Clearly, the patient presented with a limb threatening condition from which all the downstream complications flowed. I’m an ER doc not a vascular surgeon, but in looking through the retrospectoscope, it seems at the outset an opportunity was lost to provide definite treatment and salvage her limb. A GI bleed poses risks (and in this case there is a paucity of data regarding its source and severity), but it does not seem to rise to the level of a life threatening condition to preclude immediate intervention directed at her ischemic leg; and in any case short of a catastrophic bleed could be temporized with transfusion, PPI or endoscopy. Time is muscle.
This situation highlights the consequences of a culture of delay that is, unfortunately, prevalent. In a case where a patient is facing limb loss, hematochezia becomes a relatively minor concern. Was GI ever consulted? We frequently receive consults for similar cases, and in such scenarios, I advise the team to prioritize the more critical issues. If an experienced GI physician evaluates the case and recognizes key connections, it may be difficult to argue against their assessment or win the case.
I can't help but notice the culture of delay in this case and the COVID STEMI case that I published 2 weeks ago. Both had very questionable delays that ended up killing the patient. Thus far I don't think I've published any cases in which someone got sued for doing a procedure too soon, which isn't to say that it doesn't sometimes harm patients but that you're just way less likely to get sued for harming someone that way.
If the GI bleed was a concern, wouldn’t an urgent GI consult and scope have been appropriate? Though I’ll also admit to wondering why thrombectomy would be contraindicated but not heparinization.
Looking at the time frame, I really do wonder if there’s a mortality risk for showing up Friday evenings.
Seems like it would have been the perfect patient to justify an urgent colonoscopy, although it may have had limited utility if the patient wasn't adequately bowel prepped. It seems that most times GI doesn't feel that urgent scopes will benefit most patients if they're severely bleeding ("if its that bad they need to go to IR or surgery"). Probably at least worth an attending-attending discussion between vascular and GI to develop a shared plan.
I assume there was no pre-existing hypercoagulable state. No mention of any smoking history. I was successfully sued as the acting medical director employed at a rehab hospital in MS by the estate of a 50 year old BF with an over 100 PY Hx of tobacco, a chronic alcoholic with Hx of DTs who had broken her L hip and had had a left hip hemiarthroplasty done by my partner. She refused therapy at the rehab, demanded to be able to smoke and therefore per Medicare Guidelines had failed her 72 hours at the rehab and had to be discharged to the nursing home.
The internist who had cleared her medically had not evaluated her for PVD.
TEDS stockings applied at rehab for DVT prophylaxis were too tight and the patient developed some dorsal pedal friction blisters on her operated side L foot.
She was discharged to the nursing home where on arrival she had documented DP and PT doppler pulses on both feet. A day or two later her right non-operated foot became cool and pulseless. All experts agreed she was not a surgical candidate for bypass. She underwent a R BKA and during the surgery suffered an MI and went into renal failure. Then her L operated leg went pulseless and ultimately required bilateral AKA.
Months later, incredibly, she managed to return home and within a week, died when her trailer burned down, presumably from cigarette smoking. As I was the doctor leaving the state, (I wouldn’t be missed) I was the one who got sued and was left standing as the sole agent of the hospital. The internist and my orthopedic colleague were suddenly dropped from the suit. I was the only one left standing and the convenient scapegoat. The hospital settled on my behalf for $475,000 in 2016 and I took the sole hit on the NPDB. I was insured through the hospital so I could not refuse to settle, and the Plaintiff wanted to “streamline” the case and the cost of discovery by dropping other physicians, who were obligated to have followed the patient at the in-house rehab post-op. The Plaintiff attorney had even tried to sue me for causing her death from the fire, presumably because she was non-ambulatory but this was disallowed.
In my opinion, mine was a straight forward case of an acute arterial embolus from plaque that occurred after discharge from the rehab center.
