Mal practice case: snakebite

[pkwraith]

Newest EM-related case from Expert Witness:

Snake Bite! [Crofab Case]

Case #195

expertwitness.substack.com

Summary:
13 yo girl in Texas gets bit by rattlesnake
EM Doctor scores her based on Snakebite Severity Score (SSS) which is part of the hospital's snakebite protocol. SHe does not qualify for crofab based on SSS
While being observed with serial exam and labs, symptoms and lab progress so she meets criteria. Crofab completed 40 minutes later after meeting criteria.
Patient was ultimately transferred, recovered but had lingering chronic pain and dysfunction, so family sues because they felt crofab should have been given immediately, despite hospital forgiving entire hospital bill.

Doctor wins initial judge trial, parents appeared it to appearsl court which felt the "objectively [the doctor's] adherence to the guidelines posed extreme harm to [patient] and ruled for the plaintiff. Eventually made it to state Superior court where that was overturned again in favor of defendant again.

Expert plaintiff witness testimony of course by a non-Toxicology boarded doctor who claims he is a "toxinologist".
ACEP actually came to bat for the defendent this time.
And of course the context this occured in Texas, where the standard for malpractice is "willful and wanton negligence" which makes this lawsuit and the plaintiff expert witness really stomach turning.

Now, there is an argument to be made about using the Unified Treatment Algorithm and involving Poison Control Center, and the patient may have benefited from crofab earlier, but at no point with those rising this to the level of malpractice of gross negligence.

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[RustedFox]

There are no laws anymore.

 

[EctopicFetus]

Whats pathetic is the expert for the plaintiff is an ACEP apologist. crazy that this guy would sell him self out. anything for a buck i guess. What a joke.

 

[Birdstrike]

Our system sucks and this is evidence item #4,619,837.

It's hard to not take this kind of thing personally. It's best to compartmentalize it. Frivolous and unjust attacks will occur. You pay for insurance against these scurrilous attacks. As part of the deal, you also pay the insurance company to worry about it, take it personally for you so you don't have to, and to deal with it as if it's their own responsibility (because it is). Your job is to do Medicine no the law, not the insurance work. It's the insurance company and their lawyers job to worry about these attacks and you pay good money to do it. Let them do it.

Your responsibility is to review the chart. Give a deposition. Meet with your attorney and possibly (but probably not) testify in court one time. This group of tasks actually doesn't take that long. Add it up and its a few hours for a case that will spread out over years. You can choose to worry for that finite amount of hours and let it go. Or you can choose to let it ruin years of your life. It's not your responsibility to toil over it for years. But you can, if you choose to.

If I could fix the system, I would. But I can't.

 

[Apollyon]

Whats pathetic is the expert for the plaintiff is an ACEP apologist. crazy that this guy would sell him self out. anything for a buck i guess. What a joke.

But the OP says ACEP went to bat for the defendant. Was ACEP playing both sides?

 

[Kryptocoin]

"The defense then appealed to the state’s Supreme Court.
The Supreme Court reversed the appeals courts’ decision and reinstated the trial court’s dismissal of the lawsuit."

So looks like the ER doctor prevailed in the end. Willful and wanton standard was not met. Favorable malpractice laws are mainly deterrents. It doesn't stop patients from trying to sue.

 

[dozitgetchahi]

Our system sucks and this is evidence item #4,619,837.

It's hard to not take this kind of thing personally. It's best to compartmentalize it. Frivolous and unjust attacks will occur. You pay for insurance against these scurrilous attacks. As part of the deal, you also pay the insurance company to worry about it, take it personally for you so you don't have to, and to deal with it as if it's their own responsibility (because it is). Your job is to do Medicine no the law, not the insurance work. It's the insurance company and their lawyers job to worry about these attacks and you pay good money to do it. Let them do it.

Your responsibility is to review the chart. Give a deposition. Meet with your attorney and possibly (but probably not) testify in court one time. This group of tasks actually doesn't take that long. Add it up and its a few hours for a case that will spread out over years. You can choose to worry for that finite amount of hours and let it go. Or you can choose to let it ruin years of your life. It's not your responsibility to toil over it for years. But you can, if you choose to.

If I could fix the system, I would. But I can't.

