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.
It's tempting to name/shame but I have a very strict rule to not name any of the involved parties. I'd rather have this be an educational discussion, which I think is served well without names. ACEP, medical boards, and employers have mechanisms to deal with ethics violations, which I think should strongly be considered in this case.
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.
90% is a landslide in the world of newsletter polls! Keep in mind anyone can sign up for this so there's always a percentage of people with zero medical training reading this.
State boards and specialty organizations have ethics boards to deal with this sort of thing. Usually its up to the doctor to decide if they want to file something. Most don't because its an onerous process that retraumatizes people.
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 agree. Based on the information provided here, this person needs to be reported to their state medical board and ABEM. Their home institution needs to also be aware.
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.
I agree its always wise to look for clinical pearls, even when the doctor didn't fall below the standard of care. I don't think I consider 95% to qualify as a desat? If there is any valid criticism here, I think its the lack of 2nd vital signs.
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 could write an entire newsletter about egregious insurance decisions too. If its an emergency, there shouldn't be any prior auth whatsoever. Insurance companies love to claim they're trying to prevent fraud, but the rate of unethical insurance denials to physician fraud is 100:1 or worse.
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!”
If you practice in medicine long enough, eventually one of your patients will have a bad outcome despite you doing everything correctly. Thanks for reading and I hope you got your package mailed without yelling!
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...
Thanks! I've encouraged the defendant to file an ethics violation against this "expert". Hopefully he will face justice for this opinion, truly one of the most dishonest I've ever read.
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.
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.
Agreed. Can’t generalize to IM. This “expert” just increased the misery associated with this case. I hope and pray the PA and supervising doc got the support they need from their colleagues and institution.
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 $.
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
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.
Wow, it would be great to hear the full story from both the patient and clinician sides! Interesting point about the shortness of breath, I hadn't considered that.
I have more beef with the care provided than you do. Steroids are wielded with very little regard to their risk. My own development as a pediatrician was marked by the death of a kid who had poorly controlled asthma but no PCP. He went to various "clinica medica familiar" in Los Angeles and kept being given 5 day courses of prednisone. He died of a viral hepatitis and I spent a horrible night as an intern in my second month of my residency trying to get the PICU to take him upstairs, because I knew he was very, very sick but nobody believed me. I did eventually get him transferred, he started coding in the elevator on the way up.
I think giving decadron to a kid with a 103 fever prior to figuring out WHY he has a 103 fever is irresponsible. It's not ibuprofen. It's a immune system inhibitor. Croup doesn't routinely happen to 7 year olds, and it doesn't routinely cause big fevers. There is more to the picture here.
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.
The case is already settled. I hope the defendant involves submits this to ACEP for review, but ultimately the decision is theirs and I also understand if they don't want to do so because it will just re-traumatize them.
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.
It's tempting to name/shame but I have a very strict rule to not name any of the involved parties. I'd rather have this be an educational discussion, which I think is served well without names. ACEP, medical boards, and employers have mechanisms to deal with ethics violations, which I think should strongly be considered in this case.
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.
90% is a landslide in the world of newsletter polls! Keep in mind anyone can sign up for this so there's always a percentage of people with zero medical training reading this.
It doesn't border on egregious. It is BEYOND egregious.
Can anything be done by the vast majority of physician community when this is seen? Reporting to the board perhaps?
State boards and specialty organizations have ethics boards to deal with this sort of thing. Usually its up to the doctor to decide if they want to file something. Most don't because its an onerous process that retraumatizes people.
I think another reader summed it up nicely by saying "This expert opinion is heavy on the opinion and extremely light on the expert. "
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 agree. Based on the information provided here, this person needs to be reported to their state medical board and ABEM. Their home institution needs to also be aware.
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.
I agree its always wise to look for clinical pearls, even when the doctor didn't fall below the standard of care. I don't think I consider 95% to qualify as a desat? If there is any valid criticism here, I think its the lack of 2nd vital signs.
It’s a suggestion to be wary. 95% in a healthy child this early... just recheck...
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 could write an entire newsletter about egregious insurance decisions too. If its an emergency, there shouldn't be any prior auth whatsoever. Insurance companies love to claim they're trying to prevent fraud, but the rate of unethical insurance denials to physician fraud is 100:1 or worse.
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!”
If you practice in medicine long enough, eventually one of your patients will have a bad outcome despite you doing everything correctly. Thanks for reading and I hope you got your package mailed without yelling!
Apologies for how my phone autocorrected some of this.
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!
Thanks! I've encouraged the defendant to file an ethics violation against this "expert". Hopefully he will face justice for this opinion, truly one of the most dishonest I've ever read.
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.
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.
Are you kidding!? This "expert" is clearly a nutcase. There are plenty of internists in rural areas practicing emergency medicine safely.
Agreed. Can’t generalize to IM. This “expert” just increased the misery associated with this case. I hope and pray the PA and supervising doc got the support they need from their colleagues and institution.
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 $.
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
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.
Wow, it would be great to hear the full story from both the patient and clinician sides! Interesting point about the shortness of breath, I hadn't considered that.
I have more beef with the care provided than you do. Steroids are wielded with very little regard to their risk. My own development as a pediatrician was marked by the death of a kid who had poorly controlled asthma but no PCP. He went to various "clinica medica familiar" in Los Angeles and kept being given 5 day courses of prednisone. He died of a viral hepatitis and I spent a horrible night as an intern in my second month of my residency trying to get the PICU to take him upstairs, because I knew he was very, very sick but nobody believed me. I did eventually get him transferred, he started coding in the elevator on the way up.
I think giving decadron to a kid with a 103 fever prior to figuring out WHY he has a 103 fever is irresponsible. It's not ibuprofen. It's a immune system inhibitor. Croup doesn't routinely happen to 7 year olds, and it doesn't routinely cause big fevers. There is more to the picture here.
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/
The case is already settled. I hope the defendant involves submits this to ACEP for review, but ultimately the decision is theirs and I also understand if they don't want to do so because it will just re-traumatize them.