My Last Lawsuit - OR - RustedFox and Morty.

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RustedFox

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I just got a letter from the Board of Health. What follows is a summary:



******************************************************************************


-- Dear DR. RUSTEDFOX


Do you remember that med-mal lawsuit in 2020? You know; that one where BOTH the patient AND her husband told you that she WASN'T allergic to IV contrast dye despite what the chart said, so you totally did the right thing and double-checked with them before you gave it to her and then she died two weeks later of a completely unrelated cause?


That one where the patient and her husband said the same thing to the nursing and radiology staff, before they carried out the CT abdomen/pelvis that you ordered?


That one where you could totally prove that it wasn't the contrast dye that you gave, but rather the antibiotics that she was taking for like, weeks?


The one where the patient’s husband changed his mind after her unfortunate demise and said something like: "Well, maybe she WAS allergic to the contrast dye after all? Yeah! That - that HAS to be it, because old people that collect diseases like our grandkids collect Pokémon cards don't just die, right? Right?! SOMEONE'S GOTTA PAYY!"


Yeah; THAT one. Pretty radical, huh?


Yeah, so like - me and the boys down here at the board got around to it. We had a good long look. Guess what? Turns out we think that you were right all along. Damn, those people were dumb. Great move by calculating that ALDEN score to prove that it wasn't the contrast dye that caused the patient to develop Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. Not many people would have thought of doing that. Strong work - you REALLY must have paid attention in medical school. Too bad you got sued and had to settle the case anyways. Lolz. Have a good shift, bro.


- Signed,

The Mouthbreathers at the Citadel of Ricks.


*****************************************************************************


Here's my fictitious response:



- Dear Mouthbreathers,


Hey bros. [BURRRP!] Yeah; I'm really glad you finally got around to that. Like, I really don’t wanna say this buuut… I told you so. Can you guys un-sue me and give me back all the time, money, and stress that I spent on it? You know, like, erase it from my record and all? 'Cause that would be real cool. It would be like, the right thing to do on your part.


No? That sucks, bro. Cause it would have been really compelling evidence to have at the time, you know.... when the STATE BOARD OF WHATEVER says that you're smarter than all the expert witnesses that the prosecutor paid-off to sell you down the river, it's generally a good thing to know. Real game-changer, there... Probably would have changed the outcome ‘n stuff.


Did I mention that this whole thing was a rather large contributor to me totally burning out of clinical medicine, spiraling into depression, consuming a terrific number of alcohol-containing beverages (go big or go home, amirite?), having the SNRI/benzodiazepine combo-meal prescribed to me totally backfire, considering walking away from society like “Kwai-Chang Caine” style, and then briefly considering bridge jumping as a one-time extreme sport? Sure, I had other things going on in my life at the time that really sucked (that’s on me), but this one was a biggie. Could’ve really used your help awhile back, amigos.


Anyways, I feel better now after having gotten this letter waaaay later than would have been helpful. I'm gonna go ride my sweet new mountain bike. Shred you later, posers.


-- Eff you guys for real,

Rick Sanchez C-137


P.S. - It took you two YEARS and a whole BOARD of physicians to figure out what I did by myself in like, two DAYS and a few six-packs of Michelob Ultra. So, DOUBLE eff you guys [makes gesture with two middle fingers extended while moving them up-and-down in a vertical dimension immediately next to one another].


******************************************************************************



[Record scratch, freeze-frame]


Yep. That’s me. You’re probably wondering how I got here.


[VHS-tape rewind montage that lasts just long enough for your individual attention-span]


It was a day like any other. A shift like any other. A parade of senior citizens here in the United States Capitol Of Senior Citizens. EMS brings in a 79-year-old female. Syncope after lower GI bleeding; passed out on the commode, fell forward, bonked head. EMS says the volume of blood was pretty big, which we all know can mean anything.


Great historian, this one. She takes all of the medicines. All of them: Lispinopril. Propanol. Pregnasone. Hydrofoil. Metalpronoun. “That one for the thyroid”. Waterpill. Asspirin. Whatever. She can’t pronounce her name correctly, let alone know what meds she takes. Thank Christ for the medical record. She’s only been in and out of every hospital system in three counties two dozen times in the past two years. Bowel resection. Coronary artery disease; stent-and-CABG. Breast cancer. Gallbladder. Pacemaker in. Endocarditis. Pacemaker out. Wound site infection. Presently taking IV Cefokillitall and Gorillamycin daily for about 3-4 weeks now for the endocarditis and pacemaker site infection thru her PICC. Now here, with me, today, for LGIB resulting in syncope and headbonk.


Abdominal exam is benign, but I’m pushing thru a foot+ of adiposity. ‘Murica.


Last hemoglobin was 11.8 about two weeks ago. Today’s is 9.2 Hmm. That’s a big enough drop to catch my attention. Type and screen. Lock and load. CT abdomen/pelvis with contrast. Before anyone reflexively says: “Why did you even order the CT?” – both you and I know that IM is going to doc-block me if I don’t get it, so eff off.


Allergies listed:

Iodine (lol). IV dye. Shellfish. Red dye. Codeine. Penicillin.



I walk back in the exam room. This time, her husband is in the room, as is the nurse.

“Hey, we really need to see if we can identify where it is that you’re bleeding from. To do that, we need to do a CAT scan with contrast dye. On your chart, there’s an allergy listed to contrast dye, bu-“



“No. Its not contrast dye. Its red dye. I’ve had contrast before”, she interrupted.

I’m sorry… say that again?

“Yes. It’s RED dye.”

You mean, like, food coloring? Red-40? That kind of thing?

“It’s RED dye.” [husband nods in agreement, repeats that its red dye]



Me: Okay, thank you. We’re going to get that CAT scan and see if we can find the bleed.

Me, to myself: “Okay, I’m not sure what kind of fugging weirdos you guys are and I don’t care.”



I went away, clicked the button to order the CT abd/pelvis w/contrast. Barbara (which is like “Karen” for the 75+ crowd) goes to radiology. Rad tech has the same red-dye-green-light discussion with the patient. Patient signs consent. Patient gets CT scan. Patient returns from radiology. Nothing happens. CT is boring because they are. Patient gets admitted.


[Freeze-frame]


Me, looking at camera, not frozen and walking cool-ly around the scene while others remain frozen in place and in awkward positions:

“You guys probably want me to move this along at this point. I’ve been here before, so let’s make it quick. A day or so later, the patient developed a rash. That rash turned into Stevens-Johnson Syndrome. That Stevens-Johnson Syndrome turned into Toxic Epidermal Necrolysis. That Toxic Epidermal Necrolysis turned into a transfer to a burn unit for all the useless things like steroids, fluids, etc. before the patient succumbed to sepsis and multisystem organ failure. A few weeks later, I got the notice of intent.”


The allegation: This woman had an allergy to IV contrast dye listed in her chart. You gave her IV contrast dye. You didn’t pre-medicate her. A rash is an allergic reaction. She developed SJS/TEN and died. You killed her.


The defense: I reviewed the allergy with patient and husband, who both denied it to myself and multiple others; insisting strangely that the allergy was to “red dye”. If she was actually allergic; its not my fault that the patient was so ostriched. She signed the consent. Besides, SJS/TEN isn’t an “allergic reaction”, so knock that nonsense off right now. Pre-medication does nothing for moderate or severe reactions as per the radiology manual; besides that – she’s chronically on megadose prednisone for her COPD and has had loads of IV dye in the past for her collage of cardiovascular studies; often without premedicaiton. It was the Gorillamycin that likely caused the SJS/TEN, not the angelfart of IV dye that I ordered. Besides that, I needed the study; I wasn’t going to wait around for her to have another huge bleed and syncope before I acted.

More allegations: Her abdominal exam was benign. You didn’t need the CT at all.

More defense: She’s too fat for any reliable abdominal exam because ‘Murica. She’s on megadose prednisone, which even more totally nerfs the abdominal exam. Ask me how I know; I’ve made that mistake before and missed a perforated viscus that was later caught on CT when I felt discretion was the better part of valor.


Okay, let’s rumble. Deposition time comes, and I’m cooler than the other side of the pillow. I bob, I weave, we circle. I’m waiting for my opening. Opposing attorney is wearing a fishing shirt because lulz. I’m in suit-and-tie. I’m sorry to interrupt your critically important fishing schedule with my defense, you fat piece of trash. Enjoy heart disease, fugger. NOBODY is that buttery and doesn't have coronaries that hate them.

Eventually, he makes his mistake – the one I’ve been waiting for.


“So, you agree that rashes are a defining feature of allergic reactions, and that this rash began a chain of events that led to the patient’s death?”