Oh, and the other thing: “resource allocation” is garbage. The system does not support your efforts to reduce expenses. Anything you don’t do can and will lead to your ass getting hauled to court to attempt to defend a lawsuit. I don’t hesitate to order away in situations where I think I’ll need to protect myself. It’s extremely rare for me to say “boy I wish I’d never ordered that”. It’s much more common for me to wish I did.

 

[valianteffort]

The patient was ordered crofab approx 2 hours after arrival and received it approx 3 hours after arrival. I've worked in places where I know these times may not have been met due to the size of the hospital, ex: 'its coming from pharmacy after they verify it', snake bites with stable vitals are 'level 3 - place them in the waiting room', 'nurses 4th patient she didn't get to them until 1 hour after getting roomed'. I am curious if there was some sort of extra accountability the physician was hit with as they noted 'willful and wanton and reckless breaches of the standard of care by Dr. X in timely administration of antivenom' as the physician saw the patient right away and ordered it 2 hours after seeing the patient. What if the physician ordered crofab right away and it still took the same amount of time to administer it due to pharmacy delay? What if the patient was in the WR for 2 hours and then the physician ordered it right away once the patient was roomed and evaluated?

 

[Birdstrike]

The system does not support your efforts to reduce expenses. Anything you don’t do can and will lead to your ass getting hauled to court to attempt to defend a lawsuit. I don’t hesitate to order away in situations where I think I’ll need to protect myself.

The specialty societies have waged media-driven campaigns to brainwash clinicians into taking on more medical-legal risk to save money for a broken "system" they refuse to fix, because it profits them and those who line their pockets.

"Save money for hospital administrators, insurance companies! Get sued more! Everyone wins!"

The lawyers, insurance companies and hospital CEOs win. You lose.

The "physician societies" serve the lawyers and CEOs at physicians' expense.

What's wrong with this picture?

 

[Birdstrike]

You've got tests at your disposal. Order them.

 

[carbonizedeyesockets]

For those curious, Dr. Ben Abo was the "expert" witness. (It's public, but not stated on the blog.)

 

[hoot504]

For those curious, Dr. Ben Abo was the "expert" witness. (It's public, but not stated on the blog.)

Dr. Ben Abo - Kings of Pain Cast | HISTORY Channel

Dr. Ben Abo stars in The HISTORY Channel's series Kings of Pain. Find out more about Dr. Ben Abo and the rest of the cast on The HISTORY Channel.

www.history.com

Wowza.

Expert for the plaintiff or defendant?

 

[BoardingDoc]

The patient was ordered crofab approx 2 hours after arrival and received it approx 3 hours after arrival. I've worked in places where I know these times may not have been met due to the size of the hospital, ex: 'its coming from pharmacy after they verify it', snake bites with stable vitals are 'level 3 - place them in the waiting room', 'nurses 4th patient she didn't get to them until 1 hour after getting roomed'. I am curious if there was some sort of extra accountability the physician was hit with as they noted 'willful and wanton and reckless breaches of the standard of care by Dr. X in timely administration of antivenom' as the physician saw the patient right away and ordered it 2 hours after seeing the patient. What if the physician ordered crofab right away and it still took the same amount of time to administer it due to pharmacy delay? What if the patient was in the WR for 2 hours and then the physician ordered it right away once the patient was roomed and evaluated?

These are all good questions. The problem is that none of this has any bearing on whether or not you get sued. Some lawyer simply needs to think that they have a sympathetic enough client with a bad outcome that they can get paid. The details of the case seldom seem to matter.

 

[HoosierdaddyO]

Dr. Ben Abo - Kings of Pain Cast | HISTORY Channel

Dr. Ben Abo stars in The HISTORY Channel's series Kings of Pain. Find out more about Dr. Ben Abo and the rest of the cast on The HISTORY Channel.

www.history.com

Wowza.

Expert for the plaintiff or defendant?

Agreed he is big in the EMS world… I’m highly curious who he testified for and what his basis was if he did testify for the plaintiff and why he would go against acep and their backing of another ER doc???

 

[carbonizedeyesockets]

He is the one who testified for the plaintiff. (Also public.)

Not posting the article because it names the good doc who was the defendant.

 

[hoot504]

Agreed he is big in the EMS world… I’m highly curious who he testified for and what his basis was if he did testify for the plaintiff and why he would go against acep and their backing of another ER doc???

