Surreal: EM legend and Temple chair Robert McNamara loses $6.4 million lawsuit

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Originally Posted by Jarabacoa

If everyone in the USA stopped driving, how much of a decrease in global warming would that cause? Prove it.

Is there a God? Prove it.

...

Like I said before, just because our government is currently functioning idiotically does not mean the intended functions of government are idiotic.

Originally Posted by AmoryBlaine

They simply do not want to balance the federal budget, they want to talk about balancing the federal budget. The distinction is critically important.

I want to bench press 350 pounds, but I don't have a serious plan to get there. I want to be a billionaire but I don't have a business plan to do so.

Time and time again Tea Partiers have been asked exactly how they would balance the budget and time and time again they say they would lower taxes, increase military spending, and make tiny cuts in programs that liberals like (NPR, NEA, etc). This will not balance the budget. So saying this is one of their positions is just silly.

I would rather someone with a goal like this and what our current administration has. Repealing Obamacare would be step 1. That would help. All those CBO estimates are shot now that the long term care deal is off the table.

Obama has no plans to balance the budget, to stop our growing debt or to fix the jobs situation in this country. He simply wants to pander to the left side of his party. note the distinction between this and the left of the US.

FWIW balancing the budget.. a quick google search found this..

http://www.freedomworks.org/blog/dea...ea-party-budge

Cut $9+ trillion from the the budget over the next decade
Eliminate 4 departments (Energy, Education, Commerce, and HUD)
Repeal ObamaCare in its entirety
Reform entitlements
Balance the budget in 5 years, and
Stop the debt

I must have missed Obama's budget... Its not perfect but at least its a plan which is more than I can say for our current president.

Originally Posted by xaelia

Is there a God? Prove it.

...

Like I said before, just because our government is currently functioning idiotically does not mean the intended functions of government are idiotic.

Fundamentally different. The belief in global warming is/should be based in science. THe belief in god is not.

Originally Posted by AmoryBlaine

Time and time again Tea Partiers have been asked exactly how they would balance the budget and time and time again they say they would lower taxes, increase military spending, and make tiny cuts in programs that liberals like (NPR, NEA, etc). This will not balance the budget. So saying this is one of their positions is just silly.

Negative. Ask Ron Paul how he would fix the budget, and he will tell you. Increased military spending is not part of the plan. Lower taxes is. The deficit is just like obesity. You can fix it by either spending less (eating less), taking in more (exercising more), or both.
You're basically a talking points memo right now. I bet you think they're all racist too.

Originally Posted by Jarabacoa

What is your message? How would you cut the federal deficit other than making government smaller?

I would not try to cut the deficit during a recession. Economists who aren't being paid by the Koch brothers tell you this is macro-econ 101.

Originally Posted by Dr.McNinja

Negative. Ask Ron Paul how he would fix the budget, and he will tell you. Increased military spending is not part of the plan. Lower taxes is. The deficit is just like obesity. You can fix it by either spending less (eating less), taking in more (exercising more), or both.
You're basically a talking points memo right now. I bet you think they're all racist too.

Don't be an ******* just because I don't agree with you.

Ron Paul is not now, and has not ever been, a member of the Tea Party.

Originally Posted by EctopicFetus

I would rather someone with a goal like this and what our current administration has. Repealing Obamacare would be step 1. That would help. All those CBO estimates are shot now that the long term care deal is off the table.

Obama has no plans to balance the budget, to stop our growing debt or to fix the jobs situation in this country. He simply wants to pander to the left side of his party. note the distinction between this and the left of the US.

FWIW balancing the budget.. a quick google search found this..

http://www.freedomworks.org/blog/dea...ea-party-budge



I must have missed Obama's budget... Its not perfect but at least its a plan which is more than I can say for our current president.

He does not have any plan to balance the budget, such would be financial suicide during a recession. The other parts are simply untrue. But I have been alive long enough to know that this is religious dogma and not subject to facts so this is the end of my posting on this thread.

Originally Posted by Flopotomist

What did you do with that information in the EMERGENCY department? Who followed up on that lab? Was it fasting? Did you start statins on people with an isolated elevated lipid panel from the ED (hope not!)

If a lab is not going to change management in the ED, why order it?

