This crap needs to be submitted to ABEM for censure. The only way to get them out of the game is to make it where no attorney can use them as an expert.
There's no legal reason. The main risk I'm worried about is that I'll get dragged into legal action and accused of defaming someone, which could result in the entire newsletter getting shut down. I generally offer to help the defending physician make a report or submit for censure, so things are often being handled behind the scenes.
It would have been interesting if the defibrillation outcome would have succeeded if the new guidelines recently adopted by New Zealand, i.e., the double shock technique using first the pads in the usual position followed by a shock through a second set of pads with one on the back, were used.
It is not clear for how long he was in cardiac arrest on the third arrest. It is not even clear if the patient was bag valve ventilated during all this resuscitation effort . ACLS protocol always emphasize that intubation is not any better than non invasive ventilation , since he was already sedated and paralyzed i asume he was Ambu bag ventilated all the time. We don’t know much about the placement quality of the I gel ( laryngeal mask). It is common to see some degree of anoxic brain injury after three cardiac arrest. We don’t know how bad was his anoxic brain injury we can only asume that it was severe enough when family decided to withdraw and de escalate care.
sorry med mal reviewer - I disagree about whether the failed intubation caused the injury. Neither the recoverable LV dysfunction nor having an IABP placed would cause irreversible anoxic encephalopathy. There was clearly an issue resulting from either prolonged v-fib arrest or inability to intubate the patient - we would need more information on the code to adjudicate whether the arrhythmia was responsible or primary anoxia.
I do have an issue with criticizing the use of paralytics - this is clearly indicated here - but the EM physician had no plan for a backup airway. An LMA as inserted by EMS providers or a cricothyroidotomy would have been life saving here.
Thanks for the dissent! I always appreciate good criticism. IMO there is enough doubt about the exact cause that the physician shouldn't be held responsible.
So your contention is that cardiogenic shock cannot lead to anoxic brain injury? 🤨
Cerebral oxygen delivery is dependent both on blood oxygen content (PaO2/SpO2) AND cerebral perfusion. Guy was on IABP + (what sounds like) vasoactive agents after his cath.
Plus, he arrested once (or twice? The "expert" testimonies seem to differ on that fact) on top of the initial 2 VF arrests, for an indeterminate period of time. Seems to me the "well, the heart turned out just fine so he should have been okay" argument alights over the fact that the cerebral hemispheres are much more fragile birds (in terms of tolerating oxygen supply/demand mismatch) compared to the myocardium.
It is not clear for how long he was in cardiac arrest on the third arrest. It is not even clear if the patient was bag valve ventilated during all this resuscitation effort . ACLS protocol always emphasize that intubation is not any better than non invasive ventilation , since he was already sedated and paralyzed i asume he was Ambu bag ventilated all the time. We don’t know much about the placement quality of the I gel ( laryngeal mask). It is common to see some degree of anoxic brain injury after three cardiac arrest. We don’t know how bad was his anoxic brain injury we can only asume that it was severe enough when family decided to withdraw and de escalate care.
Dios Mio, I was reading the expert witnesses statements and my jaw just dropped... Then I read your comment and finally I can breathe again! Thank you for your (to my opinion) great assesment!
Btw to sue a doctor like this in Germany, you have to prove that the patient would have had a better outcome, if Intubation was without complication. Which would be impossible.
Wish it was like that here! It should be the same in the US, but there's always a few crackpot doctors who are willing to write any ridiculous opinion for cash.
The defense attorney should start the expert cross-examination by showing him the written guidelines and policy, then the next question have you ever had a difficult intubation? And the continue to
Destroy the dude until he decides that it is easier to sell Girl Scout cookies for an extra dollar.
Unfortunately their
board certification and licensing can't be challenged ( only during Covid😂)
This is one of the rare cases in which the expert is an ACEP member so there's actually a pathway to censure them. Usually they drop their ACEP membership so they cant be censured.
