Croup fatality malpratice case aka the scourge of bad EM expert witnesses

[ShockIndex]

Out of curiosity, at what point in time do you think that having not actively practiced emergency medicine for several years will make you an unreliable expert witness?

In most states, you must spend a certain percentage of your work in the ED at the time the alleged malpractice occurred in order to comment on the standard of care. So, this will probably be my last few months accepting/commenting on ED cases. All of the cases that I mention were settled more than a year ago; one occurred over a decade ago.

My primary point commenting in this thread is a reminder the we have a growing problem of clueless people practicing medicine. They hurt people, often many times before anything is done to stop them. Our system is such that the major mechanisms for restitution for these patients requires that another physician of similar training be willing to step forward and confront that reality. It’s not done behind closed curtains, nobody is getting stabbed in the back, and the accused is afforded representation and a defense. I’m all for reforms that de-monetize the process, but that ain’t happening soon.

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[ShockIndex]

I do some expert witness work.

A few things are egregious.

Most things are nonsense.

Transient Neuro symptoms in otherwise healthy people after neg CTA and low risk abdominal pain with improved exam are likely not cases I would be writing an opinion of support of.

If you're not practicing actively, I don't think you have a leg to stand on.

Again, these were not cases of low risk abdominal pain or transient neuro symptoms that got a CTA. These were acute abdominal pain patients sent home with a diagnosis of gastroenteritis, no return precautions, no MDM, and a documented exam that left us wondering if an exam was even done.

The neuro cases were people who came in with hemiplegia and dysarthria (or worse) via EMS and were sent home with no meaningful neuro exam or consideration in the MDM that these were TIAs or strokes. Neither received a CTA (not that a CTA changes how you should approach a TIA) although these cases were before the era of cath directed therapies.

What has happened is that people are injecting their fantasies into these cases and making far far less egregious.

 

[RustedFox]

In most states, you must spend a certain percentage of your work in the ED at the time the alleged malpractice occurred in order to comment on the standard of care. So, this will probably be my last few months accepting/commenting on ED cases. All of the cases that I mention were settled more than a year ago; one occurred over a decade ago.

My primary point commenting in this thread is a reminder the we have a growing problem of clueless people practicing medicine. They hurt people, often many times before anything is done to stop them. Our system is such that the major mechanisms for restitution for these patients requires that another physician of similar training be willing to step forward and confront that reality. It’s not done behind closed curtains, nobody is getting stabbed in the back, and the accused is afforded representation and a defense. I’m all for reforms that de-monetize the process, but that ain’t happening soon.

1. If I remember, you're EM/CC, or EM/IM ? No shade thrown, amigo.

2. I'm in full agreement with your second statement. Some of these people (even a few physicians that I know) are completely effing ostriched. I don't know HOW these people are permitted to practice. I hate to say it; but I've reached the point where I feel that more stringent requirements are needed in order to educate a physician. This is going to sound conceited, but I've always felt that my strong point in medicine was my pure academic "horsepower"; my ability to arrest huge amounts of data - maybe the true integration of the data and the reasons behind it came later, once I had wrestled with it for a bit - but damn, it was there, in my brain, chiseled in stone.

No joke, I remember memorizing all the lyrics to "We Didn't Start the Fire" (Billy Joel) in second grade because I really, really liked the song. I didn't know what 80% of the lyrics meant at all, but they were there, in my brain. I remember my favorite lyric being "brooklyn's got a winning team!" because I was a big baseball kid and this meant something to me.

I've had enough caffeine this morning.

 

[Brigade4Radiant]

1. If I remember, you're EM/CC, or EM/IM ? No shade thrown, amigo.

2. I'm in full agreement with your second statement. Some of these people (even a few physicians that I know) are completely effing ostriched. I don't know HOW these people are permitted to practice. I hate to say it; but I've reached the point where I feel that more stringent requirements are needed in order to educate a physician. This is going to sound conceited, but I've always felt that my strong point in medicine was my pure academic "horsepower"; my ability to arrest huge amounts of data - maybe the true integration of the data and the reasons behind it came later, once I had wrestled with it for a bit - but damn, it was there, in my brain, chiseled in stone.

No joke, I remember memorizing all the lyrics to "We Didn't Start the Fire" (Billy Joel) in second grade because I really, really liked the song. I didn't know what 80% of the lyrics meant at all, but they were there, in my brain. I remember my favorite lyric being "brooklyn's got a winning team!" because I was a big baseball kid and this meant something to me.

I've had enough caffeine this morning.

The thing is to educate a physician now its just more competitive and more expensive with less money that you can make as an attending.

 

[RustedFox]

The thing is to educate a physician now its just more competitive and more expensive with less money that you can make as an attending.

Hunh?

 

[WilcoWorld]

1. If I remember, you're EM/CC, or EM/IM ? No shade thrown, amigo.

2. I'm in full agreement with your second statement. Some of these people (even a few physicians that I know) are completely effing ostriched. I don't know HOW these people are permitted to practice. I hate to say it; but I've reached the point where I feel that more stringent requirements are needed in order to educate a physician. This is going to sound conceited, but I've always felt that my strong point in medicine was my pure academic "horsepower"; my ability to arrest huge amounts of data - maybe the true integration of the data and the reasons behind it came later, once I had wrestled with it for a bit - but damn, it was there, in my brain, chiseled in stone.

No joke, I remember memorizing all the lyrics to "We Didn't Start the Fire" (Billy Joel) in second grade because I really, really liked the song. I didn't know what 80% of the lyrics meant at all, but they were there, in my brain. I remember my favorite lyric being "brooklyn's got a winning team!" because I was a big baseball kid and this meant something to me.

I've had enough caffeine this morning.

And here I committed "Baby Got Back" to memory. Guess I'm the Brown to your Yale.

 

[RustedFox]

And here I committed "Baby Got Back" to memory. Guess I'm the Brown to your Yale.

I see you went to a powerhouse residency as well.

