what i typically do is upon reading the incidentaloma report is i add a diagnosis of imaging abnormality to the chart, it prompts me to discuss it at discharge and include it in the note as my emr will carry it through to the instruction section.
Is it standard practice for ED docs to document referral back to primary care? The ED isn't going to order an MRI, let alone serum/urine metanephrines. Why would an ED doc not document the abnormal imaging and referral back to PCP to complete work up as needed?
Referral back to PCP is pretty standard, but sometimes only communicated through an auto-generated sentences somewhere in the discharge papers. Easy to forget to tell the patient since the incidental finding is tangential to the patient's presentation.
standard of care for the EM doc would have been documentation of further evaluation needed re: the adrenal mass. working up incidentalomas in the ED falls outside of the standard of care. unfortunately that means that some of them will be missed, some patients will be lost to follow up, some docs don't take them seriously, and sometimes communication doesn't happen. that's why documentation is so important.
reviewing this case, though, there's no mention of this patients' blood pressure during her pregnancy. or other symptoms. were there abnormal readings?
sounds to me like this was more chart mining after the fact looking for someone to blame. sympathetic but agree with your point above, there was no relationship between the EM doc and the as-yet-to-be-fertilized-oocyte.
That's a good point, they didn't put any info in about her blood pressure during the pregnancy. I'm not a pheo expert but I'm wondering if it wasn't significant enough to cause HTN yet.
This is really interesting. In law school when we learned negligence, the duty element isn’t emphasized nearly as much as breach/causation/damages because duty is almost assumed. If we made it to a lawsuit, especially in medmal, the duty to the patient is almost certainly there.
The best argument for the plaintiff that comes to mind is owing a duty to “all foreseeable plaintiffs. Though I personally agree it feels like a stretch to extend the duty to all possible subsequent children, forever. This brings to mind the classic case Palsgraf v. Long Island Railroad Co., which is a monumental case in the doctrines surrounding duty to foreseeable plaintiffs. (Wikipedia it if interested).
That said, the defense asked for judgment as a matter of law (JMOL). Without knowing the jurisdiction (it’s masked in the post), in federal court JMOL would be the wrong motion pre-trial — it can only be raised at trial after the other side has been fully heard. Summary judgment is generally the correct pre-trial motion, though they're functionally the same thing. However, the rules could be different for this state's courts. Without a written opinion it’s hard to know why the judge denied the motion.
Thanks for the wonderful insights! I think I should get one credit of Civil Procedure from your comment if I ever decide to go to law school! I read the Palsgraf wikipedia page, very interesting case and extremely bizarre set of facts. I think I've only ever published one other lawsuit related to duty, in which a patient gave his girlfriend herpes: https://expertwitness.substack.com/p/expert-witness-case-19
Fascinating case. A real lesson in - among other things - being prepared for what to do with the results of a diagnostic test.
The case does make me question, is there any responsibility for providers who are aware of the adrenal lesion to counsel the patient for or against certain medications or lifestyle changes on the off chance that the lesion might be a pheochromocytoma? If it's on your differential and you're working it up, are you as the provider obligated to advise against pregnancy or steroid use or even strenuous exercise?
what i typically do is upon reading the incidentaloma report is i add a diagnosis of imaging abnormality to the chart, it prompts me to discuss it at discharge and include it in the note as my emr will carry it through to the instruction section.
Is it standard practice for ED docs to document referral back to primary care? The ED isn't going to order an MRI, let alone serum/urine metanephrines. Why would an ED doc not document the abnormal imaging and referral back to PCP to complete work up as needed?
Referral back to PCP is pretty standard, but sometimes only communicated through an auto-generated sentences somewhere in the discharge papers. Easy to forget to tell the patient since the incidental finding is tangential to the patient's presentation.
standard of care for the EM doc would have been documentation of further evaluation needed re: the adrenal mass. working up incidentalomas in the ED falls outside of the standard of care. unfortunately that means that some of them will be missed, some patients will be lost to follow up, some docs don't take them seriously, and sometimes communication doesn't happen. that's why documentation is so important.
reviewing this case, though, there's no mention of this patients' blood pressure during her pregnancy. or other symptoms. were there abnormal readings?
sounds to me like this was more chart mining after the fact looking for someone to blame. sympathetic but agree with your point above, there was no relationship between the EM doc and the as-yet-to-be-fertilized-oocyte.
That's a good point, they didn't put any info in about her blood pressure during the pregnancy. I'm not a pheo expert but I'm wondering if it wasn't significant enough to cause HTN yet.
This is really interesting. In law school when we learned negligence, the duty element isn’t emphasized nearly as much as breach/causation/damages because duty is almost assumed. If we made it to a lawsuit, especially in medmal, the duty to the patient is almost certainly there.
The best argument for the plaintiff that comes to mind is owing a duty to “all foreseeable plaintiffs. Though I personally agree it feels like a stretch to extend the duty to all possible subsequent children, forever. This brings to mind the classic case Palsgraf v. Long Island Railroad Co., which is a monumental case in the doctrines surrounding duty to foreseeable plaintiffs. (Wikipedia it if interested).
That said, the defense asked for judgment as a matter of law (JMOL). Without knowing the jurisdiction (it’s masked in the post), in federal court JMOL would be the wrong motion pre-trial — it can only be raised at trial after the other side has been fully heard. Summary judgment is generally the correct pre-trial motion, though they're functionally the same thing. However, the rules could be different for this state's courts. Without a written opinion it’s hard to know why the judge denied the motion.
Thanks for the wonderful insights! I think I should get one credit of Civil Procedure from your comment if I ever decide to go to law school! I read the Palsgraf wikipedia page, very interesting case and extremely bizarre set of facts. I think I've only ever published one other lawsuit related to duty, in which a patient gave his girlfriend herpes: https://expertwitness.substack.com/p/expert-witness-case-19
Love the Substack. Keep at it! I look forward to the weekly read.
Fascinating case. A real lesson in - among other things - being prepared for what to do with the results of a diagnostic test.
The case does make me question, is there any responsibility for providers who are aware of the adrenal lesion to counsel the patient for or against certain medications or lifestyle changes on the off chance that the lesion might be a pheochromocytoma? If it's on your differential and you're working it up, are you as the provider obligated to advise against pregnancy or steroid use or even strenuous exercise?
This is an excellent case for anestheisa professionals to review. Thank you!
Thanks for reading it!