I agree this necrotizing fasciitis is a case of fish or cut bait re: emergent thrombectomy. Although I’m sure a CBC with Hgb and clotting studies would have been done on admission to determine whether patient had compensated anemia/iron deficiency from a chronic GI bleed or was this an acute bleed ? Sounds like it was just a chronic bleed. No transfusions required etc. This would put the “need” for heparinization in better context. If it was bad enough to have required heparinization, then it was bad enough to have required emergent thrombectomy.
But asking 14.5 million? My life was never worth 14.5 million. But these vascular surgeons were smart to have gotten the hell out of Dodge by settling instead of having the hospital settle first.
Wow that is an insane case. If you have any of the expert witness opinions and want me to publish it, let me know (admin@medmalreviewer.com). Sucks to take a hit on NPDB but ultimately I think its more psychological than meaningful assuming you don't rack up 10+ reports. To be honest I'd probably rather settle in most scenarios just based on the realities of our medicolegal system but certainly doesn't seem like justice.
Vascular surgeon here--this is pretty egregious. If she didn't have weakness in leg/foot you could argue to wait until the next morning to revascularize, but if as plaintiff's expert says she had weakness and was classified as 2B, she should have gone that night irrespective of the hematochezia. As others have stated, if they felt heparin was appropriate then so was OR--the GI bleed would be a contraindication for tPA/catheter-directed thrombolysis, but that wouldn't have been appropriate for a 2b case anyway, and there are (both open and endovascular) alternatives here. Waiting days (both times!) is well below the standard of care. What really bothers me is this was clearly a teaching facility--those fellows either learned some terrible things or have some real trauma/moral injury from watching their staff persist in doing the wrong thing while the patient continued to deteriorate and ultimately died.
Thanks for commenting! I always keep in mind that we're only seeing the plaintiff's side of things so the info we have is biased, but it sounds like if what they're saying is true, it was pretty bad care. I'm hoping someone learned their lesson from this case!
Yes, great point--the plaintiff's expert report should absolutely be considered a biased recounting of the events, and it's probably worth some additional hedging/qualification on my part. Acute limb ischemia is a devastating and humbling diagnosis even with the best care.
Day 1: 30+ gent comes to freestanding ER and complains of right-sided neck pain after vigorous exercise a few hours before. ER doctor (non named in suit) does a competent exam and finds right-sided weakness and absent spinal reflexes on that side. No MRI at that facility, CT of neck read as normal (though later radiologist said it showed early hematoma of cervical spine), ER doc transfers patient to a general hospital for MRI.
ER doctor at hospital claims he never got report from first ER; he does an incomplete exam and at 0630 on day 2 admits patient to general internist who is NOT a hospitalist. Admitting doctor phones in some narcotic orders, goes to his office where he spends the morning, and finally after lunch sees patient for the first time. He orders an MRI (non stat) and a while later orders neurology consult "ASAP" (also not stat).
Around 7 pm the neurologist see the MRI films a couple of hours after they were done and starts things moving; patient transferred to tertiary care hospital where hematoma is removed and spinal cord decompressed, leaving patient still in wheelchair 16 years later.
From my testimony list:
9-17-24 Ricky Do vs. Baptist E-207079 District Court of Court Testimony
Hospitals of SE Texas et al. Jefferson Co., TX
Plaintiff
Stella Fitzgibbons, MD, FACP, FHM
Plaintiff attorney is C. Dishon Esq. in Beaumont, TX.
Day 1: 30+ gent comes to freestanding ER and complains of right-sided neck pain after vigorous exercise a few hours before. ER doctor (non named in suit) does a competent exam and finds right-sided weakness and absent spinal reflexes on that side. No MRI at that facility, CT of neck read as normal (though later radiologist said it showed early hematoma of cervical spine), ER doc transfers patient to a general hospital for MRI.
ER doctor at hospital claims he never got report from first ER; he does an incomplete exam and at 0630 on day 2 admits patient to general internist who is NOT a hospitalist. Admitting doctor phones in some narcotic orders, goes to his office where he spends the morning, and finally after lunch sees patient for the first time. He orders an MRI (non stat) and a while later orders neurology consult "ASAP" (also not stat).
