Medical Malpractice Case: Pheochromocytoma Death

[bbc586]

Case here: Pheochromocytoma Crisis Induced by Steroids [Pregnant Cardiac Arrest]

33-year-old woman seen in the ED for abdominal pain.

Diagnosed with UTI, PID.

CT showed adrenal nodule but patient (allegedly) not told about this.

She gets pregnant several months later.

Gets steroids for cervical shortening.

Goes into cardiac arrest and dies.

Everyone baffled so they do an autopsy... the adrenal lesion was a pheochromocytoma.

Family suing the ED doctor and OBGYNs who saw her during the pregnancy.

PGY-7 and I don't think I've ever seen a pheo crisis in the ED... anyone else seen one?

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[AlmostAnMD]

I now put incidental findings both as an ICD as well as on the discharge instructions and in my note because of dumb **** like this

But realistically I'd still get sued anyway probably

dumb case, dumb outcome, dumb society

 

[jwk]

Interesting that they've got both an ER doc and OB/GYN saying this is malpractice. I'm no pheo expert, but they're pretty damn rare. Had the patient followed up (gee, how often do we see that) then maybe there would have been a better outcome.

 

[RustedFox]

Interesting that they've got both an ER doc and OB/GYN saying this is malpractice. I'm no pheo expert, but they're pretty damn rare. Had the patient followed up (gee, how often do we see that) then maybe there would have been a better outcome.

You can always find someone to throw someone else under the bus.

 

[pkwraith]

It's kind of ridiculous the incompletely inane standards of treatment the expert witness MD operate in.

One of the reasons for negelet: "Failure to obtain an MRI to better evaluate the right adrenal lesion"

Yes, everyone in the ED obviously order all the MRIs for every ****ing incidentalomas. That is the standard of care in 0 Emergency Departments, and I have my doubts this expert witness practices this way.

Incidentalomas already drain a huge amount of resources because of jackpot cases like this, and you have expert witness testfying that they should be done in the ED.

 

[Kryptocoin]

I usually put in all my MDMs that "I discussed CT findings with patient". It's a broad statement that covers everything. I don't care to list specifics.

 

[nexus73]

You can always find someone to throw someone else under the bus.

Until medical board action or professional society censure becomes the norm in situations that are clearly opinions for sale it will never end. It's easy money, all it costs is your soul.

 

[BoardingDoc]

Case here: Pheochromocytoma Crisis Induced by Steroids [Pregnant Cardiac Arrest]

33-year-old woman seen in the ED for abdominal pain.

Diagnosed with UTI, PID.

CT showed adrenal nodule but patient (allegedly) not told about this.

She gets pregnant several months later.

Gets steroids for cervical shortening.

Goes into cardiac arrest and dies.

Everyone baffled so they do an autopsy... the adrenal lesion was a pheochromocytoma.

Family suing the ED doctor and OBGYNs who saw her during the pregnancy.

PGY-7 and I don't think I've ever seen a pheo crisis in the ED... anyone else seen one?

For anyone who didn't read the link, case started 2018, still ongoing. Looks like no one has offered to settle which means it may go to court. I'm sorry the lady died. That said, I very much hope her family loses this case because this is idiotic.

Document your incidentalomas in your DC instructions y'all.

 

[AlmostAnMD]

I usually put in all my MDMs that "I discussed CT findings with patient". It's a broad statement that covers everything. I don't care to list specifics.

I encourage you to reconsider. I've spoken with an MD/JD about that very topic and you are absolutely not at all covered by blanket statements, same reason a routine AMA form is useless without the specific documentation of why the patient is leaving. You need to do exactly as I said I do to avoid the most potential for litigation.

It's dumb and not fair but it's a game and you gotta play to win (or not lose).

 

[Rekt]

I encourage you to reconsider. I've spoken with an MD/JD about that very topic and you are absolutely not at all covered by blanket statements, same reason a routine AMA form is useless without the specific documentation of why the patient is leaving. You need to do exactly as I said I do to avoid the most potential for litigation.

It's dumb and not fair but it's a game and you gotta play to win (or not lose).

Agree. I document specifically every nodule. I put it as a diagnosis. I also print out the CT report and hand it to the patient. I also document I gave the patient a physical copy with incidental findings circled.

We live in a completely ridiculous society.

