Croup fatality malpratice case aka the scourge of bad EM expert witnesses

[pkwraith]

Barking Cough [Fatality]

Case #141

expertwitness.substack.com

Tragic case. 7 yo with barky cough, benign presentation in the ED, diagnosed and treated for clinical croup, positve for flu B, later had a GAS necrotizing lung infection and fatality. Reading through the case, can happen to anyone, but was boiled my blood was reading through the plaintaiff's expert opinion.

IM physician, EM boarded, ACEP and SAEM member, apparently teaches at an EM residency program
- reports croup and influenza B cannot occur at the same time
- insists "marked deviation of care" for giving decadron which resulted in overwhelming GAS infiection
- should not have given dexamethasone for clinical croup until the results of the viral PCR, which "demonstrated a reckless indifference to pending test results and instituting proper treatment, which is both shocking and outrageous and well outside the boundaries of accepted standard care"
- saying that the documentaiton in note "We will give decadron" with the note signed after the completion of the visit, is "clearing inappropriate and and lacking in honesty" and "is extremely unusual and calls into question the chain of events"
- did not offer the patient the opporutnity to be evaluated by a pediatric specialist, did not inform the parent her child had been inappropriately treated with Decadron, nor speak with a pediatric specialist under that circumstance, as should have been done, "shocking departures from the recognition of patient right"


Would I have considered a CXR for a croupy presentation in a 7 year old who is slightly out of the normal croup range and who is flu positive? Maybe. I would have thought more about it, and it is unclear if a CXR would have even changed anything. But, there is nothing about the case remotely out of the standard of care in how it was treated. But this is one of the worse expert witness opinions I've seen (after that one surgery opinion that cited medscape). Expert witesses like this should be sanctioned by every society, and case referred to their department chairs.

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[Birdstrike]

Submit it to ACEP for consideration of censure, like they did the disgraced physician on your EM textbook.

 

[Tiger26]

Absolutely should be censored by ACEP in line with the disgusting deviation of expert opinion from Peter Rosen

 

[emergentmd]

What a farce. It just shows you the lack of morals some have and will eventually be their downfall. Anyone who can give this testimony is just a miserable person going for the buck and will be their downfall

 

[Brigade4Radiant]

Awful the PA nor doctor wasn't at fault at all.

Also yes GAS can occur after influenza and nearly all of us would miss this since it is just a bad outcome. Infact all viral infections can make you more susceptible to bacteria this is well documented.

Molecular pathogenesis of secondary bacterial infection associated to viral infections including SARS-CoV-2 - PMC

Secondary bacterial infections are commonly associated with prior or concomitant respiratory viral infections. Viral infections damage respiratory airways and simultaneously defects both innate and acquired immune response that provides a favorable ...

www.ncbi.nlm.nih.gov

But we don't give antibiotics for viral infections that not the standard of care. Its crazy that this EM/IM trained guy has made such an "awful" expert opinion.

Also doing training in another specialty fellowship or otherwise often reduces your skills in that main specialty like IM or EM.

 

[EthylMethylMan]

- reports croup and influenza B cannot occur at the same time

Wtf this is totally wrong as far as I've always been taught. Flu A and B can both cause croup, no?

 

[bravotwozero]

Eff this guy.

Sorry don’t have anything useful to say.

 

[kumatie]

Someone needs to name this expert

 

[WilcoWorld]

Wtf this is totally wrong as far as I've always been taught. Flu A and B can both cause croup, no?

Yes, this is well established. I guess expert witnesses can just say whatever false things they want?

 

[WilcoWorld]

Someone needs to name this expert

I don't see any reason that expert witnesses should get anonymity.

 

[johhnybgood]

I don't see any reason that expert witnesses should get anonymity.

Yes, how do we get expert name?

 

[Birdstrike]

I don't see any reason that expert witnesses should get anonymity.

Expert witnessed generally don't get anonymity. I think you have to get a special court order for that (?)

 

[Brigade4Radiant]

Academic doctors love to throw community doctors under the bus saying we over scan don't follow guidlines but they don't hesitate to be an expert witness against you.

Also keeping the expert witness anonoymous in this case is protecting an abuser.

 

[Birdstrike]

Academic doctors love to throw community doctors under the bus saying we over scan don't follow guidlines but they don't hesitate to be an expert witness against you.

Gold standard tests are gold.

 

[WilcoWorld]

Academic doctors love to throw community doctors under the bus saying we over scan don't follow guidlines but they don't hesitate to be an expert witness against you.

Also keeping the expert witness anonoymous in this case is protecting an abuser.

