Interesting Pulmonary Embolism Lawsuit

[2021Doctor]

Two EM expert witness bash EM doc for missing Q3T3 changes
‘Gross Negligence’: A Slippery Slope for Dubious Expert Testimony
by William Sullivan, DO, JD on March 12, 2014

https://emcrit.org/wp-content/uploads/2014/04/‘Gross-Negligence’_-A-Slippery-Slope-for-Dubious-Expert-Testimony-Peter-Rosen.pdf

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[Mount Asclepius]

Late to the party…

 

[skougess]

Yeah this has been discussed already. Imagine Peter Rosen himself calling you incompetent in a court of law for discharging a PERC negative patient who ended up having a zebra PE in retrospect.

Perfect analogy for why EM is terrible now. The Boomers took their money and poop all over the next generation of doctors.

 

[BoardingDoc]

Yeah, not really sure that this topic needs yet another thread seeing as it's been exhaustively discussed in multiple old threads.

TL;DR for anyone who somehow didn't know about this already: Rosen testified that q3t3 on an EKG proved there was a PE. Doc getting sued lost. ACEP censured Rosen for his wackjob testimony rather publicly. Rosen lived out the rest of his days in disgrace and has since died. The end.

 

[2021Doctor]

Yeah, not really sure that this topic needs yet another thread seeing as it's been exhaustively discussed in multiple old threads.

TL;DR for anyone who somehow didn't know about this already: Rosen testified that q3t3 on an EKG proved there was a PE. Doc getting sued lost. ACEP censured Rosen for his wackjob testimony rather publicly. Rosen lived out the rest of his days in disgrace and has since died. The end.

I think that is a sad story.

 

[RuralEDDoc]

Yeah this has been discussed already. Imagine Peter Rosen himself calling you incompetent in a court of law for discharging a PERC negative patient who ended up having a zebra PE in retrospect.

Perfect analogy for why EM is terrible now. The Boomers took their money and poop all over the next generation of doctors.

This is incorrect. Patient was PERC positive. One week sp knee arthroscopy, leg was immobilized, patients shows up with atraumatic chest pain. EKG has S1Q3T3.
If this isn’t gross negligence, isn’t it at least a very big miss? Who assumes MSK chest pain when patient had orthopedic surgery and an immobilized leg? PE should be a top three diagnosis to evaluate for in this setting.
I think Rosen was unfairly attacked and his legacy ruined by people who didn’t know the details of the case and didn’t actually care to know.

 

[Apollyon]

This is incorrect. Patient was PERC positive. One week sp knee arthroscopy, leg was immobilized, patients shows up with atraumatic chest pain. EKG has S1Q3T3.
If this isn’t gross negligence, isn’t it at least a very big miss? Who assumes MSK chest pain when patient had orthopedic surgery and an immobilized leg? PE should be a top three diagnosis to evaluate for in this setting.
I think Rosen was unfairly attacked and his legacy ruined by people who didn’t know the details of the case and didn’t actually care to know.

IIRC, there was no S1. There were only two of the three, which is not pathognomonic for PE. That was the crux of the inexpert opinion given by the expert.

I mean, many docs put together put in the censure for Rosen. I don't think you're going to change any minds.

 

[Rekt]

This is incorrect. Patient was PERC positive. One week sp knee arthroscopy, leg was immobilized, patients shows up with atraumatic chest pain. EKG has S1Q3T3.
If this isn’t gross negligence, isn’t it at least a very big miss? Who assumes MSK chest pain when patient had orthopedic surgery and an immobilized leg? PE should be a top three diagnosis to evaluate for in this setting.
I think Rosen was unfairly attacked and his legacy ruined by people who didn’t know the details of the case and didn’t actually care to know.

I never once even looked for s1q3t3 on any ecg in any setting for any complaint. It is a useless nonspecific finding.

 

[RuralEDDoc]

IIRC, there was no S1. There were only two of the three, which is not pathognomonic for PE. That was the crux of the inexpert opinion given by the expert.

I mean, many docs put together put in the censure for Rosen. I don't think you're going to change any minds.

I don’t need to change minds, Rosen no longer walks the earth. I think this case is worth reflecting on. PE after orthopedic surgery - it’s a basic board question. Was it gross negligence to miss? I don’t know. But it’s still a miss, regardless of what the EKG shows.

