imanurse
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any public examples? Id like to see some of the craziestI’ve seen much more ridiculous expert witness opinions than this
any public examples? Id like to see some of the craziestI’ve seen much more ridiculous expert witness opinions than this
One of the more interesting is that of Peter Rosen. A Google of “Peter Rosen ACEP Censure” should be sufficient.any public examples? Id like to see some of the craziest
There should be a weekly e-newsletter exposing absurd and dubious 'expert' witness testimony and those giving it. Make them famous....I’ve seen much more ridiculous expert witness opinions than this...
I thought having protocols approved through MedExec might offer some protection as it's officially endorsed by the hospital at that time. At the end of the day though, it's ultimately the physician who is responsible for what treatment is provided and the outcome. One of the medmal attorneys I know says at the end of the day, it's a toss up if a protocol offers any defense or not.Oh it is definitely a good defense just not a perfect or automatic defense. It needs to be a reasonable policy or a policy that is beyond a providers typical knowledge. In this case it’s a great defence against. I’m just playing devils advocate. And also explaining why I don’t think the expert witness should be censured even though I completely disagree with him
In EM, pts (esp in cities, and in the South) complain of "spider bites", which are, usually, VERY straightforward abscesses. No spider is involved. Once, in 2007, a pt came in, and said she was bitten by a spider. She was telling the truth, because she brought it with her: Latrodectus mactans. It had the pathognomonic red hourglass on the abdomen. Yes, a black widow. At that time, there wasn't any antivenin, just supportive care. I don't know about now. For a brown recluse bite (Loxosceles reclusa), the differential diagnosis includes cigarette burn, and cutaneous anthrax. Again, I don't know about an antivenin, but, that bite needs surgical excision of the bite site.Please forgive the detour, but how often do you guys see a black widow, brown recluse or some other horrible arachnid bite case? Is there a crofab equivalent for these???
Recluse bites all the time. No antivenom for that. Systemic loxocelism (not common but it happens) gets admitted. A lot of times tissue you think will be toast comes back totally fine after some weeks, so early surgical excision is no longer routinely recommended from what I’ve seen. I send most to wound care for follow up.Please forgive the detour, but how often do you guys see a black widow, brown recluse or some other horrible arachnid bite case? Is there a crofab equivalent for these???
“Most”, like you’ve seen more than 1 or 2 in your career?Recluse bites all the time. No antivenom for that. Systemic loxocelism (not common but it happens) gets admitted. A lot of times tissue you think will be toast comes back totally fine after some weeks, so early surgical excision is no longer routinely recommended from what I’ve seen. I send most to wound care for follow up.
In hindsight “all the time” is an exaggeration. But I’ve worked in the SE for over 20 years, including 12 at a huge referral center.“Most”, like you’ve seen more than 1 or 2 in your career?
How are you even confirming it was a brown recluse without the patient bringing it in or snapping a picture?
I’d say 99.9% of the time a patient claims recluse bite, there is no evidence for it whatsoever. Recluse bites are actually likely much rarer than reported hence the name “recluse”.
Recluse bites all the time. No antivenom for that. Systemic loxocelism (not common but it happens) gets admitted. A lot of times tissue you think will be toast comes back totally fine after some weeks, so early surgical excision is no longer routinely recommended from what I’ve seen. I send most to wound care for follow up.
The number of times someone has told me a spider bit the back of their throat in their sleep and the patient actually has viral pharyngitis is astounding.In EM, pts (esp in cities, and in the South) complain of "spider bites", which are, usually, VERY straightforward abscesses. No spider is involved. Once, in 2007, a pt came in, and said she was bitten by a spider. She was telling the truth, because she brought it with her: Latrodectus mactans. It had the pathognomonic red hourglass on the abdomen. Yes, a black widow. At that time, there wasn't any antivenin, just supportive care. I don't know about now. For a brown recluse bite (Loxosceles reclusa), the differential diagnosis includes cigarette burn, and cutaneous anthrax. Again, I don't know about an antivenin, but, that bite needs surgical excision of the bite site.
