This is a good lawsuit

if someone says they've had suicidal thoughts, do you automatically take away their medical capacity and ship them to the nearest inpatient psych unit? I doubt it. thoughts and intent are two different things. we don't know what the H&P was, only what a triage note says. 2 sides to a story, hard to condemn a malpractice case when you only hear a triage note and a lawyer spinning a case.

(The following is my understanding...)



If someone is having suicidal/homicidal thoughts and reports this to a medical professional, the ABSOLUTE MINIMUM that should be done is to question the person as to how serious they are. A consult to psych should take place. A Psychiatrist should be the one to make any prescriptions/determinations as to how to proceed.

Personally, I would not release this patient until a psychiatric professional had signed off on it. Way too much liability.

What world do you all practice in that has the capabilities of consultation with a psychiatrist in the ER? I'm lucky to get a psych social worker to speak with a psych patient in the ED within 24h of presentation. The willingness of the psych social worker to admit the patient for inpatient psychiatric treatment depends much upon the insurance status of the patient and city-wide bed status.

The guy stated that he was having a panic attack as well as suicidal and homicidal ideations upon presentation to the ER. If 8 hours later, when interviewed by the psych social worker, he recants these ideations and states he is no longer suicidal or homicidal, our psych social worker will most likely recommend that he be discharged with outpatient followup.

Causation will be difficult to prove in this case, especially if the patient was given outpatient resources, as the event happened 10 DAYS after discharge. Regardless of whether or not the patient was held for 24-72h, it could be argued that this would not have prevented the events from occurring.

It is easy to throw rocks from an ivory tower, but when you practice in the community in many places in this country, there are no resources available for psychiatric care. The patient either boards in the ER for 3-4 days awaiting placement or is discharged with outpatient resources. If the aforementioned patient denied having active suicidal ideations or homicidal ideations upon interview with the psych social worker (usually 8 - 12 hours after initial presentation), the patient most likely would have been discharged from my ER with outpatient followup.

This is the reality of psychiatric care in the community in many poorly funded states across the US.

I've worked in two separate states, one with very good psych resources and one with horrible resources. Not to mention that I've spent 3 months of my life in med school and residency working in psych ED's. In neither state would someone with ideation who did not have plan, intent, or relevant risk factors ever be detained against their will. And if they were sent to one, they would be discharged in 1-2 hours of interviewing the pt and getting secondary history.

I cannot pass judgment on this case because I only know that the person stated ideation, which for all we know may have not even been active ideation. I do not know if these were passing thoughts or fixed thoughts, I do not know if he had intent, a plan, a weapon, a prior psych admission history, prior suicide or homicidal attempts, any drug or alcohol history, domestic violene history or restraining orders. We do not know if there is secondary history that was obtained from other sources, such as the woman in question or the pt's PMD or psychiatrist or therapist.

Rendar5 said:

I've worked in two separate states, one with very good psych resources and one with horrible resources. Not to mention that I've spent 3 months of my life in med school and residency working in psych ED's. In neither state would someone with ideation who did not have plan, intent, or relevant risk factors ever be detained against their will. And if they were sent to one, they would be discharged in 1-2 hours of interviewing the pt and getting secondary history.

I cannot pass judgment on this case because I only know that the person stated ideation, which for all we know may have not even been active ideation. I do not know if these were passing thoughts or fixed thoughts, I do not know if he had intent, a plan, a weapon, a prior psych admission history, prior suicide or homicidal attempts, any drug or alcohol history, domestic violene history or restraining orders. We do not know if there is secondary history that was obtained from other sources, such as the woman in question or the pt's PMD or psychiatrist or therapist.

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This.

And why oh why is the triage note so long?

And this is why healthcare is so expensive in this country.

Next up will probably be Lexapro facing a lawsuit from the grandpa.

This is media spin - one can't judge without knowing the details of this case. People say a lot of things in triage...

