED about the patient and that you both did your best under the circumstances. This was NOT the only patient you had to care for during the time this patient's case evolved. Juries have no clue about what we go through in real time. Very tough case and I feel for both of you. Bruce Sabatino, MD, Monroe, GA.
Very interesting case because if the patient had died from complications of MRSA then I would absolutely say they were negligent because of the Abx selection and lack of source control as you noted. The fact that the patient died from a ruptured TAA on the other hand completely changes things. I wonder if the two are even related to each other. If the patient hadn't impaled their foot 4 days earlier do they even present to a doctor or do they first show up the day after decompensating or do they just drop dead at home?
Insane outcome. If anything, I was expecting vascular to get sued for not taking the patient to the OR immediately. Why did they get let off the hook? Although if this was actually a ruptured aneurysm rather than a dissection patient was probably SOL regardless.
Ascending ruptured aneurysm requires Thoracic surgery consult, not vascular, most hospitals do not have capabilities to operate on these high risk cases and will transfer to tertiary care center!
I'm surprised they called vascular... seems like CT surgery would be the ones to manage it? Not sure if ascending dissection vs ascending aneurysm would change who manages it.
Good point that even in ideal conditions ruptured aortic aneurism has a <50% survival rate. My assumption was that there wasn't a vascular service in this hospital and the pt was being transferred to a hospital that does have it.
I feel like it seems that they had vascular but vascular just wasn’t “comfortable” taking care of it. Happens all the time at my ER - our CT surgeons say they can’t handle type A dissections here and make us transfer, for example
I also thought it was weird that they aren't named. At some point it becomes so emergent it's negligent to transport to a better facility rather than operate where you are, no?
Ascending aortic pathology currently cannot be treated by an endovascular graft. It is simply not a situation where you can just stick one in to see what happens since the patient is going to die anyways. This is a facility that likely had a vascular surgeon who was called to help triage the situation but any ascending aortic dissection or aneurysm needs to be fixed open by a cardiac surgeon at a facility with cardiac OR capability.
This is a tough case. Looks like a duck, walks like a duck but doesn't quack. If he told his examiners early on the pain traveled to the back that would have been a cause for concern but endocarditis can cause chest pain that travels to the back. Aortic dissection causes an inflammatory response, elevating the white count.
The presentation may not have added to a classical presentation of dissection: sudden severe, tearing but then how many cases are reliably typical?
Had the doctors plugged this case into A.I., dissection may have showed up in the DDx.
The key discriminator here was the traveling pain which would be atypical for endocarditis.
Was it the doctors fault for missing the diagnosis? Can't say it was. Did they live up to the standard of care? Probably.
Problem is it's hard to defend a really, really bad outcome.
The award seems over the top. Was the deceased in the top 1-5% of earners?
This is shocking. I wish you had elaborated more and included the plaintiff expert wirnesss testimony to understand how on earth the docs were found liable. This is so confusing
I wish they had included the plaintiffs expert opinion in the court records. If it was there I definitely would have published it but they kept it confidential :(
I think unexplained chest pain radiating to back in a patient in distress you must consider an aortic dissection (even though seems to be an aneurysm), and a chest CT probably was indicated…I think the foot wound led them down the wrong path but that was not the patients chief complaint!
Ascending aortic pathology currently cannot be treated by an endovascular graft. It is simply not a situation where you can just stick one in to see what happens since the patient is going to die anyways. This is a facility that likely had a vascular surgeon who was called to help triage the situation but any ascending aortic dissection or aneurysm needs to be fixed open by a cardiac surgeon at a facility with cardiac OR capability.
