$10 million dollar verdict for delay of care

[Arcan57]

I guess I'm the only one not outraged that a hospital was held accountable for useless administrators coming up with nonsense policies and then failing to actually staff in a way that makes them feasible. This wasn't some subtle presentation that got missed. And it's not like there was some unavoidable delay in care, it's the same garbage staffing and culture to maximize profits that we see everywhere.

And is this really the same hospital that sent the Ebola patient home after he presented with fever and a history of travel to an area with an active Ebola outbreak?

In the before times, setting up unrealistic policies was a good way for admin to deflect blame from their fiscal decisions, as illustrated below:

1) Hospital A cuts staffing to the point where RNs and LPNs can't turn all their patients often enough to prevent bed sores.
2) Hospital A starts getting dinged for a spike in "never" events due to these pressure ulcers.
3) CNO writes policy requiring skin risk assessment every shift, with a 6 item Braden score that must be entered into the chart.
4) Patients with very lengthy hospital stays tend to be the ones that get pressure ulcers.
5) Patients with very lengthy hospital stays tend to have at least one missing Braden score during their 3-6 months inpatient stays.
6) Nurse that missed documenting a Braden score is now responsible for the "never" event, and receives corrective counseling.
7) CNO remains blameless and continues looking for further places to cut ... I mean LEAN out their staffing so they can make the jump to a system-level position.

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[WilcoWorld]

It's been sprinkled throughout the thread, but I'm going to bring it down to a single post for clarity:

This verdict was the product of 2 things, neither of which was malpractice or error. You have a disabled patient (that costs a lot of money) and a violation of hospital policy (hoisted by one's on petard).

You can't do much about the first factor, but the second is why it's very important to know your institution's policies. Do you have a chest pain pathway? If you follow the pathway, discharge a moderate risk chest pain & they die - you'll be OK. If you deviate from the pathway and dc a super low risk chest pain and they die - you're screwed.

 

[WilcoWorld]

You have to wonder what expert wittinesses testimony was. It's quite clear that the outcomes after spinal decompression are determined by the exam prior to surgery - spinal surgery can't restore function, it can only prevent further worsening. Stated otherwise: if she was paralyzed when she arrived at the ED, she was going to be paralyzed no matter how quickly things went.

 

[emergentmd]

If you follow the pathway, discharge a moderate risk chest pain & they die

You are giving too much credit to the panel of your peers. Do you think a bunch of HS graduates will care that you followed some pathway? If you get sued, either you will settle or likely lose a piece of flesh.

 

[ScepticSkeksis]

You are giving too much credit to the panel of your peers. Do you think a bunch of HS graduates will care that you followed some pathway? If you get sued, either you will settle or likely lose a piece of flesh.

You mean the same people who are unable to care for cold/flu symptoms at home, and the people who interpret every normal, everyday ache and pain as a life-threatening reason to go to the ER?

 

[alpinism]

Word on the street is the emergency physician was also sued but settled.

Bruce Janiak was a witness and stated that he was at fault due to not calling the neurosurgeon immediately.

Its true most neurosurgeons will ask for imaging before operating but they still need to be notified.

Hate to say it but this is literally a question straight from the oral boards.

 

[alpinism]

You have to wonder what expert wittinesses testimony was. It's quite clear that the outcomes after spinal decompression are determined by the exam prior to surgery - spinal surgery can't restore function, it can only prevent further worsening. Stated otherwise: if she was paralyzed when she arrived at the ED, she was going to be paralyzed no matter how quickly things went.

Spinal Epidural Hematomas can often have a complete recovery of motor function if drained right away by neurosurgeons.

 

[Brigade4Radiant]

Word on the street is the emergency physician was also sued but settled.

Bruce Janiak was a witness and stated that he was at fault due to not calling the neurosurgeon immediately.

Its true most neurosurgeons will ask for imaging before operating but they still need to be notified.

Hate to say it but this is literally a question straight from the oral boards.

Yeah but the specialists don’t do anything in the oral boards either. You just get scored higher

If you are saying that the neurosurgeon should have drained it without imaging that simply isn’t the standard of care

“Within ten minutes of arriving at the emergency room, a "STAT" MRI was ordered for Adams so that an emergency laminectomy could be done. “

The ED doctor did an order at 4:56 and they got the results back in an hour surgery didn’t start till 10pm.

Even the call to a specialist on the oral boards they won’t get back to you immediately you still have yo manage the patient and not rely to heavily on your specialist.

