As someone in OB... intrahepatic cholestasis of pregnancy has known risk of stillbirth. Ursodiol improves symptoms and lab abnormalities but doesn't seem to decrease risk for stillbirth. We do antenatal fetal surveillance in these patients, but stillbirth in ICP is probably a sudden event rather than a chronic process and there may not be preceding signs on a weekly ultrasound. The bile acids are always send-out.
Maybe she should have been delivered earlier based on the LFTs, like the expert opinion suggests. But patients who refuse recommended interventions in pregnancy really tend to refuse preterm delivery.
Anyway, no one wants to accept that there are rare, terrible things that can happen in pregnancy that we cannot perfectly prevent.
Thanks for the comment! I didn't realize that bile acids are always send outs. Also didn't realize that ursodiol doesn't seem to reduce risk of stillbirth.
I still haven't fully digested this case. My ex and I lost our 1st baby (blighted ovum) very early in pregnancy so admittedly my situation is vastly different than losing a near term pregnancy of what appears to have been a perfectly viable baby. It was easy for me to brush of my loss, saying, "hey that's nature and proceeded with a D&C in the OB office. Pregnancy and childbirth have never been without risks and that was oh-so-true back a hundred years ago when a certain percentage of mothers died during or after childbirth, and of course, the baby too in some cases.
But the pendulum has swung the other way. Here this mother has had oodles of ED and OB visits, labs, ultrasound etc. The system has become so complex that it has become a damned if you do, damned if you don't situation in which only the parasitic lawyers win, taking at a minimum 33% of the "loot." They don't give a damn about their clients. They use them only as means to make money off the system.
I could see if this was an outrageous case of gross medical malpractice like decapitating a baby with a botched forceps delivery instead of the C section. (There was a case like this.) There were some factors which complicated this, like depending on outsourced labs, non compliance with urodiol.
In my memoirs I summed up my disgust: It is the paradox of progress: Never has the medical field been able to do so much for so many people, yet never have people been so ungrateful. "We want the latest and most expensive technology. We don't care how much it costs and we shouldn't have to pay for it. And we want it NOW, without having to wait. And if the hospital or doctor makes even an honest mistake, we want to be able to sue them for everything they've got. The fact that we are overweight, smoke, drink, and get no exercise is no excuse. "
Nothing is mentioned about this patient's own dietary, exercise or social Hx, etc. For starters, what was her pre pregnancy BMI? Cholestasis? As I recall from medical school , the mnemonic was FAT, female forty and fertile. How fat? She isn't even thirty.
As an admittedly disgruntled orthopedic surgeon whose career was ruined by an RN's premeditated mistake ( delegating behind my back a tech to select and draw up a drug I for which I had given a direct verbal order to the RN in the OR which she acknowledged, had written on her scrubs and read back to me verbatim, turned out to be a lethal drug retrieved by the tech. The tech testified she "didn't know what drug she was supposed to get." The RN didn't check and knew immediately she had violated her most sacred trust. Her testimony " There goes my license." I got my license suspended by the KY Medical Board.
NOTHING happening to the nurse or tech. I have very little empathy or sympathy for the public. They need to see what it's like when they have no health care. I've seen it in rural India, Philippines and Africa.
The anesthesiologist begged off the case when my patient, a 21 year old man, as witnessed by the two techs and the RN, had arrived in the OR for treatment of a table saw laceration involving bone, tendon, and the digital nerve to his index finger. This anesthesiologist violated hospital rules, regulations, and standards of his professional specialty which had required him to perform the Bier block- according to the KY Medical Board's own anesthesiology expert, once the patient had arrived in the formal operating room. None of the events in this case were ever disputed, just ignored.
