I have so many thoughts, but these are my initial ones:
1)This case touches on one of my pet peeves as an intensivist: serum lactate is one of the most overrated and overutilized lab tests in medicine.
Yes, an elevated lactate can help you identify a patient that's sick, and that you need to pay closer attention to (you can argue the history, vital signs, and exam should accomplish that anyway). But it has very little utility in guiding therapy. In fact, following it serially can be actively harmful at times, because it can lead to a waterlogged patient from clinicians trying to make it go away with endless fluid boluses.
It can even be troublesome for prognostic purposes. I've seen so many cases where the lactate goes up., down, and sideways, yet the patient is off pressors, extubated, and sitting up in a chair having a conversation with me. Conversely, I've seen plenty of cases where the lactate clears by day 2, and the patient is still in trouble.
Don't get me wrong, the lactate can be useful in specific circumstances, but it needs to be interpreted in context, and it's limitations understood. I'm extremely skeptical getting a lactate level would have made any difference at all in this patient's outcome.
2)One of the criticisms is inadequate fluid resuscitation. Pancreatitis, along with pre-ecclampsia is one of the most frustrating diseases when it comes to fluid management. Too little, and you have inadequate circulating blood volume. Too much, and the capillary leak causes all kinds of third spacing, organ edema, and respiratory failure. It always feels like whatever you do, it's the wrong answer.
3)I question how much of a difference ICU vs ICU Stepdown admission would have made. In my shop, at least, ICU Stepdown is run by the critical care team, and just across the hall from ICU. If someone seems to be doing okay initially, but then becomes hypotensive, it doesn't involve much in the way of time delay to start pressors and move them over. The "early central line" dogma is a residual of the Rivers trial, has been debunked, and is not really standard of care anymore: We will place a line if we can't get adequate or safe peripheral access, if the pressors doses keep escalating, or if the patient is on pressors for more than 24 hours (this is more hospital policy rather than based on evidence).
I didn't see any details about whether the patient had a prolonged period of hypotension before it was recognized and pressors were started, whether one of her PIVs running a vasopressor infiltrated, or whether the ICU team dragged their feet in placing a central line. Again, none of this has anything to do with the ED doc.
Excellent points. The entire expert opinion in regards to the sepsis management seems like it was written by someone who learned a lot about sepsis 20 years ago and hasn't bothered to do any reading since then or update their practice in any way.
Yeah, I have seen "failure to place a central line" on a few of these plaintiff expert reports. To me (and I suspect to anyone who knows what they're talking about), it looks like flooding the zone with shit just to confuse/overwhelm a jury with additional allegations. Should be extremely easy to refute that allegation, but still wastes time and effort for everyone.
Completely agree. This is all theatrics done to either intimidate the doc into settling (shame them that they didn't 'do the thing') or insist to a simple lay jury that "more = better." A really big pokey procedure needle is a very tangible way to make that point, regardless of it's validity.
A HPB surgeon should have been involved in the patients care. Infected pancreatic necrosis is a surgical disease. We have made strides in eus based and minimally invasive approaches but sometimes you just need to operate.
Without knowing all the details and images, I would guess she had a pancreatic abscess that wasn’t adequately drained by the Gastro-cystic stent. The infected area may not have been in communication with cyst cavity or represented a solid component that needed debridement (necrosectomy). I agree that this condition has a high mortality rate but she probably didn’t get the best care possible. With ongoing sepsis, drainage of the abscess should have been considered more of a priority than placing a pd stent or just changing the gastric stent. Interesting case.
Damned if you do, damned if you don't. I'd argue the stent had to be exchanged since patient has persistent nausea/vomiting and losing weight, clearly not thriving. If she had died of malnourishment, dehydration, renal failure, they would be suing for not doing the stent exchanged/ERCP.
The ED doc being added on to lawsuit seems absurd. Pt probably got assessed, admitted , and received abx/IVF, which is in a stable fluid-responsive patient is appropriate care. ICU vs other bed admission is not up to EM doctors! Unless they gave minimal to no fluids or did nothing with patient being persistently hypotensive, then Idk why they got dragged into this.
Shotgun proximity. More doctors accused on the case (which costs minimal to do, only need a shank of a 'expert' EM doc to cosign an attorney-GPT written accusation), more chances someone settles, turns on the others, etc. Plaintiff strategy >>> any ethos, as per usual.
I agree that level of care decision is made by the admitting hospitalist. Not sure why they got off but the EM docs got sued. Maybe it’s because the EM docs weren’t employed by the hospital and the hospital was already being sued? I agree that lactate almost never changes anything although yes I would have ordered it in this case and Zosyn would have been a good antibiotic for this pt
What were the cultures, and absent empirical broad spectrum antibiotic coverage, was the antibiotic given appropriate for the culture?