“No, I don’t – you’re making a critical error here. Yes; rashes are a defining feature of allergic reactions… but this rash is different. This is the rash of SJS/TEN, a phenomenon which is so extraordinarily rare so as to statistically be less likely than being struck by lightning. It's not an "allergic reaction". It typically happens after the patient has been taking a culprit drug with certain qualities and characteristics.” [YES, I ACTUALLY SAID THIS AND EVERYTHING THAT FOLLOWS.]


“What are those qualities and characteristics?”


“Well, it can happen with any drug, at any time – but most overwhelmingly commonly - the culprit drug is an antibiotic, taken for between 3 and 6 weeks, with a long half-life, a high molecular weight, and certain specific molecular structures.”


“So, do you have an alternative *culprit drug* that resulted in this patient’s death, if it wasn’t the contrast dye that YOU ordered, Dr. RustedFox?” (I could tell that he was really leaning into this punch. Good. He whiffed.)


“I do.” - So Laconic. I’m such a smug ass.


“And what might that drug be, Dr. RustedFox?”


“The Gorillamycin that the patient was prescribed for her ongoing infection. It’s an antibiotic, that the patient was taking for almost precisely 3 weeks, with a long half life, a high molecular weight, and certain specific molecular structure – in this case; a macrolide ring and several other features. When we try to identify a culprit drug, we calculate what is called the ALDEN score (you guys can google this). When you do this; you can see that the categorical outcome is that the IV contrast dye is classified as “unlikely” and the Gorillamycin is classified as “highly likely”.”


Boom! There it was; the knockout punch. Cue the slow-motion shot of the bareknuckle boxer in the Guy Ritchie movie taking a right hook across the mouth, head snapping backward, blank look in the eyes, mouth snarled, blood and spit spraying in all directions before coming off his feet and landing with a wet thud on the canvas. *DING-DING-DINNG!*


“Lets take a break.”


We break. Attorney says to me: “Yep. It’s clear to me that he didn’t see that coming at all. Strong work, Little Mac. Strong. Work.” He might as well sprayed the water bottle into my open mouth and wrapped me in a towel.


More experts are deposed. The Greek God of Immunology himself descends from Mount Cytokine to defend me. Chair of the Immunology department at Ivory Tower University Medical Center, published in all the journals, winner of all the awards, King of the Britons, Defeater of the Saxons, Sovereign of All England.

“Yeah; the kid is right.”



Pre-trial summaries are written. The attorney called me “more than capable of performing in excellent fashion under pressure”. Really, homes? You don’t say. It’s like, kind of what we do in EM.



---



Months go by. One day, I get a letter from the attorney telling me to clear my schedule next month; we’re going to trial. Cancel that trip that you had planned to Arizona to see the big rocks on your big birthday. Wait, what?! No other news? Th’hell, man?!


Yeah, so it seems that they want to expedite the trial, because the only claimant (the patient’s husband) is 87, on dialysis, in extraordinarily poor health, and could die at any hot minute if he breathes too hard or misses dialysis. He dies, and the case dies along with him. Nobody collects, including the attorneys. They wanna go.


They had one more witness to depose. Dr. Moviestar, Chair of Whatever at Old University Medical School. Apparently, this guy was, as per the summary: handsome, likeable, and straight out of central casting – a doctor straight from a primetime drama. Its not that he had any scathing criticisms of my care, other than “the scan shouldn’t have been done at all, and emergent endoscopy should have been done instead”.


Now, you and I know that there’s no way that GI is coming in to do this scope at 12:15 AM on a Saturday morning. Not in my shop. Maybe your in-house GI fellow will up at Ivy League Medical Center because he’s chained up in the call room. That’s cool that he’s into BDSM; but that’s not where I work. Get a grip. He also argued that I should have thoroughly reviewed the hundreds of pages of records (mostly from other health systems and not available to me at the time) to find the instance where the patient developed (gasp!) an uneventful rash after IV dye that resolved without incident and in response to Solu-Medrol, and that this would have changed the medical decision making to delay the emergent scan and pre-medicate the patient.


Now, this is getting complex. The insurance company fully admits that “this isn’t about the medicine; we’re concerned that Dr. Ryan Gosling will confuse a jury of ostriches into agreeing with him, because he’s pretty" and my defense of: "she was too fat for me to rely on abdominal exam and is taking megadoses of roids" wasn't exactly endearing.


Really, homey? I’m not so bad looking myself. They didn’t want to hear it.


Case settled for a quarter million.


So why was the Citadel of Ricks involved? Early on, plaintiff’s counsel filed a complaint against me to the Citadel, in an effort at getting a “free medical quality case review”. If the Citadel decided that I was an ostrich, then it’s a layup for them. If not, well – then they’ve got a problem moving the case forward at all.


So, thanks for dragging your feet on that one, Citadel of Ricks. Thanks a lot.

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I just got a letter from the Board of Health. What follows is a summary:



******************************************************************************


-- Dear DR. RUSTEDFOX


Do you remember that med-mal lawsuit in 2020? You know; that one where BOTH the patient AND her husband told you that she WASN'T allergic to IV contrast dye despite what the chart said, so you totally did the right thing and double-checked with them before you gave it to her and then she died two weeks later of a completely unrelated cause?


That one where the patient and her husband said the same thing to the nursing and radiology staff, before they carried out the CT abdomen/pelvis that you ordered?


That one where you could totally prove that it wasn't the contrast dye that you gave, but rather the antibiotics that she was taking for like, weeks?


The one where the patient’s husband changed his mind after her unfortunate demise and said something like: "Well, maybe she WAS allergic to the contrast dye after all? Yeah! That - that HAS to be it, because old people that collect diseases like our grandkids collect Pokémon cards don't just die, right? Right?! SOMEONE'S GOTTA PAYY!"


Yeah; THAT one. Pretty radical, huh?


Yeah, so like - me and the boys down here at the board got around to it. We had a good long look. Guess what? Turns out we think that you were right all along. Damn, those people were dumb. Great move by calculating that ALDEN score to prove that it wasn't the contrast dye that caused the patient to develop Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. Not many people would have thought of doing that. Strong work - you REALLY must have paid attention in medical school. Too bad you got sued and had to settle the case anyways. Lolz. Have a good shift, bro.


- Signed,

The Mouthbreathers at the Citadel of Ricks.


*****************************************************************************


Here's my fictitious response:



- Dear Mouthbreathers,


Hey bros. [BURRRP!] Yeah; I'm really glad you finally got around to that. Like, I really don’t wanna say this buuut… I told you so. Can you guys un-sue me and give me back all the time, money, and stress that I spent on it? You know, like, erase it from my record and all? 'Cause that would be real cool. It would be like, the right thing to do on your part.


No? That sucks, bro. Cause it would have been really compelling evidence to have at the time, you know.... when the STATE BOARD OF WHATEVER says that you're smarter than all the expert witnesses that the prosecutor paid-off to sell you down the river, it's generally a good thing to know. Real game-changer, there... Probably would have changed the outcome ‘n stuff.


Did I mention that this whole thing was a rather large contributor to me totally burning out of clinical medicine, spiraling into depression, consuming a terrific number of alcohol-containing beverages (go big or go home, amirite?), having the SNRI/benzodiazepine combo-meal prescribed to me totally backfire, considering walking away from society like “Kwai-Chang Caine” style, and then briefly considering bridge jumping as a one-time extreme sport? Sure, I had other things going on in my life at the time that really sucked (that’s on me), but this one was a biggie. Could’ve really used your help awhile back, amigos.


Anyways, I feel better now after having gotten this letter waaaay later than would have been helpful. I'm gonna go ride my sweet new mountain bike. Shred you later, posers.


-- Eff you guys for real,

Rick Sanchez C-137


P.S. - It took you two YEARS and a whole BOARD of physicians to figure out what I did by myself in like, two DAYS and a few six-packs of Michelob Ultra. So, DOUBLE eff you guys [makes gesture with two middle fingers extended while moving them up-and-down in a vertical dimension immediately next to one another].


******************************************************************************



[Record scratch, freeze-frame]


Yep. That’s me. You’re probably wondering how I got here.


[VHS-tape rewind montage that lasts just long enough for your individual attention-span]


It was a day like any other. A shift like any other. A parade of senior citizens here in the United States Capitol Of Senior Citizens. EMS brings in a 79-year-old female. Syncope after lower GI bleeding; passed out on the commode, fell forward, bonked head. EMS says the volume of blood was pretty big, which we all know can mean anything.


Great historian, this one. She takes all of the medicines. All of them: Lispinopril. Propanol. Pregnasone. Hydrofoil. Metalpronoun. “That one for the thyroid”. Waterpill. Asspirin. Whatever. She can’t pronounce her name correctly, let alone know what meds she takes. Thank Christ for the medical record. She’s only been in and out of every hospital system in three counties two dozen times in the past two years. Bowel resection. Coronary artery disease; stent-and-CABG. Breast cancer. Gallbladder. Pacemaker in. Endocarditis. Pacemaker out. Wound site infection. Presently taking IV Cefokillitall and Gorillamycin daily for about 3-4 weeks now for the endocarditis and pacemaker site infection thru her PICC. Now here, with me, today, for LGIB resulting in syncope and headbonk.


