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

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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.
Again, you’re trying to add qualifications to #2 an 3 and turn it into something that never happened. Stop trying to make it sound better than it was. There was never a CTA or MRI ordered in the ED - just a non con head CT. No anti-platelet therapy was given.

Having said that, I’d like to explore some of your logic here. Tell me how you are “confirming” a posterior stroke vs TIA in the ED as a means to determine who needs to be admitted. Better yet, why are you trying to do this?

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Many (perhaps most) patients with TIAs are discharged.

Most patients with abdominal pain are discharged.

You don’t seem to know normal practice patterns any more after not working in the ED for a few years. I also suspect your career was slanted more so to academics than the community, or towards non-EM medical care than working in the pit.

Expert witness testimony for egregious care is one thing. Expert witness testimony against relative standard of care is selling out. Going after pill mills isn’t the same as going after TIAs. Your lens is too discolored by your law enforcement background.

When one person is arguing against everyone else they are usually not in the right.
 
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Many (perhaps most) patients with TIAs are discharged.
No, no they are not. This has been studied. The majority of patients with TIAs in North America are admitted. Only 17% are discharged without follow-up as was done in this case. They do worse.

As for your assumptions of my career trajectory, you should probably just stop speculating.
 
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“Frivolous” is hard to define, but I know it when I see it. Thanks for the journal reference.
Ahh the Justice Stewart Standard. I like it!

Cool, now we’ve clarified the standards going forward. I assume that you’re OK with me using the same standard when determining negligence, no? 😉
 
Again, you’re trying to add qualifications to #2 an 3 and turn it into something that never happened. Stop trying to make it sound better than it was. There was never a CTA or MRI ordered in the ED - just a non con head CT. No anti-platelet therapy was given.

Having said that, I’d like to explore some of your logic here. Tell me how you are “confirming” a posterior stroke vs TIA in the ED as a means to determine who needs to be admitted. Better yet, why are you trying to do this?
TIA by definition has transient symptoms that resolve whereas strokes tend to have persistent or ongoing symptoms. Patients that have a concerning story for TIA get a CT/CTA, risk stratification and shared decision making which for the most part ends up in a discharge home. People with persistent neurologic deficits get admitted. Many of these TIAs are going home on maximal medical therapy and close neurology follow-up so I see a little advantage to admitting to the hospital.

It seems like you might have only practiced in academia. Do you admit all chest pain too? All syncope? All generalized weakness?

I wish it were that simple….
 
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Just a warning to expert witnesses, the tides are changing and many states have already removed any immunity you might have had…


A close friend of mine had a lawsuit that was frivolous and the case was dismissed by the judge with prejudice.

He was able to successfully show the damage the expert witness caused him and recovered $1.5 million from the expert witness.

Also an education for physicians, if your case is dismissed with prejudice, you can sue the expert witness in many states…
 
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No, no they are not. This has been studied. The majority of patients with TIAs in North America are admitted. Only 17% are discharged without follow-up as was done in this case. They do worse.

As for your assumptions of my career trajectory, you should probably just stop speculating.
What’s in a textbook or the literature isn’t what happens on the ground. You aren’t up to date. They also don’t do worse.

My assumptions are based upon what you’ve posted. Your prior practice environments don’t sound equivocal to the average EP.
 
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Ahh the Justice Stewart Standard. I like it!

Cool, now we’ve clarified the standards going forward. I assume that you’re OK with me using the same standard when determining negligence, no? 😉
Yes. Of course! In fact I would prefer you do use it. Tell them “some guy on the internet” said it was okay. Lol

But I have to say, I’m a little disappointed in the Heisenberg avatar. I mean, why not Uncle Hank? Or at least one of the other good guys? 😉
 
TIA by definition has transient symptoms that resolve whereas strokes tend to have persistent or ongoing symptoms. Patients that have a concerning story for TIA get a CT/CTA, risk stratification and shared decision making which for the most part ends up in a discharge home. People with persistent neurologic deficits get admitted. Many of these TIAs are going home on maximal medical therapy and close neurology follow-up so I see a little advantage to admitting to the hospital.

