This poll tells me that 6% of you need to be stripped of your license to practice medicine. A freaking trial judge has more common sense than all of you. Gross negligence my a**. The other 19% need to review snakebite guidelines or stick to your lane (if not EM or Tox).
One of the joys of running online polls is that a tiny number of people will always purposefully click the wrong answer just to be obstinate. Either that or they had a seizure while reaching out to click the button.
It was obvious to me it was non negligent. Still, given the facts of the case, the non negligence was so obvious, that the presence of the other options made me doubt myself for a second
I re-read this case as we move into warm weather and walk into snake territory. This time I read the link to Dr. Dart's reply in your addendum. Dr. Dart, in 1996, wrote this pearl of wisdom: "Inadvertent, even if well-meaning, misuse of diagnostic tests is common in clinical medicine." 28 years later, we still run into the problem of research inclusion criteria and diagnostic definitions conflated as real-time clinical tools.
For years SIRS criteria was misconstrued as a clinical tool. To this day you can still find some hospitals’ public-facing clinical pathways with this embedded conceptual error. SIRS criteria was derived from patients already diagnosed with sepsis for the purpose of studying that population. When applied to undifferentiated patients with evolving symptoms, it performs poorly. In 2014, the authors of pediatric SIRS criteria addressed this conflation of their clinical trial enrollment criteria as a clinical tool (see citation below). In 2015, a well-powered study demonstrated the problem.
Goldstein B, Randolph AG. The authors reply. Pediatr Crit Care Med. 2014 Feb;15(2):183. doi: 10.1097/PCC.0000000000000025. PMID: 24492192.
Scott HF, Deakyne SJ, Woods JM, Bajaj L. The prevalence and diagnostic utility of systemic inflammatory response syndrome vital signs in a pediatric emergency department. Acad Emerg Med. 2015 Apr;22(4):381-9. doi: 10.1111/acem.12610. Epub 2015 Mar 16. PMID: 25778743.
This is not to say that SIRS criteria doesn't have a role - it can be integrated into screening processes. But I have seen it twisted by plaintiff attorneys. The biggest problem clinically, I feel, is that it can be a distractor leading up to too much work up for kids who have a robust adaptive response, and a distractor from kids who don't meet the criteria but are actually struggling. We now have Phoenix criteria, different plot but same theme in that the criteria can inform real-time assessment but are primarily for post-hoc analysis.
Other examples, but less intense, are anaphylaxis diagnostic criteria and Centor criteria. These require judgement when symptoms are early or evolving.
I’m very familiar with this case. The “expert” advertises himself as a “toxinologist;” he is not a toxicologist. The case is a great example of the benefits of the willful and wanton standard in Texas tort law, established in 2002. Additionally, Texas caps pain and suffering and other non-economic damages at $250,000.
This was definitely and obviously not a case of willful and wanton negligence. If you want to practice medicine in a physician-supportive environment with regard to tort law, come to Texas.
Gross negligence standard definitely has its benefits, although this physician had about 5 years of stress and sleepless nights before the case was finally resolved. But definitely better than risking 5 years of stress PLUS losing a big verdict in a state with less favorable tort law. As a side note, the Locked In Syndrome case I published was also in a gross negligence state, and the EM doc lost an 8 figure verdict. It'll probably get appealed, but even favorable tort law doesn't mean zero risk.
Decades ago in Kansas, I heard of a physician that was sued for giving anti venom that resulted in anaphylaxis and death. The snake that bit the patient turned out to not be a rattlesnake, but a copperhead.
Good analysis. Not in my realm but definitely reads as "looking for someone to blame for a less-than-ideal outcome" rather than negligence.
I think its especially cynical to argue "willful and wanton" negligence when the defendant was trying to follow a set of guidelines, i.e. clearly contemplating the appropriate approach to the case. "Willful/wanton negligence" to me is like, "demonstrably not giving a shit."
IMO if the expert has just said "you should have given it earlier based on this other algorithm" that would have been fine. There was a totally reasonable way to offer some criticism (although the criticism should be directed at the hospital for using an older algorithm, not the doc for following it). But saying that the doc acted with "conscious disregard" and that she showed "willful and wanton" negligence elevates it to the level of unprofessionalism and the defendant should probably submit him for censure from any professional organization of which he is a member.
The only potential wrinkle I can see in favor of the plaintiff is the flowchart does state that reassessment should occur every 30 mins and while it looks like maybe that happened with regard to the physical exam (I don't agree with the expert that it needs to be the doctor, would seem to me this kind of assessment is within a nurse's scope), it clearly didn't happen with regard to the coags unless you are only showing select draws. It's outside my lane to say whether that alone is negligence but that's the only thing that sticks out to me.
