Is gastroenteritis that difficult to diagnose clinically....or does EVERYONE need a CT abd/pel?

[chudat]

seriously, as a rad, it's killing me. The list is evergrowing and having to read these essentially negative ct abd/pel on call kills me. Or am I just being dramatic and needs to STFU and just do my job?

or dont get me started on these CTA chest/CT abd/pel combos that gets ordered. Sweet baby jesus.

For the love of god, stop ordering so many exams.

Inshallah

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[3rdJob]

I hear you, Dr. . In my shop, one of the metrics we track is 'number of CT's' ordered for the individual Doc/MLP. Tends to be (very roughly) inversely correlated with years of experience. For me, if the story is good for gastro, and the exam is unexciting, I don't get a CT. If they're old, all bets are off because of the increasing chances of badness in grandma/grandpa.
Doesn't the radiation kill the bugs? So these CTs may be therapeutic .

 

[DeadCactus]

I don't know the specifics of the practice you're seeing, or even if it's actually emergency physicians ordering the studies, but my experience is my radiology colleagues vastly overestimate the percentage of patients I order scans on and have a USMLE level understanding of clinical diagnosis that has not been tempered by years and years of patients proving they couldn't care less what the textbook says about how a disease presents. At the end of the day, I don't care if patient care is inconvenient to the radiologist, surgeon, specialist, hospitalist, RT, or any other of the many highly opinionated colleagues who love tapping on the fishbowl glass.

 

[DoctorJDO]

meh. like you already said, just do your job. Sometimes I think some other generic specialty is full of idiots also. then I remember we all went to the same school, and you probably got the same USMLE and rotation scores I got. I'm not an idiot, and neither are you. We just practice in different environments which ultimately leads us to behave in a certain way. let's say I see a patient. Here's many reasons I order CT scans even though I don't REALLY think they need it.

1. patient wants a CT scan and we work at patient-complaint satisfaction score memorial hospital - here you go. CT scanner go brrr. you have GE, bye.
2. nurse documents 10/10 pain. patient has hx gastric bypass or some SBO in the past. writes in the chart "patient says I feel like I'm going to die". If anything ever went wrong, where do I sign the check. Do you really think some lawyer is gonna read your note that says "seems like GE" and let you off the hook?
3. Patient needs some CT of some sort in the ED, oh and btw my doc ordered a different type of CT like my abdomen as outpatient. can we just do that at the same time? CT go brrr for 15 more seconds, here you go.
4. we work in a soft department and this patient will most likely come back because they're soft too and 6 hours later "I'm not better I'm in severe pain", we're taught to take bounce-back patients seriously, high risk, etc. next doc will order it, and I will get patient complaint for missing their "colitis" that doc #2 gave abx to even though they didn't need it.
5. patient is old and terrible historian and unreliable exam and high risk for badness and no matter how good of a clinician you are, they are providing you with unreliable history and exam
6. we've seen some ****. can't tell you how many patients we've all seen with CC of "things taste weird" = massive SAH, "the inside of my abdomen feels like it disappeared" = dissection, etc
7. other people ask me to order things. Today GI called and asked me to order a CT abdomen. Medicine wanted a CT "liver phase". Ortho wanted a CT pelvis MSK. My name was on all of them but I didn't want them or need them

Thank you for all you do, though.

 

[southerndoc]

It's always easy to assess a patient retrospectively. Yes, you see the CT and diagnose enteritis, but you didn't see the patient who was primarily complaining of right lower quadrant abdominal pain and had a fever, leukocytosis, etc.

If your docs are putting "gastroenteritis" as the diagnosis, then they should be educated to put a more appropriate clinical reason for ordering the CT.

 

[chudat]

meh. like you already said, just do your job. Sometimes I think some other generic specialty is full of idiots also. then I remember we all went to the same school, and you probably got the same USMLE and rotation scores I got. I'm not an idiot, and neither are you. We just practice in different environments which ultimately leads us to behave in a certain way. let's say I see a patient. Here's many reasons I order CT scans even though I don't REALLY think they need it.

