Arm amputated after ED visit [Med Mal Case]

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40-year-old man seen in the ED with progressively enlarging mass on his arm.

X-rays show no bony abnormality, discharged, told to go see PCP.

Patient did not go see a PCP, but about a year later had a workup finally showing a tumor.

They tried to save the arm but couldnt, amputated below the elbow.

ED doc from the first visit gets sued.

Basic issue boils down to who's fault this is: Is it the doctors fault for giving a vague "go see your PCP" and allegedly not communicating the severity/potential for serious injury? Or the patients for not going to a PCP.

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"Good discharge instructions are better than an accurate diagnosis." I've said this for years (documented here on SDN). There is already another thread about discharge instructions. You can find that here. That thread speaks directly to this case (material, not the actual case).
 
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Ugh.

So many of those are so lame. So he agreed with workup was appropriate but wasn't happy with his MDM. Which is partly fair. I'll never order an MRI for a possible arm cancer. Take that **** to your PCP.

Getting bitter about it and suing because you never followed up is laaaaaameeeee

Separate question but may be state specific: I thought we couldn't be held liable for findings > 1 year from visit? That's what an MD JD told me.
 
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Ugh.

So many of those are so lame. So he agreed with workup was appropriate but wasn't happy with his MDM. Which is partly fair. I'll never order an MRI for a possible arm cancer. Take that **** to your PCP.

Getting bitter about it and suing because you never followed up is laaaaaameeeee

Separate question but may be state specific: I thought we couldn't be held liable for findings > 1 year from visit? That's what an MD JD told me.

Depends on the state and the statute of limitations. In my state, it's only 1 year, so you're not getting sued for anything after a year.
 
Depends on the state and the statute of limitations. In my state, it's only 1 year, so you're not getting sued for anything after a year.
It varies based on state law. But ypically the statute of limitations will state a time frame (3 years in my state) which applies not only to the date you saw the patient, but also from the date the problem was discovered, whichever is later.

In other words, you leave a suture needle in someone, and you’re not out of the woods at the end of the 3 years since you saw them, if the problem is diagnosed after that. The clock would then start at the time of diagnosis.
 
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Link to case

40-year-old man seen in the ED with progressively enlarging mass on his arm.

X-rays show no bony abnormality, discharged, told to go see PCP.

Patient did not go see a PCP, but about a year later had a workup finally showing a tumor.

They tried to save the arm but couldnt, amputated below the elbow.

ED doc from the first visit gets sued.

Basic issue boils down to who's fault this is: Is it the doctors fault for giving a vague "go see your PCP" and allegedly not communicating the severity/potential for serious injury? Or the patients for not going to a PCP.
Assuming time and action-specific follow up instructions were documented and given, that should be a very defendable lawsuit. The patient should have followed up. That being said, “bad outcome + sympathetic witness” often leads to a suit, and often payouts, even if the standard of care was met.

Standard of care isn’t “the standard of care.” It’s what a jury of non-doctors, as convinced by a lawyer, think and say the standard of care, is.

Yes, our system sucks.

But there’s a solution, albeit an imperfect one: Control the 99% you can control by doing your best, buying insurance and letting the insurance company and their lawyers worry about the other 1% you can’t control.

As someone having lost much sleep over this kind of stuff, I can’t tell you that this kind of stuff is not worth losing sleep over. I learned the hard way.
 
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Just one more example that you don't always get sued for practicing bad medicine, in fact many of the cases you screw up in your career never end in a suit. And yet, a case that you did nothing wrong might. It's such a screwed-up system.
 
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Basically tell every patient every incidental is 99% probably cancer (causing harm to the patient) and they need to follow up immediately within 2 days (no matter how unrealistic). Better yet, start ordering MRI and CTs in the ED, and admit for aggressive oncology workup. Clearly this is the legal standard of care.
 
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Basically tell every patient every incidental is 99% probably cancer (causing harm to the patient) and they need to follow up immediately within 2 days (no matter how unrealistic). Better yet, start ordering MRI and CTs in the ED, and admit for aggressive oncology workup. Clearly this is the legal standard of care.

Admitting MD’s hate this one simple trick!
 
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Depends on the state and the statute of limitations. In my state, it's only 1 year, so you're not getting sued for anything after a year.
1 year is nice. It's 2 years in Georgia, but there are limitations: if it's a pediatric patient the statute of limitations starts at the age of 18, if it involves an unnecessary death the clock starts when the patient dies, and there are times where it's been successfully argued that the statute of limitations didn't apply because the malpractice couldn't have been known during that 2-year time frame and was only evident many years later.

Don't rest solely on statute of limitations. It lessens your chances of being sued, but it doesn't completely eliminate. I'll discuss more when my current litigation is over.
 
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Ugh. I want to stab this “expert witness.” It’s absurd how much people will ***** themselves out for money.