 

[RuralEDDoc]

I think the real issue here is that physicians don’t like seeing fellow physicians testify against them, especially when it’s one of the founders of the specialty. That cuts deep.
I remember the uproar around this case from years ago and I was on the “F” Rosen side, until I saw the actual case details. It’s a big miss, right?

 

[WilcoWorld]

I don’t need to change minds, Rosen no longer walks the earth. I think this case is worth reflecting on. PE after orthopedic surgery - it’s a basic board question. Was it gross negligence to miss? I don’t know. But it’s still a miss, regardless of what the EKG shows.

Let's not mix issues. You make a good point, but I want to make sure it's not getting muddled. I do think we're a little quick to exculpate docs here, and I don't think that helps us. Neither to be better docs nor to speak on behalf of our specialty with credibility.

Chest pain in a patient who is 1 week post orthopedic surgery requiring leg immobilization can NOT be PERC negative. Full stop. This is important.

Rosen reportedly hung his hat on the ECG finding of S1Q3T3, but there was no S1 (also reportedly - I haven't seen the tracing). T wave inversions in lead three can be a normal finding. So Rosen was factually wrong if he called Q3T3 "pathognomonic" for PE.

 

[TooMuchResearch]

It's been a while since I've thought about this one, but I think the issue was his actual report/testimony, not the outcome of the medical case.

 

[Tenk]

Yeah, not really sure that this topic needs yet another thread seeing as it's been exhaustively discussed in multiple old threads.

TL;DR for anyone who somehow didn't know about this already: Rosen testified that q3t3 on an EKG proved there was a PE. Doc getting sued lost. ACEP censured Rosen for his wackjob testimony rather publicly. Rosen lived out the rest of his days in disgrace and has since died. The end.

CTA everyone. Got it.

 

[Kryptocoin]

The case was dismissed by both the lower court and the appeals court. The state Supreme Court changed the verdict after Rosen used his enormous influence to fabricate a new medical theory. Neither cardiomegaly nor some stupid Q3T3 is specific for PE.

Rosen could have just stated that the kid was PERC + and therefore needed further testing (dimer, CTA, vqscan). His reputation would have still been intact.

In the end, his downfall was money and hubris. Tale as old as time.

 

[icyfire111]

I read through the limited amount of information provided in the PDF. Perhaps a few things could be cleared up for me:

What exactly is a diagnosis of pleurisy? Is he alluding to an infection, inflammatory condition, autoimmune? If anything, that seems to me more of a diagnosis of exclusion.

What was the differential diagnosis in this scenario?

How does the fact that the administering of toradol relieving the chest pain rule out a PE? I've never heard of this, I'm not sure if that was the actual logic of the physician but that's what the article seems to allude to.

How is a patient with limited mobility after an orthopedic procedure not considered an elevated risk for a PE? Was a d-dimer run?

I agree that the solution can't be to CTA everyone, but I'm failing to understand the logical thought progression of this physician in this case, at least based on the information provided in this article. Even if he missed the PE, which can certainly happen for many people, I just don't understand how he ended up at a diagnosis of pleurisy.

 

[BoardingDoc]

I read through the limited amount of information provided in the PDF. Perhaps a few things could be cleared up for me:

What exactly is a diagnosis of pleurisy? Is he alluding to an infection, inflammatory condition, autoimmune? If anything, that seems to me more of a diagnosis of exclusion.

What was the differential diagnosis in this scenario?

How does the fact that the administering of toradol relieving the chest pain rule out a PE? I've never heard of this, I'm not sure if that was the actual logic of the physician but that's what the article seems to allude to.

How is a patient with limited mobility after an orthopedic procedure not considered an elevated risk for a PE? Was a d-dimer run?

I agree that the solution can't be to CTA everyone, but I'm failing to understand the logical thought progression of this physician in this case, at least based on the information provided in this article. Even if he missed the PE, which can certainly happen for many people, I just don't understand how he ended up at a diagnosis of pleurisy.

If people really want to go through a new discussion of this case, I'd suggest at least first reading through the original discussion from 9 yrs ago.

What do you think of this "expert" testimony?