Yeah the plaintiffs did really make a stink about the doc's reassessment frequency in some of the court records. But I think it's reasonable to have a nurse do some of the reassessments too. Just like neuro checks for stroke patients. The doc documented reassessments at the beginning and again once her score was >5 but didn't document any others in between, which in my opinion is well within the standard of care if the nurse is also checking and the patient is equipped with a call light and told to keep an eye on it and to notify us if changing. I often do something similar with chest pain patients.... "if you're pain gets worse, your job is to push the nurse call light and let us know".
The lab reassessments are supposed to be every 2 hours (this was listed on a different page of the snakebite algorithm but I ran out of the room to include it in the email.... 1400 pages of records from this case!)
Also was no PTT ordered or is that how "undetectable" reports out at this hospital? I'm guessing not ordered because an undetectable PTT is a critical value anywhere and so I would also think that's a problem albeit I don't think it would have mattered since the PTT wouldn't have changed whether she crossed the threshold, just the degree to which her score jumped.
I'm fairly sure that means it just wasn't checked at the repeat labs. The medical records have a little legend that says it would be marked with a "!" if it was critical and an "L" if it was just normal low.
I'm very familiar with this case. I can sympathize with the young girl and her family as did the community where this happened. Watching the news story from a few years ago is tough. All we can do is speculate as to whether or not early Crofab would have prevented the progression of nerve damage and overall drop in quality of life she's experiencing today. But a bad outcome of a patient doesn't always mean negligence, especially willful and wanton negligence. I think the state Supreme Court got this one right.
By the way, I want to tell you Med Mal Reviewer that bullet two of your editor's note is one reason why I enjoy my subscription. The professionalism of these posts every week allows me to show these to students and it makes for really good topic discussions.
Thanks! Sometimes it's tempting to name names, but it's definitely more professional to leave names out and keeps the focus on the right things. I know sometimes the defendants read the cases and a few have told me its therapeutic to read the comments.
I enjoyed this case, and refreshed my knowledge by reading up on this.
I was concerned that the redacted document repeatedly shows a letter of the physician’s name. It would seem prudent to block the entire name. Malicious individuals might find the identity easier.
Last point, even where I practice in Ohio, when I encounter a snakebite on shift, I always reach out to the regional Poison Control Center, or at the least “call a friend “(a toxicologist). As I always taught my EM residents, “never go down with the ship alone”.
Thanks! Definitely agree with calling poison control!
All of the info is public record (including patient's medical records, name, address, DOB, etc...) so I'd be well within my right to leave the whole name exposed, but I don't like to do so for privacy reasons. I almost always leave first letter exposed because when there's multiple doctors its helps avoid confusion to talk about Dr. A, Dr. B, Dr. C, etc...
This is much like the patient that presents with a non disabling stroke that doesn't warrant tPA that develops just before 4.5 hours and you give---but now has bad outcome(if you believe in tPA at all....). Frequent checks may have made a difference, maybe not, sometimes bad things happen to good people. Final decision is the correct one.
Yes I kept thinking about the parallels with tPA in this case. These extremely time-sensitive drug decisions really provide a lot of fodder for plaintiffs attorneys.
Wow, I read the excepted expert opinion. It sounds like it's written by a bot. I wonder how much this toxicologist was paid to use awkward grammar, specious sentence construction and the passive voice. Also, was he ever reported to his board? Given that he does not put in his introduction anything regarding his credentials, is he actually boarded?
I unfortunately had to cut out a page and half at the beginning of his expert opinion (space constraints due to the size of the email) in which he describes his experience in great depth. He did a 4 year EM residency, EMS fellowship, and a wilderness medicine fellowship. He did not do a toxicology fellowship but does claim "toxinology" due to his special interest in envenomations.
If she had presented a half-hour later, she might have ended up getting Crofab faster, ironically. The doctor may have been biased by the initial appearance. The algorithm as shown doesn’t appear to have time since exposure.
Yeah very real chance. The biggest difference between the SSS algorithm and the "unified" algorithm the expert cites is that the "unified" algorithm says to give Crofab if there's any worsening of symptoms after ED arrival. In the SSS algorithm they can worsen but still not rise above a 3.
This poll tells me that 6% of you need to be stripped of your license to practice medicine. A freaking trial judge has more common sense than all of you. Gross negligence my a**. The other 19% need to review snakebite guidelines or stick to your lane (if not EM or Tox).
One of the joys of running online polls is that a tiny number of people will always purposefully click the wrong answer just to be obstinate. Either that or they had a seizure while reaching out to click the button.