Abdominal exam is benign, but I’m pushing thru a foot+ of adiposity. ‘Murica.


Last hemoglobin was 11.8 about two weeks ago. Today’s is 9.2 Hmm. That’s a big enough drop to catch my attention. Type and screen. Lock and load. CT abdomen/pelvis with contrast. Before anyone reflexively says: “Why did you even order the CT?” – both you and I know that IM is going to doc-block me if I don’t get it, so eff off.


Allergies listed:

Iodine (lol). IV dye. Shellfish. Red dye. Codeine. Penicillin.



I walk back in the exam room. This time, her husband is in the room, as is the nurse.

“Hey, we really need to see if we can identify where it is that you’re bleeding from. To do that, we need to do a CAT scan with contrast dye. On your chart, there’s an allergy listed to contrast dye, bu-“



“No. Its not contrast dye. Its red dye. I’ve had contrast before”, she interrupted.

I’m sorry… say that again?

“Yes. It’s RED dye.”

You mean, like, food coloring? Red-40? That kind of thing?

“It’s RED dye.” [husband nods in agreement, repeats that its red dye]



Me: Okay, thank you. We’re going to get that CAT scan and see if we can find the bleed.

Me, to myself: “Okay, I’m not sure what kind of fugging weirdos you guys are and I don’t care.”



I went away, clicked the button to order the CT abd/pelvis w/contrast. Barbara (which is like “Karen” for the 75+ crowd) goes to radiology. Rad tech has the same red-dye-green-light discussion with the patient. Patient signs consent. Patient gets CT scan. Patient returns from radiology. Nothing happens. CT is boring because they are. Patient gets admitted.


[Freeze-frame]


Me, looking at camera, not frozen and walking cool-ly around the scene while others remain frozen in place and in awkward positions:

“You guys probably want me to move this along at this point. I’ve been here before, so let’s make it quick. A day or so later, the patient developed a rash. That rash turned into Stevens-Johnson Syndrome. That Stevens-Johnson Syndrome turned into Toxic Epidermal Necrolysis. That Toxic Epidermal Necrolysis turned into a transfer to a burn unit for all the useless things like steroids, fluids, etc. before the patient succumbed to sepsis and multisystem organ failure. A few weeks later, I got the notice of intent.”


The allegation: This woman had an allergy to IV contrast dye listed in her chart. You gave her IV contrast dye. You didn’t pre-medicate her. A rash is an allergic reaction. She developed SJS/TEN and died. You killed her.


The defense: I reviewed the allergy with patient and husband, who both denied it to myself and multiple others; insisting strangely that the allergy was to “red dye”. If she was actually allergic; its not my fault that the patient was so ostriched. She signed the consent. Besides, SJS/TEN isn’t an “allergic reaction”, so knock that nonsense off right now. Pre-medication does nothing for moderate or severe reactions as per the radiology manual; besides that – she’s chronically on megadose prednisone for her COPD and has had loads of IV dye in the past for her collage of cardiovascular studies; often without premedicaiton. It was the Gorillamycin that likely caused the SJS/TEN, not the angelfart of IV dye that I ordered. Besides that, I needed the study; I wasn’t going to wait around for her to have another huge bleed and syncope before I acted.

More allegations: Her abdominal exam was benign. You didn’t need the CT at all.

More defense: She’s too fat for any reliable abdominal exam because ‘Murica. She’s on megadose prednisone, which even more totally nerfs the abdominal exam. Ask me how I know; I’ve made that mistake before and missed a perforated viscus that was later caught on CT when I felt discretion was the better part of valor.


Okay, let’s rumble. Deposition time comes, and I’m cooler than the other side of the pillow. I bob, I weave, we circle. I’m waiting for my opening. Opposing attorney is wearing a fishing shirt because lulz. I’m in suit-and-tie. I’m sorry to interrupt your critically important fishing schedule with my defense, you fat piece of trash. Enjoy heart disease, fugger. NOBODY is that buttery and doesn't have coronaries that hate them.

Eventually, he makes his mistake – the one I’ve been waiting for.


“So, you agree that rashes are a defining feature of allergic reactions, and that this rash began a chain of events that led to the patient’s death?”

“No, I don’t – you’re making a critical error here. Yes; rashes are a defining feature of allergic reactions… but this rash is different. This is the rash of SJS/TEN, a phenomenon which is so extraordinarily rare so as to statistically be less likely than being struck by lightning. It's not an "allergic reaction". It typically happens after the patient has been taking a culprit drug with certain qualities and characteristics.” [YES, I ACTUALLY SAID THIS AND EVERYTHING THAT FOLLOWS.]


“What are those qualities and characteristics?”


“Well, it can happen with any drug, at any time – but most overwhelmingly commonly - the culprit drug is an antibiotic, taken for between 3 and 6 weeks, with a long half-life, a high molecular weight, and certain specific molecular structures.”


“So, do you have an alternative *culprit drug* that resulted in this patient’s death, if it wasn’t the contrast dye that YOU ordered, Dr. RustedFox?” (I could tell that he was really leaning into this punch. Good. He whiffed.)


“I do.” - So Laconic. I’m such a smug ass.


“And what might that drug be, Dr. RustedFox?”


“The Gorillamycin that the patient was prescribed for her ongoing infection. It’s an antibiotic, that the patient was taking for almost precisely 3 weeks, with a long half life, a high molecular weight, and certain specific molecular structure – in this case; a macrolide ring and several other features. When we try to identify a culprit drug, we calculate what is called the ALDEN score (you guys can google this). When you do this; you can see that the categorical outcome is that the IV contrast dye is classified as “unlikely” and the Gorillamycin is classified as “highly likely”.”


Boom! There it was; the knockout punch. Cue the slow-motion shot of the bareknuckle boxer in the Guy Ritchie movie taking a right hook across the mouth, head snapping backward, blank look in the eyes, mouth snarled, blood and spit spraying in all directions before coming off his feet and landing with a wet thud on the canvas. *DING-DING-DINNG!*


“Lets take a break.”


We break. Attorney says to me: “Yep. It’s clear to me that he didn’t see that coming at all. Strong work, Little Mac. Strong. Work.” He might as well sprayed the water bottle into my open mouth and wrapped me in a towel.


More experts are deposed. The Greek God of Immunology himself descends from Mount Cytokine to defend me. Chair of the Immunology department at Ivory Tower University Medical Center, published in all the journals, winner of all the awards, King of the Britons, Defeater of the Saxons, Sovereign of All England.

“Yeah; the kid is right.”



Pre-trial summaries are written. The attorney called me “more than capable of performing in excellent fashion under pressure”. Really, homes? You don’t say. It’s like, kind of what we do in EM.



---



Months go by. One day, I get a letter from the attorney telling me to clear my schedule next month; we’re going to trial. Cancel that trip that you had planned to Arizona to see the big rocks on your big birthday. Wait, what?! No other news? Th’hell, man?!


Yeah, so it seems that they want to expedite the trial, because the only claimant (the patient’s husband) is 87, on dialysis, in extraordinarily poor health, and could die at any hot minute if he breathes too hard or misses dialysis. He dies, and the case dies along with him. Nobody collects, including the attorneys. They wanna go.


They had one more witness to depose. Dr. Moviestar, Chair of Whatever at Old University Medical School. Apparently, this guy was, as per the summary: handsome, likeable, and straight out of central casting – a doctor straight from a primetime drama. Its not that he had any scathing criticisms of my care, other than “the scan shouldn’t have been done at all, and emergent endoscopy should have been done instead”.


Now, you and I know that there’s no way that GI is coming in to do this scope at 12:15 AM on a Saturday morning. Not in my shop. Maybe your in-house GI fellow will up at Ivy League Medical Center because he’s chained up in the call room. That’s cool that he’s into BDSM; but that’s not where I work. Get a grip. He also argued that I should have thoroughly reviewed the hundreds of pages of records (mostly from other health systems and not available to me at the time) to find the instance where the patient developed (gasp!) an uneventful rash after IV dye that resolved without incident and in response to Solu-Medrol, and that this would have changed the medical decision making to delay the emergent scan and pre-medicate the patient.


Now, this is getting complex. The insurance company fully admits that “this isn’t about the medicine; we’re concerned that Dr. Ryan Gosling will confuse a jury of ostriches into agreeing with him, because he’s pretty" and my defense of: "she was too fat for me to rely on abdominal exam and is taking megadoses of roids" wasn't exactly endearing.


Really, homey? I’m not so bad looking myself. They didn’t want to hear it.


Case settled for a quarter million.


