I can imagine a shovel handle doing this. The incident is not precisely described anywhere, but people don't like to fall & will perform amazingly athletic moves trying to not fall. And this was a young athletic man & may have been on slippery or uncertain footing. If the shovel had been stuck in the snow or laden with snow, I can picture his body falling forward or sideways & undergoing contortions. It would be not at all impossible for the end of the handle to be jutting upwards & jab him strongly in the LUQ. I've seen something quite similar:
I made rounds at 7 AM one day as an intern & an elderly female patient on my general surgery service looked well & had no new complaints. At that hour in Canada it is dark. At 4 PM the same day I rounded with the staff surgeon, in daylight, & we were shocked to see she was as white as a ghost. Only then did she report she'd gotten up to pee in the night & fallen, striking her LUQ against the corner of the footstool by her bed. Her Hb was 6 by 4 PM. The surgeon did a splenectomy. So weird things happen !
Interventional techniques are invaluable but I often wonder if IR do not at times persist for too long using increasingly aggressive techniques to fix what their initial attempts failed to fix. Not only that, something similar seems to be happening in the O.R., where surgeons seem so married to the idea of doing something using minimal access techniques, that they are choosing too late to convert to an open procedure. Is anyone else thinking this?
I've seen some similar trauma cases over the years. Its easy to diagnose the spleen lac in a trauma activation patient that is hypotensive with a positive FAST on arrival. The tricky ones are the ones that fell or bumped into something a few days ago and present with chief complaint of "dizziness", they don't get labeled as a trauma bc they didn't tell the triage nurse that, and you don't realize until hours later what is actually going on.
Honestly the question of whether the IR doc was negligent depends on how common it is to accidentally compromise pancreatic blood supply during a splenic embolization. This is a very technical question which as an EM doc i have no idea what the answer is - and of course the jury has even less of an idea. If the procedure was that difficult as described in the report it may have been better to abort and just do the splenectomy but again this seems like something you need to be highly specialized to be able to adjudicate.
Ha! Sorry! It does seem like path gets left out a lot, although, on the bright side, it seems like you guys get sued a lot less than some other specialties.
I recall a paper looking at malpractice suits by specialty and indeed I recall pathology is among the lowest in terms of "likelihood of being named in a lawsuit" but because so much of what we do is objectively documented for review, we were among the highest terms of "likelihood to be found guilty if sued"
I am delighted by the meteorologist consultation. The only relevance I can see here (other than making the complainant look unreliable) is that, at least for some injuries, mechanism of injury can play a role in deciding management. (I don't know if that applies to spleen injuries, but is a practice in some orthopoedic injuries where I work - a serious mechanism of injury can "overrule" a benign-appearing X-ray, or at least mandate casting and close follow-up).
The only other idea I had was if the patient had some reason to make up a false story. For example, did he have disability insurance that excluded any injury suffered while skiing, and he actually ruptured his spleen in a ski accident, so concocted the snow shovel story so he could still collect disability? I'm not calling him a liar, just trying to brainstorm why it doesn't add up.
I think this is significantly more likely. I practiced (EM) in precisely that area of Vermont and agree that it's far more likely that he sustained that injury skiing. Okemo Mountain is only a short drive from Ludlow. Most everyone pays someone with a plough to do their driveways. "Falling on a shovel" sounds like other stories we've heard.
Maybe I'm not understanding this element of it but why would that have any bearing on the hospital/physicians' defense? Would the hospital be on the hook for less $$$ if it was reckless behavior that led to the injury vs. shoveling snow? He was a free agent at the time so it's not like there's a team with a contract they are trying to void funding the defense's hiring the expert to prove he was being reckless (would that even be legal?).
Yeah thats why the meteorologist's argument baffles me.... it doesn't have anything to do with the alleged malpractice. The mechanism doesnt matter at all, just that he had a spleen injury that needed to be addressed. Wish I had a good explanation, I don't think even reckless behavior would affect the malpractice lawsuit.
I'm decently sure it was to be prepared to impeach his credibility at trial. The plaintiff would have to testify at trial, and by doing so would put his credibility for honesty in question. If the defense could attack his honesty, the plaintiff would look very bad in the eyes of the jury. It doesn't change the malpractice that came later, but when a jury is deciding to the dollar how much he deserves to be compensated, being caught in a blatant lie would likely play very poorly to the ultimate decider of fact (the jury).