 

[ShockIndex]

1. If I remember, you're EM/CC, or EM/IM ? No shade thrown, amigo.

2. I'm in full agreement with your second statement. Some of these people (even a few physicians that I know) are completely effing ostriched. I don't know HOW these people are permitted to practice. I hate to say it; but I've reached the point where I feel that more stringent requirements are needed in order to educate a physician. This is going to sound conceited, but I've always felt that my strong point in medicine was my pure academic "horsepower"; my ability to arrest huge amounts of data - maybe the true integration of the data and the reasons behind it came later, once I had wrestled with it for a bit - but damn, it was there, in my brain, chiseled in stone.

No joke, I remember memorizing all the lyrics to "We Didn't Start the Fire" (Billy Joel) in second grade because I really, really liked the song. I didn't know what 80% of the lyrics meant at all, but they were there, in my brain. I remember my favorite lyric being "brooklyn's got a winning team!" because I was a big baseball kid and this meant something to me.

I've had enough caffeine this morning.

They are permitted to practice by the attitude that permeates this thread (not necessarily by you) that expert witnesses for plaintiffs are “sell outs” or worse. It’s a well rooted culture in medicine that sustains the least among us and is about as ethical as the “blue wall of silence” that recycles the significant minority of bad cops. It’s only going to get worse as more and more medical schools move away from achievement-based metrics in their admissions (Google the resent WSJ article on med school rankings) and we replace the good physicians with low-cost alternatives and physicians committed to values other than quality. People are free it ignore or complain about it, but funny how they never want to DO anything about it, heaven forbid.

 

[Kryptocoin]

I take on about 2-3 cases per year. Virtually all are now for plaintiffs and I only work with a handful of firms. Every case that I’ve rendered an opinion on has settled before trial. Why do I do this you ask? Because some of our colleagues are *****s and kill people. Here is a little taste:
1) Slapping a fentanyl patch on an opiate naive person who goes home to bed and never wakes up; toxic levels of fentanyl in blood on postmortem.
2) One case of an EP writing horse anesthetic doses of oxy, Valium, and soma to TEENAGER with back pain who overdosed and died 24 hours after the visit.
3 Leaving someone to the ED obs unit for 24 hours with chest pain and a dilated aortic root with pericardial effusion on stress echo and a cardiologist read and documented phone call to the EP that said, “Hey, this looks like a dissection.” The CTA aortogram was ordered routine; no attempts were made at anti-impulse therapy; no calls to CT surgery…just a perplexing 12 hour delay for a CT that was ordered “routine.” The patient coded on the way to the OR.
3) Multiple cases of people in their 30-40s sent home after transient periods of hemiparesis (or something scarier like transient vertigo, double vision, hemiparesis, and dysarthria). You know, because people in their 30-40s never have strokes. Typically a neuro exam that says something like “A&Ox4, strength intact” and a negative non-contrasted head CT as a defense. Virtually every case the patient has a massive stroke within a week. Each case there was no time-specific follow-up for expedited out-patient work-up; just see your doctor in 2-3 days.
4) Multiple cases of young men with abdominal pain and vomiting being sent home w/o imaging and with a diagnosis of constipation or gastroenteritis (if the poop was at all soft) and discharge instructions to follow up with their MD in 2-4 days. All return 2-3 days later with perforated appendicitis.
5) And last but not least, my absolute favorite - missed esophageal intubation. That’s right, some of our colleagues don’t believe in capnography to confirm tube placement. It’s something that only anesthesiologists do in the OR one said in depo. They trust their exam skills and a CXR to confirm placement before wisking the patient off to CT, or better yet - an ambulance to go to another hospital. Nothing says EMTALA + lawsuit like putting a patient in an ambulance for transfer 5 min after you “secured the airway” in the esophagus for the paramedic to troubleshoot.

Outpt medicine is near dead. No such thing as "expedited" followup except maybe ortho.

Most malpractice cases are nothing more than "there's a bad outcome and someone needs to be blamed". Very few are actually gross negligence. I would be happy if most lawsuits are about drug overdose or missed intubations.These egregious cases make a small fraction of cases.

 

[Franzd'Epinay]

They are permitted to practice by the attitude that permeates this thread (not necessarily by you) that expert witnesses for plaintiffs are “sell outs” or worse. It’s a well rooted culture in medicine that sustains the least among us and is about as ethical as the “blue wall of silence” that recycles the significant minority of bad cops.

I don't disagree with you in that some people can't tolerate any criticisms of physicians, but the bolded statement is absolute nonsense. There has never been a shortage of physicians doing plaintiff expert witness work and plenty of physicians following the standard of care have had to settle or pay out BS cases.

 

[ShockIndex]

I don't disagree with you in that some people can't tolerate any criticisms of physicians, but the bolded statement is absolute nonsense. There has never been a shortage of physicians doing plaintiff expert witness work and plenty of physicians following the standard of care have had to settle or pay out BS cases

Yes, some physicians are victims of frivolous lawsuits. However, the overwhelming majority of lawsuits that settle for more than $100K have a lot of substance in my experience. (your experience may be different). Those are the cases that I’m talking about and they are unfortunately more common than many on this forum think.

For perspective, about 50% of the cases brought to me are lawyers with a legit concern for their client but no real malpractice behind the outcome. I bill them for reviewing the case but tell them no dice. Another 25% have some serious best practices issues but no standard of care issues. Often there is a lot of back and forth that drives up my hourly fee, but I inevitably tell them no dice (I don’t recall a lawyer ever changing my mind). Only 25% of the cases that I’ve reviewed resulted in a claim of negligence. I’m also very selective with the firms that I work with and the types of cases that I take.

Most recently, I’ve focused on missed esophageal intubations because these are typically slam dunks. They are also being done by people who have no business intubating in the ED or field.

 

[Kryptocoin]

Yes, some physicians are victims of frivolous lawsuits. However, the overwhelming majority of lawsuits that settle for more than $100K have a lot of substance in my experience. (your experience may be different). Those are the cases that I’m talking about and they are unfortunately more common than many on this forum think.

