As a neurologist it’s important for me to note that intracranial vertebral dissections are associated with high risk of subarachnoid hemorrhage (up to 50% in some literature) so the discussion of heparin drip is not as straightforward as the plaintiffs “expert” seems to suggest.
I ran out of room to add this, but he had another excerpt in which he acknowledged the high risk of SAH in intracranial dissections. However, he stated that he has his own pet hypothesis that intracranial dissection present with either ischemia or SAH right from the beginning. Basically implying that if there's no SAH right from the initial imaging, then you're past the risk of bleeding already and therefore giving anticoagulants is appropriate. Obviously a med mal case is not the time to argue for your own pet theories that conflict with the standard of care, but I wonder if there is any support for his opinion?
It’s true that often they present with SAH, especially if there is a dissecting aneurysm (unclear from CTA read whether the fusiform dilatation just proximal to the pica was truly aneurysmal but it certainly sounds concerning for that). But I am not aware of any data to support that if they do not present with SAH you can do whatever you want! I think most people would be very hesitant to anticoagulate.
So overall I don’t think it’s unreasonable to be worried about hemorrhage and there really isn’t support for anticoagulant va antiplatelet use in dissection…
That expert's testimony is absolutely bonkers and it feels like the defense attorney went pretty soft on him. He explicitly says he doesn't follow guidelines (which is pretty obvious given that he's saying the standard of care for a vert dissection is tPA). Even the evidence for heparin as opposed to antiplatelets doesn't really exist and anticoagulation is explicitly not recommended for intracranial dissection. Doing anything short of straight up calling him a clown seems like a missed opportunity.
It's beating a dead horse, but the fact that someone can be presented as an expert and not only not back up their assertions but explicitly state they aren't based on guidelines or scientific studies is an absolutely damning indictment of our legal system and a huge argument against lay juries for these kinds of cases.
The good news is that the defense attorney doesn't need to rip him to shreds during the deposition. That comes later in the written motion to ban him from being an expert witness for this case. The attorney can kind of just sit back and keep asking polite questions while the guy walks himself into quick sand. It would be satisfying to call him a clown but the mature attorney will just smile internally and keep him rolling.
You know, I've been hesitant to dive into expert witness work out of concern that I'm not 110% up to speed with the literature in my field. But if you can survive a deposition with "well that's like, just my experience, man," clearly I'm missing out.
I serve as an expert and really enjoy the work. I have taught residents and med students but early in my career. I am essentially a community medicine doctor. Trust me, if you are articulate, and can communicate well with other folks in decent layman vernacular than you can be an expert. Also, I extensively go over the literature and what we do on a “regular” basis in contrast to the literature and I prepare extensively prior to deposition. It makes a profound difference. Some of the depositions I see are laughable; similar to saying “timing doesn’t matter with tPA”. Lawyers recognize the difference in preparation and most of the cases I take have accepted settled immediately after my depositions. That is very meaningful to me and it makes me a better clinician. But truthfully I take a small percentage of cases that are sent my way (don’t play a bad poker hand), the time spent is larger than you think; and maybe it adds 20K to my annual income. This is good as I do it for the meaning it brings to me rather than the money. Good luck!
If you teach trainees and med students, then you are more than qualified to teach lawyers and jurors. The challenge is a combination of public speaking and thinking on your feet. We all do that regularly in the clinical realm where we are familiar and have some degree of being in charge. In the litigation realm, the culture and the language and the milieu are all different, and we're not in charge.
It's probably different for each person. For me it has been word of mouth. I think my name got out there mainly because of teaching I do for a variety of audiences and across a breadth of geography. For one particular case, a resident referred me to her sibling lawyer based on a clinical simulation I had done. Other than that, it's a matter of being conscientious and doing a good job, and that leads to more cases. When a case comes my way, I evaluate it on its own merits as to whether I'll do a preliminary review or go further.
For me it was word of mouth as well. As DJ said I was teaching on opioids/buprenorphine and a colleague told a lawyer and they called me… I don’t advertise (gross) and I mainly work with one group of clients. They spread the word to their colleagues when a specific case comes up and so on.
Opposing attorney might make you look like a big time doofus in front of a few people in a courtroom, but who cares if you're collecting a fat paycheck.