It seems like you might have only practiced in academia. Do you admit all chest pain too? All syncope? All generalized weakness?

I wish it were that simple….
OK, I was getting at the fact that a significant minority of suspected TIAs with resolved symptoms actually have strokes on subsequent MRI. So, you’re not confirming anything with your exam and CTA/CTP. Moreover, MRI is insensitive for posterior circulation strokes in the first 24 hours.

Finally, I’ve consistently described in this thread that this was a 30-40 year old patient coming in with a pretty obvious posterior circulation TIA, and everyone keeps talking about CTAs and then home as if that is remotely adequate for such a case. Would you not be in the least bit curious why such a young patient had a stroke/TIA?

But hay - it’s your dream, I’m just part of it. Go ahead and get a CTA on this guy and send him home with instructions to drink lots of fluids if that’s how you roll.
 
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Chiming in:

This is how agitating stroke alerts have become:

1. Anyone with any paresthesia +/- any "weakness" (which ends up being chronic or MSK in nature, but the triage nurse can't be bothered to parse that out) winds up with a "provider to triage" call, in which I have to stop what I'm doing and go parse it out myself. Let's say I do *activate the stroke alert protocol ".

2. Now I have to go to CT to talk with teleneurology, leaving the department on fire. After some time, I can return to the dumpster fire, having forgotten what it was that I was doing in the first place, but not before noticing 3+ more people are checking in.

3. I then have to field phone calls from both teleneurology AND radiology. Teleneurology loves to talk about their "recommendations", none of which I have control over. Radiology will give a cagey interpretation of the imaging results, first with the non-con, and then then CTA, and then the CTP. It sounds something like this: "If you look at the superior angle of the inferior dangle on the leftmost rightward aspect of the takeoff of the C1, there may or may not be an abnormality that could correspond to a finding.

That's four phone calls interrupting my workflow on top of the immediate assessment.

Is it any wonder why we don't want to go down this needlessly complicated gauntlet?
 
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Yes. Of course! In fact I would prefer you do use it. Tell them “some guy on the internet” said it was okay. Lol

But I have to say, I’m a little disappointed in the Heisenberg avatar. I mean, why not Uncle Hank? Or at least one of the other good guys? 😉
Because I’m not a good guy, at least not in a SDN way. You may notice that I don’t post here much. Often I go months without contributing. When I do post, it is as a contrarian voice on topics that interest me to disrupt what I perceive as physician group think. Last time I posted this much, I was in the anesthesia sub forum to provide an contrarian perspective to the fantasies flying around about community policing in minority neighborhoods and how the cops are the biggest threat to young black men…by anesthesiologists…who have never been cops…or who are mostly white. 🙄

So, when people decry the direction of the thread, start questioning my ethics because I’m not on “their side”, or suggesting that I’m inexperienced, then I just kick back, relax, and say to myself, “My work is done here.”
 
Says who and define frivolous. Show me some data.


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.

From your post.

Claims involving no errors or injuries account for 40%. That's a large number.

Payout was over $300,000 when there was no error.

How is that right or even reasonable?

One can do everything right but have a bad outcome. If there is a bad outcome one will likely get sued. There will be no shortage of "expert witnesses" who will crawl out of the shadows to slam the physician just because there was a bad outcome.
 
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When I do post, it is as a contrarian voice on topics that interest me to disrupt what I perceive as physician group think.
You said earlier you've practiced 20 years. I'm assuming at some point in time, probably numerous times, you've personally had a patient with a unexpected, devastating outcome. If so, do you feel like you provided negligent care that contributed to that outcome? Or, if hypothetically a lawsuit arose from one of these cases, that an expert witness would testify that you were negligent?
 
From your post.

Claims involving no errors or injuries account for 40%. That's a large number.

Payout was over $300,000 when there was no error.

How is that right or even reasonable?

