NYT article

[xaelia]

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Eh, I think we're getting hung up a little bit on the details, likely presented in a skewed fashion by the biased author.

From what I gather the ED physician is EM/PEM. She probably knows what "sick" and "not sick" look like - and this kid probably looked OK right up until he crumped, unfortunately, despite the bacteremic process going on inside. I'll start by giving the clinicians the benefit of the doubt. Single case outcomes are valid to re-evaluate systems processes in place, but not necessarily to make wholesale changes.

 

[odoreater]

The article stated that a lab report came back three hours after discharge that indicated sepsis. This isn't about nuances of diagnosis - the results indicated sepsis.

No.

See my post above.

Lawyers are held accountable for mistakes they make (as they should).

No

http://scienceblogs.com/dispatches/2011/03/31/supreme-court-strengthens-pros/

 

[Apollyon]

Wow. I go away for a couple days and find out I really made some people upset.

First off, let me apologize for coming across a bit as a know it all (in retrospect, reading my original post I sound a little like a brat).

I've actually gone and done some research following my mistake, reread the article (a poor source to judge from but the only one we have unfortunately), and consulted with a couple other doctors. Also, while I'm still a med student, I am a bit older, and have worked in emergency medicine departments/related fields for a long time now (>10 years without giving anything away. Finally I am the farthest thing from an expert, but have seen a lot of patients).

Dude - one thing: get over yourself. Seriously. First, your claim that people are "upset" puts it on them - no, it is squarely on you. Knowing how these people post online (so I "know" them, after a sort, but also several IRL), none who commented on your writings would be ones that would even think of you after they got off SDN.

Second, I had 10 years in the books in the ED and related fields (ED, EMT/paramedic, firefighter) before EM residency, and I wasn't as strident or polarizing as you have proven to be in your very few posts. That's fine if that is who you are - but that's how you will be seen. Just as an off the cuff assessment: there are a few folks on here, like EM_Rebuilder, Jeff698, docB, and FoughtFyr, who I believe are the neighbor you would like living next door to you - the guy at whose family you always wave, and if you have extra tomatoes or radishes, you bring them over to them. Hamhock and WilcoWorld are the brainy, intellectual types. Pinipig now is southerndoc 5 years ago (not in the exam prep, but the drive/direction). GenVeers is that guy down the street that yells at the clouds when there isn't something more tangible at hand.

If you want to be the guy that has the username that is almost obscene, and "cleverly" interposes the name of a convicted felon, and that the first reaction people have on seeing you've posted is that it is something opposite for opposite's sake, then, OK. Just don't assume facts not in evidence.

 

[deleted109597]

Aww, I feel left out by Apollyons caricatures. I want to be something funny too.



I still disagree with part of odoreater though. Again, while slight bandemia is not a huge help, an enormous bandemia is helpful.
I haven't seen any studies that compare bandemias of greater than 40% (of which my n=5 and all of them had sepsis, 3 had large abscesses that needed surgery, two were like this kid) vs those picky band counts of 10%. It may be that the studies need a big enough population of the huge bandemia patients, and there isn't likely a large population of them.
Of course,

On multiple logistic regression, the odds ratio for infection was 8.67 (95% CI 3.36-22.39; P < .001) for patients with band count greater than 10% and 1.6 (95% CI 0.78-3.29; P = .2) for a WBC count greater than 12 × 10(9)/L.

the evidence

In a multivariate regression analysis, independent predictors for progression were hyperthermia, neutropenia, band neutrophils appearance, hyponatremia, blood urea nitrogen level, serum lactate level, and organ failure including respiratory, cardiovascular, and central nervous system.

out there is

Bandemia was present in 80% of culture-positive patients with a normal temperature and 79% of culture-positive patients with a normal WBC count.

conflicting as well.

The band level on presentation was not found to be associated with inpatient mortality in ED patients with sepsis who are eligible for early goal-directed therapy.

(although I tend to think of this number like I do for lipase. You're more likely to die if you can't mount a response, but some people who can still have overwhelming infection).

 

[Docuronium]

I'll take the time to specifically apologize to Apolloyon, whose opinion I value. I'm sorry that I came across as a punk before. That wasn't my intention. My issue here is that everything I've learned from medicine so far (perhaps the key phrase) tells me to do a much larger work up of this kid. I would like to know as I keep moving forward in my training what are the things that make this particular case seem ok to discharge? This article is biased and doesn't seem to present the things the ED doc must have seen that made them feel comfortable discharging the patient.

I also admittedly at this point am suffering from my own bias, as I've been presented "here's a terrible thing that happened to a child, in retrospect look at a few of these values and see how obvious it was."

Finally, I don't think I'll be going to the annual SDN EM forum BBQ any time soon. I tend to tell the same stories a lot and think you fellas would jump all over me for "reposting."

 

[Docuronium]

Eh, forget it. I'll probably come back ten years from now, look at this, and be on the other side.

 

[Apollyon]

Eh, forget it. I'll probably come back ten years from now, look at this, and be on the other side.

It's just experience talking - that Dwyer turd keeps harping on the bands - his one note, and, as gettheleadout noted, he keeps telling all the docs that they are wrong - one at a time.

This wasn't a needle in a haystack - this was a needle in a pile of needles. I don't think that there is a more apt comparison.

 

[8654Marine]

I'll refrain from making any assumptions about this case, since I see very little pertinent data about this case.

I'm 10 years out of residency.

Medicine is my second career.

What I've realized is that I may not know as much as I thought or wish.

Life shows many examples that do not follow textbooks or criteria.

Jumping to strident conclusions, based on minimal data, and interpreted through minimal clinical experience is immature.

 

[Beagles]

Quote:
Originally Posted by Beagles
The article stated that a lab report came back three hours after discharge that indicated sepsis. This isn't about nuances of diagnosis - the results indicated sepsis.
No.

See my post above.


Quote:
Originally Posted by Beagles
Lawyers are held accountable for mistakes they make (as they should).
No

http://scienceblogs.com/dispatches/2...engthens-pros/

Dr. Michael B. Edmond, the chairman of the division of infectious diseases at Virginia Commonwealth University disagrees with your opinion that the lab results did not indicate sepsis. His quote in the NYT article, p. 3:

"About three hours later, Rory’s lab results were printed. He was producing neutrophils and bands, white blood cells, at rates that were 'very abnormal and would suggest a serious bacterial infection,' Dr. Edmond said".