1. patient wants a CT scan and we work at patient-complaint satisfaction score memorial hospital - here you go. CT scanner go brrr. you have GE, bye.
2. nurse documents 10/10 pain. patient has hx gastric bypass or some SBO in the past. writes in the chart "patient says I feel like I'm going to die". If anything ever went wrong, where do I sign the check. Do you really think some lawyer is gonna read your note that says "seems like GE" and let you off the hook?
3. Patient needs some CT of some sort in the ED, oh and btw my doc ordered a different type of CT like my abdomen as outpatient. can we just do that at the same time? CT go brrr for 15 more seconds, here you go.
4. we work in a soft department and this patient will most likely come back because they're soft too and 6 hours later "I'm not better I'm in severe pain", we're taught to take bounce-back patients seriously, high risk, etc. next doc will order it, and I will get patient complaint for missing their "colitis" that doc #2 gave abx to even though they didn't need it.
5. patient is old and terrible historian and unreliable exam and high risk for badness and no matter how good of a clinician you are, they are providing you with unreliable history and exam
6. we've seen some ****. can't tell you how many patients we've all seen with CC of "things taste weird" = massive SAH, "the inside of my abdomen feels like it disappeared" = dissection, etc
7. other people ask me to order things. Today GI called and asked me to order a CT abdomen. Medicine wanted a CT "liver phase". Ortho wanted a CT pelvis MSK. My name was on all of them but I didn't want them or need them

Thank you for all you do, though.

Only problem with all of that then is I sometimes get calls asking to hurry up with the reads from you guys....

 

[Radetzky]

It’s because you don’t appreciate the myriad ways in which diseases present clinically

 

[Siggy]

seriously, as a rad, it's killing me. The list is evergrowing and having to read these essentially negative ct abd/pel on call kills me. Or am I just being dramatic and needs to STFU and just do my job?

or dont get me started on these CTA chest/CT abd/pel combos that gets ordered. Sweet baby jesus.

For the love of god, stop ordering so many exams.

Inshallah

1. As I say in my pancreatitis lecture for residents, CT scans aren't indicated for the first 48-72 hours of pancreatitis... but remember... the ED isn't working up pancreatitis, they're working up abdominal pain.

2. What if the initial working diagnosis of gastroenteritis is wrong? Sometimes badness creeps in and cosplays as something else.

 

[GonnaBeADoc2222]

You're right. You need to STFU and do your job.

Get a job where you are paid by production and you will be very happy to quickly read tons of normal CTs.

 

[CoolDoc1729]

seriously, as a rad, it's killing me. The list is evergrowing and having to read these essentially negative ct abd/pel on call kills me. Or am I just being dramatic and needs to STFU and just do my job?

or dont get me started on these CTA chest/CT abd/pel combos that gets ordered. Sweet baby jesus.

For the love of god, stop ordering so many exams.

Inshallah

When I can possibly discharge a patient with no workup from the triage room for ED LOS of 9 minutes, I do and it is the high point of that hour.
Some of the CTs are generated by lazy docs and/or incompetent mid levels, no question. Im so sorry for those. One of my PAs orders CTa H&N for every dizzy person. I’ve talked to her. Ive talked to our boss. She won’t stop. If I catch it I cancel some, but I also have to manage the rest of my department.

But I think for there to be a lot less CT scans , some of these would have to change
1) malpractice climate
2) satisfaction scores
3) histrionic opiate addicted patients
4) stoic 90 year olds
5) urgent cares sending everyone for a CT head
6) PCPs sending everyone for a CT head
7) anticoagulant usage

Especially re: 1 and 2. Say you tell someone they don’t need a CT angiogram because the perc score is negative. You either order it anyway or get into an argument with them because they want it and their cousin who used to be an EMT said they needed it. Then if they’re the known 1-2-ish % that has a PE good luck, because they will definitely sue if they have any damages.

About 80% of the time, we can’t win, we are going for a draw.

 

[WilcoWorld]

I make a good faith effort to avoid unnecessary scans. Most Emergency docs do - as said above, it speeds up patient flow and makes our jobs easier when we can avoid the scan. If there are outliers in your hospital, it is reasonable to have a focused discussion with those outliers. But negative scans aren't going away unless our culture moves away from our (highly problematic) risk aversion (that actually just prioritizes proximate risk over more remote risk but doesn't decrease overall risk ).