So why was the Citadel of Ricks involved? Early on, plaintiff’s counsel filed a complaint against me to the Citadel, in an effort at getting a “free medical quality case review”. If the Citadel decided that I was an ostrich, then it’s a layup for them. If not, well – then they’ve got a problem moving the case forward at all.


So, thanks for dragging your feet on that one, Citadel of Ricks. Thanks a lot.
F*** our medicolegal system. I have nothing of value to add beyond that.

I will say that I very much appreciate you posting this. It's a nice reminder for anyone who gets hit with the lawsuit hammer that you shouldn't focus on whether or not you screwed up. You likely didn't. It also isn't worth perseverating over things like "if only I had documented this" or if "I had ordered that test" this wouldn't happen. Yes it would. The lawsuit isn't about your medical care. It's supposed to be, but it's not. It's about some lawyer who thinks they have a sympathetic enough plaintiff to convince a group of 12 random idiots that some money should get paid out. That's all. Do your depositions and whatever the hell else the lawyers on your side want you to do and get on with your life.
 
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How in god's name does Florida still manage to retain an EM workforce?
 
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Also, for the record, I absolutely love that this is my "similar threads" list at the bottom of this post.

1673003405890.png


If y'all haven't read through the RustedFox Rants compendium, I highly recommend it.
 
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How in god's name does Florida still manage to retain an EM workforce?
He settled for $0 out of his pocket and the board of Medicine agreeing with him. He probably would have won in court too.
 
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He settled for $0 out of his pocket and the board of Medicine agreeing with him. He probably would have won in court too.
I think you missed the part about bridge jumping.
 
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"why don't we have doctors/nurses/hospital beds/IV pumps?"

Because, sadly, American society at large is undeserving of them.

@RustedFox hope you're doing better after this nonsensical ordeal.
 
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This is the F$@-ing problem with MedMal in the US, it is a complete crap shoot with no basis in reality

I’m sorry you had to deal with this. You should throw that docs name everywhere so his peers can public shame him
 
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He settled for $0 out of his pocket and the board of Medicine agreeing with him. He probably would have won in court too.

He settled for a mark on his permanent record and gets to remember the case every time he applies for credentials.
 
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Lispinopril. Propanol. Pregnasone. Hydrofoil. Metalpronoun. “That one for the thyroid”. Waterpill. Asspirin. Whatever.

Sorry this happened to you, I'd probably respond in a similar fashion and I'm just hoping that I defy the odds in my career (may it be lucrative and short). But also you got me with this line. Love it.
 
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Hey all,

Yeah, this sucked. Big time.

Let's look at it as if I were both right AND wrong:

If I was right (I am): This wasn't an allergic reaction at all. The culprit drug wasn't my contrast, and I proved it thru my profound expertise with medicine. Nevermind that, I lose because America is too dumb to understand and likes "pretty" instead.

If I was wrong: This was an allergic reaction (it wasn't), but the patient was too dumb to be responsible enough to tell me of a true allergy, and kept saying pants-on-head things about red dye. I lose, because this is somehow my responsibility?

A strange game. The only winning move is not to play. How about a nice game of chess?
 
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I’m sorry you had to deal with this. You should throw that docs name everywhere so his peers can public shame him
Yes, please do. At least report the A-hole to ACEP/AAEM for unscrupulous expert witness testimony. That you had to go through this is complete BS
 
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I was just dropped from a case where the allegation was "you didn't do x."

I very clearly did x, the documentation said I did x, however myself and a whole gaggle of docs were named, who also did x.

My attorney said I did x.

Took two years to get dropped.
 
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Yes, please do. At least report the A-hole to ACEP/AAEM for unscrupulous expert witness testimony. That you had to go through this is complete BS

Third'd

Drain the bad medicine swamp!
 
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Lo siento, compadre. Get the **** out of Florida. And agreed that the expert witness needs to get kicked out of ACEP/AAEM so he never has the chance of being an expert witness again. Frivolous lawsuits would never happen if we didn’t do this **** to ourselves.
 
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Yes, please do. At least report the A-hole to ACEP/AAEM for unscrupulous expert witness testimony. That you had to go through this is complete BS
Sanctions, if successful, would be a black mark on his record, could be brought up in every future trial and possibly shut off his stream of "expert" witness income.

There needs to be pushback against these docs that cannibalize fellow emergency physicians with dubious testimony, for cash.
 
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I've been waiting for this one for awhile. That was immensely entertaining. Thanks for finally writing it but I'm sorry you had to go through that dude.

My last suit was a brand new attorney a few years out of law school who was in a minor MVC and was obviously out to collect money on the other driver. Didn't have a scratch on him. Very dramatic. He started demanding more and more studies including an MRI of his spine which I flat out refused after his non indicated pan scans were negative. He got more and more threatening and started implying that he would "make me sorry if I didn't get X,Y,Z". I documented everything including his threatening behavior and he promptly requested the medical record when he got back to his office. He then sent a letter to our hospital CEO demanding that I retract certain statements because it would interfere with his ability to obtain restoration (reparation maybe?) for the accident or something to that affect. I refused to change my record and in doing so basically took a bullet for the offending driver. He promptly sued me and said I had lied in my note and needed to be castrated in front of the medical board of examiners, etc... Never practice again, etc.. blah, blah, blah. It went through court for close to a year and then he dropped the case. It was really bizarre. He apparently couldn't convince his law partner to represent him so he ended up representing himself. My attorney exposed that he wasn't fully licensed in the state or something like that? Either way, he ended up dropping it.

That was my second suit. I honestly didn't even get flustered about it after having been through the first one. The only thing I learned from that case is that a practicing attorney as a pt can make your life incredibly difficult if you don't make them happy.
This sounds like something the state bar should know about...
 
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Yes, please do. At least report the A-hole to ACEP/AAEM for unscrupulous expert witness testimony. That you had to go through this is complete BS
There needs to be a way to tar and feather "expert witnesses" like this.
 
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I've been waiting for this one for awhile. That was immensely entertaining. Thanks for finally writing it but I'm sorry you had to go through that dude.

My last suit was a brand new attorney a few years out of law school who was in a minor MVC and was obviously out to collect money on the other driver. Didn't have a scratch on him. Very dramatic. He started demanding more and more studies including an MRI of his spine which I flat out refused after his non indicated pan scans were negative. He got more and more threatening and started implying that he would "make me sorry if I didn't get X,Y,Z". I documented everything including his threatening behavior and he promptly requested the medical record when he got back to his office. He then sent a letter to our hospital CEO demanding that I retract certain statements because it would interfere with his ability to obtain restoration (reparation maybe?) for the accident or something to that affect. I refused to change my record and in doing so basically took a bullet for the offending driver. He promptly sued me and said I had lied in my note and needed to be castrated in front of the medical board of examiners, etc... Never practice again, etc.. blah, blah, blah. It went through court for close to a year and then he dropped the case. It was really bizarre. He apparently couldn't convince his law partner to represent him so he ended up representing himself. My attorney exposed that he wasn't fully licensed in the state or something like that? Either way, he ended up dropping it.

That was my second suit. I honestly didn't even get flustered about it after having been through the first one. The only thing I learned from that case is that a practicing attorney as a pt can make your life incredibly difficult if you don't make them happy.

Thanks.
This isn't even the BIG one; the "RustedFox Rants: My Jackpot Lawsuit". This one was small potatoes.

I still get agitated when I put fingers to keyboard and type that one out. That's why it's not done/hasn't been shared.
 
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I've been waiting for this one for awhile. That was immensely entertaining. Thanks for finally writing it but I'm sorry you had to go through that dude.

My last suit was a brand new attorney a few years out of law school who was in a minor MVC and was obviously out to collect money on the other driver. Didn't have a scratch on him. Very dramatic. He started demanding more and more studies including an MRI of his spine which I flat out refused after his non indicated pan scans were negative. He got more and more threatening and started implying that he would "make me sorry if I didn't get X,Y,Z". I documented everything including his threatening behavior and he promptly requested the medical record when he got back to his office. He then sent a letter to our hospital CEO demanding that I retract certain statements because it would interfere with his ability to obtain restoration (reparation maybe?) for the accident or something to that affect. I refused to change my record and in doing so basically took a bullet for the offending driver. He promptly sued me and said I had lied in my note and needed to be castrated in front of the medical board of examiners, etc... Never practice again, etc.. blah, blah, blah. It went through court for close to a year and then he dropped the case. It was really bizarre. He apparently couldn't convince his law partner to represent him so he ended up representing himself. My attorney exposed that he wasn't fully licensed in the state or something like that? Either way, he ended up dropping it.

