Ten million dollars for a death of a young person with presumably no dependents? No amount of money will bring this person back and while the parents have suffered, funding their retirement is not the answer. The health care system simply can’t afford to hand out sums of money like this. I am glad to practice in a state where there are limits in non economic damages.
It is extremely scary for me as a resident. We’re always taught about EBM, and it’s unfortunate that Wells, PERC and Geneva all place patient as low risk and don’t account for ECG changes and yet still
the ED provider was found liable. I find this very curious that we can still follow EBM and be found liable
Totally agree. A good reminder that none of our EBM guidelines are absolute or are a guarantee of a good outcome. But if you follow them, you should not be found to be liable.
Let’s remember the sensitivity/specificity and predictive power of wells/geneva and PERC. If low risk and negative, likelihood ofPE is <2%. Which means that it’s possible 1-2 patient of each 100 chest pains we see have a PE. EBM plays the odds while a dead 21 yearold plays the emotions.
One could argue that ECG changes, especially those suggestive of RV strain should factor into gestalt.
It is scary, I don’t disagree. But I think when you look at that EKG, it looks so abnormal for a young, presumably healthy man, that that gestalt overrides the scoring systems we use and love. He had no classic signs of PE but (and I know hindsight is 20/20) something about that EKG just looked so wrong.
Yep, definitely looks abnormal. Some docs have the training to say "hey that looks like a PE!" and some don't recognize it, just have a vague sense of "that's weird" but don't know what to do with the info.
I think one big challenge is that traditional teaching about PE is that using Wells or Geneva for risk stratification is pretty ironclad. We don't really have a mental model for "overruling" Wells or Geneva. If they're low risk, they're low risk, other factors be damned. That approach works the vast vast vast majority of the time, but it didn't here.
Tragic case for sure, but also a terrible miscarriage of justice. It’s debatable whether the EM doc followed standard of care, but in no realm of reality was this gross negligence. The patient was examined, tests were ordered and interpreted, and a differential diagnosis was considered. What’s the point of laws if lawyers and juries can just make stuff up as they go?
Trying to paint this as gross negligence is absolutely obscene. This is a growing trend that really worries me... doctors do appropriate and careful workups, and then somehow a jury gets tricked into thinking that it was gross negligence. The locked-in syndrome case was also a gross negligence standard. It seems that the difference between negligence and gross negligence is only an academic white-tower legal exercise, and has no relevance to reality. When considering various forms of tort reform, maybe gross negligence standard does have some overall benefit when viewed from the population level, but I've seen it go really bad for some individual doctors. We need tort reform that encompasses much more than just gross negligence standard
Yes, that was a wild case! Trial judge threw it out because he decided it wasn't gross negligence, but then the appeals court reinstated it, then the supreme court decided it was gross negligence and threw it out again. It feels good to win in the end but the doc got dragged through an insane amount of stress over the course of many years. Gross negligence standard seems great on paper until you realize what docs go through to get vindicated.
The thing that people don't understand is that doing a workup on every PERC negative patient will not necessarily result in less deaths. If we still do a CTA PE study on all these PERC negative people, we'll end up killing a few people by anaphylactic contrast allergies, a few people by downstream cancers from additional radiation, and a few people will die from anticoagulation given to tiny PEs. The public and court system has no mental capacity to actually consider these arguments or understand trade-offs.
Well said. The risks of testing need to be stressed and are something I try to talk to patients (and more importantly, their families) about whenever I've decided I'm not doing a study (usually CT, but sometimes additional labs or procedures). Why don't medical associations have more a public-facing effort to talk about this? Seems like it would be a very high return on investment.
The newest papers that have been tossed around about overuse of CT causing cancers have actually been helpful, in my opinion. That said, it could all just be warm hugs until someone dies and the family that previously was super on board with no CT now comes knocking with their lawyer.
I doubt any hospital actually has the rad tech and radiologist capacity to cope with a 10x increase in CTA PE ordering. You'd get a mountain of indeterminate results for poor quality scans due to motion/bad bolus timing, people put on anticoagulation who didn't need it because their PE wasn't real, bunch of maybe subsegmental maybe nothing results, etc. Plus all the new incidentalomas! But it'll double as near population level CT lung cancer screening.
This is unsettling. If the patient has gone home and collapsed and died right then and there, I could see causation. The fact he lived his life for two weeks, refused transport after syncopal episode a week later, that tells me he likely didn't have a large PE the first visit or that he had time to return if he worsened as he was told to do.