Maaaaaan, why ya gotta go and make this anti-academic? I'm in academics and I only agree to testify on behalf of EM docs.

 

[carbonizedeyesockets]

This has been discussed in other forums and everyone has recommended that it be sent for review with ACEP and AAEM. I'm curious who the "expert" witness was. I'm hoping they will be outed.

And as a nod to academics, my chair in residency, whom most of you would recognize, only did expert witness work for the defense. He did it for reimbursement of lodging and travel costs. Probably one of the most principled people in EM ever.

 

[xaelia]

In my ~15-odd cases of review from my brief medmal expert exposure, I did like 80% defense.

It was informative being on the other side once, though – and I really did think the EM doc blew it. The other plaintiff work was against prison medical staffing companies.

 

[emergentmd]

Wtf this is totally wrong as far as I've always been taught. Flu A and B can both cause croup, no?

That guy is full of crock. Croup has common causes but its more of a symptom than a pathogen.

 

[thegenius]

Barking Cough [Fatality]

Case #141

expertwitness.substack.com

Tragic case. 7 yo with barky cough, benign presentation in the ED, diagnosed and treated for clinical croup, positve for flu B, later had a GAS necrotizing lung infection and fatality. Reading through the case, can happen to anyone, but was boiled my blood was reading through the plaintaiff's expert opinion.

IM physician, EM boarded, ACEP and SAEM member, apparently teaches at an EM residency program
- reports croup and influenza B cannot occur at the same time
- insists "marked deviation of care" for giving decadron which resulted in overwhelming GAS infiection
- should not have given dexamethasone for clinical croup until the results of the viral PCR, which "demonstrated a reckless indifference to pending test results and instituting proper treatment, which is both shocking and outrageous and well outside the boundaries of accepted standard care"
- saying that the documentaiton in note "We will give decadron" with the note signed after the completion of the visit, is "clearing inappropriate and and lacking in honesty" and "is extremely unusual and calls into question the chain of events"
- did not offer the patient the opporutnity to be evaluated by a pediatric specialist, did not inform the parent her child had been inappropriately treated with Decadron, nor speak with a pediatric specialist under that circumstance, as should have been done, "shocking departures from the recognition of patient right"


Would I have considered a CXR for a croupy presentation in a 7 year old who is slightly out of the normal croup range and who is flu positive? Maybe. I would have thought more about it, and it is unclear if a CXR would have even changed anything. But, there is nothing about the case remotely out of the standard of care in how it was treated. But this is one of the worse expert witness opinions I've seen (after that one surgery opinion that cited medscape). Expert witesses like this should be sanctioned by every society, and case referred to their department chairs.

I wish we had a cadre of EM docs whose only job was to seek out all "expert witness" ER doctors who testify for plantiffs and find any deviation in care when they practice. Then sue the SHIIIIIT out of them. EVERY single one.

I would pay for that service. You testify against an ER doc and write these things, you will get SUED yourself. Every week for 3 years.

 

[Janders]

Wtf this is totally wrong as far as I've always been taught. Flu A and B can both cause croup, no?

Of course it can. I've seen it, and so have many many people. Of course Para-influenza is most common, but "normal" flu, RSV, adeno and rhino have all clearly been implemented in the disease state known as croup. I'm sure covid has caused a couple episodes too.

 

[Janders]

Here this took 3 seconds on google... flu is a common cause of croup (especially when its... going around!), and perhaps triggers MORE severe croup than other virus (passes the sniff test, in general flu is a nastier thing to have than rhinovirus).

CLINICAL COURSES OF CROUP CAUSED BY INFLUENZA AND... : The Pediatric Infectious Disease Journal

An abstract is unavailable.

journals.lww.com

 

[PianoMedic]

Of course it can. I've seen it, and so have many many people. Of course Para-influenza is most common, but "normal" flu, RSV, adeno and rhino have all clearly been implemented in the disease state known as croup. I'm sure covid has caused a couple episodes too.

Worst croup I have seen yet was from covid: sternal retraction, not substernal or suprasternal. Sternum retracting directly towards the spine. Transferred to picu, PICU doc told me they’ve been seeing it a lot with omicron in kiddos. Per that doc, they look really bad early on, but once the decadron kicks in they improve dramatically and are then able to be discharged. Just like any virus likely can cause bronchiolitis, I expect nearly any virus can cause croup. It’s the site of infection that defines the disease, not the underlying agent.