I agree with others. There really isn't enough information to condemn this doc. We've all seen triage notes that sound absolutely nothing like what you see when you actually interview the patient. My personal favorite being "per family member, patient stopped breathing, turned blue and chest compressions were started" - my history "he started coughing, so I slapped him on the back, then he was fine".

fuegofrio17 said:

What world do you all practice in that has the capabilities of consultation with a psychiatrist in the ER? I'm lucky to get a psych social worker to speak with a psych patient in the ED within 24h of presentation. The willingness of the psych social worker to admit the patient for inpatient psychiatric treatment depends much upon the insurance status of the patient and city-wide bed status.

The guy stated that he was having a panic attack as well as suicidal and homicidal ideations upon presentation to the ER. If 8 hours later, when interviewed by the psych social worker, he recants these ideations and states he is no longer suicidal or homicidal, our psych social worker will most likely recommend that he be discharged with outpatient followup.

Causation will be difficult to prove in this case, especially if the patient was given outpatient resources, as the event happened 10 DAYS after discharge. Regardless of whether or not the patient was held for 24-72h, it could be argued that this would not have prevented the events from occurring.

It is easy to throw rocks from an ivory tower, but when you practice in the community in many places in this country, there are no resources available for psychiatric care. The patient either boards in the ER for 3-4 days awaiting placement or is discharged with outpatient resources. If the aforementioned patient denied having active suicidal ideations or homicidal ideations upon interview with the psych social worker (usually 8 - 12 hours after initial presentation), the patient most likely would have been discharged from my ER with outpatient followup.

This is the reality of psychiatric care in the community in many poorly funded states across the US.

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I strongly agree with nearly all of what you said.

However, in a particular situation like the one you have cited, these complex cases are often complicated drastically by a myriad of psycho-social-financial factors, which you have already eluded to--such as the patient's complete lack of any health insurance (or, if they do have insurance, an extremely complex procedural bureaucracy imposing severe limitations or absolute barriers of access to the inpatient level of psychiatric treatment). These are extremely challenging, and very real, obstacles to overcome, which quite often result in a totally impenetrable roadblock to facilitating an inpatient psych placement. Think about it: If an accepting facility knows that they will not get paid for the referred patient, why on earth would they ever agree to receive them as a transfer??

The other very salient issue in such cases is the major, widespread lack of psych beds in many areas. If no bed physically exists for the patient, then obviously a transfer is not going to be feasible.

Therefore, instead of assuming that your social worker colleagues are "unwilling" to facilitate time-efficient transfers for some of your psych patients languishing in the ED, I would rather simply encourage you to trust that the SWs are most likely UNABLE to achieve this impossible goal of securing an expeditious transfer to an inpatient psych facility.

Socrates25 said:

http://www.indianagazette.com/news/police-courts/lawsuit-filed-in-beatty-slayings,17589114/

Many medical malpractice lawsuits are BS. but this one is totally legit. I hope the doctor and the hospital pay dearly for this nonsense.

Here's the gist of the story:

Lewis Beatty diagnosed with depression, goes to hospital ER for mental treatment. This is what he says, according to triage nurse's intake notes:



The ER doc (some articles refer to him as a family med doc) releases him directly from the ER with a script for an anti anxiety medicine.

10 days later, the guy kills his wife and 2 daughters and burns their house down.

Here's the hospital lawyer's spin on this:



So let me get this straight. If I tell the doc "I'm thinking about killing my wife" has to be handled differently than "I am going to kill my wife" because one is a "threat" and the other is not.

Absolutely absurd. This guy should have been immediately transferred to inpatient psych facility. There is absolutely ZERO defense of this. This doctor and the hospital are going to lose, and they are going to lose BIG for good reason.

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#1 You have it all wrong I'm afraid. This is how one defines "good lawsuit" and "bad lawsuit."

Bad lawsuit = the one filed against me, my family or friend or the cause I support.

Good lawsuit = the one filed by myself, or my family or friend, or the cause I support.

The same goes for lawyers:

Bad lawyer = the one suing me.

Good lawyer = the one protecting and defending me from "bad lawyer."