Second, and this logic is more a work in progress in my head: In tort, medical malpractice is considered a "foreseeable risk." Meaning if I injure you, and then a doctor commits malpractice, I (the original tortfeasor) am liable for the downstream malpractice. So, I could imagine an argument for the jury's sake that he did something reckless, lied about it, that changed how the healthcare team framed his case (even if it didn't matter in reality), and thus he is contributorily negligent, which would reduce his recovery (potentially to 0 depending on the state and jury's decisions). But this is reading between the lines of the defense's ideas so take the analysis with a grain of salt.
I may be the dissenting voice on this but i view this as an unfortunate surgical error or complication and one that should not have been paid by the surgeon/radiologist but by the pt's disability insurance. Complications happen all the time and is often beyond the control of doctors. It is a grossly unfair standard to hold doctors to.
Not sure if the patient actually had disability insurance or not. Overall I favor a no-fault compensation system (as compared to our current malpractice/tort system) that would reimburse patients fairly without having to sue the doctor. The main issue is how to pay for this., but a lot of other countries do it with decent success. The way that vaccine injuries are compensated is another good alternative to consider.
Love to see folks know about the vaccine injury compensation program! I agree it's such an interesting program. This article is one of my all time favorites comparing different public health threats and their liability systems. https://pubmed.ncbi.nlm.nih.gov/17901450/
If there's ever interest in it, I have some experience with VICP and have published on it. Would be happy to chat.
I am a GYN surgeon but did military time and have worked with numerous surgeons as an assist and been on 100s of general surgery cases. This case is a NO BRAINER that turned into a DISASTER for a young person with a huge career ahead of him. It was obvious from the presentation that all he needed was a SPLENECTOMY whether it was laparoscopic or open. PERIOD. People can live without a spleen, believe it or not. Conservative management just about KILLED HIM but obviously ruined his chances of ever playing professional baseball again. I'm amazed that as the clinical picture continued to worsen and the surgeons continued to do NOTHING until they FINALLY took him to surgery only to find 5.7 liters of blood clot in the abdomen. Luckily, I live in a big city with a lot of friends who are surgeons in different areas, and I would have just gone to the RIGHT SURGEON that would have taken care of it from the beginning. This is a very good example of what happens when you wait for COMPLICATIONS TO OCCUR. And this happens way too often in modern medicine. I'm always screaming, "JUST TAKE CARE OF THE PATIENT" when this clinical nonsense is happening right before my eyes. And look what happened when IR came around? Under my care with consultant referrals, this would NEVER have happened!
Despite the redaction the plaintiff is readily identifiable. Someone else already named in the comments. The plaintiff stopped playing the season before the injury and was already on the way out. In general I agree with you, especially in academics the old trope of “surgeons just want to operate” (with the connotation of it being try even when not indicated) is so far from the truth. Tends to be the opposite sometimes. Doesn’t seem to have been the source in this one though.
Standard of care for grade IV splenic laceration is absolutely conservative care if stable, IR if not. Perhaps that was not the case historically but absolutely is now. Initial transfer should have been to somewhere with both trauma surgery and IR.
Have they done any RCTs comparing IR to splenectomy specifically in unstable patients? My understanding was that if grossly unstable, they should get a splenectomy, but maybe that is outdated now?
This patient wasn't stable but unfortunately for him wasn't grossly unstable either. It appears greater -than -usual-efforts were made to treat him by non-invasive methods, even when they weren't working. When a surgeon finally saw him, strong consideration for a minimal access approach occurred. Why? Was his physicians' judgement affected somehow by his relative celebrity as a MLB pitcher + desire to help him continue his career?
It is a travesty that suits like this still happen and despite poor evidence of malpractice there is still a pay out. I suppose we deserve our expensive healthcare.
I am not a radiologist but I read that pancreatic tail necrosis is a rare complication from splenic artery embolization (Talving P, Rauk M, Vipp L, Isand KG, Šamarin A, Põder K, Rätsep I, Saar S. Necrosis of the tail of pancreas following proximal splenic artery embolization. J Surg Case Rep. 2016 May 13;2016(5):rjw087. doi: 10.1093/jscr/rjw087. PMID: 27177891; PMCID: PMC4866485.)