One can do everything right but have a bad outcome. If there is a bad outcome one will likely get sued. There will be no shortage of "expert witnesses" who will crawl out of the shadows to slam the physician just because there was a bad outcome.
It is reasonable because it was an extreme minority of claims AND actually happens LESS frequently than the opposite circumstances where a patient was injured by error and not compensated. In other words, patients were more commonly injured by errors and not compensated than physicians were frivolously sued. Keep in mind things have likely become even more lopsided in the physicians favor since malpractice reform (that I actually support, BTW).

My purpose in posting this was to dispel the myth that the majority of lawsuits are frivolous. They are not if we are using the standard of no error under a retrospectoscope. I was not suggesting that the system is perfectly just since no system is. The current system screws doctors and patients alike. I just disagree with the groupthink around here that we should make it screw the physicians less at the patient’s expense.
 
OK, I was getting at the fact that a significant minority of suspected TIAs with resolved symptoms actually have strokes on subsequent MRI. So, you’re not confirming anything with your exam and CTA/CTP. Moreover, MRI is insensitive for posterior circulation strokes in the first 24 hours.

Finally, I’ve consistently described in this thread that this was a 30-40 year old patient coming in with a pretty obvious posterior circulation TIA, and everyone keeps talking about CTAs and then home as if that is remotely adequate for such a case. Would you not be in the least bit curious why such a young patient had a stroke/TIA?

But hay - it’s your dream, I’m just part of it. Go ahead and get a CTA on this guy and send him home with instructions to drink lots of fluids if that’s how you roll.

I agree and it is well known that MRI can miss a significant amount of posterior strokes within the first 24 hours. So how would my plan for CT, CTA and home on dual antiplatelet therapy be inappropriate w neurology follow up within few days and mri within few weeks. even if I diagnose it as a TIA and it ends up being a small subcortical stroke they are getting the exact same treatment. Exactly what is gained by hospital admission in the setting? Echo?
Statin therapy?
 
You said earlier you've practiced 20 years. I'm assuming at some point in time, probably numerous times, you've personally had a patient with an unexpected, devastating outcome. If so, do you feel like you provided negligent care that contributed to that outcome? Or, if hypothetically a lawsuit arose from one of these cases, that an expert witness would testify that you were negligent?
Yes, I’ve had devastating outcomes. Certainly some where I could have been sued but was not. I’ve also reflected on every bad (and many good) outcome to think of ways to improve my game for the next time - daily, like every goddamn day.

As for killing a patient (or sentencing them to a fate worse than death) - no. I’ve never walked away from a case and said, “well, that was a clean kill” such as leaving an ET tube in an esophagus or telling a patient with a TIA that they are dehydrated. Then again, I’ve never ordered a duragesic patch, or prescribed a bunch of opiates/benzos/soma to a teenager, or written “gastroenteritis” on a chart with belly pain and ****ty discharge instructions. Why have I not done these things? Because I completed a EM residency and do not routinely try to exceed my scope of practice? But hey, if you’re cool with our peers doing these things and not compensating their victims, then you do you.

BTW, have you - killed someone, that is?
 
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I agree and it is well known that MRI can miss a significant amount of posterior strokes within the first 24 hours. So how would my plan for CT, CTA and home on dual antiplatelet therapy be inappropriate w neurology follow up within few days and mri within few weeks. even if I diagnose it as a TIA and it ends up being a small subcortical stroke they are getting the exact same treatment. Exactly what is gained by hospital admission in the setting? Echo?
Statin therapy?
Here’s another hint - yes to the TTE with bubbles… 😉
 
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?
I'm probably not going to get asked back because I'd acknowledge a lot of uncertainty, which I doubt the attorneys would appreciate.:shrug:
 
no. I’ve never walked away from a case and said, “well, that was a clean kill” such as leaving an ET tube in an esophagus or telling a patient with a TIA that they are dehydrated.
I know that you're smart enough to recognize these two are not equivalent.
 