I had given the operating room RN a verbal order for 40ccs of plain xylocaine to be handed to me in a 60cc syringe. The RN behind my back sent an unauthorized tech to leave the room, select the medication and draw it up, again, a violation of both the RN’s and the tech's duties hospital rules, and standards of conduct. Unfortunately, I did not check what the RN handed me. I figured it was the only drug in the case and one of the most common, easily recognizable by the blue label on the 50ml bottle. The tech had instead selected Marcaine/Sensorcaine/Bupivicaine, a cardiotoxic drug and lethal when injected intravenously and is absolutely contraindicated for IV use. The tech later testified she wasn’t sure what she was supposed to get but claimed she showed it to the RN and the RN had confirmed it. The torniquet leaked or malfunctioned. My patient seized and died on the table. All experts agreed that once the drug had been injected for the Bier block, regardless when the tourniquet was released, death was imminent. Xylocaine is neurotoxic and can cause seizures as happened to my partner when he administered a Bier block in the emergency room, but there had been zero reported deaths in a review of over 5,000 Bier blocks in the Canadian Journal of Anesthesiology. It is quickly metabolized. In fact, Xylocaine had been used at the time to treat arrythmias. In contrast, Marcaine causes seizures but is also notoriously cardiotoxic. The heart goes into irreversible ventricular fibrillation.
The undisputed orthopedic standard was orthopedic surgeons routinely administered Bier blocks in the emergency room, not only in my hospital but throughout other hospitals in the state, including those of the Board’s own orthopedic expert and my highly regarded orthopedic expert. They also relied on RNs to hand them drugs in the operating room without having to double check. Legally, in common law, the Board could not rely upon the anesthesiology specialty when the specific orthopedic standard was available. They had already recognized the like specialty standard of care in their minutes before filing the lawsuit. I, like other surgeons, routinely relied on an RN, and only an RN, to take verbal orders for drugs to be handed to me in the OR. This task was NEVER to be delegated to a tech, for the very reason what happened.
The anesthesiologist was called back into the room before he had left the hospital. He knew he had abandoned the patient and while I was out having to face the family, he tried to solicit a conspiracy with the two techs and the RN in the OR “to stick together and call this a severe allergic reaction.” This kind of act “meant to deceive, defraud the public or any member thereof” according the KY Medical Practice Act should have resulted in disciplinary action against the anesthesiologist. But he got off as did the RN and the Tech. In contrast, the KY Medical Board fired off a lawsuit against my license under the assumption I had knowingly injected Marcaine in blatant violation of the KY Medical Practice Act and due process which had required a thorough investigation be performed before filing a complaint against a physician.
But the President of the KY Medical Association, a physician in my own hospital, had been discovered to have been sodomizing boys for decades in his office, had raped both his baby sitters, and a high profile OB-GYN showing up impaired for deliveries, along with my case being featured on national television’s “A Current Affair” meant that the KY Board had egg all over its face. The public was outraged and demanded action. So I was the scapegoat. The hospital and its agents, the tech, this anesthesiologist, and the RN, were all covered by KY Medical Mutual Insurance Company and all quietly settled collectively, the amounts sealed, leaving me standing alone.
I wound up settling but having to pay a $150,000 excess judgement in the companion med-mal suit and had my license suspended for “failure to check the medication,” a contemporaneous double jeopardy of two actions. Only four years into practice with what had been a spotless record, and suddenly my career was ruined. I could not even get a job at any VA (Harlingen, TX) or at the Indian Health Service (Gallup, NM). I defy anyone to find a more outrageous Board Action. But there is a whole lot more in my memoirs, My Medical-Legal Back Pages. Archway.
Its wild to me that they ruled in the patients favor… where is the negligence, relying on send-out labs? Thats a stretch. Seems like mom just wanted to never have to work a day in her life. If shes refusing medication her Ob is giving her and refusing glucose tolerance tests, i have no sympathy for her
The end of the plaintiff's expert opinion in the original article has a succinct description of what they felt was negligent... biggest one seems to be realizing her AST/ALT were rapidly elevating, knowing her pruritis was worsening, and not immediately restarting ursodiol in favor of waiting a week for send-out labs.
My impression from the original expert opinion was that they didn't restart it at the June 17 visit when AST/ALT were rising. I might have missed it somewhere else that they did restart it then?
And about this apology. Years ago, I thought most states had passed laws which made any apology by the physician inadmissible in determining liability in med-mal cases. The rationale was to appease the public who were angry with physicians because they didn't even have the decency to apologize for a mistake. Of course the physician was advised by his legal counsel to never apologize because that would be an admission of liability. It was still a no-win situation.
The theory had been that perhaps by allowing physicians to apologize without jeopardizing their liability in a lawsuit, fewer lawsuits would be filed by a more forgiving public. It didn't happen. So are we back to our old axiom of "never apologize?"