 

[Janders]

Worst croup I have seen yet was from covid: sternal retraction, not substernal or suprasternal. Sternum retracting directly towards the spine. Transferred to picu, PICU doc told me they’ve been seeing it a lot with omicron in kiddos. Per that doc, they look really bad early on, but once the decadron kicks in they improve dramatically and are then able to be discharged. Just like any virus likely can cause bronchiolitis, I expect nearly any virus can cause croup. It’s the site of infection that defines the disease, not the underlying agent.

yes my personal feeling was sometime around the omicron change I saw more "throat" symptoms like pharyngitis and (mild) croup. Not sure if this is real or just imagined...

 

[NYEMMED]

Whoever this “expert witness” was…
Hopefully they are named and hopefully their academic employer shows them the door…

 

[carbonizedeyesockets]

Whoever this “expert witness” was…
Hopefully they are named and hopefully their academic employer shows them the door…

I saw a post the other day from a academic Chair who stated that he will share testimony with chairs of departments that employ an expert witness that has made dubious claims. Apparently, this has gotten some bad expert witnesses to stop being expert witnesses. Won't get them fired, but these expert witnesses will tout their academic credentials and chairs do not want to get a bad name by association.

 

[Janders]

I saw a post the other day from a academic Chair who stated that he will share testimony with chairs of departments that employ an expert witness that has made dubious claims. Apparently, this has gotten some bad expert witnesses to stop being expert witnesses. Won't get them fired, but these expert witnesses will tout their academic credentials and chairs do not want to get a bad name by association.

Robert McNamara from Temple. AAEM

Posts things like this—

 

[carbonizedeyesockets]

Yeah, he rules.

 

[Kryptocoin]

When I was sued as a resident and later dropped, the plaintiff's expert witness was an academic chair of the EM dept. The word in town amongst the legal community, was that, this person was a known gun-for-hire. For the right price, you can get them to say whatever you want or even.....switch sides.

 

[Franzd'Epinay]

I'm not familiar with the intricacies of the legal process here. When can the defense dispute/address the plaintiff's assertions? I have to think any EM or peds-EM trained physician could have eviscerated this joke of an "expert" opinion.

It likely wouldn't have changed the outcome (as the defending parties would've settled any case of a previously-healthy pediatric death), but I wish there was a court record of this expert witness being called out for their buffoonery.

 

[PianoMedic]

I'm not familiar with the intricacies of the legal process here. When can the defense dispute/address the plaintiff's assertions? I have to think any EM or peds-EM trained physician could have eviscerated this joke of an "expert" opinion.

It likely wouldn't have changed the outcome (as the defending parties would've settled any case of a previously-healthy pediatric death), but I wish there was a court record of this expert witness being called out for their buffoonery.

I am not a lawyer and do not have direct experience with this, so someone please correct me if I’m wrong. My understanding is that you as the defendant cannot directly rebut or refute an expert witness claim. You speak to your care and what you did, maybe even why. You would bring in your own expert witness to offer a contrasting or directly rebutting testimony. In this instance, that witness could provide case reports and speak to other cases where croup was caused by a different causative agent and whatever else they felt was appropriate.

 

[Vandalia]

I have been successful in having the information in this area of my brain replaced by something more important ... like watching true crime shows with the wife. In case she has an account here .... let me make clear ... it is wonderful, yes wonderful. All this "together" time.

On to business: The first rule is that every state is different. Some states require a medical panel review before filing a suit, or something similar, but here is generically how it goes:

The plaintiff files a complaint. Unless it is res ipsa loquitur (something so obvious that there is not a need for an expert witness, like the surgeon cut off the wrong leg), there must be an expert witness who provides an affidavit as to the breach of the standard of care and usually causation.

The defendant is then served with the complaint and the attorney assigned by the malpractice carrier takes over. The defense files their answer, and that is usually a really boring document; they either admit or deny each section of the complaint. That is all they have to say and that is all they say, "Admit", "deny", etc. It is rare in malpractice cases, but the defense can also move to have the case dismissed at this stage. This is sometimes called dismissal for "failure to state a claim." This usually happens when a non-lawyer files a lawsuit, and they miss something essential, like to claim there was a patient-physician relationship. Or the forgot to actually allege that the alleged malpractice occurred in state X. The algorithm is pretty simple:

If we assume that everything in the complaint is true, could the plaintiff win?

If yes, then the motion to dismiss is denied, and the case moves to discovery.​

If no, then the complaint is dismissed, usually without prejudice. (Meaning they can attempt to file again.)​

But a motion to dismiss is incredibly rare in a medical malpractice case, so the whole thing moves on to that wonderful thing known as discovery (sarcasm.)