There is reference to an abscess. There is no walled off abscess that can be only medically treated, i.e. that cannot leak into an abdomen or contaminate blood stream. Abscesses must be surgically managed , or by CT guidance drained. Antibiotics are adjunctive.
I feel really bad for the EM docs in this case that were clearly caught in the crossfire -- we've all had this patient. Hepatobiliary trainwreck rolls in, somewhat sick, and you do the things, imaging, fluids, abx, call the people, and admit the patient. Check the boxes, move on, right? They probably didn't think twice about this patient before they were moved upstairs. Then two years later, this howler arrives.
The notion about "early central line placement" is absurd and any EM doc including that in their 'expert' opinion should be ashamed. I'm glad many of the comments below have harped on that as well. I will continue to advocate to the Med Mal Reviewer that the court case identifiers be provided so that we can independently review these cases. We need to create an independent database to name and shame these individuals. They are a tarnish to the profession and the medical community and should be labeled as such.
ICU bed requests seem to have a lot of hospital and region dependent variation. I've worked at places, small and large, where ICU admission IS largely determined by the ED physician, and others where the admitting group primarily determines level of care. The most common variation I've seen is that it's typically up to the ED to initiate a consult to the ICU for admission, who may then decline if they don't feel the pt requires their level of care. I think its reasonable to be more liberal with ICU consults in borderline patients. All that said, accusing harm as a result of a non-ICU bed in this patient is a very large stretch. More shotgunning, more is better, retrospective theatrics.
What were the cultures, and absent empirical broad spectrum antibiotic coverage, was the antibiotic given appropriate for the culture?
There is reference to an abscess. There is no walled off abscess that can be only medically treated, i.e. that cannot leak into an abdomen or contaminate blood stream. Abscesses must be surgically managed , or by CT guidance drained. Antibiotics are adjunctive.
What were the cultures, and absent empirical broad spectrum antibiotic coverage, was the antibiotic given appropriate for the culture?
There is reference to an abscess. There is no walled off abscess that can be only medically treated, that cannot leak into an abdomen or the blood stream. Abscesses must be surgically managed , or by CT guidance drained.
I have so many thoughts, but these are my initial ones:
1)This case touches on one of my pet peeves as an intensivist: serum lactate is one of the most overrated and overutilized lab tests in medicine.
Yes, an elevated lactate can help you identify a patient that's sick, and that you need to pay closer attention to (you can argue the history, vital signs, and exam should accomplish that anyway). But it has very little utility in guiding therapy. In fact, following it serially can be actively harmful at times, because it can lead to a waterlogged patient from clinicians trying to make it go away with endless fluid boluses.
It can even be troublesome for prognostic purposes. I've seen so many cases where the lactate goes up., down, and sideways, yet the patient is off pressors, extubated, and sitting up in a chair having a conversation with me. Conversely, I've seen plenty of cases where the lactate clears by day 2, and the patient is still in trouble.
Don't get me wrong, the lactate can be useful in specific circumstances, but it needs to be interpreted in context, and it's limitations understood. I'm extremely skeptical getting a lactate level would have made any difference at all in this patient's outcome.
2)One of the criticisms is inadequate fluid resuscitation. Pancreatitis, along with pre-ecclampsia is one of the most frustrating diseases when it comes to fluid management. Too little, and you have inadequate circulating blood volume. Too much, and the capillary leak causes all kinds of third spacing, organ edema, and respiratory failure. It always feels like whatever you do, it's the wrong answer.
3)I question how much of a difference ICU vs ICU Stepdown admission would have made. In my shop, at least, ICU Stepdown is run by the critical care team, and just across the hall from ICU. If someone seems to be doing okay initially, but then becomes hypotensive, it doesn't involve much in the way of time delay to start pressors and move them over. The "early central line" dogma is a residual of the Rivers trial, has been debunked, and is not really standard of care anymore: We will place a line if we can't get adequate or safe peripheral access, if the pressors doses keep escalating, or if the patient is on pressors for more than 24 hours (this is more hospital policy rather than based on evidence).
I didn't see any details about whether the patient had a prolonged period of hypotension before it was recognized and pressors were started, whether one of her PIVs running a vasopressor infiltrated, or whether the ICU team dragged their feet in placing a central line. Again, none of this has anything to do with the ED doc.
Excellent points. The entire expert opinion in regards to the sepsis management seems like it was written by someone who learned a lot about sepsis 20 years ago and hasn't bothered to do any reading since then or update their practice in any way.