So I’m surprised at how their expert could predict this event in advance.
I find it incredibly frustrating to witness the lack of accountability surrounding these issues. The arrogance and unethical behavior displayed by some so-called “experts” involved in malpractice lawsuits is disheartening. I’ve seen multiple Grade 4 splenic injuries treated successfully in healthy individuals using conservative management or embolectomy when necessary.
It’s important to recognize that even when we do everything right, we can still find ourselves in legal battles due to unfavorable outcomes. We, as physicians, can sometimes be our own worst enemies—whether it’s undermining a colleague in front of a patient or making disparaging remarks during depositions and trials.
Maybe we need to confront the reality that some of us may come across as arrogant or self-serving, often engaged in a continuous struggle with ourselves and our peers.
A recent example comes to mind: I transferred a critically ill pediatric patient to a specialized institution for further evaluation and care. A week later, I received a grievance from the mother, who said the physicians at the children’s hospital claimed her son didn’t need to be transferred and that my team didn’t know what we were doing. This kind of arrogance and malice is unacceptable.
Throughout my career, I’ve encountered numerous instances of suboptimal care, but I have never resorted to disparaging a colleague to a patient. Instead, I prefer to communicate directly with other physicians about any concerns, hoping they would do the same for me if I were in the wrong.
It’s time for us to foster a culture of collaboration and accountability in our profession.
If you're strong enough and tall enough doing the human-snow-plow thing (which is a fun macho thing to do no matter how easily you can afford a plowing service), you could conceivably double-over the shovel handle quite forcibly when the shovel suddenly hits a block of ice. Apparently being athletic enough to bust your own spleen goes along with being athletic enough to obscure a grade IV splenic lac - he hung out at home for a few days before even going to the ED. That athleticism and stoicism may actually have hurt him a bit in terms of obscuring how injured he really was. Also, if he wasn't a VIP, would IR have been the first choice, at least back then (2013)?
I have a very specific memory of pushing a snow shovel along the ground very quickly with the handle at stomach-level, then coming to a very abrupt stop when the shovel fell into a hidden crack in the concrete that was exactly parallel to the shovel. Didn't feel great.
Obviously UNSTABLE with a WORSENING CLINICAL PICTURE including A DISTENDED ABDOMEN and 5 liters of BLOOD FOUND?????? His Hematocrit dropped from 39 to 21. That is NOT a stable patient. You must be kidding me. I like to sleep at night for sure. Despite what was said about the patient being "stable." the real story is pretty obvious. This patient was at high risk for DEATH. This patient needed a trip to the OR from the beginning and a blood blood transfusion. This would have avoided a lot of complications that were documented.
“According to Christensen, Pavano did not slip and fall down. Rather, he partially lost his balance and fell onto the upright handle of the shovel he was using. As he is certainly much taller than the shovel, he likely jammed the shovel upward into the left side of his abdomen and under his left rib cage.”
Could this explain why the spleen so badly damaged? Mechanism looks plausible.
I really debated not publishing this because its super easy to Google the case. I actually had not considered what the author mentioned about a diaphragmatic rupture. The lawsuit records indicated he had a pleural effusion and then a thoracentesis but it didn't mention hemothorax or a chest tube. Seems like they would have mentioned that in the operative note?
HA! Vindication. I just read these details after I had submitted my Comment stating I believed it could happen, & posited essentially the same thing. I never heard of this guy, or how tall he is, but being tall makes it even more likely. Luckily I am 5'2" so my spleen safe.
Pro athletes are complete freaks of nature. I agree w/ the comments that his athleticism likely harmed him.
He's 6'5" per Google and I can only imagine what his version of shoveling snow looks like compared to the average person!
Skiing was likely prohibited in his MLB contract, especially since he's from the NE, which of course gives way to reporting a different mechanism of injury, so as to not lose millions ...guessing over here.