Ever heard of Peter Rosen? I bet you have. Take a gander at this really excellent article by the very smart and apparently multi-talented Emergency Physician, Dr William Sullivan, DO, JD: "...15 year old patient " "...classic case of pulmonary embolism..." “...did nothing to prove or...

forums.studentdoctor.net

 

[Rekt]

I read through the limited amount of information provided in the PDF. Perhaps a few things could be cleared up for me:

What exactly is a diagnosis of pleurisy? Is he alluding to an infection, inflammatory condition, autoimmune? If anything, that seems to me more of a diagnosis of exclusion.

What was the differential diagnosis in this scenario?

How does the fact that the administering of toradol relieving the chest pain rule out a PE? I've never heard of this, I'm not sure if that was the actual logic of the physician but that's what the article seems to allude to.

How is a patient with limited mobility after an orthopedic procedure not considered an elevated risk for a PE? Was a d-dimer run?

I agree that the solution can't be to CTA everyone, but I'm failing to understand the logical thought progression of this physician in this case, at least based on the information provided in this article. Even if he missed the PE, which can certainly happen for many people, I just don't understand how he ended up at a diagnosis of pleurisy.

I tell someone “might be pleurisy” several times a shift, but will never know the true etiology. That’s not how the ED works. We risk stratify only and discharge. The ER is not a diagnostic center.

 

[JacobMcCandles]

To me, a pleurisy diagnosis means we don’t know but the physician has decided not to tell the patient “I don’t know” so they just tell them it’s pleurisy.

 

[WilcoWorld]

To me, a pleurisy diagnosis means we don’t know but the physician has decided not to tell the patient “I don’t know” so they just tell them it’s pleurisy.

I have never made the diagnosis of pleurisy.

 

[icyfire111]

I tell someone “might be pleurisy” several times a shift, but will never know the true etiology. That’s not how the ED works. We risk stratify only and discharge. The ER is not a diagnostic center.

I think it would be better to just tell the patient you don't know what the diagnosis is as opposed to just throwing some diagnosis out there, therefore they're on heightened alert to return to the ER or seek other medical attention if symptoms persist. I've never diagnosed anyone with pleurisy, in fact I wasn't even aware that's a medical term still in use. Plus, the fact that he called it pleurisy makes it sound even worse because "pleurtic" chest pain is the classic symptom of a PE. He would have done better to have just said I don't know what it is, see your PCP tomorrow and ask him to figure it out.

 

[skougess]

I have alluded to the fact that pleural inflammation is one possible etiology of pain if they are are in the midst of a URI. But I agree that I’ve never directly diagnosed “pleurisy”.

 

[Rekt]

I think it would be better to just tell the patient you don't know what the diagnosis is as opposed to just throwing some diagnosis out there, therefore they're on heightened alert to return to the ER or seek other medical attention if symptoms persist. I've never diagnosed anyone with pleurisy, in fact I wasn't even aware that's a medical term still in use. Plus, the fact that he called it pleurisy makes it sound even worse because "pleurtic" chest pain is the classic symptom of a PE. He would have done better to have just said I don't know what it is, see your PCP tomorrow and ask him to figure it out.

There’s a stark difference of conversing with a patient stating it might be pleurisy or costochondritis or gastritis, whatever you want, and them still leaving with a medical and paperwork diagnosis of “atypical chest pain” vs actually diagnosing them with xyz. I also have never “diagnosed” pleurisy.

 

[Arcan57]

I think the real issue here is that physicians don’t like seeing fellow physicians testify against them, especially when it’s one of the founders of the specialty. That cuts deep.
I remember the uproar around this case from years ago and I was on the “F” Rosen side, until I saw the actual case details. It’s a big miss, right?

15 yo patient. Normal vital signs. Peds ICUs at the time weren't even prophylactically heparinizing 18 yrs laying comatose in bed for months and d-dimers in the pediatric population were mostly ordered as part of a DIC workup. We were kinda convinced that CT scanning kids was going to result in 100,000s of iatrogenic cancers.

Was it a miss? Sure. Was it negligent? I think in 2023, probably. In 2007, probably not. Was it ever grossly negligent? No.

I find it's super useful to look at old medmal to learn about atypical presentations and gain some insight into the ways we make mistakes as doctors and humans. I find it's a lot less useful to judge the docs involved since it's almost impossible to ignore training and information that we have post-event. How many EM docs first exposure to a young healthy teen dying of a post-op PE despite normal vitals was through this story? We still don't routinely give prophylactic anticoagulation to teenagers post-op and that's in a population where serious complications from prophylactic dose heparin would be lower than any other age group.