For perspective, about 50% of the cases brought to me are lawyers with a legit concern for their client but no real malpractice behind the outcome. I bill them for reviewing the case but tell them no dice. Another 25% have some serious best practices issues but no standard of care issues. Often there is a lot of back and forth that drives up my hourly fee, but I inevitably tell them no dice (I don’t recall a lawyer ever changing my mind). Only 25% of the cases that I’ve reviewed resulted in a claim of negligence. I’m also very selective with the firms that I work with and the types of cases that I take.

Most recently, I’ve focused on missed esophageal intubations because these are typically slam dunks. They are also being done by people who have no business intubating in the ED or field.

They don't have to change your mind. They'll just move on to another expert witness until they get the answer they want. Remember, they DO NOT have to disclose your findings or opinion to the defense side or court. That's what makes it shady because they can just keep shopping around until they find someone and no one will know how many experts declined the case.

 

[allantois]

I've recently listened to a lecture on YouTube by a JD/MD who commented that the malpractice system is really the fault of medical boards and societies for both not going after bad actors in medicine as as well as not going after bad expert witnesses. Couldn't agree more.

 

[ShockIndex]

They don't have to change your mind. They'll just move on to another expert witness until they get the answer they want. Remember, they DO NOT have to disclose your findings or opinion to the defense side or court. That's what makes it shady because they can just keep shopping around until they find someone and no one will know how many experts declined the case.

You’ve been watching too much Better Call Saul. Firms that try that will go broke fast.

 

[Kryptocoin]

You’ve been watching too much Better Call Saul.

I hope you're joking. Because if you think what I wrote is fictional, then you should spend more time with defense lawyers, not plaintiff attorneys. Expert witness shopping is a known game.

You're not the only girl they're talking to.

 

[TooMuchResearch]

That has such a negative connotation. I like to think of it this way - with the proliferation of NPs in the ED and physicians who trained at all those lovely HCA residences, there are now PLENTY of people who have no clue as to what they are doing while “practicing” in the ED. They can’t recognize a TIA to save their a$$, and they come out of training with 30-40 intubations thinking they are going to step into our world and do our job (ie the world run by those of us who actually went to medical school and completed a legit residency). I’m more than happy to prey on these people.

People graduate with 30-40 total intubations? Oof.

 

[Janders]

I am aware of a hypothetical missed appy lawsuit

Young man, truly classic gastroenteritis, entire family had it at once!
Fluids, labs, zofran, serial (documented!) exams. Felt entirely better.
D/C home.
Got strict instructions to return if worsening pain, etc. (also got the generic belly pain d/c packet).
Returned <36hr later with "I have a new, different pain in my RLQ! I came back! This is very different than my last visit?!"
Rapidly dx'd w/ appy, perforated before OR (time to OR wasn't rapid, but also well within typical).

Initial ED team named (MD, RN, other MD) along w/ all surgeons.

They got an expert to say the care wasn't good

 

[BoardingDoc]

No joke, I remember memorizing all the lyrics to "We Didn't Start the Fire" (Billy Joel) in second grade because I really, really liked the song. I didn't know what 80% of the lyrics meant at all, but they were there, in my brain. I remember my favorite lyric being "brooklyn's got a winning team!" because I was a big baseball kid and this meant something to me.

+1 to memorizing the lyrics to that song. Also to "end of the world as we know it" by REM and "one week" by barenaked ladies. I think I just have a thing for rapidfire lyrics that aren't rap.

 

[ShockIndex]

People graduate with 30-40 total intubations? Oof.

That assumes that they completed an EM residency. There are IM and FP grads performing intubations in the ED and ICU. They are who I most recently feed upon. Then, there are paramedics who goose people and fail to perform capnography which is now in many states part of the EMS protocols.

Here’s the deal - if someone chooses to take on an airway without first completing an accredited EM or anesthesia residency, or critical care fellowship AND that resource was available in their facility but they chose not to use because their IM/FP program “trained” them to intubate, then I will disassemble their dumb a$$ if they kill the patient with a missed esophageal intubation and the case gets sent to me. Virtually all of these cases involve horrible decision making a clear lack of skill through every step - things like wrong paralytic dosages, massive miscalculations in tube depth, manipulation of tubes without re-confirming placement, inappropriately using long acting paralytics for agitated patients (yes, a tube in their esophagus makes patients agitated), etc.

There is absolutely no reason for an IM or FP trained physician to be moonlighting airways in the ED or ICU when there is another board-certified EP or intensivist in the department/unit.

Of course, I give wide allowances when someone is trying to save a life in a resource constrained environment where they are the only doc.

 

[NYEMMED]

Yes, some physicians are victims of frivolous lawsuits. However, the overwhelming majority of lawsuits that settle for more than $100K have a lot of substance in my experience. (your experience may be different). Those are the cases that I’m talking about and they are unfortunately more common than many on this forum think.

For perspective, about 50% of the cases brought to me are lawyers with a legit concern for their client but no real malpractice behind the outcome. I bill them for reviewing the case but tell them no dice. Another 25% have some serious best practices issues but no standard of care issues. Often there is a lot of back and forth that drives up my hourly fee, but I inevitably tell them no dice (I don’t recall a lawyer ever changing my mind). Only 25% of the cases that I’ve reviewed resulted in a claim of negligence. I’m also very selective with the firms that I work with and the types of cases that I take.

Most recently, I’ve focused on missed esophageal intubations because these are typically slam dunks. They are also being done by people who have no business intubating in the ED or field.

I was on a credentials committee… I’ve seen the majority of cases with settlements are frivolous.

Sorry but lawyers and plaintiff expert witnesses are the problem with the broken malpractice system and are driving physician burnout and career changes.

The system needs to be reformed to a medical panel deciding if cases have merit or not, who are not influenced by well dressed lawyers throwing cash…
It will take years to change.
As a medical director (also in the past) I would never hire any doc that was a plaintiff expert witness on their CV

 

[ShockIndex]

I was on a credentials committee… I’ve seen the majority of cases with settlements are frivolous.

