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.
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.
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.
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".
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.
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?
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 don't have a lot of expertise with this, but I've been told that they rarely try to take your personal assets, even with these massive verdicts. The insurance company might get dragged into further litigation for a bad faith failure to settle.
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.
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)
absolutely ridiculous settlement. we need tort reform in this country
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.
Wow, 2 Doctors just trying to save a life get completely screwed over.
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.
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".
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.
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.
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 :(
The antibiotic choice got my attention quickly but then it devolved into something completely different. Wow what a shocking case.
What antibiotics would you have started?
What are the options for docs w these high lawsuits?
How do they financially protect themselves? What available financial tools are there to safely avoid draining assets?
What about avoiding garnishing wages?
I don't have a lot of expertise with this, but I've been told that they rarely try to take your personal assets, even with these massive verdicts. The insurance company might get dragged into further litigation for a bad faith failure to settle.