Med mal case question

[Groove]

I’m graduating in Florida next year and have been thinking of similar setups since my wife’s residency is going to keep us based here for another few years.

Right now I’m thinking Texas or Indiana are the best bets, but would be curious if you have any other places you’ve found favorable med mal climates and rates.

Find some of the bigger locums companies (Weatherby, Staffcare, etc..) and do a search on their site for locums jobs in nearby states to see if very many are available. An alternative would be to just call up Weatherby or Staffcare for instance, and simply tell them your situation and that you are looking for minimal travel from Florida but are interested in obtaining licensing and doing FT locums in states that have reliable ongoing needs. The staffcare website will give you ballpark rates which I like and you can peruse around until you find a state that offers a good combination of opportunities and pay. This is basically what I did when I was looking for locums during my last 2 years of residency and ended up getting a license in VA which used to be super quick...like 2-3 weeks or something. I've actually kept it active for my entire career as a backup for emergencies. There always seem to be locums gigs available there. I used to keep my TX license active for the same reasons but let it lapse because it's a more expensive license.

Weatherby or StaffCare would probably love to help you out. Aside from some initial haggling, I had a pretty good experience with Weatherby for a couple of years. They'd figure out all my gigs, get my flights, get my rental car, get my hotel, etc.. I just had to show up. It was pretty easy. You just gave them what days/nights you were available for the month and they did all the leg work. I've worked with some colleagues that were also pretty happy with StaffCare but I've never worked with that company.

An alternative would be to get on the major CMG sites such as TH, Apollo, Schumacher, etc.. and see which states they have a majority of sites. Call them up and see if they have any "firefighter, strike team, etc.." positions where you basically do locums just for them at any of their regional sites. These types of jobs tend to offer more $$/hr. You might even could negotiate a sign on if you guaranteed a couple of years travel locums for them. There's quite a few TH sites in TN, AR, MS with ongoing needs that wouldn't be too far to travel for you. Decent malpractice states. Certainly better than Florida.

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[Kryptocoin]

Can you refuse to settle and go to rial? Is it an option?

Yes but it depends on your insurance. Some policies have a settlement clause. Meaning, an insurance company can settle a case without your permission.

I absolutely believe you shouldn't be forced to settle a case. It should be your decision.

 

[The Knife & Gun Club]

Find some of the bigger locums companies (Weatherby, Staffcare, etc..) and do a search on their site for locums jobs in nearby states to see if very many are available. An alternative would be to just call up Weatherby or Staffcare for instance, and simply tell them your situation and that you are looking for minimal travel from Florida but are interested in obtaining licensing and doing FT locums in states that have reliable ongoing needs. The staffcare website will give you ballpark rates which I like and you can peruse around until you find a state that offers a good combination of opportunities and pay. This is basically what I did when I was looking for locums during my last 2 years of residency and ended up getting a license in VA which used to be super quick...like 2-3 weeks or something. I've actually kept it active for my entire career as a backup for emergencies. There always seem to be locums gigs available there. I used to keep my TX license active for the same reasons but let it lapse because it's a more expensive license.

Weatherby or StaffCare would probably love to help you out. Aside from some initial haggling, I had a pretty good experience with Weatherby for a couple of years. They'd figure out all my gigs, get my flights, get my rental car, get my hotel, etc.. I just had to show up. It was pretty easy. You just gave them what days/nights you were available for the month and they did all the leg work. I've worked with some colleagues that were also pretty happy with StaffCare but I've never worked with that company.

An alternative would be to get on the major CMG sites such as TH, Apollo, Schumacher, etc.. and see which states they have a majority of sites. Call them up and see if they have any "firefighter, strike team, etc.." positions where you basically do locums just for them at any of their regional sites. These types of jobs tend to offer more $$/hr. You might even could negotiate a sign on if you guaranteed a couple of years travel locums for them. There's quite a few TH sites in TN, AR, MS with ongoing needs that wouldn't be too far to travel for you. Decent malpractice states. Certainly better than Florida.

Groove this is a spectacular write up. I didn’t even know staffcere existed. How was locums straight out of residency? Terrifying night-time single coverage dumpster fires, or was it manageable?

I did actually talk to a team health person and they wanted to send me back to their firefighter team in Florida lol.

 

[Groove]

Groove this is a spectacular write up. I didn’t even know staffcere existed. How was locums straight out of residency? Terrifying night-time single coverage dumpster fires, or was it manageable?

I did actually talk to a team health person and they wanted to send me back to their firefighter team in Florida lol.

I did most of my locums during my PGY 3 and 4 years and also during my first year out. They were all single coverage EDs with limited resources. Typically, not the ideal environment for a new grad since you're working alone most of the time but totally doable. You just have to have realistic expectations considering you are staffing sites where they are obviously having great difficulty finding docs to work, usually for a myriad of reasons.

 

[johnny_bananas]

Based on this story (and the fact that neurointervention was performed within 3 hours which is hardly a delay), I'd guess that the patient likely had a large infarct core with very little salvageable penumbra tissue, and therefore would have been a poor thrombectomy candidate anyway. A CTP would probably have shown that (although CTP for a large vessel obstruction within the first 6 hours is not considered necessary). In which case, the thrombectomy didn't help, but also likely didn't hurt. So this would not have been "bad outcome after thrombectomy" but rather "poor candidate for thrombectomy who unsurprisingly didn't get better after thrombectomy". If the CTP had actually been performed, perhaps there would have been no lawsuit at all, since the fact that this was a poor thrombectomy candidate, not a bad outcome, would have been demonstrated. All speculation at this point, of course. But as others have said, I don't see where anyone dropped the ball here, or patient care suffered.

