Maybe I’m not up to date on the latest and greatest anticoagulation guidelines, but per the 2012 CHEST guidelines for isolated lower extremity injuries requiring immobilization (quad rupture would seemingly fit this) they recommend no thromboprophylaxis. Not to mention this patient was WBAT after surgery. It’s kind of like, why even consider the guidelines and not just anticoagulate everyone for every surgery if you can just get sued anytime someone gets a DVT/PE.
And I have to imagine if surgeons *did* just mindlessly anticoagulate every patient after surgery, they'd get sued for the inevitable bleeding complications. I think the most vexing thing about MedMal for me is how it often seems to devolve into monetizing bad outcomes, regardless of fault/negligence.
I was really surprised the defense didn't mount a more vigorous defense about this exact issue. Now, they may have aggressively argued it at trial, and the written documents just didn't reflect it. But it just seems like it should have been a trump card. The plaintiff also argued that the surgeon didn't advise the patient about signs/symptoms of DVT/PE, but they also could have gotten the PCP for this too, and doesn't seem like that should justify this crazy of a verdict.
The term thrombophlebitis, which is not a life threatening condition, is being incorrectly here. The PCP meant thrombosis or thromboembolism.
In any case, medically this hinges on whether the standard of care in 2015 required post operative blood thinners. I’m not aware of any evidence that it did.
I guess it would have helped the orthopedic surgeons defense if he documented a discussion of risks and benefits of post operative blood thinners, but I still can’t see how he did anything wrong. I wonder if there’s any grounds for appeal here.
With the caveat that I'm not a surgeon, this also seems like an example of pre-operative "clearance" being worthless at best and actively harmful at worst. If the documentation from the PCP wasn't there, a post-operative PE, even resulting in death, would likely just be an unfortunate but known complication, and even if a lawsuit was filed the surgeon would likely have won. Likewise, as you point out, the PCP also dodged a bullet here.
Having spoken to the orthopedic surgeons where I work, they don't consult for "medical clearance" anymore. They may still consult for "risk assessment and assistance with perioperative management", but there's no illusion of passing the onus for complications onto medicine and there is an explicit acknowledgement that some patients still require surgery even if they are high risk.
That's a very good point that I hadn't thought of... it might seem on the surface like getting pre-op "clearance" or risk-stratification would be protective, but it might actually be paradoxically *increasing* medicolegal risk. Especially given that I've seen multiple cases where it doesn't seem like the surgeon followed-up on the PCP's recommendations or there was a miscommunication.
It’s weird as well that the PCP commented on the risk of thrombosis but also didn’t make anticoagulation recommendations, which in 2015 would likely have been guided by the CHEST guidelines, in which case none would have been recommended. Accidentally or mistakenly, the guidelines were ultimately followed regardless of the paper trail.
Mostly just discouraging that apparently these CPG-type recommendations don’t matter when it comes to bad but known complications of surgeries like this.
I’m glad to be retired. The jury awards are over the top in many cases shown on this site. 8 figure awards pile up. Perhaps surgeons should put all their assets in trusts.
I think they need to consider setting up state funded secondary reinsurers. To qualify, you need to have a state license. If settlements or jury verdicts of $10,000 or more automatically trigger a report to the NPDB and if settlements of $100,000 or more must be reported to state medical board like in NC, then that means that if a doctor is competent enough to have a license to practice, he is competent enough to qualify for this back up insurance.
Of course the argument goes that then the juries would go wild with these verdicts because they would know the doctor would have an endless supply of money.
So what this case boils down to is these lawyers made off with millions of dollars. and left this orthopedist's career in limbo. Been there.
First of all, "thrombophlebitis" is not DVT and that statement of "increased risk" has nothing to do with DVT risk or prophylaxis. The expert witness for the plaintiff should lose his membership in his professional organization that has a code of conduct for expert witnesses. There is no indication for postop anticoagulation in this patient, and certainly not for weeks after surgery. What a horrible expert opinion, and ridiculous jury decision.
