$200+ million verdict: It started with a midlevel's mistake

[Taurus]

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$200+ million verdict: It started with a midlevel's mistake
A huge malpractice verdict in Florida holds lessons for all doctors who use midlevel providers.

 

[pseudoknot]

That's been discussed in the EM forum. The person in question was not a midlevel. He was unlicensed and was therefore no different than any other layperson. This case has no relevance to physicians who employ licensed PAs.

See this thread.

 

[Faebinder]

How interesting, the sequence of workup is really flawless. I mean come on, if there are no neurological symptoms + negative CT scan x2... you cant admit and MRI and neuroconsult. That is unrealistic... but the catch is that the person who did it is unlicensed their license exam x4.

Explain to me how is it like in a nightmare to get a physician to get a license but a PA can function no problem without a license? All I gotta do is walk up to a hospital and claim I am a PA and show my diploma? Sheesh.

 

[primadonna22274]

Hell no. Again, THIS GUY WAS NOT A PA. He was never licensed as a PA. See my earlier comments on the other thread.
It's certainly NOT so easy as walk up and show my diploma. The credentialing process is a bear for PAs just as it is for physicians, and it's more arduous the longer I've been in practice. The trouble is this guy is being represented as a PA which he was not. And that's a very scary problem....
What I can't understand is how the attending was working with this "extender" without knowing that he was NOT a PA. I can't imagine my attendings not knowing who I am and what my credentials and limitations are. It was a huge mess on so many levels and I'm sure that was a big part of the verdict.
Lay off Taurus. PAs don't claim this guy. He may have attended PA school but never could pass PANCE and was never licensed. Hence, not a PA.
L.

Explain to me how is it like in a nightmare to get a physician to get a license but a PA can function no problem without a license? All I gotta do is walk up to a hospital and claim I am a PA and show my diploma? Sheesh.

 

[jacksparrow82]

A CT scan with in a few hours of the onset of symptoms is almost always going to be negative for stroke. They should have gotten an MRI and consulted a neurologist. The patient was complaining of double vision, nausea, confusion and a sudden onset of severe headache. Are those not red flag neurological symptoms? The PA is not at fault, the ED docs who obviously didn't examine the patient or properly work them up are at fault.

 

[Faebinder]

I wonder if he walked around in a white coat that has "PA" on it and a hospital ID that say "PA".

 

[primadonna22274]

I hope not. If so, that's fraud, and let's throw in practicing medicine without a license. But I wasn't there so I don't know.

I wonder if he walked around in a white coat that has "PA" on it and a hospital ID that say "PA".

 

[Faebinder]

A CT scan with in a few hours of the onset of symptoms is almost always going to be negative for stroke. They should have gotten an MRI and consulted a neurologist. The patient was complaining of double vision, nausea, confusion and a sudden onset of severe headache. Are those not red flag neurological symptoms? The PA is not at fault, the ED docs who obviously didn't examine the patient or properly work them up are at fault.

Confusion... subjective. Some IV fluid and oxygen might make you less confused and mix up the picture.

Double vision... again subjective, maybe felt better lying down.

Both are possible with severe sinusitis.

Sudden "pop" heard. I bet the patient didn't come in claiming that, it was probably found in retrospective questioning after the slurred speech etc etc etc..

I will however say... he should have gotten a neurology consult, and there lies the fault. I mean why not? If the patient is sitting there for 6 hours between two CT scans, you might as well call the neurologist. Then he/she would do the full neuro exam and this whole mess would have been avoided. I am surprised an ER doc actually didn't consult a service (usually they are happy to consult on anything).

 

[jacksparrow82]

Regardless of whether one views confusion and double vision as subjective complaints, they can not be ignored or shrugged off as such. They demand a proper workup, which in his case should have been an MRI and a full neurological exam (the ED doc should be capable of this too, he didn't have to wait for a neurologist to perform a Mini-mental status exam, CN's, motor, gait and reflex exams. Even lowly med students are capable of this)

 

[Tired]

I will however say... he should have gotten a neurology consult, and there lies the fault. I mean why not? If the patient is sitting there for 6 hours between two CT scans, you might as well call the neurologist. Then he/she would do the full neuro exam and this whole mess would have been avoided. I am surprised an ER doc actually didn't consult a service (usually they are happy to consult on anything).