I meant more wowza I didn't realize sideshow bob was a practicing "toxinologist".

The article in the original post indicates that he was an expert for the plaintiff. There are also some troubling facts brought up regarding his testimony on the case.

 

[EctopicFetus]

I meant more wowza I didn't realize sideshow bob was a practicing "toxinologist".

The article in the original post indicates that he was an expert for the plaintiff. There are also some troubling facts brought up regarding his testimony on the case.

Some people will do anything for a dollar.

 

[TooMuchResearch]

The specialty societies have waged media-driven campaigns to brainwash clinicians into taking on more medical-legal risk to save money for a broken "system" they refuse to fix, because it profits them and those who line their pockets.

"Save money for hospital administrators, insurance companies! Get sued more! Everyone wins!"

The lawyers, insurance companies and hospital CEOs win. You lose.

The "physician societies" serve the lawyers and CEOs at physicians' expense.

What's wrong with this picture?

As I've said before, I'll light em up, order $1000s of dollars of tests on a patient seen yesterday, etc until the computer doesn't let me. It's what the patient wants. It's what the doctor sending them to see me wants. It's what the hospital wants. I know what happens when you don't order because you have low suspicion and the patient actually had the thing you didn't expect. Even if nothing bad happens. They will all burn you every time for every low probability miss. Keep ordering until the computer won't let you.

 

[GonnaBeADoc2222]

Medicine is incredible because you can intervene in good faith on things that are the patients fault, and still be the bad guy.

And yet, y'all wanna send your children into this mess lollll (see: other thread).

 

[dozitgetchahi]

The patient was ordered crofab approx 2 hours after arrival and received it approx 3 hours after arrival. I've worked in places where I know these times may not have been met due to the size of the hospital, ex: 'its coming from pharmacy after they verify it', snake bites with stable vitals are 'level 3 - place them in the waiting room', 'nurses 4th patient she didn't get to them until 1 hour after getting roomed'. I am curious if there was some sort of extra accountability the physician was hit with as they noted 'willful and wanton and reckless breaches of the standard of care by Dr. X in timely administration of antivenom' as the physician saw the patient right away and ordered it 2 hours after seeing the patient. What if the physician ordered crofab right away and it still took the same amount of time to administer it due to pharmacy delay? What if the patient was in the WR for 2 hours and then the physician ordered it right away once the patient was roomed and evaluated?

All very good questions, and I wondered the same thing.

Also, anyone who has ever worked in a hospital, health system, etc knows that there are so many aspects of practice that you basically have no control over. I think it’s crazy how the courts and medical boards still act as if every physician is a solo “captain of the ship” when, in reality, this is an extremely rare practice model these days.

 

[pkwraith]

As I've said before, I'll light em up, order $1000s of dollars of tests on a patient seen yesterday, etc until the computer doesn't let me. It's what the patient wants. It's what the doctor sending them to see me wants. It's what the hospital wants. I know what happens when you don't order because you have low suspicion and the patient actually had the thing you didn't expect. Even if nothing bad happens. They will all burn you every time for every low probability miss. Keep ordering until the computer won't let you.

Sure but in this case you would be going against your institutional protocol. No faster way to get sued and then lose the suit when you get hammered for going against local guidelines for example the patient gets anaphylaxis.

With the current environment, you can get sued whatever you do

 

[TrailRun]

I'm not a "Toxinologist" (had to type that twice because autocorrect says it's not a word... but the treating physician acted appropriately. My biggest problem with this case is that the alleged expert's opinion was clearly written by a lawyer. 'Acted consciously indifferent,' etc. I wish ACEP or whomever would censure docs who give such egregious, financially motivated testimony

 

[ProReduction]

This is not photoshop or AI. This is an actual picture from this guy's website.

 

[ShockIndex]

Disclosure - I know the defendant in this case as we came from the same residency program where she was a med student, AI, etc. when I was a resident. She was a rock star and our program was fortunate to have her stay for residency. In other words, I’m biased. On the other hand, the plaintiff’s witness, Dr. Ben Abo, is yet another “wilderness medicine” physician with long hair and a goatee - so again, I’m biased.

With that said, here is the Texan Supreme Court decision on the matter. While the title identifies the defendant, this case is well publicized in the lay media and it is important for EPs to understand the basis of these decisions. Most reasonable minds will conclude that the defendant is the victim here. It’s a good and thoughtful decision that showed remarkable insight into the medical minutia of this case for a group of lawyers who’ve never treated a snakebite.