So even going by the oral boards the EM “expert witness” fails to make a good point


50% of spinal epidural hematomas do not recover.

A lot of academic doctors love throwing people under the bus but they haven’t done their own pelvic exams for years

 

[Zebra Hunter]

Word on the street is the emergency physician was also sued but settled.

Bruce Janiak was a witness and stated that he was at fault due to not calling the neurosurgeon immediately.

Its true most neurosurgeons will ask for imaging before operating but they still need to be notified.

Hate to say it but this is literally a question straight from the oral boards.

So he was claiming that not only was the ER doctor negligent, but grossly negligent (as that is the standard for emergent situations in Texas) for not calling the surgeon without imaging? Has he even practiced in the last decade?

This seems like a Peter Rosen situation where we have someone whose name carries considerable weight in our specialty willingly giving questionable expert witness testimony. There is no way any expert witness can claim the ER doctor’s care was GROSSLY negligent when he got the patient to the OR in 5 hours.

 

[Dr Mantis Toboggan]

One wonders what an acceptable time frame would’ve been to these experts.

I find it hard to imagine any scenario (especially now) where you could get MRI done/read and to the OR in less than 3 hours tops.

 

[anonperson]

What magical hospital is an MRI getting done within an hour. 90 minutes is really quick and I am actually amazed it got done in that time frame.

Plus, I know this hospital has this goofy rule about taking patients to surgery within 60 minutes, which is completely unrealistic. Usually rules like this have to be voted on by medical staff. Why did the surgeons even agree to this idea? Other than obstetrics, the time frame should be vague and state surgery should be expedited as reasonably as possible.

My other issue is with OR staffing. At most hospitals, it isn't like an anesthesiologist is just free, screwing around in the call room.

On a typical weekday between the hours of 730 am to 5 pm, scheduled cases are running and the anesthesiologists are running their own rooms. What happened if this patient rolled in at 10am on a Monday and all the rooms are occupied with scheduled cases that are currently ongoing? It would be impossible to even get a room available and pull an anesthesiologist.

You would have to hope that a room was finishing and that you could bump a scheduled set of cases. It's not uncommon to have a robotic bowel resection, prostatectomy, long Ortho case etc to be running concurrently.

I know this case came in later in the afternoon, but how could you make a 60 minute rule knowing the above limitations?

Also, having gone through my own malpractice situation ( will thankfully be dropped) I was able to read the defenses "expert witness" report, I can honestly say these expert witnesses are complete dirtbags and the malpractice lawyers are complete trash.

Like it has been mentioned several times before. For any new physicians, malpractice lawsuits are not about standard of care or being nice to patients or aplogizing. If there is a bad outcome, you will get sued. You could have followed the standard of care to a T, but if you have a damaged patient, especially a permanently damaged patient, good luck. A lawyer will see $$$ and twist the facts to cloud a juries judgement.

The sad part is, bad outcome are a fact of life regardless of how good of a physician you are.

"It is possible to commit no mistakes and still lose. That is not a weakness. That is life"

Try telling that to a lawyer...

 

[WilcoWorld]

Spinal Epidural Hematomas can often have a complete recovery of motor function if drained right away by neurosurgeons.

Looks like I've had an oversimplified understanding.

"Preoperative neurological status correlated with outcome; 83% of Frankel Grade D patients recovered completely compared to 25% of Frankel Grade A patients. The rapidity of surgical intervention also correlated with outcome; greater neurological recovery occurred as the interval from symptom onset to surgery decreased."

Preop neuro status seems to still be the most important determinant of outcome, but not the only one.

 

[WilcoWorld]

You are giving too much credit to the panel of your peers. Do you think a bunch of HS graduates will care that you followed some pathway? If you get sued, either you will settle or likely lose a piece of flesh.

You mean the same people who are unable to care for cold/flu symptoms at home, and the people who interpret every normal, everyday ache and pain as a life-threatening reason to go to the ER?

I'm basing those statements on what I've been told by malpractice attorneys. 🤷‍♂️

 

[Rekt]

What magical hospital is an MRI getting done within an hour. 90 minutes is really quick and I am actually amazed it got done in that time frame.

Plus, I know this hospital has this goofy rule about taking patients to surgery within 60 minutes, which is completely unrealistic. Usually rules like this have to be voted on by medical staff. Why did the surgeons even agree to this idea? Other than obstetrics, the time frame should be vague and state surgery should be expedited as reasonably as possible.