Back in September 2020, we didn't know the large association of PE after COVID infection either. The arguably worst part is that there is this law that was supposed to help protect us from the unprecedented pandemic, staff shortages, only to be practically useless.
This is absolutely unfair for the physician. The kid got unlucky, he didn't disclose full family hx, didn't follow up, didn't agree to transport a week later, and family then feels entitled to financial compensation. Wild.
Medically, yes I would have ordered troponins based on those ugly T waves but honestly I wouldn't be shocked if the troops were normal at that point in time.
Tough case, and pretty scary. Easy to understand why EM has some of the highest burn out rates with cases like this. Provide evidenced based care and still get criticized.
One could only wish it was just criticism. Criticism is what we get from internal M&M's. A life-long public scarlet letter with years of undue stress, worry, lack of sleep, time away from family -- etc -- are what cases like these bring. There's a big, big difference and we shouldn't underplay the affect these cases have both on the physician experiencing them, and the medical community at large.
I guarantee you no peer group of non-incentivized physicians would reprimand a physician for their handling of this case in the way they did.
The doc considered PE in the differential and the patient PERCd out. The patient had reproducible chest pain in the setting of known COVID-19 and either the virus or coughing (e.g. costochondritis) were much more likely. Further workup for PE was neither evidenced based nor indicated. This is a really sad case, but a faulty verdict and I hope it is overturned on appeal.
I feel pretty strongly that this doctor practiced good, evidenced-based medicine. I guess the question is if the EKG puts this patient in a high risk category (PERC no longer applies, d-dimer is needed) even if our standard risk stratification tools put them in a low risk category. Do we need to update the standard of care workup for PE, or is this such a rare, act of God event, that no changes should be made?
Another shoutout for Dr Smith and his EKG blog. He and the other doctors on his blog are great; putting out amazing, free educational content for us to learn from. I’ve been reading it for ten years and thought of PE immediately after reading the history and looking at the EKG. Really tragic case.
Edited to add: I don’t think this case rises to gross negligence and I also feel deeply for the physician.
A tragic case — and another reminder of how grateful I am not to work in emergency medicine. Subtle T-wave inversions were missed in a few leads in a patient who had entirely unremarkable vitals and was PERC-negative and the result was a multimillion dollar judgement. It’s especially heartbreaking that the patient did not seek care earlier after the syncopal episode. I suspect there's strong chance the outcome would have been very different had he presented at that time.
EM is a tough gig, given the high percentage of ungrateful patients and hyper-critical specialists. The EKG findings are subtle but certainly there, but not sure how reasonable it is to expect every doctor to memorize them. Maybe an opportunity for AI to flag some of these rare/subtle EKG findings that most of us will never encounter in an entire career.
I think another problem here is that the T-wave inversions in this 21 y/o are located in lead III, where we can often also see inverted "pediatric" T-waves. The amount of times I've had cardiology blow off lead III in younger people definitely plays into my interpretation of these cases.
Yeah there's definitely T waves in III that can be normal, but the fact that they're also in multiple inferior leads and multiple anterior leads goes way beyond that, IMO.
Excellent question. If the doctor was demanding to settle and the insurance company refused to offer policy limits, he may have the option for a bad faith lawsuit against the insurance company.
Yes! Were there any more details on this? It seems like the physician may have gotten some bad recommendations by his counsel if that wasn't the case, but it's so impossible to know without having all the details.
Knowing that the judge (and by that, I mean jury, since the judge was spineless in this case), was not going to uphold the COVID protections + dead young person would have had me clamoring to have my insurance to settle, open up policy limits, or have me going full bore threatening a bad faith claim.
No details on the behind-the-scenes negotiations. However, its currently being appealed. I haven't seen many bad faith claims but it usually seems like they wait until the entire appeals process is over before going after the bad faith approach.
It is entirely possible that the plaintiff refused to settle.
If the plaintiff is expecting to win $10 Million at trial and they feel they have a solid case, there is no amount that the defense can offer that would satisfy them. The best an insurance company is going to offer is policy limits and most policies have $250K-300K case limits.
If I'm a plaintiff's lawyer with an emotionally compelling case and an argument for a loss of lifetime earnings, then it makes sense to roll the dice. If you settle, you only get thousands of dollars. If you win at trial, you get millions. Even if my odds of a jury verdict are only 30%, that makes my risk-adjusted win $3 Million dollars.