The number of times someone has told me a spider bit the back of their throat in their sleep and the patient actually has viral pharyngitis is astounding.
Dude, that's Emperor Palpatine level force power transfer shenanigans. That's worthy of a master class. The deception with the OSH pharmacist would make a KGB agent blush.I think I am the only physician at my hospital / ED who has treated a snake bite in living memory (25+ years). We do have scant populations of copperheads and timber rattlers nearby. In theory we stock crofab. Minor changes for reasons—
Drunk dude gets bitten by a “baby rattlesnake” (Identified by his Texan buddy…) in his dominate hand. Is intoxicated AF, has a bite mark, minimal swelling, maybe slight parathesia.
Labs, serial exam, call to regional poison control.
I would have gotten more help by calling the local Domino’s and asking them if I should suck the poison out of the wound. Literally “i have no idea about snake bites” and to my more pertinent question “we have no idea who stocks crofab”. They suggested every big tertiary center nearby had some in stock, of course.
Being the prodigal son of one of these, I knew for a fact they had none in stock. Rapid mobilization of the curious crew of nurses, techs, and UCos (we don’t see many snake bites)— every level 1 trauma/tertiary center in a 100mi radius says “AHHAHAHA crofab what? Nah man”. We get this info in 5 minutes. We don’t just call the transfer centers, we hit up the EDs and pharmacies. Strike out. I have someone on every phone in the ED, a ****ing smooth oiled information network.
Suddenly a bunch of outdoor-type-law-enforcement shows up, with a dead juvenile copperhead (they like to drop a lot of toxin…) and the patient visibly starts swelling and bitching about weird parathesias and pain.
Game on. Re-call poison control. No help. I recommend they call Colorado (I heard they know snake bites!) or Texas or Utah or something… don’t you have a mutual-support network?? This gets an audible huh and they go off on a mission. First they recommend the Zoo, and I ask if the Zoo is open at 10pm on a Friday…
Nursing supervisor finds CroFAB which was produced in about 1982, in very dusty boxes. Suddenly I’m on a three-way-call with some other state toxicologist (a lovely human!) who does teach me that expired, underdosed crofab is better than no crofab. We’re engaged with the enemy now.
Our intelligence network has continued working, and discovered a large community hospital not-too-far-away stocks a solid cache of crofab.
I call their transfer center— “we don’t have that. If we do, everyone has it. We are full. Decline transfer. *HANGUP*”
Huh.
I may, at that point, call the operator at that hospital and put on the charm. I may mention being an ER doc. I may NOT mention that I’m not one of THEIR ER docs. I may get connected with their inpatient pharmacist. I may continue the same ploy. I may say I have a guy with a copperhead bite (COOL HUH!). I may ask which exact PIXIS the crofab is in, and how many vials, because I might need a few. I may learn that X are in ED PIXIS #3, and Y are in reserve in the pharmacy. Live saver, thank you Ms. Pharmacist. I may go back to sweet talking the operator. I may get directly connected to an ED attending. I may pitch them I have a worsening dominate hand copper head bite with underdosed crofab and I’m out and he needs more. And maybe a fasciotomy. My brother in EM may hesitate, saying he doesn’t know about their ability to handle bites vis-a-vis crofab. I might tell him to ask his resource RN to check PIXIS #3, where I am confident he will find X vials. He does this. I sense the amazement on his end. He starts to ask how. I tell him don’t worry, the issue is his transfer center wants to **** me. But we… yes WE.. want to save this man’s hand. Plus have you seen a good snake envinomation? You know you want to accept this transfer… it’ll be fun. In classic EM doc fashion my brother in christ immediately says “my name is XXXX, please send him now my shift is over in 3 hours and I need this”.