While the opinion and reasoning from the plaintiff's experts is clearly flawed, I wish we had more information about how many times intubation was attempted and if the patient was successfully oxygenated via BVM between attempts. The argument that "paralyzing a patient and being unable to intubate" should never happen is just not realistic because it certainly does occur in difficult airways. Failed tracheal intubation in itself is not life threatening, as far as ventilation via BVM is adequate. In this kind of event, it's important to remember the goals of failed airway management.
A failed airway occurs after 3 unsuccessful intubation attempts. During each attempt, something should be changed from previous failure to improve the chances of intubation and a backup plan should be ready. I don't understand why the ER physician did not place a LMA after the previous failures. The case states the LMA was placed by EMS when they arrived. If for some reason a LMA could not be placed, a cricothyrotomy should have been performed.
If the documentation shows that the patient was being successfully ventilated by BVM, it's a moot point. Clearly a patient who has multiple cardiac arrests will suffer a degree of anoxic injury even with an airway. I'm glad the defense has strong experts and hopefully there is additional information in the charting about BVM oxygenation and VS during the event.
Its unclear to me if the physician documented any details about the airway attempts or if there was just a very cursory note. That documentation could have really helped him in this lawsuit if he clearly laid out the process of his failed attempts and if he was bagging the patient or if he was getting any pulse ox readings. Thanks for the comment, if they disclose the medical records I'll definitely publish them!
I agree 100% - if he/she documented successful oxygenation via BVM that would have gone a long way. I’’d be surprised if the ER physician didn’t write a more detailed note considering the complexity of the event and the fact there was a “failed airway” situation.
This is a discouraging lawsuit. Anytime an ER doc decides to take an airway, there is the risk you may not be able to intubate successfully. Any competent ER doc could find their self in this exact same scenario. It is disheartening that the plaintiffs blame the ER doc for his death and not the massive heart attack. Anyone else suspicious that the patient's family heard something along the line of "Mr. X would have been alive if the intubation went better" from a cardiologist or a CICU nurse?
Crazy to blame the ER doc for the bad outcome. But if ya miss a tube, you put the LMA in. Then you probably could bogie through the LMA tbh. Don’t hand a failed airway over the EMS. That just looks bad doesn’t it. Some devastated family looking for someone to blame will get you.
This is a hideously egregious expert testimony and needs to be submitted for censure. This won't stop until us, as a collective of reasonable physicians, put our foot down and turn in money thirsty immoral colleagues.
It’s just so weird that the EM doctor is getting sued in this case, felt like he did everything he could and everything he should have done , one can maybe he should have put in a crico but if there’s record of the saturation with the LMA, i think he could be okay
There's been no legal activity for over 8 months now! Its kind of odd to go that long with no activity, I wonder if they settled it and are just neglecting to tell the court. If thats the case eventually the judge will declare it over and I'll update the post.
Agree with the comments. Unbelievable. Has ACEP actually wielded that censure stick? (I know it is out there...but is it ever used?). And is there a public record/database of that censure?
What strikes me even more, is there is a Plaintiff lawyer who is comfortable with this person being an expert witness.
Yes, Peter Rosen was censured. I bet there others too but have not bothered to investigate. The plaintiffs lawyer does not care for the truth at all, they simply want to get paid.
This crap needs to be submitted to ABEM for censure. The only way to get them out of the game is to make it where no attorney can use them as an expert.
This is definitely top 3 worst EM opinions I've read. Seriously considering it. Completely egregious IMO. Can ABEM censure or just ACEP?
Not sure. ACEP certainly can assuming they are a member.
This expert claims FACEP so I bet they can be.
Is there any reason that you couldn't include the names of these expert witnesses on these blog posts?
There's no legal reason. The main risk I'm worried about is that I'll get dragged into legal action and accused of defaming someone, which could result in the entire newsletter getting shut down. I generally offer to help the defending physician make a report or submit for censure, so things are often being handled behind the scenes.
Right, makes sense.
Where do you get this case information? Is it LexisNexis? Is there any other way to get these case histories other than that?
These physician experts selling their opinions seem like real jerks.
They are either incompetent or wildly unethical.