Originally Posted by la gringa

have never ordered a lipid panel from the ED nor seen another provider do it.

this is from a large residency that saw a lot of "primary care" as well as the 2 community spots we rotated in in one state, and 3 different community hospitals under 3 different system umbrellas, in 3 more states. 2 of the total of 4 were near, but not in, PA.

Originally Posted by dotcb

Yes - I agree that from an EM standpoint you should NOT order tests that won't change your management.

In this case, I don't want to be discussing non-fasting lipids with low risk chest pain patients as I'm discharging patients for their follow-up.

Originally Posted by Hamhock

Lipid panels for chest pain in the ED are nonsense.

I have ordered a lipid panel once: Crazy alcoholic dude in complete withdrawl and pancreatitis who we intubated with propofol and had on a propofol drip for days.

HH

Originally Posted by southerndoc

Yep. It's those few times that I order them.

I'm not sure what the turnaround times are in your labs (since someone said who will follow up on it), but in our ED we get lipids back quickly. Haven't timed it exactly but I'd say less than 45 minutes.

If a patient does have dyslipidemia and I discharge them, yes, I do write for a statin.

This is a really interesting discussion. I can't get lipids back in less than a day although I've never tried in an ER visit. For some reason in Vegas I never see the creamy layer on the top of the tube like I did in Philly so I never think to try to check it for ER management.

That said it is technically ordered under my name every time I launch a chart pain or stroke pathway. So oddly enough I never use them but I order hundreds a month.

Trying to get back on topic. What do you think as a specialty we can do to help stop insane lawsuits? Yes a young man died and that is tragic but that doesn't mean there was something that could have been done to prevent it.
I truly believe we should really shine the light on these prostitute expert witnesses or just flat out not allow it. The sole reason people are platiff expert witnesses is for money bc I guarantee they wouldn't do it otherwise.
Maybe we should force every bc em physician to review cases "x" amount of times per yr and get paid the same as a shift
The lawyers use the malpractice system to line their pockets not get justice

Originally Posted by AmoryBlaine

But I have been alive long enough to know that this is religious dogma

I agree that it's close, but not quite to the religious fanatic.

and not subject to facts so this is the end of my posting on this thread.

What facts did you post again?

.

Originally Posted by AmoryBlaine

I would not try to cut the deficit during a recession. Economists who aren't being paid by the Koch brothers tell you this is macro-econ 101.

The recession is being perpetuated by the increasing deficits.

When we aren't in a recession, the left can constantly vote in more entitlement programs. They argue that we have the money, so why not do it.

The evil Koch brothers, huh? Well, economists not being paid by George Soros will tell you that shrinking government and encouraging free-market principles are the only thing that will get us out of this recession.

Originally Posted by xaelia

Is there a God? Prove it.

This is a rather disturbing comment, are you implying that a prove of the effectiveness of "green" measures is unneeded and must be accepted on faith?

So this thread is now about who is smarter when it comes to economics....cool...so more about lawsuits and tort reform and less about who has the bigger magic stick maybe?

Originally Posted by bougiecric

According to the lawsuit, Harlem’s ordeal began back on May 31, 2009, when emergency medical personnel transported the man to Temple University Hospital’s emergency room with complaints of chest and shoulder pain.

Harlem, who the lawsuit stated had a history of atrial fibrillation, began to experience chest and shoulder pains while playing basketball earlier that day, the record shows.

While at the hospital, Harlem was assessed by resident physician Edwards and attending physician McNamara.

The lawsuit claimed that the doctors failed to order cardiac biomarkers and a lipid panel for Harlem, who at the time had an elevated white blood cell count.

I don't know any further details about this case beyond what is cited in this article, and I understand the retrospectoscope is always perfect.

However, if you have a guy with a history of atrial fib who has exertional chest and shoulder pain he needs to get an EKG, CXR, serial markers, serum cholesterol and be placed in observation status for provocative testing. The age of 38 does not qualify one as low risk given these other factors.

When all that is negative, then and only then can you say that you have done your due diligence with regards to ACS. He probably needs an echo as well. Knowing what a patient's lipid panel is becomes particularly important if you suspect a cardiac cause of chest pain at an early age or strong family hisotry whether this is secondary to familial hyperlipidemia, or simply eating too many steaks.

Yes, I do understand that all this takes time, and that time is something that is in short supply in busy urban departments. Emergency medicine in such settings involves taking diagnostic gambles to move the meat. The more diagnostic gambles you take, the more you open yourself up to suits like this which is why it is a fruitful field for malpratice lawyers to harvest.