Is this person’s name public record? He or she should be outed.
 
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I'm going to be the contrarian for the sake of a discussion (and giving the obvious caveat that all we have is the information presented).

It doesn't sound like the physicians is getting sued over not walking the patient personally into a follow-up appointment. It sounds like they are getting sued because they and the mid-level both saw a weird growing mass on someone and somehow nowhere in any of their documentation suggested even the remote possibility it could be cancer or anything that actually needs follow-up. Which now opens the plaintive to ask how you could expect a patient to worry about follow-up when the medical professionals were so apathetic about it? We give patient's advise all the time but there is a difference between you should stop smoking and you should stop smoking because you're on oxygen and it could catch your face on fire.

It took a month to get into a PCP after the second visit and another month after that to get an MRI. The second emergency physician and PCP mid-level appear to both be absent from the suit. Why not go after them for not immediately admitting for urgent work-up? I would bet because their chart doesn't read like someone who walked into the room and blew it off as nothing important.

I think the lessons from this case highlight some pretty fundamental clinical and medicolegal practices:
1. You don't have to chase down every possible zebra and you don't have to order a test for everything on your differential but routine life/limb threatening diagnosis should be addressed in your work-up and/or documentation. You don't need a d-dimer on every chest pain patient, but PE should come up at some point in your chart. Weird mass? Cancer should probably come up somewhere.
2. Discharge information should be specific. Those premade discharge instructions are garbage especially for atypical cases like this. You don't have to write your own but you should at least provide verbal instructions and document the key points of that discussion. Especially return precautions. I would specifically list them if you don't know for sure they are already included in the premade discharge instructions and then I would still give them verbally and document that. Follow-up? I would put a specific place, specific time-frame, and instructions to return to the ED if they have trouble finding follow-up. If they don't have a specific PCP, give refer them to a specific clinic.

I don't spend a lot of time on my charts and don't write very long ones. But it doesn't take a lot time to document that you considered the bread-and-butter differential for a chief complaint, any key decisions you made, and what you told the patient the next steps were. In my opinion (what little value that is worth), three sentences covering those points are far more valuable than the billion imported labs and a novel on what specific shade of green someone's emesis was. The physician in this case got burned by crappy documentation probably driven by a bad EMR and possibly by blindly co-signing a note from a mid-level.
 
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It make one wonder why he went to the ER for a non traumatic lump.
 
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I can't believe the expert witness is harping so much on the "not dangerous" bit. Any reasonable person would interpret that as "not dangerous [at this moment]". Give any medical condition enough time and bad luck and it will kill you.
 
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I can't believe the expert witness is harping so much on the "not dangerous" bit. Any reasonable person would interpret that as "not dangerous [at this moment]". Give any medical condition enough time and bad luck and it will kill you.
Yeah, exactly. This guy could have been "MSE'd" out, quickly. "You do not have an emergency. Your discharge is forthcoming." EMTALA fulfilled.
 
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I can't believe the expert witness is harping so much on the "not dangerous" bit. Any reasonable person would interpret that as "not dangerous [at this moment]". Give any medical condition enough time and bad luck and it will kill you.

Are we supposed to start giving fat people discharge information about how they’re going to imminently die from an MI?
 
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I can't believe the expert witness is harping so much on the "not dangerous" bit. Any reasonable person would interpret that as "not dangerous [at this moment]". Give any medical condition enough time and bad luck and it will kill you.
That whole opinion is so condescending and offensive. I can't believe this case didn't get thrown out on a summary judgement.
 
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I'm going to be the contrarian for the sake of a discussion (and giving the obvious caveat that all we have is the information presented).

It doesn't sound like the physicians is getting sued over not walking the patient personally into a follow-up appointment. It sounds like they are getting sued because they and the mid-level both saw a weird growing mass on someone and somehow nowhere in any of their documentation suggested even the remote possibility it could be cancer or anything that actually needs follow-up. Which now opens the plaintive to ask how you could expect a patient to worry about follow-up when the medical professionals were so apathetic about it? We give patient's advise all the time but there is a difference between you should stop smoking and you should stop smoking because you're on oxygen and it could catch your face on fire.

It took a month to get into a PCP after the second visit and another month after that to get an MRI. The second emergency physician and PCP mid-level appear to both be absent from the suit. Why not go after them for not immediately admitting for urgent work-up? I would bet because their chart doesn't read like someone who walked into the room and blew it off as nothing important.