Me too. We weighed the nature of the claims, physician’s speciality (some get sued more than others - I’m looking at you OB ), amounts paid, and any patterns involving multiple similar claims…among other things. There were instances where we granted privileges with restrictions on procedures/practice or required remediation for repeat offenders re-applying for privileges.

Many small settlements are indeed frivolous. Far too many big ones are not. Notice how I qualified my comments to a rough amount.

So, if you are dead set against plaintiff’s witnesses and our current system requires them, how do you plan to compensate patients who are harmed by negligence while we wait for utopia?

 

[DeadCactus]

I take on about 2-3 cases per year. Virtually all are now for plaintiffs and I only work with a handful of firms. Every case that I’ve rendered an opinion on has settled before trial. Why do I do this you ask? Because some of our colleagues are *****s and kill people. Here is a little taste:
1) Slapping a fentanyl patch on an opiate naive person who goes home to bed and never wakes up; toxic levels of fentanyl in blood on postmortem.
2) One case of an EP writing horse anesthetic doses of oxy, Valium, and soma to TEENAGER with back pain who overdosed and died 24 hours after the visit.
3 Leaving someone to the ED obs unit for 24 hours with chest pain and a dilated aortic root with pericardial effusion on stress echo and a cardiologist read and documented phone call to the EP that said, “Hey, this looks like a dissection.” The CTA aortogram was ordered routine; no attempts were made at anti-impulse therapy; no calls to CT surgery…just a perplexing 12 hour delay for a CT that was ordered “routine.” The patient coded on the way to the OR.
3) Multiple cases of people in their 30-40s sent home after transient periods of hemiparesis (or something scarier like transient vertigo, double vision, hemiparesis, and dysarthria). You know, because people in their 30-40s never have strokes. Typically a neuro exam that says something like “A&Ox4, strength intact” and a negative non-contrasted head CT as a defense. Virtually every case the patient has a massive stroke within a week. Each case there was no time-specific follow-up for expedited out-patient work-up; just see your doctor in 2-3 days.
4) Multiple cases of young men with abdominal pain and vomiting being sent home w/o imaging and with a diagnosis of constipation or gastroenteritis (if the poop was at all soft) and discharge instructions to follow up with their MD in 2-4 days. All return 2-3 days later with perforated appendicitis.
5) And last but not least, my absolute favorite - missed esophageal intubation. That’s right, some of our colleagues don’t believe in capnography to confirm tube placement. It’s something that only anesthesiologists do in the OR one said in depo. They trust their exam skills and a CXR to confirm placement before wisking the patient off to CT, or better yet - an ambulance to go to another hospital. Nothing says EMTALA + lawsuit like putting a patient in an ambulance for transfer 5 min after you “secured the airway” in the esophagus for the paramedic to troubleshoot.

I'm always frustrated by the kneejerk defense of any physician who is being sued and the jump to crucify anyone who does expert witness work for the plaintiff. There are people practicing bad medicine out there and they deserve to be taken to court. Plaintiff lawyers don't want to waste their time on weak cases and deserve competent opinions both for their own sake and to protect physicians from mercenary expert witnesses.

 

[ShockIndex]

I'm always frustrated by the kneejerk defense of any physician who is being sued and the jump to crucify anyone who does expert witness work for the plaintiff. There are people practicing bad medicine out there and they deserve to be taken to court. Plaintiff lawyers don't want to waste their time on weak cases and deserve competent opinions both for their own sake and to protect physicians from mercenary expert witnesses.

Amen. There is a balance. A pretty good indicator that a witness is getting out of balance is when more than 10-15% of their income is medmal. This often begins with them taking on just about any firm as a client. Another is when they find lawyers frequently changing their mind.

As previously mention, I review up to 4 cases per year now. Only 1 or two will go anywhere. It’s less than 10% of my income, and I only work with select firms or by trusted word or mouth - balance.

 

[xaelia]

Interesting discussion.

Definitely a lot of misses and near misses out there in the health system, some due to ignorance and/or laziness.

Some of these cited examples I'm hesitant to be quite so declarative about "substandard care" because there's a difference between "ideal care" and "guideline recommended care" and ... what actually happens. To some extent, the sub-optimal care being provided by IM and FP folks in rural EDs informs the legal "standard of care", as distasteful as it would be. Misdiagnoses and inadequate safety-netting, while crap for patients, for sure, are reasonably pervasive and bad outcomes quite rare. Seeing a lawsuit settled would hardly validate an expert opinion of negligence, only that an expedient end was perceived as the optimal financial outcome.

 

[ShockIndex]

Two of the common features of the neuro cases that I’ve seen is the use of non-contrasted head CTs in the decision making and the practice of listing long differentials without further context in the MDM.

The problem with the non-con head CT is that it’s got a great sensitivity for ICH, but it’s only 50% sensitive for ischemic stroke in the first 24 hours. So, ordering a non-con CT becomes problematic because your opening the door to the other roughly 80% of vascular insults that will cause focal deficits - ie you were concerned enough to get the non-con CT, why is it sufficient to close the door on the more likely vascular problem? The other problem in this case was assigning a diagnosis of cervical radiculopathy to a patient with upper and lower body symptoms - at best that is a myelopathy that is also a CNS emergency. Bottom line, if you are reasonably certain that the cause of neuro symptoms is peripheral, then don’t confuse the picture and order central testing that is insensitive for the most common causes. Making matters worse, this patient came in with EMS as a code stroke that was down graded by the provider when the sx seemed to be improving in the scanner. Had they not cancelled the code stroke, the patient would have received a teleneuro consult…

The other provider, among other things, listed a looog differential for the vertigo, dysarthria, and hemiplegia. I mean, they listed stuff like stroke, vertebral dissection, meningitis, encephalitis, you name it. The problem is, they didn’t give any explanation as to why they were not performing adequate testing for the top three common and dangerous things in that differential. Eventually, they settled on dehydration when the head CT came back negative.

Both providers admitted in depo that a big reason for them closing the door on stroke/TIA because of the patient’s young age - cringe.

 

[Birdstrike]

My primary point commenting in this thread is a reminder the we have a growing problem of clueless people practicing medicine. They hurt people, often many times before anything is done to stop them.