 

[NYEMMED]

seriously, as a rad, it's killing me. The list is evergrowing and having to read these essentially negative ct abd/pel on call kills me. Or am I just being dramatic and needs to STFU and just do my job?

or dont get me started on these CTA chest/CT abd/pel combos that gets ordered. Sweet baby jesus.

For the love of god, stop ordering so many exams.

Inshallah

I think part of this that you don’t understand is all the factors ED docs have to deal with.

1 Malpractice- lawyer does not care what it sounds like “but doctor, you could have performed a simple 3 minute exam to ensure there wasn’t a more deadly complication occurring and you didn’t”

2 Patient satisfaction- nobody wants to walk down into the principles office and answer why the patient is complaining. Also get too many of these and you’ll get fired for some reason they find

3 Peer review- bad outcome happened, peer review committee is asking why you didn’t just get the CT and avoid this. Cases are tracked, too many cases you get put on PPE (which is reportable) and back to the principles office you go.

Jenny Mcjennerson ( credit @RustedFox
The village NP sent the patient In for a CT. Now breaking that cycle leaves me open to #1 and #2

And yes we call you for the reads because we are also being timed. Patients need to be discharged in 120 mins or less, otherwise back to the principles office.

We have lots of pressures, so please read the study

 

[Rekt]

It's very easy for any specialty to whine about EM, but the problem is no one except those in EM get it. I'm carrying 10-12 active patients at any given time, when there's 10-50 in the waiting room essentially at all times. Regardless of how busy I am, I have to be 100% immediately available for STEMI, Stroke alert, trauma, an arrest, first floor codes - no matter what.

A majority of the active patients are whiny, needy, histrionic, sent in for imaging from some completely inept mid level, or by a Friday afternoon pcp, etc.

Most patients nowadays cannot handle a single ounce of pain. You can hover your hands over their abdomen and they cry while the nurse at bedside documents tearful 10/10 pain.

I'd say my personal pretest accuracy for a negative scan vs not is >95%. I absolutely order scans I know without a doubt will be negative. Hell, sometimes I've even done it because I need to hold the room longer because I'm drowning. We have to play the game.

You're free to come see the patient yourself, examine them, write a note on why you think they don't need imaging.

Or just collect your money and thank the ED for your job security.

 

[Birdstrike]

seriously, as a rad, it's killing me. The list is evergrowing and having to read these essentially negative ct abd/pel on call kills me. Or am I just being dramatic and needs to STFU and just do my job?

or dont get me started on these CTA chest/CT abd/pel combos that gets ordered. Sweet baby jesus.

For the love of god, stop ordering so many exams.

Inshallah

You’re feeling burnout. You’re overwhelmed and irritated by the onslaught of volume. You’re not in control of it and it makes you unhappy. You see no end in sight.

This is all similar to the ER doctor trying to manage multiple critical patients, knowing there’s an onslaught of people with benign viruses in the waiting room, knowing he’ll get screamed at my admin for not seeing them in an IMPOSSIBLE 15 minutes.

He tries to see those 10 patients between codes. Then 15 more come in. Then 30. And another code!

Feel better now?

 

[chudat]

why is not possible for you guys to say, 'hey listen, i think it's mostly likely enteritis, there is no need to work you up and send you a 3k ER bill'. If the pain worsens, come back and we will do further workup'. Seems like everyone with nausea/vomiting gets a scan. Teenagers too. When I was a teen and had N/V/D, my mom told me to drink some soup. When I had a gash on my leg from a bike accident, my dad to rub some sand it in.

this way it saves everyone time and the rads can get back reading studies with actual pathology

and there is no need to call for reads. We aren't sitting back there jerkin it. We're drowning in a monsoon of studies from multiple hospitals, inpts, etc. Job security, yes true, but also adds more stress to an already stressful situation. If it is in fact that critical, open the studies and take a look yourselves. No dissection, large PE, etc, it's ok for them to wait a few minutes.

 

[MechEDoc]

Exam is likely gastroenteritis, patient is a whiny jerk and I'm afraid they will complain / sue. I check each box: labs, IV fluids, Zofran, CT Abd/Pelvis.

Great news! My history and exam are consistent with your unnecessary evaluation! Any complaint will bounce off me and stick to you. Here's your Zofran and Bentyl rx, return to care precautions, and PCP f/u instructions....