I think the lessons from this case highlight some pretty fundamental clinical and medicolegal practices:
1. You don't have to chase down every possible zebra and you don't have to order a test for everything on your differential but routine life/limb threatening diagnosis should be addressed in your work-up and/or documentation. You don't need a d-dimer on every chest pain patient, but PE should come up at some point in your chart. Weird mass? Cancer should probably come up somewhere.
2. Discharge information should be specific. Those premade discharge instructions are garbage especially for atypical cases like this. You don't have to write your own but you should at least provide verbal instructions and document the key points of that discussion. Especially return precautions. I would specifically list them if you don't know for sure they are already included in the premade discharge instructions and then I would still give them verbally and document that. Follow-up? I would put a specific place, specific time-frame, and instructions to return to the ED if they have trouble finding follow-up. If they don't have a specific PCP, give refer them to a specific clinic.

I don't spend a lot of time on my charts and don't write very long ones. But it doesn't take a lot time to document that you considered the bread-and-butter differential for a chief complaint, any key decisions you made, and what you told the patient the next steps were. In my opinion (what little value that is worth), three sentences covering those points are far more valuable than the billion imported labs and a novel on what specific shade of green someone's emesis was. The physician in this case got burned by crappy documentation probably driven by a bad EMR and possibly by blindly co-signing a note from a mid-level.

Ok so I’ll play with this reasoning.

“Dr. It says you thought it was cancer!?” Did you give him an oncologist?” Did you not call the hospitalist to admit for an MRI!??”

If you put it in you MDM and say cancer then why not admit for new onset of cancer?

A mass on the arm with no Mets needs a tissue diagnose before a diagnosis of cancer is made.

I always put that additional verbal discharge instructions were given and expressed the need for follow up. I give a specific physician who has access to our EMR based on the call sheet who can accommodate ER patients

A person should follow up with a pcp. Also for your smoking example there are a lot of flammable things in a house I do t see how telling a person to stop smoking makes any difference if they are on oxygen since so many COPDers smoke and are on oxygen.

You tell them to stop regardless

A lot of malpractice just depends on the state. As to why the you can expect the patient to followup is because the patient went to the emergency room.

Also calling the PCP doesn’t do jack because insurance determines your pcp.

Also how are you going to tell a pcp how to work something up you are concerned about and not get an Ortho referral?
 
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This guy needs to be outed.

Rosen was censured for his medical opinion. The same needs to happen here. Sorry about your arm dude but take some responsibility.

There are a lot of clues to the identity of that person even with the blacked out parts. Not a lot of docs around that BC'd in EM in 1996 and IM in 1986.
 
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Ok so I’ll play with this reasoning.

“Dr. It says you thought it was cancer!?” Did you give him an oncologist?” Did you not call the hospitalist to admit for an MRI!??”

The second EM physician and the PCP mid-level don't appear to be sued. The expert witness isn't attacking the work-up. We can concoct all sorts of theoretical lines of attack for the prosecution in any case with a bad outcome. But time is money and lawyers don't like to waste their time. Urgent outpatient referral of many serious illnesses, including cancer, is well accepted and not the low-hanging fruit a lawyer is going to chase.

I can pull just about any random person off the street, say mass, and they'll come up with cancer as a possible diagnosis. A chart which apparently showed no significant concern for cancer (if the word even appeared anywhere in the chart) and where their primary discharge diagnosis was pain shows less insight than would be expected from a stranger on the street. Who knows what happened in reality but that's not the chart I want to be relying on to convince I jury I was worried and expressed my concern to the patient. The patient just has to argue that they went to both a physician and mid-level and neither seemed to think it was a big deal, either out of apathy or a lacking differential diagnosis, and so they didn't think it was important. "You should get that checked out" is OK from your drinking buddy. A physician is going to be expected to provide guidance on whom to follow-up with, in what time-frame, and why.
 
This guy needs to be outed.

Rosen was censured for his medical opinion. The same needs to happen here. Sorry about your arm dude but take some responsibility.

There are a lot of clues to the identity of that person even with the blacked out parts. Not a lot of docs around that BC'd in EM in 1996 and IM in 1986.

I think what annoyed me most was the part where they implied you should call a primary care doctor as part of the “standard of care,” which might be possible in an academic shop where calling the pmd involves asking a resident to do it, but is pretty unrealistic in the community (though I do it selectively).

And what are you going to say?

“Hi, I have a patient you’ve never met and have no duty to that hasn’t established care who showed up in the ed with a mass that’s been present for months. I just thought you should know I’m giving him your number!”

At the most I might try to call and make sure he gets on the schedule if I was genuinely worried, but that wouldn’t really make sense here. He had a long-standing issue that he then waited 11+ months to address for a second time and had a bad outcome which may not have been avoidable even at the onset. I also think the solution of “get an mri” doesn’t really make sense for something that probably just needs a biopsy, but I’d leave that up to pmd/specialist
 
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The second EM physician and the PCP mid-level don't appear to be sued. The expert witness isn't attacking the work-up. We can concoct all sorts of theoretical lines of attack for the prosecution in any case with a bad outcome. But time is money and lawyers don't like to waste their time. Urgent outpatient referral of many serious illnesses, including cancer, is well accepted and not the low-hanging fruit a lawyer is going to chase.