Doctors can screw up and badly. I’ll never argue against that fact.

But anytime I see a plaintiff’s doctor or lawyer hide behind the “We’re protecting the public” argument, my BS detector goes wild. Working for plaintiffs attorneys and testifying against such so-called “clueless” practitioners doesn’t do anything to stop them from harming people. In fact, you make money off them. If anything, the profit motive is such that you’d prefer they stick around making mistakes so you can file more claims and earn more easy chart review money.

I’ve always made the point that attorneys will claim in court (or deposition) a doctor is incompetent and dangerous, yet do nothing to remove them from practice. They’ll even go to them as a patient later. I’ve seen it happen!

How come lawyers don’t go for a docs license after calling them a butcher in court?

Because they want to throw that fish back to be caught (sued) again. They and their “expert” witnesses have no interest in protecting the public. I know how easy that expert witness money it. MAN, it is easy money. But don’t tell me it has a THING to do with “protecting the public” from bad doctors. That’s a load of BS.

 

[ShockIndex]

Doctors can screw up and badly. I’ll never argue against that fact.

But anytime I see a plaintiff’s doctor or lawyer hide behind the “We’re protecting the public” argument, my BS detector goes wild. Working for plaintiffs attorneys and testifying against such so-called “clueless” practitioners doesn’t do anything to stop them from harming people. In fact, you make money off them. If anything, the profit motive is such that you’d prefer they stick around making mistakes so you can file more claims and earn more easy chart review money.

I’ve always made the point that attorneys will claim in court (or deposition) a doctor is incompetent and dangerous, yet do nothing to remove them from practice. They’ll even go to them as a patient later. I’ve seen in happen!

How come lawyers don’t go for a docs license after calling them a butcher in court?

Because they want to throw that fish back to be caught (sued) again. They and their “expert” witnesses have no interest in protecting the public. I know how easy that expert witness money it. MAN, it is easy money. But don’t tell me it has a THING to do with “protecting the public” from bad doctors. That’s a load of BS.

Yeah, In total I have 20 years of military and law enforcement service and probably more combat deployments than you’ve got teeth. Four of those years spent in an operational medical detachment with the DOJ making GS13 salary + LEP when I could be using my MD and residency training to make attending salary. Some of that time was spent hunting physicians who enjoy things like diversion and passing kiddy porn across state lines. Please don’t lecture me on my motives.

 

[kumatie]

Two of the common features of the neuro cases that I’ve seen is the use of non-contrasted head CTs in the decision making and the practice of listing long differentials without further context in the MDM.

The problem with the non-con head CT is that it’s got a great sensitivity for ICH, but it’s only 50% sensitive for ischemic stroke in the first 24 hours. So, ordering a non-con CT becomes problematic because your opening the door to the other roughly 80% of vascular insults that will cause focal deficits - ie you were concerned enough to get the non-con CT, why is it sufficient to close the door on the more likely vascular problem? The other problem in this case was assigning a diagnosis of cervical radiculopathy to a patient with upper and lower body symptoms - at best that is a myelopathy that is also a CNS emergency. Bottom line, if you are reasonably certain that the cause of neuro symptoms is peripheral, then don’t confuse the picture and order central testing that is insensitive for the most common causes. Making matters worse, this patient came in with EMS as a code stroke that was down graded by the provider when the sx seemed to be improving in the scanner. Had they not cancelled the code stroke, the patient would have received a teleneuro consult…

The other provider, among other things, listed a looog differential for the vertigo, dysarthria, and hemiplegia. I mean, they listed stuff like stroke, vertebral dissection, meningitis, encephalitis, you name it. The problem is, they didn’t give any explanation as to why they were not performing adequate testing for the top three common and dangerous things in that differential. Eventually, they settled on dehydration when the head CT came back negative.

Both providers admitted in depo that a big reason for them closing the door on stroke/TIA because of the patient’s young age - cringe.

Jeezus, get off your f’n high horse. You are just as bad as the expert witness in the croup case!

 

[kumatie]

Doctors can screw up and badly. I’ll never argue against that fact.

But anytime I see a plaintiff’s doctor or lawyer hide behind the “We’re protecting the public” argument, my BS detector goes wild. Working for plaintiffs attorneys and testifying against such so-called “clueless” practitioners doesn’t do anything to stop them from harming people. In fact, you make money off them. If anything, the profit motive is such that you’d prefer they stick around making mistakes so you can file more claims and earn more easy chart review money.

I’ve always made the point that attorneys will claim in court (or deposition) a doctor is incompetent and dangerous, yet do nothing to remove them from practice. They’ll even go to them as a patient later. I’ve seen in happen!

How come lawyers don’t go for a docs license after calling them a butcher in court?

Because they want to throw that fish back to be caught (sued) again. They and their “expert” witnesses have no interest in protecting the public. I know how easy that expert witness money it. MAN, it is easy money. But don’t tell me it has a THING to do with “protecting the public” from bad doctors. That’s a load of BS.

Doctors can screw up and badly. I’ll never argue against that fact.

But anytime I see a plaintiff’s doctor or lawyer hide behind the “We’re protecting the public” argument, my BS detector goes wild. Working for plaintiffs attorneys and testifying against such so-called “clueless” practitioners doesn’t do anything to stop them from harming people. In fact, you make money off them. If anything, the profit motive is such that you’d prefer they stick around making mistakes so you can file more claims and earn more easy chart review money.

I’ve always made the point that attorneys will claim in court (or deposition) a doctor is incompetent and dangerous, yet do nothing to remove them from practice. They’ll even go to them as a patient later. I’ve seen in happen!

How come lawyers don’t go for a docs license after calling them a butcher in court?

Because they want to throw that fish back to be caught (sued) again. They and their “expert” witnesses have no interest in protecting the public. I know how easy that expert witness money it. MAN, it is easy money. But don’t tell me it has a THING to do with “protecting the public” from bad doctors. That’s a load of BS.