My other issue is with OR staffing. At most hospitals, it isn't like an anesthesiologist is just free, screwing around in the call room.

On a typical weekday between the hours of 730 am to 5 pm, scheduled cases are running and the anesthesiologists are running their own rooms. What happened if this patient rolled in at 10am on a Monday and all the rooms are occupied with scheduled cases that are currently ongoing? It would be impossible to even get a room available and pull an anesthesiologist.

You would have to hope that a room was finishing and that you could bump a scheduled set of cases. It's not uncommon to have a robotic bowel resection, prostatectomy, long Ortho case etc to be running concurrently.

I know this case came in later in the afternoon, but how could you make a 60 minute rule knowing the above limitations?

Also, having gone through my own malpractice situation ( will thankfully be dropped) I was able to read the defenses "expert witness" report, I can honestly say these expert witnesses are complete dirtbags and the malpractice lawyers are complete trash.

Like it has been mentioned several times before. For any new physicians, malpractice lawsuits are not about standard of care or being nice to patients or aplogizing. If there is a bad outcome, you will get sued. You could have followed the standard of care to a T, but if you have a damaged patient, especially a permanently damaged patient, good luck. A lawyer will see $$$ and twist the facts to cloud a juries judgement.

The sad part is, bad outcome are a fact of life regardless of how good of a physician you are.

"It is possible to commit no mistakes and still lose. That is not a weakness. That is life"

Try telling that to a lawyer...

I'm not defending this case whatsoever and I actually think it's personally the most upsetting med-mal case because of how ridiculously proprosterous it is and 100% shows how broken med-mal is, but I've worked at a few hospitals that had a "crash" operating room that is usually saved for very emergent cases. I also I have no idea why a hospital would put that in place and especially have the surgeons agree with it. Completely stupid.

 

[BoardingDoc]

"It is possible to commit no mistakes and still lose. That is not a weakness. That is life"

Try telling that to a lawyer...

Picard would find a way. He certainly knows his way around a trial as seen in "The measure of a man" or "The drumhead." Both have absolutely amazing monologues.

 

[anonperson]

I'm not defending this case whatsoever and I actually think it's personally the most upsetting med-mal case because of how ridiculously proprosterous it is and 100% shows how broken med-mal is, but I've worked at a few hospitals that had a "crash" operating room that is usually saved for very emergent cases. I also I have no idea why a hospital would put that in place and especially have the surgeons agree with it. Completely stupid.

The physical room may not be an issue.

Staff is an issue. You need a scrub, circulating nurse, and anesthesiologist.

 

[cyanide12345678]

Word on the street is the emergency physician was also sued but settled.

Bruce Janiak was a witness and stated that he was at fault due to not calling the neurosurgeon immediately.

Its true most neurosurgeons will ask for imaging before operating but they still need to be notified.

Hate to say it but this is literally a question straight from the oral boards.

Will that phone call really change management or outcome?

The answer is no.

The surgeon will angrily tell you to not call him until the MRI is done.

this might be taught in a academic center, but by absolutely no means is this standard of care in most community hospitals, and 100 percent does not change outcome as surgeon flat out tells you to call back later.

 

[Dr Mantis Toboggan]

Will that phone call really change management or outcome?

The answer is no.

The surgeon will angrily tell you to not call him until the MRI is done.

this might be taught in a academic center, but by absolutely no means is this standard of care in most community hospitals, and 100 percent does not change outcome as surgeon flat out tells you to call back later.

They may hate the “heads up” but I think it’s the right thing to do in this situation. Maybe you catch the surgeon before they leave the hospital and they come and see the patient right away. Plus they are likely way more respected than the ED folks so maybe that MRI gets done faster etc. If you call them within 10 min of patient arrival and document you did all you could to push things along I’d bet you are not getting named in that scenario.

Of course in a perfect world the person doing the injection is calling them beforehand also to get them on board ASAP. It seems like this was a very straightforward if brutal complication.

 

[alpinism]

Yeah but the specialists don’t do anything in the oral boards either. You just get scored higher

If you are saying that the neurosurgeon should have drained it without imaging that simply isn’t the standard of care

“Within ten minutes of arriving at the emergency room, a "STAT" MRI was ordered for Adams so that an emergency laminectomy could be done. “

The ED doctor did an order at 4:56 and they got the results back in an hour surgery didn’t start till 10pm.

Even the call to a specialist on the oral boards they won’t get back to you immediately you still have yo manage the patient and not rely to heavily on your specialist.