That was my second suit. I honestly didn't even get flustered about it after having been through the first one. The only thing I learned from that case is that a practicing attorney as a pt can make your life incredibly difficult if you don't make them happy.
I mean if you were half the dingus he was you could likely sue him for malicious litigation and waste even more of both your time but maybe collect some money lol
 
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Lawsuits and board complaints take a big emotional toll, even when you followed standard of care, fought and won. I've been there. I'm glad you won this round, @RustedFox . I've finally come to realize the process often has little, if anything, to do with our worth as physicians. It has everything to do with lawyers fighting with each other for the privilege of hitting your med-mal insurance piñata.

This finally hit home when the biggest med-mal lawyer in town, who had spent years profiting by telling juries how incompetent my hospital, ER and docs were, had a heart attack. Where did go to be treated? That very same hospital, ER and doctors.
 
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RustedFox is definitely the Rickiest Rick of them all!
 
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I've been waiting for this one for awhile. That was immensely entertaining. Thanks for finally writing it but I'm sorry you had to go through that dude.

My last suit was a brand new attorney a few years out of law school who was in a minor MVC and was obviously out to collect money on the other driver. Didn't have a scratch on him. Very dramatic. He started demanding more and more studies including an MRI of his spine which I flat out refused after his non indicated pan scans were negative. He got more and more threatening and started implying that he would "make me sorry if I didn't get X,Y,Z". I documented everything including his threatening behavior and he promptly requested the medical record when he got back to his office. He then sent a letter to our hospital CEO demanding that I retract certain statements because it would interfere with his ability to obtain restoration (reparation maybe?) for the accident or something to that affect. I refused to change my record and in doing so basically took a bullet for the offending driver. He promptly sued me and said I had lied in my note and needed to be castrated in front of the medical board of examiners, etc... Never practice again, etc.. blah, blah, blah. It went through court for close to a year and then he dropped the case. It was really bizarre. He apparently couldn't convince his law partner to represent him so he ended up representing himself. My attorney exposed that he wasn't fully licensed in the state or something like that? Either way, he ended up dropping it.

That was my second suit. I honestly didn't even get flustered about it after having been through the first one. The only thing I learned from that case is that a practicing attorney as a pt can make your life incredibly difficult if you don't make them happy.
Thanks for standing up for yourself, and, in so doing, for the rest of us.
 
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I've been waiting for this one for awhile. That was immensely entertaining. Thanks for finally writing it but I'm sorry you had to go through that dude.

My last suit was a brand new attorney a few years out of law school who was in a minor MVC and was obviously out to collect money on the other driver. Didn't have a scratch on him. Very dramatic. He started demanding more and more studies including an MRI of his spine which I flat out refused after his non indicated pan scans were negative. He got more and more threatening and started implying that he would "make me sorry if I didn't get X,Y,Z". I documented everything including his threatening behavior and he promptly requested the medical record when he got back to his office. He then sent a letter to our hospital CEO demanding that I retract certain statements because it would interfere with his ability to obtain restoration (reparation maybe?) for the accident or something to that affect. I refused to change my record and in doing so basically took a bullet for the offending driver. He promptly sued me and said I had lied in my note and needed to be castrated in front of the medical board of examiners, etc... Never practice again, etc.. blah, blah, blah. It went through court for close to a year and then he dropped the case. It was really bizarre. He apparently couldn't convince his law partner to represent him so he ended up representing himself. My attorney exposed that he wasn't fully licensed in the state or something like that? Either way, he ended up dropping it.

That was my second suit. I honestly didn't even get flustered about it after having been through the first one. The only thing I learned from that case is that a practicing attorney as a pt can make your life incredibly difficult if you don't make them happy.
You should have sued him for wasting your time.
 
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RF, very entertaining and if you ever quit medicine, you have a great side gig waiting for you. Sorry you had to go through this and hopefully next time you can detach yourself from the lawsuit. Most times, it has nothing to do with negligence/care but just to win a settlement. Just look it form the lawyer standpoint. Death, spend 1 hr to file, spend 10 hrs for deposition, Put out a letter to settle for 300K. Settlement for 100K, he takes home 30-40K and spent prob 12 hrs doing this.

I did hospital EM for 20 yrs, probably saw 75K patients. NEVER had a lawsuit come from my ER patients. My only board complaints were 2 drug seekers who I didn't supply both resolved with me pointing to their DPS drug database clearly showing seeking behavior.

My only lawsuit was an end stage autoimmune 30ish yr old in the ICU, septic, on multiple pressors. Coded her a few times, eventually died in the hospital. I was named, our experts looked at the case and said nothing about my care caused her death.

Anyhow, lady had 2 young kids.

My schedule out 3 months ahead.
My lawyer - Can you come in next Monday to do a deposition? BUT Im working. Switch shifts around. Deposition 2 hrs of my time.
My lawyer - Can you give your version of the case - I spent 3 hrs reading over the complaints, all the hospital records, etc.
My lawyer - Plaintiff want to schedule a deposition with you next Friday. BUT Im working but if this is the only time I will switch my schedule
My lawyer - Plaintiff can't make it, we need to reschedule. But I already gave up my shift and 2K. Shrug.
My lawyer - They now want to do it in 2 wks, can you come. But I have things to do with the family. Ill be there.
Deposition took 2 hrs.

My lawyer - They want to settle for 100K. We will do whatever you want.

Choice #1 - settle and never think about this again. A mark on my record but so what? ICU end stage on pressors with bad outcome and no one blinks an eye. What sucked for me is I had a clean no suit record doing 20 yrs of EM medicine on undifferentiated pts, then I get sued by someone that was going to die no matter what I did.

Choice #2 - Go to court, cost the med mal company potentially over 100K in fees, and have this drag out for who knows how many months/years and having to change my schedule around constantly.

They know the game. Its the cost of doing business. Not a hill I would die on. Never lost any sleep. Settle and move on, i know the game.
 
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RF, very entertaining and if you ever quit medicine, you have a great side gig waiting for you. Sorry you had to go through this and hopefully next time you can detach yourself from the lawsuit. Most times, it has nothing to do with negligence/care but just to win a settlement. Just look it form the lawyer standpoint. Death, spend 1 hr to file, spend 10 hrs for deposition, Put out a letter to settle for 300K. Settlement for 100K, he takes home 30-40K and spent prob 12 hrs doing this.

I did hospital EM for 20 yrs, probably saw 75K patients. NEVER had a lawsuit come from my ER patients. My only board complaints were 2 drug seekers who I didn't supply both resolved with me pointing to their DPS drug database clearly showing seeking behavior.

My only lawsuit was an end stage autoimmune 30ish yr old in the ICU, septic, on multiple pressors. Coded her a few times, eventually died in the hospital. I was named, our experts looked at the case and said nothing about my care caused her death.

Anyhow, lady had 2 young kids.

My schedule out 3 months ahead.
My lawyer - Can you come in next Monday to do a deposition? BUT Im working. Switch shifts around. Deposition 2 hrs of my time.
My lawyer - Can you give your version of the case - I spent 3 hrs reading over the complaints, all the hospital records, etc.
My lawyer - Plaintiff want to schedule a deposition with you next Friday. BUT Im working but if this is the only time I will switch my schedule
My lawyer - Plaintiff can't make it, we need to reschedule. But I already gave up my shift and 2K. Shrug.
My lawyer - They now want to do it in 2 wks, can you come. But I have things to do with the family. Ill be there.
Deposition took 2 hrs.

My lawyer - They want to settle for 100K. We will do whatever you want.

Choice #1 - settle and never think about this again. A mark on my record but so what? ICU end stage on pressors with bad outcome and no one blinks an eye. What sucked for me is I had a clean no suit record doing 20 yrs of EM medicine on undifferentiated pts, then I get sued by someone that was going to die no matter what I did.

Choice #2 - Go to court, cost the med mal company potentially over 100K in fees, and have this drag out for who knows how many months/years and having to change my schedule around constantly.

They know the game. Its the cost of doing business. Not a hill I would die on. Never lost any sleep. Settle and move on, i know the game.

Thanks.
I'm sure times, attitudes, environments, and other things were different. I missed "the good days". Now, I wouldn't recommend EM to anyone.
 
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Lawsuits and board complaints take a big emotional toll, even when you followed standard of care, fought and won. I've been there. I'm glad you won this round, @RustedFox . I've finally come to realize the process often has little, if anything, to do with our worth as physicians. It has everything to do with lawyers fighting with each other for the privilege of hitting your med-mal insurance piñata.

This finally hit home when the biggest med-mal lawyer in town, who had spent years profiting by telling juries how incompetent my hospital, ER and docs were, had a heart attack. Where did go to be treated? That very same hospital, ER and doctors.

... but did I win?

"It didn't feel like a win"
 
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More experts are deposed. The Greek God of Immunology himself descends from Mount Cytokine to defend me. Chair of the Immunology department at Ivory Tower University Medical Center, published in all the journals, winner of all the awards, King of the Britons, Defeater of the Saxons, Sovereign of All England.
This might just be the most brilliant bit of medical writing I've ever read.
I mean, I know Fox in person. He really is brilliant. (And a nice, albeit crazy guy). WTF is an ALDEN score? Sheesh. Imma have to look that up. Later. Some day. Maybe.