I sleep well, I get fewer complaints, and maybe, just maybe, I'll find a Zebra every once in a while.

 

[MechEDoc]

why is not possible for you guys to say, 'hey listen, i think it's mostly likely enteritis, there is no need to work you up and send you a 3k ER bill'. If the pain worsens, come back and we will do further workup'. Seems like everyone with nausea/vomiting gets a scan. Teenagers too. When I was a teen and had N/V/D, my mom told me to drink some soup. When I had a gash on my leg from a bike accident, my dad to rub some sand it in.

this way it saves everyone time and the rads can get back reading studies with actual pathology

I'm not incentivized for rads getting to read "actual pathology". That's like patients only coming to the ER for actual emergencies!

Most patients that are getting these studies aren't paying their bill (think Medicaid and Medicare...)

I am incentivized for not getting complaints, bounce backs, and misses.

Also, patient's love technology, not opinions. Scenario 1) "you seem to have gastroenteritis, it should be self limited, but you'll need to suck it up for a few days" (i.e. you're a total wimp who can't handle life), 2) "all these tests are very reassuring, you have gastroenteritis, you should be fine, good thing you came in when you did!"

In the second scenario the patient is happy and the system gets to bill for a level 5 visit with lots of studies!* Win, win!

*Even better if there is a standing order set and the nurses send a full GI PCR before the doc even sees the patient! This is for a patient with four loose stools over one hour (don't ask how I came up with this exact example)

 

[NYEMMED]

why is not possible for you guys to say, 'hey listen, i think it's mostly likely enteritis, there is no need to work you up and send you a 3k ER bill'. If the pain worsens, come back and we will do further workup'. Seems like everyone with nausea/vomiting gets a scan. Teenagers too. When I was a teen and had N/V/D, my mom told me to drink some soup. When I had a gash on my leg from a bike accident, my dad to rub some sand it in.

this way it saves everyone time and the rads can get back reading studies with actual pathology

and there is no need to call for reads. We aren't sitting back there jerkin it. We're drowning in a monsoon of studies from multiple hospitals, inpts, etc. Job security, yes true, but also adds more stress to an already stressful situation. If it is in fact that critical, open the studies and take a look yourselves. No dissection, large PE, etc, it's ok for them to wait a few minutes.

Because that won’t work. We’ve been there done that, and many got burned.

Oh also any 30 day return to ED (ED discharged patient that returns within 30 days) is also a metric we are tracked on.
Otherwise we go to the principles office again for that too.

Also rare but, when you have a 16 year old with “gastro” looks good but family demands a CT and you reluctantly order it after discussing it is unnecessary. And the CT is read “small bowel obstruction with ruptured bowel and surrounding abscess”
You put your foot on your mouth and apologize. Also, you are still going to the principles office for that too

 

[TrailRun]

I guess for the same reason you can’t tell exactly what’s going on from the picture and make us “correlate clinically” for everything. And I love the reads that say “xxx could be infectious, inflammatory or neoplastic.” Isn’t that everything?

We are all in this together

 

[chudat]

I guess for the same reason you can’t tell exactly what’s going on from the picture and make us “correlate clinically” for everything. And I love the reads that say “xxx could be infectious, inflammatory or neoplastic.” Isn’t that everything?

We are all in this together

Yeah for sure.

I'm feeling the burnout from exponential uptick in volume. Hopefully the quarterly bonus will ease the frustration.

 

[Brigade4Radiant]

Yeah for sure.

I'm feeling the burnout from exponential uptick in volume. Hopefully the quarterly bonus will ease the frustration.

Yeah so are we.

People going to the ER especially flu season. YOu are also under severe time constraints because the waiting room is so packed. Patients also wait for hours to see a physician.

 

[Tenk]

This new generation of 20-30 year olds act like they are literally dying when you place your hand on their abdomen. They have zero coping skills and when you try to discuss testing versus not testing, they want every possible test done known to mankind. Blame their parents, not the ED doc.

 

[thegenius]

seriously, as a rad, it's killing me. The list is evergrowing and having to read these essentially negative ct abd/pel on call kills me. Or am I just being dramatic and needs to STFU and just do my job?

or dont get me started on these CTA chest/CT abd/pel combos that gets ordered. Sweet baby jesus.