Lets be honest, it's entirely subjective. There are no good or bad lawsuits. Just yours (for or against).

#2 Don't think you can decide a legal case based on a news story. Any news article I've had intimate knowledge of was 1/2 wrong and the other half was full of half-truths. Remember: A journalist is nothing more than a blogger with a paycheck.

Lawyers will manipulate the media to incite emotions and bias a jury, so that when that jury is seated, they have an edge. It's a chess match.

Now, is this a "good lawsuit" or "bad lawsuit"? I don't know. I'll tell you when I feel the need to take a side.

Good day.

I agree that, while the triage note is very concerning, it's not enough to damn the doc.

Let's imagine the guy says that, yes, he thought about killing his wife and himself, but he had no plan, that the feelings have passed, and that he "would never actually do that, because I have too much to live for." Furthermore, he doesn't drink, he owns no guns, he's never tried suicide before, and his brother will come pick him up. Oh yeah, there are no beds, but social work can get him follow up with a counsellor tomorrow.

Just try to get that guy admitted to a Psych floor around the holidays in the upper midwest - it aint gonna happen.

Never throw another doc under the bus based on what's written in the paper. A malpractice verdict doesn't fix any of this. I'm sure there's more to this story. I do, however, suspect it will be settled for less than policy limits.

Spinach Dip said:

(The following is my understanding...)

If someone is having suicidal/homicidal thoughts and reports this to a medical professional, the ABSOLUTE MINIMUM that should be done is to question the person as to how serious they are. A consult to psych should take place. A Psychiatrist should be the one to make any prescriptions/determinations as to how to proceed.

Personally, I would not release this patient until a psychiatric professional had signed off on it. Way too much liability.

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This is just not the case. There is a difference between "suicidal thoughts" and true suicidal ideation that requires intervention. People come in with complaint of "suicidal thoughts" by family, EMS, triage, etc., regularly. Half of the time these people are intoxicated and coming down off of a cocaine binge. Regardless, when you ask these patients with "suicidal thoughts", "Is there a chance you would hurt yourself if you went home right now," sometimes they say no. These people do not get psychiatric consults. They go home and you document what they said. Patients with SI who are intoxicated, sober up, and are no longer having active SI, go home.

A psych consult in the community or obtaining psych placement can be a week-long process. Some places, the ER doc coming on rounds on psych patients boarded in the ED who are awaiting psych disposition. You do not consult psych or hold patients against their will for "suicidal thoughts reported to any medical professional".

The fact is that this patient may have been discharged appropriately, it's impossible to say. Mental illness is difficult to manage and there are inadequate inpatient and outpatient resources in our system to begin with. The first thing everyone wants to do when something like this happens is blame the system or the people in the system for not preventing it, when the fact is that you've got psychopaths, *****s, substance abusers, and people with mental illness who are going to do these types of things (unfortunately) and it cannot always be prevented, even when everything works appropriately.

TimesNewRoman said:

Sorry if this is in extremely poor taste, but I couldn't help but thinking about this:

http://www.youtube.com/watch?v=M902ZJHzaLE

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Chris Rock is awesome; one of the funniest guys alive.

Socrates25 said:

So what happens when psych tells you to have them follow-up in 3 months in their outpatient clinic. You going to send the patient on their merry way?

Another point I want to make is that I think we should treat homicidal ideation as very different than suicidial ideation, even though everybody on this board and probably most psych docs treat them equally The threshold for intervention should be lower for homicidal ideation compared to suicide.

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I've never sent a "homicidal ideations" patient home. Ever. I don't care how flippant the comment was. Any homicidal ideations/threats/joke = lock up, on my watch, with a report to Police and notification of the person threatened. "Duty to warn" over rides HIPAA every time. Suicidal ideation are much more contextual.