So to file a complaint, all that is needed is an expert witness who will testify to the breach of the standard of care. It really doesn't matter what he says or how credible he is. The plaintiff is not required to use him all through the case. So - depending on the state - there is nothing to prevent the plaintiff from finding a guy who was fired from a dozen jobs to provide the initial expert opinion, then if it the case turns out to be worthwhile, get someone "good" for the later stages of the case.

Expert Witness Requirements by State

Ignore the company, but they have a good state-by-state summary: Active Clinical Practice Requirements

So, in around half the states you don't even have to be licensed to be an expert witness - early on. When it gets to a trial, however, each side has to convince a judge that the specific expert witness is qualified, and that his or her testimony is based on scientific principles:

Rule 702(b): Expert scientific testimony is admissible only if the court is satisfied that the expert testimony rests upon reliable scientific principles.

More specifically, at trial, the witness needs to have the background to be able to convince the jury to believe her, and not the other gal.

But for the initial complaint, all they really need is someone with a pulse. It does help if the guy with the pulse has an elite name behind her, so that maybe they can bamboozle the malpractice carrier.

(As far as the trial alone is considered, the only time that expert witnesses "butt heads" is at trial. However, since these cases almost always end up with settlements, when it gets to discovery each side is attempting to convince the other of the strength of their own case.)

Oh, great, time for the Antifreeze Murder Retrial on CourtTV. Retirement is wonderful ... it really is ... wonderful.

 

[thegenius]

I'm not familiar with the intricacies of the legal process here. When can the defense dispute/address the plaintiff's assertions? I have to think any EM or peds-EM trained physician could have eviscerated this joke of an "expert" opinion.

It likely wouldn't have changed the outcome (as the defending parties would've settled any case of a previously-healthy pediatric death), but I wish there was a court record of this expert witness being called out for their buffoonery.

Yea I wonder if plantiff attorneys and defense attorneys and call their own "expert witness" to refute the other-side's "expert witness" testimony. This can be an infinite loop. Money permitting obviously.

 

[EthylMethylMan]

Of course it can. I've seen it, and so have many many people. Of course Para-influenza is most common, but "normal" flu, RSV, adeno and rhino have all clearly been implemented in the disease state known as croup. I'm sure covid has caused a couple episodes too.

Yeah that's what I thought. Wanted to make sure I wasn't going crazy.

I don't know how any of this stuff works legally. Just curious, is this statement given by the prosecution's "expert" under oath? Like is he swearing that the info he provides is accurate as far as he knows? It's just wild to me that an ER doc would either be so ignorant of basic pediatrics/ID info, or be inclined to mislead lay people at the expense of a colleague.

 

[Birdstrike]

I don't know how any of this stuff works legally.

The problem with expert opinion, is that it is opinion. You can have two textbook authors that have two directly opposite "factual" opinions. Who's right? The one with the book?

A jury of people without medical degrees decides who is most believable. That's it. That's the best we've got.

I haven't done a tone of work in this realm, but some. And some of the "expert" opinions you'll see are laughable. Are they dumb or just hired for pay-to-say?

Sometimes it's hard to tell.

 

[Janders]

Yeah that's what I thought. Wanted to make sure I wasn't going crazy.

I don't know how any of this stuff works legally. Just curious, is this statement given by the prosecution's "expert" under oath? Like is he swearing that the info he provides is accurate as far as he knows? It's just wild to me that an ER doc would either be so ignorant of basic pediatrics/ID info, or be inclined to mislead lay people at the expense of a colleague.

I mean this one is especially egregious but yes they give written info, deposition and court testimony which is “truthful”. But also parts are opinion. And certainly they can lean and twist what most of us would fine a 2 standard deviation away from the average stance to “normal”.

Making things up, but “CT finding X can be a sign of Y, which your client woefully ignored and thus led to Z” which may be potentially true, but X might be also a random incidentaloma seen almost everyday and ignored 99% of the time. Explaining this to no experts can be tough.

 

[Vandalia]

When you think about expert opinions, keep in mind the junk you deal with at 2 am from hospitalists and proceduralists. Except now those same people are writing it down and being paid a lot for it. Or more specifically for EM, the idiots in residency who always wanted to ask the bizarre question or make the crazy comment in conferences.

