Internist Bashes EM doc on Huff Post

[ShockIndex]

I'm with you here, except that you accept the report of loosing a pint of blood every hour for several hours. Of course, if someone is loosing their entire blood volume in under 10 hours, IV fluids and watchful waiting are insufficient. But the outcome described in the piece seems incongruous with this. It looks like he got transfused one unit and was discharged the next day. If that's the case, then I don't believe he was actually bleeding as briskly as he thought he was.

Stated otherwise: I completely agree that we should not wait for someone with ongoing massive hemorrhage to fully decompensate before we take action. I think the author of this piece did not actually have ongoing massive hemorrhage.

There are 3 aspects to this article that make me think he may be full of crap.

1) Timeline. You touched on this. The guy bleeds on Friday evening, hemostasis achieved in the early hours of Saturday morning, and is discharged on Sunday. This is not the hospital LOS of someone who sustained complications such as worsening post-op MI, CHF, AKI, testicular atrophy, etc. from hemorrhaging shock. I suspect that these problems either pre-existed the bleeding event or developed months afterward. Regardless, it seems like he is overplaying the disability angle. More on that in point 3 below…

2) He directs most of his ire at the EP, but his outcome was driven by the GI and hospitalist’s alleged inactions. The EP was mostly guilty of a bad interpersonal interaction and I’m not ruling out a lot of shared responsibility. This is pretty classic - an IM trained guy wants to sue the EP but not his fellow internists with whom he hob-knobs in the lounge even though they were knee deep in the decision making.

3) Finally, the guy supposedly enjoys lecturing about his childhood PTSD according to the bio at the bottom of the article. That, coupled with this article being published in HuffPo, tells me a lot about the fragility and perpetual need for ego stroking of this individual. See point 1 above…

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[skougess]

The whole story is self-reported and there are a lot of reasons to believe that this author is full of crap.

Having said that, I’m deconstructing this case into the basics of a guy comes in to the ED reporting BRBPR, and then proceeds to pass multiple episodes of BRBPR in front of my staff every hour or 2 with each episode being “a couple of pints.” In that circumstance, my response is not to start some IVF, check serial hemoglobins, and admit to the hospitalist. That kind of thinking at 6PM results in things like 1AM colonoscopies or visits to IR which is what reportedly happened here…if we believe the author.

I suppose my larger point is that some patients surprise us by looking pretty good from a vitals perspective but then go on to bleed at a fair clip. Putting these patients with unrelenting bright red blood loss from any orifice on the floor at night with a hospitalist is risky at most hospitals. They generally warrant an ICU admission if not a more expedited interrogation of the blood loss. The floor is where you put people with reasonable certainty of hemostasis.

Again, I don’t fault the EP. We all get surprised by these patients. It’s the GI who made the call to put this guy on the floor with ongoing BRBPR.

I mean on the flip side, where exactly the patient gets admitted (ICU vs floor) is frequently based on hospital-specific culture. My role as an EM physician is to make sure a patient who needs to be admitted gets admitted SOMEWHERE. Barring obvious ICU criteria (intubated, shock, etc), most of the time I couldn’t care less which level of care. If I’ve called the GI doc about this GI bleed and the patient is stable, I don’t really have skin in the game which of the hospitalist vs the intensivist wants the patient less. As long as they don’t go home, either can take them.

 

[thegenius]

I mean on the flip side, where exactly the patient gets admitted (ICU vs floor) is frequently based on hospital-specific culture. My role as an EM physician is to make sure a patient who needs to be admitted gets admitted SOMEWHERE. Barring obvious ICU criteria (intubated, shock, etc), most of the time I couldn’t care less which level of care. If I’ve called the GI doc about this GI bleed and the patient is stable, I don’t really have skin in the game which of the hospitalist vs the intensivist wants the patient less. As long as they don’t go home, either can take them.

It's true I'm surprised at the number of things admitted to the ICU at our community hospital. Lots of relatively easy stuff or straightforword that doesn't seemingly require services of a critical care doc.

 

[JacobMcCandles]

It's true I'm surprised at the number of things admitted to the ICU at our community hospital. Lots of relatively easy stuff or straightforword that doesn't seemingly require services of a critical care doc.