If what was written in the article was actually documented in the H&P, this was a no-brainer admit to medicine.

It's the equivalent of the obese guy with hypertension, chest pain, and a negative EKG.

With all the crap that gets admitted from the ER, I am absolutely blown away that there was any question on this. If you're suspicious enough to scan a guy's head twice, they need to stay in the hospital.

 

[Ypo.]

PA controversy aside, I think we are missing the real point here.

200 MILLION DOLLARS??!?!??!? For ONE life?? Florida is f'ed up, man. This is utterly ridiculous. Nobody needs to inherit 200 million, no matter how bad the error. 👎mad:

 

[yaah]

Hell no. Again, THIS GUY WAS NOT A PA. He was never licensed as a PA.

The other problem is that the article says that the guy in question, PA or not, is dead now.

 

[jacksparrow82]

PA controversy aside, I think we are missing the real point here.

200 MILLION DOLLARS??!?!??!? For ONE life?? Florida is f'ed up, man. This is utterly ridiculous. Nobody needs to inherit 200 million, no matter how bad the error. 👎mad:

Yeah, I have to agree with that. You can blame the lawyers for being that greedy I'm sure. This is in my opinion the thing that really sucks about being a physician. You can literally have your life's work ripped away from you at any time by a greedy lawyer.

 

[Faebinder]

Can they actually appeal this... truly... 200+ million dollars...

Lets say the average physician makes $200k a year. He would need to work 1,000 years to make this much money. Seriously, this is insane and I shake my head in disbelief every time I look at that number.

 

[primadonna22274]

Somehow I missed the $200 million. I think my brain kept telling me it was $200k which seems reasonable. But $200 million? I don't know anyone who's worth that. That's completely ridiculous. There's a problem with our jury system that has no concept of how much money that is and awards it anyway.

 

[Fah-Q]

Confusion... subjective. Some IV fluid and oxygen might make you less confused and mix up the picture.

Double vision... again subjective, maybe felt better lying down.

Both are possible with severe sinusitis.

Good lord, I hope you are joking.

 

[elwademd]

other than the problem (unlicensed pa in the er) already mentioned, the other problems were:
1. the (unlicensed) pa and the physician in question didn't have their stories straight
2. the group/hospital/case could have been settled before trial for 2 million
3. the (unlicensed) pa and the physician blamed each other in court

 

[elwademd]

That's been discussed in the EM forum. The person in question was not a midlevel. He was unlicensed and was therefore no different than any other layperson. This case has no relevance to physicians who employ licensed PAs.

See this thread.

an unlicensed midlevel is still a midlevel.

when you finish medical school, if you don't go to residency, you are still a physician. you just happen to be unlicensed. even if you go to internship/residency, you are, for a time, unlicensed. this does not make you a "layperson" by virtue of your education.

so, if you were to have to go to court as an intern, you couldn't claim "i'm unlicensed, and therefore a layperson." you would be held to a little higher standard then a layperson.

as such, the pa, by virtue of his education, even without license, would and should be held to a higher standard then a layperson.

a layperson can claim tylenol should be good for any headache.
one would think that someone with some amount of medical education would be held to a higher standard then that.

 

[LADoc00]

LOL@200 million.....the plantiff will be lucky if he sees 2 million, probably more like sub 1 million after lawyer fees.

 

[DrDawg]

They would have settled if there was real malpractice here. The real problem seems to be that an unlicenced person provided medical care. The ED attending denied knowledge of this person status, and the Medical Director denied responsiblity for their employment. If this midlevel was licensed there likely would not have been a $200million reward or any award.