I can pull just about any random person off the street, say mass, and they'll come up with cancer as a possible diagnosis. A chart which apparently showed no significant concern for cancer (if the word even appeared anywhere in the chart) and where their primary discharge diagnosis was pain shows less insight than would be expected from a stranger on the street. Who knows what happened in reality but that's not the chart I want to be relying on to convince I jury I was worried and expressed my concern to the patient. The patient just has to argue that they went to both a physician and mid-level and neither seemed to think it was a big deal, either out of apathy or a lacking differential diagnosis, and so they didn't think it was important. "You should get that checked out" is OK from your drinking buddy. A physician is going to be expected to provide guidance on whom to follow-up with, in what time-frame, and why.

I find this a bit of a stretch.

He has a known history of nf in his family. There is a zero percent chance this guy didn’t know malignancy or related process was on the list.

Anyone off the street can tell you that you should have a primary doctor at 40 years old, especially with a fx significant for a rare genetic condition. It might be difficult for this guy due to social reasons, but that doesn’t make it appropriate to show up to the ed with expectations that we’ll manage everything.

After he went to the Ed, he was told to see a primary care doctor. It says it directly in there. Hopefully they also passed along the recommendation for mri, though the need for that vs proceeding to biopsy on an extremity is not totally clear to me.

Regardless, he waited 11 months and then finally followed up in the ed, which is not what he was directed to do, and seemingly implies he understood it might be an urgent process (twice). The difference seems to be that they gave him a phone number this time, so he showed up to an np and got a work up over two months.

If he’s capable of finding the ed, he should be capable of googling a primary care doctor, and he was told to do so. If he had addressed the mass with a primary doc six months earlier, or even after he was told to the first time, he might not have lost the arm, but he still might have.

They’re after the first doc because it’s an easier target when it’s not clear things could have happened faster with second doc, and I doubt there is any other reason. Case is a load of bull
 
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I find this a bit of a stretch.

He has a known history of nf in his family. There is a zero percent chance this guy didn’t know malignancy or related process was on the list.

Anyone off the street can tell you that you should have a primary doctor at 40 years old, especially with a fx significant for a rare genetic condition. It might be difficult for this guy due to social reasons, but that doesn’t make it appropriate to show up to the ed with expectations that we’ll manage everything.

After he went to the Ed, he was told to see a primary care doctor. It says it directly in there. Hopefully they also passed along the recommendation for mri, though the need for that vs proceeding to biopsy on an extremity is not totally clear to me.

Regardless, he waited 11 months and then finally followed up in the ed, which is not what he was directed to do, and seemingly implies he understood it might be an urgent process (twice). The difference seems to be that they gave him a phone number this time, so he showed up to an np and got a work up over two months.

If he’s capable of finding the ed, he should be capable of googling a primary care doctor, and he was told to do so. If he had addressed the mass with a primary doc six months earlier, or even after he was told to the first time, he might not have lost the arm, but he still might have.

They’re after the first doc because it’s an easier target when it’s not clear things could have happened faster with second doc, and I doubt there is any other reason. Case is a load of bull

This is another example of #EMTALAfailure

He goes to the ED (most likely because it's free) and gets an appropriate free MSE, there is no emergent medical condition determined, and he gets free advice, being: "Follow up with your doctor". Likely that doctor and group got no or minimal compensation, and now he is playing the lawsuit lottery.
 
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I find this a bit of a stretch.

He has a known history of nf in his family. There is a zero percent chance this guy didn’t know malignancy or related process was on the list.

Anyone off the street can tell you that you should have a primary doctor at 40 years old, especially with a fx significant for a rare genetic condition. It might be difficult for this guy due to social reasons, but that doesn’t make it appropriate to show up to the ed with expectations that we’ll manage everything.

After he went to the Ed, he was told to see a primary care doctor. It says it directly in there. Hopefully they also passed along the recommendation for mri, though the need for that vs proceeding to biopsy on an extremity is not totally clear to me.

Regardless, he waited 11 months and then finally followed up in the ed, which is not what he was directed to do, and seemingly implies he understood it might be an urgent process (twice). The difference seems to be that they gave him a phone number this time, so he showed up to an np and got a work up over two months.

If he’s capable of finding the ed, he should be capable of googling a primary care doctor, and he was told to do so. If he had addressed the mass with a primary doc six months earlier, or even after he was told to the first time, he might not have lost the arm, but he still might have.

They’re after the first doc because it’s an easier target when it’s not clear things could have happened faster with second doc, and I doubt there is any other reason. Case is a load of bull

We don't have the medical record. We definitely don't know how the ED visit actually went. But there is a difference between checking the follow-up with your PCP box (even better when the EMR has no PCP listed) versus saying follow-up within [number] weeks with [person/clinic] for this [reason] and I'd take a bet on which type of follow-up instructions are in the chart.

