The ED doctor actually called the urologist to make sure he’d be able to make an appointment. I agree with your point that patients need to take some responsibility in managing their own care. In terms of the CTA- these are routinely ordered in patients with suspected stroke and known kidney disease. In stroke alerts- we don’t even wait for creatinine to come back in most cases.
Agree, kidney function never even comes to mind when its a stroke activation. Straight to radiology and push the contrast. My bigger fear is contrast allergy causing anaphylaxis.
In regards to CT-A in setting of renal disease, i usually have a conversation with the pt and family and discuss risks of ESRD, and permanent dialysis as possiblities. It's rare but so is a stroke after stopping coumadin for a few days. That said, i really hate how doctors are held for bad outcomes, which we have absolutely no control over, unless we flippantly treat outside the standard of care. In this case, the ER doctor did what all other doctors would of done.
I agree with your point on the ED plaintiff expert opinion being willfully dishonest in his testimony. Surprising he's teaching faculty at some mountain west program. The board needs to penalize these people.
100%, CTA in the ED at the time of the stroke presentation might have changed management. If thrombus was noted in the Basilar artery at that time, he may have been a candidate for thrombectomy.
It may not have been there given his symptoms and the fact that the MRI only showed that one initial infarct but renal dysfunction is not a valid reason not to obtain a contrast study in that setting anymore.
Can we please start naming and shaming these unethical "expert" witnesses. It's insane what they can get away with, with absolutely no recourse. The damage they cause to their peers, the patients and families they supposedly to be helping (by setting unhinged expectations and casting unjust blame), and the medical community is massive. If medical societies, boards, and academic institutions won't hold them responsible for their words/lies, then I think we as individual physicians should have the ability to tell them how this harms us all. I honestly don't know how they sleep at night. If the Expert Witness doesn't feel comfortable publishing this information (I don't blame them), perhaps they could at least give us the county/case info that's publicly available so we can do this research ourselves. If there was a known database that called your expert statements into question (maybe with direct quotes and responses/reasoning/citations that explain why), I think it would go a long way in pairing down these all too common sham experts.
I want to do it but I also don't want to deal with the blowback from it, possible defamation lawsuits, etc... FWIW I always offer to help file ethics complaints. This guy was FACEP but is retired now.
I read this case and it seemed like a very routine case in regards to decision-making that happens all the time. If someone's bleeding on anticoagulation, stop the anticoagulation (happens all the time) but the fact that someone had a stroke afterwards doesn't mean that the decision to stop anticoagulation was the wrong decision. It means a very unfortunate thing happened. Our neurologists tell patients all the time, anticoagulation doesn't eliminate stroke risk, it only LOWERS it, so when someone has a stroke on eliquis, it doesn't mean that the provider was wrong to put them on eliquis.
Totally agree. An excellent point in regards to counseling patients that anticoagulation only lowers risk. Sadly, "unfortunate thing happened" = lawsuit.
I'm wondering why he had a stroke when he did (and agree it wasn't afib). If he had a UTI, maybe he had some systemic inflammation exacerbating his diseased endothelium, making his narrow vertebral and basilar arteries even narrower. Or maybe he got dehydrated, compromising his already compromised cerebral circulation. Hard to know of course, but interesting.
What angers me about this is I could easily see the plaintiff's "expert" coming across as at least superficially convincing to a lay jury.
Thankfully, the defense assembled a superb defense here. I like the defense ED physician highlighting the Sophie's choice of risking a stroke versus massive hemorrhage, and the neurologist neutered the causation argument.
I worry constantly about this problem. Every thing we do is a risk - if we don’t do it there’s a risk. Lawyers don’t seem to understand that.
I don’t understand the logic behind the defense saying - the stroke was probably not related to stopping the Coumadin. Doesn’t that imply that if the cva were related to stopping the Coumadin, you would then admit your guilt?
Regarding the patient being non-compliant. Louisiana , along with 12 other states (Alaska, Arizona, California, Florida, Kentucky, Mississippi, Missouri, New Mexico, New York, Rhode Island, South Dakota, and Washington) recognizes the doctrine of pure comparative fault. Under the doctrine of pure comparative fault, any award of damages awarded from a court are reduced in proportion to the patient’s contribution to their own injury. This doctrine is extremely friendly to patients in that they can recover for damages even if they are found to have been 99% at fault.
I really enjoy reading the experts' reports in these cases. In this case, it appears that the first report (plaintiff) was written primarily by a lawyer, and the doctor essentially just signed off on it. The other two reports were written by the doctors themselves. Jurors would figure that out too - who would trust a doctor who communicates the way that first report was written? Most of the sentences begin with "I", and the content is very 'ad hominem' attacking another doctor.
The ED doctor actually called the urologist to make sure he’d be able to make an appointment. I agree with your point that patients need to take some responsibility in managing their own care. In terms of the CTA- these are routinely ordered in patients with suspected stroke and known kidney disease. In stroke alerts- we don’t even wait for creatinine to come back in most cases.
Agree, kidney function never even comes to mind when its a stroke activation. Straight to radiology and push the contrast. My bigger fear is contrast allergy causing anaphylaxis.