 

[primadonna22274]

I agree that the never-licensed PA by virtue of attending and graduating from a PA program (although one wonders if he should have graduated if he could never pass the licensing exam) should be held to a higher standard than a layperson. I won't argue that point with you. However, he should NOT have been in a patient care role, as it certainly appears that he was. Heck, the attending didn't know he wasn't a licensed PA. Big problem. We can't ask the unlicensed PA because he's dead...also a red flag.
If he were truly "just a scribe", the attending physician would not have been duped, or misled perhaps, into thinking he was working with a PA. That point still bothers me greatly.

an unlicensed midlevel is still a midlevel.

when you finish medical school, if you don't go to residency, you are still a physician. you just happen to be unlicensed. even if you go to internship/residency, you are, for a time, unlicensed. this does not make you a "layperson" by virtue of your education.

so, if you were to have to go to court as an intern, you couldn't claim "i'm unlicensed, and therefore a layperson." you would be held to a little higher standard then a layperson.

as such, the pa, by virtue of his education, even without license, would and should be held to a higher standard then a layperson.

a layperson can claim tylenol should be good for any headache.
one would think that someone with some amount of medical education would be held to a higher standard then that.

 

[pseudoknot]

You really missed the point here. It's not that they are held to a higher or lower standard than a layperson. Both are held to an infinitely high standard compared to a licensed professional, because if the MD was relying on an unlicensed provider and there was an adverse outcome, it's basically automatic malpractice.

If the person in question had been a licensed PA then this suit would have either been settled or dismissed, almost certainly. There is no lesson here for those who work with real midlevel providers.

Also, if you graduate medical school and are not licensed, then no, legally you aren't a physician. Residents work under training licenses.

an unlicensed midlevel is still a midlevel.

when you finish medical school, if you don't go to residency, you are still a physician. you just happen to be unlicensed. even if you go to internship/residency, you are, for a time, unlicensed. this does not make you a "layperson" by virtue of your education.

so, if you were to have to go to court as an intern, you couldn't claim "i'm unlicensed, and therefore a layperson." you would be held to a little higher standard then a layperson.

as such, the pa, by virtue of his education, even without license, would and should be held to a higher standard then a layperson.

a layperson can claim tylenol should be good for any headache.
one would think that someone with some amount of medical education would be held to a higher standard then that.

 

[core0]

an unlicensed midlevel is still a midlevel.

when you finish medical school, if you don't go to residency, you are still a physician. you just happen to be unlicensed. even if you go to internship/residency, you are, for a time, unlicensed. this does not make you a "layperson" by virtue of your education.

so, if you were to have to go to court as an intern, you couldn't claim "i'm unlicensed, and therefore a layperson." you would be held to a little higher standard then a layperson.

as such, the pa, by virtue of his education, even without license, would and should be held to a higher standard then a layperson.

a layperson can claim tylenol should be good for any headache.
one would think that someone with some amount of medical education would be held to a higher standard then that.

One of the problems with the term "midlevel" is that there is no standard definition so it can be whatever someone claims it is. Medicare for example uses the term Non-physician provider which is specific to licensed providers with a certain skill set.

You use the example of interns or residents. Everywhere I've been interns and residents need either a license or a training license. They are not allowed to work until they have them.

Look at the following example: A physician without a license goes to work in an ER.
A resident without a training license goes into work in an ER.
A PA without a license goes to work in an ER.

What do all these have in common. They are practicing medicine without a license. They are held to the same standard as if someone with no medical training was practicing as a physician in that same ER. They are illegally practicing medicine. There is no standard for practicing illegally.

The other issue is that you talked about is the standard since someone is trained as a PA. Since the all states require licensure and most states require certification this is the standard. The reason that states will not license uncertified PAs is that they have not proven that they can practice at the standard required of PAs. In addition there is no proof that the "PA" in the article ever went to PA school.

Florida has a particular problem with this. There is a large group of politically connected people there, some of whom claim that they were trained as physicians in their home country. Since this country is no longer friendly with the US there is no way to confirm that they went to medical school. Because of this they are not eligible for the ECFMG. Because of their political connections the State of Florida directed they be eligible as PAs. The NCCPA declined to certify them since they had not graduated from an accredited PA program. The state of Florida then designed their own PA exam. Not one of these "PAs" could pass the home grown test. However because of the way the law was written, as long as they did not fail the test more than 5 or 6 times they could continue to practice under a "temporary" license. Some of these "PAs" have been practicing on the temporary license for more than 10 years. My guess is that this is the case here.