It was obvious to me it was non negligent. Still, given the facts of the case, the non negligence was so obvious, that the presence of the other options made me doubt myself for a second
I re-read this case as we move into warm weather and walk into snake territory. This time I read the link to Dr. Dart's reply in your addendum. Dr. Dart, in 1996, wrote this pearl of wisdom: "Inadvertent, even if well-meaning, misuse of diagnostic tests is common in clinical medicine." 28 years later, we still run into the problem of research inclusion criteria and diagnostic definitions conflated as real-time clinical tools.
What's another good example?
SIRS criteria!
For years SIRS criteria was misconstrued as a clinical tool. To this day you can still find some hospitals’ public-facing clinical pathways with this embedded conceptual error. SIRS criteria was derived from patients already diagnosed with sepsis for the purpose of studying that population. When applied to undifferentiated patients with evolving symptoms, it performs poorly. In 2014, the authors of pediatric SIRS criteria addressed this conflation of their clinical trial enrollment criteria as a clinical tool (see citation below). In 2015, a well-powered study demonstrated the problem.
Goldstein B, Randolph AG. The authors reply. Pediatr Crit Care Med. 2014 Feb;15(2):183. doi: 10.1097/PCC.0000000000000025. PMID: 24492192.
Scott HF, Deakyne SJ, Woods JM, Bajaj L. The prevalence and diagnostic utility of systemic inflammatory response syndrome vital signs in a pediatric emergency department. Acad Emerg Med. 2015 Apr;22(4):381-9. doi: 10.1111/acem.12610. Epub 2015 Mar 16. PMID: 25778743.
This is not to say that SIRS criteria doesn't have a role - it can be integrated into screening processes. But I have seen it twisted by plaintiff attorneys. The biggest problem clinically, I feel, is that it can be a distractor leading up to too much work up for kids who have a robust adaptive response, and a distractor from kids who don't meet the criteria but are actually struggling. We now have Phoenix criteria, different plot but same theme in that the criteria can inform real-time assessment but are primarily for post-hoc analysis.
Other examples, but less intense, are anaphylaxis diagnostic criteria and Centor criteria. These require judgement when symptoms are early or evolving.
Great examples! I've seen SIRS mentioned by experts under very dubious circumstances before...
I’m very familiar with this case. The “expert” advertises himself as a “toxinologist;” he is not a toxicologist. The case is a great example of the benefits of the willful and wanton standard in Texas tort law, established in 2002. Additionally, Texas caps pain and suffering and other non-economic damages at $250,000.
This was definitely and obviously not a case of willful and wanton negligence. If you want to practice medicine in a physician-supportive environment with regard to tort law, come to Texas.
Gross negligence standard definitely has its benefits, although this physician had about 5 years of stress and sleepless nights before the case was finally resolved. But definitely better than risking 5 years of stress PLUS losing a big verdict in a state with less favorable tort law. As a side note, the Locked In Syndrome case I published was also in a gross negligence state, and the EM doc lost an 8 figure verdict. It'll probably get appealed, but even favorable tort law doesn't mean zero risk.
Oh and I also thought the "toxinologist" thing was funny too
Decades ago in Kansas, I heard of a physician that was sued for giving anti venom that resulted in anaphylaxis and death. The snake that bit the patient turned out to not be a rattlesnake, but a copperhead.
Crazy... if you find the case or any articles about it, I'd love to read them!
Good analysis. Not in my realm but definitely reads as "looking for someone to blame for a less-than-ideal outcome" rather than negligence.
I think its especially cynical to argue "willful and wanton" negligence when the defendant was trying to follow a set of guidelines, i.e. clearly contemplating the appropriate approach to the case. "Willful/wanton negligence" to me is like, "demonstrably not giving a shit."
IMO if the expert has just said "you should have given it earlier based on this other algorithm" that would have been fine. There was a totally reasonable way to offer some criticism (although the criticism should be directed at the hospital for using an older algorithm, not the doc for following it). But saying that the doc acted with "conscious disregard" and that she showed "willful and wanton" negligence elevates it to the level of unprofessionalism and the defendant should probably submit him for censure from any professional organization of which he is a member.
The only potential wrinkle I can see in favor of the plaintiff is the flowchart does state that reassessment should occur every 30 mins and while it looks like maybe that happened with regard to the physical exam (I don't agree with the expert that it needs to be the doctor, would seem to me this kind of assessment is within a nurse's scope), it clearly didn't happen with regard to the coags unless you are only showing select draws. It's outside my lane to say whether that alone is negligence but that's the only thing that sticks out to me.