I’m surprised they didn’t sue Dunkin’ Donuts for having ice on their side walk but a 12 M payday is not bad. What ever happened to ‘known risks’. Should airlines or car makers be sued every time someone gets a DVT riding in their carrier? Were they ‘warned’ of the risks of a long flight or car ride. After all, someone else is always to blame.
It looks like they actually did sue Dunkin too. The plaintiff filed a motion to block any mention of this separate lawsuit at trial, since they were afraid the jury might think the patient's family already got a bunch of money and didn't need any more.
I have to stop reading these because I get so upset. My first gripe is there is a reason they call these legal expert witnesses "whores." They prostitute themselves out to the lawyers for essentially what is a bribe. This expert is affiliated with a medical center academic institution and has an inherent bias to make himself appear as all knowing and oh so righteous.
So what happens when the patient throws an embolus immediately post operatively and dies, like on the table before she is awakened from anesthesia, like mine did, an attractive, fit, 18-year-old gal with no medical problems whom I had treated initially in a long leg cast for a tibia fracture, but due to progressive loss of reduction, I had to intervene with a manipulation and pass a percutaneous antegrade unreamed Rush rod, an unreamed rush rod! (I did not get sued), but still, in some states, I would have gotten sued in a New-York-minute.
And anticoagulation is not without its risks either and I'll leave that to other specialists to discuss.
And before I was forced into early retirement in 2016, they couldn't even agree on what kind of prophylaxis- ASA, Lovenox, Coumadin, sequential compression, TEDS or how long the window period of treatment, which tells you there is no good answer which means there is always a risk to living, and that is dying! The best defense probably is early mobilization which was done here.
And as usual, this guy was overweight (Gee, I would have never guessed walking out of Dunkin Doughnuts) and again, as in my last post, no indication of how obese, with no BMI indicated, because that is a taboo subject.
This was an eye-opening case. The expert indicated that he deviated from the standard of care when not giving anticoagulation, but I don't think the guidelines recommend anticoagulation in this case? And, what if he DID anticoagulate him, and then he had a massive brain hemorrhage? He probably would have been accused by another "expert" that the anticoagulation was not necessary. Damned if you do, damned if you don't. My heart goes out to this surgeon.
This case is a slam dunk for the pltf. I am surprised neither he nor the hospital anesthesiologist had a copy of the pre op clearance. My extensive surgical experience, would indicate that Anes. would not proceed without the written medical clearance in hand. Did the operating surgeon just therefore take the word of the patient or PCP that he was medically cleared for surgery?
After a Quad tendon repair the knee is kept immobile in a brace/knee immobilizer. An obese man is not that active after such an operative procedure. Such a high risk situation with pre operative and post operative stasis, would require post operative anticoagulation, and there are many regimens for anticoagulation which exclude ASA to which he was allergic.
Additionally with a Quad tendon injury, and so many weeks from the date of injury to surgery, one could make a strong case for a preop US study to rule out DVT. DVT may very well have been present before surgery was performed. In which case an IVC filter is often placed so as to perform the operative procedure.
The contracting company i work for always settles. they dont even give you a choice in the matter. I'm starting to see why . After reading alot of these med mal cases I dont think I've ever seen a physician win a case even if they did nothing wrong. What's the point of even trying to fight. These expert witnesses are the absolute worst. They tout around a load of horse crap and as long as it sounds like its right the jury ( comprised of people not in the medical field) will eat it up.
Med Mal cases should only consist of juries of medical professionals after all, those are our " peers"
The doctor wins in the large majority of cases that go to trial. I think something like 80%+. I've published a couple notable ones recently that went the other way, so it's a bit of a skewed perspective.
Oh come on. The doctor never wins. The case gets publicized and even if the doctor is found not liable, his name has already been smeared, plus all the aggravation, worry and stress he has to endure during the process. Ever try to sue a lawyer? I did four of them, for egregious legal malpractice, which even the special appointed judge had opined on. But suddenly all material facts are dismissed as speculative. The lawyers all get off, their names ort the case are never published, the state bar does nothing to them. There is no one on this earth that hates lawyers more than I do.