For the love of god, stop ordering so many exams.

Inshallah

Hey man. Yea for the most part you can probably just STFU LOL. But honestly I like you rads guys. I asked our rads here if we order too many tests and he said "it's community medicine. This is what we expect."

It's hard to render EBM care when your ER is flooded with people and we have a mandate to dispo all them immediately. So part of what we do is offload that risk to others. It's just the way it is.

I once looked at the last 50 CT Chest PE studies ordered at my work one evening when it wasn't busy. 49 / 50 were neg for PE. Kind of embarrassing TBH.

Community medicine on all levels (inpatient, ER) is ****. One of the rads here told me about a stroke that was admitted once. The ER ordered CT Head/Neck angio looking at the vasculature. The next day the inpatient team ordered MRI Brain and MRA Head/Neck looking at the vasculature. The following day some inpatient dingus ordered a carotid ultrasound. All three were negative. Embarrassing!

 

[chudat]

Hey man. Yea for the most part you can probably just STFU LOL. But honestly I like you rads guys. I asked our rads here if we order too many tests and he said "it's community medicine. This is what we expect."

It's hard to render EBM care when your ER is flooded with people and we have a mandate to dispo all them immediately. So part of what we do is offload that risk to others. It's just the way it is.

I once looked at the last 50 CT Chest PE studies ordered at my work one evening when it wasn't busy. 49 / 50 were neg for PE. Kind of embarrassing TBH.

Community medicine on all levels (inpatient, ER) is ****. One of the rads here told me about a stroke that was admitted once. The ER ordered CT Head/Neck angio looking at the vasculature. The next day the inpatient team ordered MRI Brain and MRA Head/Neck looking at the vasculature. The following day some inpatient dingus ordered a carotid ultrasound. All three were negative.

I mean you nailed it. I practice at a community setting But why should community medicine be held to a different standard?

 

[thegenius]

I mean you nailed it. I practice at a community setting But why should community medicine be held to a different standard?

Less resources. If I'm at an academic hospital where I have residents in all specialties full time, that is very helpful.
For instance, pt comes in with some throat problem or globus sensation. I would rather have someone just do direct visualization of the glottis, and if I could or get an ENT resident to do it, fine that is good. But in community that is hard. So lots of people will just scan the neck.

Lots of docs here scan peritonsillar abscesses regularly for instance. I don't really understand why as it's a visual diagnosis. ENT drains them all the time without scanning. Unless there is something goofy with the history or physical, it isn't needed. At an academic hospital we can just drain it ourselves or call ENT to do it. In the community these are scanned for some reason.

And basically what @DoctorJDO said above. Happens all the time.

 

[thegenius]

It’s because you don’t appreciate the myriad ways in which diseases present clinically

I think what he's getting at is if 19 out of 20 CT's are negative, then we should probably be a little better and judicious at ordering tests. I don't know what a proper hit rate should be, but 19/20 is not that great.

 

[thegenius]

why is not possible for you guys to say, 'hey listen, i think it's mostly likely enteritis, there is no need to work you up and send you a 3k ER bill'. If the pain worsens, come back and we will do further workup'. Seems like everyone with nausea/vomiting gets a scan. Teenagers too. When I was a teen and had N/V/D, my mom told me to drink some soup. When I had a gash on my leg from a bike accident, my dad to rub some sand it in.

We can!

this way it saves everyone time and the rads can get back reading studies with actual pathology

and there is no need to call for reads. We aren't sitting back there jerkin it. We're drowning in a monsoon of studies from multiple hospitals, inpts, etc. Job security, yes true, but also adds more stress to an already stressful situation. If it is in fact that critical, open the studies and take a look yourselves. No dissection, large PE, etc, it's ok for them to wait a few minutes.

LOL. I never really took your initial post as a pure slam on ER docs (just a little poke), and you certainly are getting a ribbing on here. I'm laughing more than anything.

I practice at three ER's and I practice differently at each one.

 

[thegenius]

Also, patient's love technology, not opinions. Scenario 1) "you seem to have gastroenteritis, it should be self limited, but you'll need to suck it up for a few days" (i.e. you're a total wimp who can't handle life), 2) "all these tests are very reassuring, you have gastroenteritis, you should be fine, good thing you came in when you did!"