 

[icyfire111]

15 yo patient. Normal vital signs. Peds ICUs at the time weren't even prophylactically heparinizing 18 yrs laying comatose in bed for months and d-dimers in the pediatric population were mostly ordered as part of a DIC workup. We were kinda convinced that CT scanning kids was going to result in 100,000s of iatrogenic cancers.

Was it a miss? Sure. Was it negligent? I think in 2023, probably. In 2007, probably not. Was it ever grossly negligent? No.

I find it's super useful to look at old medmal to learn about atypical presentations and gain some insight into the ways we make mistakes as doctors and humans. I find it's a lot less useful to judge the docs involved since it's almost impossible to ignore training and information that we have post-event. How many EM docs first exposure to a young healthy teen dying of a post-op PE despite normal vitals was through this story? We still don't routinely give prophylactic anticoagulation to teenagers post-op and that's in a population where serious complications from prophylactic dose heparin would be lower than any other age group.

Agreed that this is a very atypical presentation and in fact, not even faulting him for necessarily missing the diagnosis of PE, it could happen to anyone. It's just more of a criticism of the diagnosis of pleurisy which I think is inadequate, maybe even a bit lazy you could say. But I agree, these are great teaching cases, in fact, I think prior medmal cases should be thoroughly reviewed in residency programs.

 

[RuralEDDoc]

In 2007, although seemingly a million years ago, we still considered PE in patients in chest pain one week after ortho surgery/leg immobilization.
I don’t see why this diagnosis keeps coming up as one in a million. It seems, IDK, fairly straightforward and not zebra like in any way. Yes I have the retrospectoscope. But still, why say this is super unexpected or incredibly rare when it’s not?

 

[Arcan57]

In 2007, although seemingly a million years ago, we still considered PE in patients in chest pain one week after ortho surgery/leg immobilization.
I don’t see why this diagnosis keeps coming up as one in a million. It seems, IDK, fairly straightforward and not zebra like in any way. Yes I have the retrospectoscope. But still, why say this is super unexpected or incredibly rare when it’s not?

15 yr old. That’s what makes this different from run of the mill “think about PE in post op patients with chest pain” . Incidence seems to be about 4/1000 in adolescents for symptomatic VTE after arthroscopy and that’s from a study published a decade after this case that acknowledges there haven’t been good prior studies on the topic. In this study, all the teens that developed VTE had identifiable risk factors. If a rare enough disease that good studies don’t exist on it despite the operation being a common one for adolescents to undergo and what would eventually be estimated as a 0.25% incidence of LE VTE post op (none of them had PEs) that eventually lead to a sudden fatal PE qualifies as a straightforward obvious diagnosis to you, I feel confident that we have very different levels of risk tolerance.

 

[Mount Asclepius]

Adolescent PEs are an uncommon occurrence. Pleuritic chest pain post-op makes you only think of one diagnosis though.

However, this case is so old and previously discussed, I don’t think it warrants a lot more new discussion.

If the CTA is negative for PE, and it hurts with inspiration there is only a few things it can be. Pleurisy is one of them. I tell people fairly frequently that it’s a possibility for why it hurts when they breathe. I don’t put it as a formal diagnosis, just like I don’t put costochondritis as a formal diagnosis. Lining of the lungs could certainly be inflamed. You can’t sit on the witness stand without any evidence and defend yourself unfortunately as people only care about tests not our expert opinions. Leave it vague. Acute chest pain. Pleurisy isn’t really any different than costochronditiris though in terms of actually being able to prove it. It’s also probably not some rare thing.

 

[Brigade4Radiant]

Yeah I really don’t fear scanning mid teens most of them are adult size anyway.

 

[Birdstrike]

If people really want to go through a new discussion of this case, I'd suggest at least first reading through the original discussion from 9 yrs ago.

What do you think of this "expert" testimony?

Ever heard of Peter Rosen? I bet you have. Take a gander at this really excellent article by the very smart and apparently multi-talented Emergency Physician, Dr William Sullivan, DO, JD: "...15 year old patient " "...classic case of pulmonary embolism..." “...did nothing to prove or...

forums.studentdoctor.net

Agree. Probably should lock this thread, or at least merge it with the original.