Around 7 pm the neurologist see the MRI films a couple of hours after they were done and starts things moving; patient transferred to tertiary care hospital where hematoma is removed and spinal cord decompressed, leaving patient still in wheelchair 16 years later.
From my testimony list:
9-17-24 Ricky Do vs. Baptist E-207079 District Court of Court Testimony
Hospitals of SE Texas et al. Jefferson Co., TX
Plaintiff
Stella Fitzgibbons, MD, FACP, FHM
Plaintiff attorney is C. Dishon Esq. in Beaumont, TX.
Excuse me, I am aware of another case with a multimillion dollar jury verdict for failure to diagnoses and treat a spinal cord lesion in a timely fashion. How do I send the details to your newsletter?
News articles are ok, but if you have the docket number and jurisdiction that is the most helpful. And if you have a copy of the actual expert witness report, that's the absolute best.
The plaintiff's attorney will hire economics and rehab experts to write opinions about lost income and cost of ongoing care. Then they will pick a high number and really try to get the jury to anchor on it, mentioning it from jury selection to opening statements to closing statements. It's like a jedi mind trick to get their brain thinking into the high 8-figure range. I heard a plaintiff attorney say that they used to suggest lower amounts because they wanted to seem "reasonable" to the jury, but they did some research and actually found that the higher the amount you suggest, the more likely they are to win and the more they get awarded. A change in plaintiff tactics over the past few years.
Wow. I'm guessing if their settlement offer is $14 million, they're thinking there's a solid chance they would win even more than that at jury trial? Or it's just a negotiating tactic.
Clearly, the patient presented with a limb threatening condition from which all the downstream complications flowed. I’m an ER doc not a vascular surgeon, but in looking through the retrospectoscope, it seems at the outset an opportunity was lost to provide definite treatment and salvage her limb. A GI bleed poses risks (and in this case there is a paucity of data regarding its source and severity), but it does not seem to rise to the level of a life threatening condition to preclude immediate intervention directed at her ischemic leg; and in any case short of a catastrophic bleed could be temporized with transfusion, PPI or endoscopy. Time is muscle.
This situation highlights the consequences of a culture of delay that is, unfortunately, prevalent. In a case where a patient is facing limb loss, hematochezia becomes a relatively minor concern. Was GI ever consulted? We frequently receive consults for similar cases, and in such scenarios, I advise the team to prioritize the more critical issues. If an experienced GI physician evaluates the case and recognizes key connections, it may be difficult to argue against their assessment or win the case.
I can't help but notice the culture of delay in this case and the COVID STEMI case that I published 2 weeks ago. Both had very questionable delays that ended up killing the patient. Thus far I don't think I've published any cases in which someone got sued for doing a procedure too soon, which isn't to say that it doesn't sometimes harm patients but that you're just way less likely to get sued for harming someone that way.
Eloquently put
If the GI bleed was a concern, wouldn’t an urgent GI consult and scope have been appropriate? Though I’ll also admit to wondering why thrombectomy would be contraindicated but not heparinization.
Looking at the time frame, I really do wonder if there’s a mortality risk for showing up Friday evenings.
Seems like it would have been the perfect patient to justify an urgent colonoscopy, although it may have had limited utility if the patient wasn't adequately bowel prepped. It seems that most times GI doesn't feel that urgent scopes will benefit most patients if they're severely bleeding ("if its that bad they need to go to IR or surgery"). Probably at least worth an attending-attending discussion between vascular and GI to develop a shared plan.
I assume there was no pre-existing hypercoagulable state. No mention of any smoking history. I was successfully sued as the acting medical director employed at a rehab hospital in MS by the estate of a 50 year old BF with an over 100 PY Hx of tobacco, a chronic alcoholic with Hx of DTs who had broken her L hip and had had a left hip hemiarthroplasty done by my partner. She refused therapy at the rehab, demanded to be able to smoke and therefore per Medicare Guidelines had failed her 72 hours at the rehab and had to be discharged to the nursing home.