If they are actively suicidal/homicidal, I won't send them home, regardless of what the mental health social worker person tells me. I had one similar situation while moonlighting at a place where the rep "cleared" the pt for discharge. He then disappears and I read the guys note and it was just so much bull$hit. I remember thinking "there's no way this is the correct dispo for this pt and there's also no way this would protect me in a court of law". We boarded the guy for a couple of days until we could get him transferred. I still remember walking back into the guys room "Hey buddy...you still feel like killing yourself? 'Yea, I want to jump out in front of a truck, end it really quick...' Right on... I'm gonna keep you here for a little bit, ok?" It didn't go exactly like that, but close enough.

I think the whole "SI/HI thoughts" is a very grey area and most of us are not idiots and know how to dispo these pt's correctly.

Reporters can spin cases like this in a million different ways. Who knows if this guy handled it correctly. There's just not enough information.

What I wouldn't want to see happen... ER docs getting sued for a psych pt seen for X, up to a month ago, who makes some stupid decision to kill himself or someone else and then they try to finger the last doc to see him for anything "psych related" and make a case out of it. Especially, if it can be argued that the pt was properly managed and dispositioned at the time.

Socrates25 said:

So what happens when psych tells you to have them follow-up in 3 months in their outpatient clinic. You going to send the patient on their merry way?

Another point I want to make is that I think we should treat homicidal ideation as very different than suicidial ideation, even though everybody on this board and probably most psych docs treat them equally The threshold for intervention should be lower for homicidal ideation compared to suicide.

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For ideation without intent or plan or other concerning risk factors, pt gets detailed psych note explaining pt very low risk for completed suicide and referal to one of my group's therapist and their primary doc. HI does get treated with much more concern and would include a conversation with the targeted person. But if its just a fleeting thought. "I'm so mad I could kill her" in triage and "What?, No I wouldn't kill her, what are you crazy?" in the examining room, then they're discharged.

Socrates25 said:

So what happens when psych tells you to have them follow-up in 3 months in their outpatient clinic. You going to send the patient on their merry way?

Another point I want to make is that I think we should treat homicidal ideation as very different than suicidial ideation, even though everybody on this board and probably most psych docs treat them equally The threshold for intervention should be lower for homicidal ideation compared to suicide.

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For ideation without intent or plan or other concerning risk factors, pt gets detailed psych note explaining pt very low risk for completed suicide and referal to one of my group's therapist and their primary doc. HI does get treated with much more concern and would include a conversation with the targeted person. But if its just a fleeting thought. "I'm so mad I could kill her" in triage and "What?, No I wouldn't kill her, what are you crazy?" in the examining room, then they're dischargable.

Rendar5 said:

if someone says they've had suicidal thoughts, do you automatically take away their medical capacity and ship them to the nearest inpatient psych unit? I doubt it. thoughts and intent are two different things. we don't know what the H&P was, only what a triage note says. 2 sides to a story, hard to condemn a malpractice case when you only hear a triage note and a lawyer spinning a case.

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If a patient even hints at harming themselves or someone else, my signature is not going to be on their discharge paperwork.

Sent from my A110 using Tapatalk 2

We send ppl home with <1% risk of MI, PE, SAH, CVA home all the time, because we risk stratify them as such. Why wouldn't you treat SI as such in those you risk stratify to very low risk of suicidal completion? That's like saying that no chest pain or dyspnea goes home with your signature on it.

I have some idea how to risk stratify SI, don't really have the same sense for HI.

In residency I have psych and inpatient facilities where I work.
I'm sure it's much harder in the community where not d/c patient home means you could tie up a bed for a week.

Having been a psychiatrist in a past life and now an EM attending, I would suggest that the facts presented are concerning and certainly in retrospect it will be a tough defense.

With that said, I entirely agree that condemning someone without the full story is likely not wise.

Lets also agree that we all feel bad for this situation. There are dead folks, and a likely genuinely caring physician who is likely feeling terrible about the situation.

I can imagine many situations in which I could make a similar mistake...
1. Busy ED, I dont read the triage note but talk to the patient and they tell it slightly different. They chalk it up to anxiety and I buy in

2. The patient realizes between traige and my visit that I may put them on a hold and they decide to lie to me. They have little past history of violence and so get released

3. The patient convinced us all including himself he was okay and goes home only to have some new stressor / trigger / inciter and loses it...

