recently settled malpractice suit in boston

[deleted52758]

http://www.bostonglobe.com/metro/20...isdiagnosed/LzW5fnCj977ZDt8hZOrpJL/story.html

Absolutely terrified about the ramifications of this, and I also feel so sad for the physician involved, who is well known at my hospital to be a compassionate and competent physician.
I can not imagine what he is going through, but I also can not believe that this verdict happened. I feel like ACEP or a governing body should release a statement stating that they vehemently disagree with this sort of verdict so that this isnt used in future legal precedence cases.

UGH! Somedays I really dislike our profession (most days i love what I do, this is just not one of them)

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[link2swim06]

Another reason I want to practice in a state like Texas.

I don't think the jury understands how dumb of an idea it is to get an EKG for every 20 yo with a cold or bronchitis.

 

[EM4life]

I don't think we get the whole picture here, I mean to imply that an getting an EKG would have made the diagnosis of myocarditis I think is also a little ridiculous, who were the expert witnesses, did the physician consider myocarditis in the differential. There are so many factors that would make this a winning/losing case, I'm not sure that every 20 year old that drops dead from myocarditis (which is a little unusual in of itself) would result in a complete loss in medical malpractice lawsuit in the setting of good charting and expert testimony. Anyway, sad sad case for all parties involved, hope our fellow physician involved is doing okay.

 

[JMC2010]

I would have done the same thing as the physician almost certainly

 

[gman33]

Cases like this almost force you to get an EKG if the words Chest Pain appear in the chart.
Plenty of patients with URI, bronchitis type symptoms will answer yes if you ask about CP.
If I think they really have bronchitis and it's not documented by a helpful triage nurse that the patient reports CP, then maybe no EKG.

If somebody wrote CP most of my attendings will want an EKG, no matter what I want.
I really want to practice EBM and do what is in the best interest of the patient.
Unfortunately that's not the environment where I am going to practice.
It remains to be seen how I will actually practice once I get out on my own.

 

[Iamnotme]

I don't think we get the whole picture here, I mean to imply that an getting an EKG would have made the diagnosis of myocarditis I think is also a little ridiculous, who were the expert witnesses, did the physician consider myocarditis in the differential. There are so many factors that would make this a winning/losing case, I'm not sure that every 20 year old that drops dead from myocarditis (which is a little unusual in of itself) would result in a complete loss in medical malpractice lawsuit in the setting of good charting and expert testimony. Anyway, sad sad case for all parties involved, hope our fellow physician involved is doing okay.

The whole lawsuit is so ridiculous. I also can't tolerate it when ignorant people, like the attorneys says things like, the EKG would have shown the myocarditis. What the heck does the attorney know? This is why I very very vehemently believe that juries in med mal cases should be all physicians. Attorneys and law people have absolutely no idea of whether medical care was appropriate or not. It just seems extremely odd that a 23yo would die from myocarditis within hours like that. I don't think we are getting the whole story here though.

It is so irrational that we have this punishing medical practice environment. Just like you don't or can't sue a lawyer for losing a case or the mechanic for screwing up your car, etc. these multi-million dollar settlements over "negligence" which are frequently mostly emotion based are sickening.

Individuals with no medical background should not be determining these kinds of cases. It's absurd. And while the death certainly is tragic, calling the physician "negligent" because he did not order an EKG is rather harsh. I am not sure that most physicians would order an EKG at the drop of a hat for a kid who seems otherwise healthy because he's complaining of fever and cough. Also it is very rare for someone to die overnight of myocarditis. Something is not adding up.

Also, why is it that states like Tx and IN can have tort reform but other states don't?

 

[RustedFox]

Cases like this almost force you to get an EKG if the words Chest Pain appear in the chart.
Plenty of patients with URI, bronchitis type symptoms will answer yes if you ask about CP.
If I think they really have bronchitis and it's not documented by a helpful triage nurse that the patient reports CP, then maybe no EKG.

If somebody wrote CP most of my attendings will want an EKG, no matter what I want.
I really want to practice EBM and do what is in the best interest of the patient.
Unfortunately that's not the environment where I am going to practice.
It remains to be seen how I will actually practice once I get out on my own.

This.

All day long.

Yep. If the words CP come anywhere near the chart, I get the EKG.