(But in this scenario, I am a high powered, aggressive malpractice attorney, so I feel that my actual odds of prevailing at trial are more like 60-70% on a good day.)
Pretty widely accepted that plaintiffs usually only win 20-30% of med mal trials. So there's definitely incentive to settle. I'd be super curious to know how close they got on settlement negotiations.
This is all pretty bad information, in my experience.
Through all my locums and full time work I've never seen a EM group offer less than $1M for an individual cap. In many cases it's higher. I'm not sure what you're basing $250k on. I flat wouldn't accept any job offer with that.
The other math you provide is more debatable, but I'd argue that no plaintiff attorney is expecting to get $10M at trial. Outside of landmark cases (I suppose you *could* argue this is one...), my understanding is that they make the majority of their money on smaller settlements and verdicts. Settling is usually to the benefit of the plaintiff as it's guaranteed money NOW that the plaintiff and attorney get to walk away with NOW. No drawn out appeals, no waiting on bad faith claims, etc. That means the attorney can then churn their resources onto another case. Waiting years to see a penny of that unlikely $"X"M, of which there will usually be a vastly reduced post-settlement, frankly isn't usually worth it. $300k in the pocket now is what they're usually seeking.
So much as to say -- dangling a settlement at policy limits in front of a plaintiff attorney is usually a pretty juicy steak that not many would turn down.
I was an EM intern in New Jersey when Covid happened. I remember for one of our weekly conferences i reviewed an executive order that the governor put out that was worded similarly, it made an exception for “gross negligence.” The attendings at the time were wisely concerned about that, and even in the midst of a fucking once in a century pandemic the med mal lawyers pushed back against the executive order. There is absolutely no way a jury will reliably distinguish between regular negligence and gross negligence. With normal vital signs, I don’t think there was any negligence in this case, let alone “gross negligence.”
Some docs acted like these executive orders would really provide good protection... maybe they do in some states and some scenarios but in this case it's clear that it was just a false reassurance.
It was all sugar on a non-existant shit donut they gave us for working with solar-washed re-used N95s. Management and leadership lapped it up too -- kept docs in the trenches with the false reassurance that the shitty care they were being forced to provide was going to be protected or "backed up" if "anything ever happened." I'm glad you published this case to show what a farce that all was.
This COVID law was worded in a really strange way. I think some other states were a bit more clear. I've read it about 100 times now and still can't quite tell what they were trying to say, which honestly may be what the politicians wanted... make it so bizarre and vague that anyone who reads it can kind of convince themself it suits their purpose. The jury in this clearly took it to mean that it only applies if the hospital absolutely overflows, runs out of equipment, all the staff die, extreme scenarios like that, etc...
This is so ridiculous. In my estimation this ED physician did nothing wrong. He died weeks later after having refused ambulance transport for re-eval. This verdict is a travesty. What other profession faces this sort of threat? Just goes to show that no one should practice in a non-tort reform state.
Not commenting on the legitimacy or opinion of the outcome of velocity, I can candidly state that during my practice has been persistent or worsening symptoms after approximately 7 to 10 days triggers consideration for the development of thrombus in situ of a pulmonary embolism. “The timeline didn’t make sense for COVID. The patient described 2 weeks of symptoms of cough and congestion. However, it wasn’t until the last few days that he developed shortness of breath with exertion and chest pain.” This story with the development of dyspnea on exertion, which is one of the more specific symptoms of PE, may have triggered me to at least get a dimer if not a CT angiogram out right. But that’s based solely on my personal experience during Covid.
Yes, there were nuances to the history beyond simply "chest pain and shortness of breath". It can be hard to tune into those nuances in the sea of covid patients, all with very similar symptoms.
I've been under the impression a t wave inversion in lead III is a normal variant (according to LITFL). Maybe if there was a previous EKG to compare (unlikely given it was an otherwise healthy, young male) this would have been a new finding.
Personally, if I saw a t wave inversion in V1, even V2, and lead III in a young, thin male I would not consider PE because I would consider persistent rightward deviation as a more likely explanation. There is, however, TWI in avF and V3 which is more suggestive of pathology. Would I have caught it? Probably not. Hindsight is 20/20. But now every post- viral syncope or chest pain/ SOB is now getting a d-dimer, regardless of their PERC score. Thanks legal system for scaring me to bankruptcy. This is just another case of an unfortunate, unpredictable outcome despite practicing within the standard of care= bad luck for the ER doctor. I hope he/she can recover and continue to practice good medicine.