 

[HemeOncHopeful19]

I would love to see a future case where the patient portal is queried to see if patient ever opened their own scan results now that they have to have full access to their chart.

 

[RoyBasch]

I usually put in all my MDMs that "I discussed CT findings with patient". It's a broad statement that covers everything. I don't care to list specifics.

This is not specific enough and does not meet a legal standard of protection.

Agree. I document specifically every nodule. I put it as a diagnosis. I also print out the CT report and hand it to the patient. I also document I gave the patient a physical copy with incidental findings circled.

We live in a completely ridiculous society.

This is the way.

I try to do this every time. Yes it is a hassle. No I'm not sure I do it EVERY time when surges of patients come in and I'm getting crushed. But I try.

I would love to see a future case where the patient portal is queried to see if patient ever opened their own scan results now that they have to have full access to their chart.

Interesting question. If patients have full access to their records, are they now responsible (especially if the CT report has instructions written by the radiologist in their summary such as: "Adrenal mass, recommend dedicated multiphase CT or MRI to better evaluate" or "5mm pulmonary nodule in left upper lung, by Fleischner criteria, follow up non contrast CT in 6 months to document stability recommended." (most radiologist I work with usually put this in their reports).

 

[southerndoc]

I now put incidental findings both as an ICD as well as on the discharge instructions and in my note because of dumb **** like this

But realistically I'd still get sued anyway probably

dumb case, dumb outcome, dumb society

Have a few more months before I can talk about my case (which I was dropped from), but the plaintiff is considering filing again against another party. It involves an incidental finding on a patient who was admitted. There were ED docs that threw me under the bus in their pay-for-hire expert witness. The case truly is astonishing that I was named.

I also put in the final diagnosis and have a dot phrase that I notified the patient about it. Dot phrase is specific for pulmonary nodules. Have one for coronary artery calcifications as well. All others I just free text. When I add a diagnosis of "pulmonary nodule seen on computed tomography scan" I add it to their problem list as well.

My attorney said that because my state has a gross negligence clause, he is finding an increasing number of lawsuits against ED physicians due to incidental findings.

 

[southerndoc]

This is not specific enough and does not meet a legal standard of protection.


This is the way.

I try to do this every time. Yes it is a hassle. No I'm not sure I do it EVERY time when surges of patients come in and I'm getting crushed. But I try.



Interesting question. If patients have full access to their records, are they now responsible (especially if the CT report has instructions written by the radiologist in their summary such as: "Adrenal mass, recommend dedicated multiphase CT or MRI to better evaluate" or "5mm pulmonary nodule in left upper lung, by Fleischner criteria, follow up non contrast CT in 6 months to document stability recommended." (most radiologist I work with usually put this in their reports).

They should be, but this is one case where a plaintiff would argue they didn't know what it meant.

 

[HemeOncHopeful19]

They should be, but this is one case where a plaintiff would argue they didn't know what it meant.

I was thinking particularly in this case where patient was a nurse I feel like it would be hard to argue they didn’t understand what “recommend MRI to evaluate” meant

 

[nexus73]

Have a few more months before I can talk about my case (which I was dropped from), but the plaintiff is considering filing again against another party. It involves an incidental finding on a patient who was admitted. There were ED docs that threw me under the bus in their pay-for-hire expert witness. The case truly is astonishing that I was named.

I also put in the final diagnosis and have a dot phrase that I notified the patient about it. Dot phrase is specific for pulmonary nodules. Have one for coronary artery calcifications as well. All others I just free text. When I add a diagnosis of "pulmonary nodule seen on computed tomography scan" I add it to their problem list as well.

My attorney said that because my state has a gross negligence clause, he is finding an increasing number of lawsuits against ED physicians due to incidental findings.

I’d expect a gross negligence standard to reduce the number of lawsuits.

 

[turkeyjerky]

My attorney said that because my state has a gross negligence clause, he is finding an increasing number of lawsuits against ED physicians due to incidental findings.

Can you elaborate on this? I don't understand the legal reasoning there.

Question for the field--I usually write out in the discharge instructions box the incidental finding and recommended f/u (most of the time I just recommend to discuss further w/u as needed w/ PCP). I basically never give out the actual report, and don't usually write anything into my MDM regarding it (although the d/c instructions usually are in the note w/ cerner). Is this adequate?