I can imagine a shovel handle doing this. The incident is not precisely described anywhere, but people don't like to fall & will perform amazingly athletic moves trying to not fall. And this was a young athletic man & may have been on slippery or uncertain footing. If the shovel had been stuck in the snow or laden with snow, I can picture his body falling forward or sideways & undergoing contortions. It would be not at all impossible for the end of the handle to be jutting upwards & jab him strongly in the LUQ. I've seen something quite similar:
I made rounds at 7 AM one day as an intern & an elderly female patient on my general surgery service looked well & had no new complaints. At that hour in Canada it is dark. At 4 PM the same day I rounded with the staff surgeon, in daylight, & we were shocked to see she was as white as a ghost. Only then did she report she'd gotten up to pee in the night & fallen, striking her LUQ against the corner of the footstool by her bed. Her Hb was 6 by 4 PM. The surgeon did a splenectomy. So weird things happen !
Interventional techniques are invaluable but I often wonder if IR do not at times persist for too long using increasingly aggressive techniques to fix what their initial attempts failed to fix. Not only that, something similar seems to be happening in the O.R., where surgeons seem so married to the idea of doing something using minimal access techniques, that they are choosing too late to convert to an open procedure. Is anyone else thinking this?
I've seen some similar trauma cases over the years. Its easy to diagnose the spleen lac in a trauma activation patient that is hypotensive with a positive FAST on arrival. The tricky ones are the ones that fell or bumped into something a few days ago and present with chief complaint of "dizziness", they don't get labeled as a trauma bc they didn't tell the triage nurse that, and you don't realize until hours later what is actually going on.
Honestly the question of whether the IR doc was negligent depends on how common it is to accidentally compromise pancreatic blood supply during a splenic embolization. This is a very technical question which as an EM doc i have no idea what the answer is - and of course the jury has even less of an idea. If the procedure was that difficult as described in the report it may have been better to abort and just do the splenectomy but again this seems like something you need to be highly specialized to be able to adjudicate.
"Unfortunately they did not include the path report or any other labs in the court records."
Like the great GomerBlog once said "Here We Go Again, Pathology Was Left Out of Another Article"
https://gomerblog.com/2017/07/pathology-left-another-one/
Ha! Sorry! It does seem like path gets left out a lot, although, on the bright side, it seems like you guys get sued a lot less than some other specialties.
I recall a paper looking at malpractice suits by specialty and indeed I recall pathology is among the lowest in terms of "likelihood of being named in a lawsuit" but because so much of what we do is objectively documented for review, we were among the highest terms of "likelihood to be found guilty if sued"
I am delighted by the meteorologist consultation. The only relevance I can see here (other than making the complainant look unreliable) is that, at least for some injuries, mechanism of injury can play a role in deciding management. (I don't know if that applies to spleen injuries, but is a practice in some orthopoedic injuries where I work - a serious mechanism of injury can "overrule" a benign-appearing X-ray, or at least mandate casting and close follow-up).
The only other idea I had was if the patient had some reason to make up a false story. For example, did he have disability insurance that excluded any injury suffered while skiing, and he actually ruptured his spleen in a ski accident, so concocted the snow shovel story so he could still collect disability? I'm not calling him a liar, just trying to brainstorm why it doesn't add up.
I think this is significantly more likely. I practiced (EM) in precisely that area of Vermont and agree that it's far more likely that he sustained that injury skiing. Okemo Mountain is only a short drive from Ludlow. Most everyone pays someone with a plough to do their driveways. "Falling on a shovel" sounds like other stories we've heard.
Maybe I'm not understanding this element of it but why would that have any bearing on the hospital/physicians' defense? Would the hospital be on the hook for less $$$ if it was reckless behavior that led to the injury vs. shoveling snow? He was a free agent at the time so it's not like there's a team with a contract they are trying to void funding the defense's hiring the expert to prove he was being reckless (would that even be legal?).
Yeah thats why the meteorologist's argument baffles me.... it doesn't have anything to do with the alleged malpractice. The mechanism doesnt matter at all, just that he had a spleen injury that needed to be addressed. Wish I had a good explanation, I don't think even reckless behavior would affect the malpractice lawsuit.
I'm decently sure it was to be prepared to impeach his credibility at trial. The plaintiff would have to testify at trial, and by doing so would put his credibility for honesty in question. If the defense could attack his honesty, the plaintiff would look very bad in the eyes of the jury. It doesn't change the malpractice that came later, but when a jury is deciding to the dollar how much he deserves to be compensated, being caught in a blatant lie would likely play very poorly to the ultimate decider of fact (the jury).