The internist who had cleared her medically had not evaluated her for PVD.
TEDS stockings applied at rehab for DVT prophylaxis were too tight and the patient developed some dorsal pedal friction blisters on her operated side L foot.
She was discharged to the nursing home where on arrival she had documented DP and PT doppler pulses on both feet. A day or two later her right non-operated foot became cool and pulseless. All experts agreed she was not a surgical candidate for bypass. She underwent a R BKA and during the surgery suffered an MI and went into renal failure. Then her L operated leg went pulseless and ultimately required bilateral AKA.
Months later, incredibly, she managed to return home and within a week, died when her trailer burned down, presumably from cigarette smoking. As I was the doctor leaving the state, (I wouldn’t be missed) I was the one who got sued and was left standing as the sole agent of the hospital. The internist and my orthopedic colleague were suddenly dropped from the suit. I was the only one left standing and the convenient scapegoat. The hospital settled on my behalf for $475,000 in 2016 and I took the sole hit on the NPDB. I was insured through the hospital so I could not refuse to settle, and the Plaintiff wanted to “streamline” the case and the cost of discovery by dropping other physicians, who were obligated to have followed the patient at the in-house rehab post-op. The Plaintiff attorney had even tried to sue me for causing her death from the fire, presumably because she was non-ambulatory but this was disallowed.
In my opinion, mine was a straight forward case of an acute arterial embolus from plaque that occurred after discharge from the rehab center.
I agree this necrotizing fasciitis is a case of fish or cut bait re: emergent thrombectomy. Although I’m sure a CBC with Hgb and clotting studies would have been done on admission to determine whether patient had compensated anemia/iron deficiency from a chronic GI bleed or was this an acute bleed ? Sounds like it was just a chronic bleed. No transfusions required etc. This would put the “need” for heparinization in better context. If it was bad enough to have required heparinization, then it was bad enough to have required emergent thrombectomy.
But asking 14.5 million? My life was never worth 14.5 million. But these vascular surgeons were smart to have gotten the hell out of Dodge by settling instead of having the hospital settle first.
Wow that is an insane case. If you have any of the expert witness opinions and want me to publish it, let me know (admin@medmalreviewer.com). Sucks to take a hit on NPDB but ultimately I think its more psychological than meaningful assuming you don't rack up 10+ reports. To be honest I'd probably rather settle in most scenarios just based on the realities of our medicolegal system but certainly doesn't seem like justice.
Vascular surgeon here--this is pretty egregious. If she didn't have weakness in leg/foot you could argue to wait until the next morning to revascularize, but if as plaintiff's expert says she had weakness and was classified as 2B, she should have gone that night irrespective of the hematochezia. As others have stated, if they felt heparin was appropriate then so was OR--the GI bleed would be a contraindication for tPA/catheter-directed thrombolysis, but that wouldn't have been appropriate for a 2b case anyway, and there are (both open and endovascular) alternatives here. Waiting days (both times!) is well below the standard of care. What really bothers me is this was clearly a teaching facility--those fellows either learned some terrible things or have some real trauma/moral injury from watching their staff persist in doing the wrong thing while the patient continued to deteriorate and ultimately died.
Thanks for commenting! I always keep in mind that we're only seeing the plaintiff's side of things so the info we have is biased, but it sounds like if what they're saying is true, it was pretty bad care. I'm hoping someone learned their lesson from this case!
Yes, great point--the plaintiff's expert report should absolutely be considered a biased recounting of the events, and it's probably worth some additional hedging/qualification on my part. Acute limb ischemia is a devastating and humbling diagnosis even with the best care.
https://www.law.com/texaslawyer/2024/10/01/beaumont-jury-awards-59-7m-to-man-paralyzed-from-medical-neglect/?slreturn=20241015171341 This describes the case but you need a subscription to access it. I am going to see if the plaintiff attorney on the case will have a nice neat report, but here is the gist of it::
Day 1: 30+ gent comes to freestanding ER and complains of right-sided neck pain after vigorous exercise a few hours before. ER doctor (non named in suit) does a competent exam and finds right-sided weakness and absent spinal reflexes on that side. No MRI at that facility, CT of neck read as normal (though later radiologist said it showed early hematoma of cervical spine), ER doc transfers patient to a general hospital for MRI.