Lawyers name every single person who touches the chart. Physicians frequently won't assign their name to sign-out patients who are admitted or discharged because they're afraid of the legal repercussions. They didn't go after the second emergency physician because they don't think there is a case there.

I'm not here to argue the morality of the lawsuit. But I think the first physician is in a terrible medicolegal position. It's easy to paint a picture that the initial team blew it off and falsely reassured the patient. The possibility of cancer doesn't show up anywhere in their documentation, they gave vague open-ended follow-up instructions, and they gave pre-populated discharge instructions focused on pain with poorly worded reassurance. After the second ED visit, the same patient manages to follow-up with a PCP, MRI, and specialists within weeks/months. It's so painfully easy to paint a picture that the delay in follow-up after the initial visit was false reassurance at the first ED visit.

There are definitely nonsense medicolegal lawsuits out there; it's important to not make it easy with crappy documentation. But communication is part of medicine and there are a lot of physicians who suck at it and end up sued either because their poor communication skills either harm patients or angers them and send them running to a lawyer.

This generation is lucky to have ready access to information on cases like this. They represent a good opportunity to improve clinically and medicolegally. Crying bull**** on every case does nothing to make use of these resources. At the end of the day some guy lost his arm and a physician is now dragged through the medicolegal system. I'd like to avoid both outcomes in my practice and "f*** him, he should have followed up sooner" doesn't do anything to facilitate that.

My takeaways:
1. Document the life and limb threats you considered.
2. Give patients clear follow-up information. Person, time-frame, reason, and back-up plan. Voiced to the patient and documented somewhere.
3. Don't use prepopulated discharge information that doesn't actually fit the case.
 
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The second EM physician and the PCP mid-level don't appear to be sued. The expert witness isn't attacking the work-up. We can concoct all sorts of theoretical lines of attack for the prosecution in any case with a bad outcome. But time is money and lawyers don't like to waste their time. Urgent outpatient referral of many serious illnesses, including cancer, is well accepted and not the low-hanging fruit a lawyer is going to chase.

I can pull just about any random person off the street, say mass, and they'll come up with cancer as a possible diagnosis. A chart which apparently showed no significant concern for cancer (if the word even appeared anywhere in the chart) and where their primary discharge diagnosis was pain shows less insight than would be expected from a stranger on the street. Who knows what happened in reality but that's not the chart I want to be relying on to convince I jury I was worried and expressed my concern to the patient. The patient just has to argue that they went to both a physician and mid-level and neither seemed to think it was a big deal, either out of apathy or a lacking differential diagnosis, and so they didn't think it was important. "You should get that checked out" is OK from your drinking buddy. A physician is going to be expected to provide guidance on whom to follow-up with, in what time-frame, and why.
How many times have you taken money to testify against fellow EM physicians?

Before you answer, I'll go first. Zero.

Your turn.
 
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We don't have the medical record. We definitely don't know how the ED visit actually went. But there is a difference between checking the follow-up with your PCP box (even better when the EMR has no PCP listed) versus saying follow-up within [number] weeks with [person/clinic] for this [reason] and I'd take a bet on which type of follow-up instructions are in the chart.

Lawyers name every single person who touches the chart. Physicians frequently won't assign their name to sign-out patients who are admitted or discharged because they're afraid of the legal repercussions. They didn't go after the second emergency physician because they don't think there is a case there.

I'm not here to argue the morality of the lawsuit. But I think the first physician is in a terrible medicolegal position. It's easy to paint a picture that the initial team blew it off and falsely reassured the patient. The possibility of cancer doesn't show up anywhere in their documentation, they gave vague open-ended follow-up instructions, and they gave pre-populated discharge instructions focused on pain with poorly worded reassurance. After the second ED visit, the same patient manages to follow-up with a PCP, MRI, and specialists within weeks/months. It's so painfully easy to paint a picture that the delay in follow-up after the initial visit was false reassurance at the first ED visit.

There are definitely nonsense medicolegal lawsuits out there; it's important to not make it easy with crappy documentation. But communication is part of medicine and there are a lot of physicians who suck at it and end up sued either because their poor communication skills either harm patients or angers them and send them running to a lawyer.

This generation is lucky to have ready access to information on cases like this. They represent a good opportunity to improve clinically and medicolegally. Crying bull**** on every case does nothing to make use of these resources. At the end of the day some guy lost his arm and a physician is now dragged through the medicolegal system. I'd like to avoid both outcomes in my practice and "f*** him, he should have followed up sooner" doesn't do anything to facilitate that.