My reasoning is that this his all 3 birds w/ one stone, it provides a written record to the patient, it ensures that it gets verbally communicated (as the nurses read this section verbatim to the patient) and it provides documented evidence that the preceding two events occurred.

The fact that you got named for something like this on an admitted patient is honestly frightening. I would've assumed we'd get pass on admitted patients.

 

[BoardingDoc]

Can you elaborate on this? I don't understand the legal reasoning there.

Question for the field--I usually write out in the discharge instructions box the incidental finding and recommended f/u (most of the time I just recommend to discuss further w/u as needed w/ PCP). I basically never give out the actual report, and don't usually write anything into my MDM regarding it (although the d/c instructions usually are in the note w/ cerner). Is this adequate?

My reasoning is that this his all 3 birds w/ one stone, it provides a written record to the patient, it ensures that it gets verbally communicated (as the nurses read this section verbatim to the patient) and it provides documented evidence that the preceding two events occurred.

The fact that you got named for something like this on an admitted patient is honestly frightening. I would've assumed we'd get pass on admitted patients.

I would imagine that you're probably fine. My practice is to include a 1 liner in my MDM e.g. "incidental thyroid nodule noted on CT. Pt informed and told to followup with PCP for further evaluation within the next 2 weeks." I then reiterate that in the DC which as you said, is read out loud to the patient at time of DC.

 

[southerndoc]

@turkeyjerky If you admit a patient for something like a stroke, then it's covered under the gross negligence clause. However, our court has ruled that just because you get care in the ED, not everything related to the patient gets gross negligence protection. An incidental finding circumvents the gross negligence protection. The case stemmed from a person who lost their leg (and I think ultimately died) after a PA ordered a DVT ultrasound and discharged the patient. The patient came back with an ischemic limb. The court ruled that the leg pain did not constitute enough of a risk for gross negligence protection.

Gliemmo v. Cousineau, 287 Ga. 7 | Casetext Search + Citator

Read Gliemmo v. Cousineau, 287 Ga. 7, see flags on bad law, and search Casetext’s comprehensive legal database

casetext.com

 

[anonperson]

Case here: Pheochromocytoma Crisis Induced by Steroids [Pregnant Cardiac Arrest]

33-year-old woman seen in the ED for abdominal pain.

Diagnosed with UTI, PID.

CT showed adrenal nodule but patient (allegedly) not told about this.

She gets pregnant several months later.

Gets steroids for cervical shortening.

Goes into cardiac arrest and dies.

Everyone baffled so they do an autopsy... the adrenal lesion was a pheochromocytoma.

Family suing the ED doctor and OBGYNs who saw her during the pregnancy.

PGY-7 and I don't think I've ever seen a pheo crisis in the ED... anyone else seen one?

Was this some type of integrated health system like Kaiser?

Otherwise how would the OBGYN or even PCP be aware of this CT scan?

These "expert" witnesses are something else. They should be named and shamed for this BS.

The current medical malpractice system is so broken though. It's basically monetary revenge for a bad outcome even if no malpractice occurred while sleazy malpractice lawyers help facilitate the whole thing.

 

[thegenius]

It's kind of ridiculous the incompletely inane standards of treatment the expert witness MD operate in.

One of the reasons for negelet: "Failure to obtain an MRI to better evaluate the right adrenal lesion"

Yes, everyone in the ED obviously order all the MRIs for every ****ing incidentalomas. That is the standard of care in 0 Emergency Departments, and I have my doubts this expert witness practices this way.

Incidentalomas already drain a huge amount of resources because of jackpot cases like this, and you have expert witness testfying that they should be done in the ED.

Yea makes you want to look up all the expert witnesses records themselves to see if they follow their own advice. Of course they don't.

Thankfully this stuff is kind of rare...I try to put these incidentalomas into the diagnoses.

But lets be real. When there is a bad outcome someone is going to pay no matter what. It's perverse.

 

[thegenius]

I encourage you to reconsider. I've spoken with an MD/JD about that very topic and you are absolutely not at all covered by blanket statements, same reason a routine AMA form is useless without the specific documentation of why the patient is leaving. You need to do exactly as I said I do to avoid the most potential for litigation.

It's dumb and not fair but it's a game and you gotta play to win (or not lose).