Anyway I’m sure there are 2984 ways I could get sued in the above story, of which only like 7 are my fault. Dude’s hand ended up doing well, but he soaked up a lot of crofab.
Just to clarify, and I 100% believe it happened, but is this not a major EMTALA violation?I call their transfer center— “we don’t have that. If we do, everyone has it. We are full. Decline transfer. *HANGUP*”
Have to have capability and capacity. Sounds like no capacity.Just to clarify, and I 100% believe it happened, but is this not a major EMTALA violation?
It would seem that if it is anyone’s job to be well versed in knowing or finding out what a hospital’s capabilities are, it would be the transfer center’s job…
I too have really enjoyed the few times in my career where I have called a different hospital as “Dr HOHopeful” and gotten help from their operator, it feels like being a secret agent although to be honest I bet you could have called and just said “this is Dr X from Y hospital I really need to talk to your pharmacy” and they would still transfer you.
That's still some of the biggest **** in medicine. The ED creates capacity all the time when there is none, especially when a patient truly needs it. Hospitals would work so much better if they were ran like EDs rather than like 9am to 3pm (with a 2 hour lunch) Monday through Thursday banks.Have to have capability and capacity. Sounds like no capacity.
Nursing supervisor finds CroFAB which was produced in about 1982, in very dusty boxes. Suddenly I’m on a three-way-call with some other state toxicologist (a lovely human!) who does teach me that expired, underdosed crofab is better than no crofab. We’re engaged with the enemy now.
Our intelligence network has continued working, and discovered a large community hospital not-too-far-away stocks a solid cache of crofab.
I call their transfer center— “we don’t have that. If we do, everyone has it. We are full. Decline transfer. *HANGUP*”
Copperheads, not having a rattle, tend to inject more venom. Juveniles, being juvenile, tend to inject everything they have, because they have not yet developed the instinctual skill of estimating how much venom to use on the target. So, worst of the worst.dead juvenile copperhead (they like to drop a lot of toxin…)
Just to clarify, and I 100% believe it happened, but is this not a major EMTALA violation?
It would seem that if it is anyone’s job to be well versed in knowing or finding out what a hospital’s capabilities are, it would be the transfer center’s job…
I too have really enjoyed the few times in my career where I have called a different hospital as “Dr HOHopeful” and gotten help from their operator, it feels like being a secret agent although to be honest I bet you could have called and just said “this is Dr X from Y hospital I really need to talk to your pharmacy” and they would still transfer you.
From what I was repeatedly told by my toxicology faculty in med school and residency (same guy), it is not correct that younger snakes will hit you with more venom. If anything, they're likely to hit you with less, being smaller. He also told me how commonly this is believed, despite being inaccurate.Copperheads, not having a rattle, tend to inject more venom. Juveniles, being juvenile, tend to inject everything they have, because they have not yet developed the instinctual skill of estimating how much venom to use on the target. So, worst of the worst.
The head toxicologist where I trained in one of the most endemic rattlesnake areas in the US taught that smaller snakes were more likely to deliver venomous bites due to a lack of control versus adults. Volume can be lower, but tend to release larger percentage. Adults have greater percentage of dry bites. This tends to also be my anecdotal experience. Sounds like we need a medical ophiologist to chime in for more advanced understanding. Either way, avoid the Ts. If you don’t, then go to a hospital where @Janders is working.From what I was repeatedly told by my toxicology faculty in med school and residency (same guy), it is not correct that younger snakes will hit you with more venom. If anything, they're likely to hit you with less, being smaller. He also told me how commonly this is believed, despite being inaccurate.
Per these guys (Snake Bite Foundation) and their referenced studies: "The head toxicologist where I trained in one of the most endemic rattlesnake areas in the US taught that smaller snakes were more likely to deliver venomous bites due to a lack of control versus adults. Volume can be lower, but tend to release larger percentage. Adults have greater percentage of dry bites. This tends to also be my anecdotal experience. Sounds like we need a medical ophiologist to chime in for more advanced understanding. Either way, avoid the Ts. If you don’t, then go to a hospital where @Janders is working.