You say "he had no collateral blood flow", how do you know that without a CTA or CTP?

" the fact that neurointervention was performed within 3 hours which is hardly a delay"

3 hours is a significant delay!

This is not to put any blame on the original poster, as I am not familiar with the case, but I wanted to correct this inaccuracy.

From the patient’s perspective, for every minute faster to recanalization, the average patient gains a week of disability-free life. Save a minute, save a week.

 

[johnny_bananas]

As a stroke neurologist....I have no words. It sounds like you did everything you could. For what it’s worth, I never bat an eye at getting contrasted studies in patients that we are truly concerned about an LVO (“neurons over nephrons”), but I think it’s crazy that this case was even considered for litigation, never mind settled. Especially for a case in 2015, where the evidence for thrombectomy was not nearly as “gold standard” as it is today for LVO.

"Especially for a case in 2015, where the evidence for thrombectomy was not nearly as “gold standard”

I guess it depends when in 2015, already in June the AHA/ASA guidelines were out recommending EVT for LVOs. Mr CLEAN was published in January, ESCAPE in March.

https://www.ahajournals.org/doi/10.1161/str.0000000000000074

 

[The Knife & Gun Club]

" the fact that neurointervention was performed within 3 hours which is hardly a delay"

3 hours is a significant delay!

This is not to put any blame on the original poster, as I am not familiar with the case, but I wanted to correct this inaccuracy.

From the patient’s perspective, for every minute faster to recanalization, the average patient gains a week of disability-free life. Save a minute, save a week.

I think they’re saying delay vs standard of care. Idk how fast you all are able to go from stroke alert to angio suite but 3 hours isn’t a horrendous door to needle time in a shop that doesn’t have nsgy in house 24/7.

 

[The Knife & Gun Club]

"Especially for a case in 2015, where the evidence for thrombectomy was not nearly as “gold standard”

I guess it depends when in 2015, already in June the AHA/ASA guidelines were out recommending EVT for LVOs. Mr CLEAN was published in January, ESCAPE in March.

https://www.ahajournals.org/doi/10.1161/str.0000000000000074

Again don’t view these cases from the golden lense of an academic tertiary center. There’s many shops that were not yet routinely doing thrombectomy as standard of care well into 2015 and beyond.

Like in 2019 our community shop became a stroke “some important BS metric” center. They got a Neuro-interventionalist. One dude. Prior to that they had 0 dudes. And this is for a hospital that took stroke care pretty seriously, had a Neuro intensivist, 200 inpatient beds, etc.

 

[larpleston]

" the fact that neurointervention was performed within 3 hours which is hardly a delay"

3 hours is a significant delay!

This is not to put any blame on the original poster, as I am not familiar with the case, but I wanted to correct this inaccuracy.

From the patient’s perspective, for every minute faster to recanalization, the average patient gains a week of disability-free life. Save a minute, save a week.

Except it's not. You are biased by being in training at an academic site with in house everything (not the reality at 90% of hospitals in this country).

Here's a study from Mayo in Florida where they almost certainly have an interventional suite ready to go at any hour of the day. They went from 170 minutes to 130 minutes after doing a massive QI project. So 130 minutes with everything going right. Now add on the extra time when you don't have a neurointerventionalist twiddling their thumbs down the hall.

Reducing Door-to-Reperfusion Time for Mechanical Thrombectomy With a Multitiered Notification System for Acute Ischemic Stroke

To reduce door-to-angiographic reperfusion (DTR) time to 120 minutes for patients presenting with acute ischemic stroke attributed to anterior circulation large-vessel occlusion amenable to endovascular mechanical thrombectomy.Patients treated with mechanical ...

www.ncbi.nlm.nih.gov

 

[johnny_bananas]

I think they’re saying delay vs standard of care. Idk how fast you all are able to go from stroke alert to angio suite but 3 hours isn’t a horrendous door to needle time in a shop that doesn’t have nsgy in house 24/7.

I do work in an academic hospital, and we don't have neuro-interventionalists or stroke neurologists in-house. 3 hours is horrendous, the majority of cases should be within 30 minutes from CTA.

Let us remember why the delay occurred in the first place. There was a significant delay to obtain the CTA, and apparently a difficulty getting a hold of a neuro-interventionalist, completely preventable. An academic centre is not special in any way, these issues are largely preventable with correct systems in place, and can be achieved in "community shops".

I understand this is an unfortunate situation and I am certainly not placing blame on anyone, but we should not pretend that this is "normal" or acceptable to wait 3 hours to get the patient to the angio suite.

Here is what the ASA/AHA guideline said in 2015 advising for "rapid access to cerebral angiography."

"Endovascular therapy requires the patient to be at an experienced stroke center with rapid access to cerebral angiography and qualified neurointerventionalists. Systems should be designed, executed, and monitored to emphasize expeditious assessment and treatment. Outcomes for all patients should be tracked. Facilities are encouraged to define criteria that can be used to credential individuals who can perform safe and timely intra-arterial revascularization procedures (Class I; Level of Evidence E).