And another digression. I had asked the question in my memoirs why physicians have two separate vulnerabilities. Given that it is unusual or extremely risky for a physician to go bare, then for all practical purposes, if a physician doesn't have private or hospital malpractice insurance, he can't practice. If he doesn't have a license, he can't practice. As my wrongful death med-malpractice lawsuit was combined with the KY Medical Licensure Board suspension, I was faced with a two front battle. The licensure board and the med mal case itself. A pincer. Some (many?) of these lawsuits hit otherwise competent, steady practitioners like a lightning bolt out of the sky.
My argument is that the state should combine both the insurance and licensing of physicians into one agency. If a physician is competent enough to have a license, he should be good enough to be insured by a state-funded agency to avoid these ruinous lawsuits like the one mentioned earlier about the Locked-in Syndrome. I say this even though my license was suspended by the KY Medical Board, even when the Board had ZERO evidence that I had fallen below the standard of care for a doctor in my own specialty (the time-honored standard to establish negligence). The KY Board had even admitted in its minutes that they needed to get a board consultant panel member/expert in my specialty. But when their same specialty expert thoroughly exonerated me, the KY state medical practice act statutes went right out the window, and they then held me to anesthesiology standards.
The KY Medical Board had an ongoing public relations agenda and they needed to serve up a physician immediately. But my unprecedented suspension notwithstanding, I would be very interested in a debate on whether med-mal insurance companies should be shut down and instead combine licensing with automatic insurance coverage. Besides, any judgment or settlement of $10,000 triggers a report to the NPDB, and there is a threshold amount that will automatically trigger an investigation by the State Medical Board, at least in NC.
I would be very interested in hearing both sides of this argument.
As someone in OB... intrahepatic cholestasis of pregnancy has known risk of stillbirth. Ursodiol improves symptoms and lab abnormalities but doesn't seem to decrease risk for stillbirth. We do antenatal fetal surveillance in these patients, but stillbirth in ICP is probably a sudden event rather than a chronic process and there may not be preceding signs on a weekly ultrasound. The bile acids are always send-out.
Maybe she should have been delivered earlier based on the LFTs, like the expert opinion suggests. But patients who refuse recommended interventions in pregnancy really tend to refuse preterm delivery.
Anyway, no one wants to accept that there are rare, terrible things that can happen in pregnancy that we cannot perfectly prevent.
"...there are rare, terrible things that can happen in pregnancy that we cannot perfectly prevent."
Just like anything in medicine, sometimes you make the perfect, textbook decisions, and things still go sideways. It's not always somebody's fault.
Thanks for the comment! I didn't realize that bile acids are always send outs. Also didn't realize that ursodiol doesn't seem to reduce risk of stillbirth.
I still haven't fully digested this case. My ex and I lost our 1st baby (blighted ovum) very early in pregnancy so admittedly my situation is vastly different than losing a near term pregnancy of what appears to have been a perfectly viable baby. It was easy for me to brush of my loss, saying, "hey that's nature and proceeded with a D&C in the OB office. Pregnancy and childbirth have never been without risks and that was oh-so-true back a hundred years ago when a certain percentage of mothers died during or after childbirth, and of course, the baby too in some cases.
But the pendulum has swung the other way. Here this mother has had oodles of ED and OB visits, labs, ultrasound etc. The system has become so complex that it has become a damned if you do, damned if you don't situation in which only the parasitic lawyers win, taking at a minimum 33% of the "loot." They don't give a damn about their clients. They use them only as means to make money off the system.
I could see if this was an outrageous case of gross medical malpractice like decapitating a baby with a botched forceps delivery instead of the C section. (There was a case like this.) There were some factors which complicated this, like depending on outsourced labs, non compliance with urodiol.
In my memoirs I summed up my disgust: It is the paradox of progress: Never has the medical field been able to do so much for so many people, yet never have people been so ungrateful. "We want the latest and most expensive technology. We don't care how much it costs and we shouldn't have to pay for it. And we want it NOW, without having to wait. And if the hospital or doctor makes even an honest mistake, we want to be able to sue them for everything they've got. The fact that we are overweight, smoke, drink, and get no exercise is no excuse. "
Nothing is mentioned about this patient's own dietary, exercise or social Hx, etc. For starters, what was her pre pregnancy BMI? Cholestasis? As I recall from medical school , the mnemonic was FAT, female forty and fertile. How fat? She isn't even thirty.