The way some people talk about central lines you would think the line insertion itself was some kind of magical therapy
Yeah, I have seen "failure to place a central line" on a few of these plaintiff expert reports. To me (and I suspect to anyone who knows what they're talking about), it looks like flooding the zone with shit just to confuse/overwhelm a jury with additional allegations. Should be extremely easy to refute that allegation, but still wastes time and effort for everyone.
Completely agree. This is all theatrics done to either intimidate the doc into settling (shame them that they didn't 'do the thing') or insist to a simple lay jury that "more = better." A really big pokey procedure needle is a very tangible way to make that point, regardless of it's validity.
A HPB surgeon should have been involved in the patients care. Infected pancreatic necrosis is a surgical disease. We have made strides in eus based and minimally invasive approaches but sometimes you just need to operate.
Without knowing all the details and images, I would guess she had a pancreatic abscess that wasn’t adequately drained by the Gastro-cystic stent. The infected area may not have been in communication with cyst cavity or represented a solid component that needed debridement (necrosectomy). I agree that this condition has a high mortality rate but she probably didn’t get the best care possible. With ongoing sepsis, drainage of the abscess should have been considered more of a priority than placing a pd stent or just changing the gastric stent. Interesting case.
Damned if you do, damned if you don't. I'd argue the stent had to be exchanged since patient has persistent nausea/vomiting and losing weight, clearly not thriving. If she had died of malnourishment, dehydration, renal failure, they would be suing for not doing the stent exchanged/ERCP.
The ED doc being added on to lawsuit seems absurd. Pt probably got assessed, admitted , and received abx/IVF, which is in a stable fluid-responsive patient is appropriate care. ICU vs other bed admission is not up to EM doctors! Unless they gave minimal to no fluids or did nothing with patient being persistently hypotensive, then Idk why they got dragged into this.
Shotgun proximity. More doctors accused on the case (which costs minimal to do, only need a shank of a 'expert' EM doc to cosign an attorney-GPT written accusation), more chances someone settles, turns on the others, etc. Plaintiff strategy >>> any ethos, as per usual.
I agree that level of care decision is made by the admitting hospitalist. Not sure why they got off but the EM docs got sued. Maybe it’s because the EM docs weren’t employed by the hospital and the hospital was already being sued? I agree that lactate almost never changes anything although yes I would have ordered it in this case and Zosyn would have been a good antibiotic for this pt
I agree with you... I probably would have ordered a lactate and broad specturm abx but I'm not sure it would have made much of a difference.
Was an Autopsy performed?
What were the cultures, and absent empirical broad spectrum antibiotic coverage, was the antibiotic given appropriate for the culture?
There is reference to an abscess. There is no walled off abscess that can be only medically treated, i.e. that cannot leak into an abdomen or contaminate blood stream. Abscesses must be surgically managed , or by CT guidance drained. Antibiotics are adjunctive.
Unfortunately, no autopsy was done.
I feel really bad for the EM docs in this case that were clearly caught in the crossfire -- we've all had this patient. Hepatobiliary trainwreck rolls in, somewhat sick, and you do the things, imaging, fluids, abx, call the people, and admit the patient. Check the boxes, move on, right? They probably didn't think twice about this patient before they were moved upstairs. Then two years later, this howler arrives.
The notion about "early central line placement" is absurd and any EM doc including that in their 'expert' opinion should be ashamed. I'm glad many of the comments below have harped on that as well. I will continue to advocate to the Med Mal Reviewer that the court case identifiers be provided so that we can independently review these cases. We need to create an independent database to name and shame these individuals. They are a tarnish to the profession and the medical community and should be labeled as such.
ICU bed requests seem to have a lot of hospital and region dependent variation. I've worked at places, small and large, where ICU admission IS largely determined by the ED physician, and others where the admitting group primarily determines level of care. The most common variation I've seen is that it's typically up to the ED to initiate a consult to the ICU for admission, who may then decline if they don't feel the pt requires their level of care. I think its reasonable to be more liberal with ICU consults in borderline patients. All that said, accusing harm as a result of a non-ICU bed in this patient is a very large stretch. More shotgunning, more is better, retrospective theatrics.
Was an Autopsy performed?
What were the cultures, and absent empirical broad spectrum antibiotic coverage, was the antibiotic given appropriate for the culture?
There is reference to an abscess. There is no walled off abscess that can be only medically treated, i.e. that cannot leak into an abdomen or contaminate blood stream. Abscesses must be surgically managed , or by CT guidance drained. Antibiotics are adjunctive.
Was an Autopsy performed?
What were the cultures, and absent empirical broad spectrum antibiotic coverage, was the antibiotic given appropriate for the culture?
There is reference to an abscess. There is no walled off abscess that can be only medically treated, that cannot leak into an abdomen or the blood stream. Abscesses must be surgically managed , or by CT guidance drained.