It seems like outside of the obvious intubated patient the main criteria for ICU admission is the PITA factor from a nursing standpoint.

 

[alphaholic06]

It seems like outside of the obvious intubated patient the main criteria for ICU admission is the PITA factor from a nursing standpoint.

This!

 

[CoolDoc1729]

It seems like outside of the obvious intubated patient the main criteria for ICU admission is the PITA factor from a nursing standpoint.

Even on our step down unit the nurses are 6-7:1 sometimes now. It’s not quite nursing PITA so much as .. if this patients nurse has five other patients, are they likely to have a bad outcome due to inadequate attention? The other day I had a guy with a submandibular phlegmon “possible developing Ludwig angina” per rads, and also a sugar over 700 but no acidosis .. the resident says is that all for icu? I said. Do you think that patient should be on a nursing team with 5 other patients ? She backed off really quick.
If they’re truly just PITA a sitter should do the trick

 

[JacobMcCandles]

Even on our step down unit the nurses are 6-7:1 sometimes now. It’s not quite nursing PITA so much as .. if this patients nurse has five other patients, are they likely to have a bad outcome due to inadequate attention? The other day I had a guy with a submandibular phlegmon “possible developing Ludwig angina” per rads, and also a sugar over 700 but no acidosis .. the resident says is that all for icu? I said. Do you think that patient should be on a nursing team with 5 other patients ? She backed off really quick.
If they’re truly just PITA a sitter should do the trick

Except a sitter can’t give meds and do many other nursing tasks. Unit placement based on nursing ratios is bad for everyone. I feel bad for the people who get ICU beds who don’t truly get ICU care but still get an ICU level bill.

 

[CoolDoc1729]

Except a sitter can’t give meds and do many other nursing tasks. Unit placement based on nursing ratios is bad for everyone. I feel bad for the people who get ICU beds who don’t truly get ICU care but still get an ICU level bill.

Well, right. If they need high level nursing care they go to icu. If they are just agitated and need constant redirection a sitter should be fine. There’s definitely both under the umbrella of “PITA” lol. I definitely care more about safety than about the eventual bill, and I can’t do anything about the nursing staffing ratios.

 

[DocEspana]

Pro tip: if you really want to get the physician's attention, splatter a copious bloody diarrhea onto the floor in your room. This will accentuate the volume and get you an admission right away.

 

[DocEspana]

It’s crazy how all day he lost a couple pints of blood twice an hour and he is still alive. Dr woods is a hero! /s

Very active bone marrow. Its a genetic blessing.

 

[GassYous]

Even on our step down unit the nurses are 6-7:1 sometimes now. It’s not quite nursing PITA so much as .. if this patients nurse has five other patients, are they likely to have a bad outcome due to inadequate attention? The other day I had a guy with a submandibular phlegmon “possible developing Ludwig angina” per rads, and also a sugar over 700 but no acidosis .. the resident says is that all for icu? I said. Do you think that patient should be on a nursing team with 5 other patients ? She backed off really quick.
If they’re truly just PITA a sitter should do the trick

Is that a joke? Ludwig angina can lead to a lost airway so fast. The only time I lost an airway and patient needed a trach was a ludwig angina patient.

 

[CoolDoc1729]

Is that a joke? Ludwig angina can lead to a lost airway so fast. The only time I lost an airway and patient needed a trach was a ludwig angina patient.

It was odd to have to justify that going to the unit, yes

 

[polishdoc]

What do y'all think of this article? I hate to see doctors publicly bashing other doctors, especially in the press.

I'm A Doctor Who Almost Died Because My Own Doctors Refused To Do This 1 Basic Thing

My take:
-pt is likely annoying and difficult, which didn't help his situation
-EM doc likely had poor bedside manner, albeit maybe not as bad as pt says (one sided story)
-EM doc actually did the right thing and got the GI doc to see him in person in the ED
-GI doc didn't take him to the colo suite, and pt was OK with this?!
-pt is psych-splitting, hates the EM doc even though GI doc made the wrong choice
-likely there's more missing to the story --> pt tried to sue with 6 rejections from malpractice attorneys

Do you think if you're life threateningly hypovolemic with an underlying physiologic tachycardic response, would the beta blocker reduce your HR to 60? I don't.