I don't understand can you explain further?

So if a patient has a diagnoses of UTI (primary), Hypokalemia (3.1, secondary), Anemia (11.8, secondary), and Hepatic Hemangioma (incidentaloma found on CT to r/o kidney stone, secondary)....and I write
"You must see your doctor in 1-2 weeks to discuss every single diagnosis listed to detemine if you need further workup"

what more do you need to do?

 

[AlmostAnMD]

I don't understand can you explain further?

So if a patient has a diagnoses of UTI (primary), Hypokalemia (3.1, secondary), Anemia (11.8, secondary), and Hepatic Hemangioma (incidentaloma found on CT to r/o kidney stone, secondary)....and I write
"You must see your doctor in 1-2 weeks to discuss every single diagnosis listed to detemine if you need further workup"

what more do you need to do?

You're not going to like my answer. thats still not enough.

Another med mal case i got to see was similar to your dc instructions. Patient still didn't follow up and claimed she would have if she had known the findings were cancerous. Expert raked him over the coals because he should have warned the patient the nodule can become CANCER, and the CANCER might get worse if not evaluated.

I'm on your side here, but the lawyers aren't. Thats why I craft careful documentation of all incidentalomas. Not just, follow up

 

[southerndoc]

I don't understand can you explain further?

So if a patient has a diagnoses of UTI (primary), Hypokalemia (3.1, secondary), Anemia (11.8, secondary), and Hepatic Hemangioma (incidentaloma found on CT to r/o kidney stone, secondary)....and I write
"You must see your doctor in 1-2 weeks to discuss every single diagnosis listed to detemine if you need further workup"

what more do you need to do?

You're not documenting you discussed it. If you document that you went over the findings and discussed the importance of early follow-up, then that's one thing. You're basically putting it into the discharge instructions and expecting the patient to read it. Malpractice attorneys can and have successfully litigated against physicians because they wrote something in the discharge instructions instead of discussing it with the patient. Plaintiff's counsel in one case that I remember made reference to the discharge instructions being as likely to be read by the patient as the warning tags on new furniture being read by a new homeowner.

 

[RustedFox]

I have an *incidental* autotext that goes something like:

"Care was taken to discuss the incidental findings ( ............. ) on today's imaging findings and the need for timely follow-up was emphasized to the patient, who indicated understanding of the importance of and need for follow-up as described in the discharge instructions. A copy of today's radiology result was given to the patient by myself to facilitate ease of discussion/follow-up."

 

[Franzd'Epinay]

@turkeyjerky If you admit a patient for something like a stroke, then it's covered under the gross negligence clause. However, our court has ruled that just because you get care in the ED, not everything related to the patient gets gross negligence protection. An incidental finding circumvents the gross negligence protection. The case stemmed from a person who lost their leg (and I think ultimately died) after a PA ordered a DVT ultrasound and discharged the patient. The patient came back with an ischemic limb. The court ruled that the leg pain did not constitute enough of a risk for gross negligence protection.

Gliemmo v. Cousineau, 287 Ga. 7 | Casetext Search + Citator

Read Gliemmo v. Cousineau, 287 Ga. 7, see flags on bad law, and search Casetext’s comprehensive legal database

casetext.com

I'm sorry, can you dumb this way down?

Specifically, if you could expand on your use of "gross negligence clause" and "gross negligence protection", that would be a great help.

 

[nexus73]

I'm sorry, can you dumb this way down?

Specifically, if you could expand on your use of "gross negligence clause" and "gross negligence protection", that would be a great help.

not OP, but from reading the case the court found it unequal to protect an ED doctor from a lawsuit for an emergent condition, but not protect the EMTs driving the person to the ED for the same emergent condition, so rather than providing legal protection for care provided specifically in an ED, they interpreted it as providing protection for care of emergent conditions wherever that care may be provided. BUT, if you're an ED doctor treating a sprained ankle you don't get extra protection because a sprained ankle isn't an emergency. Seems kind of lame to me, because benign problems (leg pain, back pain, etc) can have underlying emergent problems, and I assume the intent of the legislation was not to carve out only legal protection for emergent conditions, but just the fact the ED is a high risk, high volume job, with no continuity, protecting ED doctors (and EMTs, urgent cares as well honestly) makes it so they can actually do their jobs and afford liability insurance.