It's a bit tricky because TWI in V1 can be normal variant, as can TWI in lead III. But the constellation of multiple anterior and inferior T wave inversions apparently has a decently strong association with PE (but not always!)
Unfortunate outcome for all involved. To be fair, the EKG findings were not entirely nonspecific and should probably resulted in additional laboratory evaluation.
Though the patient was PERC negative, he was symptomatic with escalating symptoms. With an abnormal EKG. IMO, PERC was not reliable in this situation. Pt was diagnosed with COVID two weeks prior. SOB began 3 days prior to ED visit and pleuritic CP 2 days prior. He was concerned enough that he was seen at an UC then the ED. All of that history should not have been minimized because he had a negative PERC. I do believe, at times, that there is an age bias when it comes to young people because they compensate so well clinically. When performing PERC and Well's criteria, that compensation should be considered. Since COVID began, I have changed my practice to consider COVID a risk factor for a PE, particularly in patients under 50. I have had to change my clinical approach to raise my suspicions. That is unfortunately not considered in the PERC/Wells criteria, which are simply guidelines, not laws. I work in a very rural part of New Zealand with no ED and no CT. I would have sent this patient for a CTA.
With all that being said, no way would I agree that this was gross negligence in any way, shape or form. This is one of the reasons I left U.S. medicine, this kind of crap that makes EM docs easy scapegoats.
Wow, no ED and no CT presents a tough challenge! I was doing a little bit of literature searching and it turns out the risk of thromboembolic disease in the first few weeks of COVID are much higher than the risk of oral contraceptives. I think if this patient was a female who had just been started on OCPs, it probably would have triggered a workup, because we're trained so aggressively about that risk factor. That being said, the connection between COVID and DVT/PE wasn't as well established at the time so its hard to say if it was actually standard of care to make that connection.
I absolutely believe the ED doc met the current standard of care. I'm just emphasizing that perhaps we need to remember that PERC(which was developed prior to COVID) is a tool and not an absolute. What bothers me, besides the abnormal EKG, is his escalating symptoms(SOB, pleuritic vs MSK CP). In light of a known vasculopathic process, perhaps the suspicion for a PE should have been higher. My two cents.
Definitely agree with you on both points for 5. Add both of those plus a very sympathetic patient and you gotta settle that case. Wild to me that this made it to trial.
EMS not being added to the lawsuit just shows you how powerful "if it wasn't documented, it didn't happen" and the inverse can be. Who do you trust more, a document signed & dated by the patient at the time of care or multiple witnesses after the fact (maybe even years afterwards at trial)? Just because someone remembers something doesn't mean it actually happened.
I think they felt that they had a strong argument in that the doctor followed evidenced-based care. You can easily show a jury... these are the guidelines for how to work up a PE. The doctor followed the guidelines. Most rational juries will follow that argument and give a defense verdict. For whatever reason, this one did not.
This site is always compelling. And the poll and comments are interesting. We all know to be on our toes when we review these cases (like taking a board exam)-something happened or we would not be reading about it. So, I immediately looked at the EKG and knew that this was a PE case (again, context bias). I have been in EM for a long time but have tried not to be complacent about learning something most weeks-especially the ever-expanding knowledge base of EKG changes. So, while the EKG changes are subtle (or not), in the right scenario, they can suggest further investigation is optimal. That being said, in September 2020, this case represented standard care (remember such is not optimal or best care-but average care). We all strive to be the best we can at all times but we also know that sometimes we are average and such is not negligent care. This is a very unfortunate case. And, it appears that even the well-intended veil of limited liability during a national disaster quickly faded from the public (jury) consideration.
Thanks for reading! I always learn something from writing these cases and it's good to know others benefit from it too. I think my overall assessment is that while not the best care possible, it did meet the standard of care. There's a good chance I may have missed those EKG findings before I did research for this case.
Ten million dollars for a death of a young person with presumably no dependents? No amount of money will bring this person back and while the parents have suffered, funding their retirement is not the answer. The health care system simply can’t afford to hand out sums of money like this. I am glad to practice in a state where there are limits in non economic damages.