 

[deleted109597]

Also, why is it that states like Tx and IN can have tort reform but other states don't?

Political leanings and public outreach. The Texas constitution was changed by a public vote to allow it.

Vote with your feet. If people can't see doctors, they might change their minds.

 

[Birdstrike]

http://www.bostonglobe.com/metro/20...isdiagnosed/LzW5fnCj977ZDt8hZOrpJL/story.html

Absolutely terrified about the ramifications of this, and I also feel so sad for the physician involved, who is well known at my hospital to be a compassionate and competent physician.
I can not imagine what he is going through, but I also can not believe that this verdict happened. I feel like ACEP or a governing body should release a statement stating that they vehemently disagree with this sort of verdict so that this isnt used in future legal precedence cases.

UGH! Somedays I really dislike our profession (most days i love what I do, this is just not one of them)

What "ramifications," are you "absolutely terrified" about, in relation to this?

 

[Birdstrike]

Vote with your feet. If people can't see doctors, they might change their minds.

+1,000,000

 

[scummie]

I was going to write something here but got so mad instead I can't think to write.

 

[deleted52758]

honestly, we talked about the case today in our faculty meeting, and it was as it is written. The guy had a fever to 100.7, RR 18, not hypoxic, Diagnosed with a bronchitis, given an antibiotic, and was found dead the next day. Post showed a myocarditis. Something doesnt add up, because it doesnt add up! THe physician is a well liked, extremely smart physician, who was not fired by our hospital group or let go, but got a job out in california.
I honestly think ACEP should step up here and issue a statement regarding this. I am trying to send emails to people who may have connections to get some more formal statement out there. We should stand by this physician as the majority of us would not order EKG's in this case, and even if an ekg is ordered, it's not diagnostic for myocarditis. I think the expert witness that gave their testimony should stand by their testimony, honestly try to look in the face of every emergency physician that they will deal with. I could not be more upset about this, and feel just horrible for this physician.

 

[deleted52758]

What "ramifications," are you "absolutely terrified" about, in relation to this?

it is going to make lesser doctors who are scared to practice more defensive medicine. We talked about it in our meeting, troponins on these cases? Echos? where does it end?

 

[EM4life]

There are no new ramifications, ridiculous cases like this happen regularly, esp in states that do not protect physicians, hence why docs are fleeing to places like Texas.

Medical culture also needs to stop treating cases like these as outliers and the physicians who get sued as diseased. We need to be able to talk about these things without fear of judgement or ramifications. In reality, like everyone has said, this case could've been anyone's and they would've probably done the same thing. Hell I probably saw half a dozen of these during my last shift. Anyway, this post made me think of this Ted lecture which discusses physician error (not implying this case was an error) and our discussion of them

http://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that

 

[Birdstrike]

it is going to make lesser doctors who are scared to practice more defensive medicine. We talked about it in our meeting, troponins on these cases? Echos? where does it end?

I think it already has done that. It ends when we convince the public that "medical malpractice" is not a battle over money between doctors and lawyers. It ends when we show the public how much defensive medicine harms them much like a disease, in serious and sometimes subtle, hidden and insidious ways. (It would also help, if doctors stopped taking cash to testify against their own, see other thread). We need to take this past the attorneys, directly to the public, which is partly why I wrote this:

http://www.kevinmd.com/blog/2012/10/death-defensive-medicine.html

 

[TooMuchResearch]

Just read a PCP clinic note for a pt. Healthy, mid-20s female, presents with sternal pain, reproducible by palpation, 12 hours after using some new chest press machine at the gym. A/P, in its entirety: Chest pain, probably musculoskeletal, will get ECG.

 

[Janders]

Recently saw a case of likely viral myocarditis death (post-mortum wasn't 100% clear...)

EKG in the ED did NOT show anything exciting.
Troponin in the ED, and repeated 6 hours later, was NEGATIVE.
Despite that, said patient died within 24 hours of admission.

You can't win these.

 

[Interpolfanclub]

Lamentable. I know AAEM has a section where you can post egregious testimony. Seems like a case where a young person died and the jury just wanted someone to pay.

 

[Tiger26]

Unfortunately, troponins have very poor sensitivity for myocarditis

 

[xaelia]

Lamentable. I know AAEM has a section where you can post egregious testimony. Seems like a case where a young person died and the jury just wanted someone to pay.