If he was an expert witness for the plaintiff, this testimony would carry significant weight on the issue of whether the clinician met the standard of care.

For your assessment, based on an internet article you found, that lawyers are not accountable for mistakes: if I weren't careful with my words, I would say that your response is dismissive, immature, and naive (similar to many comments on this thread in response to those would had different opinions); if I were careful with my words, perhaps I would say that it is uninformed.

That article dealt with the concept of sovereign immunity (from the English concept of not being able to sue the King). Public sector employees, including doctors and lawyers, can only be sued if an exception by statute exists that allows suit. Private lawyers are routinely disciplined by respective state bar associations, similar to state medical licensing and clinical privileges for doctors.

Most of the discussion here relates to the issue of whether the standard of care was met. I will be the first to admit that those here have far more knowledge and experience (for now at least) to give an opinion on that issue. I have stated that my response is limited from a legal perspective (the perspective that matters as this case moves forward). From that perspective, I would say that the defendants (including the hospital and clinician) have an upward battle. Knowledgeable medical professionals, including Dr. Edward, seem to feel that the standard was not met.

Medico-legal lesson (yes, it is unsolicited so feel free to disregard): Don't discharge patients before lab results you ordered aren't back. If you must for whatever reason, review them later and/or have protocols in place to ensure that they are reviewed with appropriate follow-up as needed.

 

[odoreater]

Dr. Michael B. Edmond, the chairman of the division of infectious diseases at Virginia Commonwealth University disagrees with your opinion that the lab results did not indicate sepsis. His quote in the NYT article, p. 3:

"About three hours later, Rory's lab results were printed. He was producing neutrophils and bands, white blood cells, at rates that were 'very abnormal and would suggest a serious bacterial infection,' Dr. Edmond said".

Wonderful---your appeal to authority and the NY Times cherry picking of a willing expert trumps all of the available literature demonstrating equivocal results in elucidating a significant discriminatory zone via use of peripheral bands to distinguish bacterial from viral etiologies (or stress response etc.)

Keep thinking like a lawyer and not a physician---you are doing a wonderful job of it. The quote in the NY Times article certainly trumps established likelihood ratios.

If he was an expert witness for the plaintiff, this testimony would carry significant weight on the issue of whether the clinician met the standard of care.

Of course it would--because your former profession would make sure it would regardless of the ambiguity of the scientific evidence.

For your assessment, based on an internet article you found, that lawyers are not accountable for mistakes: if I weren't careful with my words, I would say that your response is dismissive, immature, and naive (similar to many comments on this thread in response to those would had different opinions); if I were careful with my words, perhaps I would say that it is uninformed.

That article dealt with the concept of sovereign immunity (from the English concept of not being able to sue the King). Public sector employees, including doctors and lawyers, can only be sued if an exception by statute exists that allows suit. Private lawyers are routinely disciplined by respective state bar associations, similar to state medical licensing and clinical privileges for doctors.

Are you sure you were a lawyer?

This is straight forward---you said lawyers are always held accountable I linked an article that dealt with prosecutorial immunity as a direct counterfactual.

Most of the discussion here relates to the issue of whether the standard of care was met. I will be the first to admit that those here have far more knowledge and experience (for now at least) to give an opinion on that issue.

Yep---I did that. I have way more experience and knowledge than you on this issue.

I have stated that my response is limited from a legal and ignorant MEDICAL perspective (the perspective that matters as this case moves forward into a realm where science no longer matters).

Fixed that for you.

From that perspective, I would say that the defendants (including the hospital and clinician) have an upward battle. Knowledgeable medical professionals, including Dr. Edward, seem to feel that the standard was not met.

He is an expert because the NY Times quoted him. Amazing.

Knowledgable professionals who do not practice emergency medicine and are NOT experts in the field of emergency medicine. Luckily for lawyers like you NY state does not require (as many others rightly do) that expert witness are from the same specialty as the defendant. Maybe one day when you are no longer in medical school and active within emergency medicine you'll realize why this is a vast difference and why ACEP/AAEM have sought tort reform (successfully in progressive states) to demand same-specialty expert witnessing.

Medico-legal lesson (yes, it is unsolicited so feel free to disregard): Don't discharge patients before lab results you ordered aren't back. If you must for whatever reason, review them later and/or have protocols in place to ensure that they are reviewed with appropriate follow-up as needed.

Real Medical Legal lesson (solicited)---bad things happen regardless of care rendered. Bad things will always happen. As long as they do (which they always will) we are all lucky to have you and your profession to make sure that the public knows that regardless of the circumstances someone can always be held responsible.

Bravo.

 

[odoreater]

Aww, I feel left out by Apollyons caricatures. I want to be something funny too.



I still disagree with part of odoreater though. Again, while slight bandemia is not a huge help, an enormous bandemia is helpful.
I haven't seen any studies that compare bandemias of greater than 40% (of which my n=5 and all of them had sepsis, 3 had large abscesses that needed surgery, two were like this kid) vs those picky band counts of 10%. It may be that the studies need a big enough population of the huge bandemia patients, and there isn't likely a large population of them.
Of course,

the evidence

out there is

conflicting as well.

(although I tend to think of this number like I do for lipase. You're more likely to die if you can't mount a response, but some people who can still have overwhelming infection).

Agreed the evidence is conflicting but the best LR+ reported has been ~ 5 which does little to change pre-test probability. Nate Kuperman's study indicated no difference in children with influenza like illness and subsequently diagnosed bacterial infection. It may in fact be true that if we do a larger study the degree of bandemia will be useful but currently the literature simply does not support it.

 

[odoreater]

I'll refrain from making any assumptions about this case, since I see very little pertinent data about this case.

I'm 10 years out of residency.

Medicine is my second career.

What I've realized is that I may not know as much as I thought or wish.

Life shows many examples that do not follow textbooks or criteria.

Jumping to strident conclusions, based on minimal data, and interpreted through minimal clinical experience is immature.

👍👍

😍😍

 

[deleted109597]

I'll refrain from making any assumptions about this case, since I see very little pertinent data about this case.

I'm 10 years out of residency.

Medicine is my second career.

What I've realized is that I may not know as much as I thought or wish.

Life shows many examples that do not follow textbooks or criteria.

Jumping to strident conclusions, based on minimal data, and interpreted through minimal clinical experience is immature.