The moral of the story is that if you employ someone to practice medicine illegally you are going to pay a big price.

David Carpenter, PA-C

 

[BSN2DOC]

PA controversy aside, I think we are missing the real point here.

200 MILLION DOLLARS??!?!??!? For ONE life?? Florida is f'ed up, man. This is utterly ridiculous. Nobody needs to inherit 200 million, no matter how bad the error. 👎mad:

Are you f'ing serious? How about you put a price on your life -- what is it?

I completely agree that many lawsuits are absolutely insane and many should not be awarded anything -- many are seeking an easy win-fall.

Howevere -- this is not the case for this guy! I would sue for everything I could get my hands on. In our society, money is the only way to obtain some sort of compensation and to prove a point to those who did you wrong.

 

[dara678]

Confusion... subjective. Some IV fluid and oxygen might make you less confused and mix up the picture.

Double vision... again subjective, maybe felt better lying down.

Both are possible with severe sinusitis.

Sudden "pop" heard. I bet the patient didn't come in claiming that, it was probably found in retrospective questioning after the slurred speech etc etc etc..

Really? I guess I haven't had that much experience, but I haven't ever had a patient with severe sinusitis presenting with confusion and double vision. I don't even understand how the pathophysiology of that in relation to sinusitis would work. In any case, having just been released from my last rotation of medical school, neurology, I think confusion and double vision as well as a severe headache in the context of hypertension, high cholesterol, and fam hx of stroke deserves a thorough stroke workup. we all know that ct without contrast can't show a stroke in the first couple of hours, so at that point the pt deserved a second neuro exam and if he STILL had the same symptoms then an MRI and neuro consult should have been ordered staightaway. Whoever was involved in this patient's care, PA and MD both, were negligent. Not that I think the family deserved $200 million for it, but who's to put a price on a human life ...

 

[dara678]

Also, whether or not the PA was licensed, it is ultimately the duty of the MD supervising him to check his work. If this doc had done his job then this tragedy could have been prevented.

 

[Faebinder]

Really? I guess I haven't had that much experience, but I haven't ever had a patient with severe sinusitis presenting with confusion and double vision. I don't even understand how the pathophysiology of that in relation to sinusitis would work. In any case, having just been released from my last rotation of medical school, neurology, I think confusion and double vision as well as a severe headache in the context of hypertension, high cholesterol, and fam hx of stroke deserves a thorough stroke workup. we all know that ct without contrast can't show a stroke in the first couple of hours, so at that point the pt deserved a second neuro exam and if he STILL had the same symptoms then an MRI and neuro consult should have been ordered staightaway. Whoever was involved in this patient's care, PA and MD both, were negligent. Not that I think the family deserved $200 million for it, but who's to put a price on a human life ...

You guys keep acting like the man is a clear cut cookie case from the book. Wait till your the intern and half your patients are confused with bad vision. Are you going to MRI every confused person that walks in through the ER door? That's a lot of MRIs. I got plenty of patients (coming in with their family!) who would happily claim confusion and some "blurry" vision to get some Xanax/Percocet. And of course they come in with the MHx of DM, HTN, Chronic Pelvic Pain, <insert your favorite comorbidity>. Regardless, as I stated, they should have gotten a neurology consult for a real full neurological exam to straighten out the symptoms then decide MRI or not and if the scenario is true then the symptoms wouldn't have resolved.

 

[Tired]

You guys keep acting like the man is a clear cut cookie case from the book. Wait till your the intern and half your patients are confused with bad vision. Are you going to MRI every confused person that walks in through the ER door? That's a lot of MRIs. I got plenty of patients (coming in with their family!) who would happily claim confusion and some "blurry" vision to get some Xanax/Percocet. And of course they come in with the MHx of DM, HTN, Chronic Pelvic Pain, <insert your favorite comorbidity>. Regardless, as I stated, they should have gotten a neurology consult for a real full neurological exam to straighten out the symptoms then decide MRI or not and if the scenario is true then the symptoms wouldn't have resolved.

First of all, I dunno why you keep insisting you need neurology to do a neurologic exam. Any jacka$$ with a reflex hammer can do a neuro exam.