The more of your newsletters I read, the more I want to quit medicine. Time and again, these lawsuits have almost nothing to do with quality of care and all to do with "bad outcomes." "Shit happens so 'someone' must pay"... and doctors usually have deep pockets and insurance to cover it.
I left one anesthesia job because certain surgeons were doing things clearly outside the standard of care (VBAC's) and I knew it was only a matter of time until there was a bad outcome and that it would be indefensible (not because of my care/skill but because the OR team could not meet standards of care.) I felt like a walking lottery ticket.
The closest I have ever (knowingly) come to a lawsuit was also as an anesthesiologist when a trauma patient scheduled to go to the OR "crashed" and was trasnferred to a tertiary care center. There was a delay in the transfer (due to air ambulance availability) and the patient (a 17 yo girl) had a bad outcome (paraplegia) even though the outcome did not have a single thing to do with quality of care. Despite the patient being 100% at fault for accident (unrestrained, impaired driver who ran off the road and was ejected from vehicle), and the fact that the outcome would likely have been unchanged even if she had crashed into a Level 1 trauma center, every single provider involved in her care was named in the lawsuit. I was not named because my name was not yet on the chart as we were still waiting to take her to the OR when she became acutely paraplegic. Every entity and institution settled, except the general surgeon who first saw her in the ER. He actually "won" at trial, which was still had a very high emotional and financial cost (office closed for 2 weeks for the trial- plus time away from work for trial prep.
Perhaps it's time to do away with some malpractice cases and create government funded "shit happens" insurance to pay fopr these catastrophic outcomes were no one is really at fault?
BTW- our State HAS a "pre-trial review" process to evaluate the merit for all potential malpractice cases.... and this case was found to "not meet the criteria" of malpractice.... yet the plaintiff's attorneys pursued the lawsuit, anyway. So, wht's the point of have these checks/balances if they are non-binding?
Stay strong, don't quit! Patients need you. I really hope this newsletter doesn't drive people to quit medicine. Even when there are frivolous lawsuits, I think its still a valuable exercise to comb through things and figure out what we could do better if we're in these situations. There's always room for improvement, even if the standard of care has been met. I actually really like your idea of pay outs for people with catastrophic injuries, without having to come up with an imaginary charade where we have to pretend the doctor did something wrong. Unfortunately the plaintiffs bar has a very effective lobby and it will never happen.
Thanks, this terrifying scenario is why I absolutely hate and fear the "dizzy" complaint, i staff ALL of these with my supervising MD, probably to the point of being annoying.....
The expert is likely Lou Caplan. He is quoting his papers verbatim. I'm curious to see how this turns out if it makes it to trial given a jury might be swayed by his very impressive CV and accomplishments. Provide an update when available!
Just checked and the last update is "court declared a mistrial before completion of trial". First lawsuit I've covered that ended in a mistrial! Unfortunately this courthouse is a big headache to get records from... costs hundreds of dollars to get records and they literally snail mail them to me so it takes a while.
I settled a suit this year... when they sent the 13 page list of interrogatories they requested usernames and passwords (!) for all of my email, and social media accounts; and IDs and passwords for any fitness tracker devices. --- I declined to share any of it. The fact that the judge ordered the physician to share all of this is terrifying.
Now that you mention it, it does feel weird to forcefully turn a patient’s neck when vertebral artery dissection is within the differential. We had a very dedicated faculty member during residency who taught and tested us on the performance of HINTS exam twice yearly. The head impulse portion, if done correctly, requires quite a bit of force and I can see how it could exacerbate or cause a dissection, especially in an arthritic old patient’s c spine. NIHSS + skew + gait sounds more reasonable, and I will probably start using it.
HINTS got super popular there for a while, but I think there is some very appropriate pushback now. Another serious downside is that there is no proof besides your documentation of what the exam showed. If you get a false negative HINTS exam, you're going to be trying to convince a jury that you did or did not see a slight flicker of their eyes. Compare that to an imaging study, which is memorialized forever and can be pulled up on a screen for review years later.
2) do not post, like or comment on Facebook, instagram etc as those are time stamped and can be used to suggest (rightly?) that you were not focused on your work
3) anything that you use at work — phone, text messages can be analyzed to show you were not focused on your patients.