Apologies if any of this looks like finger pointing, but I'm merely treating it like an M&M. Thus, we should learn what (if any) mistakes were made, and prevent such things from happening in the future.
I don't think I ever said Dr. Scribner was personally at fault.

 

[Hamhock]

but I am not sure that this death could've been prevented without a significant increase in utilization of resources in identifying this pt out of the thousands of other febrile, vomiting, 12 year olds.

Like a lactate?

HH

{Yes, I know he is not technically an adult...but still your post was just begging for the answer and this giant kid is in many ways an adult; not just a small adult}

 

[Beagles]

Quote:
Originally Posted by Beagles
Dr. Michael B. Edmond, the chairman of the division of infectious diseases at Virginia Commonwealth University disagrees with your opinion that the lab results did not indicate sepsis. His quote in the NYT article, p. 3:

"About three hours later, Rory’s lab results were printed. He was producing neutrophils and bands, white blood cells, at rates that were 'very abnormal and would suggest a serious bacterial infection,' Dr. Edmond said".

response by odoreater:

Wonderful---your appeal to authority and the NY Times cherry picking of a willing expert trumps all of the available literature demonstrating equivocal results in elucidating a significant discriminatory zone via use of peripheral bands to distinguish bacterial from viral etiologies (or stress response etc.)

Keep thinking like a lawyer and not a physician---you are doing a wonderful job of it. The quote in the NY Times article certainly trumps established likelihood ratios.

He is an expert because the NY Times quoted him. Amazing.

Knowledgable professionals who do not practice emergency medicine and are NOT experts in the field of emergency medicine. Luckily for lawyers like you NY state does not require (as many others rightly do) that expert witness are from the same specialty as the defendant. Maybe one day when you are no longer in medical school and active within emergency medicine you'll realize why this is a vast difference and why ACEP/AAEM have sought tort reform (successfully in progressive states) to demand same-specialty expert witnessing.

I am not relying upon the NY Times Article. Dr. Michael Edward opines the the lab results suggested a serious bacterial infection. A reasonable response based on that would be to investigate this further. I have no opinion on whether the lab results suggested since as you point out, I am not qualified to render an opinion.

My only opinion is that once you order a lab test, wait for the results before discharge.

You are right that various states don't require same specialists to qualify as experts. This does not affect me because I don't practice med mal nor do I plan to do so in the future. I do, however, hope to be active in professional organizations.

Quote:
Originally Posted by Beagles
That article dealt with the concept of sovereign immunity (from the English concept of not being able to sue the King). Public sector employees, including doctors and lawyers, can only be sued if an exception by statute exists that allows suit. Private lawyers are routinely disciplined by respective state bar associations, similar to state medical licensing and clinical privileges for doctors.

response by odoreater:

Are you sure you were a lawyer?

This is straight forward---you said lawyers are always held accountable I linked an article that dealt with prosecutorial immunity as a direct counterfactual.

You misquote what I said, but you seem to do much of that by "fixing" my responses as well below. I never said that lawyers are always held accountable similar to doctors never always being held accountable for their mistakes.

I am a lawyer and continue to be one in the future by mixing by legal background into the field of medicine, perhaps in the area of public policy.

Quote:
Quote:
Originally Posted by Beagles
Most of the discussion here relates to the issue of whether the standard of care was met. I will be the first to admit that those here have far more knowledge and experience (for now at least) to give an opinion on that issue.

Response by odoreater:

Yep---I did that. I have way more experience and knowledge than you on this issue.

I don't question your professional competence as you did mine so I don't dispute this.

Quote:
Quote:
Originally Posted by Beagles
I have stated that my response is limited from a legal and ignorant MEDICAL perspective (the perspective that matters as this case moves forward into a realm where science no longer matters).

Response by odoreater:

Fixed that for you.

Yes, you misquoted me. Thanks for "fixing" it.

Originally Posted by Beagles
Medico-legal lesson (yes, it is unsolicited so feel free to disregard): Don't discharge patients before lab results you ordered aren't back. If you must for whatever reason, review them later and/or have protocols in place to ensure that they are reviewed with appropriate follow-up as needed.

Response by odoreater:

Real Medical Legal lesson (solicited)---bad things happen regardless of care rendered. Bad things will always happen. As long as they do (which they always will) we are all lucky to have you and your profession to make sure that the public knows that regardless of the circumstances someone can always be held responsible.

Bravo.

You seem to know it all and have the answers so my simple advice would not benefit you. With that attitude, my colleagues in med-mal will keep busy. By the way, you are easily frazzled and come across as the classic stereotype of the "all-knowing doc." You would not do well on the witness stand.

Not interested in getting into a pissing contest so take care.

 

[WilcoWorld]

...
My only opinion is that once you order a lab test, wait for the results before discharge.
...

I absolutely agree 100% of the time, except for the exceptions.

 

[WilcoWorld]

On the one hand, if I order a CBC I really want to know that result. If I order it and later the patient decides he/she isn't willing to stay for the result I'll document that they left against my advice.

On the other hand, I've discharged a lot of people with toxic granulocytes on their differential. Every time I've done it I've had the thought "You know, 'toxic granulocytes' would sound pretty bad to a jury...", but I still discharged them because they were fine.

 

[Beagles]

WilcoWorld: I am not interested in offending anyone but the nexus between law and medicine interests me so I am offering my opinion on your comments. If you are not interested, you can obviously disregard.

On the one hand, if I order a CBC I really want to know that result. If I order it and later the patient decides he/she isn't willing to stay for the result I'll document that they left against my advice.

This is good strategy - documentation. But these facts are different than those presented in the article. There, the clinician seems to have ordered the test and discharged the patient before the tests came back.

On the other hand, I've discharged a lot of people with toxic granulocytes on their differential. Every time I've done it I've had the thought "You know, 'toxic granulocytes' would sound pretty bad to a jury...", but I still discharged them because they were fine.

But you realized that there was a differential in the first place, meaning that the tests came back. You made a medical judgment based upon your interpretation of the results. Reasonably minded docs can have different opinions and judgment calls looking at the same test results.

The clinicians in this thread evidence that different opinions may exist. But the central point in the NYT article was that the clinician there never even got to that point because, again, the lab results came back after discharge. If the clinician there had reviewed the lab tests, recognized the threat of sepsis, documented his or her rationale for discharging the patient notwithstanding, and the patient later died; the risk of liability for malpractice would be less.

