That "expert" opinion is terrifying. At what point do you just name and shame them on this page? They do not sound like they have any idea what they are doing, or if they do, they are lying to the court by writing these false statements. I agree with your analysis! Flu and croup are not mutually exclusive; flu can cause croup. While I don't treat children, steroids are a common treatment for bronchitis and other respiratory infections and it seemed wholly appropriate to treat empirically for steroids regardless of the eventual respiratory panel result. The criticism that a subspecialist should have been called is frankly bizarre. The treatment completely fit the presentation; a second set of eyeballs does not mean the care is better, even if they're attached to a subspecialist. Should I start consulting Pulmonary every time I see someone with a virus? After all, if that person died of an unforseeable complication, the family could say that if I had offered a Pulm consult, they would have accepted, and thus through some tortured logic, the pulmonologist would have saved their family member's life! It is so frustrating that the defendents settled and just reflects the sheer dysfunction in our medicolegal system. I am honestly grossed out by this expert opinion. It made me feel unclean to read it, it was so sleazy.
This report is unequivocally unethical. Anyone who disagrees is simply, matter of factly, wrong. I will never be convinced otherwise. Submit it to all member professional societies for testimonial peer review. Submit to the licensing state board for review. That’s the only way to rid medicine of these unethical practitioners.
The “expert” statements border on egregious. It appears to be a selling your integrity for $. There are always lessons to be learned but this appears to be one of those “but for the grace of God…” occurrences. The other troubling observation is that only 90% of the survey respondents thought the expert opinion was unethical.
Jan 10, 2023·edited Jan 10, 2023Liked by Med Mal Reviewer
I'm distressed thinking that this physician has participated and will continue to participate as an expert witness against physicians with either (a) a poor knowledge of the standards of medical practice or (b) an indifference to the standards of practice and a compulsion to conflate half-truths for financial gain. Most likely both.
As you said, it also crushes me that this person is a medical school faculty member. Someone who states their opinions in a way that calls into question their moral values and academic qualifications should probably not be someone else's mentor.
Apr 20, 2023·edited Apr 21, 2023Liked by Med Mal Reviewer
Despite the distraction of the misinformation and unprofessional tone of that expert opinion, there are clinical lessons in this case. How often do previously well school-age children have desats within just a few hours of any illness? 95% was not bad, but it was not normal, and it happened remarkably early in the illness. Also, Flu B doesn't tend to present as dramatically as Flu A. Tachycardia and high fever at illness onset is typical for Flu A, but not so much for Flu B. It would have been good practice to recheck that pulse ox and see if it was persistent. It would have been good practice to recheck that heart rate and see if it came down with defervescence. I also wonder how much the physician got involved in talking with the parents. Since the PA presented the case as pretty much a completed package, it's unlikely the physician had any kind of meaningful conversation with the parents. A good conversation helps us be better diagnosticians.
Back in the days when I was working as a pediatrician in the overseas, an infant came in with stroke. I ordered brain MRI, but that needs prior auth. So, I personally spoke to the insurance company's physician who approve these " expensive" imaging studies. He actually did not approve the study even though I explained that we will be looking for something like AVMs..etc. It turned out that he is an adult cardiologist!!! A cardiologist was giving decisions for a health insurance company for things not related to cardiology!! This applies to this expert who is IM doctor and giving opinion on a pediatric case!!
I agree given the benefit of hindsight the team would rather had not administered the dexamethasone, but to call it “reckless, shocking, and outrageous” is out there (or reflects lack of relevant experience to this patient presentation). Does the expert in this case eschew decadron in suspected meningitis?
Timely antibiotics were warranted (again, thank you hindsight), but to say steroids suppressed the immune response resulting in further harm is disingenuous (see debate regarding use of steroids in sepsis - obviously these patients are receiving antibiotics but my point is steroids are not solely responsible for dooming a patient with sepsis).
As you mentioned, tragic case - thank you for sharing.
I read this case while waiting in line at the post office and I wanted to yell at my phone! Horrifically tragic is the only superlative I have for this case. But I am pissed at the expert witness who threw a fellow doc under the bus like that. You pointed out everything I was angry about but I will repeat one that I thought was so egregious: parainfluenza is the only cause of croup! You freaking idiot!
If the PA and Doc who were sued in this case ever read this. You did just fine. You met the standard of care perfectly. The only thing at this could have been avoided is if you diverged from the standard of care and somehow convinced a hospitality to admit a kid who basically met all discharge criteria. I basically have nightmares of a case like this.