Hayes WK. Venom metering by juvenile prairie rattle- snakes (Crotalus v. viridis): effects of prey size and experience. Anim Behav. 1995;50:33–40.
This doesn’t factor in dry bites. If a greater percentage of adult bites are dry, then you might have a better outcome compared to if bitten by a baby rattler.Per these guys (Snake Bite Foundation) and their referenced studies: "
Contrary to popular belief, the bite of a baby rattlesnake is almost always far less serious than the bite of a larger adult rattlesnake. The notion that baby rattlesnakes cannot control the quantity of venom injected (referred to in the field of Herpetology as “venom metering”) is a myth that has been disproven multiple times through well-designed studies. See this excellent paper by the esteemed rattlesnake venom researcher Dr. William Hayes for evidence of this fact:
Are baby rattlesnakes really more dangerous than adults? — The Asclepius Snakebite Foundation
Contrary to popular belief, the bite of a baby rattlesnake is almost always far less serious than the bite of an adult rattlesnake. The notion that baby rattlesnakes cannot control the quantity of venom injected is one of those myths that is so often repeated as fact, yet it been disprovenwww.snakebitefoundation.org
Mine was 20+ years ago, so, shows you how research and medicine changes! I got it from Eric Lavonas.From what I was repeatedly told by my toxicology faculty in med school and residency (same guy), it is not correct that younger snakes will hit you with more venom. If anything, they're likely to hit you with less, being smaller. He also told me how commonly this is believed, despite being inaccurate.
Yes. After they tell me a spider bit the back of their throat while they were sleeping and they swallowed it, I ask how they know this information, and they tell me that they looked it up online and that this happens very often.People actually say this? Wow…
"I'm sorry. We don't have capacity to care for this patient. Is there anything else I can help you with? No? Good luck."Just to clarify, and I 100% believe it happened, but is this not a major EMTALA violation?
It would seem that if it is anyone’s job to be well versed in knowing or finding out what a hospital’s capabilities are, it would be the transfer center’s job…
I too have really enjoyed the few times in my career where I have called a different hospital as “Dr HOHopeful” and gotten help from their operator, it feels like being a secret agent although to be honest I bet you could have called and just said “this is Dr X from Y hospital I really need to talk to your pharmacy” and they would still transfer you.
Anyone have to deal with bites/stings from other varmints? Like scorpions or jellyfish? I suppose this is more in line with wilderness medicine. My Microbiology colleagues make noise every now and then of having an Medical Entomology elective course.Yes. After they tell me a spider bit the back of their throat while they were sleeping and they swallowed it, I ask how they know this information, and they tell me that they looked it up online and that this happens very often.
These patients do not report living in insect or arachnid infested places.
I can't be the only person who's had this happen multiple times, right?
Scorpions yeah. Where I practice this is probably the most common reason for pediatric intubations. Still rare, thankfully.Anyone have to deal with bites/stings from other varmints? Like scorpions or jellyfish? I suppose this is more in line with wilderness medicine. My Microbiology colleagues make noise every now and then of having a Medical Entomology elective course.
Its probably a medical student, and its almost certainly a streamlined version of Goldfarb's tox textbook, but yes. That point is accurate (except for the "calls earn the PCC money" element). I said something quite similar the other day.Why wouldn't adhering to policy be a good defense? Like wut lol.
Why would you ever call poison control? So that some RN can read uptodate to you?
Please forgive the detour, but how often do you guys see a black widow, brown recluse or some other horrible arachnid bite case? Is there a crofab equivalent for these???
Never knew where the name of the condition came from. Now I do. Interesting.4) loxosceles reclusa may be extremely geographically specific, but it has some cousin species that, confusingly, are also called recluse spiders despite being loxosceles and not reclusas.