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Here’s another hint - yes to the TTE with bubbles… 😉
And in small chance that is positive is PFO getting fixed emergently. Again, I still don’t hear a good argument how doing ct/cta==> dapt ==> neurology follow up for outpatient MRI and echo is below standard of care.

Or more to the point that admission would change patients clinical course?
 
I know that you're smart enough to recognize these two are not equivalent.
I never said they were. Nor do they need to be equivalent to be horrifically egregious. I just said that I never did either. Have you ever sent home someone with transient hemiplegia and dysarthria with no discharge instructions telling them that they had a TIA and could have a stroke? I didn’t think so.

BTW, if I could choose between goosed and dead vs. posterior stroked and alive - I’ll take the former. Again, YMMV…
 
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Yes, I’ve had devastating outcomes. Certainly some where I could have been sued but was not. I’ve also reflected on every bad (and many good) outcome to think of ways to improve my game for the next time - daily, like every goddamn day.

As for killing a patient (or sentencing them to a fate worse than death) - no. I’ve never walked away from a case and said, “well, that was a clean kill” such as leaving an ET tube in an esophagus or telling a patient with a TIA that they are dehydrated. Then again, I’ve never ordered a duragesic patch, or prescribed a bunch of opiates/bentos/soma to a teenager, or written “gastroenteritis” on a chart with belly pain and ****ty discharge instructions. Why have I not done these things? Because I completed a EM residency and do not routinely try to exceed my scope of practice? But hey, if you’re cool with our peers doing these things and not compensating their victims, then you do you.

BTW, have you - killed someone, that is?
Neuro does always want IVF on the strokes … maybe they’re all just dehydrated /s
 
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It is reasonable because it was an extreme minority of claims AND actually happens LESS frequently than the opposite circumstances where a patient was injured by error and not compensated. In other words, patients were more commonly injured by errors and not compensated than physicians were frivolously sued. Keep in mind things have likely become even more lopsided in the physicians favor since malpractice reform (that I actually support, BTW).

My purpose in posting this was to dispel the myth that the majority of lawsuits are frivolous. They are not if we are using the standard of no error under a retrospectoscope. I was not suggesting that the system is perfectly just since no system is. The current system screws doctors and patients alike. I just disagree with the groupthink around here that we should make it screw the physicians less at the patient’s expense.
37% of patients had an injury but no error.

They still got settlements of $300,000+.

That just proves that if there is a bad outcome patients will sue and can win/settle for large amounts.

That goes with the idea that I have stated from the start, if there is a bad outcome even if no error occurred, you will get screwed over.

That is a major problem.
 
And in small chance that is positive is PFO getting fixed emergently. Again, I still don’t hear a good argument how doing ct/cta==> dapt ==> neurology follow up for outpatient MRI and echo is below standard of care.

Or more to the point that admission would change patients clinical course?
There were two separate cases. Both were offered or fixed emergently on representation.

One had a large, mobile AV veg that was fixed emergently on his subsequent visit for a stroke. His case was complicated by hemorrhagic conversion after heparinization on bypass. There was a lot of back and forth with the EP claiming that the major damages were caused by the hemorrhagic conversion from the stroke and CT surgery decision to replace the valve so soon after an ischemic stroke. That decision was a strategic mistake on the EP’s part IMHO.

The other was a straight forward intracardiac shunt. Repair was offered but the patient was transition to comfort measures.
 
37% of patients had an injury but no error.

They still got settlements of $300,000+.

That just proves that if there is a bad outcome patients will sue and can win/settle for large amounts.

That goes with the idea that I have stated from the start, if there is a bad outcome even if no error occurred, you will get screwed over.

That is a major problem.
…might get screw over Hommie, might get screwed over. Try and be an optimist.

Keep in mind that only 28% of cases without error resulted in compensation. That means that roughly 10% of claims in the study were without error and resulted in a payment.

Regardless, it is a problem. However, it is probably not a major driver of lawsuits and certainly doesn’t support the notion that a majority of suits are frivolous as was claimed. It’s also not that surprising since the standard for most torts is “more likely than not.” It actually supports the notion that our system is pretty good at separating the wheat from the shaft. The trick is fixing it in a manner that is not in the patient’s detriment. However, any fix will still have some residual injustice. That’s just life. Nobody explained this before you chose this career?
 