Tough, as always, without complete information. My initial feeling was outrage at the injustice, But then I reconsidered. This poor man had a constellation of symptoms that included pain, severe pain, located to some degree in the chest and back -- the upper body -- and a physical exam that was uninteresting. Not shingles this time. A list of possible diagnoses would have included all causes, including all of the zebras, of which endocarditis was just one. His blood work, EKG, CXR did not narrow the ddx sufficiently to pick one dx over the others -- with sufficient certainty to eliminate the bad ones. My feeling is that pain requiring morphine is not likely due to endocarditis (is this true?), that the wbc, neutrophil/lymphocyte ratio were nonspecific, consistent with endocarditis but also with just about any serious process, including the other zebras, and that his 4-day-old foot fb, without erythema, perhaps with no signs whatsoever of inflammation, was probably not reasonably considered to be source of bacteremia and heart valve seeding, vegetation growth, deformation, especially in 4 days, and he was, we are told, without tachycardia and never febrile. What murmur was detected? - benign murmurs are common. So, was there really justification to go with a working diagnosis of endocarditis? -- especially since doing so put aside immediately pursuing and ruling out the other zebras, potentially very deadly zebras. Generally, if one sets aside dangerous diagnoses, having 'ruled them out' ONLY by having established an alternative dx, then that alternative dx must be known to be absolutely certainly correct -- and one will be safe unless two processes are happening simultaneously. There must be a name for this process -- elimination not by proving absence but by finding an iron-clad-certain other dx. I don't see that the working diagnosis of endocarditis was certain enough to make it safe to forgo immediate echo / CT evaluation for other possible diagnoses - including, of course aortic trouble. An echocardiogram was ordered - to take place when? and why? -- to confirm the diagnosis of endocarditis (and, if correct, to further define the pathology) -- point being that the diagnosis of endocarditis was far from confirmed; it was an ill-supported theory, and, to be repetitive, the other diagnoses in the differential were far from ruled out. In-house management seems to have been attentive, but whatever it was that provoked CT evaluation -- 10/10 uncontrolled pain, hypoxemia -- perhaps considering PE rather than aortic trouble -- came too late. A note about the N/V; a common symptom, but here, with coronary syndrome felt not to to be the issue, might it have been due to vagus nerve 'irritation', due to aortic / mediastinal trouble. This can happen, and might N/V be a keep-it-in-mind flag for aneurysm or dissection? In similar vein, as it were, I had a patient, many years ago, who came to our 30-40-pt/day community ED very late in the evening because he had temporarily lost his voice. Christmas time, singing in a chorus, he experienced some upper body pain - I think not so much precordial as upper chest or shoulder or neck - perhaps epigastric - I don't recall the location, but I do recall that pain had been felt and noted, but not severe, and not the reason for his coming in. He presented because, as he was singing, he suddenly he lost his voice -- "I was singing but no sound was coming out". Then his voice returned, and was normal, but this is why he came in -- and at triage was not complaining of CP, so went to an unmonitored bed, where I saw him, in no distress, with normal voice, VS and exam, but with that history. EKG, CXR were normal. Red flag. Pain -- wherever in the upper body it was, even though not severe -- and loss of voice = ?recurrent laryngeal nerve stress = look at the aorta. Immediate CT (was early CT days, 40 years ago, a big deal, radiology had to approve and the CT tech to motorcycle in, in the middle of the night). CT showed ascending aortic / arch trouble - I don't recall the details. OR stat. The thoracic surgeon came in immediately, established that our OR did not have the necessary equipment. The surgeon rode with the patient in the ambulance to the nearby County Hospital, where said surgeon was on staff, a 10 minute ride, and he took the pt immediately to the OR. Sadly, he died in surgery. Point being, upper body pain, with dys-/a-phonia, think aorta, and perhaps similarly, upper body pain, with N/V, consider horses - coronary syndrome, GI troubles, etc, etc, but keep aorta on the list, and maybe bump it up a notch, until proven otherwise. As for the punishment, if there was error, 29 million dollars, likely far more than lost wages, and likely far more than the two docs combined were going to earn in the remaining years of their careers, a sentence to a lifetime of hard labor, can that be reasonable? A drunk driver who kills can be out of jail in two years, and with a $10,000 fine - or some such comparatively trivial punishment. Also, unfortunate in this case that the CXR in the ED did not show or suggest the trouble - happens. Also, was ED ultrasound available? If not, why not, and if so, was it done, failing to detect trouble (so, get the CT), or was it even considered?
Another example of why medical malpractice cases should be tried by a jury of medical professionals.