It would have been interesting if the defibrillation outcome would have succeeded if the new guidelines recently adopted by New Zealand, i.e., the double shock technique using first the pads in the usual position followed by a shock through a second set of pads with one on the back, were used.
Agreed, I know some people here in the US do it but not commonly.
It is not clear for how long he was in cardiac arrest on the third arrest. It is not even clear if the patient was bag valve ventilated during all this resuscitation effort . ACLS protocol always emphasize that intubation is not any better than non invasive ventilation , since he was already sedated and paralyzed i asume he was Ambu bag ventilated all the time. We don’t know much about the placement quality of the I gel ( laryngeal mask). It is common to see some degree of anoxic brain injury after three cardiac arrest. We don’t know how bad was his anoxic brain injury we can only asume that it was severe enough when family decided to withdraw and de escalate care.
sorry med mal reviewer - I disagree about whether the failed intubation caused the injury. Neither the recoverable LV dysfunction nor having an IABP placed would cause irreversible anoxic encephalopathy. There was clearly an issue resulting from either prolonged v-fib arrest or inability to intubate the patient - we would need more information on the code to adjudicate whether the arrhythmia was responsible or primary anoxia.
I do have an issue with criticizing the use of paralytics - this is clearly indicated here - but the EM physician had no plan for a backup airway. An LMA as inserted by EMS providers or a cricothyroidotomy would have been life saving here.
Thanks for the dissent! I always appreciate good criticism. IMO there is enough doubt about the exact cause that the physician shouldn't be held responsible.
So your contention is that cardiogenic shock cannot lead to anoxic brain injury? 🤨
Cerebral oxygen delivery is dependent both on blood oxygen content (PaO2/SpO2) AND cerebral perfusion. Guy was on IABP + (what sounds like) vasoactive agents after his cath.
Plus, he arrested once (or twice? The "expert" testimonies seem to differ on that fact) on top of the initial 2 VF arrests, for an indeterminate period of time. Seems to me the "well, the heart turned out just fine so he should have been okay" argument alights over the fact that the cerebral hemispheres are much more fragile birds (in terms of tolerating oxygen supply/demand mismatch) compared to the myocardium.
It is not clear for how long he was in cardiac arrest on the third arrest. It is not even clear if the patient was bag valve ventilated during all this resuscitation effort . ACLS protocol always emphasize that intubation is not any better than non invasive ventilation , since he was already sedated and paralyzed i asume he was Ambu bag ventilated all the time. We don’t know much about the placement quality of the I gel ( laryngeal mask). It is common to see some degree of anoxic brain injury after three cardiac arrest. We don’t know how bad was his anoxic brain injury we can only asume that it was severe enough when family decided to withdraw and de escalate care.
Did they document oxygenation/ventilation between intubation attempts?
No. Unclear if there was no waveform for the oxygen, keep in mind its a FSED with one doc and maybe only 1-2 nurses so they're scrambling.
Dios Mio, I was reading the expert witnesses statements and my jaw just dropped... Then I read your comment and finally I can breathe again! Thank you for your (to my opinion) great assesment!
Btw to sue a doctor like this in Germany, you have to prove that the patient would have had a better outcome, if Intubation was without complication. Which would be impossible.
Wish it was like that here! It should be the same in the US, but there's always a few crackpot doctors who are willing to write any ridiculous opinion for cash.
This ED physician can and should be turned to the college (ACEP ethics committee), where their egregious “expert“ opinion given under oath from
The case chart reviews are scrutinized but underused. He clearly violated this Policy with an off-the-wall Negligence and Causation;
https://www.acep.org/patient-care/policy-statements/expert-witness-guidelines-for-the-specialty-of-emergency-m edicine.
The defense attorney should start the expert cross-examination by showing him the written guidelines and policy, then the next question have you ever had a difficult intubation? And the continue to
Destroy the dude until he decides that it is easier to sell Girl Scout cookies for an extra dollar.