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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?
To be fair, I have seen a fair number of board complaints against physicians who have consistently demonstrated incompetence. For some strange reason, they are usually radiologists. I don't know if that is primarily because they leave behind evidence, or because new technologies can emerge that they have no experience in, or they think they know something they haven't done for decades. Usually it results in a prohibition against interpreting certain types of imaging, e.g., cross-sectional, or mamo, or whatever.
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.
The other point is that rarely is there an allegation that the physician is dangerous or incompetent. (As long as you ignore the legal language. Sort of like how I routinely got complaints that a physician would say "patient denies smoking" and the patient took that to mean the physician was calling them a liar. It is just the way we write.)

As an example, one of my kids was driving through Las Vegas and took their eyes off the road to change the Sirius Channel. There was a traffic backup ahead and they hit the car in front of them. Generally great drivers, only accident on their record, but their great record doesn't mean they weren't liable in that particular incident.

You can be a terrible physician and never be negligent. On the other hand, you can be the best neurosurgeon in the country, and sneeze and transect the spinal cord and you are liable. In my experience, we tend to conflate the two categories.
 
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I never said they were. Nor do they need to be equivalent to be horrifically egregious. I just said that I never did either. Have you ever sent home someone with transient hemiplegia and dysarthria with no discharge instructions telling them that they had a TIA and could have a stroke? I didn’t think so.

BTW, if I could choose between goosed and dead vs. posterior stroked and alive - I’ll take the former. Again, YMMV…
No, but you did call both a "clean kill" and I see an esophageal intubation as that, but I don't think discharging a TIA fits the bill.
 
I’ve discharged TIA many times. Usually get a CT and often CTA. Never really understood the admit for MRI to see if there was a tiny stroke…. what do you do differently? Many are maximally medically managed already. Same for chest pain, two negative trops and pain free, unless ridiculous risk factors, I do shared decision making and most are comfortable with plan to talk to their PCP/cardiologist about stress testing (which has the sensitivity/specificity of a coin flip). And for vertebro-basilar ischemia, CTA and MRI both are not great. And I’m sure not going to do a HINTS (when else in medicine do we base a life or death diagnosis on our physical exam- I mean we get X-rays to assess for pneumonia even though that misses 50%).
 
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No, but you did call both a "clean kill" and I see an esophageal intubation as that, but I don't think discharging a TIA fits the bill.
There is discharging a TIA, then there is discharging a TIA who was hemiplegic and dysarthric with just hydration instructions. It may not fit your bill but it certainly punched the patient’s ticket.

And for about the 10th time in this thread including my original post, it was coupled with a ****ty exam, faulty medical decision making that relied on a non-con CT and many other deficiencies that you can expect with a non-EM trained person exceeding their scope of practice.
 
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I’ve discharged TIA many times. Usually get a CT and often CTA. Never really understood the admit for MRI to see if there was a tiny stroke…. what do you do differently? Many are maximally medically managed already. Same for chest pain, two negative trops and pain free, unless ridiculous risk factors, I do shared decision making and most are comfortable with plan to talk to their PCP/cardiologist about stress testing (which has the sensitivity/specificity of a coin flip). And for vertebro-basilar ischemia, CTA and MRI both are not great. And I’m sure not going to do a HINTS (when else in medicine do we base a life or death diagnosis on our physical exam- I mean we get X-rays to assess for pneumonia even though that misses 50%).
And you probably wouldn’t be negligent, but that’s not what happened here.
 
I don't think some realize how the pandemic, staffing shortages and hospital boarding has significantly affected who gets admitted. Prior soft admits like CP with negative high sensitivity troponin testing, TIAs (with resolved symptoms by definition), syncope (majority of all comers are low risk), head injuries on anticoagulation with negative head CTs mostly all go home. A lot of conditions that were always previously admitted like PEs are sometimes now going home too. Specialists and hospitals have created protocols for more aggressive outpatient management. I think we've all found that there isn't a significant change in outcome for these patients whether or not admission occurs. This is the problem when you have physicians who no longer practice trying to determine what should and shouldn't be admitted.
 