Second, and this logic is more a work in progress in my head: In tort, medical malpractice is considered a "foreseeable risk." Meaning if I injure you, and then a doctor commits malpractice, I (the original tortfeasor) am liable for the downstream malpractice. So, I could imagine an argument for the jury's sake that he did something reckless, lied about it, that changed how the healthcare team framed his case (even if it didn't matter in reality), and thus he is contributorily negligent, which would reduce his recovery (potentially to 0 depending on the state and jury's decisions). But this is reading between the lines of the defense's ideas so take the analysis with a grain of salt.
Thanks for the insight! Certainly seem like a plausible interpretation.
I may be the dissenting voice on this but i view this as an unfortunate surgical error or complication and one that should not have been paid by the surgeon/radiologist but by the pt's disability insurance. Complications happen all the time and is often beyond the control of doctors. It is a grossly unfair standard to hold doctors to.
Not sure if the patient actually had disability insurance or not. Overall I favor a no-fault compensation system (as compared to our current malpractice/tort system) that would reimburse patients fairly without having to sue the doctor. The main issue is how to pay for this., but a lot of other countries do it with decent success. The way that vaccine injuries are compensated is another good alternative to consider.
Love to see folks know about the vaccine injury compensation program! I agree it's such an interesting program. This article is one of my all time favorites comparing different public health threats and their liability systems. https://pubmed.ncbi.nlm.nih.gov/17901450/
If there's ever interest in it, I have some experience with VICP and have published on it. Would be happy to chat.
I am a GYN surgeon but did military time and have worked with numerous surgeons as an assist and been on 100s of general surgery cases. This case is a NO BRAINER that turned into a DISASTER for a young person with a huge career ahead of him. It was obvious from the presentation that all he needed was a SPLENECTOMY whether it was laparoscopic or open. PERIOD. People can live without a spleen, believe it or not. Conservative management just about KILLED HIM but obviously ruined his chances of ever playing professional baseball again. I'm amazed that as the clinical picture continued to worsen and the surgeons continued to do NOTHING until they FINALLY took him to surgery only to find 5.7 liters of blood clot in the abdomen. Luckily, I live in a big city with a lot of friends who are surgeons in different areas, and I would have just gone to the RIGHT SURGEON that would have taken care of it from the beginning. This is a very good example of what happens when you wait for COMPLICATIONS TO OCCUR. And this happens way too often in modern medicine. I'm always screaming, "JUST TAKE CARE OF THE PATIENT" when this clinical nonsense is happening right before my eyes. And look what happened when IR came around? Under my care with consultant referrals, this would NEVER have happened!
Despite the redaction the plaintiff is readily identifiable. Someone else already named in the comments. The plaintiff stopped playing the season before the injury and was already on the way out. In general I agree with you, especially in academics the old trope of “surgeons just want to operate” (with the connotation of it being try even when not indicated) is so far from the truth. Tends to be the opposite sometimes. Doesn’t seem to have been the source in this one though.
Standard of care for grade IV splenic laceration is absolutely conservative care if stable, IR if not. Perhaps that was not the case historically but absolutely is now. Initial transfer should have been to somewhere with both trauma surgery and IR.
Have they done any RCTs comparing IR to splenectomy specifically in unstable patients? My understanding was that if grossly unstable, they should get a splenectomy, but maybe that is outdated now?
This patient wasn't stable but unfortunately for him wasn't grossly unstable either. It appears greater -than -usual-efforts were made to treat him by non-invasive methods, even when they weren't working. When a surgeon finally saw him, strong consideration for a minimal access approach occurred. Why? Was his physicians' judgement affected somehow by his relative celebrity as a MLB pitcher + desire to help him continue his career?
It is a travesty that suits like this still happen and despite poor evidence of malpractice there is still a pay out. I suppose we deserve our expensive healthcare.
I am not a radiologist but I read that pancreatic tail necrosis is a rare complication from splenic artery embolization (Talving P, Rauk M, Vipp L, Isand KG, Šamarin A, Põder K, Rätsep I, Saar S. Necrosis of the tail of pancreas following proximal splenic artery embolization. J Surg Case Rep. 2016 May 13;2016(5):rjw087. doi: 10.1093/jscr/rjw087. PMID: 27177891; PMCID: PMC4866485.)