Don't get a retiring GI doc to do your procedure on the day of his retirement!!

This is Lawrence Mieczkowski MD, the annoying, arrogant, stupid, doctor shopping, poorly trained, inexperienced with hemorrhagic shock (med school ER rotation in a Level 1 trauma center, residency at inner city Level 1 trauma center, ten years of hospitalist work), never was PCP (Did primary care and specialty work all of my career), pleading for IVF (wrong!), unable to estimate blood loss accurately (standard bedpan holds 1000 cc and my bright red and clotted blood filled up over half of the bedpan on the bedside commode), dumb**** (really!), doctor most of you have blasted and criticized anonymously. So brave of you to hide behind a platform where you don't have to reveal your real name. WOW! I somehow came across this forum and read everyone's comments. Hard to understand also how one of you was upset over the outpouring of support on Doximity. Have to wonder how many of you treat a 15 y/o female was raped!) Since you all had full access to my name and my training, I am very willing to engage with every one of you through Doximity where I can find out where you practice and what your training is. I welcome the opportunity to interact directly with you by phone as well.

I wrote my article after reading an editorial on Misdiagnosis in the Emergency Department published in Jama on February 28. His editorial was in response to the release of a 744-page document released by The Agency for Healthcare Research and Quality in December 2022 by the Johns Hopkins University Evidence-Based Practice Center. Take a look at. 130 million ER visits, 7.5 million errors, 2.5 million harms, and 350,000 patients suffering potentially permanent disability and death (like me and many others who shared their encounters in the ER on HuffPost and Doximity). The response to my article obviously resonated across the US and the UK since it had over 1.5 million views.

I will not respond on this forum for the above reasons, so don't waste your time writing a reply here. Final note, take a look at the bleeding arteriole responsible for my losing 7 units of blood, from 14 down to 7.

 

[polishdoc]

This is Lawrence Mieczkowski MD, the annoying, arrogant, stupid, doctor shopping, poorly trained, inexperienced with hemorrhagic shock (med school ER rotation in a Level 1 trauma center, residency at inner city Level 1 trauma center, ten years of hospitalist work), never was PCP (Did primary care and specialty work all of my career), pleading for IVF (wrong!), unable to estimate blood loss accurately (standard bedpan holds 1000 cc and my bright red and clotted blood filled up over half of the bedpan on the bedside commode), dumb**** (really!), doctor most of you have blasted and criticized anonymously. So brave of you to hide behind a platform where you don't have to reveal your real name. WOW! I somehow came across this forum and read everyone's comments. Hard to understand also how one of you was upset over the outpouring of support on Doximity. Have to wonder how many of you treat a 15 y/o female was raped!) Since you all had full access to my name and my training, I am very willing to engage with every one of you through Doximity where I can find out where you practice and what your training is. I welcome the opportunity to interact directly with you by phone as well.

I wrote my article after reading an editorial on Misdiagnosis in the Emergency Department published in Jama on February 28. His editorial was in response to the release of a 744-page document released by The Agency for Healthcare Research and Quality in December 2022 by the Johns Hopkins University Evidence-Based Practice Center. Take a look at. 130 million ER visits, 7.5 million errors, 2.5 million harms, and 350,000 patients suffering potentially permanent disability and death (like me and many others who shared their encounters in the ER on HuffPost and Doximity). The response to my article obviously resonated across the US and the UK since it had over 1.5 million views.

I will not respond on this forum for the above reasons, so don't waste your time writing a reply here. Final note, take a look at the bleeding arteriole responsible for my losing 7 units of blood, from 14 down to 7.

PS. I was diagnosed with HFpEF, heart failure with preserved ejection fraction. Read up on it. No IM or FP physician will diagnose this as it requires simultaneous left and right heart caths.

 

[WilcoWorld]

I will not respond on this forum for the above reasons, so don't waste your time writing a reply here.