4)focus on your patients they are your priority during your shift.
Also Consider using DuckDuckGo or similar. Use a VPN. Know that if you are using the hospital network/WiFi (even if you are on your phone or laptop) they can see/ track and record everything. Make sure tracking cookies are turned off. Use Signal or similar for messaging.
"Weak and dizzy" patients are the bane of every ER doctor's existence, but I don't think this patient fell in that category. Its important to distinguish between the extremely vague weak/dizzy we see all the time in the elderly vs the relatively young person who had high velocity neck movement and now has acute severe dizziness and vomiting. Agree to be careful with social media usage. Its fine to do it on a break but not when something is actively happening (although plaintiffs attorneys will make literally any single episode of accessing social media or using your phone in any way make you look incompetent, even if thats not true).
This is a horrible case. The diagnosis was caught promptly and standard of care treatment was started immediately, before the patient deteriorated in spite of it. All this reads like damn good care with a poor outcome. And all the actors who contributie to that care get sued afterwards?
Can you clarify this for me? Who hired this expert neurologist - are they hired by the plaintiff? When I read their words, I was a little struck my the nonchalant nature of the lack of time limits he applied to tPA. I get what he's trying to say about how not every patient is a guideline but I've never heard of tPA being given past 4.5 hours.
This case is really good for perspective. I'm a hospitalist who triages neurologic patients all the time, good to be aware of all possible outcomes.
The expert was for the plaintiff. His testimony about lack of time limits for tPA is pretty bad in my opinion. If you have some theories about giving tPA later, that's a fine topic to explore in a research setting, maybe you could even discover something that could benefit patients and revise future guidelines! But you cant show up to a malpractice lawsuit and just blatantly ignore the standards by which your specialty operates.
As a neurologist it’s important for me to note that intracranial vertebral dissections are associated with high risk of subarachnoid hemorrhage (up to 50% in some literature) so the discussion of heparin drip is not as straightforward as the plaintiffs “expert” seems to suggest.
I ran out of room to add this, but he had another excerpt in which he acknowledged the high risk of SAH in intracranial dissections. However, he stated that he has his own pet hypothesis that intracranial dissection present with either ischemia or SAH right from the beginning. Basically implying that if there's no SAH right from the initial imaging, then you're past the risk of bleeding already and therefore giving anticoagulants is appropriate. Obviously a med mal case is not the time to argue for your own pet theories that conflict with the standard of care, but I wonder if there is any support for his opinion?
It’s true that often they present with SAH, especially if there is a dissecting aneurysm (unclear from CTA read whether the fusiform dilatation just proximal to the pica was truly aneurysmal but it certainly sounds concerning for that). But I am not aware of any data to support that if they do not present with SAH you can do whatever you want! I think most people would be very hesitant to anticoagulate.
Then there’s this case report of a patient with an undiagnosed vertebral artery dissection and left mca syndrome who got tpa and had large SAH after: https://neurointervention.org/m/journal/view.php?doi=10.5469/neuroint.2021.00458
So overall I don’t think it’s unreasonable to be worried about hemorrhage and there really isn’t support for anticoagulant va antiplatelet use in dissection…
That expert's testimony is absolutely bonkers and it feels like the defense attorney went pretty soft on him. He explicitly says he doesn't follow guidelines (which is pretty obvious given that he's saying the standard of care for a vert dissection is tPA). Even the evidence for heparin as opposed to antiplatelets doesn't really exist and anticoagulation is explicitly not recommended for intracranial dissection. Doing anything short of straight up calling him a clown seems like a missed opportunity.
It's beating a dead horse, but the fact that someone can be presented as an expert and not only not back up their assertions but explicitly state they aren't based on guidelines or scientific studies is an absolutely damning indictment of our legal system and a huge argument against lay juries for these kinds of cases.
The good news is that the defense attorney doesn't need to rip him to shreds during the deposition. That comes later in the written motion to ban him from being an expert witness for this case. The attorney can kind of just sit back and keep asking polite questions while the guy walks himself into quick sand. It would be satisfying to call him a clown but the mature attorney will just smile internally and keep him rolling.