Thank you! Said perfectly. This is exactly my take on Index, wtf is going on with this thread?! It is about ****ty expert witnesses, not a place for someone like Index to prove that he is…exactly that which he thinks he is not.

 

[ShockIndex]

Thank you! Said perfectly. This is exactly my take on Index, wtf is going on with this thread?! It is about ****ty expert witnesses, not a place for someone like Index to prove that he is…exactly that which he thinks he is not.

So sorry to interrupt your echo chamber. I’ll shut up so that you can keep listening to how the problem with medicine is all malpractice caused by unethical expert witnesses who just want to make money. Oh crap, don’t forget the administrators - they’re all bad too.

 

[Birdstrike]

Yeah, In total I have 20 years of military and law enforcement service and probably more combat deployments than you’ve got teeth. Four of those years spent in an operational medical detachment with the DOJ making GS13 salary + LEP when I could be using my MD and residency training to make attending salary. Some of that time was spent hunting physicians who enjoy things like diversion and passing kiddy porn across state lines. Please don’t lecture me on my motives.

Interesting sidebar about non-medical experience, dentition and criminal conduct by doctors. But the thread is about dubious expert testimony in civil cases. I still don't see how taking money to testify against so-called "clueless" doctors in civil cases stops them from being clueless and continuing to hurt the public.

Do you file board complaints to suspend the licenses of the "clueless" and harmful doctors you sue in civil court, to protect the public or do you and your attorney's just cash the checks and send them back out so they can harm (and be sued) again?

 

[Kryptocoin]

Doctors can screw up and badly. I’ll never argue against that fact.

But anytime I see a plaintiff’s doctor or lawyer hide behind the “We’re protecting the public” argument, my BS detector goes wild. Working for plaintiffs attorneys and testifying against such so-called “clueless” practitioners doesn’t do anything to stop them from harming people. In fact, you make money off them. If anything, the profit motive is such that you’d prefer they stick around making mistakes so you can file more claims and earn more easy chart review money.

I’ve always made the point that attorneys will claim in court (or deposition) a doctor is incompetent and dangerous, yet do nothing to remove them from practice. They’ll even go to them as a patient later. I’ve seen it happen!

How come lawyers don’t go for a docs license after calling them a butcher in court?

Because they want to throw that fish back to be caught (sued) again. They and their “expert” witnesses have no interest in protecting the public. I know how easy that expert witness money it. MAN, it is easy money. But don’t tell me it has a THING to do with “protecting the public” from bad doctors. That’s a load of BS.

The latest study shows 75% of EM physicians will be named in a suit some time in their career. How does that not raise some kind of red flag that the malpractice industry is just another unregulated for-profit industry. I never really bought the "protecting the public" argument.

 

[Birdstrike]

The latest study shows 75% of EM physicians will be named in a suit some time in their career. How does that not raise some kind of red flag that the malpractice industry is just another unregulated for-profit industry. I never really bought the "protecting the public" argument.

It's more than a red flag. Clearly, there is no profession where 75% of practitioners are dangerous and incompetent. But if there was, any ethical system claiming to "protect the public" from those bad actors would necessarily need to be focused on ridding the system of those bad actors, not recycling their "harm" to be profited from multiple times over a career. Never forget, that each one of those suits needs a profiteer to give it the spark of life.

 

[ShockIndex]

Interesting sidebar about non-medical experience, dentition and criminal conduct by doctors. But the thread is about dubious expert testimony in civil cases. I still don't see how taking money to testify against so-called "clueless" doctors in civil cases stops them from being clueless and continuing to hurt the public.

Now that we are back to being polite and civil I’m happy to answer your question.

Many cases actually do get reported to state and federal regulators. All but 1 if the airway cases that I was involved in did. The paramedic was disciplined/remediated by his state as well as his MD as I recall. There were EMTALA issues surrounding the missed esophageal intubation that was put on an ambulance. CMS cited the hospital after another missed esophageal intubation due to inadequate monitoring issues when the patient died after getting a long acting paralytic.

The reason why state medical boards are not more involved in these cases has a lot of reasons:

1) Many state boards only entertain complaints from patients, surviving family members, or other physicians; lawyers often are not considered to have standing to file complaints in many circumstances. Other boards simply have no interest.

For example, I did occasional moonlighting while an FBI agent and tried to contact several PCP offices on a handful of patients who came in to the ED overdosed or high as a kite after being prescribed the trifecta (opiate, benzo, stimulant) for their ADHD, chronic pain, and anxiety. I figured that I’d give the PCPs the benefit of a call - for most I was sent to voicemail. When the PCPs didn’t return my messages, I file state board complaints for dangerous prescribing; anyone who repeatedly prescribes oxy, xanax, and adderall to the same patient who has previously overdosed is either an idiot or glorified drug dealer. Keep in mind it takes about 30-60 minutes to type up a board complaint properly - I did about 5 in 1 week. I noted in my complaints that the database queries looked like a Costo receipt of controlled substances. Not only did none of those complaints result in any action, some of the PCPs called my director to get me fired. He asked (?told) me to stop.

2) Lawyers are hired to represent their client’s interest and seek fair compensation for damages. They are not being paid to punish, remediate our peers, or otherwise clean up our messes. Several times when I suggested that they have their clients file a complaint to strengthen their cases, they have told me that doing so would have the opposite effect as it would make their client seem vindictive in the eyes of a jury.

Finally, several years ago my wife made me hang up my boots, badge, and guns for a real job. I was in my mid-40s and the FBI’s mission was increasingly taking on street-level LE building RICO cases on cartel and gangs. That’s a young man’s game with long hours of survalence; I’ve got a kid now. However, I find medmal work to be a great complement to my current career that allows me to use my investigative roots, experience in the court room, etc. Each case is like solving a mystery.

 

[Janders]

Just some of the thought process here

Young patient. Vertigo. Benign exam. But we get a head Ct bc the patients aunt had a tumor or the patient wanted it or whatever.

It that “bad” utilization? Maybe

Is it default malpractice because it is insensitive?

You tell the patient to see their PCP within two days.

You should have said come back if hemispheric and see dr “doesn’t take your insurance” from neurology in 1.5 days?