MARSILLO v. DUNNICK (Opinion)

The Supreme Court of Texas considered a medical negligence case where a 13-year-old girl, Raynee Dunnick, was bitten by a rattlesnake and was treated by Dr. Kristy Marsillo at a local hospital. The hospital had a specific guideline for snakebite treatment, which was followed by Dr. Marsillo...

law.justia.com

Some of the key issues that the Justices mentioned in this decision include a detailed timeline of facts. While there was a supposed “4-hour delay” in administering CroFab, much of that delay was due to the fact that defendant was repeatedly evaluating the patient who did not meet the local protocol’s criteria for CroFab. Once criteria was met, the patient received CroFab after about 30 min of it being ordered. The justices even noted the actions that the pharmacy would need to take to prepare the drug.

More importantly, the justices did a remarkable job dissecting the opinions of the plaintiff’s expert, Dr. Abo, as being conclusions not based on any evidence or medical basis. Specifically, Dr. Abo asserted that the standard of care required that rattlesnake bites required immediate administration of antivenom at the first signs of envenomation, regardless of severity, but provided no evidentiary basis for this conclusion.

I’m no longer an ACEP member, so I do not have access to their directory to see if Benjamin N. Abo, DO, EMT -P is in good standing. I can’t find him on AAEM’s directory. It appears that he graduated from Touro University of Osteopath Medicine in 2011 and completed his residency at Mount Sinai Medical Center of Florida (Miami) followed by an EMS fellowship at UF. Although he allows the lay media to refer to him as an “toxicologist” I believe that this is based solely on the fact that Abo likes to handle snakes as I do not see where he has completed a tox fellowship or passed their Board. If an ACEP member, I’m interested in seeing if ACEP is willing to censure Dr. Abo for his unusual and misleading testimony.

 

[CoolDoc1729]

Our system sucks and this is evidence item #4,619,837.

It's hard to not take this kind of thing personally. It's best to compartmentalize it. Frivolous and unjust attacks will occur. You pay for insurance against these scurrilous attacks. As part of the deal, you also pay the insurance company to worry about it, take it personally for you so you don't have to, and to deal with it as if it's their own responsibility (because it is). Your job is to do Medicine no the law, not the insurance work. It's the insurance company and their lawyers job to worry about these attacks and you pay good money to do it. Let them do it.

Your responsibility is to review the chart. Give a deposition. Meet with your attorney and possibly (but probably not) testify in court one time. This group of tasks actually doesn't take that long. Add it up and its a few hours for a case that will spread out over years. You can choose to worry for that finite amount of hours and let it go. Or you can choose to let it ruin years of your life. It's not your responsibility to toil over it for years. But you can, if you choose to.

If I could fix the system, I would. But I can't.

I think it’s easier said than done, to only worry during depositions and while reviewing the chart.

My experience (n=2) is that every time stuff related to the lawsuit (other people’s depositions, scheduling stuff, etc) trickles in via email or snail mail, it makes me feel less joy and more cynicism for a day or two.

And they drag on for YEARS of this … the malpractice system as it sits feels punitive and beyond inefficient. It takes forever for truly wronged patients to get anything, it makes the docs feel defensive and burned out, and the lawyers are just racking up hours so there’s no incentive for them to change any of this. It is by far the thing that bothers me most about a career in medicine.

 

[JacobMcCandles]

This is not photoshop or AI. This is an actual picture from this guy's website.

Only the good Lord knows where that banana has been.

 

[Zebra Hunter]

Couple disclaimers: this is clearly not gross negligence and I’m very happy that the defendant ultimately won, and Dr. Abo should be censured for claiming gross negligence in this case; however, I do believe the hospital’s Crofab algorithm is not based on the standard recommendations regarding crotalidae envenomations (and more specifically rattlesnakes which have lower rates of ‘dry bites’ than copperheads), and are utilizing a research tool (snakebite severity score) that was never meant for clinical practice, and has never been validated.

Based on the initial images demonstrating significant local swelling and report of this clearly being a rattlesnake envenomation, I’m not sure there is a toxicologist out there that wouldn’t recommend immediate administration of crofab.