Second, the telling this isn't the H&P, although I would argue that a patient reporting a "pop" in the head accompanied by sudden onset headache is hardly the typical story of a drug addict or sinus infection. The telling thing is that they were so concerned about this dude's story that they kept him around for serial CT scans.

I'm a damn Ortho intern. Even I know that (1) serial head CT scans is not a common technique to evaluate patients in the ER; (2) CT findings in acute stroke may not appear for 24hrs post-event. If I know these things, then this was malpractice, pure and simple.

 

[sirus_virus]

Yeah, I have to agree with that. You can blame the lawyers for being that greedy I'm sure. This is in my opinion the thing that really sucks about being a physician. You can literally have your life's work ripped away from you at any time by a greedy lawyer.

Well said. So when you guys decide on where or what to practice, make sure you remember that.

 

[Tired]

Well said. So when you guys decide on where or what to practice, make sure you remember that.

I'm gonna go bare.

 

[primadonna22274]

That takes cajones my friend.
My friend and former supervising physician very strongly considered "going bare" when she decided to change jobs and had to pay an outrageous tail (FP, no OB). She ended up going to work for a community health center where she's paid a low-end salary but has federal malpractice coverage and can practice with much less fear of being sued. She also runs a free health clinic twice a month, strictly volunteer, and has no malpractice coverage for that.

I'm gonna go bare.

 

[Faebinder]

That takes cajones my friend.
My friend and former supervising physician very strongly considered "going bare" when she decided to change jobs and had to pay an outrageous tail (FP, no OB). She ended up going to work for a community health center where she's paid a low-end salary but has federal malpractice coverage and can practice with much less fear of being sued. She also runs a free health clinic twice a month, strictly volunteer, and has no malpractice coverage for that.

How much tail are we talking? I keep hearing about outrageous tails now a days.

 

[elwademd]

You really missed the point here. It's not that they are held to a higher or lower standard than a layperson. Both are held to an infinitely high standard compared to a licensed professional, because if the MD was relying on an unlicensed provider and there was an adverse outcome, it's basically automatic malpractice.

If the person in question had been a licensed PA then this suit would have either been settled or dismissed, almost certainly. There is no lesson here for those who work with real midlevel providers.

Also, if you graduate medical school and are not licensed, then no, legally you aren't a physician. Residents work under training licenses.

One of the problems with the term "midlevel" is that there is no standard definition so it can be whatever someone claims it is. Medicare for example uses the term Non-physician provider which is specific to licensed providers with a certain skill set.

You use the example of interns or residents. Everywhere I've been interns and residents need either a license or a training license. They are not allowed to work until they have them.

Look at the following example: A physician without a license goes to work in an ER.
A resident without a training license goes into work in an ER.
A PA without a license goes to work in an ER.

What do all these have in common. They are practicing medicine without a license. They are held to the same standard as if someone with no medical training was practicing as a physician in that same ER. They are illegally practicing medicine. There is no standard for practicing illegally.

The other issue is that you talked about is the standard since someone is trained as a PA. Since the all states require licensure and most states require certification this is the standard. The reason that states will not license uncertified PAs is that they have not proven that they can practice at the standard required of PAs. In addition there is no proof that the "PA" in the article ever went to PA school.

Florida has a particular problem with this. There is a large group of politically connected people there, some of whom claim that they were trained as physicians in their home country. Since this country is no longer friendly with the US there is no way to confirm that they went to medical school. Because of this they are not eligible for the ECFMG. Because of their political connections the State of Florida directed they be eligible as PAs. The NCCPA declined to certify them since they had not graduated from an accredited PA program. The state of Florida then designed their own PA exam. Not one of these "PAs" could pass the home grown test. However because of the way the law was written, as long as they did not fail the test more than 5 or 6 times they could continue to practice under a "temporary" license. Some of these "PAs" have been practicing on the temporary license for more than 10 years. My guess is that this is the case here.

The moral of the story is that if you employ someone to practice medicine illegally you are going to pay a big price.