We are getting to see the cases that are actually considered worthy of having a lawyer take them on. They do reject a many of them, and many more don't make it in court. Classic hearing hoofbeats problem.
I have encountered several nurses who lurk as assassins, willing and waiting to write up doctors at the drop of a hat. Pure passive-aggressive. But if you read my memoirs, you might understand.
The plaintiff expert devoted a paragraph to criticizing Dr. F for not counseling the patient on signs and symptoms of DVT. This patient, however, had no sentinel signs and symptoms, which perhaps speaks to the importance of doing a surveillance DVT US when a patient is going through a particularly high-risk time (e.g. post-op, reduced mobility) even if asymptomatic. I know, there's a lot of room for argument there - who knows if an US on May 22 would have shown something or prompted anti-coagulation. Ironically though, the surgeon and/or hospital had demanded a thorough pre-op eval ("clearance"), yet the post-op eval was thin even though at that point he was at significantly higher risk for all the things that older obese post-op people are at risk for.
These outrageous malpractice verdicts have me scared to death. I now wonder if there’s any point to saving for retirement if I could wind up with a 10 million dollar judgment. All that work, extra shifts, saving, not going on luxury vacations so that I have a cushion and financial stability…. gone… along with my house, car, everything. It’s made me wonder if I should just start living the high life and not saving. Verdicts like this are simply depressing. My life isn’t worth 10 million and I’m still working and have many productive years ahead. I’m significantly younger than the patient in question. So I guess if I die from a PE 3 weeks after surgery- my family wins the lottery.
Maybe I’m not up to date on the latest and greatest anticoagulation guidelines, but per the 2012 CHEST guidelines for isolated lower extremity injuries requiring immobilization (quad rupture would seemingly fit this) they recommend no thromboprophylaxis. Not to mention this patient was WBAT after surgery. It’s kind of like, why even consider the guidelines and not just anticoagulate everyone for every surgery if you can just get sued anytime someone gets a DVT/PE.
And I have to imagine if surgeons *did* just mindlessly anticoagulate every patient after surgery, they'd get sued for the inevitable bleeding complications. I think the most vexing thing about MedMal for me is how it often seems to devolve into monetizing bad outcomes, regardless of fault/negligence.
I was really surprised the defense didn't mount a more vigorous defense about this exact issue. Now, they may have aggressively argued it at trial, and the written documents just didn't reflect it. But it just seems like it should have been a trump card. The plaintiff also argued that the surgeon didn't advise the patient about signs/symptoms of DVT/PE, but they also could have gotten the PCP for this too, and doesn't seem like that should justify this crazy of a verdict.
The term thrombophlebitis, which is not a life threatening condition, is being incorrectly here. The PCP meant thrombosis or thromboembolism.
In any case, medically this hinges on whether the standard of care in 2015 required post operative blood thinners. I’m not aware of any evidence that it did.
I guess it would have helped the orthopedic surgeons defense if he documented a discussion of risks and benefits of post operative blood thinners, but I still can’t see how he did anything wrong. I wonder if there’s any grounds for appeal here.
I wondered about that as well. Thrombophlebitis / SVT is not synonymous with DVT.
With the caveat that I'm not a surgeon, this also seems like an example of pre-operative "clearance" being worthless at best and actively harmful at worst. If the documentation from the PCP wasn't there, a post-operative PE, even resulting in death, would likely just be an unfortunate but known complication, and even if a lawsuit was filed the surgeon would likely have won. Likewise, as you point out, the PCP also dodged a bullet here.
Having spoken to the orthopedic surgeons where I work, they don't consult for "medical clearance" anymore. They may still consult for "risk assessment and assistance with perioperative management", but there's no illusion of passing the onus for complications onto medicine and there is an explicit acknowledgement that some patients still require surgery even if they are high risk.