The only thing on the hospital’s algorithm for snakebites should have been “call poison control”. I’m surprised the hospital wasn’t named in the suit despite the treating physician just following institutional policy.

Edit: Appears I was wrong on the dry bite percentage, which is near identical between rattlesnake and copperhead. It is due to rattlesnake envenomation typically being more severe.

 

[Apollyon]

Copperheads envenomate more than rattlesnakes because the copperheads don't have rattles. IIRC, about 25% of rattlesnake bites are "dry".

 

[ShockIndex]

A quick UpToDate refresher on Cotalinae bites lists the indications for antivenom as:
1) neck / face with any swelling
2) other bite site with progressive swelling but no definition of progressive
3) evidence of hemotoxicity / coagulopathy
4) evidence of systemic toxicity

Strong recommendation for poison control early in the course.

There is no distinction of copperhead, rattlesnake, or water moccasins.

 

[ShockIndex]

Couple disclaimers: this is clearly not gross negligence and I’m very happy that the defendant ultimately won, and Dr. Abo should be censured for claiming gross negligence in this case; however, I do believe the hospital’s Crofab algorithm is not based on the standard recommendations regarding crotalidae envenomations (and more specifically rattlesnakes which have lower rates of ‘dry bites’ than copperheads), and are utilizing a research tool (snakebite severity score) that was never meant for clinical practice, and has never been validated.

Based on the initial images demonstrating significant local swelling and report of this clearly being a rattlesnake envenomation, I’m not sure there is a toxicologist out there that wouldn’t recommend immediate administration of crofab.

The only thing on the hospital’s algorithm for snakebites should have been “call poison control”. I’m surprised the hospital wasn’t named in the suit despite the treating physician just following institutional policy.

I suspect that the plaintiffs went after the physician rather than the hospital because the it was a large health system with a much larger legal war chest. They were probably hoping for a quick settlement.

This case sounds like BS. I seem recall that the patient was discharged within 48 hours with crutches. I’m having a hard time believing that she has 1 million in damages from chronic pain, loss of function, loss of consortium (joke), etc.

 

[Rendar5]

Zebra Hunter,

If what you say is true, then that argues against censuring The expert witness.

I’m not sure there is a toxicologist out there that wouldn’t recommend immediate administration of crofab.

Would constitute deviation from standard of care.

And making a conscious decision to ignore the snakebite and stick with the protocol would make it potentially gross negligence vs negligence.

Now if I were an expert I would hold the hospital liable, not the physician, for instituting an inappropriate policy. Mostly because I am not a trained toxicologist and would not know the policy was inappropriate. But you can’t blame the expert for providing an opinion if there is an actual case that could be made. The expert made a good faith opinion. Just a stupid one in letting the plaintiff attorney pursue the case against the physician.

 

[Rendar5]

Just an example. Say a hospital instituted a policy to only cath inferior STEMI and never to cath or TNK/tpa a lateral STEMI. A physician who just admitted a giant lateral STEMI with a bad outcome would easily be held liable for gross negligence for following a stupid policy. Would you suggest censuring someone for providing an opinion on that?

I’d suggest looking at the EW deposition first before censuring him. Then if he says ridiculous things as opposed to what you said, go for it. If he said things in line with what you explained then I don’t think it warrants a censure.

 

[Rekt]

Just an example. Say a hospital instituted a policy to only cath inferior STEMI and never to cath or TNK/tpa a lateral STEMI. A physician who just admitted a giant lateral STEMI with a bad outcome would easily be held liable for gross negligence for following a stupid policy. Would you suggest censuring someone for providing an opinion on that?

I’d suggest looking at the EW deposition first before censuring him. Then if he says ridiculous things as opposed to what you said, go for it. If he said things in line with what you explained then I don’t think it warrants a censure.

Terrible take. Snakebites are incredibly rare depending on where you trained and work. I’ve seen 10x as many ascending aortic dissections than I have snake bites and see STEMIs weekly. Snake bites are not bread and butter EM. Sure I studied it a bunch of times for in service and written, but the first thing I’d be doing is looking up what I’m doing with it. Either calling tox or just giving antivenom regardless of hospital burden or cost. If the hospital had some type of algorithm then I’d easily consider that as well.