It is extremely scary for me as a resident. We’re always taught about EBM, and it’s unfortunate that Wells, PERC and Geneva all place patient as low risk and don’t account for ECG changes and yet still
the ED provider was found liable. I find this very curious that we can still follow EBM and be found liable
Totally agree. A good reminder that none of our EBM guidelines are absolute or are a guarantee of a good outcome. But if you follow them, you should not be found to be liable.
Let’s remember the sensitivity/specificity and predictive power of wells/geneva and PERC. If low risk and negative, likelihood ofPE is <2%. Which means that it’s possible 1-2 patient of each 100 chest pains we see have a PE. EBM plays the odds while a dead 21 yearold plays the emotions.
One could argue that ECG changes, especially those suggestive of RV strain should factor into gestalt.
It is scary, I don’t disagree. But I think when you look at that EKG, it looks so abnormal for a young, presumably healthy man, that that gestalt overrides the scoring systems we use and love. He had no classic signs of PE but (and I know hindsight is 20/20) something about that EKG just looked so wrong.
Yep, definitely looks abnormal. Some docs have the training to say "hey that looks like a PE!" and some don't recognize it, just have a vague sense of "that's weird" but don't know what to do with the info.
I think one big challenge is that traditional teaching about PE is that using Wells or Geneva for risk stratification is pretty ironclad. We don't really have a mental model for "overruling" Wells or Geneva. If they're low risk, they're low risk, other factors be damned. That approach works the vast vast vast majority of the time, but it didn't here.
Tragic case for sure, but also a terrible miscarriage of justice. It’s debatable whether the EM doc followed standard of care, but in no realm of reality was this gross negligence. The patient was examined, tests were ordered and interpreted, and a differential diagnosis was considered. What’s the point of laws if lawyers and juries can just make stuff up as they go?
Trying to paint this as gross negligence is absolutely obscene. This is a growing trend that really worries me... doctors do appropriate and careful workups, and then somehow a jury gets tricked into thinking that it was gross negligence. The locked-in syndrome case was also a gross negligence standard. It seems that the difference between negligence and gross negligence is only an academic white-tower legal exercise, and has no relevance to reality. When considering various forms of tort reform, maybe gross negligence standard does have some overall benefit when viewed from the population level, but I've seen it go really bad for some individual doctors. We need tort reform that encompasses much more than just gross negligence standard
Also reminds me of that snakebite antivenom case you covered where the doc followed hospital protocol and still got sued for gross negligence.
Aren’t many Good Samaritan protections also based on a gross negligence standard? The downstream effects of this standard being eroded are chilling.
Yes, that was a wild case! Trial judge threw it out because he decided it wasn't gross negligence, but then the appeals court reinstated it, then the supreme court decided it was gross negligence and threw it out again. It feels good to win in the end but the doc got dragged through an insane amount of stress over the course of many years. Gross negligence standard seems great on paper until you realize what docs go through to get vindicated.
Yes, I would have thought applying a well accepted PERC neg decision tool would have trumped a rather unknown EKG association with PE.
Metrics be damned, everyone gets a work up
The thing that people don't understand is that doing a workup on every PERC negative patient will not necessarily result in less deaths. If we still do a CTA PE study on all these PERC negative people, we'll end up killing a few people by anaphylactic contrast allergies, a few people by downstream cancers from additional radiation, and a few people will die from anticoagulation given to tiny PEs. The public and court system has no mental capacity to actually consider these arguments or understand trade-offs.
Well said. The risks of testing need to be stressed and are something I try to talk to patients (and more importantly, their families) about whenever I've decided I'm not doing a study (usually CT, but sometimes additional labs or procedures). Why don't medical associations have more a public-facing effort to talk about this? Seems like it would be a very high return on investment.
The newest papers that have been tossed around about overuse of CT causing cancers have actually been helpful, in my opinion. That said, it could all just be warm hugs until someone dies and the family that previously was super on board with no CT now comes knocking with their lawyer.
I doubt any hospital actually has the rad tech and radiologist capacity to cope with a 10x increase in CTA PE ordering. You'd get a mountain of indeterminate results for poor quality scans due to motion/bad bolus timing, people put on anticoagulation who didn't need it because their PE wasn't real, bunch of maybe subsegmental maybe nothing results, etc. Plus all the new incidentalomas! But it'll double as near population level CT lung cancer screening.