David Carpenter, PA-C

once you graduate medical school, you are a physician. however, you can not practice on your own, as you are an unlicensed physician. depending on the state you go to, and the rules/regulatoins, you may or may not have to get a training license in order to work as a physician.

in california, interns do not work under training licenses. yet, they complete internship without issues. this is not working "illegally". hell, myself, and every resident i know in california did not have a license during internship (as the california medical board does actually not allow you to apply for your license until you've completed 12 months of training).

with that said, once you obtain your license (either as a "training" license in some states, or a standard medical license in other states), you are then a licensed physician.

when i was deposed for a case (i nor the hospital in which i work were named, it was actually a cases involving estate matters) that occurred during my intern year, i was never asked if i was licensed or not by either party's lawyers.



back to the case at hand though... if you read the case, the issue of whether or not the pa was licensed came up during the discovery phase. the plaintiffs clearly thought they had a case prior to the court date (hence the reason they filed in the 1st place). the issue of licensure came up during discovery, and since the pa was unlicensed, it allowed the plaintiffs to go for more money (in terms of punitive damages) because an unlicensed pa is illegally practicing medicine (which is actually a criminal offense in most states, something the article does not go into).

 

[primadonna22274]

It may not seem outrageous to a specialist, but for a single parent family doctor it was huge (I think between $30-50k). She had to draw from her 401(k) to pay it off. Uncool.

How much tail are we talking? I keep hearing about outrageous tails now a days.

 

[f_w]

Just a couple of points:

- The case was settled after trial for an undisclosed amount (nobody ever collects on a 50 or 200mil 'award', those are just numbers made up by the jury to make themselves feel good). That final amount was probably somewhere south of 10mil.

- Whether the PA was licensed or not played only insofar a role that the fact and the obfuscation by the ER group incensed the jury to a point that the question whether actual malpractice was committed moved into the background.

- If you delegate some of your professional responsibilities to someone else, make sure you know that persons credentials and that you had a chance to see the quality of their work (make sure your lines of supervision are crystal clear. At times PAs are hired by the hospital, nevertheless you as a physician not employed by the hospital will be the person supervising that PA).

- Don't get roped into a situation where you are working with an 'extender' that is supposedly 'supervised' by another physician (e.g. the medical director of an ER service company who is peacefully sleeping 3 states away and who will claim that his supervision is limited to the 5 charts he audits every other month but not to the work the PA did under YOUR supervision).

- It is impossible to judge the merits of a case from this type of secondary reporting. However: Every day, patients are being seen for various neurologic symptoms and discharged with a NCCT and limited further evaluation. I have seen this go horribly wrong in similar scenarios.

- If you don't know what the hell is going on, don't put a diagnosis on a discharge paper that might explain what you see. If you discharge someone with 'headache' after you have done a diligent workup and tucked them in for short-term follow-up and they come back with something bad, you are in a better position than if you sent them home with 'sinusitis' and a Z-pack (same applies to the scores of kids with small-bowel volvulus who are routinely sent home with 'gastroenteritis, drink lots of fluids and call your pediatrician').

 

[THP]

Sometimes people have strokes and they die. I don't see why they are owed something because of this. What if they lived far from any hospital and just died - who would be at fault then? I just don't understand the mentality. Its not like they walked through the door perfectly healthy and the ED doc or PA killed them.

Also, as a general question, what is the point of having a PA work for you if you can't trust them to do some simple stuff. If you have to review everything they do in agonizing detail you might as well do it yourself.

 

[HMSBeagle]

Jesus Christ when will people learn that you can't trust many people in this career and that you have to be extra careful with everything. This will continue to happen until someone from congress or something dies because of a mistake made by a midlevel many of whom want to plat doctor yet do not have proper training to do so.

 

[Chronic Student]

Just playing devils advocate.

Do you think a doctor has ever killed a patient?

My point is that every practicioner makes good calls, mistakes and we all will at one point or another; save, hurt or kill someone. That is fact and the thing to do is not to accept it sitting down and strive to not make mistakes and sure as hell not make them a second time.

I am a PA. I don't want to play doctor, I just enjoy helping people and I'm pretty good at my job.

You are maligning an entire profession, when (IMO) you should really be focused on the incompetent/dangerous ones.

Anyway, that is my opinion and you are allowed yours.