That's a very good point that I hadn't thought of... it might seem on the surface like getting pre-op "clearance" or risk-stratification would be protective, but it might actually be paradoxically *increasing* medicolegal risk. Especially given that I've seen multiple cases where it doesn't seem like the surgeon followed-up on the PCP's recommendations or there was a miscommunication.
It’s weird as well that the PCP commented on the risk of thrombosis but also didn’t make anticoagulation recommendations, which in 2015 would likely have been guided by the CHEST guidelines, in which case none would have been recommended. Accidentally or mistakenly, the guidelines were ultimately followed regardless of the paper trail.
Mostly just discouraging that apparently these CPG-type recommendations don’t matter when it comes to bad but known complications of surgeries like this.
I’m glad to be retired. The jury awards are over the top in many cases shown on this site. 8 figure awards pile up. Perhaps surgeons should put all their assets in trusts.
I think they need to consider setting up state funded secondary reinsurers. To qualify, you need to have a state license. If settlements or jury verdicts of $10,000 or more automatically trigger a report to the NPDB and if settlements of $100,000 or more must be reported to state medical board like in NC, then that means that if a doctor is competent enough to have a license to practice, he is competent enough to qualify for this back up insurance.
Of course the argument goes that then the juries would go wild with these verdicts because they would know the doctor would have an endless supply of money.
So what this case boils down to is these lawyers made off with millions of dollars. and left this orthopedist's career in limbo. Been there.
First of all, "thrombophlebitis" is not DVT and that statement of "increased risk" has nothing to do with DVT risk or prophylaxis. The expert witness for the plaintiff should lose his membership in his professional organization that has a code of conduct for expert witnesses. There is no indication for postop anticoagulation in this patient, and certainly not for weeks after surgery. What a horrible expert opinion, and ridiculous jury decision.
I’m surprised they didn’t sue Dunkin’ Donuts for having ice on their side walk but a 12 M payday is not bad. What ever happened to ‘known risks’. Should airlines or car makers be sued every time someone gets a DVT riding in their carrier? Were they ‘warned’ of the risks of a long flight or car ride. After all, someone else is always to blame.
It looks like they actually did sue Dunkin too. The plaintiff filed a motion to block any mention of this separate lawsuit at trial, since they were afraid the jury might think the patient's family already got a bunch of money and didn't need any more.
So it’s basically a litigious patient/ family
Have you looked at a car manual lately? It's 3 pages about maintenance, and 397 pages of warnings, specifically for what you mentioned.
I have to stop reading these because I get so upset. My first gripe is there is a reason they call these legal expert witnesses "whores." They prostitute themselves out to the lawyers for essentially what is a bribe. This expert is affiliated with a medical center academic institution and has an inherent bias to make himself appear as all knowing and oh so righteous.
So what happens when the patient throws an embolus immediately post operatively and dies, like on the table before she is awakened from anesthesia, like mine did, an attractive, fit, 18-year-old gal with no medical problems whom I had treated initially in a long leg cast for a tibia fracture, but due to progressive loss of reduction, I had to intervene with a manipulation and pass a percutaneous antegrade unreamed Rush rod, an unreamed rush rod! (I did not get sued), but still, in some states, I would have gotten sued in a New-York-minute.
And anticoagulation is not without its risks either and I'll leave that to other specialists to discuss.
And before I was forced into early retirement in 2016, they couldn't even agree on what kind of prophylaxis- ASA, Lovenox, Coumadin, sequential compression, TEDS or how long the window period of treatment, which tells you there is no good answer which means there is always a risk to living, and that is dying! The best defense probably is early mobilization which was done here.
And as usual, this guy was overweight (Gee, I would have never guessed walking out of Dunkin Doughnuts) and again, as in my last post, no indication of how obese, with no BMI indicated, because that is a taboo subject.
This was an eye-opening case. The expert indicated that he deviated from the standard of care when not giving anticoagulation, but I don't think the guidelines recommend anticoagulation in this case? And, what if he DID anticoagulate him, and then he had a massive brain hemorrhage? He probably would have been accused by another "expert" that the anticoagulation was not necessary. Damned if you do, damned if you don't. My heart goes out to this surgeon.