4. I get collateral information from friends of the patient who agree to take responosibility for his safety and those of the other people and discharge him.

on and on and on....


At the end of the day, truly homicidal or suicidal individuals are the only patient group for whom our treatment goals and theirs are directly at odds with each other...we want them to live and be happy, they want to die and sometimes hurt others. I was never more scared and off balance about making a mistake then when I was a psychiatrist and I have made some decisions that I found out were wrong; I know how easy it is to do it.

Please dont be too quick to pass judgement...Im confident that the physician would never intentionally permit this to happen...there is a reason why the error occurred.

TL

Birdstrike said:

Good lawyer = the one protecting and defending me from "bad lawyer."

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Woo-hoo!

Socrates25 said:

There is absolutely ZERO defense of this. This doctor and the hospital are going to lose, and they are going to lose BIG for good reason.

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As for the OP, I am going to disagree that there is "zero defense" for this. As you very well know, physicians have a duty to maintain patient confidences. The duty to warn in psychiatric cases is an exception to that stringent duty, and it's only supposed to be overriden where there's a very specific threat leveled toward another person.

Did that happen here? Maybe not. The law supposedly sets a pretty high bar before requiring docs to rat out a patient to the cops or to allegedly threatened third parties, with good reason. If it starts becoming known, or even suspected, that physicians are getting so spooked by potential lawsuits that they're dropping dimes on everyone seeking treatment for psychiatric issues, patients are going to stop seeking that treatment.

And there's almost always a defense of some kind. I've come up with some pretty good ones for cases arguably "less defensible" than this one.

Socrates25 said:

So what happens when psych tells you to have them follow-up in 3 months in their outpatient clinic. You going to send the patient on their merry way?

Another point I want to make is that I think we should treat homicidal ideation as very different than suicidial ideation, even though everybody on this board and probably most psych docs treat them equally The threshold for intervention should be lower for homicidal ideation compared to suicide.

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Your going to have a hard time admitting em. If their admission reason is SI/HI, and they have been seen and cleared by the psychiatrist who recommends discharge and follow up, send them out. They are the authority in the field. Not you. Not me. And if they say send them home, you can bet your ass I'm gonna refuse the admission to medicine for observation when I already know the psychiatrist evaluated them and said dc.

No different then if I call cardio for an nstemi that I feel strongly needs to go to cath. If they say no, the answer is no. They are the authority in the field, not me. They perform the procedure not me. You can have your thoughts and your gestalt on a patients condition, but if you call a consult to a specialist in the field of your patients complaint, and you then argue and refute their recommendation, why did you call them?

The vague suicidal cases are probably some of the tougher decisions we make.

Case from last night: 16 year old with hx of depression, previous suicide attempt gets sent to school nurse by teacher for "looking pale." During the routine screening questions the nurse asks this girl if she has had any suicidal thoughts. Girl says yes, who doesn't think about killing themself at some point?

This starts 4 alarm fire which ends with her being brought to ER by grandfather who has legal custody. Like all good peds psych cases the social situation is a disaster and they both obviously dislike each other. Girl admits being depressed, no appetite, not sleeping and persistent suicidal thoughts that "I would never act on." She states "If I were to kill myself I'd overdose." No pills in the house but there is a gun in the grandfather's room. The girl states it is a ".38"

She states that yes, she has had suicidal thoughts lately but again, would never actually kill herself. She did try to overdose once in the past.

What do you guys do with this young lady? This is during a shift where we are so busy that we're doing EKGs in the doctor's lounge because there isn't anywhere else to put the chest painers. Go.

Interpolfanclub said:

The vague suicidal cases are probably some of the tougher decisions we make.

Case from last night: 16 year old with hx of depression, previous suicide attempt gets sent to school nurse by teacher for "looking pale." During the routine screening questions the nurse asks this girl if she has had any suicidal thoughts. Girl says yes, who doesn't think about killing themself at some point?