My takeaways:
1. Document the life and limb threats you considered.
2. Give patients clear follow-up information. Person, time-frame, reason, and back-up plan. Voiced to the patient and documented somewhere.
3. Don't use prepopulated discharge information that doesn't actually fit the case.

Dude. He had a tumor. This is, by definition, not an emergency. End of discussion.
 
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How many times have you taken money to testify against fellow EM physicians?

Before you answer, I'll go first. Zero.

Your turn.

Zero. You don’t need to be a plaintiff’s expert witness to think about what they would want to say about a case. If I was in the business of making money sueing emergency physicians, I would keep my mouth shut not try to pull lessons learned out of bad outcomes.
 
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We don't have the medical record. We definitely don't know how the ED visit actually went. But there is a difference between checking the follow-up with your PCP box (even better when the EMR has no PCP listed) versus saying follow-up within [number] weeks with [person/clinic] for this [reason] and I'd take a bet on which type of follow-up instructions are in the chart.

Lawyers name every single person who touches the chart. Physicians frequently won't assign their name to sign-out patients who are admitted or discharged because they're afraid of the legal repercussions. They didn't go after the second emergency physician because they don't think there is a case there.

I'm not here to argue the morality of the lawsuit. But I think the first physician is in a terrible medicolegal position. It's easy to paint a picture that the initial team blew it off and falsely reassured the patient. The possibility of cancer doesn't show up anywhere in their documentation, they gave vague open-ended follow-up instructions, and they gave pre-populated discharge instructions focused on pain with poorly worded reassurance. After the second ED visit, the same patient manages to follow-up with a PCP, MRI, and specialists within weeks/months. It's so painfully easy to paint a picture that the delay in follow-up after the initial visit was false reassurance at the first ED visit.

There are definitely nonsense medicolegal lawsuits out there; it's important to not make it easy with crappy documentation. But communication is part of medicine and there are a lot of physicians who suck at it and end up sued either because their poor communication skills either harm patients or angers them and send them running to a lawyer.

This generation is lucky to have ready access to information on cases like this. They represent a good opportunity to improve clinically and medicolegally. Crying bull**** on every case does nothing to make use of these resources. At the end of the day some guy lost his arm and a physician is now dragged through the medicolegal system. I'd like to avoid both outcomes in my practice and "f*** him, he should have followed up sooner" doesn't do anything to facilitate that.

My takeaways:
1. Document the life and limb threats you considered.
2. Give patients clear follow-up information. Person, time-frame, reason, and back-up plan. Voiced to the patient and documented somewhere.
3. Don't use prepopulated discharge information that doesn't actually fit the case.

Would you hold still hold your view that this lawsuit has merit if this case were exactly the same, but the time period between the two ED visits were 2 years instead? How about 5 years? 10 years?
 
Would you hold still hold your view that this lawsuit has merit if this case were exactly the same, but the time period between the two ED visits were 2 years instead? How about 5 years? 10 years?

I wouldn't necessarily use the word merit because it implies an opinion on fairness or morality to me.

Do I think a multi-year delay in follow-up would be helpful to the defendant? Yes. The further out it goes, the weaker their case that the lack of urgency in follow-up was the direct cause of the amputation. The further out the follow-up, the stronger the defendants case that even the most lackadaisical interpretation of "follow-up with a PCP" would have saved his arm.

Nobody can be perfect with their documentation.

I agree. Personally, I subscribe to a similar philosophy as Birdstrike and view medicolegal risk more like a car accident where you take basic precautions and accept someone may just randomly slam into you one day so you have insurance to protect yourself.

But as far as I can tell, this physician now has to deal with a malpractice case because they didn't put cancer in their chart. And the same case replays over and over in the medicolegal literature with PE, myocarditis, meningitis, foreign bodies, etc. That's like not wearing a seatbelt. Would they maybe still have been sued? Sure. But there are far more avenues for defending how they evaluated and treated for disease X than there are trying to argue they thought about something that never showed up in your chart. Having to start a malpractice case having to defend that you actually thought about some bread-and-butter differential in a medical student level review book is a bad look in front of a jury. One word in the chart and they could argue they clearly thought it might be cancer and then build into what their typical and customary practices would be and how that would include stressing the importance of follow-up and then build into the many reasons a patient might not follow-up promptly. Instead they're stuck arguing that they really did think about cancer but didn't write it down. Just one word; it might even have been enough to dissuade the lawyer from taking the case. Throw in "I stressed the importance of urgent outpatient follow-up" and I doubt this would have gone anywhere.

My documentation is on the shorter side. I think the return on a lot of the recommended medicolegal charting practices are not particularly worthwhile in terms of time and benefit. But I think the differential, discharge, and important conversations are high-risk and warrant a sentence or two.
 
Ugh. I want to stab this “expert witness.” It’s absurd how much people will ***** themselves out for money.

Is this person’s name public record? He or she should be outed.

