As a former hospitalist, this is a bread and butter case and this outcome is embarrassing. I would absolutely settle. Did no one review the abdominal xray?? NPO, ngt for decompression, IV Fluids, general surgery consult, small bowel series/follow-through in a couple days. Thank you and good night.
Seems fairly basic. Odd that 2 hospitalists who both saw the patient weren't concerned though. She basically got 3 opinions that same day, 2 said everything was fine and 1 raised major red flags.
I think $6.5M is far too much for a frail 77yo who already had 2 hip replacements. They are unlikely to live 5-10yrs, no loss of earnings. I am curious what the financial pros think? However post-op ileus/obstruction was considered, there to be diagnosed and still missed. I would consider that the very definition of negligence. Had she been diagnosed and treated she may still have had complications and may have died for another reason. Regardless she would be in a rehab/SNF and not go back to her prior baseline
I don't think the plaintiffs genuinely thought they could $6.5 million, but they wanted to start the negotiation from an elevated position. This is probably partially why it hasn't settled yet.
Agree with Laura. Question for Med Mal Reviewer: in the course of reviewing these cases, are the opinions of "Financial Experts" available? I suspect the economic damages in this case are actually quite limited and the majority of the suggested $6.5m are non-economic damages. If financial expert opinions are available, they would be excellent supplement to many of these cases.
There's a lot of variability in how the attorneys include the financial experts. I'd say about 1/4 of the cases disclose a financial or economic expert. Of those, about half just give such a vague disclosure that I find it a waste of space ("Mr. Smith will testify about economic damages"). The rest of the time they'll include an actual dollar amount of lost wages, future care expenses, etc... that is much more interesting to see (although doesnt often include the methodology on how they reached it). I'll start including all the ones that have exact dollar amounts! Unfortunately this case didn't have one. I think the attorney just randomly shot out a big number for the psychological anchoring benefit while negotiating.
As a bedside nurse I'm not surprised that bowel movement size was an issue in a case, and I was hoping you'd talk about it more lol. It's so subjective and a lot of times when I'm documenting I go back and forth.... was that "medium" or "large"? Was it a "small" BM or was it a "smear"? I don't recall ever getting formal guidance on this, either in my education or during job training. By contrast, we did learn how to judge other subjective things like urine color, how to quantify %s of meals eaten, etc.
I'm also interested in others' thoughts on the family saying the patient's BM was so small it didn't count vs the nurse documenting a large BM. I can easily picture, for example, the pt having a small BM, the family leaves the room bc they don't want to be there, and then the pt poops a lot more when she's turned for cleaning. But I can also easily imagine an inexperienced nurse giving an enema, seeing a lot of fluid come out and documenting bowel movement when it was really just the enema coming back out.
Some thought-provoking communication issues here too, like the nurse documenting the doctor wanted the pt NPO, but no one ever putting in the order (for days?).
Deciding the size seems so subjective as to be almost totally useless. I think your idea about the family having missed what actually happen is valid, I've seen that happen multiple times. Complaints that the doctor never examined the patient when they were actually in the room for 30 minutes prior to the family arriving, etc...
Do you think the nephrology fellow/attending should have been named? An alarming finding was documented, but did they make any effort to address it, even if it wasn't related to the kidneys? Also, from an EM perspective, I would definitely order a CT abdomen if the X ray shows an abnormality. Actually who am I kidding I would've just started with the CT. The point about failing to put in an NG tube though I don't totally agree with because the evidence for those is questionable, but yes she should've been NPO.
I think its a valid point about the neph fellow. If it was just abdominal pain he documented it probably would have been fine to leave it to the primary team, but if its to the point that its causing respiratory dysfunction, he easily could have been named for not notifying the primary team more urgently. Personally I don't think he deserves to be sued for this but it is a good lesson that everyone's responsible to raise the alarm if something is amiss.
I agree with ordering a CT, but since we're both EM we automatically reflex to CTs. I think it seems pretty standard to just do plain films on the floor for this sort of thing.
It was the ortho expert witness adding a bit more commentary: "This documentation, while incorrect, also internally conflicted with the documented assessment/plan: "post-op ileus; Advance diet as per primary team; continue bowel regiment.'"