There is discharging a TIA, then there is discharging a TIA who was hemiplegic and dysarthric with just hydration instructions. It may not fit your bill but it certainly punched the patient’s ticket.
Well, you left the hemiplegia out of the post I was replying to. I'm just trying to respect nuance here.
 
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Well, you left the hemiplegia out of the post I was replying to. I'm just trying to respect nuance here.
Brother, I’ve been very descriptive in this thread with these belly pain and TIA/stroke patients. You’re not an offender, but far too many people are trying to re-write the script on these cases to make it sound like the cases were run of the mill weak and dizzy that got dropped. They were not. Like I said before, one was even a code stroke activation by EMS that the physician down graded. That means someone with far less training did a better job than the doctor in one case. Both had neuro exams that left everyone wondering if there might still be residual deficits.

Then I got people telling me that it sounds like I spent most of my career in one place or the another. You can’t make this **** up.
 
I don't think some realize how the pandemic, staffing shortages and hospital boarding has significantly affected who gets admitted. Prior soft admits like CP with negative high sensitivity troponin testing, TIAs (with resolved symptoms by definition), syncope (majority of all comers are low risk), head injuries on anticoagulation with negative head CTs mostly all go home. A lot of conditions that were always previously admitted like PEs are sometimes now going home too. Specialists and hospitals have created protocols for more aggressive outpatient management. I think we've all found that there isn't a significant change in outcome for these patients whether or not admission occurs. This is the problem when you have physicians who no longer practice trying to determine what should and shouldn't be admitted.
Like I said, all of these cases have been settled. They happened long before the pandemic. I have not taken any EM cases that originated since the start of the pandemic because I’m not qualified to comment on pandemic and post-pandemic standards of care in the ED. However, I never said that I don’t practice - I do, just not in the ED. Unless you’ve got inpatient and ICU privileges, then I have a much better grasp of what is admitted, discharged, and appropriate for outpatient mgmt than you may think.
 
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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.
I suppose that I should amend #2 to “admit, place in observation status, or arrange expedited follow-up.” Probably most of my TIAs technically were not admitted, rather placed on obs. Regardless, neither happened to these patients. Hopefully you will excuse my lack of precision when the post was originally written - I was 1.5 glasses deep in my bottle of Scotch at the time.
 
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However, I never said that I don’t practice - I do, just not in the ED. Unless you’ve got inpatient and ICU privileges, then I have a much better grasp of what is admitted, discharged, and appropriate for outpatient mgmt than you may think.
That may be. In my experience though previously training under a large number of EM/CC physicians I found that many tended to practice more conservatively, utilized more testing, admitted more patients and struggled keeping up with busy patient volumes in comparison to their solely EM counterparts even in an academic setting. Overall EM/CC physicians typically practice more so in academic environments without near as much experience in the community setting, which is more reflective of general emergency medicine.

I have all the respect in the world for EM/CC as I almost pursued that path. What ultimately deterred me though was believing that the majority didn't do both fields well simultaneously and were better off picking one or the other. That rare bird was an allstar in both fields, but most didn't practice EM as well as the best EPs. By virtue of being driven, well trained physicians they certainly could practice EM. Most usually eventually gravitate towards CC to get away from the hoards of worried well and non-intubated, verbose patients with personality disorders. I'm also fully supportive of setting the standard of non-HCA residency trained board certified EPs in the ED. I just don't think some of these cases necessarily distinguish that difference. You have to be careful establishing the standard from a slightly different practice environment.

Lastly, I'd also argue that EPs are best equipped to determine ED disposition even if we don't manage inpatients. I follow up on all of my admitted patients and have a good idea of what is accomplished in the inpatient setting. The inpatient physicians don't see the 70-80% of patients that I send home appropriately. Many of whom were dizzy.
 
