Midlevel's miss leads to $200+ verdict

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NSAIDAllergy said:
No matter who is working with/for you, trust but verify!

http://www.modernmedicine.com/moder...Article/detail/476100?contextCategoryId=40169

Any thoughts?
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That doesn't so much seem like a Midlevel miss as the guy was not licensed as a midlevel nor privileged to examine patients. The group should never had employed him and he definitely should not have seen patients and he should have known that. If they were using him as a physician extender in any role beyond scribing, then they likely are guilty of gross negligence.
 
Brief summary: missed cerebellar stroke based on exam of unlicensed PA (supervising Doc says he didn't know the PA was unlicensed). 217 Million verdict.

1. Don't hire unlicensed MLPs

2. If your MLP has a case that seems suspicious you should see it too

3. You should see all red flag complaints (worst HA of my life)

Honestly reading the summary of the case if the MLP had been licensed and a thorough neuro exam documented I think the dispo would not have been unreasonable. There are a lot of complicating factors that lead to this verdict.
 
does this scare the **** out of anyone but me? Suppose the exam was repeated and it was the same as the midlevel (licensed or not) described. This guy still would have gotten burned. We all discharge people like this all the time. It might have been more appropriate to LP him than get an MRI, but even that would have been negative. His initial complaint sounded more like migraine, but I could see this guy easily being discharged home on a busy night with a normal neuro exam the waking up with symptoms and get raked over the coals by a jury of people who think doctors are perfect and filthy rich
 
Glad I turned down that job in Florida. The malpractice is horrendous there.

100 million in punitive damages?

That means that 117 million was ACTUAL damages. How on Earth can you get to 117 million? If the guy had worked as a machine operator for 50 years, you might be looking at 10-20 million.
 
CueDoc said:
His initial complaint sounded more like migraine, but I could see this guy easily being discharged home on a busy night with a normal neuro exam the waking up with symptoms and get raked over the coals by a jury of people who think doctors are perfect and filthy rich
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From the article:
Headache, nausea, dizziness, confusion, and double vision. He described a personal history of hypertension, diabetes, and elevated cholesterol, plus a family history of stroke. Mark Herranz, a physician extender, examined Navarro, who reported the sudden onset of a severe headache and feeling a "pop" in his head.
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Easy to look at this in hindsight, but the confusion doesn't really fit with migraine, does it? Plus the risk factors, and the feeling of a "pop in his head." That's a scary HPI, don't you guys think?

Absolutely amazed to read that they didn't try to settle this:

While the plaintiffs had offered to settle the case for $2 million before trial, liability insurer ProNational Insurance insisted that the care provided wasn't negligent.
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A horrible outcome after a patient was seen and treated by a "scribe" acting as a PA because he couldn't pass the licensure exam and you're not going to settle????? Ironic, since you hear so many stories of carriers settling BS cases just to get rid of them.
 
WallowaWanderer said:
A horrible outcome after a patient was seen and treated by a "scribe" acting as a PA because he couldn't pass the licensure exam and you're not going to settle????? Ironic, since you hear so many stories of carriers settling BS cases just to get rid of them.
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Very good point..if there was a time to bite the bullet and pay out this was it.
 
I have to agree with most of what has been said before. Major points that got my attention.

1. This guy was not a midlevel. He did not pass his boards and did not hold a license. Period.

2. He did confer with the doc who approved the tests. However, do you really want to accept the word of a guy who couldn't pass his PA boards. I'm not saying my boards were a walk in the park, but they can easily be passed by most.

3. I could see the patient being discharged and I know it is easy to say this in hindsight, but my spidey sense would have been going off. Then again I do neuro.

4. Shakes head in confusion. Why didn't they settle?

5. If you hire a midlevel, keep the reigns on tight until you trust them and make sure they know their limitations and for god sakes make sure they know to come grab you when something does not seem right.
 
RE: Cuedoc
Yeah we send this home every day but if you hadn't used an unlicensed midlevel you would have a case for precisely the fact that we DO all send this home every day.

RE: why didn't they settle - I suspect that the insurer didn't know the midlevel was unlicensed. It seems that fact didn't come out until about a year into the case.
 
I've always been a pretty good defender of midlevels, esp. PAs. However, I had the unfortunate experience of having pneumonia and bacteremia for which I went to the university hospital ER associated with my program. Blood cultures were drawn and I was sent home. A few days later, I get a call from the ER PA to inform me that my blood cultures were positive for S. pneumo. which is only sensitive to ceftriaxone and vancomycin. However, I have nothing to worry about because she can just call in a prescription for PO vancomycin for me 😱

Needless to say, she got a little lecture from me about the indications for po vanc and I got an admission. I mean, that is just plain old scary and blatant malpractice. How many times has this PA done this before resulting in a patient with pneumonia and bacteremia ending up in the ICU from septic shock because they're getting no treatment?

Would scare the crap out of me if I were and ED attending relying on the person as a physician extender.
 
At my PA program, they teach us about using labs or imaging to support a clinical diagnosis, not to substitute for one. They teach us about empiric abx coverage. They teach us about "worst headache of my life," they teach us about gradually developing our very own Spidey-sense, and they teach us that anything you're not 105% sure about, you ask the SP.