If a hospital, whether that be academic or community, cannot achieve this they should not pretend to be a stroke centre, and the patient should be sent to a hospital that can provide the care they advertise. How would you feel if your family member had a large stroke/LVO and had to wait 3 hours to arrive to the angio suite?

 

[johnny_bananas]

Except it's not. You are biased by being in training at an academic site with in house everything (not the reality at 90% of hospitals in this country).

Here's a study from Mayo in Florida where they almost certainly have an interventional suite ready to go at any hour of the day. They went from 170 minutes to 130 minutes after doing a massive QI project. So 130 minutes with everything going right. Now add on the extra time when you don't have a neurointerventionalist twiddling their thumbs down the hall.

Reducing Door-to-Reperfusion Time for Mechanical Thrombectomy With a Multitiered Notification System for Acute Ischemic Stroke

To reduce door-to-angiographic reperfusion (DTR) time to 120 minutes for patients presenting with acute ischemic stroke attributed to anterior circulation large-vessel occlusion amenable to endovascular mechanical thrombectomy.Patients treated with mechanical ...

www.ncbi.nlm.nih.gov

Thanks for the article, the paper you sent was measuring door-to-reperfusion, which can vary quite a bit depending on how difficult the thrombectomy is.

I am talking about door-to-groin puncture, which is the amount of time to evaluate the patient, obtain the CTA, and send the patient to the angio suite. Do you think that should take 3 hours?

 

[larpleston]

Thanks for the article, the paper you sent was measuring door-to-reperfusion, which can vary quite a bit depending on how difficult the thrombectomy is.

I am talking about door-to-groin puncture, which is the amount of time to evaluate the patient, obtain the CTA, and send the patient to the angio suite. Do you think that should take 3 hours?

Do I think it should? No. Do I have a good understanding of why it does as the doc responsible for orchestrating the logistics of making it happen? Yes. Does the neurologist have any understanding of the flow of the ER and EMS systems that ultimately determine how long it takes? Also no. Humility bro, it’s a hell of a drug. You just don’t get why it takes so long, because dispositioning undifferentiated patients to wherever they need to be is not part of your job. No harm in admitting that. And FYI, 3% of patients had door to perfusion times of less than 60 minutes in 2018 (source is lmgtfy), subtract 20 minutes for puncture or whatever other number you’d like.

 

[southerndoc]

I do work in an academic hospital, and we don't have neuro-interventionalists or stroke neurologists in-house. 3 hours is horrendous, the majority of cases should be within 30 minutes from CTA.

Let us remember why the delay occurred in the first place. There was a significant delay to obtain the CTA, and apparently a difficulty getting a hold of a neuro-interventionalist, completely preventable. An academic centre is not special in any way, these issues are largely preventable with correct systems in place, and can be achieved in "community shops".

I understand this is an unfortunate situation and I am certainly not placing blame on anyone, but we should not pretend that this is "normal" or acceptable to wait 3 hours to get the patient to the angio suite.

Here is what the ASA/AHA guideline said in 2015 advising for "rapid access to cerebral angiography."

"Endovascular therapy requires the patient to be at an experienced stroke center with rapid access to cerebral angiography and qualified neurointerventionalists. Systems should be designed, executed, and monitored to emphasize expeditious assessment and treatment. Outcomes for all patients should be tracked. Facilities are encouraged to define criteria that can be used to credential individuals who can perform safe and timely intra-arterial revascularization procedures (Class I; Level of Evidence E).

If a hospital, whether that be academic or community, cannot achieve this they should not pretend to be a stroke centre, and the patient should be sent to a hospital that can provide the care they advertise. How would you feel if your family member had a large stroke/LVO and had to wait 3 hours to arrive to the angio suite?

You say you're not placing blame on anyone, yet you're placing blame by saying 3 hours is horrendous, there was a significant delay in obtaining the CTA, and difficulty getting ahold of the neurointerventionist. That's casting blame.

I agree with you that a shop with an endovascular stroke program should be able to get someone on the table within 30 minutes in ideal situations. We strive for this, but can't achieve it 100% of the time due to multiple strokes at once among other delays. We achieve it most times though.

For a place that has to transfer, this is never going to happen.

 

[johnny_bananas]

Do I think it should? No. Do I have a good understanding of why it does as the doc responsible for orchestrating the logistics of making it happen? Yes. Does the neurologist have any understanding of the flow of the ER and EMS systems that ultimately determine how long it takes? Also no. Humility bro, it’s a hell of a drug. You just don’t get why it takes so long, because dispositioning undifferentiated patients to wherever they need to be is not part of your job. No harm in admitting that. And FYI, 3% of patients had door to perfusion times of less than 60 minutes in 2018 (source is lmgtfy), subtract 20 minutes for puncture or whatever other number you’d like.

Normalizing systems that lead to failure is not being “humble” but being part of the problematic system that will only lead to similar unfortunate outcomes in the future. Just ask yourself if this was your family member, would you be defending the delay to CTA?

“You just don’t get why it takes so long, because dispositioning undifferentiated patients to wherever they need to be is not part of your job.”

Actually I do, any consult I receive from the ER or code stroke protocol I am responsible for disposition. Even if that patient is not a stroke. ED physicians are not the only ones that deal with triaging patients/issues.