Do not take this as a defense of Pennsylvania's medicolegal system, which is somewhat less civilized than those of Botswana and Zimbabwe. You couldn't pay me enough to practice there.

Originally Posted by Old_Mil

However, if you have a guy with a history of atrial fib who has exertional chest and shoulder pain he needs to get an EKG, CXR, serial markers, serum cholesterol and be placed in observation status for provocative testing. The age of 38 does not qualify one as low risk given these other factors.

When all that is negative, then and only then can you say that you have done your due diligence with regards to ACS. He probably needs an echo as well. Knowing what a patient's lipid panel is becomes particularly important if you suspect a cardiac cause of chest pain at an early age or strong family hisotry whether this is secondary to familial hyperlipidemia, or simply eating too many steaks.

Are you looking for CAD? If so, then some of what you are proposing makes sense.

Cholesterol is a risk factor for CAD. The level has nothing to do with ACS (except if you can tell me the patient has NO coronary artery disease).

I am looking for ACS, not CAD. The degree of CAD and the patient's future risk is the domain of the PCP and cardiologist. My job is rule-out ACS and then send the patient to Cards or IM/FM for this "due dillgence".

Reasoning like you described in your post, Old-Mill, is what "expert" witnesses are using to crush EM docs. The search for CAD is not the job of the EM doc.

HH

You have to think who's saying he had afib? Do you think a pillar of em would send home a 38 yom with afib, syncope, and exertional chest pain? The answer is no of course not
Most likely it was 38 yom with no med hx, no syncope, normal EKG, +cough, questionable infiltrate on cxr, What would you do...probably the exact same thing, I know I would. I think I did it 3x today.
Don't these become public record? I would love to read what the docs and lawyers said
This is how the lawyers make money by convincing juries the doctor made a mistake. Truth is the guy has bad protoplasm and bad luck and died at 38, it stinks but why is the doc at fault

Originally Posted by Hamhock

Are you looking for CAD? If so, then some of what you are proposing makes sense.

Cholesterol is a risk factor for CAD. The level has nothing to do with ACS (except if you can tell me the patient has NO coronary artery disease).

I am looking for ACS, not CAD. The degree of CAD and the patient's future risk is the domain of the PCP and cardiologist. My job is rule-out ACS and then send the patient to Cards or IM/FM for this "due dillgence".

Reasoning like you described in your post, Old-Mill, is what "expert" witnesses are using to crush EM docs. The search for CAD is not the job of the EM doc.

HH

Amen. Read "Do risk factors for chronic coronary heart disease
help diagnose acute myocardial infarction in the
Emergency Department?" by Body et al in Resuscitation 2008. (the answer is: no).

.

Originally Posted by Old_Mil

I don't know any further details about this case beyond what is cited in this article, and I understand the retrospectoscope is always perfect.

However, if you have a guy with a history of atrial fib who has exertional chest and shoulder pain he needs to get an EKG, CXR, serial markers, serum cholesterol and be placed in observation status for provocative testing. The age of 38 does not qualify one as low risk given these other factors.

When all that is negative, then and only then can you say that you have done your due diligence with regards to ACS. He probably needs an echo as well. Knowing what a patient's lipid panel is becomes particularly important if you suspect a cardiac cause of chest pain at an early age or strong family hisotry whether this is secondary to familial hyperlipidemia, or simply eating too many steaks.

Yes, I do understand that all this takes time, and that time is something that is in short supply in busy urban departments. Emergency medicine in such settings involves taking diagnostic gambles to move the meat. The more diagnostic gambles you take, the more you open yourself up to suits like this which is why it is a fruitful field for malpratice lawyers to harvest.

Do not take this as a defense of Pennsylvania's medicolegal system, which is somewhat less civilized than those of Botswana and Zimbabwe. You couldn't pay me enough to practice there.

The resident physician Marsha W. Edwards was also involved. Any chances that Dr. McNamara was in a hurry/too busy and trusted her, so he didn't double check her work/findings? I'm not trying to blame on the resident; but with Dr. McNamara's skills, knowledge, and experiences, I don't think he would fail to order the cardiac biomarkers and possibly a lipid panel.

What is the obsession with the NON-fasting lipid panel? I have never ordered this in the ED. Even on chest pains that are getting admitted for acute mi, acs, rule out whatever. Why would a 38 yo with chest pain, cough get one?