So the fact that the patient died here is not the crux that forms liability. It is not even a misdiagnosis in my opinion because the clinician never even got to the point of reviewing the lab results to form an opinion about the threat of sepsis. Again, the liability arises in my opinion because of discharge before the lab results came back without any follow-up. Moreover, a reasonably minded doc, if viewing the lab results, would have done more to explore the sepsis possibility given the dire conditions if treatment was not provided soon. This step never occurred because the lab results were never reviewed before discharge. This is the simple message that a judge or jury will understand.

I think I have repeated myself regarding my opinion ad nauseam and may have overstayed my welcome on this thread.

 

[Apollyon]

For your assessment, based on an internet article you found, that lawyers are not accountable for mistakes: if I weren't careful with my words, I would say that your response is dismissive, immature, and naive (similar to many comments on this thread in response to those would had different opinions); if I were careful with my words, perhaps I would say that it is uninformed.

That article dealt with the concept of sovereign immunity (from the English concept of not being able to sue the King). Public sector employees, including doctors and lawyers, can only be sued if an exception by statute exists that allows suit. Private lawyers are routinely disciplined by respective state bar associations, similar to state medical licensing and clinical privileges for doctors.

Most of the discussion here relates to the issue of whether the standard of care was met. I will be the first to admit that those here have far more knowledge and experience (for now at least) to give an opinion on that issue. I have stated that my response is limited from a legal perspective (the perspective that matters as this case moves forward). From that perspective, I would say that the defendants (including the hospital and clinician) have an upward battle. Knowledgeable medical professionals, including Dr. Edward, seem to feel that the standard was not met.

Medico-legal lesson (yes, it is unsolicited so feel free to disregard): Don't discharge patients before lab results you ordered aren't back. If you must for whatever reason, review them later and/or have protocols in place to ensure that they are reviewed with appropriate follow-up as needed.

Wow...I was going to parse this out, but each paragraph needs to be addressed.

Lawyers are not accountable for mistakes? Accounted for in what manner? Would you consider losing at trial (whether criminal or civil) to be an error? See, the way I see it, a conviction is like getting the diagnosis. We both "know" we are right.

Next, discipline by the state bar or the state medical board (or the hospital board) are NOT the same thing as getting sued for malpractice. Although one punishment is the same (entry into the databank - NPDB/HIPDB - into which 25% of doctors have an entry, and any doctors for whom there has been a payout for a malpractice claim (even if it didn't go to trial, even if it is $500) gets a ding). However, a ding in the DB for malpractice is quite different from a consent order or a reprimand or censure, which are clearly disciplinary. For one, the malpractice claims are civil torts, whereas the other side are incidents that could be decided to violate criminal statutes. How many lawyers get sued for legal malpractice - even when the grounds for appeal are presented as "inadequate counsel"? How many attorneys actually carry malpractice insurance? (Coincidentally, it was mentioned on the replay episode of "Suits" earlier tonight - I'll wager dollars to doughnuts that that was the first time literally millions of Americans ever heard or considered that legal malpractice even exists.)

Point next is your incredibly conceited statement of "have far more knowledge and experience (for now at least)" - you know what? You will NEVER, EVER have as much experience as me. EVER. It is galling, appalling, and, frankly, shocking that you would make such a statement. Do you actually believe your own press? To take a page from my prepubescent nephew, do you like the smell of your own farts?

The last issue is the condescension of your medico-legal lesson (yes, it is unsolicited so feel free to disregard) - really? What if it WAS solicited? It's just the way you word it that makes you sound like you are not "one of us". As odoreater stated, you are thinking like a lawyer and not like a doctor (or, should I say "like an attorney, and not like a physician"?). I went to med school with 3 attorneys. One was "normal". One was lukewarm; just like a glass of lukewarm water, a sip was good, but anything more than that was 'ick'. One had never, ever had a real job - bachelor's --> MPH --> J.D. --> Ph.D --> M.D. He actually did a med/peds residency - and immediately on completion went on staff of a journal. I was not impressed, but that is just an aside.

I could NOT possibly care any less if you are going or not going to do med mal - after all, 99% of attorneys make all the rest look bad. However, just try a little modesty on for size - just once, maybe?

 

[Beagles]

Sorry guys but couldn't resist....

Wow...I was going to parse this out, but each paragraph needs to be addressed.

Lawyers are not accountable for mistakes? Accounted for in what manner? Would you consider losing at trial (whether criminal or civil) to be an error? See, the way I see it, a conviction is like getting the diagnosis. We both "know" we are right.

Next, discipline by the state bar or the state medical board (or the hospital board) are NOT the same thing as getting sued for malpractice. Although one punishment is the same (entry into the databank - NPDB/HIPDB - into which 25% of doctors have an entry, and any doctors for whom there has been a payout for a malpractice claim (even if it didn't go to trial, even if it is $500) gets a ding). However, a ding in the DB for malpractice is quite different from a consent order or a reprimand or censure, which are clearly disciplinary. For one, the malpractice claims are civil torts, whereas the other side are incidents that could be decided to violate criminal statutes. How many lawyers get sued for legal malpractice - even when the grounds for appeal are presented as "inadequate counsel"? How many attorneys actually carry malpractice insurance? (Coincidentally, it was mentioned on the replay episode of "Suits" earlier tonight - I'll wager dollars to doughnuts that that was the first time literally millions of Americans ever heard or considered that legal malpractice even exists.)

You base your knowledge on the legal system on "Suits." This like me using "ER" or "Grey's Anatomy" as support. It is apparent that you nothing about the legal system and your hypocrisy is amazing. You criticize my participation on this thread based on my lack of knowledge (and apparently will never have enough experience as you and galling to even think so but more on that later) but yet you make sweeping statements about the law?

Lawyers do get routinely sued by former clients. Moreover, a discipline by a state bar may have even harsher consequences. Lawyers have to take the state bar exam for each state. If they are disciplined and can't practice in their own state, they can't just move to another state.

Point next is your incredibly conceited statement of "have far more knowledge and experience (for now at least)" - you know what? You will NEVER, EVER have as much experience as me. EVER. It is galling, appalling, and, frankly, shocking that you would make such a statement. Do you actually believe your own press? To take a page from my prepubescent nephew, do you like the smell of your own farts?