 

[johnny_bananas]

You say you're not placing blame on anyone, yet you're placing blame by saying 3 hours is horrendous, there was a significant delay in obtaining the CTA, and difficulty getting ahold of the neurointerventionist. That's casting blame.

I agree with you that a shop with an endovascular stroke program should be able to get someone on the table within 30 minutes in ideal situations. We strive for this, but can't achieve it 100% of the time due to multiple strokes at once among other delays. We achieve it most times though.

For a place that has to transfer, this is never going to happen.

I said I am not placing blame on any individual, and certainly not the original poster. I don’t know the specific details of the case, but as the case was explained it does sound that the 'system' failed in multiple ways. Why did the radiologist/tech cancel a code stroke CTA over a creatine? Why was there no timely follow-up after the CTA was cancelled? I agree with you that systems are not always ideal, but we should not pretend there was no human error in this situation, and this was not preventable.

Even the example you gave, of multiple strokes at the same time would not lead to a delay of 3 hours, that is how “horrendous” of a delay it is.

Imagine if this was your family member, how would you feel if I said, well we strive for ideal situations, “but can’t achieve it 100% of the time” that is why there was a delay of 3 hours?

 

[larpleston]

Actually I do, any consult I receive from the ER or code stroke protocol I am responsible for disposition. Even if that patient is not a stroke. ED physicians are not the only ones that deal with triaging patients/issues.

Lol no you’re not. You give a recommendation, same as any consultant. Everything prior to that recommendation is handled by the ER doc.

Seriously, we don’t even get credit for being triage monkeys anymore 🤣🤣🤣

Side note, one of the biggest mistakes made in EM was being too ‘normal’ and blue collar. We ditched the coat and the stethoscope around the neck and the C suite and our colleagues stopped taking us seriously. Heck, it was a major factor for many of us in choosing this specialty. We don’t exhibit the delusional levels of hubris endemic to so many subspecialists and we aren’t taken seriously as a result. If only we could fall on the same part of the Dunning Kruger curve as all these jokers we interact with everyday we wouldn’t have fallen so far in the house of medicine.

 

[BoardingDoc]

Normalizing systems that lead to failure is not being “humble” but being part of the problematic system that will only lead to similar unfortunate outcomes in the future. Just ask yourself if this was your family member, would you be defending the delay to CTA?

“You just don’t get why it takes so long, because dispositioning undifferentiated patients to wherever they need to be is not part of your job.”

Actually I do, any consult I receive from the ER or code stroke protocol I am responsible for disposition. Even if that patient is not a stroke. ED physicians are not the only ones that deal with triaging patients/issues.

No one is discounting your help or the fact that you are involved in these consults. That said, having that experience makes you as much of an expert in the realities of ED logistics as me diagnosing a stroke makes me an expert in the actual process of a neurologic intervention. These logistic issues are doubly challenging when looking at a case that originates in a community hospital and requires a transfer.

 

[The Knife & Gun Club]

Normalizing systems that lead to failure is not being “humble” but being part of the problematic system that will only lead to similar unfortunate outcomes in the future. Just ask yourself if this was your family member, would you be defending the delay to CTA?

“You just don’t get why it takes so long, because dispositioning undifferentiated patients to wherever they need to be is not part of your job.”

Actually I do, any consult I receive from the ER or code stroke protocol I am responsible for disposition. Even if that patient is not a stroke. ED physicians are not the only ones that deal with triaging patients/issues.

Look, man. I know you want to come over to the ER forum and cast shade on our stroke care. But take a second to think about how you sound. Have you ever managed a pod in an ER? No one down here is twiddling their thumbs while a stroke burns brain.

Imagine you’re doing this stroke alert but also have 5 other time sensitive stroke alert grade patients going on at the same time in various stages of their work up. Someone needs a tube, someone needs a line, a code is being run on a patient. You step away for 20 minutes and when you get back realize no one shot the CTA cuz some rad tech canceled the study. You call them back and wheel them back to the scanner. Argue with the tech who’s a traveler and doesn’t want to “risk his license.” The ED doc then relays to the neurologist who relays to the neurosurgeon now have a scan! You can imagine how all those little time blips add up.

 

[southerndoc]

Don't feed the troll. Seriously, this person is a neurologist that probably serves as an expert witness and is too defensive of the perfection of medicine to even have a discussion with.

Back to the OP, I don't think you did anything wrong.

 

[Vandalia]

If a hospital, whether that be academic or community, cannot achieve this they should not pretend to be a stroke centre, and the patient should be sent to a hospital that can provide the care they advertise. How would you feel if your family member had a large stroke/LVO and had to wait 3 hours to arrive to the angio suite?

In most of the United States it would take over 3 hours to get them to such a facility.

 

[johnny_bananas]

Look, man. I know you want to come over to the ER forum and cast shade on our stroke care. But take a second to think about how you sound. Have you ever managed a pod in an ER? No one down here is twiddling their thumbs while a stroke burns brain.

Imagine you’re doing this stroke alert but also have 5 other time sensitive stroke alert grade patients going on at the same time in various stages of their work up. Someone needs a tube, someone needs a line, a code is being run on a patient. You step away for 20 minutes and when you get back realize no one shot the CTA cuz some rad tech canceled the study. You call them back and wheel them back to the scanner. Argue with the tech who’s a traveler and doesn’t want to “risk his license.” The ED doc then relays to the neurologist who relays to the neurosurgeon now have a scan! You can imagine how all those little time blips add up.