 

[ShockIndex]

I take on about 2-3 cases per year. Virtually all are now for plaintiffs and I only work with a handful of firms. Every case that I’ve rendered an opinion on has settled before trial. Why do I do this you ask? Because some of our colleagues are *****s and kill people. Here is a little taste:
1) Slapping a fentanyl patch on an opiate naive person who goes home to bed and never wakes up; toxic levels of fentanyl in blood on postmortem.
2) One case of an EP writing horse anesthetic doses of oxy, Valium, and soma to TEENAGER with back pain who overdosed and died 24 hours after the visit.
3 Leaving someone to the ED obs unit for 24 hours with chest pain and a dilated aortic root with pericardial effusion on stress echo and a cardiologist read and documented phone call to the EP that said, “Hey, this looks like a dissection.” The CTA aortogram was ordered routine; no attempts were made at anti-impulse therapy; no calls to CT surgery…just a perplexing 12 hour delay for a CT that was ordered “routine.” The patient coded on the way to the OR.
3) Multiple cases of people in their 30-40s sent home after transient periods of hemiparesis (or something scarier like transient vertigo, double vision, hemiparesis, and dysarthria). You know, because people in their 30-40s never have strokes. Typically a neuro exam that says something like “A&Ox4, strength intact” and a negative non-contrasted head CT as a defense. Virtually every case the patient has a massive stroke within a week. Each case there was no time-specific follow-up for expedited out-patient work-up; just see your doctor in 2-3 days.
4) Multiple cases of young men with abdominal pain and vomiting being sent home w/o imaging and with a diagnosis of constipation or gastroenteritis (if the poop was at all soft) and discharge instructions to follow up with their MD in 2-4 days. All return 2-3 days later with perforated appendicitis.
5) And last but not least, my absolute favorite - missed esophageal intubation. That’s right, some of our colleagues don’t believe in capnography to confirm tube placement. It’s something that only anesthesiologists do in the OR one said in depo. They trust their exam skills and a CXR to confirm placement before wisking the patient off to CT, or better yet - an ambulance to go to another hospital. Nothing says EMTALA + lawsuit like putting a patient in an ambulance for transfer 5 min after you “secured the airway” in the esophagus for the paramedic to troubleshoot.

 

[johhnybgood]

I take on about 2-3 cases per year. Virtually all are now for plaintiffs and I only work with a handful of firms. Every case that I’ve rendered an opinion on has settled before trial. Why do I do this you ask? Because some of our colleagues are *****s and kill people. Here is a little taste:
1) Slapping a fentanyl patch on an opiate naive person who goes home to bed and never wakes up; toxic levels of fentanyl in blood on postmortem.
2) One case of an EP writing horse anesthetic doses of oxy, Valium, and soma to TEENAGER with back pain who overdosed and died 24 hours after the visit.
3 Leaving someone to the ED obs unit for 24 hours with chest pain and a dilated aortic root with pericardial effusion on stress echo and a cardiologist read and documented phone call to the EP that said, “Hey, this looks like a dissection.” The CTA aortogram was ordered routine; no attempts were made at anti-impulse therapy; no calls to CT surgery…just a perplexing 12 hour delay for a CT that was ordered “routine.” The patient coded on the way to the OR.
3) Multiple cases of people in their 30-40s sent home after transient periods of hemiparesis (or something scarier like transient vertigo, double vision, hemiparesis, and dysarthria). You know, because people in their 30-40s never have strokes. Typically a neuro exam that says something like “A&Ox4, strength intact” and a negative non-contrasted head CT as a defense. Virtually every case the patient has a massive stroke within a week. Each case there was no time-specific follow-up for expedited out-patient work-up; just see your doctor in 2-3 days.
4) Multiple cases of young men with abdominal pain and vomiting being sent home w/o imaging and with a diagnosis of constipation or gastroenteritis (if the poop was at all soft) and discharge instructions to follow up with their MD in 2-4 days. All return 2-3 days later with perforated appendicitis.
5) And last but not least, my absolute favorite - missed esophageal intubation. That’s right, some of our colleagues don’t believe in capnography to confirm tube placement. It’s something that only anesthesiologists do in the OR one said in depo. They trust their exam skills and a CXR to confirm placement before wisking the patient off to CT, or better yet - an ambulance to go to another hospital. Nothing says EMTALA + lawsuit like putting a patient in an ambulance for transfer 5 min after you “secured the airway” in the esophagus for the paramedic to troubleshoot.

1. Agree. Ridiculous. Bad medicine.
2. Agree. Horrendous
3. Routinely send home patient w ct/cta and low abcd2 score +\- antiplatelets. If I admitted every dizzy or transient neurological symptom, be no room for anyone else. What am I missing? Our group covers 4 hospitals and follow this protocol and have not had bad bounce backs.
3. Dissection delay- big oops
4. Routinely do not image nausea and vomiting. If labs okay, symptoms resolve===> home. Strict return precautions. What makes these so egregious?
5. Missed tube into a bus is a problem.