So even going by the oral boards the EM “expert witness” fails to make a good point


50% of spinal epidural hematomas do not recover.

A lot of academic doctors love throwing people under the bus but they haven’t done their own pelvic exams for years

The patient basically suffered a traumatic spinal cord injury with acute onset complete paralysis.

It's no different than if someone was stabbed in the back and couldn't move their lower extremities.

This should be a level one trauma alert -> NSY consult -> CT scan -> OR in under 60 minutes.

Spinal injuries and especially spinal hematomas are incredibly rare in the united states and many neurosurgeons aren't very experienced with management guidelines especially in cases of acute onset complete paralysis. Due to this many will often reflexively treat acute onset cases the same as chronic onset cases and want an MRI before any operations. MRI scans are by far the best imaging modality for small hematomas but they aren't required for massive hematomas which can be visualized on modern thin slice CT scans. In patients with acute traumatic injuries its normally recommended to get a CT then go straight to surgery if necessary.

From the most recent neurosurgical guidelines:

"Thus, for patients with acute spinal cord injury, the authors agree that every effort should be made to obtain an MRI of the relevant spinal section to assist with operative planning, diagnostics, and prognostication, but this should not delay emergent operative intervention."

Management of Acute Traumatic Spinal Cord Injury: A Review of the Literature

Traumatic spinal cord injury (TSCI) is a debilitating disease that poses significant functional and economic burden on both the individual and societal levels. Prognosis is dependent on the extent of the spinal injury and the severity of neurological dysfunction. If not treated rapidly, patients...

www.frontiersin.org

 

[Brigade4Radiant]

The patient basically suffered a traumatic spinal cord injury with acute onset complete paralysis.

It's no different than if someone was stabbed in the back and couldn't move their lower extremities.

This should be a level one trauma alert -> NSY consult -> CT scan -> OR in under 60 minutes.

Spinal injuries and especially spinal hematomas are incredibly rare in the united states and many neurosurgeons aren't very experienced with management guidelines especially in cases of acute onset complete paralysis. Due to this many will often reflexively treat acute onset cases the same as chronic onset cases and want an MRI before any operations. MRI scans are by far the best imaging modality for small hematomas but they aren't required for massive hematomas which can be visualized on modern thin slice CT scans. In patients with acute traumatic injuries its normally recommended to get a CT then go straight to surgery if necessary.

From the most recent neurosurgical guidelines:

"Thus, for patients with acute spinal cord injury, the authors agree that every effort should be made to obtain an MRI of the relevant spinal section to assist with operative planning, diagnostics, and prognostication, but this should not delay emergent operative intervention."

Management of Acute Traumatic Spinal Cord Injury: A Review of the Literature

Traumatic spinal cord injury (TSCI) is a debilitating disease that poses significant functional and economic burden on both the individual and societal levels. Prognosis is dependent on the extent of the spinal injury and the severity of neurological dysfunction. If not treated rapidly, patients...

www.frontiersin.org

The paper you state still states that ct should be done before neurosurgeon consult

“Thus, for patients with acute spinal cord injury, the authors agree that every effort should be made to obtain an MRI of the relevant spinal section to assist with operative planning, diagnostics, and prognostication, but this should not delay emergent operative intervention where the area of injury is clear with an actively declining neurological exam, to reduce an unstable fracture, or otherwise in a hemodynamically unstable patient.”

Also Level 1 alerts work at level one trauma centers. what if the initial CT scan was negative? You could argue that the CT was a delay in care.

 

[thegenius]

Picard would find a way. He certainly knows his way around a trial as seen in "The measure of a man" or "The drumhead." Both have absolutely amazing monologues.

I would have rushed Picard to the MRI myself if he came in paralyzed from an epidural. I would run the MRI machine myself, run a variety of tests, and call every doctor in the hospital to the ER immediately for a consult, and would threaten EMTALA violations left and right. Then I would get fired a month later, and hopefully accept a position as junior resident doc onboard the Enterprise.

 

[thegenius]

Spinal Epidural Hematomas can often have a complete recovery of motor function if drained right away by neurosurgeons.

Would they every do surgery without imaging? And how did neurosurgeons perform this surgery prior to the advent of MRI?

 

[Kryptocoin]

I've called NSG a few times on pts that I'm concerned about spinal abscess or cauda equina, and they all hang up on me when I tell them MRI is "pending." Neurosurgeons don't trust our exams or clinical impression. They only go by imaging results. It's a pipe dream and non-real world idea that a neurosurgeon would take a pt to the OR without confirmatory imaging.