Cast shade? I never casted any blame on the ED physician, in fact how the case was described, to me it sounded like the stroke neurologist was responsible, but I don’t think it is helpful to talk about the role of the individual physicians as we don’t have the details.

The only reason I posted was to dispel the myth that 3 hours is the standard of care or acceptable as someone posted, it is not! To be honest, I am surprised by how many of you are trying to defend it. The fact that no one can answer how they would feel if this was their family member speaks volumes, **** happens to other patients, but we all know you would feel differently if this was your family member.

And again with the assumptions. You honestly think me or other physicians don’t deal with multiple emergencies at the same time? I might deal with multiple stroke protocols, unstable patients in the neurology inpatients service or ICU. It is not an excuse!

Let me spell out the times in a typical situation for your guys:
-15 minutes (neurological examination, BW, CT transfer).
-10 minutes (CT/CTA).
-15 minutes speaking to the stroke neurologist, reviewing images.
-10 minutes transfer to angio suite if there is no tPA.

There is 2.16 hours left. The CT/CTA was cancelled, you are all suggesting that it takes an additional 2.16 hours to obtain another CT/CTA? Say I was the stroke neurologist on the other end and I am sequentially dealing with another emergent case. How long does it take to page the radiologist/tech to scream at them? Just kidding, I would politely tell them I need another CTA right away, and to never cancel a acute stroke CTA, unless said otherwise.

 

[johnny_bananas]

Don't feed the troll. Seriously, this person is a neurologist that probably serves as an expert witness and is too defensive of the perfection of medicine to even have a discussion with.

Back to the OP, I don't think you did anything wrong.

Keep your head in the sand, you sound like an excellent physician!

 

[johnny_bananas]

In most of the United States it would take over 3 hours to get them to such a facility.

The patient did not not need any transfer, only for the techs to be instructed not to cancel CTAs in a code stroke, or for a physician (my opinion the stroke neurologist but I don't know the specifics) to follow up on the patient in a timely manner and realize the CTA was cancelled. All human errors, the remedy is not a "specialized" facility.

 

[johnny_bananas]

No one is discounting your help or the fact that you are involved in these consults. That said, having that experience makes you as much of an expert in the realities of ED logistics as me diagnosing a stroke makes me an expert in the actual process of a neurologic intervention. These logistic issues are doubly challenging when looking at a case that originates in a community hospital and requires a transfer.

The response was to ’The Knife & Gun Club’ who assumed I don’t deal with disposition issues. Also, the case was not requiring a transfer, but a CTA.

 

[namethatsmell]

Don't feed the troll. Seriously, this person is a neurologist that probably serves as an expert witness and is too defensive of the perfection of medicine to even have a discussion with.

Back to the OP, I don't think you did anything wrong.

1000% agree

And what's with the repeated "what if it were your family member"...quasi-strawman argument. Pleeeeease.

Of course we want door-->needle/knife de jour to be as fast as possible...and the reality is that this timing depends on the frequently overwhelmed+dysfunctional system over which most of us have no meaningful control. That doesn't mean it's not worth fighting for--it is. And we do this every single shift.

But IF it were my family member...I'd expect a dedicated interventional stroke doc waiting 24/7 in the ER to receive my loved one, said doc to never be wrong and make 0 mistakes while telling pithy jokes to brighten everybody's day, and along the way take the initiative to do things like push my loved one to the scanner if an unexpected logistical issue popped up. You know, a doc who's responsible to make sure everything is perfect in spite of a deeply flawed and imperfect system.

 

[johnny_bananas]

Lol no you’re not. You give a recommendation, same as any consultant. Everything prior to that recommendation is handled by the ER doc.

Seriously, we don’t even get credit for being triage monkeys anymore 🤣🤣🤣

Side note, one of the biggest mistakes made in EM was being too ‘normal’ and blue collar. We ditched the coat and the stethoscope around the neck and the C suite and our colleagues stopped taking us seriously. Heck, it was a major factor for many of us in choosing this specialty. We don’t exhibit the delusional levels of hubris endemic to so many subspecialists and we aren’t taken seriously as a result. If only we could fall on the same part of the Dunning Kruger curve as all these jokers we interact with everyday we wouldn’t have fallen so far in the house of medicine.

Lol no you’re not. You give a recommendation, same as any consultant. Everything prior to that recommendation is handled by the ER doc.

Seriously, we don’t even get credit for being triage monkeys anymore 🤣🤣🤣

Side note, one of the biggest mistakes made in EM was being too ‘normal’ and blue collar. We ditched the coat and the stethoscope around the neck and the C suite and our colleagues stopped taking us seriously. Heck, it was a major factor for many of us in choosing this specialty. We don’t exhibit the delusional levels of hubris endemic to so many subspecialists and we aren’t taken seriously as a result. If only we could fall on the same part of the Dunning Kruger curve as all these jokers we interact with everyday we wouldn’t have fallen so far in the house of medicine.

Lol, there are other hospitals than your community hospital you work in, you do realize that?

 

[Mount Asclepius]

Hey Johnny,
Let me hear you say, this s**t is bananas.

Sincerely,
I ain't no hollaback girl

(You don’t have a very good understanding of life in the ED)

 

[namethatsmell]

The patient did not not need any transfer, only for the techs to be instructed not to cancel CTAs in a code stroke, or for a physician (my opinion the stroke neurologist but I don't know the specifics) to follow up on the patient in a timely manner and realize the CTA was cancelled. All human errors, the remedy is not a "specialized" facility.