Would love to see who stood up there and said the standard of care was violated, that the EKG was necessary, the EKG would have been diagnostic of myocarditis, and detection of myocarditis would have been otherwise life-saving.

Otherwise, this is nonsense zero-miss lunacy. This is precisely where we need our professional societies to be putting out policies that allow reasonable practice variation and miss rates, particularly for atypical and rare presentations.

 

[Arcan57]

Would love to see who stood up there and said the standard of care was violated, that the EKG was necessary, the EKG would have been diagnostic of myocarditis, and detection of myocarditis would have been otherwise life-saving.

Otherwise, this is nonsense zero-miss lunacy. This is precisely where we need our professional societies to be putting out policies that allow reasonable practice variation and miss rates, particularly for atypical and rare presentations.

We'll never be completely protected from lightning strike events (which I'd categorize this lawsuit as), but the n=0 culture that pervades medicine is an insidious cancer. I don't know why people would rather spend 10x the effort enforcing bad rules as coming up with good ones. The unintended consequences ping through our system and expend resources sorely needed for other patients. Think of the implications for our health system of our current zero-miss standard for patients with end-stage illnesses. Think of the cost of head CT'ing Alzheimer's patients that haven't recognized their children in years, not just in monetary resources but also in delaying other diagnoses that require a CT scan. It's a dereliction of duty on the part of our thought leaders and administrators not to try and find the location of the tipping point between not-enough and too-much intervention .

 

[doctorFred]

"lightning strike event" is the perfect terminology. you're almost certain to go your entire career without being involved in a case like this, just like you're almost certain to live your entire life without being struck by lightning. either event is rare and catastrophic. that's life. that risk goes away when you're dead (or retired.)

there's no reason for this case to have absolutely any bearing on your daily practice.

 

[scummie]

http://www.miamiherald.com/2014/03/13/3992854/fla-supreme-court-rejects-damage.html

Gotta love this wonderful state!! Casey Anthony, Zimmerman, now this.

 

[em1234]

I'm sure I'll enjoy never practicing there.

 

[EM2BE]

I have so many problems with the article.

"misdiagnosed as a lung infection" - last time I checked, some lung infections cause myocarditis, so the patient likely had both

“This was very preventable,” he said. “This was a virus, a very preventable condition if a doctor spends time figuring it out.” - How are you going to prevent this virus?

"negligent in his care and treatment of Kace, which was a substantial contributing factor in his death." - pretty sure there was no negligence here. I would assume they said something about coming back if they felt worse and the vital signs were normal.

Also, as many of you have said, an EKG would not have helped diagnose myocarditis. We can't admit everyone with a cold "just in case." I wish people would just accept tragedy happens, people get sick unexpectedly, just as they die in MVCs unexpectedly. Society needs to change the blame game. Why does someone always have to be held responsible for a tragic occurrence?

 

[laserbeam]

Isn't Massachusetts a tort reform state?

 

[edmadison]

http://www.bostonglobe.com/metro/20...isdiagnosed/LzW5fnCj977ZDt8hZOrpJL/story.html

Absolutely terrified about the ramifications of this, and I also feel so sad for the physician involved, who is well known at my hospital to be a compassionate and competent physician.
I can not imagine what he is going through, but I also can not believe that this verdict happened. I feel like ACEP or a governing body should release a statement stating that they vehemently disagree with this sort of verdict so that this isnt used in future legal precedence cases.

UGH! Somedays I really dislike our profession (most days i love what I do, this is just not one of them)

From a legal perspective, jury verdicts do not create precedence. However, from a practical sense, any jackpot verdict lights up the eyes of the ambulance chasing lawyers and the people watching their commercials on TV.

The trouble with cases like this is that they make for great drama in the court room. When the plaintiff's attorney examines the defendant asking him about a $50 test that takes only 5 minutes, it is virtually impossible to educate the jury about positive and negative predictive value. Lay people associate chest pain with heart disease. Of course you should get and ECG. I'm not a doctor and I know that" It sucks, but that's the world we live in.

Ed

 

[deleted109597]

Isn't Massachusetts a tort reform state?