 

[ShockIndex]

1. Agree. Ridiculous. Bad medicine.
2. Agree. Horrendous
3. Routinely send home patient w ct/cta and low abcd2 score +\- antiplatelets. If I admitted every dizzy or transient neurological symptom, be no room for anyone else. What am I missing? Our group covers 4 hospitals and follow this protocol and have not had bad bounce backs.
3. Dissection delay- big oops
4. Routinely do not image nausea and vomiting. If labs okay, symptoms resolve===> home. Strict return precautions. What makes these so egregious?
5. Missed tube into a bus is a problem.

This standard of care issues with 3 and 4 centered around discharging patients having dangerous symptoms with a benign diagnosis and inadequate follow-up. It’s not so much that the diagnosis was missed; more that there was absolutely no reasonable safety net discharge plan. For example, I recall that the patient with transient vertigo and dysarthria being discharged with “dehydration” as a cause for his symptoms and being told to drink more water. Moreover, there is a BIG difference between transient dizziness and hemiplegia + dysarthria or vertigo + dysarthria. There is also a BIG difference between a patients with just nausea and vomiting and those primarily complaining of abdominal pain with some nausea and vomiting.

Moreover, when it comes to symptoms of a TIA, I’d be VERY careful using the ABCD2 score since it failed prospective validation and had a sensitivity in the high 80% on a meta-analysis (ABCD2 score and secondary stroke prevention: meta-analysis and effect per 1,000 patients triaged - PubMed). In fact, ACEP’s clinical guideline on TIA specifically tells us NOT to use it (Level B recommendation). However, if you work in a resource constrained environment where imaging isn’t available, then sending someone home with an obvious TIA for an expedited work up within 24-48 hours might be reasonable. However, this is typically impractical in most EDs in the US or requires more effort than most of can exert on a typical shift. I’m not going to tell you that your group is practicing bad medicine. I will say that young people with transient hemiplegia are relatively rare in my practice. I don’t think that I will come close to filling the hospital if I leaned on my hospitalist or obs unit to get their TIA work up.

When it comes to patients with abdominal pain, I have no problem with forgoing imaging if it is coupled with safe return precautions that typically accompanies a symptomatic diagnosis that adequately conveys an appropriate level of diagnostic uncertainty (ie undifferentiated abdominal pain). Usually that is accompanied by multiple, well documented abdominal exams and a frank discussion with the patient that something serious may still be lurking. Telling your patient with abdominal pain that they have gastroenteritis or constipation and should see their doctor in a few days if unimproved is a great way to pay my kid’s tuition (any we appreciate your support).

 

[WilcoWorld]

I take on about 2-3 cases per year. Virtually all are now for plaintiffs and I only work with a handful of firms. Every case that I’ve rendered an opinion on has settled before trial. Why do I do this you ask? Because some of our colleagues are *****s and kill people. Here is a little taste:
1) Slapping a fentanyl patch on an opiate naive person who goes home to bed and never wakes up; toxic levels of fentanyl in blood on postmortem.
2) One case of an EP writing horse anesthetic doses of oxy, Valium, and soma to TEENAGER with back pain who overdosed and died 24 hours after the visit.
3 Leaving someone to the ED obs unit for 24 hours with chest pain and a dilated aortic root with pericardial effusion on stress echo and a cardiologist read and documented phone call to the EP that said, “Hey, this looks like a dissection.” The CTA aortogram was ordered routine; no attempts were made at anti-impulse therapy; no calls to CT surgery…just a perplexing 12 hour delay for a CT that was ordered “routine.” The patient coded on the way to the OR.
3) Multiple cases of people in their 30-40s sent home after transient periods of hemiparesis (or something scarier like transient vertigo, double vision, hemiparesis, and dysarthria). You know, because people in their 30-40s never have strokes. Typically a neuro exam that says something like “A&Ox4, strength intact” and a negative non-contrasted head CT as a defense. Virtually every case the patient has a massive stroke within a week. Each case there was no time-specific follow-up for expedited out-patient work-up; just see your doctor in 2-3 days.
4) Multiple cases of young men with abdominal pain and vomiting being sent home w/o imaging and with a diagnosis of constipation or gastroenteritis (if the poop was at all soft) and discharge instructions to follow up with their MD in 2-4 days. All return 2-3 days later with perforated appendicitis.
5) And last but not least, my absolute favorite - missed esophageal intubation. That’s right, some of our colleagues don’t believe in capnography to confirm tube placement. It’s something that only anesthesiologists do in the OR one said in depo. They trust their exam skills and a CXR to confirm placement before wisking the patient off to CT, or better yet - an ambulance to go to another hospital. Nothing says EMTALA + lawsuit like putting a patient in an ambulance for transfer 5 min after you “secured the airway” in the esophagus for the paramedic to troubleshoot.