You just accurately described a textbook system issue (multiple issues, actually). How in the world does patient care improve if we respond by deciding to just select a fall guy/girl and chalk everything up to their sole actions while ignoring the reality of the environment? Doing so not only borders on moral injury, it also solves nothing, sows discord and mistrust amongst colleagues, and dooms the cycle to continue....

FWIW, I'm not sure that's what you're suggesting or trying to put words in your mouth. I honestly can't tell.

 

[johnny_bananas]

1000% agree

And what's with the repeated "what if it were your family member"...quasi-strawman argument. Pleeeeease.

Of course we want door-->needle/knife de jour to be as fast as possible...and the reality is that this timing depends on the frequently overwhelmed+dysfunctional system over which most of us have no meaningful control. That doesn't mean it's not worth fighting for--it is. And we do this every single shift.

But IF it were my family member...I'd expect a dedicated interventional stroke doc waiting 24/7 in the ER to receive my loved one, said doc to never be wrong and make 0 mistakes while telling pithy jokes to brighten everybody's day, and along the way take the initiative to do things like push my loved one to the scanner if an unexpected logistical issue popped up. You know, a doc who's responsible to make sure everything is perfect in spite of a deeply flawed and imperfect system.

There was a dedicated stroke neurologist and interventionalist at the hospital.

 

[thegenius]

For a place that has to transfer, this is never going to happen.

Never ever! I can’t get an accepting physician on the phone in 30 mins. Hell we can’t even push tPA within 30 minutes sometimes.

 

[thegenius]

Don't feed the troll. Seriously, this person is a neurologist that probably serves as an expert witness and is too defensive of the perfection of medicine to even have a discussion with.

Back to the OP, I don't think you did anything wrong.

I hope this neurologist appears within 30 seconds of being consulted and renders a timely opinion in 5-10 minutes. I never want a delay out of him.

 

[johnny_bananas]

You just accurately described a textbook system issue (multiple issues, actually). How in the world does patient care improve if we respond by deciding to just select a fall guy/girl and chalk everything up to their sole actions while ignoring the reality of the environment? Doing so not only borders on moral injury, it also solves nothing, sows discord and mistrust amongst colleagues, and dooms the cycle to continue....

FWIW, I'm not sure that's what you're suggesting or trying to put words in your mouth. I honestly can't tell.

This will be my last post on the subject, since it seems I touched a nerve, when all I was trying to do is correct the notion that 3 hours (door to angio suite) is not within standard of care as someone suggested.

I certainly was not casting blame on the ED physician. Again, how I look at it, the stroke neurologist should have followed up on the CTA, but like I said multiple times I don't think we know the specifics of the case to address the responsibility of the physicians.

We can blame the system all we want and the "reality of the environment", but we are part of that system and human error contributes to mistakes. Ignoring this is not helpful, and perpetuates error, and the attitude exhibited by posters that these things happen due to the chaotic environment means that it will continue to reoccur. It would be important for all ED physicians to clarify who is responsible for following up on CT/CTAs after a code stroke. As I mentioned and for some reason was not believed, where I work, after a code stroke the ED physicians have minimal role. It is absolutely clear that neurologists follow up on CT/CTAs.

 

[johnny_bananas]

I hope this neurologist appears within 30 seconds of being consulted and renders a timely opinion in 5-10 minutes. I never want a delay out of him.

Does anyone actually read posts before commenting. Where I work, when a code stroke is activated, the neurologist is the MRP. We don't give an opinion to the EM physician, we deal with the case ourselves. Also we are not talking about a 5-10 minute delay, but a >2 hour delay.

 

[cyanide12345678]

My attorney explained that this investigation will happen, although no one knows when. I could receive the certified letter today or years from now. He said that in 95% of cases, nothing happens in terms of disciplinary action. Other cases may involve CME, fines in the 2-5k range that malpractice insurance doesn’t cover or even suspension/loss of license.

The malpractice climate in Florida is very unfriendly and I’m constantly in fear of another lawsuit.

I've been involved in one lawsuit, i was dismissed because i had almost nothing to do with the case other than responding to a code blue, but even that experience sucked. Our system is so completely broken.

I tried moving to Texas partly because i fear further lawsuits but the job market was crappy, so i picked indiana personally. I never thought id move here, but i truly only made that decision based on tort reform, taxes, cost of living.

I can't believe you were held responsible for a bad outcome from a thrombectomy. I don't know what an ER doctor has to do with that. With hospitals being so full and delays in care everywhere, i feel like the next couple of years there might be a lot of lawsuits.

 

[MedicineZ0Z]

I did most of my locums during my PGY 3 and 4 years and also during my first year out. They were all single coverage EDs with limited resources. Typically, not the ideal environment for a new grad since you're working alone most of the time but totally doable. You just have to have realistic expectations considering you are staffing sites where they are obviously having great difficulty finding docs to work, usually for a myriad of reasons.

The patient populations who come to those ERs are also far less likely to sue. In addition, the standard of care is somewhat "different" in rural settings. You're basically limited by your resources.