 

[ShockIndex]

It's more than a red flag. Clearly, there is no profession where 75% of practitioners are dangerous and incompetent. But if there was, any ethical system claiming to "protect the public" from those bad actors would necessarily need to be focused on ridding the system of those bad actors, not recycling their "harm" to be profited from multiple times over a career. Never forget, that each one of those suits needs a profiteer to give it the spark of life.

Simply being named in a lawsuit does not mean that you are dangerous or incompetent in the overwhelming majority of instances. The vast majority of physicians being successfully sued simply made a mistake and were negligent in that particular case. While that negligence caused damages, it is often finite and limited to that moment - it does not usually reflect on their practice. While I listed 5 or 6 egregious cases, those were among a list of 40ish cases that I’ve reviewed. They were listed to illustrate a point that not all expert witness testimonies are a farce.

 

[ShockIndex]

Just some of the thought process here

Young patient. Vertigo. Benign exam. But we get a head Ct bc the patients aunt had a tumor or the patient wanted it or whatever.

It that “bad” utilization? Maybe

Is it default malpractice because it is insensitive?

You tell the patient to see their PCP within two days.

You should have said come back if hemispheric and see dr “doesn’t take your insurance” from neurology in 1.5 days?

Getting a head CT for peripheral vertigo is a waste of time and radiation, but it’s not malpractice.

 

[allantois]

Now that we are back to being polite and civil I’m happy to answer your question.

Many cases actually do get reported to state and federal regulators. All but 1 if the airway cases that I was involved in did. The paramedic was disciplined/remediated by his state as well as his MD as I recall. There were EMTALA issues surrounding the missed esophageal intubation that was put on an ambulance. CMS cited the hospital after another missed esophageal intubation due to inadequate monitoring issues when the patient died after getting a long acting paralytic.

The reason why state medical boards are not more involved in these cases has a lot of reasons:

1) Many state boards only entertain complaints from patients, surviving family members, or other physicians; lawyers often are not considered to have standing to file complaints in many circumstances. Other boards simply have no interest.

For example, I did occasional moonlighting while an FBI agent and tried to contact several PCP offices on a handful of patients who came in to the ED overdosed or high as a kite after being prescribed the trifecta (opiate, benzo, stimulant) for their ADHD, chronic pain, and anxiety. I figured that I’d give the PCPs the benefit of a call - for most I was sent to voicemail. When the PCPs didn’t return my messages, I file state board complaints for dangerous prescribing; anyone who repeatedly prescribes oxy, xanax, and adderall to the same patient who has previously overdosed is either an idiot or glorified drug dealer. Keep in mind it takes about 30-60 minutes to type up a board complaint properly - I did about 5 in 1 week. I noted in my complaints that the database queries looked like a Costo receipt of controlled substances. Not only did none of those complaints result in any action, some of the PCPs called my director to get me fired. He asked (?told) me to stop.

2) Lawyers are hired to represent their client’s interest and seek fair compensation for damages. They are not being paid to punish, remediate our peers, or otherwise clean up our messes. Several times when I suggested that they have their clients file a complaint to strengthen their cases, they have told me that doing so would have the opposite effect as it would make their client seem vindictive in the eyes of a jury.

Finally, several years ago my wife made me hang up my boots, badge, and guns for a real job. I was in my mid-40s and the FBI’s mission was increasingly taking on street-level LE building RICO cases on cartel and gangs. That’s a young man’s game with long hours of survalence; I’ve got a kid now. However, I find medmal work to be a great complement to my current career that allows me to use my investigative roots, experience in the court room, etc. Each case is like solving a mystery.

Physicians know who the bad actors in the community are. I know who the idiots prescribing benzo/opioids are. I even know one whose patient ODed from their cocktail of meds who was then sanctioned but continues to practice prescribing the same dangerous crap glorified by his patients. The fact that they get to keep their license absolutely baffles me

 

[ShockIndex]

Physicians know who the bad actors in the community are. I know who the idiots prescribing benzo/opioids are. I even know one whose patient ODed from their cocktail of meds who was then sanctioned but continues to practice prescribing the same dangerous crap glorified by his patients. The fact that they get to keep their license absolutely baffles me

I actually had 2 separate conversations with various members of the NC board about this guy:

Mount Holly doctor to get prison time for sex-for-pills scheme

The former Mount Holly doctor who admitted to trading pills for sex will likely spend three years in a federal prison. Michael Smith appeared in court on Friday, weeks after pleading guilty to char…

www.gastongazette.com

The first was in around 2013 in a semi-official capacity when a EP friend at a local hospital was inundated by overdoses from his office and multiple local agencies started to get interested. So, I approached the medical board to see if he was on their radar since he was certainly was on ours. My concern was met an attitude that I came from the wrong 3-letter agency to be concerned with a local diversion issue (I wasn’t; half his drugs and sex trafficking went across the NC/SC line and the case that we eventually brought involved no less than federal 5 agencies). However, at that point we had no idea how bad it was, and had I known I probably would not have gone outside of LE channels. My next conversation came about 4 years ago (after conviction but before sentencing) to see how we could have worked together better to mitigate the harm from this guy through early intervention using the CS database and tips from local EDs. Let’s just say that it still wasn’t a priority.

 

[anonperson]

So sorry to interrupt your echo chamber. I’ll shut up so that you can keep listening to how the problem with medicine is all malpractice caused by unethical expert witnesses who just want to make money. Oh crap, don’t forget the administrators - they’re all bad too.

Administration is by definition bad. Some are less bad than others.

To think otherwise is ignorant.

Expert witnesses are typically dirtbags. You keep telling yourself you're one of the good guys. Hired guns to Monday morning quarterback difficult situations so a lawyer can buy a second house and some pi$$ed of family member gets some revenge.

Sure there are egregious cases but I highly doubt you were only involved in the egregious ones. The money's too good and the works too easy.

Malpractice system is completely broken and sell out physicians help feed the fire

 

[xaelia]

Getting a head CT for peripheral vertigo is a waste of time and radiation, but it’s not malpractice.