Absolutely astonishing and horrifying to me that two physicians, who performed reasonable workups and were ambushed by an AAA they had no particular reason to suspect, are now liable for more money than they would likely make in their careers.
This kind of case and in particular this kind of judgment is exactly why the ED orders so many unnecessary scans.
Yep, agree that its a big reason. Also... even if there was no liability, it's very crushing and demoralizing to take care of someone and miss something big and they die. You really take that personally, just on a human level, when it happens.
Very true. I think for most people though even worse than that is doing something that causes their death. In addition to "what if I miss something" there's a what if the patient has an unknown contrast allergy and the unnecessary CTA sends them into anaphylactic shock and they die? On the one hand, you would probably feel worse if that was the cause of death than a missed diagnosis, on the other hand, I think we all know the outcome of that malpractice trial would be totally different.
Absolutely right. And what is laughable is that academia still teaches with the thought that “we don’t teach defensive medicine”. That’s insane and ignorant. We must teach defensive medicine (with reasonable consideration of resources and work ups) and I do because I know how devastating a lawsuit is for one’s career, sleep, mental health and future decisions. Not to mention what genuine malpractice (I don’t this this case is substandard care) does to a patient and their family. This case is terrifying yet these cases are so educational and help me to be a better teacher, EM physician, and expert witness.
That's why the scans are not "unnecessary". In point of fact, they are profoundly necessary, for virtually every pt w/ even the remotest chance of dissection/aneurysm. There will never be a time, there has never been a time, in the whole history of medicine, in which a back seat jockey/expert in "retrospectoscopic" medicine, testified, "I would NEVER have ordered that scan. The EM physician was ENTIRELY justified in NOT ordering that scan". What they WILL testify to (needless is say), is something on the order of, "Of COURSE, the circumstances of THIS PARTICULAR CASE (and no other) warranted CTA C/A/P, and any minimally competent physician should have realized that. The EM physician was eminently at fault, and this poor, sweet innocent child/wife is absent her father/husband forever."
When the risks outweigh the benefits, it is indeed unnecessary. "The risks and benefits" should ideally not be driven by legal procedures but I know that is a pipe dream.
absolutely ridiculous settlement. we need tort reform in this country
The standard of evidence for medical malpractice when it comes to rare conditions presenting in an unusual way should be much higher than that for common conditions presenting in an unusual way or rare conditions presenting in a typical way.
Some states require the plaintiff to prove gross negligence for emergency medical conditions, which theoretically is a much higher bar.
In Utah, by statute, for emergency medicine the burden of proof is "clear and convincing" (versus "preponderance of the evidence" for non-EM med mal cases).
Does that apply to any case seen in an ER? What if they're in the ER and its not an emergency medical condition, or the doc they see isn't EM trained?
It's a fairly new statute (enacted 2009) and I haven't seen any judicial interpretation yet--the law develops slowly in Utah. In practice, we've been treating it as applying to any case seen in the ER. The statute applies to "emergency care" (separately defined) "from the time that the person presents at the emergency department of a hospital and including any subsequent transfer to another hospital, until the condition has been stabilized and the patient is either discharged from the emergency department or admitted to another department of the hospital." (Utah Code 58-13-2.5(2)) I would think that, if challenged, the courts would be receptive to an argument that it applies to *any* care given in the ER, even if the doc isn't EM trained and even if, in hindsight, it wasn't an "emergency medical condition".
As a side note, the definition of "emergency medical condition" is:
(54) "Emergency medical condition" means a medical condition that:
(a) manifests itself by acute symptoms, including severe pain; and
(b) would cause a prudent layperson possessing an average knowledge of medicine and health to reasonably expect the absence of immediate medical attention through a hospital emergency department to result in:
(i) placing the layperson's health or the layperson's unborn child's health in serious jeopardy;
(ii) serious impairment to bodily functions; or
(iii) serious dysfunction of any bodily organ or part.
Utah Code 31A-1-301(54)
Yeah that seems like it would apply to any care in the ER, by any type of doctor. I haven't done much looking at cases from Utah, I'll have to check it out. Thanks for sharing, that was very informative!