 

[thegenius]

Does anyone actually read posts before commenting. Where I work, when a code stroke is activated, the neurologist is the MRP. We don't give an opinion to the EM physician, we deal with the case ourselves. Also we are not talking about a 5-10 minute delay, but a >2 hour delay.

I don’t know what an MRP is, and I can assure you that your arrangement is not the case in 99% of all ERs.

 

[johnny_bananas]

I don’t know what an MRP is, and I can assure you that your arrangement is not the case in 99% of all ERs.

MRP - most responsible physician. I don't know the frequency of arrangements, you might be right. The initial comment was to the poster who wrote "You just don’t get why it takes so long, because dispositioning undifferentiated patients to wherever they need to be is not part of your job."

 

[Groove]

You guys do realize this bananas character is likely a resident/fellow, right?

 

[johnny_bananas]

You guys do realize this bananas character is likely a resident/fellow, right?

Let us follow your logic or lack thereof.

If your assumption was true, would anything I said be less true? Would that change the fact that 3hrs from door-to-angio suite is not within standard of care, which one of your colleagues initially suggested and I attempted to correct. There is a common theme between many of you, you make assumptions about other physicians experiences (ad hominem) without ever disputing the actual facts!

Not sure why I keep responding as I am wasting my time, those who choose so can live in ignorance about the facts and be surprised when it bites you in your ass. This will be my last post, take care.

 

[bravotwozero]

"You don’t have a very good understanding of life in the ED."

From speaking to you guys, it seems like a place where mistakes happen and excuses are given. "Bro you don't know how hard we have it!" "Brha you don't know the dysfunctional system we work in" "Bro you don't deal with multiple emergencies at the same time" "Bro you are not the MRP"

And this is what I hear when I didn't even blame the ED physician in first place. All I said, is the fact that 3 hours door to angio suite is not even remotely the standard of care, which one of your ED physicians posted.

I don’t know what you’re on, but lower the dosage

 

[GassYous]

Let us follow your logic or lack thereof.

If your assumption was true, would anything I said be less true? Would that change the fact that 3hrs from door-to-angio suite is not within standard of care, which one of your colleagues initially suggested and I attempted to correct. There is a common theme between many of you, you make assumptions about other physicians experiences (ad hominem) without ever disputing the actual facts!

Not sure why I keep responding as I am wasting my time, those who choose so can live in ignorance about the facts and be surprised when it bites you in your ass. This will be my last post, take care.

You're not as smart or clever as you seem to think you are.

 

[johnny_bananas]

I don’t know what you’re on, but lower the dosage

Not sure where you dug that comment from because I deleted it 5 minutes after I posted it. That comment I did and do retract, it was an unnecessary characterization.

 

[Groove]

Let us follow your logic or lack thereof.

If your assumption was true, would anything I said be less true? Would that change the fact that 3hrs from door-to-angio suite is not within standard of care, which one of your colleagues initially suggested and I attempted to correct. There is a common theme between many of you, you make assumptions about other physicians experiences (ad hominem) without ever disputing the actual facts!

Not sure why I keep responding as I am wasting my time, those who choose so can live in ignorance about the facts and be surprised when it bites you in your ass. This will be my last post, take care.

It won't be your last post because posters like you love the attention, positive or negative. You love arguing with people on SDN because it gives you what you lack the most...validation.

Only a disgruntled resident/fellow with endless time on their hands, suffering from an almost daily insult to their ego from academic attendings, condescending nurses, in a constant state of insecurity, self doubt and subordination has the actual wherewithal and/or time to write 20+ posts on a subject within 36 hours on an anonymous Internet forum. It's like the one place you guys can spar and intellectually joust with an attending, pose as someone with more experience than you actually possess, hurl a few insults, ad hominems and not get reprimanded in your program. It's the one place where anyone without adequate training or real world experience can suddenly become an expert on a subject with a few journals, a calculator, uptodate and the magic of the internet. The fact that you have come in here and attempted to argue with just about everyone who has disagreed with you, most of which are attendings who probably have enough cumulative real world experience to put you back in diapers 2 or 3 times over is incredibly humorous but not entirely surprising.

At first, I was interested in what you had to say...thinking you were some faculty attending with 20 years experience about to teach us a few things on how to improve our practice. Now, it's obvious who you are and I'm just...incredibly bored.

Now, before you start gulping another cup of coffee, frenetically typing away on your laptop while muttering curses to ER docs everywhere...just remember...you said that would be your last post!

P.S. I've lost count of the hospitals I've worked at but I'm still waiting to work in one where I can call the stroke neurologist the MRP!

 

[Groove]

MRP - most responsible physician.

You down with MRP? YEAH YOU KNOW ME. Who's down with MRP? EVERY LAST HOMIE!

 

[johnny_bananas]

It won't be your last post because posters like you love the attention, positive or negative. You love arguing with people on SDN because it gives you what you lack the most...validation.

Only a disgruntled resident/fellow with endless time on their hands, suffering from an almost daily insult to their ego from academic attendings, condescending nurses, in a constant state of insecurity, self doubt and subordination has the actual wherewithal and/or time to write 20+ posts on a subject within 36 hours on an anonymous Internet forum. It's like the one place you guys can spar and intellectually joust with an attending, pose as someone with more experience than you actually possess, hurl a few insults, ad hominems and not get reprimanded in your program. It's the one place where anyone without adequate training or real world experience can suddenly become an expert on a subject with a few journals, a calculator, uptodate and the magic of the internet. The fact that you have come in here and attempted to argue with just about everyone who has disagreed with you, most of which are attendings who probably have enough cumulative real world experience to put you back in diapers 2 or 3 times over is incredibly humorous but not entirely surprising.