 

[southerndoc]

not OP, but from reading the case the court found it unequal to protect an ED doctor from a lawsuit for an emergent condition, but not protect the EMTs driving the person to the ED for the same emergent condition, so rather than providing legal protection for care provided specifically in an ED, they interpreted it as providing protection for care of emergent conditions wherever that care may be provided. BUT, if you're an ED doctor treating a sprained ankle you don't get extra protection because a sprained ankle isn't an emergency. Seems kind of lame to me, because benign problems (leg pain, back pain, etc) can have underlying emergent problems, and I assume the intent of the legislation was not to carve out only legal protection for emergent conditions, but just the fact the ED is a high risk, high volume job, with no continuity, protecting ED doctors (and EMTs, urgent cares as well honestly) makes it so they can actually do their jobs and afford liability insurance.

This is basically how it was interpreted. Just because a patient presents to the ED doesn't mean they have an emergency that is protected under the gross negligence clause.

 

[thegenius]

I have an *incidental* autotext that goes something like:

"Care was taken to discuss the incidental findings ( ............. ) on today's imaging findings and the need for timely follow-up was emphasized to the patient, who indicated understanding of the importance of and need for follow-up as described in the discharge instructions. A copy of today's radiology result was given to the patient by myself to facilitate ease of discussion/follow-up."

Apparently not good enough

 

[BoardingDoc]

Apparently not good enough

? Elaborate.

 

[Tenk]

Yeah always say you discussed abnormal ct findings in the chart and recommended follow up. If they don’t have a pcp, refer them to one that they won’t follow up with because all patients suck.

 

[RoyBasch]

You're not documenting you discussed it. If you document that you went over the findings and discussed the importance of early follow-up, then that's one thing. You're basically putting it into the discharge instructions and expecting the patient to read it. Malpractice attorneys can and have successfully litigated against physicians because they wrote something in the discharge instructions instead of discussing it with the patient. Plaintiff's counsel in one case that I remember made reference to the discharge instructions being as likely to be read by the patient as the warning tags on new furniture being read by a new homeowner.

I have heard this before, that providing patients written instructions is not enough as attorneys can argue the patient didn't read it. I try to document that I explained it to the patient verbally (and document that I explained it). Although then attorneys can argue people don't remember things they are told and need important information in writing. So basically they can argue that patients cannot be responsible neither for things they are told nor things they have in writing. Essentially, patient's are not responsible for any bad thing that happens to them no matter what.

Also, I do find the furniture tag metaphor infuriating. Because--yes people do not read them--but those tags are quite literally there as they supposedly meet the legal standard of due diligence to warn of potential danger/harm.

 

[thegenius]

? Elaborate.

Well above my post you have to be explicit and say the worst possible thing, like "this pulm nodule could turn into cancer years later, please see your doctor" and the commend by rusted fox didn't.

 

[BoardingDoc]

Well above my post you have to be explicit and say the worst possible thing, like "this pulm nodule could turn into cancer years later, please see your doctor" and the commend by rusted fox didn't.

I would think that Rusted's comment would be defensible. The comment you're referring to talks about cases where you simply document the incidentaloma in your DC instructions. Rusted does that, and also posts his little macro which specifically documents that the details of the incidentaloma were discussed and that he stressed the need for early followup.

Obviously listing every possible bad thing on there would be better, but this case you've demonstrated that you both gave them written instructions about it, and personally discussed the finding and that it needs rapid followup.

 

[Angry Birds]

PGY-7 and I don't think I've ever seen a pheo crisis in the ED...anyone else seen one?

I’m currently PGY-12

 

[Angry Birds]

I have an *incidental* autotext that goes something like:

"Care was taken to discuss the incidental findings ( ............. ) on today's imaging findings and the need for timely follow-up was emphasized to the patient, who indicated understanding of the importance of and need for follow-up as described in the discharge instructions. A copy of today's radiology result was given to the patient by myself to facilitate ease of discussion/follow-up."

This is fantastic

 

[thegenius]

I would think that Rusted's comment would be defensible. The comment you're referring to talks about cases where you simply document the incidentaloma in your DC instructions. Rusted does that, and also posts his little macro which specifically documents that the details of the incidentaloma were discussed and that he stressed the need for early followup.