Originally Posted by EM DR

The resident physician Marsha W. Edwards was also involved. Any chances that Dr. McNamara was in a hurry/too busy and trusted her, so he didn't double check her work/findings? I'm not trying to blame on the resident; but with Dr. McNamara's skills, knowledge, and experiences, I don't think he would fail to order the cardiac biomarkers and possibly a lipid panel.

See below.

Originally Posted by jendc08

What is the obsession with the NON-fasting lipid panel? I have never ordered this in the ED. Even on chest pains that are getting admitted for acute mi, acs, rule out whatever. Why would a 38 yo with chest pain, cough get one?

I concur. I was thinking the same thing - the value of a non-fasting lipid panel is nil. If I EVER ordered one, it was strictly for the convenience of the admitting doc. To say that ordering one should be standard, as the POS lawyers say, "strains credibility".

Originally Posted by Apollyon

I concur. I was thinking the same thing - the value of a non-fasting lipid panel is nil. If I EVER ordered one, it was strictly for the convenience of the admitting doc. To say that ordering one should be standard, as the POS lawyers say, "strains credibility".

My physician has switched to non-fasting lipid panels. He says its the latest trend. Haven't looked up the research myself, but don't see why he would mislead me.

Originally Posted by southerndoc

My physician has switched to non-fasting lipid panels. He says its the latest trend. Haven't looked up the research myself, but don't see why he would mislead me.

Right now, if I had a random lipid done on me, you would think I am a walking time bomb, despite my fasting total cholesterol of 160.

Originally Posted by southerndoc

My physician has switched to non-fasting lipid panels. He says its the latest trend. Haven't looked up the research myself, but don't see why he would mislead me.

But your physician is not an EM doc, right?

We don't -- or, at least -- shouldn't care about lipids. I don't care about risk factor modification or identification. I care about ACS.

On the most lenient side: high lipids are - alone - at best - an OK indicator of some risk of CAD. I just don't care in the ED.

We have to separate our specialty from that of acute IM, FM, or Peds. We are our own specialty. We don't care about asymptomatic CAD. We care about ACS.

Who cares what the IM literature says about fasting vs. non-fasting lipids for modification of some CAD risk factor?

HH

Originally Posted by Hamhock

We don't -- or, at least -- shouldn't care about lipids. I don't care about risk factor modification or identification. I care about ACS.

Isn't dyslipidemia one of the risk factors of TIMI scoring? Doesn't TIMI scoring help predict risk factors for ACS?

Originally Posted by southerndoc

Isn't dyslipidemia one of the risk factors of TIMI scoring? Doesn't TIMI scoring help predict risk factors for ACS?

Yes but not at a level of discrimination that is useful to us as ED docs. The lowest risk TIMI patients still had an event rate of 4.7% which is too high to send home. Also an HDL <40 is only one of 3 factors needed to get even a point on TIMI.

Originally Posted by EM DR

The resident physician Marsha W. Edwards was also involved. Any chances that Dr. McNamara was in a hurry/too busy and trusted her, so he didn't double check her work/findings? I'm not trying to blame on the resident; but with Dr. McNamara's skills, knowledge, and experiences, I don't think he would fail to order the cardiac biomarkers and possibly a lipid panel.

He's an amazing clinician and having trained under him, I can tell you that his clinical judgement and bedside gestalt of patients is outstanding. He would never, in my experience, order a lipid panel in the ED, nor should he. As for the biomarkers, in a 38 year old with questionable history, depending on the actual HPI, there may be zero utility in ordering them. The bad outcome 3 months later doesn't, in my mind, implicate a miss on this visit necessarily.

We see pts routinely with shoulder pathology, PNA, radicular symptoms etc that have left chest/arm discomfort that do not need or get biomarkers. To order them on every chest pain is poor resource utilization. Would a single set, or even admission have changed the clinical outcome? Probably not. Many (probably most) patients do not get cath or even inpatient stress testing--the system is often too burdened to accommodate this. If he didn't follow up in the intervening 3 months, a 3 set rule out at presentation (obviously assuming a rule out and not NSTEMI) would not have changed anything other than the named defendant, but wouldn't have equalled better medical care if the initial HPI is not suggestive of ACS.

Also, do not underestimate the Philadelphia legal system. They had to change the law to prohibit importing cases into the county because it is such a legal hell hole.