At first, I was interested in what you had to say...thinking you were some faculty attending with 20 years experience about to teach us a few things on how to improve our practice. Now, it's obvious who you are and I'm just...incredibly bored.

Now, before you start gulping another cup of coffee, frenetically typing away on your laptop while muttering curses to ER docs everywhere...just remember...you said that would be your last post!

P.S. I've lost count of the hospitals I've worked at but I'm still waiting to work in one where I can call the stroke neurologist the MRP!

You are right on one point, this was not my last post, but it has nothing to do with attention, and more to do with correcting untruths and having some time to do it.

“Only a disgruntled resident/fellow with endless time on their hands, suffering from an almost daily insult to their ego from academic attendings, condescending nurses, in a constant state of insecurity, self doubt and subordination has the actual wherewithal..........”

Classic example of projection, you are displacing your own experiences and feelings onto me. Do they not value you at your job? You don’t have to stay if you are unhappy, I assure you, there is a right fit for you somewhere.

"At first, I was interested in what you had to say...thinking you were some faculty attending with 20 years experience about to teach us a few things on how to improve our practice."

This is laughable, and you are again making my point. What does 20 years of experience have anything to do with arguing the initial point I made. Let us remember, all I said was 3 hours (door-to-angio suite) is not within standard of care, and this resulted in multiple ad hominem attacks like this one. I was not trying to teach, you can open up a journal and teach yourself, I would recommend starting with AHA/ASA guidelines. I was just pointing out the obvious and trying to correct a misconception created by one of your colleagues. To be honest, I am very surprised by the reaction, I didn't realize how thin skinned and sensitive some of you are, breaking down mentally after a simple correction.

"I’ve lost count of the hospitals I've worked at but I'm still waiting to work in one where I can call the stroke neurologist the MRP!"

You should apply to work in an academic institution you might like it. Not sure if you have the credentials though.

 

[Matthew9Thirtyfive]

Okay, looks like a timeout is in order to keep the thread from going completely into another dimension. Let’s try to keep things professional around here.

 

[namethatsmell]

We can blame the system all we want and the "reality of the environment", but we are part of that system and human error contributes to mistakes. Ignoring this is not helpful, and perpetuates error, and the attitude exhibited by posters that these things happen due to the chaotic environment means that it will continue to reoccur. It would be important for all ED physicians to clarify who is responsible for following up on CT/CTAs after a code stroke. As I mentioned and for some reason was not believed, where I work, after a code stroke the ED physicians have minimal role. It is absolutely clear that neurologists follow up on CT/CTAs.

The following is not for johnny_bananas (for all I know, we actually agree on some things), but rather any med students reading this thread who thinks the above post is somehow laudable or should be normalized...

Mr. Bananas is correct -- to varying degrees, we're all part of the "system." And human errors absolutely contribute to mistakes. No question.

The real question is: what do we do about it?

Do we take a myopic view and focus all the energy of an inquiry and blame upon one or a few individuals, dish out some "justice," potentially --and needlessly--ruin some professional careers and further thin the healthcare workforce, all the while doing nothing to improve the system to try to prevent the problem from happening again?

Or, do we acknowledge that to create enduring safeguards against medical errors, we need to broaden our view to embrace all the system and human factors that impact how a patient is cared for? Do we try to create processes to make the system safer and also resilient enough to withstand human errors, and along the way empower everybody in the hospital to speak up if they see something potentially unsafe going on...and without fear of reprisal?

If somebody really has an eye towards improving patient safety and preventing errors for repeating...and also make medicine a more collegial and sustainable field to work in...the latter, not the former, is the way.

 

[WilcoWorld]

Usually I don't think poster's level of training should impact a scientific discussion. We should be able to adjudicate based on facts and logic, not titles. This is a special case, however, as we're arguing what the standard of care was in Florida in 2015. With an area of medicine changing as rapidly as thrombectomy over the last decade having the experience of having practiced 6+ years ago does actually matter when discussing something so variable as standard of care.

 

[thegenius]

I have no idea what the standard of care is for doing a thrombectomy, as we don’t do them at my facility. I do agree that it takes forever to transfer these people and I wouldn’t be surprised if door - transfer - puncture time is on the order of 2-3 hours. The closest hospital that does thrombectomy where I work is about 45 mins away by ambulance.

If door to puncture time is an important metric to be a stroke center, and a particular hospital doesn’t do thrombectomy, then how can it be credentialed if the closest transfer time is 45 mins away and knowing it often takes 2-3 hours to transfer people?

 

[turkeyjerky]

I have no idea what the standard of care is for doing a thrombectomy, as we don’t do them at my facility. I do agree that it takes forever to transfer these people and I wouldn’t be surprised if door - transfer - puncture time is on the order of 2-3 hours. The closest hospital that does thrombectomy where I work is about 45 mins away by ambulance.

If door to puncture time is an important metric to be a stroke center, and a particular hospital doesn’t do thrombectomy, then how can it be credentialed if the closest transfer time is 45 mins away and knowing it often takes 2-3 hours to transfer people?

That assumes that stroke neurologists and the AHA actually care about logistical reality, which is clearly not the case.