This is unsettling. If the patient has gone home and collapsed and died right then and there, I could see causation. The fact he lived his life for two weeks, refused transport after syncopal episode a week later, that tells me he likely didn't have a large PE the first visit or that he had time to return if he worsened as he was told to do.
Back in September 2020, we didn't know the large association of PE after COVID infection either. The arguably worst part is that there is this law that was supposed to help protect us from the unprecedented pandemic, staff shortages, only to be practically useless.
This is absolutely unfair for the physician. The kid got unlucky, he didn't disclose full family hx, didn't follow up, didn't agree to transport a week later, and family then feels entitled to financial compensation. Wild.
Medically, yes I would have ordered troponins based on those ugly T waves but honestly I wouldn't be shocked if the troops were normal at that point in time.
Tough case, and pretty scary. Easy to understand why EM has some of the highest burn out rates with cases like this. Provide evidenced based care and still get criticized.
One could only wish it was just criticism. Criticism is what we get from internal M&M's. A life-long public scarlet letter with years of undue stress, worry, lack of sleep, time away from family -- etc -- are what cases like these bring. There's a big, big difference and we shouldn't underplay the affect these cases have both on the physician experiencing them, and the medical community at large.
I guarantee you no peer group of non-incentivized physicians would reprimand a physician for their handling of this case in the way they did.
The doc considered PE in the differential and the patient PERCd out. The patient had reproducible chest pain in the setting of known COVID-19 and either the virus or coughing (e.g. costochondritis) were much more likely. Further workup for PE was neither evidenced based nor indicated. This is a really sad case, but a faulty verdict and I hope it is overturned on appeal.
I feel pretty strongly that this doctor practiced good, evidenced-based medicine. I guess the question is if the EKG puts this patient in a high risk category (PERC no longer applies, d-dimer is needed) even if our standard risk stratification tools put them in a low risk category. Do we need to update the standard of care workup for PE, or is this such a rare, act of God event, that no changes should be made?
Another shoutout for Dr Smith and his EKG blog. He and the other doctors on his blog are great; putting out amazing, free educational content for us to learn from. I’ve been reading it for ten years and thought of PE immediately after reading the history and looking at the EKG. Really tragic case.
Edited to add: I don’t think this case rises to gross negligence and I also feel deeply for the physician.
A tragic case — and another reminder of how grateful I am not to work in emergency medicine. Subtle T-wave inversions were missed in a few leads in a patient who had entirely unremarkable vitals and was PERC-negative and the result was a multimillion dollar judgement. It’s especially heartbreaking that the patient did not seek care earlier after the syncopal episode. I suspect there's strong chance the outcome would have been very different had he presented at that time.
EM is a tough gig, given the high percentage of ungrateful patients and hyper-critical specialists. The EKG findings are subtle but certainly there, but not sure how reasonable it is to expect every doctor to memorize them. Maybe an opportunity for AI to flag some of these rare/subtle EKG findings that most of us will never encounter in an entire career.
I think another problem here is that the T-wave inversions in this 21 y/o are located in lead III, where we can often also see inverted "pediatric" T-waves. The amount of times I've had cardiology blow off lead III in younger people definitely plays into my interpretation of these cases.
Yeah there's definitely T waves in III that can be normal, but the fact that they're also in multiple inferior leads and multiple anterior leads goes way beyond that, IMO.
Wonder how hard they worked to try to settle. A deceased 21 year old college student is a very sympathetic plaintiff
Excellent question. If the doctor was demanding to settle and the insurance company refused to offer policy limits, he may have the option for a bad faith lawsuit against the insurance company.
Yes! Were there any more details on this? It seems like the physician may have gotten some bad recommendations by his counsel if that wasn't the case, but it's so impossible to know without having all the details.
Knowing that the judge (and by that, I mean jury, since the judge was spineless in this case), was not going to uphold the COVID protections + dead young person would have had me clamoring to have my insurance to settle, open up policy limits, or have me going full bore threatening a bad faith claim.
No details on the behind-the-scenes negotiations. However, its currently being appealed. I haven't seen many bad faith claims but it usually seems like they wait until the entire appeals process is over before going after the bad faith approach.
It is entirely possible that the plaintiff refused to settle.
If the plaintiff is expecting to win $10 Million at trial and they feel they have a solid case, there is no amount that the defense can offer that would satisfy them. The best an insurance company is going to offer is policy limits and most policies have $250K-300K case limits.