I am still surprised about this verdict from Texas. They're probably spooked from all of the mayhem caused by Dr. Death.

 

[thegenius]

The patient basically suffered a traumatic spinal cord injury with acute onset complete paralysis.

It's no different than if someone was stabbed in the back and couldn't move their lower extremities.

This should be a level one trauma alert -> NSY consult -> CT scan -> OR in under 60 minutes.

Spinal injuries and especially spinal hematomas are incredibly rare in the united states and many neurosurgeons aren't very experienced with management guidelines especially in cases of acute onset complete paralysis. Due to this many will often reflexively treat acute onset cases the same as chronic onset cases and want an MRI before any operations. MRI scans are by far the best imaging modality for small hematomas but they aren't required for massive hematomas which can be visualized on modern thin slice CT scans. In patients with acute traumatic injuries its normally recommended to get a CT then go straight to surgery if necessary.

From the most recent neurosurgical guidelines:

"Thus, for patients with acute spinal cord injury, the authors agree that every effort should be made to obtain an MRI of the relevant spinal section to assist with operative planning, diagnostics, and prognostication, but this should not delay emergent operative intervention."

Management of Acute Traumatic Spinal Cord Injury: A Review of the Literature

Traumatic spinal cord injury (TSCI) is a debilitating disease that poses significant functional and economic burden on both the individual and societal levels. Prognosis is dependent on the extent of the spinal injury and the severity of neurological dysfunction. If not treated rapidly, patients...

www.frontiersin.org

Dude, many excellent points. Won't fly when you call your trauma surgeon, but this is an excellent point, all of them in fact!

 

[Arcan57]

The patient basically suffered a traumatic spinal cord injury with acute onset complete paralysis.

It's no different than if someone was stabbed in the back and couldn't move their lower extremities.

This should be a level one trauma alert -> NSY consult -> CT scan -> OR in under 60 minutes.

Spinal injuries and especially spinal hematomas are incredibly rare in the united states and many neurosurgeons aren't very experienced with management guidelines especially in cases of acute onset complete paralysis. Due to this many will often reflexively treat acute onset cases the same as chronic onset cases and want an MRI before any operations. MRI scans are by far the best imaging modality for small hematomas but they aren't required for massive hematomas which can be visualized on modern thin slice CT scans. In patients with acute traumatic injuries its normally recommended to get a CT then go straight to surgery if necessary.

From the most recent neurosurgical guidelines:

"Thus, for patients with acute spinal cord injury, the authors agree that every effort should be made to obtain an MRI of the relevant spinal section to assist with operative planning, diagnostics, and prognostication, but this should not delay emergent operative intervention."

Management of Acute Traumatic Spinal Cord Injury: A Review of the Literature

Traumatic spinal cord injury (TSCI) is a debilitating disease that poses significant functional and economic burden on both the individual and societal levels. Prognosis is dependent on the extent of the spinal injury and the severity of neurological dysfunction. If not treated rapidly, patients...

www.frontiersin.org

What do the neurosurgeons say when you tell them that a post-ESI patient with weakness is basically the same as a stab wound to the back? Do they buy into your post-ESI weakness is a Level 1 trauma model? What caliber of gun are you holding to their head when you tell them they have to cut open a person's spine without their preferred imaging? Do you remind them that they're not experienced with management guidelines as you're pointing the gun?

Maybe this is the one hospital that had everything together and could have gone to the OR immediately and this poor person would be dancing right now. But it feels more likely that factors the ED doc had no control over meant that wasn't going to happen. It's good to know there are ED docs out there willing to do the hard work of holding that unfortunate ED doc accountable.

And in regards to your prior post, you know what everyone thinks of the oral boards when they take them? That they're fake. The scenarios represent wispy rememberings of attendings from a bygone era. They feel like they're occasionally updated with slightly more modern takes from academics projecting fantasies where every consultant is either perfect, useless, or evil and it's always obvious which.

 

[RustedFox]

The patient basically suffered a traumatic spinal cord injury with acute onset complete paralysis.

It's no different than if someone was stabbed in the back and couldn't move their lower extremities.

This should be a level one trauma alert -> NSY consult -> CT scan -> OR in under 60 minutes.