As an admittedly disgruntled orthopedic surgeon whose career was ruined by an RN's premeditated mistake ( delegating behind my back a tech to select and draw up a drug I for which I had given a direct verbal order to the RN in the OR which she acknowledged, had written on her scrubs and read back to me verbatim, turned out to be a lethal drug retrieved by the tech. The tech testified she "didn't know what drug she was supposed to get." The RN didn't check and knew immediately she had violated her most sacred trust. Her testimony " There goes my license." I got my license suspended by the KY Medical Board.
NOTHING happening to the nurse or tech. I have very little empathy or sympathy for the public. They need to see what it's like when they have no health care. I've seen it in rural India, Philippines and Africa.
That’s a crazy story and I’m sorry this happened to you. What was the drug? How exactly did the medical board conclude it was your fault?
The anesthesiologist begged off the case when my patient, a 21 year old man, as witnessed by the two techs and the RN, had arrived in the OR for treatment of a table saw laceration involving bone, tendon, and the digital nerve to his index finger. This anesthesiologist violated hospital rules, regulations, and standards of his professional specialty which had required him to perform the Bier block- according to the KY Medical Board's own anesthesiology expert, once the patient had arrived in the formal operating room. None of the events in this case were ever disputed, just ignored.
I had given the operating room RN a verbal order for 40ccs of plain xylocaine to be handed to me in a 60cc syringe. The RN behind my back sent an unauthorized tech to leave the room, select the medication and draw it up, again, a violation of both the RN’s and the tech's duties hospital rules, and standards of conduct. Unfortunately, I did not check what the RN handed me. I figured it was the only drug in the case and one of the most common, easily recognizable by the blue label on the 50ml bottle. The tech had instead selected Marcaine/Sensorcaine/Bupivicaine, a cardiotoxic drug and lethal when injected intravenously and is absolutely contraindicated for IV use. The tech later testified she wasn’t sure what she was supposed to get but claimed she showed it to the RN and the RN had confirmed it. The torniquet leaked or malfunctioned. My patient seized and died on the table. All experts agreed that once the drug had been injected for the Bier block, regardless when the tourniquet was released, death was imminent. Xylocaine is neurotoxic and can cause seizures as happened to my partner when he administered a Bier block in the emergency room, but there had been zero reported deaths in a review of over 5,000 Bier blocks in the Canadian Journal of Anesthesiology. It is quickly metabolized. In fact, Xylocaine had been used at the time to treat arrythmias. In contrast, Marcaine causes seizures but is also notoriously cardiotoxic. The heart goes into irreversible ventricular fibrillation.
The undisputed orthopedic standard was orthopedic surgeons routinely administered Bier blocks in the emergency room, not only in my hospital but throughout other hospitals in the state, including those of the Board’s own orthopedic expert and my highly regarded orthopedic expert. They also relied on RNs to hand them drugs in the operating room without having to double check. Legally, in common law, the Board could not rely upon the anesthesiology specialty when the specific orthopedic standard was available. They had already recognized the like specialty standard of care in their minutes before filing the lawsuit. I, like other surgeons, routinely relied on an RN, and only an RN, to take verbal orders for drugs to be handed to me in the OR. This task was NEVER to be delegated to a tech, for the very reason what happened.
The anesthesiologist was called back into the room before he had left the hospital. He knew he had abandoned the patient and while I was out having to face the family, he tried to solicit a conspiracy with the two techs and the RN in the OR “to stick together and call this a severe allergic reaction.” This kind of act “meant to deceive, defraud the public or any member thereof” according the KY Medical Practice Act should have resulted in disciplinary action against the anesthesiologist. But he got off as did the RN and the Tech. In contrast, the KY Medical Board fired off a lawsuit against my license under the assumption I had knowingly injected Marcaine in blatant violation of the KY Medical Practice Act and due process which had required a thorough investigation be performed before filing a complaint against a physician.