My pleasure! Thanks for your newsletter, I really enjoy reading it. (I assume you're familiar with Dr. Chuck Pilcher's newsletters? If not, check them out, I think you'd appreciate them)
Wow, 2 Doctors just trying to save a life get completely screwed over.
This seems like a crazy verdict for a presentation that was most suggestive of an infectious process and a CXR that was read as consistent with pneumonia.
Other than inappropriate/insufficient antibiotic choice, I don't see how this represents negligence. Both hospitalist and ER doc appear to follow standard of care.
Most of the money went to the 2 young daughters. My heart really goes out to them but it seems like the jury was probably swayed by their emotions and pity for the girls and translated this into "the docs need to pay".
Terrifying they ended up getting successfully sued for $20 million dollars. I do agree that source control of the foot and broad spectrum ABX with MRSA coverage should have been started, but endocarditis was a very reasonable differential in light of the evidence.
Outstanding summary of the case and how things evolved, and what the witnesses testified, etc. Also, excellent teaching points by the reviewer. I agree with everything he said, and would add that the apparent infection/sepsis/possible endocarditis findings clearly led the physicians down one path for diagnostic and therapeutic intervention. This kind of situation can lead to "anchoring" bias, where the working diagnosis tends to prevent perception of or more serious consideration of other possible diagnoses. Having said that, the extreme pain (especially to the upper and lower back) and cardiovascular "equivalent" symptoms such as paleness, sweating, and shortness of breath were probably CLUES that there was SOMETHING ELSE going on IN ADDITION to infection and endocarditis. Retrospectively, that is easy to say. But in real-time ED practice, not necessarily easy to recognize and/or act on. Clearly, this was a case where a very good start was made at arriving at and treating a reasonable working diagnosis. And I am certain neither physician had the mindset at the time of admission ... "We know everything about what is causing ALL of the patient's signs and symptoms and our workup, assessment, and treatment plan is finalized." NO, in real time, they appreciated that there were still unanswered questions and possible other coexisting acute diagnoses involved in this case. I am certain that, given enough time for the tests to be done, etc., all relevant diagnoses would have been made and appropriately acted upon. It is so unfortunate that "time ran out" for this patient and these poor doctors -- who both seem to have done their best under the circumstances. This was NOT a case of a patient being admitted with an unreasonable working diagnosis and treatment plan and then languishing or being ignored on the ward. They recognized things were changing and escalated his level of care appropriately (ICU transfer, more tests and consults ordered, etc). I do feel that the jury just felt sorry for the wife and daughters, and that is what led to their verdict -- more than a true assessment of "malpractice." One other point -- a cringer -- Kiss of death giving Toradol, right? Again, you cringe in hindsight, not necessarily in real time. But I am sure the prosecuting attorney had a field day with that. The whole thing is so sad. I practiced for 40 years in the ER, and I don't think I would necessarily have done anything different. Probably, a Chest CT would have been a saving factor if it had been done in the ED. That is the only thing that may have saved the day -- and not necessarily the patient, mind you. It would only have been ordered if the ED doctor had a nagging feeling that "something else might be going on, and I just want to be thorough before I call for the hospitalist to admit." Also, even if the aneurysm was diagnosed in the ED and an operation was done upon urgent transfer elsewhere, the patient may still have ruptured and died before making it to the OR. Or he could have also died after the operation. Many of them do. I suspect the aneurysm was, in fact, dissecting before rupture. So this was not a good prognosis under any circumstances. OK, I have gone on too long. Just a very heart-wrenching case. To the doctors involved: Brush yourselves off and don't beat yourself up too badly over this. You are both excellent physicians, and I am certain you have saved many, many lives to your credit. This case was extremely challenging, and it was difficult to account for the entire clinical picture on the basis of an AA alone. Your initial working diagnosis and treatment plan was reasonable. I believe you both CARED about the patient and that you both did your best under the circumstances. This was NOT the only patient you had to care for during the time this patient's case evolved. Juries have no clue about what we go through in real time. Very tough case and I feel for both of you. Bruce Sabatino, MD, Monroe, GA.