Spinal injuries and especially spinal hematomas are incredibly rare in the united states and many neurosurgeons aren't very experienced with management guidelines especially in cases of acute onset complete paralysis. Due to this many will often reflexively treat acute onset cases the same as chronic onset cases and want an MRI before any operations. MRI scans are by far the best imaging modality for small hematomas but they aren't required for massive hematomas which can be visualized on modern thin slice CT scans. In patients with acute traumatic injuries its normally recommended to get a CT then go straight to surgery if necessary.

From the most recent neurosurgical guidelines:

"Thus, for patients with acute spinal cord injury, the authors agree that every effort should be made to obtain an MRI of the relevant spinal section to assist with operative planning, diagnostics, and prognostication, but this should not delay emergent operative intervention."

Management of Acute Traumatic Spinal Cord Injury: A Review of the Literature

Traumatic spinal cord injury (TSCI) is a debilitating disease that poses significant functional and economic burden on both the individual and societal levels. Prognosis is dependent on the extent of the spinal injury and the severity of neurological dysfunction. If not treated rapidly, patients...

www.frontiersin.org

This had better be sarcasm or such.

 

[RustedFox]

Picard would find a way. He certainly knows his way around a trial as seen in "The measure of a man" or "The drumhead." Both have absolutely amazing monologues.

I would have rushed Picard to the MRI himself if he came in paralyzed from an epidural. I would run the MRI machine myself, run a variety of tests, and call every doctor in the hospital to the ER immediately for a consult, and would threaten EMTALA violations left and right. Then I would get fired a month later, and hopefully accept a position as junior resident doc onboard the Enterprise.

Wow. You guys are losers.

I say that in good ribbing, amigos.

 

[thegenius]

Wow. You guys are losers.

I say that in good ribbing, amigos.

That's why we'll be on the bridge, and you will be somewhere on Deck 22, Section 5.

 

[cyanide12345678]

This is what's wrong with Medicine. You defending this verdict. Go **** yourself. You're literally trash for this statement. I 100% hope with every cell in my body you get sued for something that is complete nonsense.

I'll take the ban

Maybe they work in academia. Academics is a lot of text book practice as you focus on teaching. Community medicine just doesn’t function that way.

 

[thegenius]

I've called NSG a few times on pts that I'm concerned about spinal abscess or cauda equina, and they all hang up on me when I tell them MRI is "pending." Neurosurgeons don't trust our exams or clinical impression. They only go by imaging results. It's a pipe dream and non-real world idea that a neurosurgeon would take a pt to the OR without confirmatory imaging.

I am still surprised about this verdict from Texas. They're probably spooked from all of the mayhem caused by Dr. Death.

What we need is a NSG to testify against another NSG saying they should have gone to the ED immediately, and taken the patient to the OR immediately.
If ****ing ER docs testify against other ER docs, why can't NSG testify against their own kind as well?

 

[FutureInternist]

I really wish nationally we would have tort reform where all states and federal court cases require a panel of docs to review before litigation could proceed. That would eliminate a lot of litigation provided they don't have these guns for hire review cases. Should be random sampling of same specialty docs practicing in that state.

Come to NM 😏

 

[StIGMA]

In residency, my neuro attending had stroke-like symptoms on rounds (turns out, complex migraine) and was getting MRI brain in <10min with stroke attending reading it. I think thats what the population expects for as standard of care for themselves (but not their neighbor).

 

[emergentmd]

This is a case where I settle, spend as little time dealing with it, move one, and do not change my practice one bit.

Sometimes you just happen to be the one holding the lawsuit bomb. I could not imagine calling any surgeon before imaging anymore.

How many Chole or appy do we sit on for hours waiting for imaging. I would say that outcome would be worse if we take all clinical appy to the OR vs the bad outcomes with delay for imaging.

If I were a pt, I sure would want a CT before surgery lays a hand on me. I have seen many epipoleic appendigitis that I was sure to be an appy.

 

[alpinism]

What do the neurosurgeons say when you tell them that a post-ESI patient with weakness is basically the same as a stab wound to the back? Do they buy into your post-ESI weakness is a Level 1 trauma model? What caliber of gun are you holding to their head when you tell them they have to cut open a person's spine without their preferred imaging? Do you remind them that they're not experienced with management guidelines as you're pointing the gun?

Maybe this is the one hospital that had everything together and could have gone to the OR immediately and this poor person would be dancing right now. But it feels more likely that factors the ED doc had no control over meant that wasn't going to happen. It's good to know there are ED docs out there willing to do the hard work of holding that unfortunate ED doc accountable.

