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.
Wait a minute. Was the CT scan reading by a radiologist available to the ED physician when he discharged the patient? If so, then the ED physician fell below the standard of care. If the ED physician did NOT have the benefit of the radiologist’s report then it behooved the radiologist in my opinion, to have made a special call to the ED physician and inform him of the adrenal mass for appropriate immediate follow up after the patient was discharged.
I was successfully sued when the radiologist at my local hospital in KY not only failed to diagnose a hot Tc99 bone scan that lit up my patient’s (a 37 year old man with atypical back pain) entire spine and ribs like a Christmas tree visible from across the hall but merely said the findings were “unusual” for a 37 year old man. These abnormal scan results were not called to me by the radiologist and the report was not brought to my attention on one week follow up when the patient said that he was feeling better. I sent him to PT. 6 weeks later he was a lot worse and I referred him to the Spine clinic in Louisville. There he was diagnosed with advanced metastatic multiple myeloma (MM) and died a few months later. As the physician who had ordered the Bone Scan, it was my duty to have followed up on it and so I had fallen below the standard of care by Doctrine of Respondeat Superior for my employees who had not provided me with a complete chart form the previous week. But the radiologist who missed this alarming scan was not named in the lawsuit, which was settled for $275K.
It is NOT the ED physician’s task to read and interpret radiological studies especially in the heat of battle in a busy ED if he cannot reasonably make a diagnosis on clinical and lab grounds only. That is why radiology is a specialty and radiologists are paid and paid well to read and to relay pertinent findings- that’s my opinion- and in many cases these x-rays and CT scans, telemedicine notwithstanding, are read the following morning when the radiologist rolls into the reading room and logs on to his computer. I’m not digging on radiologists, as my son is an associate professor of neuroradiology in San Antonio. I just can’t believe this radiologist would not have had the courtesy to contact the ED physician and the patient with these “incidental” findings that completely altered the landscape.
Back in 1992, this advanced MM was invariably fatal, although when I applied for Med Mal Insurance in NY, the review panel also lit into me for having chosen the wrong test (20% of MM not detected by bone scan) for a man with atypical back pain complicated by intermittent low back pain from known chronic Grade 1 spondylolisthesis, even though I had suspected something else and thus had ordered this Bone Scan on his initial visit. He claimed he had injured his back recently on a water slide, which was not consistent in a 37 year old man with no osteoporosis.
On discovery, going back 3 months it was learned this patient had been seen at the Louisville Hospital for this injury where a 30% wedge compression fracture had been diagnosed, but not taken in context. A fall from a second floor, could cause this, yes, but a little bump on a waterslide? No! I did not have the records from Louisville.
The Louisville Hospital was not named. I was the only one sued.
So what was and is the current standard for radiologists? Just diagnose and adios?
Are Radiologists who are on call, also required to report findings promptly after the Scans are completed, or is the standard that these can be read the next morning? The risks to loss of follow up or referral mix ups are too great IMHO.
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.
Wait a minute. Was the CT scan reading by a radiologist available to the ED physician when he discharged the patient? If so, then the ED physician fell below the standard of care. If the ED physician did NOT have the benefit of the radiologist’s report then it behooved the radiologist in my opinion, to have made a special call to the ED physician and inform him of the adrenal mass for appropriate immediate follow up after the patient was discharged.
I was successfully sued when the radiologist at my local hospital in KY not only failed to diagnose a hot Tc99 bone scan that lit up my patient’s (a 37 year old man with atypical back pain) entire spine and ribs like a Christmas tree visible from across the hall but merely said the findings were “unusual” for a 37 year old man. These abnormal scan results were not called to me by the radiologist and the report was not brought to my attention on one week follow up when the patient said that he was feeling better. I sent him to PT. 6 weeks later he was a lot worse and I referred him to the Spine clinic in Louisville. There he was diagnosed with advanced metastatic multiple myeloma (MM) and died a few months later. As the physician who had ordered the Bone Scan, it was my duty to have followed up on it and so I had fallen below the standard of care by Doctrine of Respondeat Superior for my employees who had not provided me with a complete chart form the previous week. But the radiologist who missed this alarming scan was not named in the lawsuit, which was settled for $275K.
It is NOT the ED physician’s task to read and interpret radiological studies especially in the heat of battle in a busy ED if he cannot reasonably make a diagnosis on clinical and lab grounds only. That is why radiology is a specialty and radiologists are paid and paid well to read and to relay pertinent findings- that’s my opinion- and in many cases these x-rays and CT scans, telemedicine notwithstanding, are read the following morning when the radiologist rolls into the reading room and logs on to his computer. I’m not digging on radiologists, as my son is an associate professor of neuroradiology in San Antonio. I just can’t believe this radiologist would not have had the courtesy to contact the ED physician and the patient with these “incidental” findings that completely altered the landscape.
Back in 1992, this advanced MM was invariably fatal, although when I applied for Med Mal Insurance in NY, the review panel also lit into me for having chosen the wrong test (20% of MM not detected by bone scan) for a man with atypical back pain complicated by intermittent low back pain from known chronic Grade 1 spondylolisthesis, even though I had suspected something else and thus had ordered this Bone Scan on his initial visit. He claimed he had injured his back recently on a water slide, which was not consistent in a 37 year old man with no osteoporosis.
On discovery, going back 3 months it was learned this patient had been seen at the Louisville Hospital for this injury where a 30% wedge compression fracture had been diagnosed, but not taken in context. A fall from a second floor, could cause this, yes, but a little bump on a waterslide? No! I did not have the records from Louisville.
The Louisville Hospital was not named. I was the only one sued.
So what was and is the current standard for radiologists? Just diagnose and adios?
Are Radiologists who are on call, also required to report findings promptly after the Scans are completed, or is the standard that these can be read the next morning? The risks to loss of follow up or referral mix ups are too great IMHO.
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!