These run the gamut from egregious to "there, but for the grace of God, go I".
I hope that your testimony does as well.

 

[RustedFox]

1. Agree. Ridiculous. Bad medicine.
2. Agree. Horrendous
3. Routinely send home patient w ct/cta and low abcd2 score +\- antiplatelets. If I admitted every dizzy or transient neurological symptom, be no room for anyone else. What am I missing? Our group covers 4 hospitals and follow this protocol and have not had bad bounce backs.
3. Dissection delay- big oops
4. Routinely do not image nausea and vomiting. If labs okay, symptoms resolve===> home. Strict return precautions. What makes these so egregious?
5. Missed tube into a bus is a problem.

1. I'm in agreement. That's just stupid.
2. Dear god, man.
3. STAT CT and call to vascular surgery. What's "anti-impulse therapy"... fancy way of saying BP reduction?
4. There would have to be something convincing, or my spider sense would have to tingle for me to admit all these.
5. Two benign exams and all better? Home.
6. Yeah, this is bad.

 

[ShockIndex]

These run the gamut from egregious to "there, but for the grace of God, go I".
I hope that your testimony does as well.

These have all been settled. Fairly quickly. It wasn’t close.

 

[ShockIndex]

1. I'm in agreement. That's just stupid.
2. Dear god, man.
3. STAT CT and call to vascular surgery. What's "anti-impulse therapy"... fancy way of saying BP reduction?
4. There would have to be something convincing, or my spider sense would have to tingle for me to admit all these.
5. Two benign exams and all better? Home.
6. Yeah, this is bad.

3. Anti-impulse therapy means lowering the shear stress across the aorta that occur with each systolic peak in BP. Thus, it involves controlling the HR and blood pressure by typically leading with a beta-blocker since vasodilators reflexively increase the heart rate leading no real change (or possibly increases) in shear forces.
4. These are cases of transient hemiplegia or hemiplegia with central vertigo and dysarthria. People who can’t move 1 side of their body or speak when they come into your ED should make you feel like Chis Matthews listening to Obama ().
5. These are not cases of repeat exams. These are 1 poorly documented exam and home with a diagnosis of gastroenteritis w/o diarrhea or constipation and no discharge instructions discussions about alternative diagnosis.

 

[Mount Asclepius]

These have all been settled. Fairly quickly. It wasn’t close.

That doesn’t mean you were right. Just sold out.

 

[Brigade4Radiant]

The close follow up thing doesn’t really make sense. Follow up depends upon your insurance. The follow up plan is just come back to the ER if your symptoms worsen.

Repeat exams for abdominal pain? So you pushed on someone’s tender belly and then you gave them pain medicine and now it’s a little less tender?

Sending someone home with alternate diagnosis on the chart does what exactly? If you sent them home, you sent them home. They came back in two days and had a ruptured appendix they came back because they’re pain was worsening.

You have no control over someone’s “expedited follow-up”

Also, add something “may still be lurking. Why didn’t you order a CT?”

Your multiple abdominal exams are done within at least six hours, which if they have a appendicitis serial abd exams are done at least every six hours if you admit them


Also, it depends on where are these places are.

Also, are you an hourly place community or academic or RVU?

 

[ShockIndex]

The close follow up thing doesn’t really make sense. Follow up depends upon your insurance. The follow up plan is just come back to the ER if your symptoms worsen.

Repeat exams for abdominal pain? So you pushed on someone’s tender belly and then you gave them pain medicine and now it’s a little less tender?

Sending someone home with alternate diagnosis on the chart does what exactly? If you sent them home, you sent them home. They came back in two days and had a ruptured appendix they came back because they’re pain was worsening.

You have no control over someone’s “expedited follow-up”

Also, add something “may still be lurking. Why didn’t you order a CT?”

Your multiple abdominal exams are done within at least six hours, which if they have a appendicitis serial abd exams are done at least every six hours if you admit them


Also, it depends on where are these places are.

Also, are you an hourly place community or academic or RVU?

When it comes to repeat abdominal exams, most of us perform them because plenty of patients present with some vague tenderness that often spontaneously resolves without any intervention thus obviating the need for imaging provided that reasonable discharge and follow-up instructions are provided. Giving analgesics is not an issue when it comes to the value of repeat or serial exams and this comes decades of data specifically on appendicitis (analgesics probably improve your exam in many cases). The flip side of that coin is that very few EPs are going to discharge someone with persistent pain and worsening tenderness on repeat exam without imaging. If they are elderly, that CT is coming with an admission.