You know nothing about me and to make a statement like that? Really classy and by the way, great example of modesty. Should I kneel before your presence? I sympathize for docs that get sued (after I too will be a doc), but it is attitudes and egos that you display for which I feel less sympathy.

The last issue is the condescension of your medico-legal lesson (yes, it is unsolicited so feel free to disregard) - really? What if it WAS solicited? It's just the way you word it that makes you sound like you are not "one of us". As odoreater stated, you are thinking like a lawyer and not like a doctor (or, should I say "like an attorney, and not like a physician"?). I went to med school with 3 attorneys. One was "normal". One was lukewarm; just like a glass of lukewarm water, a sip was good, but anything more than that was 'ick'. One had never, ever had a real job - bachelor's --> MPH --> J.D. --> Ph.D --> M.D. He actually did a med/peds residency - and immediately on completion went on staff of a journal. I was not impressed, but that is just an aside.

If it were solicited, I would gladly give my opinion. Yes, it is an aside. I went to law school with a physician. He's now a patent attorney. He was a nice guy and I can't really compare with him different temperature states of water (nor do I want to).

"One of us?" Ah, yes the herd mentality of medicine. No, I don't want to think like every other sheep. Having this "thinking like us" mentality is not for the medical profession. And a bit boring, no?

I could NOT possibly care any less if you are going or not going to do med mal - after all, 99% of attorneys make all the rest look bad. However, just try a little modesty on for size - just once, maybe?

Another blanket statement that offends a whole class of professionals. Real classy and modest. Your response is what furthers the public's view that doctor's can be out-of-touch and pompous, arrogant, _______. I never want to think your way. Perhaps you can be civil, no?

 

[Apollyon]

Sorry guys but couldn't resist....



You base your knowledge on the legal system on "Suits." This like me using "ER" or "Grey's Anatomy" as support. It is apparent that you nothing about the legal system and your hypocrisy is amazing. You criticize my participation on this thread based on my lack of knowledge (and apparently will never have enough experience as you and galling to even think so but more on that later) but yet you make sweeping statements about the law?

Lawyers do get routinely sued by former clients. Moreover, a discipline by a state bar may have even harsher consequences. Lawyers have to take the state bar exam for each state. If they are disciplined and can't practice in their own state, they can't just move to another state.



You know nothing about me and to make a statement like that? Really classy and by the way, great example of modesty. Should I kneel before your presence? I sympathize for docs that get sued (after I too will be a doc), but it is attitudes and egos that you display for which I feel less sympathy.



If it were solicited, I would gladly give my opinion. Yes, it is an aside. I went to law school with a physician. He's now a patent attorney. He was a nice guy and I can't really compare with him different temperature states of water (nor do I want to).

"One of us?" Ah, yes the herd mentality of medicine. No, I don't want to think like every other sheep. Having this "thinking like us" mentality is not for the medical profession. And a bit boring, no?



Another blanket statement that offends a whole class of professionals. Real classy and modest. Your response is what furthers the public's view that doctor's can be out-of-touch and pompous, arrogant, _______. I never want to think your way. Perhaps you can be civil, no?

So, if I quote "Backdraft", everything I know about firefighting I learned from a film? No, I was a firefighter for 9 years.

If I quote "Saving Private Ryan" or "Full Metal Jacket", everything I know about the military I know from a film? No, I went to military college (not just ROTC).

If I quote "G-String Divas" or "Cathouse" on HBO, everything I know...oh, wait.

What is that thing they teach in law school, counselor? "If you can't argue the facts, argue the law. If you can't argue the law, argue the facts. If you can't argue the facts or the law, pound the table." You're pounding the hell out of the table here.

So, to clarify: "one of us" = "emergency physicians". If that wasn't clear to you, maybe you need some help with comprehension, although the conversation in the thread and the forum - "Emergency Medicine" on "the Student Doctor Network" seems to be quite a very specific niche.

As for "ego" and "pack mentality" and "sheep" and whatever tripe you put up, are you trying to be a turd? Do you have to work at being antagonistic? Do you intend to live up to stereotypes of attorneys? I'll give you a hint - in medicine, being congenial and convivial and sincere will get you much further than those traits would in a legal office.

Just a note about being disbarred - the general public (and, I would guess, a number - if not a majority - of doctors) believe that being disbarred is permanent - but, no! In my brief Google search (although that is not the limit of what I know of the law - I also have looked at Wikipedia), I found that, in Florida, for example, after 5 years, attorneys not permanently disbarred can reapply, although, historically, less than 5% do.

Here's an old pair of phrases that you perchance might take to heart: "speak, that I may know thee" vs. "better to be thought a fool, than to open one's mouth and remove all doubt".

As for the anecdote about lawyers that went to med school, you mention one doctor that went to law school, and is now a patent attorney - I would guess working with medical devices. I thought about another doc with whom I worked that went to law school - he even served as a JAG with the USMC, in intelligence - but hasn't practiced law in almost 20 years. In my anecdotal, individual experience, all lawyers I know that went to med school all practice medicine - all left the courtroom and legal office, and none went back to it. Why is that?

Res ipse loquitur (and that's a joke, son, for people that know me on SDN)

 

[Beagles]

So, if I quote "Backdraft", everything I know about firefighting I learned from a film? No, I was a firefighter for 9 years.

If I quote "Saving Private Ryan" or "Full Metal Jacket", everything I know about the military I know from a film? No, I went to military college (not just ROTC).

If I quote "G-String Divas" or "Cathouse" on HBO, everything I know...oh, wait.

What is that thing they teach in law school, counselor? "If you can't argue the facts, argue the law. If you can't argue the law, argue the facts. If you can't argue the facts or the law, pound the table." You're pounding the hell out of the table here.

So, to clarify: "one of us" = "emergency physicians". If that wasn't clear to you, maybe you need some help with comprehension, although the conversation in the thread and the forum - "Emergency Medicine" on "the Student Doctor Network" seems to be quite a very specific niche.

As for "ego" and "pack mentality" and "sheep" and whatever tripe you put up, are you trying to be a turd? Do you have to work at being antagonistic? Do you intend to live up to stereotypes of attorneys? I'll give you a hint - in medicine, being congenial and convivial and sincere will get you much further than those traits would in a legal office.