 

[Rendar5]

15 yr old. That’s what makes this different from run of the mill “think about PE in post op patients with chest pain” . Incidence seems to be about 4/1000 in adolescents for symptomatic VTE after arthroscopy and that’s from a study published a decade after this case that acknowledges there haven’t been good prior studies on the topic. In this study, all the teens that developed VTE had identifiable risk factors. If a rare enough disease that good studies don’t exist on it despite the operation being a common one for adolescents to undergo and what would eventually be estimated as a 0.25% incidence of LE VTE post op (none of them had PEs) that eventually lead to a sudden fatal PE qualifies as a straightforward obvious diagnosis to you, I feel confident that we have very different levels of risk tolerance.

If I’m reading this correctly, it sounds like you’re talking general disease incident type statistics which may be the wrong statistic to apply here. For an orthopedist, a 0.25% occurrence rate of VTE disease postop is important because it tells you whether or not you need to prophylactically treat.

For an EM doc we don’t have that percentage because we don’t deal with all postop patients. We deal with patients having symptoms. This automatically alters the odds by eliminating a huge portion of the denominator of those who never develop symptoms going to the ED. By virtue of the patient having symptoms and coming to the emergency department, the odds are much different (can’t say how different. Just different)

Take 1000 post op patients. 4 of them develop VTE disease. Those are what the orthopedist sees. Remove 950 patients who don’t develop symptoms of VTE disease. Say this includes 2 patients with VTE disease who didnt develop objective symptoms. Now you’re left with 2 patients with actual VTE out of 50 patients with symptoms concerning for it. Odds for the orthopedists on routine follow up is 0.25% still. Odds for the ED doc who only sees symptomatic patients is 4%. These are not actual numbers. These are made up numbers to show how the odds for us cannot necessarily be drawn from the general population odds.

 

[Apollyon]

Yeah I really don’t fear scanning mid teens most of them are adult size anyway.

Working on the ambulance 30 years ago now (seriously, WTF?), we had a 12 year old kid hit by a car. We took him to the trauma center, where they complained about that, and why we didn't take him to the children's hospital. The "kid" weighed 250lbs and was 6ft tall! (He was the length of the stretcher.) I was 160lbs at the time.

 

[Arcan57]

If I’m reading this correctly, it sounds like you’re talking general disease incident type statistics which may be the wrong statistic to apply here. For an orthopedist, a 0.25% occurrence rate of VTE disease postop is important because it tells you whether or not you need to prophylactically treat.

For an EM doc we don’t have that percentage because we don’t deal with all postop patients. We deal with patients having symptoms. This automatically alters the odds by eliminating a huge portion of the denominator of those who never develop symptoms going to the ED. By virtue of the patient having symptoms and coming to the emergency department, the odds are much different (can’t say how different. Just different)

Take 1000 post op patients. 4 of them develop VTE disease. Those are what the orthopedist sees. Remove 950 patients who don’t develop symptoms of VTE disease. Say this includes 2 patients with VTE disease who didnt develop objective symptoms. Now you’re left with 2 patients with actual VTE out of 50 patients with symptoms concerning for it. Odds for the orthopedists on routine follow up is 0.25% still. Odds for the ED doc who only sees symptomatic patients is 4%. These are not actual numbers. These are made up numbers to show how the odds for us cannot necessarily be drawn from the general population odds.

My point was that the disease that the prior poster was postulating was a straightforward diagnosis was so rare that it would be over a decade after the index case before we had a study that came close to addressing the question of how rare it actually was. My argument was not intended to be taken as providing rigorous statistical proof of the chance an adolescent pt in the ED has a post knee arthroscopy PE when presenting with chest pain. Your point that we care about the chance a symptom means a disease far more than the incidence of the disease in the population is spot on.

I provided the incidence to give a feel for how often VTE (in this case non-PE VTE) happens. I couldn’t and remain unable to find data on incidence of all cause post op pleurisy in adolescents undergoing knee surgery (that present to the ED if you wanted to make the study completely impossible to perform) which would be the relevant denominator in to the ED doc.

I think the conversation in this thread does bring up the fact that we as a specialty still grapple with significant heterogeneity in good faith estimates of how difficult a given disease is to diagnose in the ED. And that often what we base that estimate on isn’t empirically derived.