Docs do too! It's fun to look at pictures and look at internal abscesses that, for instance, fistulate a bladder and bowel.

 

[RoyBasch]

2. nurse documents 10/10 pain. patient has hx gastric bypass or some SBO in the past. writes in the chart "patient says I feel like I'm going to die". If anything ever went wrong, where do I sign the check. Do you really think some lawyer is gonna read your note that says "seems like GE" and let you off the hook?

This **** kills me. It's always the same nurses that document the most hysterical triage notes that get the most huffy when you then proceed with a thorough workup that they feel is "over-kill."

Nursing school seems to never teach that documentation is more your impression of what is going on then court-room stenography word-for-word transcription.

Pro-tip to the nurses: If you don't want to do "full workups" then phrases like "I feel like I'm going to die" or "sudden and worse pain in my life" or "patient complains of headache, chest pain, abdominal pain, shortness of breath, weakness of their left arm, and vaginal discharge" should not be anywhere near your triage note.

 

[Rekt]

This **** kills me. It's always the same nurses that document the most hysterical triage notes that get the most huffy when you then proceed with a thorough workup that they feel is "over-kill."

Nursing school seems to never teach that documentation is more your impression of what is going on then court-room stenography word-for-word transcription.

Pro-tip to the nurses: If you don't want to do "full workups" then phrases like "I feel like I'm going to die" or "sudden and worse pain in my life" or "patient complains of headache, chest pain, abdominal pain, shortness of breath, weakness of their left arm, and vaginal discharge" should not be anywhere near your triage note.

I can't stand this.

The dichotomy between how old school nurses document vs. new grad nurses is so vast.

Old school triage: "abd pain x3d, texting on phone during triage"
New grad: "2yo old, projectile vomiting x4d, lethargic, no po intake, mom says pt very sick, they're very worried, pt appears ill, tachypneic, labored". --> Kid sitting in gurney completely fine watching some braindead show on Youtube.

I feel like all these new grad nurses document against docs in an adversarial way.

 

[RustedFox]

I had a guy last night ask ME if I thought a CT and/pelvis was necessary.

I said "no".

He said he "wanted it anyway".

I said "okay".

I'm still confused.

I swallowed shampoo.

Probably gonna die.

It smelled like fruit.

That was a lie.

 

[thegenius]

I had a guy last night ask ME if I thought a CT and/pelvis was necessary.

I said "no".

He said he "wanted it anyway".

I said "okay".

I'm still confused.

I swallowed shampoo.

Probably gonna die.

It smelled like fruit.

That was a lie.

Almost a hiaku - and you weren't even trying

 

[thegenius]

I had a guy last night ask ME if I thought a CT and/pelvis was necessary.

I said "no".

He said he "wanted it anyway".

Don't you just want to say "Fine, it's $450."

"Well I have insurance."

"Well then you can pay for it out of pocket, and then get your insurance to reimburse you. Umm...sir...I'm waiting for the $450. We take cash, check, VISA, or Mastercard."

 

[pkwraith]

I'm sure the rads get their revenge for our pan scans with making us explain mesenteric panniculitis to our well informed patient, or the mild small bowel dilation but could be "early partial small bowel obstruction" (which never ever becomes an actual bowel obstruction but is 99% gastroenteritis).

 

[RustedFox]

Don't you just want to say "Fine, it's $450."

"Well I have insurance."

"Well then you can pay for it out of pocket, and then get your insurance to reimburse you. Umm...sir...I'm waiting for the $450. We take cash, check, VISA, or Mastercard."

Medicare. They DGAF.

 

[RoyBasch]

I'm sure the rads get their revenge for our pan scans with making us explain mesenteric panniculitis to our well informed patient, or the mild small bowel dilation but could be "early partial small bowel obstruction" (which never ever becomes an actual bowel obstruction but is 99% gastroenteritis).

“Bowel wall edema that could be infectious vs inflammatory vs ischemic in etiology” is my favorite.

 

[The Knife & Gun Club]

seriously, as a rad, it's killing me. The list is evergrowing and having to read these essentially negative ct abd/pel on call kills me. Or am I just being dramatic and needs to STFU and just do my job?

or dont get me started on these CTA chest/CT abd/pel combos that gets ordered. Sweet baby jesus.