Just a note about being disbarred - the general public (and, I would guess, a number - if not a majority - of doctors) believe that being disbarred is permanent - but, no! In my brief Google search (although that is not the limit of what I know of the law - I also have looked at Wikipedia), I found that, in Florida, for example, after 5 years, attorneys not permanently disbarred can reapply, although, historically, less than 5% do.

Here's an old pair of phrases that you perchance might take to heart: "speak, that I may know thee" vs. "better to be thought a fool, than to open one's mouth and remove all doubt".

As for the anecdote about lawyers that went to med school, you mention one doctor that went to law school, and is now a patent attorney - I would guess working with medical devices. I thought about another doc with whom I worked that went to law school - he even served as a JAG with the USMC, in intelligence - but hasn't practiced law in almost 20 years. In my anecdotal, individual experience, all lawyers I know that went to med school all practice medicine - all left the courtroom and legal office, and none went back to it. Why is that?

Res ipse loquitur (and that's a joke, son, for people that know me on SDN)

Apollyon:

My intent was to participate in this thread because I have expertise in law, and especially in the field of litigation. I have litigated hundreds of cases (including jury trials, bench trials, and appellate matters), both from the public and private sector. I offered an opinion on what I saw as the liability risks. That is all.

For some reason, a few including you have started personal attacks and you continue to do so by suggesting that my reading comprehension is lacking and that I am trying to be a "turd." But whatever.

This may be a thread on doctors and EM docs in particular but I can assure you that neither a judge nor a jury will "think like us (ie, EM docs)." The attorneys will think like me and present their case accordingly. Your firefighting background won't help you in a courtroom. And sorry, your internet search on the law does not make you an expert in this field.

I am not going to attack you personally because I don't know you. I have no reason to doubt your competency in medicine.

Although you have made it clear that it is "shocking" the the absurd "gall" that I would have to ever think that I would reach your level in terms of medical competency, I do fully plan on becoming a proficient and competent clinician.

I am not running away from the law and plan to continue to practice in some way and as mentioned, perhaps participate in public policy matters.

When I am done with my medical education and training, I hope to work with colleagues that both agree and challenge me. I don't consider this to be antagonism. I consider personal attacks to be antagonism.

But I can't offer any liability advice that you need from me (your firefighting background and wikipedia solidifies your understanding of the law and the courtroom).

Thank you.

Your "son"

 

[Apollyon]

But I can't offer any liability advice that you need from me (your firefighting background and wikipedia solidifies your understanding of the law and the courtroom).

Thank you.

Your "son"

"That's a joke, son" refers to Foghorn Leghorn, a Warner Brothers cartoon character. The character was a caricature of Strom Thurmond. I guess you missed that one.

Referring to Wikipedia is an example of absurdity; apparently, you missed that one, too.

And your insulting firefighters, of which there are many around here, is just not called for. You may have litigated many cases, but my one time having to actually be in court as an expert witness was just fine. I don't insult attorneys so when they come to the ED.

 

[Beagles]

"That's a joke, son" refers to Foghorn Leghorn, a Warner Brothers cartoon character. The character was a caricature of Strom Thurmond. I guess you missed that one.

Referring to Wikipedia is an example of absurdity; apparently, you missed that one, too.

And your insulting firefighters, of which there are many around here, is just not called for. You may have litigated many cases, but my one time having to actually be in court as an expert witness was just fine. I don't insult attorneys so when they come to the ED.

Well with all of your references, including "G-String Divas," "Cathouse," the temperature states of water, and other "truisms," it is frankly difficult to discern what you are saying. Also, I stopped watching cartoons decades ago so yes I missed your references.

Anyone who reads this exchange would know that I am not insulting firefighters. You may not insult attorneys who come to your ED. You only insult them anonymously on the Internet.

Your one actual time court explains a lot. I would not hire you as an expert if I ever needed one again. Not for your lack of medical knowledge (that I don't question), but difficulty in expressing ideas without going on tangents.

That said, I have no beef with you sir. Nor do I have beef with clinicians for obvious reasons (I will become one). For whatever reason, something I said caused you to go off. My exchange with you on this topic has gone way off topic. Have a good day sir.

 

[odoreater]

For whatever reason, something I said caused you to go off. My exchange with you on this topic has gone way off topic. Have a good day sir.

Perhaps it was something along these lines:

Beagles: Hello everyone. I am a lawyer who is barely a medical student with virtually no training in medicine. Based upon my vast experience in medicine I have concluded that the labs indicate sepsis. This is not about nuance in diagnosis.

Other people who are actual physicians: No they do not. The labs are not specific and there is little evidence to support a concrete diagnosis of sepsis based upon the results.

Beagles: I read the NY Times article and have no clinical experience therefore I will repeat myself and ignore any evidence you present demonstrating the poor test characteristics of peripheral bandemia.

Other people who are actual physicians: You can't continue to insist something that you do not understand. You are no longer a lawyer and diagnostic testing does not deal in absolutes but in degrees of risk.

Beagles: The labs indicate sepsis. There was an expert that had 30 words in the article who confirmed what I already believed to be true and I have ignored all of your "sciencey" talk about likelihood ratios and other things I do not understand. Therefore I appeal to authority, discount all of what you have presented and continue to insist upon what I had originally asserted.

Other people who are actual physicians: You are acting more like a lawyer than a physician.

Beagles: No I'm not. You'd make a poor witness. I have experts who would back me up in the NY Times. What matters now is what would happen in court.

Other people who are actual physicians: <Sigh>

 

[Apollyon]

Well with all of your references, including "G-String Divas," "Cathouse," the temperature states of water, and other "truisms," it is frankly difficult to discern what you are saying. Also, I stopped watching cartoons decades ago so yes I missed your references.

Anyone who reads this exchange would know that I am not insulting firefighters. You may not insult attorneys who come to your ED. You only insult them anonymously on the Internet.

Your one actual time court explains a lot. I would not hire you as an expert if I ever needed one again. Not for your lack of medical knowledge (that I don't question), but difficulty in expressing ideas without going on tangents.

That said, I have no beef with you sir. Nor do I have beef with clinicians for obvious reasons (I will become one). For whatever reason, something I said caused you to go off. My exchange with you on this topic has gone way off topic. Have a good day sir.

Again, you reinforce stereotypes physicians have of attorneys. All you know how to do (apparently) is the adversarial approach just like in court.