That ed doctor went above and beyond
In regards to CT-A in setting of renal disease, i usually have a conversation with the pt and family and discuss risks of ESRD, and permanent dialysis as possiblities. It's rare but so is a stroke after stopping coumadin for a few days. That said, i really hate how doctors are held for bad outcomes, which we have absolutely no control over, unless we flippantly treat outside the standard of care. In this case, the ER doctor did what all other doctors would of done.
I agree with your point on the ED plaintiff expert opinion being willfully dishonest in his testimony. Surprising he's teaching faculty at some mountain west program. The board needs to penalize these people.
100%, CTA in the ED at the time of the stroke presentation might have changed management. If thrombus was noted in the Basilar artery at that time, he may have been a candidate for thrombectomy.
It may not have been there given his symptoms and the fact that the MRI only showed that one initial infarct but renal dysfunction is not a valid reason not to obtain a contrast study in that setting anymore.
I agree I think a CTA was definitely warranted and may* have changed outcomes.
Can we please start naming and shaming these unethical "expert" witnesses. It's insane what they can get away with, with absolutely no recourse. The damage they cause to their peers, the patients and families they supposedly to be helping (by setting unhinged expectations and casting unjust blame), and the medical community is massive. If medical societies, boards, and academic institutions won't hold them responsible for their words/lies, then I think we as individual physicians should have the ability to tell them how this harms us all. I honestly don't know how they sleep at night. If the Expert Witness doesn't feel comfortable publishing this information (I don't blame them), perhaps they could at least give us the county/case info that's publicly available so we can do this research ourselves. If there was a known database that called your expert statements into question (maybe with direct quotes and responses/reasoning/citations that explain why), I think it would go a long way in pairing down these all too common sham experts.
I want to do it but I also don't want to deal with the blowback from it, possible defamation lawsuits, etc... FWIW I always offer to help file ethics complaints. This guy was FACEP but is retired now.
I would not want to cross an unethical person well versed in our legal system either.
100% Agreed. I don't understand why medical boards don't penalize these people.
I read this case and it seemed like a very routine case in regards to decision-making that happens all the time. If someone's bleeding on anticoagulation, stop the anticoagulation (happens all the time) but the fact that someone had a stroke afterwards doesn't mean that the decision to stop anticoagulation was the wrong decision. It means a very unfortunate thing happened. Our neurologists tell patients all the time, anticoagulation doesn't eliminate stroke risk, it only LOWERS it, so when someone has a stroke on eliquis, it doesn't mean that the provider was wrong to put them on eliquis.
Your point #2 is always a good reminder.
Totally agree. An excellent point in regards to counseling patients that anticoagulation only lowers risk. Sadly, "unfortunate thing happened" = lawsuit.
I'm wondering why he had a stroke when he did (and agree it wasn't afib). If he had a UTI, maybe he had some systemic inflammation exacerbating his diseased endothelium, making his narrow vertebral and basilar arteries even narrower. Or maybe he got dehydrated, compromising his already compromised cerebral circulation. Hard to know of course, but interesting.
What angers me about this is I could easily see the plaintiff's "expert" coming across as at least superficially convincing to a lay jury.
Thankfully, the defense assembled a superb defense here. I like the defense ED physician highlighting the Sophie's choice of risking a stroke versus massive hemorrhage, and the neurologist neutered the causation argument.
I worry constantly about this problem. Every thing we do is a risk - if we don’t do it there’s a risk. Lawyers don’t seem to understand that.
I don’t understand the logic behind the defense saying - the stroke was probably not related to stopping the Coumadin. Doesn’t that imply that if the cva were related to stopping the Coumadin, you would then admit your guilt?
Regarding the patient being non-compliant. Louisiana , along with 12 other states (Alaska, Arizona, California, Florida, Kentucky, Mississippi, Missouri, New Mexico, New York, Rhode Island, South Dakota, and Washington) recognizes the doctrine of pure comparative fault. Under the doctrine of pure comparative fault, any award of damages awarded from a court are reduced in proportion to the patient’s contribution to their own injury. This doctrine is extremely friendly to patients in that they can recover for damages even if they are found to have been 99% at fault.
If an early CTA could have lead to more management options, the plaintiff should have looked into naming the admitting hospitalist.
I see your point but the hospitalist should never take the fall for that, its up to the EM doc and neurologist.
Stroke work up occurs quickly in the emergency department- usually the admitting hospital
Is not responsible for ordering, and following up on, vascular imaging for stroke alerts.
Yes of course, that's the key takeaway from this case. /s
I really enjoy reading the experts' reports in these cases. In this case, it appears that the first report (plaintiff) was written primarily by a lawyer, and the doctor essentially just signed off on it. The other two reports were written by the doctors themselves. Jurors would figure that out too - who would trust a doctor who communicates the way that first report was written? Most of the sentences begin with "I", and the content is very 'ad hominem' attacking another doctor.
I often see language that looks like it was written by a plaintiff's attorney and signed by a doctor. Seems unethical to me.