You know, I've been hesitant to dive into expert witness work out of concern that I'm not 110% up to speed with the literature in my field. But if you can survive a deposition with "well that's like, just my experience, man," clearly I'm missing out.
I serve as an expert and really enjoy the work. I have taught residents and med students but early in my career. I am essentially a community medicine doctor. Trust me, if you are articulate, and can communicate well with other folks in decent layman vernacular than you can be an expert. Also, I extensively go over the literature and what we do on a “regular” basis in contrast to the literature and I prepare extensively prior to deposition. It makes a profound difference. Some of the depositions I see are laughable; similar to saying “timing doesn’t matter with tPA”. Lawyers recognize the difference in preparation and most of the cases I take have accepted settled immediately after my depositions. That is very meaningful to me and it makes me a better clinician. But truthfully I take a small percentage of cases that are sent my way (don’t play a bad poker hand), the time spent is larger than you think; and maybe it adds 20K to my annual income. This is good as I do it for the meaning it brings to me rather than the money. Good luck!
I trust the expert doctors who only do a small handful every year way more than the ones I see doing dozens of cases.
I agree - you got to do it for the right reasons. It's very educational, and you need to choose cases that you believe in.
If you teach trainees and med students, then you are more than qualified to teach lawyers and jurors. The challenge is a combination of public speaking and thinking on your feet. We all do that regularly in the clinical realm where we are familiar and have some degree of being in charge. In the litigation realm, the culture and the language and the milieu are all different, and we're not in charge.
how does one go about getting involved in medical legal cases as an expert witness.
It's probably different for each person. For me it has been word of mouth. I think my name got out there mainly because of teaching I do for a variety of audiences and across a breadth of geography. For one particular case, a resident referred me to her sibling lawyer based on a clinical simulation I had done. Other than that, it's a matter of being conscientious and doing a good job, and that leads to more cases. When a case comes my way, I evaluate it on its own merits as to whether I'll do a preliminary review or go further.
For me it was word of mouth as well. As DJ said I was teaching on opioids/buprenorphine and a colleague told a lawyer and they called me… I don’t advertise (gross) and I mainly work with one group of clients. They spread the word to their colleagues when a specific case comes up and so on.
Opposing attorney might make you look like a big time doofus in front of a few people in a courtroom, but who cares if you're collecting a fat paycheck.
The more of your newsletters I read, the more I want to quit medicine. Time and again, these lawsuits have almost nothing to do with quality of care and all to do with "bad outcomes." "Shit happens so 'someone' must pay"... and doctors usually have deep pockets and insurance to cover it.
I left one anesthesia job because certain surgeons were doing things clearly outside the standard of care (VBAC's) and I knew it was only a matter of time until there was a bad outcome and that it would be indefensible (not because of my care/skill but because the OR team could not meet standards of care.) I felt like a walking lottery ticket.
The closest I have ever (knowingly) come to a lawsuit was also as an anesthesiologist when a trauma patient scheduled to go to the OR "crashed" and was trasnferred to a tertiary care center. There was a delay in the transfer (due to air ambulance availability) and the patient (a 17 yo girl) had a bad outcome (paraplegia) even though the outcome did not have a single thing to do with quality of care. Despite the patient being 100% at fault for accident (unrestrained, impaired driver who ran off the road and was ejected from vehicle), and the fact that the outcome would likely have been unchanged even if she had crashed into a Level 1 trauma center, every single provider involved in her care was named in the lawsuit. I was not named because my name was not yet on the chart as we were still waiting to take her to the OR when she became acutely paraplegic. Every entity and institution settled, except the general surgeon who first saw her in the ER. He actually "won" at trial, which was still had a very high emotional and financial cost (office closed for 2 weeks for the trial- plus time away from work for trial prep.
Perhaps it's time to do away with some malpractice cases and create government funded "shit happens" insurance to pay fopr these catastrophic outcomes were no one is really at fault?
BTW- our State HAS a "pre-trial review" process to evaluate the merit for all potential malpractice cases.... and this case was found to "not meet the criteria" of malpractice.... yet the plaintiff's attorneys pursued the lawsuit, anyway. So, wht's the point of have these checks/balances if they are non-binding?
