On one hand he makes a valid point that highlighting a case of one missed diagnosis doesn't definitively prove the point. The Med-mal world is full of MDs who missed PEs too - those things still scare the crap out of me!
On the other hand, the NP lobby uses their own unscientific rhetorical tools to claim they're more compassionate, thorough, etc. So maybe fair is fair and we should continue to highlight every time some midlevel blows a key diagnosis or step in management.
But calling it a "crushed sternum" when there was no traumatic incident and treating a sinus tach with adenosine, I find that hard to believe any 4th year med student would do that.
Here is the summary of the case! Credit to a Reddit member.
NP graduates from a family nurse practitioner program in December, testifies that all but 2 weeks of it were done online. In January, gets hired to do SOLO 24-hour shifts in an ED as her very first NP job. No on-site supervision or backup. Testifies as part of the deposition that she had never performed acute care. Had no experience as an NP in an ED. Was being paid 70 an hour (likely why they had NPs instead of MDs - can't attract a doctor to that setting). In August, was reprimanded for not getting notes done on time and needing to improve the content and style of her presentations to MDs. On September 1, they notified her she was being terminated, but could finish out her shifts for the rest of the month. This case actually occurs about two weeks after she received a termination notice. Of note, this was a 24-hour shift where she was scheduled to work until 10pm the night before at another hospital...
19 year old on OCPs came in tachycardic, hypoxic, hypotensive with systolics in the low 80s, complaining of chest pain, shortness of breath, and had passed out at home. Even the EMS documentation said they were concerned for a PE. Patient gets put on oxygen.
The NP gets a urine drug screen that's presumptive positive for methamphetamines but negative for amphetamines. That means it's a negative test - meth is metabolized into amphetamines, so you can't be truly positive for meth but negative for amphetamines. Patient, her boyfriend, and patient's mom all deny meth use. NP reruns the test and it comes back negative. Later, a blood test is also negative, but whatever.
The NP had ordered a CT (not CTA) but cancelled it once the UDS came back. And in the deposition, she actually said she ordered a CT head because of the syncope. I mean... what??
Patient eventually develops what the NP interpreted as PSVT, but what apparently was actually just appropriate sinus tachycardia. She gets adenosine. Terrible idea in someone with a PE.
She calls to admit the patient, and an NP takes that call. It seems like the second NP pointed out the abnormal vitals. After this, the NP in the ED orders a CT and a d-dimer at the same time. Not a CTA. The NP looks at the CT, interprets it as being "a crushed sternum" (???) and calls to transfer the patient. Prior to the receiving physician from the other hospital calling her back, the radiologist calls and tells her about the PEs. When the receiving physician calls back, the NP testified she told the receiving physician that the radiologist notified her about the PE.
But the only anticoagulation she ordered for the patient was prophylactic-dose Lovenox. With a total ED length of stay of 11 hours. Despite hemodynamic instability.
She ultimately did get transferred and had to get tPA, and died within two hours of landing at the receiving hospital.
ABIM Chair 100% should have done his due diligence and read up on the case before defending this as being something that just as easily could have been done by a physician. This is not a "I delivered excellent care but made a single mistake in interpreting a CT scan," as the headline implies. Because I can't really blame any hospital who hires an EM doc who screws up this bad -- this is beyond the pale for what one would expect from an EM doc. But a hospital who hires a new grad family practice NP to do UNSUPERVISED 24 HOUR SHIFTS WITHOUT ANY PRIOR ED EXPERIENCE? That hospital should know better. I wish this staffing model wasn't the reality... but it is.