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There are bad actors among any and all professions; doctors, clergy, business, police - any I mention you can recall stories from the mass media. To support one of the most erudite folks on SDN, my buddy @WilcoWorld (he and I are both smart, but he is also educated), to deny this is hubris. I have a buddy that is now retired from the NYPD. For sergeant, an officer had to do 18 months of either narcotics (ugh - almost no one took that) or Internal Affairs. He told me that most of the complaints were absolute BS - closed right there, no investigation needed. An off the cuff estimate was "99%". But, he said, there were two that they did look into - one was cleared, but the other was a total POS, and needed to go.

What was it, the Archdiocese of Boston that was bankrupted by payouts, or was that the one where the Cardinal was kicked out of the priesthood and laicized for being a pedo?

And, it became enough that the American Board of Psychiatry and Neurology made it unethical for a psychiatrist to ever have a relationship with a pt, ever, no matter how long a time interval (for color, I worked with an EP that met their spouse when the spouse was a trauma in the ED).

In short, it happens. To monolithically crap on docs that look into problem docs for plaintiffs is either the aforementioned hubris, or the "fallacy of anecdote" - "I've never seen it, so, it doesn't exist". But, what is the old saw? "The doc that gets sued is never the one you expected". And, 5/6 that go to trial are decided in favor of the doc. So, there's "jackpot justice", but, also, the bad outcome, whether from no motive errors, or actual bad people (Chris Duntch, Michael Swango).

If you've never been the victim of violent crime, or been to a crime scene, or witnessed malpractice, Gods bless you. However, to deny that it occurs is, and to insult those that investigate it, to paraphrase @RustedFox , being an "ostrich".
 
That may be. In my experience though previously training under a large number of EM/CC physicians I found that many tended to practice more conservatively, utilized more testing, admitted more patients and struggled keeping up with busy patient volumes in comparison to their solely EM counterparts even in an academic setting.
Wow, it sounds like you trained at a horrible program. Do better.
 
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Oh Asclepius, I’m just pulling your chain. If you’re going to keep sending me these low, hanging balls, well…I’ll just keep swinging.

Anyway, how about this, you stop making silly assumptions about me and I’ll stop assuming that you approve of someone sending home obvious posterior circulation TIAs with dehydration instructions and a scant neuro exam. Fair? Honestly, I will.
 
I agree and it is well known that MRI can miss a significant amount of posterior strokes within the first 24 hours. So how would my plan for CT, CTA and home on dual antiplatelet therapy be inappropriate w neurology follow up within few days and mri within few weeks. even if I diagnose it as a TIA and it ends up being a small subcortical stroke they are getting the exact same treatment. Exactly what is gained by hospital admission in the setting? Echo?
Statin therapy?
I’m not here to retrain you on the contemporary mgmt of TIAs. If you want to send all or most of your TIAs home after CTA for an MRI in a few weeks, then you do you. I’ve already referenced the ACEP and AHA guidelines that suggest you NOT do that. Here is a podcast from AAEM/JEM Feb dated 2020 telling not to do that:



They even tell you why you should not do that.

And, yes - the podcast mentions TTEs are important in young people with TIAs or strokes.
 
Wow, it sounds like you trained at a horrible program. Do better.
Nope, I really valued my program and training.

Oh Asclepius, I’m just pulling your chain. If you’re going to keep sending me these low, hanging balls, well…I’ll just keep swinging.

Anyway, how about this, you stop making silly assumptions about me and I’ll stop assuming that you approve of someone sending home obvious posterior circulation TIAs with dehydration instructions and a scant neuro exam. Fair? Honestly, I will.
I don’t think they’re “silly assumptions.” It provides important context to your posts. I won’t make any more ‘assumptions’ about you. I’ve made my point and said my piece.

I’m not saying I would practice/document the exact same way. I’d just be more likely to refer practice I disagree with to peer review (which would still take significant deviation from the norm) than I would serve as a plaintiff’s expert witness.
 