 

[ShockIndex]

Just an example. Say a hospital instituted a policy to only cath inferior STEMI and never to cath or TNK/tpa a lateral STEMI. A physician who just admitted a giant lateral STEMI with a bad outcome would easily be held liable for gross negligence for following a stupid policy. Would you suggest censuring someone for providing an opinion on that?

I’d suggest looking at the EW deposition first before censuring him. Then if he says ridiculous things as opposed to what you said, go for it. If he said things in line with what you explained then I don’t think it warrants a censure.

I get that you’re using hyperbole. However, there are multiple professional societies providing guidance and even oversight on the institutional management of emergency department patients with STEMI - AHA, ACEP, Joint Commission, and even AAEM all have something to say and the message is remarkably well aligned.

No such consensus exists for when to give antivenom for rattlesnake bites.

Also, I’ve read Dr. Abo’s affidavit. It’s interesting to say the least.

 

[Mount Asclepius]

I deal with snakebites regularly. Poison control is not helpful in the immediate management. This lawsuit was a big reach.

 

[Mount Asclepius]

@Rekt We see snakebites several times per month seasonally in an endemic area. Administer anti-venom for non-dry bite envenomations and admit. Why do you need poison control? Why are you rolling your eyes? It’s super easy medicine.

 

[southerndoc]

Agreed he is big in the EMS world… I’m highly curious who he testified for and what his basis was if he did testify for the plaintiff and why he would go against acep and their backing of another ER doc???

Big in EMS world? Never heard of him until today.

 

[HoosierdaddyO]

Big in EMS world? Never heard of him until today.

He is rather active at NAEMSP… just bc ya never heard of him doesn’t mean he’s not known in a small community lol🤷‍♂️😋

 

[BoardingDoc]

He is rather active at NAEMSP… just bc ya never heard of him doesn’t mean he’s not known in a small community lol🤷‍♂️😋

Is the "small community" ems? Because it I recall correctly, southerndoc is an EMS director.

 

[HoosierdaddyO]

Is the "small community" ems? Because it I recall correctly, southerndoc is an EMS director.

Haha I am one as well😊

 

[Rendar5]

Terrible take. Snakebites are incredibly rare depending on where you trained and work. I’ve seen 10x as many ascending aortic dissections than I have snake bites and see STEMIs weekly. Snake bites are not bread and butter EM. Sure I studied it a bunch of times for in service and written, but the first thing I’d be doing is looking up what I’m doing with it. Either calling tox or just giving antivenom regardless of hospital burden or cost. If the hospital had some type of algorithm then I’d easily consider that as well.

I agree with you.
I’m just saying adhering to a hospital policy isn’t a perfect or automatic defense and the expert witness isn’t so far off as to be censured based on what I have heard here. I would also call poison control as I do not know the standard of care for envenomations.

 

[GonnaBeADoc2222]

I agree with you.
I’m just saying adhering to a hospital policy isn’t a perfect or automatic defense and the expert witness isn’t so far off as to be censured based on what I have heard here. I would also call poison control as I do not know the standard of care for envenomations.

Why wouldn't adhering to policy be a good defense? Like wut lol.

Why would you ever call poison control? So that some RN can read uptodate to you?

Everytime I call poison control it's the same answer "get labs, check EKG, observe for 6 hours."

If I'm involving poison control it's because it's a complex tox case that I don't see often and I'm talking to the attending toxicologist.

 

[carbonizedeyesockets]

The doc followed the standard of care. The standard of care was the guideline established by the hospital.

Suit should have been against the hospital for establishing a standard if it was not in line with recommendations from whatever expert organization or consensus panel.

 

[HemeOncHopeful19]

I’m interested in everyone’s thoughts from a discussion elsewhere on the internet the impression I got seemed to be:

1) This doc should not be thrown under the bus and was rightfully exonerated, BUT…

2) The scoring system that protocol used was designed for research and not clinical purposes

3) The hospital “protocol” has more to do with preventing the use of a very expensive medication in a setting where the patient may have bad (or no) insurance

4) If my kid was bit by a rattlesnake in this situation I should absolutely want Crofab ordered on initial eval

 

[GonnaBeADoc2222]

I’m interested in everyone’s thoughts from a discussion elsewhere on the internet the impression I got seemed to be:

1) This doc should not be thrown under the bus and was rightfully exonerated, BUT…

2) The scoring system that protocol used was designed for research and not clinical purposes

3) The hospital “protocol” has more to do with preventing the use of a very expensive medication in a setting where the patient may have bad (or no) insurance

4) If my kid was bit by a rattlesnake in this situation I should absolutely want Crofab ordered on initial eval

I mean there's criteria right? And risks of administration?