 

[Taurus]

Keep everyone who works with you on a short lease. Midlevels, medical students, nurses. Doublecheck their work. Don't take their word for it. Afterall, it's your license is on the line.

 

[Museless]

If the person in question had been a licensed PA then this suit would have either been settled or dismissed, almost certainly.

If a licensed PA misdiagnosed, the lawsuit would've settled or dismissed? You're dreaming.

http://www.post-gazette.com/pg/07328/836466-85.stm

 

[Taurus]

If a licensed PA misdiagnosed, the lawsuit would've settled or dismissed? You're dreaming.

http://www.post-gazette.com/pg/07328/836466-85.stm

That's a tragic but good example of why it's so important to not simply take the word of someone who you are supposed to be supervising. If your license is on the line, don't get lazy. Do your job and examine the patients yourself.

 

[Tired]

Keep everyone who works with you on a short lease. Midlevels, medical students, nurses. Doublecheck their work. Don't take their word for it. Afterall, it's your license is on the line.

It's ironic that I have a Chief Resident and Attending breathing down my neck 90hrs/wk, but the midlevels get a free pass to do whatever they want.

 

[yaah]

It's ironic that I have a Chief Resident and Attending breathing down my neck 90hrs/wk, but the midlevels get a free pass to do whatever they want.

You don't get paid overtime when you stay late, I suspect they do. That's probably a barrier to midlevels ever "replacing" physicians - midlevels aren't going to work more than their contract unless they get paid.

 

[Chronic Student]

You don't get paid overtime when you stay late, I suspect they do. That's probably a barrier to midlevels ever "replacing" physicians - midlevels aren't going to work more than their contract unless they get paid.

From my personal experience and those of my friends and former classmates, I would say that it is the exception rather than the rule.

The only people I know that get overtime work in ER or for the hospital as a hospitalist PA.

I work in surgery and get a salary. No extra pay for being on call every other week for an entire week. I stay until the cases are over and all the patients are seen. It can be 3 in the afternoon or 3 in the morning when we are done.

If I got paid for call and overtime I would be rich. If you look at my pay it sounds great until you account for my hours and then it looks much less attractive.

Anyhow, in response to Tireds post. I have my boss breathing down my neck and he keeps me on a fairly short leash, no free pass here. In addition, I work under hospital restrictions that are quite a bit more restrictive than what the state will allow me to do.

I truly think that PAs can be a huge asset to the medical community and I have helped my doctor to actually improve the care of our patients not lessen it. The caveat is that you do need to take the time to train us and we must have oversight.

One of the most important points here is that we are under the control of the state medical board and if a PA makes a huge error than some of the blame must be shared by the supervising physician.

Just my .02.

 

[f_w]

I have my boss breathing down my neck and he keeps me on a fairly short leash, no free pass here. In addition, I work under hospital restrictions that are quite a bit more restrictive than what the state will allow me to do.

I truly think that PAs can be a huge asset to the medical community and I have helped my doctor to actually improve the care of our patients not lessen it. The caveat is that you do need to take the time to train us and we must have oversight.

 

[tr]

A CT scan with in a few hours of the onset of symptoms is almost always going to be negative for stroke. They should have gotten an MRI and consulted a neurologist. The patient was complaining of double vision, nausea, confusion and a sudden onset of severe headache. Are those not red flag neurological symptoms? The PA is not at fault, the ED docs who obviously didn't examine the patient or properly work them up are at fault.

You didn't read the article carefully. The original Sx were sudden-onset HA and a "pop." I agree those are very worrisome but they are worrisome for hemorrhage - not ischemia - which a CT would have detected immediately. The double vision, slurring, etc. didn't show up until the next day.

"a physician extender examined Navarro, who reported the sudden onset of a severe headache and feeling a "pop" in his head. Herranz ordered blood tests and a CT scan (without contrast)...
The first CT scan was negative for stroke, as was a second, done a few hours later with contrast...
The next morning, Navarro awoke with a severe headache, slurred speech, nausea, confusion, and trouble walking. His wife brought him back to the ED. A new CT scan showed that he'd suffered a stroke"

The whole workup is a little bit weird to say the least. If you are concerned for stroke (which they evidently were since they kept him around and re-scanned him - and why the contrast, anyone know?) then yeah, you buy yourself an MRI and/or neuro consult (if one is available).