My only board complaint thusfar (knock on wood) was an 8 page handwritten rant. No lawyer would take his case (because I didn't do anything wrong and he wasn't harmed and he was an idiot and even after I dumped him on medicine after he bounced back and they tried to send him home because him saying his "painful hernia needed surgery" wasn't exactly a medical emergency... but one was going to do it New Years Day, I still had to suffer through the same crap.

Citadel of Ricks. I love it. But yeah, would have been nice if they'd hurried the hell up.
Sorry you went through all it, but that, my friend, was some epic storytelling.
You'd kill a TED talk. But just for doctors.
 
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RF, all EM docs old and new, you have all signed up for a job that is unique. Not anyone is capable of doing it..

You get undifferentiated puzzles, try to solve it, and then must forget. You have to have short memory, make decisions without ever monday morning QB, and accept that bad outcomes will happen.

I always tell my docs that I have their backs if they made reasonable decisions regardless of outcome. I tell my RN manager that I back her up no matter the outcome if she makes a decision that she feel was right at the moment.

I would rather back up a doc who made a reasonable decision with bad outcome than a doc who made a poor decision that did not have a bad outcome.

We pay roulette every patient we see, we must accept it. Docs who can not accept this will end up miserable and a poor EM doc.

RF, try to move on and don't feel bad. You had a binary decision. CT with Contrast vs CT without vs NO CT. If you picked No CT or CT without and missed a bleed, then hard to back you up WHEN the pt told you they did not have contrast allergy. Hell, if I really needed a CT with, I would probably done it and dealt with the reaction.

You made the correct decision (I would have made the same) and this is just EM life. You are better off with this outcome than picking the other two regardless of outcome.

I love poker and EM is like poker. People get beat on the river and get pissed eventhough they made the right decision. I rather make the right decision, get beat on the river than make the wrong decision and happen to luck out on the river.

In the long run you will be a better/more successful poker player (EM doc) when you make the right decision in the moment. Helps you sleep better at night.
 
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The only thing I am more disgusted with than the American healthcare system is the American justice system; the former really being the product of the latter
 
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I only skimmed this but which antibiotic was the real culprit?

I’ve consulted on between 50-100 cases of SJS/TEN and never seen one from contrast. The few case reports on it I’m not sure I really believe as there are a bunch of things that look like SJS and aren’t….
 
I only skimmed this but which antibiotic was the real culprit?

I’ve consulted on between 50-100 cases of SJS/TEN and never seen one from contrast. The few case reports on it I’m not sure I really believe as there are a bunch of things that look like SJS and aren’t….
It’s Gorillamycin
 
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Was there any way you could have delayed trial? Like gotten into a car accident? Or entered drug rehab in Switzerland for 3 months? Or say you need more time for expert witnesses, or experts aren't available on their time frame?

Game theory wise, if the only way to win is not to play, and hope the plaintiff dies, I mean, why not? I mean if plaintiff can expedite, why can't you try to de-expedite? It's all a game after all.
 
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I only skimmed this but which antibiotic was the real culprit?

I’ve consulted on between 50-100 cases of SJS/TEN and never seen one from contrast. The few case reports on it I’m not sure I really believe as there are a bunch of things that look like SJS and aren’t….

Gorillamycin.

Yeah; this was brought up as well. My experts said that there was about 10 or so cases of SJS-TEN from contrast in the literature, and most weren't SJS-TEN.

Their experts said there were dozens to hundreds.
 
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I just got a letter from the Board of Health. What follows is a summary:



******************************************************************************


-- Dear DR. RUSTEDFOX


Do you remember that med-mal lawsuit in 2020? You know; that one where BOTH the patient AND her husband told you that she WASN'T allergic to IV contrast dye despite what the chart said, so you totally did the right thing and double-checked with them before you gave it to her and then she died two weeks later of a completely unrelated cause?


That one where the patient and her husband said the same thing to the nursing and radiology staff, before they carried out the CT abdomen/pelvis that you ordered?


That one where you could totally prove that it wasn't the contrast dye that you gave, but rather the antibiotics that she was taking for like, weeks?


The one where the patient’s husband changed his mind after her unfortunate demise and said something like: "Well, maybe she WAS allergic to the contrast dye after all? Yeah! That - that HAS to be it, because old people that collect diseases like our grandkids collect Pokémon cards don't just die, right? Right?! SOMEONE'S GOTTA PAYY!"


Yeah; THAT one. Pretty radical, huh?


Yeah, so like - me and the boys down here at the board got around to it. We had a good long look. Guess what? Turns out we think that you were right all along. Damn, those people were dumb. Great move by calculating that ALDEN score to prove that it wasn't the contrast dye that caused the patient to develop Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. Not many people would have thought of doing that. Strong work - you REALLY must have paid attention in medical school. Too bad you got sued and had to settle the case anyways. Lolz. Have a good shift, bro.


- Signed,

The Mouthbreathers at the Citadel of Ricks.


*****************************************************************************


Here's my fictitious response:



- Dear Mouthbreathers,


Hey bros. [BURRRP!] Yeah; I'm really glad you finally got around to that. Like, I really don’t wanna say this buuut… I told you so. Can you guys un-sue me and give me back all the time, money, and stress that I spent on it? You know, like, erase it from my record and all? 'Cause that would be real cool. It would be like, the right thing to do on your part.


No? That sucks, bro. Cause it would have been really compelling evidence to have at the time, you know.... when the STATE BOARD OF WHATEVER says that you're smarter than all the expert witnesses that the prosecutor paid-off to sell you down the river, it's generally a good thing to know. Real game-changer, there... Probably would have changed the outcome ‘n stuff.


Did I mention that this whole thing was a rather large contributor to me totally burning out of clinical medicine, spiraling into depression, consuming a terrific number of alcohol-containing beverages (go big or go home, amirite?), having the SNRI/benzodiazepine combo-meal prescribed to me totally backfire, considering walking away from society like “Kwai-Chang Caine” style, and then briefly considering bridge jumping as a one-time extreme sport? Sure, I had other things going on in my life at the time that really sucked (that’s on me), but this one was a biggie. Could’ve really used your help awhile back, amigos.


Anyways, I feel better now after having gotten this letter waaaay later than would have been helpful. I'm gonna go ride my sweet new mountain bike. Shred you later, posers.


-- Eff you guys for real,

Rick Sanchez C-137


P.S. - It took you two YEARS and a whole BOARD of physicians to figure out what I did by myself in like, two DAYS and a few six-packs of Michelob Ultra. So, DOUBLE eff you guys [makes gesture with two middle fingers extended while moving them up-and-down in a vertical dimension immediately next to one another].


******************************************************************************



[Record scratch, freeze-frame]


Yep. That’s me. You’re probably wondering how I got here.


[VHS-tape rewind montage that lasts just long enough for your individual attention-span]


It was a day like any other. A shift like any other. A parade of senior citizens here in the United States Capitol Of Senior Citizens. EMS brings in a 79-year-old female. Syncope after lower GI bleeding; passed out on the commode, fell forward, bonked head. EMS says the volume of blood was pretty big, which we all know can mean anything.


Great historian, this one. She takes all of the medicines. All of them: Lispinopril. Propanol. Pregnasone. Hydrofoil. Metalpronoun. “That one for the thyroid”. Waterpill. Asspirin. Whatever. She can’t pronounce her name correctly, let alone know what meds she takes. Thank Christ for the medical record. She’s only been in and out of every hospital system in three counties two dozen times in the past two years. Bowel resection. Coronary artery disease; stent-and-CABG. Breast cancer. Gallbladder. Pacemaker in. Endocarditis. Pacemaker out. Wound site infection. Presently taking IV Cefokillitall and Gorillamycin daily for about 3-4 weeks now for the endocarditis and pacemaker site infection thru her PICC. Now here, with me, today, for LGIB resulting in syncope and headbonk.


Abdominal exam is benign, but I’m pushing thru a foot+ of adiposity. ‘Murica.


Last hemoglobin was 11.8 about two weeks ago. Today’s is 9.2 Hmm. That’s a big enough drop to catch my attention. Type and screen. Lock and load. CT abdomen/pelvis with contrast. Before anyone reflexively says: “Why did you even order the CT?” – both you and I know that IM is going to doc-block me if I don’t get it, so eff off.


Allergies listed:

Iodine (lol). IV dye. Shellfish. Red dye. Codeine. Penicillin.



I walk back in the exam room. This time, her husband is in the room, as is the nurse.