I discharged a flu patient (RR, SPO2, BP normal) home with tamiflu. They came back with wheezing and a low O2 sat that resolved after being given Albuterol. But the ER doc admitted them for obs (despite having normalized vitals in the ER). Now they are intubated and proned in the ICU. So basically I don’t know what to say other than repeat the mantra of “be careful with bounce backs” and now add “Beware of the flu!”
Maybe this is how an internist practises emergency medicine? They never discharge a child, but always send them to a pediatric emergentologist, as they are not competent to make their own assessments.
Great example of where to lay the blame in unethical malpractice cases. At the feet of physicians, physician assistants and nurse practitioners who will say anything if paid enough $.
As a pediatrician and an expert witness, I was beyond appalled and outraged when I read the "expert witness" opinion in this case...I could feel my blood pressure rising as I did so!
Thankfully, Med Mal Reviewer's analysis allowed me to avoid a cerebrovascular event...
As did the comments which preceded mine...
And which, honestly, render any further explanation by me unnecessary.
My thanks and my compliments to Med Mal Reviewer and to all of you below...
Because of the case involving paediatrics are always messy and the physician apparently did what they could’ve done and also the right thing. Its really sad to both parties
If this case is ongoing, I would recommend that they submit the expert testimony to ACEP regarding the credibility of the statements. If ACEP agrees that this is unprofessional, they can censure the testimony. Such a determination more or less nullifies the testimony in court and censure by a professional organization significantly hinders the ability of this expert witness to do this again in the future. The same goes for other physicians who feel they have been harmed by inaccurate testimony.
As someone who has personally suffered from necrotizing GAS pneumonia/toxic shock syndrome, it's not an easy diagnosis to catch, because things go from OK to very bad very quickly (luckily for me, I deteriorated in the ER). And we also just don't know to look for it, because it is so rare. While hindsight is certainly 20/20, I will always place more scrutiny on a case where the parent/patient are complaining of shortness of breath. Agree that the EW is egregious. I would have probably gotten a CXR. Not sure it would have changed much if the patient's overall clinical appearance was well-appearing at the time.
The best disinfectant is sunlight. The best way to hold unethical expert witnesses to account is to have them post their opinions in the lounge at work. If you wouldn't stand by it in front of your peers, perhaps it isn't a fair opinion.
That "expert" opinion is terrifying. At what point do you just name and shame them on this page? They do not sound like they have any idea what they are doing, or if they do, they are lying to the court by writing these false statements. I agree with your analysis! Flu and croup are not mutually exclusive; flu can cause croup. While I don't treat children, steroids are a common treatment for bronchitis and other respiratory infections and it seemed wholly appropriate to treat empirically for steroids regardless of the eventual respiratory panel result. The criticism that a subspecialist should have been called is frankly bizarre. The treatment completely fit the presentation; a second set of eyeballs does not mean the care is better, even if they're attached to a subspecialist. Should I start consulting Pulmonary every time I see someone with a virus? After all, if that person died of an unforseeable complication, the family could say that if I had offered a Pulm consult, they would have accepted, and thus through some tortured logic, the pulmonologist would have saved their family member's life! It is so frustrating that the defendents settled and just reflects the sheer dysfunction in our medicolegal system. I am honestly grossed out by this expert opinion. It made me feel unclean to read it, it was so sleazy.
This report is unequivocally unethical. Anyone who disagrees is simply, matter of factly, wrong. I will never be convinced otherwise. Submit it to all member professional societies for testimonial peer review. Submit to the licensing state board for review. That’s the only way to rid medicine of these unethical practitioners.
The “expert” statements border on egregious. It appears to be a selling your integrity for $. There are always lessons to be learned but this appears to be one of those “but for the grace of God…” occurrences. The other troubling observation is that only 90% of the survey respondents thought the expert opinion was unethical.
I'm distressed thinking that this physician has participated and will continue to participate as an expert witness against physicians with either (a) a poor knowledge of the standards of medical practice or (b) an indifference to the standards of practice and a compulsion to conflate half-truths for financial gain. Most likely both.
As you said, it also crushes me that this person is a medical school faculty member. Someone who states their opinions in a way that calls into question their moral values and academic qualifications should probably not be someone else's mentor.