If I'm a plaintiff's lawyer with an emotionally compelling case and an argument for a loss of lifetime earnings, then it makes sense to roll the dice. If you settle, you only get thousands of dollars. If you win at trial, you get millions. Even if my odds of a jury verdict are only 30%, that makes my risk-adjusted win $3 Million dollars.
(But in this scenario, I am a high powered, aggressive malpractice attorney, so I feel that my actual odds of prevailing at trial are more like 60-70% on a good day.)
Pretty widely accepted that plaintiffs usually only win 20-30% of med mal trials. So there's definitely incentive to settle. I'd be super curious to know how close they got on settlement negotiations.
This is all pretty bad information, in my experience.
Through all my locums and full time work I've never seen a EM group offer less than $1M for an individual cap. In many cases it's higher. I'm not sure what you're basing $250k on. I flat wouldn't accept any job offer with that.
The other math you provide is more debatable, but I'd argue that no plaintiff attorney is expecting to get $10M at trial. Outside of landmark cases (I suppose you *could* argue this is one...), my understanding is that they make the majority of their money on smaller settlements and verdicts. Settling is usually to the benefit of the plaintiff as it's guaranteed money NOW that the plaintiff and attorney get to walk away with NOW. No drawn out appeals, no waiting on bad faith claims, etc. That means the attorney can then churn their resources onto another case. Waiting years to see a penny of that unlikely $"X"M, of which there will usually be a vastly reduced post-settlement, frankly isn't usually worth it. $300k in the pocket now is what they're usually seeking.
So much as to say -- dangling a settlement at policy limits in front of a plaintiff attorney is usually a pretty juicy steak that not many would turn down.
I was an EM intern in New Jersey when Covid happened. I remember for one of our weekly conferences i reviewed an executive order that the governor put out that was worded similarly, it made an exception for “gross negligence.” The attendings at the time were wisely concerned about that, and even in the midst of a fucking once in a century pandemic the med mal lawyers pushed back against the executive order. There is absolutely no way a jury will reliably distinguish between regular negligence and gross negligence. With normal vital signs, I don’t think there was any negligence in this case, let alone “gross negligence.”
Some docs acted like these executive orders would really provide good protection... maybe they do in some states and some scenarios but in this case it's clear that it was just a false reassurance.
It was all sugar on a non-existant shit donut they gave us for working with solar-washed re-used N95s. Management and leadership lapped it up too -- kept docs in the trenches with the false reassurance that the shitty care they were being forced to provide was going to be protected or "backed up" if "anything ever happened." I'm glad you published this case to show what a farce that all was.
This COVID law was worded in a really strange way. I think some other states were a bit more clear. I've read it about 100 times now and still can't quite tell what they were trying to say, which honestly may be what the politicians wanted... make it so bizarre and vague that anyone who reads it can kind of convince themself it suits their purpose. The jury in this clearly took it to mean that it only applies if the hospital absolutely overflows, runs out of equipment, all the staff die, extreme scenarios like that, etc...
This is so ridiculous. In my estimation this ED physician did nothing wrong. He died weeks later after having refused ambulance transport for re-eval. This verdict is a travesty. What other profession faces this sort of threat? Just goes to show that no one should practice in a non-tort reform state.
Not commenting on the legitimacy or opinion of the outcome of velocity, I can candidly state that during my practice has been persistent or worsening symptoms after approximately 7 to 10 days triggers consideration for the development of thrombus in situ of a pulmonary embolism. “The timeline didn’t make sense for COVID. The patient described 2 weeks of symptoms of cough and congestion. However, it wasn’t until the last few days that he developed shortness of breath with exertion and chest pain.” This story with the development of dyspnea on exertion, which is one of the more specific symptoms of PE, may have triggered me to at least get a dimer if not a CT angiogram out right. But that’s based solely on my personal experience during Covid.
Yes, there were nuances to the history beyond simply "chest pain and shortness of breath". It can be hard to tune into those nuances in the sea of covid patients, all with very similar symptoms.
I've been under the impression a t wave inversion in lead III is a normal variant (according to LITFL). Maybe if there was a previous EKG to compare (unlikely given it was an otherwise healthy, young male) this would have been a new finding.