Yeah the plaintiffs did really make a stink about the doc's reassessment frequency in some of the court records. But I think it's reasonable to have a nurse do some of the reassessments too. Just like neuro checks for stroke patients. The doc documented reassessments at the beginning and again once her score was >5 but didn't document any others in between, which in my opinion is well within the standard of care if the nurse is also checking and the patient is equipped with a call light and told to keep an eye on it and to notify us if changing. I often do something similar with chest pain patients.... "if you're pain gets worse, your job is to push the nurse call light and let us know".
The lab reassessments are supposed to be every 2 hours (this was listed on a different page of the snakebite algorithm but I ran out of the room to include it in the email.... 1400 pages of records from this case!)
Oh, in that case I can’t find anything this doc did wrong
Also was no PTT ordered or is that how "undetectable" reports out at this hospital? I'm guessing not ordered because an undetectable PTT is a critical value anywhere and so I would also think that's a problem albeit I don't think it would have mattered since the PTT wouldn't have changed whether she crossed the threshold, just the degree to which her score jumped.
I'm fairly sure that means it just wasn't checked at the repeat labs. The medical records have a little legend that says it would be marked with a "!" if it was critical and an "L" if it was just normal low.
I figured as much. I was digging for anything in favor of the plantiff
I'm very familiar with this case. I can sympathize with the young girl and her family as did the community where this happened. Watching the news story from a few years ago is tough. All we can do is speculate as to whether or not early Crofab would have prevented the progression of nerve damage and overall drop in quality of life she's experiencing today. But a bad outcome of a patient doesn't always mean negligence, especially willful and wanton negligence. I think the state Supreme Court got this one right.
By the way, I want to tell you Med Mal Reviewer that bullet two of your editor's note is one reason why I enjoy my subscription. The professionalism of these posts every week allows me to show these to students and it makes for really good topic discussions.
Thanks! Sometimes it's tempting to name names, but it's definitely more professional to leave names out and keeps the focus on the right things. I know sometimes the defendants read the cases and a few have told me its therapeutic to read the comments.
I enjoyed this case, and refreshed my knowledge by reading up on this.
I was concerned that the redacted document repeatedly shows a letter of the physician’s name. It would seem prudent to block the entire name. Malicious individuals might find the identity easier.
Last point, even where I practice in Ohio, when I encounter a snakebite on shift, I always reach out to the regional Poison Control Center, or at the least “call a friend “(a toxicologist). As I always taught my EM residents, “never go down with the ship alone”.
I love the cases. Keep them coming!
Thanks! Definitely agree with calling poison control!
All of the info is public record (including patient's medical records, name, address, DOB, etc...) so I'd be well within my right to leave the whole name exposed, but I don't like to do so for privacy reasons. I almost always leave first letter exposed because when there's multiple doctors its helps avoid confusion to talk about Dr. A, Dr. B, Dr. C, etc...
This is much like the patient that presents with a non disabling stroke that doesn't warrant tPA that develops just before 4.5 hours and you give---but now has bad outcome(if you believe in tPA at all....). Frequent checks may have made a difference, maybe not, sometimes bad things happen to good people. Final decision is the correct one.
Yes I kept thinking about the parallels with tPA in this case. These extremely time-sensitive drug decisions really provide a lot of fodder for plaintiffs attorneys.
Dr B. A. should be referred to ACEP and AAEM for his outrageous testimony.
Wow, I read the excepted expert opinion. It sounds like it's written by a bot. I wonder how much this toxicologist was paid to use awkward grammar, specious sentence construction and the passive voice. Also, was he ever reported to his board? Given that he does not put in his introduction anything regarding his credentials, is he actually boarded?
I unfortunately had to cut out a page and half at the beginning of his expert opinion (space constraints due to the size of the email) in which he describes his experience in great depth. He did a 4 year EM residency, EMS fellowship, and a wilderness medicine fellowship. He did not do a toxicology fellowship but does claim "toxinology" due to his special interest in envenomations.
I also noticed the expert referenced a book/article from 2019 when the incident happened in 2018
Ah good eye, I hadn't seen that
He also cited his own article.
If she had presented a half-hour later, she might have ended up getting Crofab faster, ironically. The doctor may have been biased by the initial appearance. The algorithm as shown doesn’t appear to have time since exposure.
Yeah very real chance. The biggest difference between the SSS algorithm and the "unified" algorithm the expert cites is that the "unified" algorithm says to give Crofab if there's any worsening of symptoms after ED arrival. In the SSS algorithm they can worsen but still not rise above a 3.