So I’m surprised at how their expert could predict this event in advance.
Experts can predict a shocking amount of complications if they are properly incentivized and given a retrospectoscope.
I find it incredibly frustrating to witness the lack of accountability surrounding these issues. The arrogance and unethical behavior displayed by some so-called “experts” involved in malpractice lawsuits is disheartening. I’ve seen multiple Grade 4 splenic injuries treated successfully in healthy individuals using conservative management or embolectomy when necessary.
It’s important to recognize that even when we do everything right, we can still find ourselves in legal battles due to unfavorable outcomes. We, as physicians, can sometimes be our own worst enemies—whether it’s undermining a colleague in front of a patient or making disparaging remarks during depositions and trials.
Maybe we need to confront the reality that some of us may come across as arrogant or self-serving, often engaged in a continuous struggle with ourselves and our peers.
A recent example comes to mind: I transferred a critically ill pediatric patient to a specialized institution for further evaluation and care. A week later, I received a grievance from the mother, who said the physicians at the children’s hospital claimed her son didn’t need to be transferred and that my team didn’t know what we were doing. This kind of arrogance and malice is unacceptable.
Throughout my career, I’ve encountered numerous instances of suboptimal care, but I have never resorted to disparaging a colleague to a patient. Instead, I prefer to communicate directly with other physicians about any concerns, hoping they would do the same for me if I were in the wrong.
It’s time for us to foster a culture of collaboration and accountability in our profession.
If you're strong enough and tall enough doing the human-snow-plow thing (which is a fun macho thing to do no matter how easily you can afford a plowing service), you could conceivably double-over the shovel handle quite forcibly when the shovel suddenly hits a block of ice. Apparently being athletic enough to bust your own spleen goes along with being athletic enough to obscure a grade IV splenic lac - he hung out at home for a few days before even going to the ED. That athleticism and stoicism may actually have hurt him a bit in terms of obscuring how injured he really was. Also, if he wasn't a VIP, would IR have been the first choice, at least back then (2013)?
I have a very specific memory of pushing a snow shovel along the ground very quickly with the handle at stomach-level, then coming to a very abrupt stop when the shovel fell into a hidden crack in the concrete that was exactly parallel to the shovel. Didn't feel great.
I was just thinking the same.
When it happened to me I was just thankful it wasn't at groin level.
Obviously UNSTABLE with a WORSENING CLINICAL PICTURE including A DISTENDED ABDOMEN and 5 liters of BLOOD FOUND?????? His Hematocrit dropped from 39 to 21. That is NOT a stable patient. You must be kidding me. I like to sleep at night for sure. Despite what was said about the patient being "stable." the real story is pretty obvious. This patient was at high risk for DEATH. This patient needed a trip to the OR from the beginning and a blood blood transfusion. This would have avoided a lot of complications that were documented.
From https://bleacherreport.com/articles/1531947-doctors-carl-pavano-nearly-died-from-ruptured-spleen
“According to Christensen, Pavano did not slip and fall down. Rather, he partially lost his balance and fell onto the upright handle of the shovel he was using. As he is certainly much taller than the shovel, he likely jammed the shovel upward into the left side of his abdomen and under his left rib cage.”
Could this explain why the spleen so badly damaged? Mechanism looks plausible.
I really debated not publishing this because its super easy to Google the case. I actually had not considered what the author mentioned about a diaphragmatic rupture. The lawsuit records indicated he had a pleural effusion and then a thoracentesis but it didn't mention hemothorax or a chest tube. Seems like they would have mentioned that in the operative note?
HA! Vindication. I just read these details after I had submitted my Comment stating I believed it could happen, & posited essentially the same thing. I never heard of this guy, or how tall he is, but being tall makes it even more likely. Luckily I am 5'2" so my spleen safe.
Pro athletes are complete freaks of nature. I agree w/ the comments that his athleticism likely harmed him.
He's 6'5" per Google and I can only imagine what his version of shoveling snow looks like compared to the average person!
Skiing was likely prohibited in his MLB contract, especially since he's from the NE, which of course gives way to reporting a different mechanism of injury, so as to not lose millions ...guessing over here.