Obviously listing every possible bad thing on there would be better, but this case you've demonstrated that you both gave them written instructions about it, and personally discussed the finding and that it needs rapid followup.

Someone mentioned above it's not good enough to say AND write that you have an incidentaloma...if that incidentaloma can be something really bad in the future like cancer (e.g. a pulm nodule, fatty liver today -> cirrhosis later -> increases risk for HCC, etc.) and you don't mention that then you can be successfully sued.

And frankly I've heard this before. What lawyers say is "If someone is told their car is making sounds, they might ignore that warning. But if they were told that the sounds might indicate their car will blow up in the future, they will go in and get it fixed."

This whole thing is ridiculous. This is why people can't get appointments to see doctors because everybody is going to the doctor to get every last symptom worked up to the hilt.

 

[WilcoWorld]

Someone mentioned above it's not good enough to say AND write that you have an incidentaloma...if that incidentaloma can be something really bad in the future like cancer (e.g. a pulm nodule, fatty liver today -> cirrhosis later -> increases risk for HCC, etc.) and you don't mention that then you can be successfully sued.

And frankly I've heard this before. What lawyers say is "If someone is told their car is making sounds, they might ignore that warning. But if they were told that the sounds might indicate their car will blow up in the future, they will go in and get it fixed."

This whole thing is ridiculous. This is why people can't get appointments to see doctors because everybody is going to the doctor to get every last symptom worked up to the hilt.

I think we're chasing rainbows here. The likelihood that any of us will loose a suit like this one is quite low. The likelihood that anyone can create a BULLETPROOF practice to avoid any possibility of getting sued is zero. @RustedFox practice strikes me as reasonably effective and also, you know, doable. It may not be perfect, but nothing is.

 

[Angry Birds]

I learned about pheochromocytoma on House.

 

[Brigade4Radiant]

It depends on which state that is. Malpractice and legal advice is pretty worthless unless you know the state

 

[thegenius]

Yesterday I had abd pain in a woman and it ended up not being an emergency. But interesting she had 3+ glucosuria without hyperglycemia (I had to look up causes as I haven't really seen this outside of pregnancy) and mildly dilated intraductal bili tree without elevated LFTs or post-prandial pain.

I spent 10 minutes saying you gotta see this doctor, that doctor, this could end up being bad in several years, yada yada yada. I thought about this thread.

 

[Birdstrike]

One time I saw a patient for hip pain. I ordered a hip x-ray. At their follow up she handed me the hip x-ray report and also a report of a CT myelogram that I did not order. The hip x-ray was normal, but the CT myelogram, ordered by her neurosurgeon, showed two spinal tumors. One of the tumors was new and the other was previously known to the patient and the surgeon, and was the reason she was following with the neurosurgeon. I documented that he ordered the test, that she knew of the result and had a follow up appointment schedule with the neurosurgeon to discuss the study results. I then addressed the hip pain with the patient, which was the reason for her visit. The story should end here.

I never saw her again, but after whatever catastrophic outcome she ended up having, she triggered a medical board investigation against me for it. It turns out, radiology had inadvertently listed me as the ordering M.D. on the myelogram. After writing a response report, pouring over piles of office and hospital records, meeting with a lawyer, experiencing significant stress, and waiting 7 months, I was cleared.

Having the documentation was a godsend.

 

[nexus73]

One time I saw a patient for hip pain. I ordered a hip x-ray. At their follow up she handed me the hip x-ray report and also a report of a CT myelogram that I did not order. The hip x-ray was normal, but the CT myelogram, ordered by her neurosurgeon, showed two spinal tumors. One of the tumors was new and the other was previously known to the patient and the surgeon, and was the reason she was following with the neurosurgeon. I documented that he ordered the test, that she knew of the result and had a follow up appointment schedule with the neurosurgeon to discuss the study results. I then addressed the hip pain with the patient, which was the reason for her visit. The story should end here.

I never saw her again, but after whatever catastrophic outcome she ended up having, she triggered a medical board investigation against me for it. It turns out, radiology had inadvertently listed me as the ordering M.D. on the myelogram. After writing a response report, pouring over piles of office and hospital records, meeting with a lawyer, experiencing significant stress, and waiting 7 months, I was cleared.

Having the documentation was a godsend.

so the system works!!