And in regards to your prior post, you know what everyone thinks of the oral boards when they take them? That they're fake. The scenarios represent wispy rememberings of attendings from a bygone era. They feel like they're occasionally updated with slightly more modern takes from academics projecting fantasies where every consultant is either perfect, useless, or evil and it's always obvious which.

Meh I work in one of the most dysfunctional hospitals in the country where our neurosurgeons frequently refuse to see patients even after getting the imaging that's requested. That doesn't mean I don't call if needed because "they will not do anything" or "they start yelling and get angry."

Look we have tough job and sometimes you have to fight with your consultants to get the right thing done for patients. Now obviously you can't force them to operate but you can at least call them about patients that will likely need an emergent operation. This is especially true for anything time sensitive when even short delays result in severe consequences. All I'm saying is that if that was my family I'd sure as hell be calling them right after the patient arrived to inform them about the case and request they come and see the patient in the emergency department.

 

[alpinism]

This is what's wrong with Medicine. You defending this verdict. Go **** yourself. You're literally trash for this statement. I 100% hope with every cell in my body you get sued for something that is complete nonsense.

I'll take the ban

To be clear the lawsuit is ridiculous and he should not have been sued.

However I do think in this case we should always call neurosurgery.

 

[RustedFox]

This is what's wrong with Medicine. You defending this verdict. Go **** yourself. You're literally trash for this statement. I 100% hope with every cell in my body you get sued for something that is complete nonsense.

I'll take the ban

Don't ban him, mods.
I've been sued for complete nonsense.

I actually just got a letter yesterday from the Board of Medicine about my one case, and I'm now free to talk about it.

Which means...

 

[Brigade4Radiant]

Meh I work in one of the most dysfunctional hospitals in the country where our neurosurgeons frequently refuse to see patients even after getting the imaging that's requested. That doesn't mean I don't call if needed because "they will not do anything" or "they start yelling and get angry."

Look we have tough job and sometimes you have to fight with your consultants to get the right thing done for patients. Now obviously you can't force them to operate but you can at least call them about patients that will likely need an emergent operation. This is especially true for anything time sensitive when even short delays result in severe consequences. All I'm saying is that if that was my family I'd sure as hell be calling them right after the patient arrived to inform them about the case and request they come and see the patient in the emergency department.

Yeah but it’s considered unethical to treat your own family. So they come see the patient to just take them to the operating room? The nervous system isn’t like the GI system you don’t blindly operate

If this is what you are advocating then you should be doing this for all chest, abd, stroke alerts and headache as well. There is no he should have done this or that. It isn't indicated.

If what you are saying is true then EM as a speciality shouldn't exist. Specialists should be in the ED 24/7

 

[FutureInternist]

That's why we'll be on the bridge, and you will be somewhere on Deck 22, Section 5.

If you haven’t already, watch Orville on Hulu.

Star Trek plus some Family Guy humor.

Good stuff

 

[GassYous]

These days with staffing shortages you can barely get a patient transferred from one place to another within an hour. Epidural hematomas are so rare, a lot more so than patients who claim symptoms consistent with the diagnosis.

 

[Iamnew2]

It doesn't look like the lack of 24/7 MRI was the issue. It looks like the patient came to the ED with a clear likely dx of epidural hematoma after an ESI, got a stat MRI ordered within 10 min of arriving, but then took 1.5 hrs to have the MRI actually performed. It's not definite from the article, but it doesn't seem like the emergency doc was named. Looks like they went after the pain doc for the injection (settled) and the hospital for the delay in performing the MRI (lost in court).

EDIT: you said fast access, so yeah, agree that seems to be the problem.

Perfect example of why I decided not to do pain.

 

[RustedFox]

If you haven’t already, watch Orville on Hulu.

Star Trek plus some Family Guy humor.

Good stuff

To be clear, I don't begrudge or belittle you guys your Star Trek fandom one bit. I'm just playing on the "Trekkies are losers" trope that's just an easy target. Live long and prosper, amigos.

 

[sloh]

This was likely a cord stick and any surgery wouldn’t have improved the outcome regardless of timing. Paralysis from a procedure that usually doesn’t even work. What a shame.

 

[bravotwozero]

Word on the street is the emergency physician was also sued but settled.

Bruce Janiak was a witness and stated that he was at fault due to not calling the neurosurgeon immediately.

EFF this guy .

If I ever touch base with the EP that got screwed over by him, I will plead with him to report the a hole to AAEM and ACEP, as he should.