I think another reader summed it up nicely by saying "This expert opinion is heavy on the opinion and extremely light on the expert. "
Despite the distraction of the misinformation and unprofessional tone of that expert opinion, there are clinical lessons in this case. How often do previously well school-age children have desats within just a few hours of any illness? 95% was not bad, but it was not normal, and it happened remarkably early in the illness. Also, Flu B doesn't tend to present as dramatically as Flu A. Tachycardia and high fever at illness onset is typical for Flu A, but not so much for Flu B. It would have been good practice to recheck that pulse ox and see if it was persistent. It would have been good practice to recheck that heart rate and see if it came down with defervescence. I also wonder how much the physician got involved in talking with the parents. Since the PA presented the case as pretty much a completed package, it's unlikely the physician had any kind of meaningful conversation with the parents. A good conversation helps us be better diagnosticians.
Back in the days when I was working as a pediatrician in the overseas, an infant came in with stroke. I ordered brain MRI, but that needs prior auth. So, I personally spoke to the insurance company's physician who approve these " expensive" imaging studies. He actually did not approve the study even though I explained that we will be looking for something like AVMs..etc. It turned out that he is an adult cardiologist!!! A cardiologist was giving decisions for a health insurance company for things not related to cardiology!! This applies to this expert who is IM doctor and giving opinion on a pediatric case!!
I agree given the benefit of hindsight the team would rather had not administered the dexamethasone, but to call it “reckless, shocking, and outrageous” is out there (or reflects lack of relevant experience to this patient presentation). Does the expert in this case eschew decadron in suspected meningitis?
Timely antibiotics were warranted (again, thank you hindsight), but to say steroids suppressed the immune response resulting in further harm is disingenuous (see debate regarding use of steroids in sepsis - obviously these patients are receiving antibiotics but my point is steroids are not solely responsible for dooming a patient with sepsis).
As you mentioned, tragic case - thank you for sharing.
I read this case while waiting in line at the post office and I wanted to yell at my phone! Horrifically tragic is the only superlative I have for this case. But I am pissed at the expert witness who threw a fellow doc under the bus like that. You pointed out everything I was angry about but I will repeat one that I thought was so egregious: parainfluenza is the only cause of croup! You freaking idiot!
If the PA and Doc who were sued in this case ever read this. You did just fine. You met the standard of care perfectly. The only thing at this could have been avoided is if you diverged from the standard of care and somehow convinced a hospitality to admit a kid who basically met all discharge criteria. I basically have nightmares of a case like this.
I discharged a flu patient (RR, SPO2, BP normal) home with tamiflu. They came back with wheezing and a low O2 sat that resolved after being given Albuterol. But the ER doc admitted them for obs (despite having normalized vitals in the ER). Now they are intubated and proned in the ICU. So basically I don’t know what to say other than repeat the mantra of “be careful with bounce backs” and now add “Beware of the flu!”
Maybe this is how an internist practises emergency medicine? They never discharge a child, but always send them to a pediatric emergentologist, as they are not competent to make their own assessments.
Great example of where to lay the blame in unethical malpractice cases. At the feet of physicians, physician assistants and nurse practitioners who will say anything if paid enough $.
As a pediatrician and an expert witness, I was beyond appalled and outraged when I read the "expert witness" opinion in this case...I could feel my blood pressure rising as I did so!
Thankfully, Med Mal Reviewer's analysis allowed me to avoid a cerebrovascular event...
As did the comments which preceded mine...
And which, honestly, render any further explanation by me unnecessary.
My thanks and my compliments to Med Mal Reviewer and to all of you below...
Keep up the good work!
Because of the case involving paediatrics are always messy and the physician apparently did what they could’ve done and also the right thing. Its really sad to both parties
If this case is ongoing, I would recommend that they submit the expert testimony to ACEP regarding the credibility of the statements. If ACEP agrees that this is unprofessional, they can censure the testimony. Such a determination more or less nullifies the testimony in court and censure by a professional organization significantly hinders the ability of this expert witness to do this again in the future. The same goes for other physicians who feel they have been harmed by inaccurate testimony.
www.acep.org/life-as-a-physician/ethics--legal/standard-of-care-review/procedure-for-review-of-testimony-regarding-standard-of-care-in-emergency-medicine/
As someone who has personally suffered from necrotizing GAS pneumonia/toxic shock syndrome, it's not an easy diagnosis to catch, because things go from OK to very bad very quickly (luckily for me, I deteriorated in the ER). And we also just don't know to look for it, because it is so rare. While hindsight is certainly 20/20, I will always place more scrutiny on a case where the parent/patient are complaining of shortness of breath. Agree that the EW is egregious. I would have probably gotten a CXR. Not sure it would have changed much if the patient's overall clinical appearance was well-appearing at the time.
The best disinfectant is sunlight. The best way to hold unethical expert witnesses to account is to have them post their opinions in the lounge at work. If you wouldn't stand by it in front of your peers, perhaps it isn't a fair opinion.