This case is a slam dunk for the pltf. I am surprised neither he nor the hospital anesthesiologist had a copy of the pre op clearance. My extensive surgical experience, would indicate that Anes. would not proceed without the written medical clearance in hand. Did the operating surgeon just therefore take the word of the patient or PCP that he was medically cleared for surgery?
After a Quad tendon repair the knee is kept immobile in a brace/knee immobilizer. An obese man is not that active after such an operative procedure. Such a high risk situation with pre operative and post operative stasis, would require post operative anticoagulation, and there are many regimens for anticoagulation which exclude ASA to which he was allergic.
Additionally with a Quad tendon injury, and so many weeks from the date of injury to surgery, one could make a strong case for a preop US study to rule out DVT. DVT may very well have been present before surgery was performed. In which case an IVC filter is often placed so as to perform the operative procedure.
The contracting company i work for always settles. they dont even give you a choice in the matter. I'm starting to see why . After reading alot of these med mal cases I dont think I've ever seen a physician win a case even if they did nothing wrong. What's the point of even trying to fight. These expert witnesses are the absolute worst. They tout around a load of horse crap and as long as it sounds like its right the jury ( comprised of people not in the medical field) will eat it up.
Med Mal cases should only consist of juries of medical professionals after all, those are our " peers"
The doctor wins in the large majority of cases that go to trial. I think something like 80%+. I've published a couple notable ones recently that went the other way, so it's a bit of a skewed perspective.
Oh come on. The doctor never wins. The case gets publicized and even if the doctor is found not liable, his name has already been smeared, plus all the aggravation, worry and stress he has to endure during the process. Ever try to sue a lawyer? I did four of them, for egregious legal malpractice, which even the special appointed judge had opined on. But suddenly all material facts are dismissed as speculative. The lawyers all get off, their names ort the case are never published, the state bar does nothing to them. There is no one on this earth that hates lawyers more than I do.
Me. I was married to one.
We are getting to see the cases that are actually considered worthy of having a lawyer take them on. They do reject a many of them, and many more don't make it in court. Classic hearing hoofbeats problem.
yes im aware of that.., but alot of them i've read are cases where the physicians did nothing wrong and still lost.
Do not rely on a nurse to even know her own name.
It's like relying on a surgeon to be a decent human being when talking to others they consider beneath them (aka 99% of the population), I guess.
Also, am a dude, sorry to disappoint :)
I have encountered several nurses who lurk as assassins, willing and waiting to write up doctors at the drop of a hat. Pure passive-aggressive. But if you read my memoirs, you might understand.
That’s why in France for instance pre-anesthesia consult is an obligation stated in the law
The plaintiff expert devoted a paragraph to criticizing Dr. F for not counseling the patient on signs and symptoms of DVT. This patient, however, had no sentinel signs and symptoms, which perhaps speaks to the importance of doing a surveillance DVT US when a patient is going through a particularly high-risk time (e.g. post-op, reduced mobility) even if asymptomatic. I know, there's a lot of room for argument there - who knows if an US on May 22 would have shown something or prompted anti-coagulation. Ironically though, the surgeon and/or hospital had demanded a thorough pre-op eval ("clearance"), yet the post-op eval was thin even though at that point he was at significantly higher risk for all the things that older obese post-op people are at risk for.
These outrageous malpractice verdicts have me scared to death. I now wonder if there’s any point to saving for retirement if I could wind up with a 10 million dollar judgment. All that work, extra shifts, saving, not going on luxury vacations so that I have a cushion and financial stability…. gone… along with my house, car, everything. It’s made me wonder if I should just start living the high life and not saving. Verdicts like this are simply depressing. My life isn’t worth 10 million and I’m still working and have many productive years ahead. I’m significantly younger than the patient in question. So I guess if I die from a PE 3 weeks after surgery- my family wins the lottery.
Not if the jury finds out you were an MD.