In a word, no.
http://www.emreportcard.org/Massachusetts/

Massachusetts' Medical Liability Environment lags behind the rest of the country, with relatively few liability reforms in place and one of the highest average malpractice award payments in the country at $519,991ómore than $200,000 higher than the national average. There have been small advances in this area in recent years. Massachusetts included apology inadmissibility language in the state's new health care reform law, and the state developed a demonstration project to examine the benefits of a ìDisclosure, Apology and Offerî system for early resolution of medical malpractice claims. Massachusetts must continue to build on these efforts to bring the state's excessive medical malpractice awards more in line with national averages.

 

[laserbeam]

In a word, no.
http://www.emreportcard.org/Massachusetts/

I found the following on the internet. Obviously from the case in Boston, the list is not correct.

http://www.newphysician.com/articles/tort_reform_list.html

Which States Have Tort Reform?

According to the Health and Human Services' Agency for Healthcare Research and Quality, the following states have imposed limits on non-economic damages ranging from $250,000 to $750,000.
These states include:

• Alabama
• Alaska
• California
• Colorado
• Florida
• Hawaii
• Idaho
• Illinois
• Indiana
• Kansas
• Louisiana
• Maryland
• Massachusetts
• Michigan
• Missouri
• Montana
• New Mexico
• North Dakota
• South Dakota
• Texas
• Utah
• Virginia
• West Virginia
• Wisconsin

There are about 12 percent more physicians per capita in states with damage caps than in states without caps, according to HHS.

 

[deleted109597]

Tort reform=/= only malpractice caps. As is evident here.
Caps have been in place since 1970 and haven't been shown to be effective. Real tort reform is much newer.

 

[docbonez]

1) would an EKG have diagnosed myocarditis (maybe, maybe not) - If you have an arrythmia, STE or STD.. fine, but most likely you might have some nonspecific changes... what do you do with nonspecific findings assuming the pt appeared fine in the ED? rule them out w/ troponins? echo? d/c with PMD f/u? you let them go home.. they die. would an EKG have changed anything?

2) if a 20 year old guy, who presumably looked fine during the ED visit died by the next morning, what is the BEST situation that could have happened if presumably the myocartitis was diagnosed and they werent discharged? hospitalized, probably get intubated at some point before he codes, maybe ecmo if the hospital had it (which is probably the only thing that would have made a difference in this case).

are these questions not reasonable for the defense to pose to 'expert witnesses'?

 

[Substance]

I wonder what kind of work was done by the medical examiner on that case?

I know that forensic path is the doldrums of pathology, which is the doldrums of medicine, and would not doubt that the interpretation was screwed up somehow.

 

[southerndoc]

During residency, I was taught young people only need an EKG and chest X-ray. Over the years, I've seen some interesting cases while sitting on our health system's QA committee. I now always check a troponin on every chest pain. I've caught a couple of cases of myocarditis that way. One with a troponin of 70.

You can argue a single troponin raises risk of malpractice but I disagree. It's poor risk stratification that raises risk. I'm not as concerned about ACS/MI in a 25 year old as I am myocarditis, PE, anomalous right coronary, dissection, etc. I document these things in my note.

 

[Birdstrike]

I've picked up myocarditis twice in kids with a troponin. One was 13 years old.

 

[doctalaughs]

Interesting thread. I'm not in EM (I'm a dermatologist) but this type of thing applies to every specialty and I don't know if the "lightning strike" analogy always works. I might look at a mole and tell it's 99.999% certain it's benign, but nothing is ever 100% certain. So if I examine 100,000 benign moles that people point out (which doesn't take more than a decade or so in practice) eventually I will probably miss a melanoma. In retrospect the expert witness will ask "well, how hard is it to do a biopsy on a mole?" Except if I biopsy every one that I'm 99.999% certain is benign that's probably 25 million dollars in wasted healthcare dollars. Unfortunately, some people practice like that and it's because of the system we have created.

 

[goodoldalky]

The fact is that if you see enough patients, you will eventually see someone, provide a complete, competent, reasonable medical evaluation and disposition the patient appropriately, and they'll go home and die. Maybe from something related or maybe unrelated to why they saw you. Sounds like that is what happened to this MD who had his unlucky chart pull. These types of cases are the reason we buy malpractice insurance and tend to gravitate toward states with more appropriate tort climate. Based on what little I know about this case (I do wonder if he was markedly tachycardic), I imagine many of us here would not have ordered an EKG and if we did it would have unlikely had an effect on the outcome.