But it's not grossly, evidently negligent. I think the whole call is a bit fuzzy. Headache and CT neg x2... really, if you MRI'ed everyone who walked into the ED with a headache and negative CT scan your NNTT for cerebellar stroke would be somewhere in the hundred thousands. OK the headache was sudden... and there was the 'pop'... but those are most consistent with a bleed, not a thrombotic event, and CT is extremely sensitive for bleed.

Also, the article is not actually clear on what kind of stroke the guy suffered. It says he got a shunt, so perhaps we are talking hemorrhagic stroke. If that is the case then the CT was the correct test, they did it twice, and you can't fault the workup at all.

OTOH it says the plaintiffs are claiming MRI was the appropriate test, which implies the stroke was ischemic. In that case the presentation was extremely atypical and again, the whole thing is extremely unfortunate but I'm not sure you can fault the workup.

 

[Towel]

... OTOH it says the plaintiffs are claiming MRI was the appropriate test, which implies the stroke was ischemic. In that case the presentation was extremely atypical and again, the whole thing is extremely unfortunate but I'm not sure you can fault the workup.

Nice post. I'd guess the poor fellow had hemorrhagic conversion 24 hours after a small ischemic stroke. Or maybe an initial TIA followed by a large ischemic stroke 24 hours later. After a large ischemic event you'll often see enough edema to require decompression, so the shunt doesn't push you one way or the other.

Anyway, if you have a thorough, documented neuro exam and two negative CTs (w/o contrast more for time than anything else, so why not add it to the f/u if you're worried about other lesions?) it would be accepted practice, I'd think, to send the patient home with instructions to return if anything unusual happens and ASAP follow-up. There are probably two things the plantiff's lawyers were arguing about MRI. Diffusion-weighted sequences on MRI can move the detection threshold for ischemia up to just a few hours, but it's not available everywhere (nor is part of any standard ER stroke algorithm, because it takes too long). MRI is also better (though not necessarily preferred) for ruling out cerebellar bleed because CT has artifacts in the posterior fossa from the surrounding bone. But the real issues here, I'm sure, were the lack of a careful, documented neuro exam and the attending's admission that he didn't lay eyes on the patient. Really, the latter is enough to make any case open-and-shut, regardless of the technical adequacy of the work-up.

Very sad for the patient, but also for the MD/hospital. You get the impression that the patient would have had a normal neuro exam on the initial visit that, properly documented, would have made a lawsuit very difficult.

 

[f_w]

Diffusion-weighted sequences on MRI can move the detection threshold for ischemia up to just a few hours,

Make that minutes.

but it's not available everywhere

It should be available on every hospital based 1.5T scanner installed in the last 10 years.

(nor is part of any standard ER stroke algorithm, because it takes too long).

It takes 2min 30sec on my scanners. Hardly a long sequence.

But the real issues here, I'm sure, were the lack of a careful, documented neuro exam and the attending's admission that he didn't lay eyes on the patient.

The real issue is practice of medicine by an unlicensed practicioner and the attempt by its employer to lie about it.

 

[Faebinder]

Make that minutes.



It should be available on every hospital based 1.5T scanner installed in the last 10 years.



It takes 2min 30sec on my scanners. Hardly a long sequence.



The real issue is practice of medicine by an unlicensed practicioner and the attempt by its employer to lie about it.

Oh come on, you know what he/she is talking about. In places like the VAs it takes an act of congress to get an MRI or a PET scan. I admit it is getting better but it aint ready to be done instead of a CT scan yet.

 

[f_w]

Oh come on, you know what he/she is talking about. In places like the VAs it takes an act of congress to get an MRI or a PET scan. I admit it is getting better but it aint ready to be done instead of a CT scan yet.

I may have misunderstood his/her post. To me it sounded like: 'DWI is something esoteric that is sparsely available and consumes a lot of time'. Neither of these is imho true.

If you have time to do a second CT, you could have done an MRI instead.