Noted

 

[skougess]

Noted

Wouldn’t even know where to begin. *shrug*

Seems like the six malpractice attorneys that turned him down did all my arguing for me anyway.

 

[GassYous]

I'm not sure I want to engage on doximity with a guy who posts a picture of his bleeding butthole

 

[BoardingDoc]

PS. I was diagnosed with HFpEF, heart failure with preserved ejection fraction. Read up on it. No IM or FP physician will diagnose this as it requires simultaneous left and right heart caths.

Umm, no it doesn't. HFpEF doesn't need a cath of any kind to diagnose in most cases, and simply needs an echo and labs. In cases of diagnostic ambiguity, a RHC can be obtained to measure PCWP. There is no indication to perform a LHC simply to diagnose HFpEF.

I do appreciate you coming here to write this though. Strong assertions like this one, where you are simultaneously confident and incorrect, help provide further context to your article.

 

[WilcoWorld]

Umm, no it doesn't. HFpEF doesn't need a cath of any kind to diagnose in most cases, and simply needs an echo and labs. In cases of diagnostic ambiguity, a RHC can be obtained to measure PCWP. There is no indication to perform a LHC simply to diagnose HFpEF.

I do appreciate you coming here to write this though. Strong assertions like this one, where you are simultaneously confident and incorrect, help provide further context to your article.

Makes me wonder how you treat YOUR patients, "doctor".

 

[skougess]

Just re-read the article. Just wild that this guy received perfect standard of care and still complained so much. Admission for a clinically significant GI bleed. Urgent scope to emergent scope when it showed itself as more serious.

I wonder if this story would have even been written if Doc M had just taken up his doctors on the benzo that was offered to him for anxiety during his admission. He clearly had/has a lot.

 

[WilcoWorld]

Not to be preachy, but I would encourage us to treat Lawrence Mieczkowski like a patient, not a colleague, because that's what he is here. He's not here to express professionally considered concern. This is a display of emotion.

Colleagues - I'll engage with vigorous discussion, patients get pity and compassion. I'm sorry that he experienced a complication from his colonoscopy - sounds like it was very frightening for him. I'm glad there were doctors and nurses working that night who could save his life.

 

[VA Hopeful Dr]

Not to be preachy, but I would encourage us to treat Lawrence Mieczkowski like a patient, not a colleague, because that's what he is here. He's not here to express professionally considered concern. This is a display of emotion.

Colleagues - I'll engage with vigorous discussion, patients get pity and compassion. I'm sorry that he experienced a complication from his colonoscopy - sounds like it was very frightening for him. I'm glad there were doctors and nurses working that night who could save his life.

When patients come here to complain about their medical care we usually ban them...

 

[WilcoWorld]

When patients come here to complain about their medical care we usually ban them...

The original article was essentially HuffPo publishing a patient complaint.

 

[Beeftenderloin]

This is Lawrence Mieczkowski MD, the annoying, arrogant, stupid, doctor shopping, poorly trained, inexperienced with hemorrhagic shock (med school ER rotation in a Level 1 trauma center, residency at inner city Level 1 trauma center, ten years of hospitalist work), never was PCP (Did primary care and specialty work all of my career), pleading for IVF (wrong!), unable to estimate blood loss accurately (standard bedpan holds 1000 cc and my bright red and clotted blood filled up over half of the bedpan on the bedside commode), dumb**** (really!), doctor most of you have blasted and criticized anonymously. So brave of you to hide behind a platform where you don't have to reveal your real name. WOW! I somehow came across this forum and read everyone's comments. Hard to understand also how one of you was upset over the outpouring of support on Doximity. Have to wonder how many of you treat a 15 y/o female was raped!) Since you all had full access to my name and my training, I am very willing to engage with every one of you through Doximity where I can find out where you practice and what your training is. I welcome the opportunity to interact directly with you by phone as well.

I wrote my article after reading an editorial on Misdiagnosis in the Emergency Department published in Jama on February 28. His editorial was in response to the release of a 744-page document released by The Agency for Healthcare Research and Quality in December 2022 by the Johns Hopkins University Evidence-Based Practice Center. Take a look at. 130 million ER visits, 7.5 million errors, 2.5 million harms, and 350,000 patients suffering potentially permanent disability and death (like me and many others who shared their encounters in the ER on HuffPost and Doximity). The response to my article obviously resonated across the US and the UK since it had over 1.5 million views.