But the President of the KY Medical Association, a physician in my own hospital, had been discovered to have been sodomizing boys for decades in his office, had raped both his baby sitters, and a high profile OB-GYN showing up impaired for deliveries, along with my case being featured on national television’s “A Current Affair” meant that the KY Board had egg all over its face. The public was outraged and demanded action. So I was the scapegoat. The hospital and its agents, the tech, this anesthesiologist, and the RN, were all covered by KY Medical Mutual Insurance Company and all quietly settled collectively, the amounts sealed, leaving me standing alone.
I wound up settling but having to pay a $150,000 excess judgement in the companion med-mal suit and had my license suspended for “failure to check the medication,” a contemporaneous double jeopardy of two actions. Only four years into practice with what had been a spotless record, and suddenly my career was ruined. I could not even get a job at any VA (Harlingen, TX) or at the Indian Health Service (Gallup, NM). I defy anyone to find a more outrageous Board Action. But there is a whole lot more in my memoirs, My Medical-Legal Back Pages. Archway.
Damn
Sorry to hear you’ve been through so much. It’s not enough to know you didn’t do anything wrong.
Its wild to me that they ruled in the patients favor… where is the negligence, relying on send-out labs? Thats a stretch. Seems like mom just wanted to never have to work a day in her life. If shes refusing medication her Ob is giving her and refusing glucose tolerance tests, i have no sympathy for her
The end of the plaintiff's expert opinion in the original article has a succinct description of what they felt was negligent... biggest one seems to be realizing her AST/ALT were rapidly elevating, knowing her pruritis was worsening, and not immediately restarting ursodiol in favor of waiting a week for send-out labs.
The above case makes it seem like the doc did restart ursodiol simultaneously while sending out labs.
My impression from the original expert opinion was that they didn't restart it at the June 17 visit when AST/ALT were rising. I might have missed it somewhere else that they did restart it then?
In the summary:
“Her OBGYN told her to re-start ursodiol and sent repeat labs again.”
That’s unbelievable. Where was the negligence? Who is choosing the jury and who are these people that make ridiculous verdicts??
That’s unbelievable. Where was the negligence? Who is choosing the jury and who are these people that make ridiculous verdicts??
And about this apology. Years ago, I thought most states had passed laws which made any apology by the physician inadmissible in determining liability in med-mal cases. The rationale was to appease the public who were angry with physicians because they didn't even have the decency to apologize for a mistake. Of course the physician was advised by his legal counsel to never apologize because that would be an admission of liability. It was still a no-win situation.
The theory had been that perhaps by allowing physicians to apologize without jeopardizing their liability in a lawsuit, fewer lawsuits would be filed by a more forgiving public. It didn't happen. So are we back to our old axiom of "never apologize?"
And another digression. I had asked the question in my memoirs why physicians have two separate vulnerabilities. Given that it is unusual or extremely risky for a physician to go bare, then for all practical purposes, if a physician doesn't have private or hospital malpractice insurance, he can't practice. If he doesn't have a license, he can't practice. As my wrongful death med-malpractice lawsuit was combined with the KY Medical Licensure Board suspension, I was faced with a two front battle. The licensure board and the med mal case itself. A pincer. Some (many?) of these lawsuits hit otherwise competent, steady practitioners like a lightning bolt out of the sky.
My argument is that the state should combine both the insurance and licensing of physicians into one agency. If a physician is competent enough to have a license, he should be good enough to be insured by a state-funded agency to avoid these ruinous lawsuits like the one mentioned earlier about the Locked-in Syndrome. I say this even though my license was suspended by the KY Medical Board, even when the Board had ZERO evidence that I had fallen below the standard of care for a doctor in my own specialty (the time-honored standard to establish negligence). The KY Board had even admitted in its minutes that they needed to get a board consultant panel member/expert in my specialty. But when their same specialty expert thoroughly exonerated me, the KY state medical practice act statutes went right out the window, and they then held me to anesthesiology standards.
The KY Medical Board had an ongoing public relations agenda and they needed to serve up a physician immediately. But my unprecedented suspension notwithstanding, I would be very interested in a debate on whether med-mal insurance companies should be shut down and instead combine licensing with automatic insurance coverage. Besides, any judgment or settlement of $10,000 triggers a report to the NPDB, and there is a threshold amount that will automatically trigger an investigation by the State Medical Board, at least in NC.
I would be very interested in hearing both sides of this argument.