Stay strong, don't quit! Patients need you. I really hope this newsletter doesn't drive people to quit medicine. Even when there are frivolous lawsuits, I think its still a valuable exercise to comb through things and figure out what we could do better if we're in these situations. There's always room for improvement, even if the standard of care has been met. I actually really like your idea of pay outs for people with catastrophic injuries, without having to come up with an imaginary charade where we have to pretend the doctor did something wrong. Unfortunately the plaintiffs bar has a very effective lobby and it will never happen.
Thanks, this terrifying scenario is why I absolutely hate and fear the "dizzy" complaint, i staff ALL of these with my supervising MD, probably to the point of being annoying.....
The expert is likely Lou Caplan. He is quoting his papers verbatim. I'm curious to see how this turns out if it makes it to trial given a jury might be swayed by his very impressive CV and accomplishments. Provide an update when available!
Just checked and the last update is "court declared a mistrial before completion of trial". First lawsuit I've covered that ended in a mistrial! Unfortunately this courthouse is a big headache to get records from... costs hundreds of dollars to get records and they literally snail mail them to me so it takes a while.
I settled a suit this year... when they sent the 13 page list of interrogatories they requested usernames and passwords (!) for all of my email, and social media accounts; and IDs and passwords for any fitness tracker devices. --- I declined to share any of it. The fact that the judge ordered the physician to share all of this is terrifying.
This is wild. What did they say when you declined?
Now that you mention it, it does feel weird to forcefully turn a patient’s neck when vertebral artery dissection is within the differential. We had a very dedicated faculty member during residency who taught and tested us on the performance of HINTS exam twice yearly. The head impulse portion, if done correctly, requires quite a bit of force and I can see how it could exacerbate or cause a dissection, especially in an arthritic old patient’s c spine. NIHSS + skew + gait sounds more reasonable, and I will probably start using it.
HINTS got super popular there for a while, but I think there is some very appropriate pushback now. Another serious downside is that there is no proof besides your documentation of what the exam showed. If you get a false negative HINTS exam, you're going to be trying to convince a jury that you did or did not see a slight flicker of their eyes. Compare that to an imaging study, which is memorialized forever and can be pulled up on a screen for review years later.
Lessons
1) avoid weak and dizzy patients
2) do not post, like or comment on Facebook, instagram etc as those are time stamped and can be used to suggest (rightly?) that you were not focused on your work
3) anything that you use at work — phone, text messages can be analyzed to show you were not focused on your patients.
4)focus on your patients they are your priority during your shift.
Also Consider using DuckDuckGo or similar. Use a VPN. Know that if you are using the hospital network/WiFi (even if you are on your phone or laptop) they can see/ track and record everything. Make sure tracking cookies are turned off. Use Signal or similar for messaging.
"Weak and dizzy" patients are the bane of every ER doctor's existence, but I don't think this patient fell in that category. Its important to distinguish between the extremely vague weak/dizzy we see all the time in the elderly vs the relatively young person who had high velocity neck movement and now has acute severe dizziness and vomiting. Agree to be careful with social media usage. Its fine to do it on a break but not when something is actively happening (although plaintiffs attorneys will make literally any single episode of accessing social media or using your phone in any way make you look incompetent, even if thats not true).
This is a horrible case. The diagnosis was caught promptly and standard of care treatment was started immediately, before the patient deteriorated in spite of it. All this reads like damn good care with a poor outcome. And all the actors who contributie to that care get sued afterwards?
Can you clarify this for me? Who hired this expert neurologist - are they hired by the plaintiff? When I read their words, I was a little struck my the nonchalant nature of the lack of time limits he applied to tPA. I get what he's trying to say about how not every patient is a guideline but I've never heard of tPA being given past 4.5 hours.
This case is really good for perspective. I'm a hospitalist who triages neurologic patients all the time, good to be aware of all possible outcomes.
The expert was for the plaintiff. His testimony about lack of time limits for tPA is pretty bad in my opinion. If you have some theories about giving tPA later, that's a fine topic to explore in a research setting, maybe you could even discover something that could benefit patients and revise future guidelines! But you cant show up to a malpractice lawsuit and just blatantly ignore the standards by which your specialty operates.