You wouldn't hire me? I am certified as an expert witness. However, from what I know of you solely from this thread, I wonder (leaning towards suspect) that you are the type that would delay payment for services rendered, if not outright sending a worthless check. You think that that is just the way things are done. It may be in the bizarro world of law. However, where the rubber meets the road, that crap does not fly.

And I can't hew to a point? Oh, please. How about this, as I have said it several times, and, yet, it seems to roll off you like water off a duck's back, physicians have stereotypes of attorneys (such as "99% of attorneys make all the rest look bad"), and you are doing nothing to dispel that.

Odoreater has summed you up well. If the measure of a man is how he treats someone when no one is looking, I have a strong feeling that you kick, insult, degrade, and humiliate that person - but what is worse is that, I suspect, you don't even think that such things are wrong, because "we all do it" ("we" in this case being other attorneys).

Then again, maybe, in real life, you're not a narrow minded, haughty, inflexible, distasteful person. Equating a person's online behavior with reality is fraught with peril - maybe less if one is an experienced litigator with hundreds of cases argued, but, still, an unreliable augur of true life. There is a wide range, from absolute parity to complete dissociation. Although I have not looked closely at what you have posted, I recall you stating you "would not do med mal" - in these hundreds of courtroom cases, what type of cases have you done? If you have been a criminal defense attorney - a "hired gun" - defending the rabble of society (or at least who could pay your fee), then I might actually throw up.

And "Jeopardy!" is just starting - and one of the contestants was announced as a "medical malpractice attorney" - what will you make of THAT?

(Oh, and one confession - I have never actually watched "Cathouse" on HBO, and I think I saw 2 or 3 episodes of "G String Divas" over the past 10 years, as it was released in 2000.)

 

[Zanegray]

yikes. yikes.

 

[Docuronium]

If we'd like to take another shot at this, I for one, as a medical student, would like to know perhaps how we can learn from this rather than ripping each other, quite thoroughly, to pieces.

This was really tragic, and who knows, even if the labs came back the doc may not have changed their management plan so (probably) nothing would have changed. But how can we work to fix this system and how can we take better care of our patients (which may have been impossible in this particular case).

Saw that the NYT had a brief following and mentioned "heated discussions online."

 

[Beagles]

I agree with the policy that NYU has now initiated (requiring ordered lab results to be reviewed before discharge). Yeah, I know I am just a medical student as a few have pointed out (knows nothing yet) but seems like correct policy. That or at least required follow-up with the patient if nothing questionable comes up on the results.

Based on some responses on this thread as well as some of the comments in the article, I think that you will find that there are EM physicians who agree as well.

 

[strongboy2005]

I agree with the policy that NYU has now initiated (requiring ordered lab results to be reviewed before discharge). Yeah, I know I am just a medical student as a few have pointed out (knows nothing yet) but seems like correct policy. That or at least required follow-up with the patient if nothing questionable comes up on the results.

Based on some responses on this thread as well as some of the comments in the article, I think that you will find that there are EM physicians who agree as well.

Some lab results take days to come back.

 

[Beagles]

Some lab results take days to come back.

I obviously don't know all the details and NYU is liking working them out as well. But the article posted by Kaushik states that certain relevant tests will be reviewed before discharge. It also states that when this is not possible, that the physician will review them after discharge and share the results with the patient.

 

[danielmd06]

This is another tragic story that raises certain questions and illustrates certain concerns I have about the public perception of modern medicine and doctors' relationships to our patients and the whole of the American public.

I saw the most altruistic, intelligent, caring, and dedicated people in medical school. They made up the supermajority of my class. It saddens me to see physicians increasingly viewed with suspicion, doubt, and anger. It saddens me to see the increasing gulf that seems to be growing between the public opinion and ourselves. I make it a high priority to have the very best relationship I can with my patients, and have been blessed in my first year of private practice to have had what I would consider to be an overwhelmingly positive reception. But I read online articles that seem to attack us and I think to myself: "How did this happen?"

Having read this entire thread and the articles, I considered whether or not to opine. I decided to do so, with a target audience of the individuals in medical school, health related professional training, residency, and fellowship.

I am not an emergency medicine physician, and therefore feel pointedly incapable of even beginning to comment on the appropriateness (or lack thereof) of clinical evaluation and management of this terrible occurrence. I am rather surprised that some non-EM physicians seem willing to weigh in (especially in a negative fashion) for quotations in the NYT. I am rather surprised at the author of these articles posting the name of a specific physician publicly. I feel the deepest sympathy for this grieving family who have lost such a wonderful young man. I have a one year old son myself, and cannot help but feel horror for the unexpected loss this family suffered. Stories like this make me feel almost helpless about what the future holds for my own son as he grows, learns to drive, and gains the inevitable bumps, bruises, cuts, and gashes of childhood, adolescence, and adulthood.

I would gently urge some of the more junior people (or those with minimal medical training) to heed the well-intentioned wisdom of the more senior physicians commenting on this thread. It seems as though the ambiguities of laboratory studies, physical examination, and patient management have been explicated quite well by those best able to comment. In addition, allow me to add that the longer you practice, the more you learn, and the more you read....but the less you seem to know. You can trust me on that. Put another way, you realize that as a human being, no matter how much training, no matter how smart, no matter how well meaning, no matter how many safety and/or institutional algorithms are in place, and no matter how compulsively you keep trying...you still keep making mistakes. Not because we're incompetent, cruel, careless, weak, stupid, or apathetic. Rather, it's because we're all human and all of us will always make mistakes. Worse, as doctors, when we make these mistakes, there are sometimes terrible consequences. We know this. And we thusly keep doing our best *not* to make them.

Those of us who've done this job throughout residency and fellowship know this unfortunate but inarguable truth. It frightens us, and humbles us. When these errors happen, they leave a permanent imprint on us every single time. Every. Single. Time. Ask any physician about the mistakes they've made. They'll tell you each one in vivid detail. How? Because the memory is everlastingly fresh. It can happen to any of us in the right set (or I should say the wrong set) of circumstances. Perhaps that is why some of the physicians posting here are so ready to defend an unknown colleague. They know that but for the grace of God they could be in the exact same situation.

Please, be extremely careful about moral superiority or righteous indignation in such tragedies as this. Carelessly commenting about how easily such a thing could have been avoided, how flawed a laboratory system works, or how you would act so very differently than another physician usually betrays a lack of experience and knowledge rather than the opposite.