For the love of god, stop ordering so many exams.

Inshallah

There are certainly terrible ER docs who CT A/P every belly pain, and we all know one or two. At the same time there are some ED docs who are far more judicious with their imaging and rely more heavily on exam and risk factors. However you as a rad will never know those ED docs exist because you all never even hear about the people who we just stick in a corner room with a bag of fluids and some zofran.

An interesting anecdote that I like to share from my wife’s OBGYN world. Last year when she was the on call resident she fielded every ED consult for our 120,000 volume ER, 14 hours a day, 6 days a week. There were some EM docs she knew by name and badge number, and some who, despite working the exact same number of shifts she had never even heard of.

 

[chudat]

Locked-In Syndrome Malpractice Case Ends With $75M Verdict

After a chiropractic neck adjustment led to a stroke, the patient's attorney alleged that hospital physicians failed to act swiftly, resulting in locked-in syndrome.

www.medscape.com

Saw this in my feed today.
We are really brother in arms.

Explain to me how the chiro isnt on hook for anything.

 

[Birdstrike]

seriously, as a rad, it's killing me. The list is evergrowing and having to read these essentially negative ct abd/pel on call kills me.

You guys invented real life x-ray vision PLUS a way to make a s* *t-ton of money by looking at pictures without having to interact with humanity. You should be jumping up and down for joy, popping champagne bottles, celebrating that the plan workout, NOT complaining because the plan worked too good.


"Up in the hot tub, poppin' bubbly...
...I don't wanna be a player no more
I'm not a player, I just crush a lot" - Big Pun, Still Not A Player

 

[BoardingDoc]

Locked-In Syndrome Malpractice Case Ends With $75M Verdict

After a chiropractic neck adjustment led to a stroke, the patient's attorney alleged that hospital physicians failed to act swiftly, resulting in locked-in syndrome.

www.medscape.com

Saw this in my feed today.
We are really brother in arms.

Explain to me how the chiro isnt on hook for anything.

Can someone who understands malpractice cases explain how this award works? Most docs have a 3M or 5M malpractice insurance cap. That's 10M between rads and the ed doc. Where does the other 65M come from?

 

[CoolDoc1729]

When I was a teen and had N/V/D, my mom told me to drink some soup. When I had a gash on my leg from a bike accident, my dad to rub some sand it in.

Lol. Now when children as young as 5 have minor discomfort the parents ask them if they think they need to go to the hospital , and if they say yes, they come on in. Sometimes I ask people whether the 7 year old gets to make any other $5-10k decisions, then they complain to admin. Sometimes I ask them if they really think chest pain in a 9 year old could be that serious, and then they complain to admin. I try very hard to avoid scanning kids even if the complaint is rlq pain with vomiting and fever. I start with labs and US and hope for the best. If that is not diagnostic and the kid seems ok we talk about obs at home and return precautions, versus CT. Then 1/3 the time I have to end up adding CT then they complain to admin about wait time and I hear about length of stay.
I’m sorry you’re feeling overwhelmed and I get it, but I don’t think you’re placing the blame where most of it belongs.

 

[Birdstrike]

Can someone who understands malpractice cases explain how this award works? Most docs have a 3M or 5M malpractice insurance cap. That's 10M between rads and the ed doc. Where does the other 65M come from?

I'm guessing the award will be reduced on appeal. If not, how much they can get above the insurance coverage would depend on laws in the given state regarding debt collection and wage garnishment.

 

[evert1de101]

Is human illness this hard to manage at home or does everyone need to come to the ED?
Is human illness this hard to diagnose clinically or does everyone need a test?
Is human illness this hard to treat on your own or does everyone need a consult?
Is human illness this hard to consult and discharge or does everyone need admission?

I was burned out once too. Then I discovered a little trick where I put the patient first and forget about everything else. Now I consider it a privilege to go to work and see every single patient within 5 minutes while my consultants take 1-2 hours to work on their imaging reports and consult notes. This is not sarcasm by the way, I'm serious.

 

[Siggy]

Locked-In Syndrome Malpractice Case Ends With $75M Verdict

After a chiropractic neck adjustment led to a stroke, the patient's attorney alleged that hospital physicians failed to act swiftly, resulting in locked-in syndrome.

www.medscape.com

Saw this in my feed today.
We are really brother in arms.