“Hey, we really need to see if we can identify where it is that you’re bleeding from. To do that, we need to do a CAT scan with contrast dye. On your chart, there’s an allergy listed to contrast dye, bu-“



“No. Its not contrast dye. Its red dye. I’ve had contrast before”, she interrupted.

I’m sorry… say that again?

“Yes. It’s RED dye.”

You mean, like, food coloring? Red-40? That kind of thing?

“It’s RED dye.” [husband nods in agreement, repeats that its red dye]



Me: Okay, thank you. We’re going to get that CAT scan and see if we can find the bleed.

Me, to myself: “Okay, I’m not sure what kind of fugging weirdos you guys are and I don’t care.”



I went away, clicked the button to order the CT abd/pelvis w/contrast. Barbara (which is like “Karen” for the 75+ crowd) goes to radiology. Rad tech has the same red-dye-green-light discussion with the patient. Patient signs consent. Patient gets CT scan. Patient returns from radiology. Nothing happens. CT is boring because they are. Patient gets admitted.


[Freeze-frame]


Me, looking at camera, not frozen and walking cool-ly around the scene while others remain frozen in place and in awkward positions:

“You guys probably want me to move this along at this point. I’ve been here before, so let’s make it quick. A day or so later, the patient developed a rash. That rash turned into Stevens-Johnson Syndrome. That Stevens-Johnson Syndrome turned into Toxic Epidermal Necrolysis. That Toxic Epidermal Necrolysis turned into a transfer to a burn unit for all the useless things like steroids, fluids, etc. before the patient succumbed to sepsis and multisystem organ failure. A few weeks later, I got the notice of intent.”


The allegation: This woman had an allergy to IV contrast dye listed in her chart. You gave her IV contrast dye. You didn’t pre-medicate her. A rash is an allergic reaction. She developed SJS/TEN and died. You killed her.


The defense: I reviewed the allergy with patient and husband, who both denied it to myself and multiple others; insisting strangely that the allergy was to “red dye”. If she was actually allergic; its not my fault that the patient was so ostriched. She signed the consent. Besides, SJS/TEN isn’t an “allergic reaction”, so knock that nonsense off right now. Pre-medication does nothing for moderate or severe reactions as per the radiology manual; besides that – she’s chronically on megadose prednisone for her COPD and has had loads of IV dye in the past for her collage of cardiovascular studies; often without premedicaiton. It was the Gorillamycin that likely caused the SJS/TEN, not the angelfart of IV dye that I ordered. Besides that, I needed the study; I wasn’t going to wait around for her to have another huge bleed and syncope before I acted.

More allegations: Her abdominal exam was benign. You didn’t need the CT at all.

More defense: She’s too fat for any reliable abdominal exam because ‘Murica. She’s on megadose prednisone, which even more totally nerfs the abdominal exam. Ask me how I know; I’ve made that mistake before and missed a perforated viscus that was later caught on CT when I felt discretion was the better part of valor.


Okay, let’s rumble. Deposition time comes, and I’m cooler than the other side of the pillow. I bob, I weave, we circle. I’m waiting for my opening. Opposing attorney is wearing a fishing shirt because lulz. I’m in suit-and-tie. I’m sorry to interrupt your critically important fishing schedule with my defense, you fat piece of trash. Enjoy heart disease, fugger. NOBODY is that buttery and doesn't have coronaries that hate them.

Eventually, he makes his mistake – the one I’ve been waiting for.


“So, you agree that rashes are a defining feature of allergic reactions, and that this rash began a chain of events that led to the patient’s death?”

“No, I don’t – you’re making a critical error here. Yes; rashes are a defining feature of allergic reactions… but this rash is different. This is the rash of SJS/TEN, a phenomenon which is so extraordinarily rare so as to statistically be less likely than being struck by lightning. It's not an "allergic reaction". It typically happens after the patient has been taking a culprit drug with certain qualities and characteristics.” [YES, I ACTUALLY SAID THIS AND EVERYTHING THAT FOLLOWS.]


“What are those qualities and characteristics?”


“Well, it can happen with any drug, at any time – but most overwhelmingly commonly - the culprit drug is an antibiotic, taken for between 3 and 6 weeks, with a long half-life, a high molecular weight, and certain specific molecular structures.”


“So, do you have an alternative *culprit drug* that resulted in this patient’s death, if it wasn’t the contrast dye that YOU ordered, Dr. RustedFox?” (I could tell that he was really leaning into this punch. Good. He whiffed.)


“I do.” - So Laconic. I’m such a smug ass.


“And what might that drug be, Dr. RustedFox?”


“The Gorillamycin that the patient was prescribed for her ongoing infection. It’s an antibiotic, that the patient was taking for almost precisely 3 weeks, with a long half life, a high molecular weight, and certain specific molecular structure – in this case; a macrolide ring and several other features. When we try to identify a culprit drug, we calculate what is called the ALDEN score (you guys can google this). When you do this; you can see that the categorical outcome is that the IV contrast dye is classified as “unlikely” and the Gorillamycin is classified as “highly likely”.”


Boom! There it was; the knockout punch. Cue the slow-motion shot of the bareknuckle boxer in the Guy Ritchie movie taking a right hook across the mouth, head snapping backward, blank look in the eyes, mouth snarled, blood and spit spraying in all directions before coming off his feet and landing with a wet thud on the canvas. *DING-DING-DINNG!*


“Lets take a break.”


We break. Attorney says to me: “Yep. It’s clear to me that he didn’t see that coming at all. Strong work, Little Mac. Strong. Work.” He might as well sprayed the water bottle into my open mouth and wrapped me in a towel.


More experts are deposed. The Greek God of Immunology himself descends from Mount Cytokine to defend me. Chair of the Immunology department at Ivory Tower University Medical Center, published in all the journals, winner of all the awards, King of the Britons, Defeater of the Saxons, Sovereign of All England.

“Yeah; the kid is right.”



Pre-trial summaries are written. The attorney called me “more than capable of performing in excellent fashion under pressure”. Really, homes? You don’t say. It’s like, kind of what we do in EM.



---



Months go by. One day, I get a letter from the attorney telling me to clear my schedule next month; we’re going to trial. Cancel that trip that you had planned to Arizona to see the big rocks on your big birthday. Wait, what?! No other news? Th’hell, man?!


Yeah, so it seems that they want to expedite the trial, because the only claimant (the patient’s husband) is 87, on dialysis, in extraordinarily poor health, and could die at any hot minute if he breathes too hard or misses dialysis. He dies, and the case dies along with him. Nobody collects, including the attorneys. They wanna go.


They had one more witness to depose. Dr. Moviestar, Chair of Whatever at Old University Medical School. Apparently, this guy was, as per the summary: handsome, likeable, and straight out of central casting – a doctor straight from a primetime drama. Its not that he had any scathing criticisms of my care, other than “the scan shouldn’t have been done at all, and emergent endoscopy should have been done instead”.


Now, you and I know that there’s no way that GI is coming in to do this scope at 12:15 AM on a Saturday morning. Not in my shop. Maybe your in-house GI fellow will up at Ivy League Medical Center because he’s chained up in the call room. That’s cool that he’s into BDSM; but that’s not where I work. Get a grip. He also argued that I should have thoroughly reviewed the hundreds of pages of records (mostly from other health systems and not available to me at the time) to find the instance where the patient developed (gasp!) an uneventful rash after IV dye that resolved without incident and in response to Solu-Medrol, and that this would have changed the medical decision making to delay the emergent scan and pre-medicate the patient.


Now, this is getting complex. The insurance company fully admits that “this isn’t about the medicine; we’re concerned that Dr. Ryan Gosling will confuse a jury of ostriches into agreeing with him, because he’s pretty" and my defense of: "she was too fat for me to rely on abdominal exam and is taking megadoses of roids" wasn't exactly endearing.


Really, homey? I’m not so bad looking myself. They didn’t want to hear it.


Case settled for a quarter million.


So why was the Citadel of Ricks involved? Early on, plaintiff’s counsel filed a complaint against me to the Citadel, in an effort at getting a “free medical quality case review”. If the Citadel decided that I was an ostrich, then it’s a layup for them. If not, well – then they’ve got a problem moving the case forward at all.


So, thanks for dragging your feet on that one, Citadel of Ricks. Thanks a lot.
I gotta say, your willingness to be vulnerable is impressive - thank you. You didn’t deserve this.

Seeing accounts like this helps me prepare for the inevitable first time I get a notice.
 
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I gotta say, your willingness to be vulnerable is impressive - thank you. You didn’t deserve this.

Seeing accounts like this helps me prepare for the inevitable first time I get a notice.
This is why we should post about these things so our colleagues know they aren't alone.

I'm waiting a few more months for things to really settle before I post about my absurd case.
 