Very interesting case because if the patient had died from complications of MRSA then I would absolutely say they were negligent because of the Abx selection and lack of source control as you noted. The fact that the patient died from a ruptured TAA on the other hand completely changes things. I wonder if the two are even related to each other. If the patient hadn't impaled their foot 4 days earlier do they even present to a doctor or do they first show up the day after decompensating or do they just drop dead at home?
Insane outcome. If anything, I was expecting vascular to get sued for not taking the patient to the OR immediately. Why did they get let off the hook? Although if this was actually a ruptured aneurysm rather than a dissection patient was probably SOL regardless.
Ascending ruptured aneurysm requires Thoracic surgery consult, not vascular, most hospitals do not have capabilities to operate on these high risk cases and will transfer to tertiary care center!
I'm surprised they called vascular... seems like CT surgery would be the ones to manage it? Not sure if ascending dissection vs ascending aneurysm would change who manages it.
Good point that even in ideal conditions ruptured aortic aneurism has a <50% survival rate. My assumption was that there wasn't a vascular service in this hospital and the pt was being transferred to a hospital that does have it.
I feel like it seems that they had vascular but vascular just wasn’t “comfortable” taking care of it. Happens all the time at my ER - our CT surgeons say they can’t handle type A dissections here and make us transfer, for example
I also thought it was weird that they aren't named. At some point it becomes so emergent it's negligent to transport to a better facility rather than operate where you are, no?
I'm guessing they didn't have the right staff or equipment or expertise with what he needed done.
Ascending aortic pathology currently cannot be treated by an endovascular graft. It is simply not a situation where you can just stick one in to see what happens since the patient is going to die anyways. This is a facility that likely had a vascular surgeon who was called to help triage the situation but any ascending aortic dissection or aneurysm needs to be fixed open by a cardiac surgeon at a facility with cardiac OR capability.
This is a tough case. Looks like a duck, walks like a duck but doesn't quack. If he told his examiners early on the pain traveled to the back that would have been a cause for concern but endocarditis can cause chest pain that travels to the back. Aortic dissection causes an inflammatory response, elevating the white count.
The presentation may not have added to a classical presentation of dissection: sudden severe, tearing but then how many cases are reliably typical?
Had the doctors plugged this case into A.I., dissection may have showed up in the DDx.
The key discriminator here was the traveling pain which would be atypical for endocarditis.
Was it the doctors fault for missing the diagnosis? Can't say it was. Did they live up to the standard of care? Probably.
Problem is it's hard to defend a really, really bad outcome.
The award seems over the top. Was the deceased in the top 1-5% of earners?
Not as far as I can tell.
Third paragraph from the bottom, "The troponin was normal."
Appreciate you spotting that! Don't know how I missed it.
This is shocking. I wish you had elaborated more and included the plaintiff expert wirnesss testimony to understand how on earth the docs were found liable. This is so confusing
I wish they had included the plaintiffs expert opinion in the court records. If it was there I definitely would have published it but they kept it confidential :(
I think unexplained chest pain radiating to back in a patient in distress you must consider an aortic dissection (even though seems to be an aneurysm), and a chest CT probably was indicated…I think the foot wound led them down the wrong path but that was not the patients chief complaint!
What about emergent Endovascular repair for thoracic aortic aneurysm?
I'm not a surgeon, but if they had the device at the hospital, it seems inserting it, though risky, would be faster and less risky than transferring.
Ascending aortic pathology currently cannot be treated by an endovascular graft. It is simply not a situation where you can just stick one in to see what happens since the patient is going to die anyways. This is a facility that likely had a vascular surgeon who was called to help triage the situation but any ascending aortic dissection or aneurysm needs to be fixed open by a cardiac surgeon at a facility with cardiac OR capability.
