The more I read these cases, the more I realize that I can't help but be biased toward the defendants. I can imagine what was going through the ED attending's mind.
I wonder if simple documentation stating that the patient was told to avoid aspirin, take a PPI and follow up with GI would have been enough to save this attending from a lawsuit, regardless of whether or not the duodenum perforates.
I have issues with this expert witness testimony. 1. The workup for either pancreatitis or biliary tract disease is unlikely to have included an inpatient EGD unless choledocholithiasis was suspected. Sure. An ultrasound is a better test for biliary disease, but it would not have revealed the duodenal ulcer and is therefore utterly irrelevant. To suggest that diagnosis and treatment of a totally seperate pathology may have incidentally prevented this outcome? Very weak. 2. We all learned in med school the classic association between duodenal ulcers and Helicobacter pylori. Certainly, the aspirin didn't help the situation, but can we say that the aspirin was solely responsible? No. 3. The testament that all hospitalized patients receive a PPI is way too broad. I would agree that this patient would likely receive a PPI based on her chief complaint, but the nuance matters here. Giving every patient a PPI regardless of complaint is a bad medical practice and specificity is important in these cases where you are bring interviewed as a purported expert. It makes me question if he should be testifying on what hospitalists would/would not do.
One of the pearls I received from the wizened ER docs as an intern is that you can discharge a chief complaint without a solid diagnosis once, but the second visit, you need to admit. It seemed defensive to me as a baby doc, but over time, I see the wisdom. At a bare minimum, for its CYA value.
I agree its a pretty weak expert opinion. A big stretch to say that they should have worked up the patient for the wrong thing. Also got some emails basically saying the same thing about the PPI issue. Not everyone needs or gets them!
My ED has a unspoken rule, a second visit to ED within a week for similar complaint warrants admission, no matter how severe or how well patient appeared to be, because apparently it did not work the first time in ED
I agree with the general sentiment of that, although not quite to the absolute level. Majority of the time I'm definitely upping the workup and really starting to consider the most bizarre and strange diagnosis that could be causing their symptoms.
What is the reasoning behind the decreased reliability of pain localization in older patients? Apologies if that's a dumb question, I'm still pre-clinical and haven't heard about this rule yet.
I'm going to be honest and say I havent seen a good explanation for *why* the pain doesnt localize well in the elderly. I'd guess bc of changes related to the nervous system innervating the abdomen but that is very much a guess.
Ive noticed this to be true many times in any age with abdominal pain.....
cant begin to tell you how many times classic postprandial right upper quadrant abdominal pain with no pain at mcburneys point ended up being an appy after obs and re-eval.....
The more I read these cases, the more I realize that I can't help but be biased toward the defendants. I can imagine what was going through the ED attending's mind.
I wonder if simple documentation stating that the patient was told to avoid aspirin, take a PPI and follow up with GI would have been enough to save this attending from a lawsuit, regardless of whether or not the duodenum perforates.
Hard to know if it would have stopped a lawsuit, but definitely could have helped the defense.
I'm a pharmacist and this case is making me pull my hair out!
I have issues with this expert witness testimony. 1. The workup for either pancreatitis or biliary tract disease is unlikely to have included an inpatient EGD unless choledocholithiasis was suspected. Sure. An ultrasound is a better test for biliary disease, but it would not have revealed the duodenal ulcer and is therefore utterly irrelevant. To suggest that diagnosis and treatment of a totally seperate pathology may have incidentally prevented this outcome? Very weak. 2. We all learned in med school the classic association between duodenal ulcers and Helicobacter pylori. Certainly, the aspirin didn't help the situation, but can we say that the aspirin was solely responsible? No. 3. The testament that all hospitalized patients receive a PPI is way too broad. I would agree that this patient would likely receive a PPI based on her chief complaint, but the nuance matters here. Giving every patient a PPI regardless of complaint is a bad medical practice and specificity is important in these cases where you are bring interviewed as a purported expert. It makes me question if he should be testifying on what hospitalists would/would not do.
One of the pearls I received from the wizened ER docs as an intern is that you can discharge a chief complaint without a solid diagnosis once, but the second visit, you need to admit. It seemed defensive to me as a baby doc, but over time, I see the wisdom. At a bare minimum, for its CYA value.
I agree its a pretty weak expert opinion. A big stretch to say that they should have worked up the patient for the wrong thing. Also got some emails basically saying the same thing about the PPI issue. Not everyone needs or gets them!
Agree with you that a patient that comes back is a different patient than the first time.
My ED has a unspoken rule, a second visit to ED within a week for similar complaint warrants admission, no matter how severe or how well patient appeared to be, because apparently it did not work the first time in ED
I agree with the general sentiment of that, although not quite to the absolute level. Majority of the time I'm definitely upping the workup and really starting to consider the most bizarre and strange diagnosis that could be causing their symptoms.
my rule of thumb on bouncebacks
ALLWAYS order one more test than the last guy
ALLWAYS have the supervising physician consult and review the workup prior to discharge.
What is the reasoning behind the decreased reliability of pain localization in older patients? Apologies if that's a dumb question, I'm still pre-clinical and haven't heard about this rule yet.
Looks like the reason is age-related "peritoneal denervation". At least, thats the consensus opinion.
I'm going to be honest and say I havent seen a good explanation for *why* the pain doesnt localize well in the elderly. I'd guess bc of changes related to the nervous system innervating the abdomen but that is very much a guess.
Ive noticed this to be true many times in any age with abdominal pain.....
cant begin to tell you how many times classic postprandial right upper quadrant abdominal pain with no pain at mcburneys point ended up being an appy after obs and re-eval.....