This starts 4 alarm fire which ends with her being brought to ER by grandfather who has legal custody. Like all good peds psych cases the social situation is a disaster and they both obviously dislike each other. Girl admits being depressed, no appetite, not sleeping and persistent suicidal thoughts that "I would never act on." She states "If I were to kill myself I'd overdose." No pills in the house but there is a gun in the grandfather's room. The girl states it is a ".38"

She states that yes, she has had suicidal thoughts lately but again, would never actually kill herself. She did try to overdose once in the past.

What do you guys do with this young lady? This is during a shift where we are so busy that we're doing EKGs in the doctor's lounge because there isn't anywhere else to put the chest painers. Go.

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I'm thanking my lucky stars that I can consult a psychiatrist before this girl gets sent home with outpatient followup.

In my shop - psych consult.

If I had less mental health resources, probably discharge w/ extensive documentation emphasizing the reassuring factors about the case.

Interpolfanclub said:

The vague suicidal cases are probably some of the tougher decisions we make.

Case from last night: 16 year old with hx of depression, previous suicide attempt gets sent to school nurse by teacher for "looking pale." During the routine screening questions the nurse asks this girl if she has had any suicidal thoughts. Girl says yes, who doesn't think about killing themself at some point?

This starts 4 alarm fire which ends with her being brought to ER by grandfather who has legal custody. Like all good peds psych cases the social situation is a disaster and they both obviously dislike each other. Girl admits being depressed, no appetite, not sleeping and persistent suicidal thoughts that "I would never act on." She states "If I were to kill myself I'd overdose." No pills in the house but there is a gun in the grandfather's room. The girl states it is a ".38"

She states that yes, she has had suicidal thoughts lately but again, would never actually kill herself. She did try to overdose once in the past.

What do you guys do with this young lady? This is during a shift where we are so busy that we're doing EKGs in the doctor's lounge because there isn't anywhere else to put the chest painers. Go.

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Interpolfanclub said:

The vague suicidal cases are probably some of the tougher decisions we make.

Case from last night: 16 year old with hx of depression,
What do you guys do with this young lady? This is during a shift where we are so busy that we're doing EKGs in the doctor's lounge because there isn't anywhere else to put the chest painers. Go.

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The complicating factor in this case is the age. This is a child, not a young lady. The legal situation as far as committment, consent for hospitalization, etc is very different compared to an 18 y.o.

Bostonredsox said:

Your going to have a hard time admitting em. If their admission reason is SI/HI, and they have been seen and cleared by the psychiatrist who recommends discharge and follow up, send them out. They are the authority in the field. Not you. Not me. And if they say send them home, you can bet your ass I'm gonna refuse the admission to medicine for observation when I already know the psychiatrist evaluated them and said dc.

No different then if I call cardio for an nstemi that I feel strongly needs to go to cath. If they say no, the answer is no. They are the authority in the field, not me. They perform the procedure not me. You can have your thoughts and your gestalt on a patients condition, but if you call a consult to a specialist in the field of your patients complaint, and you then argue and refute their recommendation, why did you call them?

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BoSox....your analogy is slightly flawed. The cardiologist not cath'ing the NSTEMI isn't the issue. You're still not the last one holding the hot potato. The patient was ADMITTED to the appropriate specialist, and what they do after that is their problem.

it is more analagous to the chest pain patient that you call the cardiologist to admit, says, "he's fine, do another trop and dc home" and then the patient goes home and has his MI and comes back sicker or dead. the cardiologist says, "well if Dr X told me he was that sick I never would have told him to send him home." and you open your check book and say "how much?"

a psychiatrist over the phone without ever seeing the patient is different than a psych consult where the patient is directly evaluated.

bottom line: crazy patients are not the ones you want to be betting your livelihood on. you never want to be the last one holding the hot potato with a potential high risk/red flag patient. and just because someone says send a patient home, doesn't mean you're under any obligation to do so until you work out an appropriate disposition that works for you and the patient. not saying its easy, or everyone has same resources, but still don't have to dc just because someone on the phone tells you to.