You're an onc right? Does everyone with malignancy x get chemotx y?

 

[anonperson]

I’m interested in everyone’s thoughts from a discussion elsewhere on the internet the impression I got seemed to be:

1) This doc should not be thrown under the bus and was rightfully exonerated, BUT…

2) The scoring system that protocol used was designed for research and not clinical purposes

3) The hospital “protocol” has more to do with preventing the use of a very expensive medication in a setting where the patient may have bad (or no) insurance

4) If my kid was bit by a rattlesnake in this situation I should absolutely want Crofab ordered on initial eval

Who made the protocol?

We can't just say the hospital. In any half way functioning hospital, it's members of the department (physicians) who create and vote on these protocols with input from various other players.

These things get voted on and approved by the department and then the med exec committee.

If this protocol wasn't reasonable that needs to be addressed and changed from a department level.

 

[ShockIndex]

I’m interested in everyone’s thoughts from a discussion elsewhere on the internet the impression I got seemed to be:

1) This doc should not be thrown under the bus and was rightfully exonerated, BUT…

2) The scoring system that protocol used was designed for research and not clinical purposes

3) The hospital “protocol” has more to do with preventing the use of a very expensive medication in a setting where the patient may have bad (or no) insurance

4) If my kid was bit by a rattlesnake in this situation I should absolutely want Crofab ordered on initial eval

A couple of thoughts. The TX SC Justices noted in their decision that the hospital policy was balancing 3 apects of care: conservation of a scarce resource, beneficence of treatment, and harm caused by treatment. In doing so, they probably looked at the risks of the drug (which are not trivial), and harms association with its use.

Interestingly, my understanding of CoFab is that it’s been studied as a stand alone therapy against placebo in a couple of small, open label trials. Most of these studies report modest short-term functional and pain control improvements but the data does not support CroFab as a therapy that would have prevented $1M in damages if given 3 hours earlier as was claimed by the plaintiffs. In EM we see similar claims with TPA and stroke - “if only Aunty Emma had received that clot buster in the ED, she wouldn’t be sentenced to a life of blinking for her food.”

Moreover, I previously posted the summary recommendations from UpToDate that CroFab be considered in consultation with a toxicologist for evidence of “progressive” swelling outside of the head/neck. There is no definition of progressive and the hospital’s protocol MAY be a reasonable standard until such time the tox community can come up with guidance.

Regardless, it would appear that the standard advocated by Dr. Abo that CroFab be given at the first sign of rattlesnake envenomation certainly does not rise to a standard of care much less gross negligence. It is debatable as to whether that standard would even be good medicine.

 

[Rendar5]

Why wouldn't adhering to policy be a good defense? Like wut lol.

Why would you ever call poison control? So that some RN can read uptodate to you?

Everytime I call poison control it's the same answer "get labs, check EKG, observe for 6 hours."

If I'm involving poison control it's because it's a complex tox case that I don't see often and I'm talking to the attending toxicologist.

Oh it is definitely a good defense just not a perfect or automatic defense. It needs to be a reasonable policy or a policy that is beyond a providers typical knowledge. In this case it’s a great defence against. I’m just playing devils advocate. And also explaining why I don’t think the expert witness should be censured even though I completely disagree with him

 

[GonnaBeADoc2222]

Oh it is definitely a good defense just not a perfect or automatic defense. It needs to be a reasonable policy or a policy that is beyond a providers typical knowledge. In this case it’s a great defence against. I’m just playing devils advocate. And also explaining why I don’t think the expert witness should be censured even though I completely disagree with him

Why shouldn't he be censured?

He purports to be something he isn't and gave bull**** testimony.

 

[Rendar5]

Why shouldn't he be censured?

He purports to be something he isn't and gave bull**** testimony.

You just had some people in this thread say they would have given crofab immediately. That means there is an arguable case for deviation and direct damages. Arguable doesn’t mean correct. But I’ve seen much more ridiculous expert witness opinions than this (I’ve done prelim reviews on around 15 cases for defense attorneys this year)