Huh. Apparently the word for prostitute that starts with w is banned. God forbid med students actually walk into an ER and hear any of my co-faculty, residents or nursing staff speak.
 
Huh. Apparently the word for prostitute that starts with w is banned. God forbid med students actually walk into an ER and hear any of my co-faculty, residents or nursing staff speak.
Yes, you set off the SDN Censor Alarms. I got 15 text messages when you posted it, and because I didn't reply quickly, my home phone and cell phone rang all because you chose a word that most of us use in the ER every single day.

Just kidding. Even re-tarded is censored on SDN for some reason.
 
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Yes, you set off the SDN Censor Alarms. I got 15 text messages when you posted it, and because I didn't reply quickly, my home phone and cell phone rang all because you chose a word that most of us use in the ER every single day.

Just kidding. Even re-tarded is censored on SDN for some reason.

Yea. I mean, I feel like re-tarded can be offensive and it’s reasonable to avoid it (although I tend to err on the side of personal liberty). If you’re offended by the term w-ho-re, it’s because you’re a w-ho-re, in which case I doubt you’re frequenting the sdn forums. If you are, I’m interested in the backstory that led you here.
 
I found the guy in about 15 minutes; or if not him, someone unfortunate enough to match in every respect.

Note when he says he was first licensed (1986), and when he became "board certified" in Emergency Medicine (1996). The phrase is in quotes for a reason.

I will give you a hint to start the search: What do you think the first word in "XXXX Professional Services, a 400 physician IPA" would be? Engineering? Zoological? Dental?

Once you link the IPA to a hospital, it becomes pretty easy.

In his favor, I had a friend of mine who does malpractice defense work run his name through one of their databases and it didn't pop up, so he apparently has not made too much of a career out of that.

As a warning, if you do appear as an expert witness (on either side), LexisNexis has databases on you that include everything up to and including your underwear size.
 
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I found the guy in about 15 minutes; or if not him, someone unfortunate enough to match in every respect.

Note when he says he was first licensed (1986), and when he became "board certified" in Emergency Medicine (1996). The phrase is in quotes for a reason.

I will give you a hint to start the search: What do you think the first word in "XXXX Professional Services, a 400 physician IPA" would be? Engineering? Zoological? Dental?

Once you link the IPA to a hospital, it becomes pretty easy.

In his favor, I had a friend of mine who does malpractice defense work run his name through one of their databases and it didn't pop up, so he apparently has not made too much of a career out of that.

As a warning, if you do appear as an expert witness (on either side), LexisNexis has databases on you that include everything up to and including your underwear size.

do it....
 
Lol, yeah, "Board Certified" in EM..... by AAPS. Actually board certified in? IM.

How is this fact not being brought up as a way to eviscerate this "expert" witness?
 
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After the second ED visit, the same patient manages to follow-up with a PCP, MRI, and specialists within weeks/months. It's so painfully easy to paint a picture that the delay in follow-up after the initial visit was false reassurance at the first ED visit.

There are definitely nonsense medicolegal lawsuits out there; it's important to not make it easy with crappy documentation. But communication is part of medicine and there are a lot of physicians who suck at it and end up sued either because their poor communication skills either harm patients or angers them and send them running to a lawyer.

This generation is lucky to have ready access to information on cases like this. They represent a good opportunity to improve clinically and medicolegally. Crying bull**** on every case does nothing to make use of these resources. At the end of the day some guy lost his arm and a physician is now dragged through the medicolegal system. I'd like to avoid both outcomes in my practice and "f*** him, he should have followed up sooner" doesn't do anything to facilitate that.

My takeaways:
1. Document the life and limb threats you considered.
2. Give patients clear follow-up information. Person, time-frame, reason, and back-up plan. Voiced to the patient and documented somewhere.
3. Don't use prepopulated discharge information that doesn't actually fit the case.

1. Show me anywhere that I said “fuc* him, he should have followed up sooner”

2. No matter what time frame they put on their documentation the idea that he was supposed to wait until the next year is ludicrous, and then when he did follow up it was with the ed, not a pmd.

3. I can think a case is complete bs without missing that it still reflects a chance to learn how lawyers think.

I do think this case is without merit. I think the testimony listed is also without merit, and written by someone who apparently isn’t even certified by our board.

That doesn’t mean I didn’t learn anything from it. I always take time to write name, # (on call doc if none listed), and within 1 week for essentially any complaint, with a fall back of come back to ed if things are worsening, x,y, z or you can’t follow up. Since 1 week follow up is generally unrealistic I tell patients they have to at least call in that time frame and run their symptoms by someone if any are persisting. Limits bounces.

I also think it’s stupid that something that is obviously common sense is the thing generating hand wringing by physicians over whether something was another docs fault based on a chart they never saw, based on the account of a biased “expert” witness.
 