I will not respond on this forum for the above reasons, so don't waste your time writing a reply here. Final note, take a look at the bleeding arteriole responsible for my losing 7 units of blood, from 14 down to 7.

I’m quite sure virtually every emerge doc on this forum has cared for more rape victims than you, many of them probably before they even finished training. Real weird flex.

And did you seriously just cite a 1 month EM rotation at a trauma center as med student as some kind of evidence of expertise in hemorrhagic shock management?

PS. I was diagnosed with HFpEF, heart failure with preserved ejection fraction. Read up on it. No IM or FP physician will diagnose this as it requires simultaneous left and right heart caths.

This isn’t even remotely accurate. The ONLY thing you need is an echo with diastology. I won’t fault you for knowing nothing about hemorrhagic shock as an internist, but heart failure? Come on, thats literally bread and butter IM.

 

[Brigade4Radiant]

Not to be preachy, but I would encourage us to treat Lawrence Mieczkowski like a patient, not a colleague, because that's what he is here. He's not here to express professionally considered concern. This is a display of emotion.

Colleagues - I'll engage with vigorous discussion, patients get pity and compassion. I'm sorry that he experienced a complication from his colonoscopy - sounds like it was very frightening for him. I'm glad there were doctors and nurses working that night who could save his life.

A person can be treated like a patient if there is a doctor patient relationship if not I think it’s a little misguided to treat non patients as patients

Also he needs to be corrected on his wrong takes on medicine since often times lawsuits result when other doctors throw someone under the bus

 

[Kryptocoin]

So brave of you to hide behind a platform where you don't have to reveal your real name. WOW! I somehow came across this forum and read everyone's comments. Hard to understand also how one of you was upset over the outpouring of support on Doximity. Have to wonder how many of you treat a 15 y/o female was raped!)

I bet very few, if any, those doctors on Doximity that gave you "outpouring support" were actually board certified EM physicians. We are experts in resuscitation and WE are telling you that you're in over your head.

We sound harsh because you were lawsuit shopping for something that absolutely did not meet any standard of gross negligence .

 

[Gastrapathy]

What a tool. You have to be really unappealing for a malpractice attorney to turn you down without even sending a demand letter and he went 0/6.

He had a post-polypectomy hemorrhage. This is managed like any other LGIB except we know the source (unless there are multiple polyps removed like in this case) and if the polyp was distal, we can sometimes get away without a prep. He was stable at presentation and demanded transfusions and a stat GI consult before he even had labs back. I'm not sure which is worse (ok its the transfusion since we're just useless and the blood is harmful). In the rarest of cases where the patient is unstable with brisk ongoing bleeding, the next step should be a GI bleed protocol CT-Angio and, if positive, trans-arterial embolization.

For this guy and nearly everyone else, he needs to be parked somewhere, floor or step-down depending on your institution, transfused a little as needed and prepped for a scope. Once he's done, he can have a colonoscopy and you'll all be shocked to discover that this will happen in the morning everywhere except UCLA or when you have a VIP patient like this.

His advice to patients is terrible too. It's like a parody of choosing wisely only you write the exact opposite of the right thing to do. Pay for your own ultrasound, see midlevels, **** on hospital doctors, etc. He says not to yell at the doctor or that might get you labeled as difficult. That feels suspiciously like a confession that he yelled and was so labeled but I'm pretty sure I would have found him difficult regardless of his volume.

 

[DocEspana]

I just accidentally downloaded a colonic photoshoot. This is not an auspicious day for me.

 

[VA Hopeful Dr]

I just accidentally downloaded a colonic photoshoot. This is not an auspicious day for me.

Yeah, "accidentally"...

 

[DocEspana]

Yeah, "accidentally"...

I was hoping it would be the bucket of blood clots we were all promised

 

[JacobMcCandles]

You lost me when you used a one-month ER rotation as part of your credentials.