 

[emergentmd]

That doesn't mean I don't call if needed because "they will not do anything" or "they start yelling and get angry."

There are many ways to manage an ER. You can choose to be that guy who calls all the time and pisses off consultants/create a toxic job. Or you can chose to do standard of care for your site/community. I chose the later as the former just makes it worse for pts and all involved. Keep calling specialists before what they "need" is back and you risk alienating them when you really need them. You just have to practice within standard of care and sometimes you will get screwed over.

In my 20+ yrs as an EM attending, I tend to err on protecting my specialists and I can't think of a time where alittle delay had any adverse effects. As protect them, I get them to respond quicker and admissions much easier. Overall much better for pt care.

 

[BoardingDoc]

To be clear, I don't begrudge or belittle you guys your Star Trek fandom one bit. I'm just playing on the "Trekkies are losers" trope that's just an easy target. Live long and prosper, amigos.

You're all good man. I can't speak for anyone else, but I'd imagine the other trek fans here are like me in that I give precisely zero f***s about whether or not someone thinks I'm cool for liking star trek. One of the few perks of getting older: that kind of worry died out a long time ago.

 

[southerndoc]

You're all good man. I can't speak for anyone else, but I'd imagine the other trek fans here are like me in that I give precisely zero f***s about whether or not someone thinks I'm cool for liking star trek. One of the few perks of getting older: that kind of worry died out a long time ago.

Also the same. I just don't care what people think about me as I've gotten older.

Today I pulled out in front of a car that was a 1/8 mile away. He was driving about 60 in a 25. I don't speed anymore and he got behind me and started blowing his horn. I got to the red light and got into the left turning lane. He pulled up beside me, rolled down the window, and started cussing at me, flipping me off, etc. I could care less. I started to hit the siren in my car, but I just didn't even give a crap to do that. I just went on my merry way feeling sorry for the guy having a temper like that.

 

[namethatsmell]

Perfect example of why I decided not to do pain.

I think I get what you're saying, and when I was in fellowship the possibility of this terrified me.

Ever worry you'll goose a tube or fail a difficult airway? Yup, that's pretty rare. And it's still faaar more common than something like this injury happening. If paralysis following an injection was anything more than an exceedingly rare event, than a) nobody would do pain procedures and b) no patient would get them. If your training is decent and you're appropriately cautious, the likelihood of this approaches zero (will never be zero, **** still happens) and over time you learn to accept that there are always some risks in life no matter what.

Without seeing treatment notes/images, there's suggestions of this procedure not being done as conservatively/safely as possible (though not necessarily against "standard of care" per se).

The prospect of something like this is still awful and keeps every sane pain doc humble.

 

[Iamnew2]

I think I get what you're saying, and when I was in fellowship the possibility of this terrified me.

Ever worry you'll goose a tube or fail a difficult airway? Yup, that's pretty rare. And it's still faaar more common than something like this injury happening. If paralysis following an injection was anything more than an exceedingly rare event, than a) nobody would do pain procedures and b) no patient would get them. If your training is decent and you're appropriately cautious, the likelihood of this approaches zero (will never be zero, **** still happens) and over time you learn to accept that there are always some risks in life no matter what.

Without seeing treatment notes/images, there's suggestions of this procedure not being done as conservatively/safely as possible (though not necessarily against "standard of care" per se).

The prospect of something like this is still awful and keeps every sane pain doc humble.

Sorry I'm not an ED doc, I was just perusing and saw this but I did a pain fellowship but was terrified of this happening so I decided my sanity and mental health was more important. Yes you are right it's rare but it can happen as it did here.

 

[WilcoWorld]

Also the same. I just don't care what people think about me as I've gotten older.

Today I pulled out in front of a car that was a 1/8 mile away. He was driving about 60 in a 25. I don't speed anymore and he got behind me and started blowing his horn. I got to the red light and got into the left turning lane. He pulled up beside me, rolled down the window, and started cussing at me, flipping me off, etc. I could care less. I started to hit the siren in my car, but I just didn't even give a crap to do that. I just went on my merry way feeling sorry for the guy having a temper like that.

good move

 

[ScepticSkeksis]

You're all good man. I can't speak for anyone else, but I'd imagine the other trek fans here are like me in that I give precisely zero f***s about whether or not someone thinks I'm cool for liking star trek. One of the few perks of getting older: that kind of worry died out a long time ago.

Remember that episode where they grew Worf a freakin' spine??? Dr. Polasky would have had this patient up and walking in less than 10 minutes.