I've listened to some malpractice cases on YouTube where the witnesses did not even testify that there was a malpractice event, yet some obscene amount of money was still awarded by the jury. An average American cannot follow simple 2 minute explanation of diabetes - do you really think they are gonna follow or understand hours of expert witness testimony citing different landmark studies? They will go by what feels right.
 
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If someone has a long commute/nothing better to do with their life:

This is a good series to follow about an ER case

 
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I've listened to some malpractice cases on YouTube where the witnesses did not even testify that there was a malpractice event, yet some obscene amount of money was still awarded by the jury. An average American cannot follow simple 2 minute explanation of diabetes - do you really think they are gonna follow or understand hours of expert witness testimony citing different landmark studies? They will go by what feels right.
Could you provide a link for some context? That sounds a bit - strange…perhaps impossible even?
 
Could you provide a link for some context? That sounds a bit - strange…perhaps impossible even?

It's the case above; TBH coming from psychiatry background I could barely get through listening about the knee lol but hopefully some of you will have more interest. There's also other malpractice cases on that channel. It just makes my blood boil listening to lawyers questioning of medical professionals

 
Could you provide a link for some context? That sounds a bit - strange…perhaps impossible even?

What's strange; that Americans are too dumb to understand exculpatory evidence?
Go read my last thread: "RustedFox and Morty".
 
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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.

Expert witnesses are there to be paid by the plantiff attorneys and without exception they all take the money. Regardless of the claim. Maybe not you, not him, not John, or Jane, but there are ER docs who will take the thousands of dollars under any circumstance and say crappy and untrue things while under oath. So yea as a group it's not one bad apple spoils the bunch, it's like 2/3 of them.
 
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Expert witnesses are there to be paid by the plantiff attorneys and without exception they all take the money.
What is this even supposed to mean? Yea, people get paid to do their job. Physicians get paid to treat patients too! Physicians also have a financial incentives that don't align with doing the right thing at times. Somehow people still manage to act reasonably ethical.

Regardless of the claim. Maybe not you, not him, not John, or Jane, but there are ER docs who will take the thousands of dollars under any circumstance and say crappy and untrue things while under oath. So yea as a group it's not one bad apple spoils the bunch, it's like 2/3 of them.
Weird, it's almost like demonizing physicians who do plaintiff work would keep ethical physicians from wanting to do the work because they actual care about their professional reputation more than money.

This is cartoonishly ridiculous. No one would argue that there are unethical lawyers and expert witnesses. Most people wouldn't even argue that there are a lot. But exaggerating the incidence and turning it into this weird fetish of demonizing anyone, anywhere who does any plaintiff expert witness work has no basis in logic. This is purely a weird need to circle the wagons and just makes physicians look corrupt and unprofessional.
 
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What is this even supposed to mean? Yea, people get paid to do their job. Physicians get paid to treat patients too! Physicians also have a financial incentives that don't align with doing the right thing at times. Somehow people still manage to act reasonably ethical.


Weird, it's almost like demonizing physicians who do plaintiff work would keep ethical physicians from wanting to do the work because they actual care about their professional reputation more than money.

This is cartoonishly ridiculous. No one would argue that there are unethical lawyers and expert witnesses. Most people wouldn't even argue that there are a lot. But exaggerating the incidence and turning it into this weird fetish of demonizing anyone, anywhere who does any plaintiff expert witness work has no basis in logic. This is purely a weird need to circle the wagons and just makes physicians look corrupt and unprofessional.

Medical expert witnessing is solely a for-profit exercise with almost zero macro benefit to societal healthcare. It is not some noble calling. Lawsuits do not improve healthcare outcomes or even make healthcare safer. If it did, the US would be 1#. Other countries without malpractice litigation have far better outcomes than we do.

We should stop defending an unregulated industry with almost zero practice standards. Anyone with a pulse and medical license can be an expert witness. There is almost no barrier to entry. I've worked with NPs that did case reviews and gave expert opinions to law firms! The joke writes itself.
 
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