I'd go so far as to sadly say, getting a head CT for vertigo, and relying upon it inappropriately, is so prevalent, it's almost "standard of care". 🙃

 

[NYEMMED]

Simply being named in a lawsuit does not mean that you are dangerous or incompetent in the overwhelming majority of instances. The vast majority of physicians being successfully sued simply made a mistake and were negligent in that particular case. While that negligence caused damages, it is often finite and limited to that moment - it does not usually reflect on their practice. While I listed 5 or 6 egregious cases, those were among a list of 40ish cases that I’ve reviewed. They were listed to illustrate a point that not all expert witness testimonies are a farce.

Remember every frivolous case (and we all know there are tons) starts with an “expert witness”
You may be the one decent one, but you are part of a group of slimy people saying anything for cash….

 

[WilcoWorld]

Doesn't matter if it's coming from an Ivory Tower Sissy or an expert witness with money coming out of his ears: It's sound medical wisdom to remember that non-con HCT is useful for ruling out ICH and mass effect. Be a good Bayseien and don't let that non-con HCT change your post test probability for stroke.

 

[Birdstrike]

The majority of cases filed are not malpractice. They are frivolous. These cases in particular are the bread and butter for the plaintiffs attorneys and their consultants because they can make many quick settlements and avoid a more costly and labor intensive trial with no guarantee of a win. They can do this because they’ve set up the system such that it costs more money for the defendent to prove their innocence than it does to pay the settlement fee. It amounts to legalized extortion.

 

[WilcoWorld]

I think there's an interesting meta take on this thread: we are sorely lacking in humility. And you know what I've seen save a lot of (patients' and physicians') butts? Humility.

When I tell a patient "I think you're OK, but I'm not certain. I can't ever be certain, please come back if XYZ changes and we'll have another look" the vast majority of my patients find that satisfactory. A small minority insist on further testing, and my system can handle that small minority. Early in my career I thought I had to project certainty - it's interesting that when I ordered more tests to be "certain" I saw that my patients were less happy with their care.

In this thread I see a lot of that (false) certainty, but it's certainty about things like the universal evil of administrators and expert witnesses or certainty about the accuracy of one's retrospectroscope. I won't deign to offer advice, I'll instead reflect on my own experience. I have found that the more I embrace humility, the happier (and safer) I (and my patients) seem to be.

 

[ShockIndex]

Doesn't matter if it's coming from an Ivory Tower Sissy or an expert witness with money coming out of his ears: It's sound medical wisdom to remember that non-con HCT is useful for ruling out ICH and mass effect. Be a good Bayseien and don't let that non-con HCT change your post test probability for stroke.

I suppose there are 4 very simple questions to ask:

1) Is transient of central vertigo with hemiparesis and dysarthria consistent with a TIA or stroke?

2) Is the standard of care in most emergency departments in the US for board certified EP to recognize this as a stroke/TIA and to admit someone with that constellation of symptoms despite a negative head CT?

3) Should a patient who is sent home and returns with a devastating posterior stroke 72 hours later be compensated by the physician since they will be blinking for food for the rest of their life?

I’m going to say yes to all 3 - definitely yes and the patient should not have to sue someone to make it happen. Just have the insurance cut the check for the 30+ years of lost wages and people like me won’t need to exist. We will just sink back into the primordial slime.

But notice how there are people in this thread talking about ABCD2 scores and needlessly filling their hospital up with dizzy people if they were to admit these cases. A big reason for the growing skepticism of our profession is the fact that a lot of our peers will answer points 2 and 3 with a lot of qualifiers.

 

[JacobMcCandles]

However, I find medmal work to be a great complement to my current career that allows me to use my investigative roots, experience in the court room, etc. Each case is like solving a mystery.

Isn't the whole point of a malpractice case because there was gross negligence? I don't think a malpractice case should be a mystery but maybe that's just me.

 

[ShockIndex]

The majority of cases filed are not malpractice. They are frivolous.

Says who and define frivolous. Show me some data.

https://www.nejm.org/doi/full/10.1056/nejmsa054479

In this NEJM, just 3 percent of the claims had no verifiable medical injuries, and 37 percent did not involve errors. Most of those were not compensated. That seems to undermine the entire premise of your post unless frivolous is any claim with which you disagree. Moreover, most people agree that the effect of tort reform has lowered those numbers.

 

[Birdstrike]

I have found that the more I embrace humility, the happier (and safer) I (and my patients) seem to be.

Good post. How would what you’ve learned about embracing humility apply to working as an expert witness for plaintiffs attorneys in cases against fellow doctors?

 

[johhnybgood]

I suppose there are 4 very simple questions to ask:

1) Is transient of central vertigo with hemiparesis and dysarthria consistent with a TIA or stroke?

2) Is the standard of care in most emergency departments in the US for board certified EP to recognize this as a stroke/TIA and to admit someone with that constellation of symptoms despite a negative head CT?

3) Should a patient who is sent home and returns with a devastating posterior stroke 72 hours later be compensated by the physician since they will be blinking for food for the rest of their life?

I’m going to say yes to all 3 - definitely yes and the patient should have to sue someone to make it happen. Just have the insurance cut the check for the 30+ years of lost wages and people like me won’t need to exist. We will just sink back into the primordial slime.

But notice how there are people in this thread talking about ABCD2 scores and needlessly filling their hospital up with dizzy people if they were to admit these cases. A big reason for the growing skepticism of our profession is the fact that a lot of our peers will answer points 2 and 3 with a lot of qualifiers.

2. Would argue that it is not the standard of care to admit TIA (standard of care has varied regionally). Confirmed stroke. yes. Work it up, definitely. CT, CTA, EKG, cardiac monitoring and close follow up w/ neurology. Many times we are able to get MRI in the ED as well. Yes we use ABCD2 score, but have not agreed w/ neurology on a better validation tool a this time.

3. would have admitting patient 3 days earlier prevented the devastating posterior stroke? Or just optics better? Completing a CTA/MRI and starting pt on DAPT may still have ended up in same result for that patient.