I truly am sorry that you have had medical issues after this incident but I don't believe it is as cut and dry as you make it out to be with regards to causation. We all know that there are always two sides to this story and I don't really see any concern for negligence or gross malpractice and that is from your side of the events. Having spoken to and been turned down by 6 malpractice attorneys is definitely a red flag that things likely aren't quite what they seem.

PS: The 15-year-old rape comment doesn't make sense and seemed to come out of left field. I'm not sure what that has to do with anything.

PPS: I'm not sure how you didn't think you'd receive criticism after putting this piece in the Huff Post.

 

[hoot504]

PS. I was diagnosed with HFpEF, heart failure with preserved ejection fraction. Read up on it. No IM or FP physician will diagnose this as it requires simultaneous left and right heart caths.

Yeah we're all well versed in this. No need to 'read up on it'.

There are so many subtle and not-so-subtle errors in not only your article but your two posts here that I find it really hard to believe you ever seriously practiced hospital medicine. If you did, it must have been a long time ago, and I'm afraid for your patients.

 

[WilcoWorld]

A person can be treated like a patient if there is a doctor patient relationship if not I think it’s a little misguided to treat non patients as patients

Also he needs to be corrected on his wrong takes on medicine since often times lawsuits result when other doctors throw someone under the bus

Fair points. I do not dispute them.

 

[AlvinKamara]

I feel bad for this guy. Clearly a lot of complex issues. Hope he feels better soon.

 

[Kryptocoin]

I feel bad for this guy. Clearly a lot of complex issues. Hope he feels better soon.

First step: See a therapist. He's clearly displaying some narcissistic traits or at the very least, some high level of entitlement.

Second step: Take some CME.

 

[southerndoc]

I think he has said enough to justify the ED doc suing for libel. If I knew the ED doc, I would certainly send it to him/her with encouragement to sue.

 

[thegenius]

I feel bad for this guy. Clearly a lot of complex issues. Hope he feels better soon.

I agree I really want to respond but everyone else is saying what I want to say. The vast majority of his ire should be directed at the GI doc. I suppose there might have been a delay in screening him for blood based on his account, but there isn’t much anyone can do besides the GI doc.

It’s seems like he’s practicing medicine like it was done 30 years ago. Simultaneous left and right sided heart caths? You kidding me?

Poor guy I feel bad for his patients.

 

[greatnt249]

PS. I was diagnosed with HFpEF, heart failure with preserved ejection fraction. Read up on it. No IM or FP physician will diagnose this as it requires simultaneous left and right heart caths.

No, it doesn't.

 

[JacobMcCandles]

No, it doesn't.

It’s like the simultaneous EGD and colonoscopy. I believe it’s called a skewer.

 

[greatnt249]

It’s like the simultaneous EGD and colonoscopy. I believe it’s called a skewer.

I mean, simultaneous right/left heart catheterization is a thing, I just don't need it to diagnose generic HFpEF. In fact, the only thing I would use it for would be to assess for constrictive pericarditis, but I would have thought he would have mentioned that part.

 

[Brigade4Radiant]

The thing about EM is that you can't be very weak in your medicine knowledge in places around the city. Only in very rural areas can you get away with being out to date. EM is so second guessed that we have to know our stuff. At my old place where we called some primary care doctors they wanted me to give blood to patient's with a hemoglobin of 10.

 

[RustedFox]

The thing about EM is that you can't be very weak in your medicine knowledge in places around the city. Only in very rural areas can you get away with being out to date. EM is so second guessed that we have to know our stuff. At my old place where we called some primary care doctors they wanted me to give blood to patient's with a hemoglobin of 10.

Same here.
"Why haven't you transfused him?!"
Because you're practicing in 1987.

 

[Birdstrike]

Everyone here, is doing something great.

 

[allantois]

Clearly the underlying issue is dementia

 

[thegenius]

Clearly the underlying issue is dementia

Remember he got it from the bloodloss! And his cardiomyopathy too. Somehow anemia causes HFpEF. And dementia. LOL Remember it can't cause systolic dysfunction, ONLY DIASTOLIC dysfunction.

This doc is practicing medicine in the 1980s. He really is.