Personally, if I saw a t wave inversion in V1, even V2, and lead III in a young, thin male I would not consider PE because I would consider persistent rightward deviation as a more likely explanation. There is, however, TWI in avF and V3 which is more suggestive of pathology. Would I have caught it? Probably not. Hindsight is 20/20. But now every post- viral syncope or chest pain/ SOB is now getting a d-dimer, regardless of their PERC score. Thanks legal system for scaring me to bankruptcy. This is just another case of an unfortunate, unpredictable outcome despite practicing within the standard of care= bad luck for the ER doctor. I hope he/she can recover and continue to practice good medicine.
It's a bit tricky because TWI in V1 can be normal variant, as can TWI in lead III. But the constellation of multiple anterior and inferior T wave inversions apparently has a decently strong association with PE (but not always!)
Unfortunate outcome for all involved. To be fair, the EKG findings were not entirely nonspecific and should probably resulted in additional laboratory evaluation.
Though the patient was PERC negative, he was symptomatic with escalating symptoms. With an abnormal EKG. IMO, PERC was not reliable in this situation. Pt was diagnosed with COVID two weeks prior. SOB began 3 days prior to ED visit and pleuritic CP 2 days prior. He was concerned enough that he was seen at an UC then the ED. All of that history should not have been minimized because he had a negative PERC. I do believe, at times, that there is an age bias when it comes to young people because they compensate so well clinically. When performing PERC and Well's criteria, that compensation should be considered. Since COVID began, I have changed my practice to consider COVID a risk factor for a PE, particularly in patients under 50. I have had to change my clinical approach to raise my suspicions. That is unfortunately not considered in the PERC/Wells criteria, which are simply guidelines, not laws. I work in a very rural part of New Zealand with no ED and no CT. I would have sent this patient for a CTA.
With all that being said, no way would I agree that this was gross negligence in any way, shape or form. This is one of the reasons I left U.S. medicine, this kind of crap that makes EM docs easy scapegoats.
Wow, no ED and no CT presents a tough challenge! I was doing a little bit of literature searching and it turns out the risk of thromboembolic disease in the first few weeks of COVID are much higher than the risk of oral contraceptives. I think if this patient was a female who had just been started on OCPs, it probably would have triggered a workup, because we're trained so aggressively about that risk factor. That being said, the connection between COVID and DVT/PE wasn't as well established at the time so its hard to say if it was actually standard of care to make that connection.
I absolutely believe the ED doc met the current standard of care. I'm just emphasizing that perhaps we need to remember that PERC(which was developed prior to COVID) is a tool and not an absolute. What bothers me, besides the abnormal EKG, is his escalating symptoms(SOB, pleuritic vs MSK CP). In light of a known vasculopathic process, perhaps the suspicion for a PE should have been higher. My two cents.
Definitely agree with you on both points for 5. Add both of those plus a very sympathetic patient and you gotta settle that case. Wild to me that this made it to trial.
EMS not being added to the lawsuit just shows you how powerful "if it wasn't documented, it didn't happen" and the inverse can be. Who do you trust more, a document signed & dated by the patient at the time of care or multiple witnesses after the fact (maybe even years afterwards at trial)? Just because someone remembers something doesn't mean it actually happened.
I think they felt that they had a strong argument in that the doctor followed evidenced-based care. You can easily show a jury... these are the guidelines for how to work up a PE. The doctor followed the guidelines. Most rational juries will follow that argument and give a defense verdict. For whatever reason, this one did not.
This site is always compelling. And the poll and comments are interesting. We all know to be on our toes when we review these cases (like taking a board exam)-something happened or we would not be reading about it. So, I immediately looked at the EKG and knew that this was a PE case (again, context bias). I have been in EM for a long time but have tried not to be complacent about learning something most weeks-especially the ever-expanding knowledge base of EKG changes. So, while the EKG changes are subtle (or not), in the right scenario, they can suggest further investigation is optimal. That being said, in September 2020, this case represented standard care (remember such is not optimal or best care-but average care). We all strive to be the best we can at all times but we also know that sometimes we are average and such is not negligent care. This is a very unfortunate case. And, it appears that even the well-intended veil of limited liability during a national disaster quickly faded from the public (jury) consideration.
Thanks for reading! I always learn something from writing these cases and it's good to know others benefit from it too. I think my overall assessment is that while not the best care possible, it did meet the standard of care. There's a good chance I may have missed those EKG findings before I did research for this case.