My wife had a surgical complication which left her with permanent disability in a limb. We talked to a lawyer firm. They had an expert review the case. His conclusion? "It happens." The plaintiff expert said there was no case. Then, there's this meathead? I mean, it takes $1mil to take a case to trial. Why use something specious, like this, as your base rationale to start the process? Defense specialists will just cut this up, like a Cuisinart. The plaintiff specialist should be the most arch, not the most rosy.
 
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My wife had a surgical complication which left her with permanent disability in a limb. We talked to a lawyer firm. They had an expert review the case. His conclusion? "It happens." The plaintiff expert said there was no case. Then, there's this meathead? I mean, it takes $1mil to take a case to trial. Why use something specious, like this, as your base rationale to start the process? Defense specialists will just cut this up, like a Cuisinart. The plaintiff specialist should be the most arch, not the most rosy.
That is why if you get the malpractice defense guys drunk they will tell you the lawyers they actually worry about in that area. Or at least a little tipsy.

There are the ones who are scary, who only take solid cases, and get all their ducks in a row.

Then there are the ones who also do deeds and wills and feel, "it is worth a gamble."

While almost all cases are done on a contingency basis, there are those that are done on a straight up "I will pay your hourly rate" basis. These are the people who have money, perhaps from life insurance, and are mad. The bad news is that the wealthy mad ones will keep going to the bitter end; the good news is, to quote a friend of mine, "People's 'principles' generally do not outlast the first bill from their attorney."

Although I am loathe to say it, along the lines of Apollyon's comments, the scary ones want experts who tell them the truth. They don't want to end up paying high six-figures out of their own pockets and then find the expert oversold the case.
 
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In my discharge instructions I always mention what imaging was suggested: “call in 1 day to make fu appt with pcp at next available appointment to obtain mri of your arm as we discussed”

I then send a note on epic to the pcp. My ass would have been covered.

I do this not only because it may save my ass down the line but hey may also help out the patient and pcp. I do get a lot of thank yous from PCPs for closing the loop for them. Way more than I get from patients now that I think about it... :/
 
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yeah that's definitely a helpful feature on EPIC, can communicate with the patient's PCP in real time. The PCPs really appreciate this.
 
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I thought this stood for the American association of physicians and surgeons... TIL it stands for something else as well

That's my understanding as well, and they don't board certify anyone in anything. The certification bodies for EM are ABEM, ABOEM, NBPAS, and ABPS. The professional organizations are AAEM and ACEP. Anything outside of that is well, not.
 
yeah that's definitely a helpful feature on EPIC, can communicate with the patient's PCP in real time. The PCPs really appreciate this.

Heard an anecdote from a guy who works in Australia that their EMR is light-years ahead of anything we have here in the states.
"One system. Everywhere. Can send a note to any doc about any matter. Instantly."

How Meditech is still a thing in the US is amazing.
 
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Heard an anecdote from a guy who works in Australia that their EMR is light-years ahead of anything we have here in the states.
"One system. Everywhere. Can send a note to any doc about any matter. Instantly."

How Meditech is still a thing in the US is amazing.
It's bizarre to me how we are okay with our EMRs in the US. HIPAA takes the blame usually for why we can't have interconnected, networked systems with a good interface and easy access to results. We have the largest tech companies in the world who write most of the software that the world uses in consumer appliances. Surely there's a way.....
 
It's bizarre to me how we are okay with our EMRs in the US. HIPAA takes the blame usually for why we can't have interconnected, networked systems with a good interface and easy access to results. We have the largest tech companies in the world who write most of the software that the world uses in consumer appliances. Surely there's a way.....

This is made twice as frustrating when you ask some tech-illiterate BOOMER what medications they take, and the answer that you get is:

"Hurrr durr; I dunno - they're all in the computahs up at Mass Gen - just get into their computahs and find em."

Me (internally): No sir, that's a cybercrime.

Bonus points awarded if they pull what they refer to as a "flip phone" out of their pocket and bash it with their fat index finger a few times before getting confused and putting it away. Seriously, they must think that pushing the buttons harder has something to do with the desired function.
 
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"Good discharge instructions are better than an accurate diagnosis." I've said this for years (documented here on SDN). There is already another thread about discharge instructions. You can find that here. That thread speaks directly to this case (material, not the actual case).

This is rock solid advice and will remain ingrained in my brain
 
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In my discharge instructions I always mention what imaging was suggested: “call in 1 day to make fu appt with pcp at next available appointment to obtain mri of your arm as we discussed”

I then send a note on epic to the pcp. My ass would have been covered.

I do this not only because it may save my ass down the line but hey may also help out the patient and pcp. I do get a lot of thank yous from PCPs for closing the loop for them. Way more than I get from patients now that I think about it... :/
If he had a pcp, he wouldn't be in the ER.
 
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