From my own experience, I've gathered that if you're new to a practice and the SP is too busy to help when you need it, then you need to figure something out because that SP is going to help you kill somebody soon. (And if you've been a scribe someplace for months or years and they like you, that doesn't mean it's okay for you to see patients and help your buddies earn more, regardless of how well they pay.)

And, as has been said, this guy wasn't a PA-C (even after FOUR whacks at the Board exam!), he was a scribe. Phrases like "physician extender" are vague, and just help to muddy the waters at a time when a huge percentage of the public still has no idea what the heck a PA is.

None of that answers CueDoc's really good question, but "Midlevel" means something specific that this not-a-provider is most definitely not.
 
pillowhead said:
I've always been a pretty good defender of midlevels, esp. PAs. However, I had the unfortunate experience of having pneumonia and bacteremia for which I went to the university hospital ER associated with my program. Blood cultures were drawn and I was sent home. A few days later, I get a call from the ER PA to inform me that my blood cultures were positive for S. pneumo. which is only sensitive to ceftriaxone and vancomycin. However, I have nothing to worry about because she can just call in a prescription for PO vancomycin for me 😱

Needless to say, she got a little lecture from me about the indications for po vanc and I got an admission. I mean, that is just plain old scary and blatant malpractice. How many times has this PA done this before resulting in a patient with pneumonia and bacteremia ending up in the ICU from septic shock because they're getting no treatment?

Would scare the crap out of me if I were and ED attending relying on the person as a physician extender.
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First off, WTF. PO Vanc, what a *****.

Treating pseudomembranous colitis (even then as a second line drug) I could see. The other thing is that stuff is top dollar.

It never even leaves your GI tract. That sort of stuff is exactly what I do my best to avoid so mid-levels can gain some respect.

Ahhh, it makes me want to pull my hair out and I don't have much to spare.
 
Definitely a disturbing case all around.
I agree with my fellow PAs: this guy was NOT a PA. He may have at one time attended and even graduated from a PA program but if he was not a certified and licensed PA he was not a PA at all. It's scary to think of a group utilizing an unlicensed provider in this sense at all--I've never worked in a situation with "scribes" but I can see it was an accident waiting to happen in this setting. IF the scribe was just a scribe, that might be one thing, but the presumption that this scribe was a PA because he apparently must have been represented as such is frightening. I mean really, how does the attending not know the qualifications of those with whom s/he is working?
When I work the ED I have a scope of practice that is signed by each of my attending physicians. When a new MD/DO joins the group s/he has to review each of our scopes of practice and sign off on it, and s/he gets a chance to review our licensure and qualifications. In our ED (and I've argued this is overkill and overmanagement but I guess we wouldn't run into this situation) every patient we see also is seen by the attending before dispo. It's inefficient but I suppose the docs are more comfortable with it. It gets old after you've been doing this for several years though.
Did you guys catch the part where the not-a-PA "died before trial"? Curious what's up with that.
I have no problem with "trust, but verify". I appreciate a conscientious and reliable supervising physician that I can go to when I'm stumped and/or worried. We as PAs need to know you guys have our backs, and we will repay you kindly in turn.
L.
 
I wonder about the use of the word "scribe" in this article. I am a scribe and my job is to chart. All the scribes who work in our EM group are pre-med, with a few pre-PA. I wonder if this was a case where a scribe worked there, went to PA school but couldn't pass boards, then returned to the ED and told them he'd work for cheap if he could see patients. Who knows? This is kind of a weird story.

Anyone know what the original probability of finding the infarct on two serial scans with contrast was?
 
This guy was not a PA. It is not appropriate to even discuss this guy in the same sentence with PA's, because he WAS NOT ONE. He never passed his boards. He was not working as a PA. When I was a PA, I used to see this all the time. I used to see docs hiring unlicensed FMG's as "PA's" when they were not actually anything but an unlicensed FMG...(meaning can only function as a medical student). PA's are highly valuable, even in academic centers. They keep continuity on services where there would otherwise be monthly resident changes. Here where I am, the PA's are first to come to the ED for trauma's, heme/onc, plastics, NSG. They help out a great deal. In our ICU, they have the same role.
 
corpsmanUP said:
This guy was not a PA. It is not appropriate to even discuss this guy in the same sentence with PA's, because he WAS NOT ONE. He never passed his boards. He was not working as a PA. When I was a PA, I used to see this all the time. I used to see docs hiring unlicensed FMG's as "PA's" when they were not actually anything but an unlicensed FMG...(meaning can only function as a medical student). PA's are highly valuable, even in academic centers. They keep continuity on services where there would otherwise be monthly resident changes. Here where I am, the PA's are first to come to the ED for trauma's, heme/onc, plastics, NSG. They help out a great deal. In our ICU, they have the same role.
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agree- this guy was probably an fmg. florida used to allow fmg's to sit for a special board exam to become pa's(they don't anymore).
any group that doesn't check on the status of an applicants license has more problems than we can list here.....
bottom line as above:
1.guy was not a pa.
2.guy did not have a medical license of any kind.
the doc in question was put in a bad position if he really didn't know 1 and 2 above.
 
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