Tough, as always, without complete information. My initial feeling was outrage at the injustice, But then I reconsidered. This poor man had a constellation of symptoms that included pain, severe pain, located to some degree in the chest and back -- the upper body -- and a physical exam that was uninteresting. Not shingles this time. A list of possible diagnoses would have included all causes, including all of the zebras, of which endocarditis was just one. His blood work, EKG, CXR did not narrow the ddx sufficiently to pick one dx over the others -- with sufficient certainty to eliminate the bad ones. My feeling is that pain requiring morphine is not likely due to endocarditis (is this true?), that the wbc, neutrophil/lymphocyte ratio were nonspecific, consistent with endocarditis but also with just about any serious process, including the other zebras, and that his 4-day-old foot fb, without erythema, perhaps with no signs whatsoever of inflammation, was probably not reasonably considered to be source of bacteremia and heart valve seeding, vegetation growth, deformation, especially in 4 days, and he was, we are told, without tachycardia and never febrile. What murmur was detected? - benign murmurs are common. So, was there really justification to go with a working diagnosis of endocarditis? -- especially since doing so put aside immediately pursuing and ruling out the other zebras, potentially very deadly zebras. Generally, if one sets aside dangerous diagnoses, having 'ruled them out' ONLY by having established an alternative dx, then that alternative dx must be known to be absolutely certainly correct -- and one will be safe unless two processes are happening simultaneously. There must be a name for this process -- elimination not by proving absence but by finding an iron-clad-certain other dx. I don't see that the working diagnosis of endocarditis was certain enough to make it safe to forgo immediate echo / CT evaluation for other possible diagnoses - including, of course aortic trouble. An echocardiogram was ordered - to take place when? and why? -- to confirm the diagnosis of endocarditis (and, if correct, to further define the pathology) -- point being that the diagnosis of endocarditis was far from confirmed; it was an ill-supported theory, and, to be repetitive, the other diagnoses in the differential were far from ruled out. In-house management seems to have been attentive, but whatever it was that provoked CT evaluation -- 10/10 uncontrolled pain, hypoxemia -- perhaps considering PE rather than aortic trouble -- came too late. A note about the N/V; a common symptom, but here, with coronary syndrome felt not to to be the issue, might it have been due to vagus nerve 'irritation', due to aortic / mediastinal trouble. This can happen, and might N/V be a keep-it-in-mind flag for aneurysm or dissection? In similar vein, as it were, I had a patient, many years ago, who came to our 30-40-pt/day community ED very late in the evening because he had temporarily lost his voice. Christmas time, singing in a chorus, he experienced some upper body pain - I think not so much precordial as upper chest or shoulder or neck - perhaps epigastric - I don't recall the location, but I do recall that pain had been felt and noted, but not severe, and not the reason for his coming in. He presented because, as he was singing, he suddenly he lost his voice -- "I was singing but no sound was coming out". Then his voice returned, and was normal, but this is why he came in -- and at triage was not complaining of CP, so went to an unmonitored bed, where I saw him, in no distress, with normal voice, VS and exam, but with that history. EKG, CXR were normal. Red flag. Pain -- wherever in the upper body it was, even though not severe -- and loss of voice = ?recurrent laryngeal nerve stress = look at the aorta. Immediate CT (was early CT days, 40 years ago, a big deal, radiology had to approve and the CT tech to motorcycle in, in the middle of the night). CT showed ascending aortic / arch trouble - I don't recall the details. OR stat. The thoracic surgeon came in immediately, established that our OR did not have the necessary equipment. The surgeon rode with the patient in the ambulance to the nearby County Hospital, where said surgeon was on staff, a 10 minute ride, and he took the pt immediately to the OR. Sadly, he died in surgery. Point being, upper body pain, with dys-/a-phonia, think aorta, and perhaps similarly, upper body pain, with N/V, consider horses - coronary syndrome, GI troubles, etc, etc, but keep aorta on the list, and maybe bump it up a notch, until proven otherwise. As for the punishment, if there was error, 29 million dollars, likely far more than lost wages, and likely far more than the two docs combined were going to earn in the remaining years of their careers, a sentence to a lifetime of hard labor, can that be reasonable? A drunk driver who kills can be out of jail in two years, and with a $10,000 fine - or some such comparatively trivial punishment. Also, unfortunate in this case that the CXR in the ED did not show or suggest the trouble - happens. Also, was ED ultrasound available? If not, why not, and if so, was it done, failing to detect trouble (so, get the CT), or was it even considered?