ER doctor at hospital claims he never got report from first ER; he does an incomplete exam and at 0630 on day 2 admits patient to general internist who is NOT a hospitalist. Admitting doctor phones in some narcotic orders, goes to his office where he spends the morning, and finally after lunch sees patient for the first time. He orders an MRI (non stat) and a while later orders neurology consult "ASAP" (also not stat).
Around 7 pm the neurologist see the MRI films a couple of hours after they were done and starts things moving; patient transferred to tertiary care hospital where hematoma is removed and spinal cord decompressed, leaving patient still in wheelchair 16 years later.
From my testimony list:
9-17-24 Ricky Do vs. Baptist E-207079 District Court of Court Testimony
Hospitals of SE Texas et al. Jefferson Co., TX
Plaintiff
Stella Fitzgibbons, MD, FACP, FHM
Plaintiff attorney is C. Dishon Esq. in Beaumont, TX.
https://www.law.com/texaslawyer/2024/10/01/beaumont-jury-awards-59-7m-to-man-paralyzed-from-medical-neglect/?slreturn=20241015171341 This describes the case but you need a subscription to access it. I am going to see if the plaintiff attorney on the case will have a nice neat report, but here is the gist of it::
Day 1: 30+ gent comes to freestanding ER and complains of right-sided neck pain after vigorous exercise a few hours before. ER doctor (non named in suit) does a competent exam and finds right-sided weakness and absent spinal reflexes on that side. No MRI at that facility, CT of neck read as normal (though later radiologist said it showed early hematoma of cervical spine), ER doc transfers patient to a general hospital for MRI.
ER doctor at hospital claims he never got report from first ER; he does an incomplete exam and at 0630 on day 2 admits patient to general internist who is NOT a hospitalist. Admitting doctor phones in some narcotic orders, goes to his office where he spends the morning, and finally after lunch sees patient for the first time. He orders an MRI (non stat) and a while later orders neurology consult "ASAP" (also not stat).
Around 7 pm the neurologist see the MRI films a couple of hours after they were done and starts things moving; patient transferred to tertiary care hospital where hematoma is removed and spinal cord decompressed, leaving patient still in wheelchair 16 years later.
From my testimony list:
9-17-24 Ricky Do vs. Baptist E-207079 District Court of Court Testimony
Hospitals of SE Texas et al. Jefferson Co., TX
Plaintiff
Stella Fitzgibbons, MD, FACP, FHM
Plaintiff attorney is C. Dishon Esq. in Beaumont, TX.
Excuse me, I am aware of another case with a multimillion dollar jury verdict for failure to diagnoses and treat a spinal cord lesion in a timely fashion. How do I send the details to your newsletter?
admin@medmalreviewer.com
News articles are ok, but if you have the docket number and jurisdiction that is the most helpful. And if you have a copy of the actual expert witness report, that's the absolute best.
14.5 million? How do they come up with these amounts?
The plaintiff's attorney will hire economics and rehab experts to write opinions about lost income and cost of ongoing care. Then they will pick a high number and really try to get the jury to anchor on it, mentioning it from jury selection to opening statements to closing statements. It's like a jedi mind trick to get their brain thinking into the high 8-figure range. I heard a plaintiff attorney say that they used to suggest lower amounts because they wanted to seem "reasonable" to the jury, but they did some research and actually found that the higher the amount you suggest, the more likely they are to win and the more they get awarded. A change in plaintiff tactics over the past few years.
Wow. I'm guessing if their settlement offer is $14 million, they're thinking there's a solid chance they would win even more than that at jury trial? Or it's just a negotiating tactic.
Hard to say. I think it's pretty unlikely but not totally impossible.