Sending someone with acute abdominal pain home with a diagnosis of gastroenteritis when no gastroenteritis exists (or constipation for that matter) is a problem because it makes the patient think that they have a benign, self-limited process. If someone comes to the ED with acute abdominal pain and a relatively benign exam, it’s fine to forgo ANY testing. Someone previously mentioned benign labs, but there really is no laboratory test that should make you feel good about sending home someone with abdominal pain. The key to not being successfully sued in this instance is telling the patient that they have abdominal pain and you don’t know what is causing it; for the chart I use the diagnosis undifferentiated abdominal pain but abdominal pain NOS is probably fine. The other half of not getting sued is telling the patient that they may get worse and that if they are not obviously better, then invite them to come back to your ED in 12-24 hours for a repeat exam. Telling them to see a PCP in a few days that they either don’t have or can’t get into to see in a timely manner it a big risk to your malpractice and the patient’s health. In both of these case there were lots of other “best practices issues” such as discrepancies in the nursing chart (one case was discharged with 8/10 pain and the other having an abdominal exam that was effectively limited to something like “soft and no peritoneal signs” but not clearly documenting the absence of tenderness). Regardless, if you are routinely assigning diagnoses like gastroenteritis and constipation to young patients with acute abdominal pain as a chief complaint, then you are doing “it”wrong - especially if you’re telling them to see a PCP several days later if unimproved.

If you doubt me on this, just take a look at the case law on missed appendicitis in the ED. These are themes. People who trained in EM should know the pitfalls here. One of these 2 cases settled before deposition which is a big hint.

Where I have practiced is rather immaterial to the case law, but I divided my roughly 20 years of EM fairly equally between community, .mil, and .edu. I no longer practice in the ED for the past 2.5 years.

 

[ShockIndex]

That doesn’t mean you were right. Just sold out.

That doesn’t mean you were right. Just sold out.

That has such a negative connotation. I like to think of it this way - with the proliferation of NPs in the ED and physicians who trained at all those lovely HCA residences, there are now PLENTY of people who have no clue as to what they are doing while “practicing” in the ED. They can’t recognize a TIA to save their a$$, and they come out of training with 30-40 intubations thinking they are going to step into our world and do our job (ie the world run by those of us who actually went to medical school and completed a legit residency). I’m more than happy to prey on these people.

 

[BoardingDoc]

Where I have practiced is rather immaterial to the case law, but I divided my roughly 20 years of EM fairly equally between community, .mil, and .edu. I no longer practice in the ED for the past 2.5 years.

Out of curiosity, at what point in time do you think that having not actively practiced emergency medicine for several years will make you an unreliable expert witness?

 

[CoolDoc1729]

Out of curiosity, at what point in time do you think that having not actively practiced emergency medicine for several years will make you an unreliable expert witness?

I’d add that working in the emergency department has changed drastically in the last 3 years. I no longer see the majority of my patients in ER rooms, 3/4 of my practice is in the waiting room including half the ESI 2’s. I’ve coded two waiting room patients, and for the amount I work I am relatively more fortunate than my colleagues in that it’s been just 2, and I’ve gotten them both back. I could just not see the waiting room patients, as less than 5% of my pay is based on productivity, but a) they are humans that need things, b) it is boring to sit at my desk and wait for people to decompensate, c) if we don’t have a physician presence out there people do leave who really shouldn’t (hypoxic; tachy to 130s; imaging already showing something urgent and bad, etc)

Yet I worry about the upcoming barrage of lawsuits. Yes I know what we “should» have done for this patient, and if I had twice as many nurses I would have .. but for example realistically if someone’s k is 6.3 and their dialysis is in 10 minutes across the street they should probably just go as I can’t get them in a room in the foreseeable future, you know ? And I’m not convinced that anything is going to be better in the next 5-10 years. I’m not sure if you could argue for a pre covid standard of care if the department has 1/3 the staff.

I agree with most of the more egregious cases above , but with the possible Tia patient, or a low ish risk chest pain. If they can see their pcp tomorrow.. they might still be in the wr tomorrow if I “admit them”… I’m not sure what the right answer is with the young people with little kids that don’t want to sit in the wr for 3 days. Of course those are also the people who have the most to lose if they are permanently disabled or die.

 

[GonnaBeADoc2222]

I do some expert witness work.

A few things are egregious.

Most things are nonsense.

Transient Neuro symptoms in otherwise healthy people after neg CTA and low risk abdominal pain with improved exam are likely not cases I would be writing an opinion of support of.

If you're not practicing actively, I don't think you have a leg to stand on.