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RF, very entertaining and if you ever quit medicine, you have a great side gig waiting for you. Sorry you had to go through this and hopefully next time you can detach yourself from the lawsuit. Most times, it has nothing to do with negligence/care but just to win a settlement. Just look it form the lawyer standpoint. Death, spend 1 hr to file, spend 10 hrs for deposition, Put out a letter to settle for 300K. Settlement for 100K, he takes home 30-40K and spent prob 12 hrs doing this.

I did hospital EM for 20 yrs, probably saw 75K patients. NEVER had a lawsuit come from my ER patients. My only board complaints were 2 drug seekers who I didn't supply both resolved with me pointing to their DPS drug database clearly showing seeking behavior.

My only lawsuit was an end stage autoimmune 30ish yr old in the ICU, septic, on multiple pressors. Coded her a few times, eventually died in the hospital. I was named, our experts looked at the case and said nothing about my care caused her death.

Anyhow, lady had 2 young kids.

My schedule out 3 months ahead.
My lawyer - Can you come in next Monday to do a deposition? BUT Im working. Switch shifts around. Deposition 2 hrs of my time.
My lawyer - Can you give your version of the case - I spent 3 hrs reading over the complaints, all the hospital records, etc.
My lawyer - Plaintiff want to schedule a deposition with you next Friday. BUT Im working but if this is the only time I will switch my schedule
My lawyer - Plaintiff can't make it, we need to reschedule. But I already gave up my shift and 2K. Shrug.
My lawyer - They now want to do it in 2 wks, can you come. But I have things to do with the family. Ill be there.
Deposition took 2 hrs.

My lawyer - They want to settle for 100K. We will do whatever you want.

Choice #1 - settle and never think about this again. A mark on my record but so what? ICU end stage on pressors with bad outcome and no one blinks an eye. What sucked for me is I had a clean no suit record doing 20 yrs of EM medicine on undifferentiated pts, then I get sued by someone that was going to die no matter what I did.

Choice #2 - Go to court, cost the med mal company potentially over 100K in fees, and have this drag out for who knows how many months/years and having to change my schedule around constantly.

They know the game. Its the cost of doing business. Not a hill I would die on. Never lost any sleep. Settle and move on, i know the game.


While I understand your point, you were also in a unique position. You got sued toward the end of your hospital career. Most of us probably won't care if we were one foot out the door anyways. However, some ER docs get sued very early in their careers. You don't know if this is one of several or just the only one.

I was named as a resident. My old attending didn't care and left it up to me to decide if we should settle or fight. We fought and won (pretrial dismissal).

My advice to residents and early career doctors is to fight these f*ckers and not settle. Make them sweat. Mid-career and older attendings have the liberty to weigh risks vs. benefits.
 
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RF, very entertaining and if you ever quit medicine, you have a great side gig waiting for you. Sorry you had to go through this and hopefully next time you can detach yourself from the lawsuit. Most times, it has nothing to do with negligence/care but just to win a settlement. Just look it form the lawyer standpoint. Death, spend 1 hr to file, spend 10 hrs for deposition, Put out a letter to settle for 300K. Settlement for 100K, he takes home 30-40K and spent prob 12 hrs doing this.

I did hospital EM for 20 yrs, probably saw 75K patients. NEVER had a lawsuit come from my ER patients. My only board complaints were 2 drug seekers who I didn't supply both resolved with me pointing to their DPS drug database clearly showing seeking behavior.

My only lawsuit was an end stage autoimmune 30ish yr old in the ICU, septic, on multiple pressors. Coded her a few times, eventually died in the hospital. I was named, our experts looked at the case and said nothing about my care caused her death.

Anyhow, lady had 2 young kids.

My schedule out 3 months ahead.
My lawyer - Can you come in next Monday to do a deposition? BUT Im working. Switch shifts around. Deposition 2 hrs of my time.
My lawyer - Can you give your version of the case - I spent 3 hrs reading over the complaints, all the hospital records, etc.
My lawyer - Plaintiff want to schedule a deposition with you next Friday. BUT Im working but if this is the only time I will switch my schedule
My lawyer - Plaintiff can't make it, we need to reschedule. But I already gave up my shift and 2K. Shrug.
My lawyer - They now want to do it in 2 wks, can you come. But I have things to do with the family. Ill be there.
Deposition took 2 hrs.

My lawyer - They want to settle for 100K. We will do whatever you want.

Choice #1 - settle and never think about this again. A mark on my record but so what? ICU end stage on pressors with bad outcome and no one blinks an eye. What sucked for me is I had a clean no suit record doing 20 yrs of EM medicine on undifferentiated pts, then I get sued by someone that was going to die no matter what I did.

Choice #2 - Go to court, cost the med mal company potentially over 100K in fees, and have this drag out for who knows how many months/years and having to change my schedule around constantly.

They know the game. Its the cost of doing business. Not a hill I would die on. Never lost any sleep. Settle and move on, i know the game.

This is a wise attitude, but also an easier attitude to have when you have multiple streams of income.

I have a spotless medmal record (knock on wood, I saw a ton of kids) except for one case I was named and dropped in during residency. When I think of picking up more shifts, the potential for a big medmal case is definitely a dissuader. The criminalization of physicians is deeply dissuasive to continuing the practice of medicine, that's for sure.
 
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This is a wise attitude, but also an easier attitude to have when you have multiple streams of income.

I have a spotless medmal record (knock on wood, I saw a ton of kids) except for one case I was named and dropped in during residency. When I think of picking up more shifts, the potential for a big medmal case is definitely a dissuader. The criminalization of physicians is deeply dissuasive to continuing the practice of medicine, that's for sure.
This happened in year 14ish and way before leaving the hospital/increased income. Had 3 young kids all under 8 so still looking at many years of work.

It doesn't change the fact that settlement has a much lower risk profile esp with a low amount. On top of the unforeseeable time commitment and inevitable schedule disruption, civil verdict does not need to be unanimous/beyond reasonable doubt and ends up with expert vs expert. Jurors seeing 2 young kids without any financial support could easily pick the plaintiff's side using a preponderance of the evidence.

I have been through MEC and settlement raises little flags but when someone actually loses, its a bigger mark. I would say that the vast vast majority of cases never go to trial but settled eventually.

Lawyers on both sides do not care about right vs wrong. One side wants to settle for the most they can get and the other settle for the least. There typically is a number where both are happy.
 
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Best thing I've read on SDN so far. I'd give it double likes if I could.
 
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Excellent post. Thank you.

Your case is bull****. I know you know that, but as humans it never hurts to hear from others outside of own heads that yuuuuup you literally did everything right (and still got sued).

Kudos to people willing to talk about their med-mal experiences. It's so helpful. I've posted about mine before, but of course was nowhere near as memorable/powerful as your writing is terrific.

A buddy and I once surmised that the easiest way to fix the medmal system is for all docs to demand a change and stop seeing patients (outside of seeing truly life/limb-threatening cases) until such a change materialized. Would wake people up pretty quickly. Of course, we realized nothing like that will ever happen for a multitude of reasons. So instead of a brief pause in elective care in the country, we'll have the continued downward spiral of burnout and physicians leaving medicine (and being replaced with midlevels) and the concomitant reduction in access to care and quality of care.
 
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Thanks to all for the feedback, well-wishings, and PMs.
Hearing from you guys is incredible. I'm really happy to know that my obra here is appreciated.

When I look back, it was this one thing that made it near-intolerable for me:

I was being sued (and had a board complaint filed!) for the patient's complete inability to exercise even the slightest amount of responsibility for self. It came down to: the expectation of the patient is that the American Medical System should carry them forever, without any effort on their part, and even in spite of their own stupidity, AND guarantee their health for-ever-and-ever-amen. This patient was 80 years old with all the diseases, taking all the medicines, and both she and her husband REALLY had the expectation of living forever at infinite cost (none of which they would pay). It was that realization that made me say: "Nope. I'm tying a handkerchief to a stick and walking into the forest."

Nevermind the fact that the case went from "there's no way we can lose; this attorney is an ostrich for wanting to go to trial" to "wait, ostriches on the jury will see *handsome* and like that, and will hear me say "too fat for a reliable exam, need CT" and hate that... let's settle it." Forget the high science. Forget the (forgive me, guys) absolute genius of me coming up with the ALDEN score defense.

People like white magic, because science is too hard - and whatever they don't understand, is by default: categorically "wrong".
 
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Oh, and it bears repeating: premedication with steroids would have done absolutely nothing; as per the ACR contrast manual. It says, right in there; plain as day: "premedication should never delay an emergent scan."
 
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I was being sued (and had a board complaint filed!) for the patient's complete inability to exercise even the slightest amount of responsibility for self.
You are trying to rationalize something that is irrational. Its all about making money and getting a settlement.

Medmals have actuaries/risk managers whose job is to seek low settlements. If it costs them 100K to settle, 50K to go through a trial and could lose 2M, they should settle.
 
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But why does this read like something written by Samuel Shem?
 
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