Unfortunately their
board certification and licensing can't be challenged ( only during Covid😂)
This is one of the rare cases in which the expert is an ACEP member so there's actually a pathway to censure them. Usually they drop their ACEP membership so they cant be censured.
While the opinion and reasoning from the plaintiff's experts is clearly flawed, I wish we had more information about how many times intubation was attempted and if the patient was successfully oxygenated via BVM between attempts. The argument that "paralyzing a patient and being unable to intubate" should never happen is just not realistic because it certainly does occur in difficult airways. Failed tracheal intubation in itself is not life threatening, as far as ventilation via BVM is adequate. In this kind of event, it's important to remember the goals of failed airway management.
A failed airway occurs after 3 unsuccessful intubation attempts. During each attempt, something should be changed from previous failure to improve the chances of intubation and a backup plan should be ready. I don't understand why the ER physician did not place a LMA after the previous failures. The case states the LMA was placed by EMS when they arrived. If for some reason a LMA could not be placed, a cricothyrotomy should have been performed.
If the documentation shows that the patient was being successfully ventilated by BVM, it's a moot point. Clearly a patient who has multiple cardiac arrests will suffer a degree of anoxic injury even with an airway. I'm glad the defense has strong experts and hopefully there is additional information in the charting about BVM oxygenation and VS during the event.
Its unclear to me if the physician documented any details about the airway attempts or if there was just a very cursory note. That documentation could have really helped him in this lawsuit if he clearly laid out the process of his failed attempts and if he was bagging the patient or if he was getting any pulse ox readings. Thanks for the comment, if they disclose the medical records I'll definitely publish them!
I agree 100% - if he/she documented successful oxygenation via BVM that would have gone a long way. I’’d be surprised if the ER physician didn’t write a more detailed note considering the complexity of the event and the fact there was a “failed airway” situation.
This is a discouraging lawsuit. Anytime an ER doc decides to take an airway, there is the risk you may not be able to intubate successfully. Any competent ER doc could find their self in this exact same scenario. It is disheartening that the plaintiffs blame the ER doc for his death and not the massive heart attack. Anyone else suspicious that the patient's family heard something along the line of "Mr. X would have been alive if the intubation went better" from a cardiologist or a CICU nurse?
Very, very common that the idea for a lawsuit comes from another clinician planting the idea in the family's head.
Crazy to blame the ER doc for the bad outcome. But if ya miss a tube, you put the LMA in. Then you probably could bogie through the LMA tbh. Don’t hand a failed airway over the EMS. That just looks bad doesn’t it. Some devastated family looking for someone to blame will get you.
This is a hideously egregious expert testimony and needs to be submitted for censure. This won't stop until us, as a collective of reasonable physicians, put our foot down and turn in money thirsty immoral colleagues.
I'm a bit afraid its a game of whack a mole. You can censure one bad expert but a dozen more will pop up in their place.
Is there any update regarding the case?
It’s just so weird that the EM doctor is getting sued in this case, felt like he did everything he could and everything he should have done , one can maybe he should have put in a crico but if there’s record of the saturation with the LMA, i think he could be okay
There's been no legal activity for over 8 months now! Its kind of odd to go that long with no activity, I wonder if they settled it and are just neglecting to tell the court. If thats the case eventually the judge will declare it over and I'll update the post.
How about now?
It settled! I'll get the case updated soon. Looks like they reached one big settlement with all defendants at once. Terms are confidential.
Agree with the comments. Unbelievable. Has ACEP actually wielded that censure stick? (I know it is out there...but is it ever used?). And is there a public record/database of that censure?
What strikes me even more, is there is a Plaintiff lawyer who is comfortable with this person being an expert witness.
Yes, Peter Rosen was censured. I bet there others too but have not bothered to investigate. The plaintiffs lawyer does not care for the truth at all, they simply want to get paid.
Not sure how I had missed that bit o news. (I should read more lol..). Thanks. Some interesting comments across the web...
https://journals.lww.com/em-news/Fulltext/2017/04000/News__Rosen,_Censured_by_ACEP,_Disputes_Claims_as.1.aspx