Explain to me how the chiro isnt on hook for anything.

It was covered by The Expert Witness newsletter a few days ago.

Chiro settled.

Moral of the story, if the patient is young and survived with catastrophic injury, settle. This is like that EVAC/Bert Fish/premature delivery case where the ambulance company was hit for $10 million and almost went bankrupt. Instead of taking a settlement offer for insurance limits, they asked why it was their fault for relying on the EM physician's pelvic exam? Don't matter, baby has cerebral palsy and will require life long care. Someone has to pay... that care isn't going to be free.

Locked-In Syndrome [Chiropractor Adjusts Neck]

Case #131

expertwitness.substack.com

 

[NYEMMED]

Can someone who understands malpractice cases explain how this award works? Most docs have a 3M or 5M malpractice insurance cap. That's 10M between rads and the ed doc. Where does the other 65M come from?

If they are lucky it will be appealed to policy limits

If not, bank accounts, house, wages, investments, etc etc

 

[Clean7795]

It was covered by The Expert Witness newsletter a few days ago.

Chiro settled.

Moral of the story, if the patient is young and survived with catastrophic injury, settle. This is like that EVAC/Bert Fish/premature delivery case where the ambulance company was hit for $10 million and almost went bankrupt. Instead of taking a settlement offer for insurance limits, they asked why it was their fault for relying on the EM physician's pelvic exam? Don't matter, baby has cerebral palsy and will require life long care. Someone has to pay... that care isn't going to be free.

Locked-In Syndrome [Chiropractor Adjusts Neck]

Case #131

expertwitness.substack.com

This does show that imaging does not always protect you.

I have seen several cases in residency where a rad from Outside Hospital relied on a very low pre-test probability of badness (usually based on patient population & ER ordering practices), rushed the job, and missed a severe injury. In court it will be the ER doc, rad, and whoever the admitting/consultant doc is who gets nailed.

Anyway it's not my job to police people's ordering patterns. If there are outliers the chiefs of each department usually handle them.

 

[Siggy]

This does show that imaging does not always protect you.

I have seen several cases in residency where a rad from Outside Hospital relied on a very low pre-test probability of badness (usually based on patient population & ER ordering practices), rushed the job, and missed a severe injury. In court it will be the ER doc, rad, and whoever the admitting/consultant doc is who gets nailed.

Anyway it's not my job to police people's ordering patterns. If there are outliers the chiefs of each department usually handle them.

Testing only protects you if you act on it. Personally, I'm surprised that the intensivist wasn't 5% responsible. You admit something like that to me and neuro doesn't act, I'm calling neuro myself and documenting the conversation.

I think the documentation screwed everyone over as well. EM had to retract their "normal exam" and threw the scribe under the bus. The neurologist claimed to be called prior to the CT results coming back (but shouldn't neuro read their own results anyways?). I'm also surprised that the neurologist didn't get held responsible unless they could prove that they were called before the CTA. After all, it's very convient to document 3 days later when the outcome is known and know to throw EM under the bus.

 

[maxxor]

When I cover the ER, I don't complain about what the ER is ordering. That's like hating on your colleagues, man. They can't control what comes in the door any more than we can control what pops on the list.

Instead, I complain when the volume is too high to do a good job and that whoever is making radiology staffing decisions is cheaping out on patient care and contributing to burnout.

Multimillion ER radiology malpractice verdicts are getting more common. I remember when the missed lung cancer chest X-ray was $16 million in MA; now we have this $75 million one hanging in the air.

 

[Siggy]

Sometimes the health system will cover the cost. The recent MedMal Review case sent via email a few days ago definitely caused concern. Young guy with neck pain, goes to chiropractor, has AMS/neuro deficits (ED doc document normal neuro exam despite eventually needing to intubate him), radiologist didn't appropriately read the dissection with occlusion... patient ended up in locked-in syndrome. Jury awarded $75 million.

That’s literally the case being discussed. The Expert Witness sub stack is linked above.

 

[southerndoc]

That’s literally the case being discussed. The Expert Witness sub stack is linked above.

I must have zoned out while going through this thread. :O