As a former hospitalist, this is a bread and butter case and this outcome is embarrassing. I would absolutely settle. Did no one review the abdominal xray?? NPO, ngt for decompression, IV Fluids, general surgery consult, small bowel series/follow-through in a couple days. Thank you and good night.
Seems fairly basic. Odd that 2 hospitalists who both saw the patient weren't concerned though. She basically got 3 opinions that same day, 2 said everything was fine and 1 raised major red flags.
I think $6.5M is far too much for a frail 77yo who already had 2 hip replacements. They are unlikely to live 5-10yrs, no loss of earnings. I am curious what the financial pros think? However post-op ileus/obstruction was considered, there to be diagnosed and still missed. I would consider that the very definition of negligence. Had she been diagnosed and treated she may still have had complications and may have died for another reason. Regardless she would be in a rehab/SNF and not go back to her prior baseline
I don't think the plaintiffs genuinely thought they could $6.5 million, but they wanted to start the negotiation from an elevated position. This is probably partially why it hasn't settled yet.
Agree with Laura. Question for Med Mal Reviewer: in the course of reviewing these cases, are the opinions of "Financial Experts" available? I suspect the economic damages in this case are actually quite limited and the majority of the suggested $6.5m are non-economic damages. If financial expert opinions are available, they would be excellent supplement to many of these cases.
There's a lot of variability in how the attorneys include the financial experts. I'd say about 1/4 of the cases disclose a financial or economic expert. Of those, about half just give such a vague disclosure that I find it a waste of space ("Mr. Smith will testify about economic damages"). The rest of the time they'll include an actual dollar amount of lost wages, future care expenses, etc... that is much more interesting to see (although doesnt often include the methodology on how they reached it). I'll start including all the ones that have exact dollar amounts! Unfortunately this case didn't have one. I think the attorney just randomly shot out a big number for the psychological anchoring benefit while negotiating.
As a bedside nurse I'm not surprised that bowel movement size was an issue in a case, and I was hoping you'd talk about it more lol. It's so subjective and a lot of times when I'm documenting I go back and forth.... was that "medium" or "large"? Was it a "small" BM or was it a "smear"? I don't recall ever getting formal guidance on this, either in my education or during job training. By contrast, we did learn how to judge other subjective things like urine color, how to quantify %s of meals eaten, etc.
I'm also interested in others' thoughts on the family saying the patient's BM was so small it didn't count vs the nurse documenting a large BM. I can easily picture, for example, the pt having a small BM, the family leaves the room bc they don't want to be there, and then the pt poops a lot more when she's turned for cleaning. But I can also easily imagine an inexperienced nurse giving an enema, seeing a lot of fluid come out and documenting bowel movement when it was really just the enema coming back out.
Some thought-provoking communication issues here too, like the nurse documenting the doctor wanted the pt NPO, but no one ever putting in the order (for days?).
Deciding the size seems so subjective as to be almost totally useless. I think your idea about the family having missed what actually happen is valid, I've seen that happen multiple times. Complaints that the doctor never examined the patient when they were actually in the room for 30 minutes prior to the family arriving, etc...
Do you think the nephrology fellow/attending should have been named? An alarming finding was documented, but did they make any effort to address it, even if it wasn't related to the kidneys? Also, from an EM perspective, I would definitely order a CT abdomen if the X ray shows an abnormality. Actually who am I kidding I would've just started with the CT. The point about failing to put in an NG tube though I don't totally agree with because the evidence for those is questionable, but yes she should've been NPO.
I think its a valid point about the neph fellow. If it was just abdominal pain he documented it probably would have been fine to leave it to the primary team, but if its to the point that its causing respiratory dysfunction, he easily could have been named for not notifying the primary team more urgently. Personally I don't think he deserves to be sued for this but it is a good lesson that everyone's responsible to raise the alarm if something is amiss.
I agree with ordering a CT, but since we're both EM we automatically reflex to CTs. I think it seems pretty standard to just do plain films on the floor for this sort of thing.
What was footnote 1 in the ortho's opinion?
It was the ortho expert witness adding a bit more commentary: "This documentation, while incorrect, also internally conflicted with the documented assessment/plan: "post-op ileus; Advance diet as per primary team; continue bowel regiment.'"