It's human nature to want explanations for pain. It's understandable to want a reason for why bad things happen to good people. Perhaps less understandable is the fact that it's become somewhat of an American staple to find someone to blame rather than focusing on how the medical system could be made to better serve our patients (and protect them from such happenings).

Certain lawyers (and the greedy, and the well-intentioned-but-misguided) are not blameless in this current medicolegal climate. These individuals will tell you that ludicrously high verdicts for plaintiffs dissuade hospitals from making the same mistakes again and thus protect patients and elevate the quality of patient care. Most of us realize this is really a lie. Don't forget that the lawyers can easily make more money than a victim or their family in such cases as this. And their venal interests are too often masked behind self righteousness and an espoused passion for defending the rights of the wronged. Hell hath no fury like a vested interest masquerading as a moral principle.

Perhaps I'm cynical. I don't think such threats do anything to make care better. If anything, I feel that the tension, pressure, and pure fear that such verdicts engender only make us clumsier and even more prone to errors than we would otherwise be. Also, we order too many tests for this reason, and thus drive up the cost of healthcare further. Perhaps I'm just wrong and those of you reading this are free to disagree. However, it's my personal opinion that people tend to perform at their very best with motivations other than fear.

In closing, I wish we could focus more on how to truly make the system better rather than argue with each other, focus on where to assign blame, or decide whom to punish. There is a difference.

 

[Beagles]

I sent a private message to danielmd06 and asked him not to share it because of a fear that I would get lambasted. But I have reconsidered and want to share it. Please know that this too is coming from a place of humility. I am not speaking from a place of self-righteousness and hope that it is not received as such. I am sharing my thoughts because I am and will become a part of the medical community. I may have a unique perspective because of my legal background but this too should be considered. I too want the medical profession to get better, more so because I again am part of it.

The issue of medical mistakes should be discussed. Not for the purpose of placing blame but for the purpose of reducing this serious problem. Studies that I have seen estimate that 100,000 deaths occur each year as a result of medical mistakes (this does not count the mistakes that result in non-mortal injuries). Other studies suggest that medical mistakes is a top 10 killer in the U.S. Of course, no physician wants to make a mistake and is utterly devastated because of it as a consequence. I also know that medical mistakes are inevitable.

But we can't ignore them because if we do, the divide between the public and clinicians will get wider. We must discuss them not for the purpose of assigning blame but for the purpose of initiating even better controls to address this serious problem.

I understand that lawyers may have bad stereotypes with physicians and that med-mal is a concern. But the reality is that med-mal suits are decreasing year-by-year. For a different perspective on tort reform, I recommend a the documentary called, "Hot Coffee" by Susan Saladoff.

Finally, I would be doing a disservice to the legal profession if I did not state this: there are greedy and altruistic people in both camps (lawyers and doctors). I have met many altruistic people in the field of law, both in school and practice who have devoted themselves to public service.

I may be lambasted anyway for this but I am glad that I said it.

Promise, last post from me on this subject. If anyone has comment/issue/question, feel free to send me a message.

 

[thorg12]

I had a very similar case to this today. young pt 10ish; nausea, vomiting, abdominal pain, febrile. nothing on physical exam, able to jump up and down; tachy to 130, got fluids, zofran, wbc 15, normal auto diff...wait for it, 1 hour later bc i was in with sick pt...lab calls and band 30% pt eating doritos and feels great; called pediatrician and she'll see her tomorrow, and gave strict instructions to come back if her symptoms return at all; are we supposed to admit this its now?

 

[Apollyon]

The issue of medical mistakes should be discussed. Not for the purpose of placing blame but for the purpose of reducing this serious problem. Studies that I have seen estimate that 100,000 deaths occur each year as a result of medical mistakes (this does not count the mistakes that result in non-mortal injuries). Other studies suggest that medical mistakes is a top 10 killer in the U.S. Of course, no physician wants to make a mistake and is utterly devastated because of it as a consequence. I also know that medical mistakes are inevitable.

The 98000 number from the Institute of Medicine in 1999 was challenged, and, for example, in 2001, a study in JAMA suggested it might be MUCH lower, with the real total being between 5000 and 15000.

I mean, at 100K/year, that would be a million EXTRA dead from when I graduated med school - added to those that came in to the ED very ill or already dead (in cardiac arrest). In the words of the band KoRn, there should be "dead bodies everywhere". Like dark matter, if they exist, why can't we see them?

 

[docB]

In closing, I wish we could focus more on how to truly make the system better rather than argue with each other, focus on where to assign blame, or decide whom to punish. There is a difference.

Until we reform the medical malpractice system (and really the tort system as a whole) we will not have anyone who is willing to go out on a limb and risk losing everything to try to correct systems problems. Because our system creates incentives to make grave allegations and try to move blame to the deepest pockets rather than the truly culpable no one is concerned with fixing the system, only with dodging the bullets or making the $$$.

The best thing we could do is to separate the punishment and compensation functions that are currently both served by the perversion of the current system.

 

[Socrates25]

I had a very similar case to this today. young pt 10ish; nausea, vomiting, abdominal pain, febrile. nothing on physical exam, able to jump up and down; tachy to 130, got fluids, zofran, wbc 15, normal auto diff...wait for it, 1 hour later bc i was in with sick pt...lab calls and band 30% pt eating doritos and feels great; called pediatrician and she'll see her tomorrow, and gave strict instructions to come back if her symptoms return at all; are we supposed to admit this its now?

If you have good follow-up its fine to d/c home with strict instructions to return ASAP for any changes. You need to draw a blood culture before d/c from the ER and there needs to be a good contact number documented in the chart for call backs for positive blood cultures. But that follow-up appointment better be iron-clad, none of this "call your PCP in the AM" stuff. Short of that locked down f/u appt, then yes you need to admit to obs for 24-48 hours, wait for blood cultures to be negative and document a decrease in bands before d/c home.

 

[Socrates25]

For a different perspective on tort reform, I recommend a the documentary called, "Hot Coffee" by Susan Saladoff.

Let me guess, its about the McDonalds coffee incident and the book makes stupid claims that McDs is at fault because they served their coffee at temps they knew could burn people.

Let me counter that with a similar example:

My driveway to the house is steep. It frequently ices over in winter. I've seen people slip and fall on it before as they are walking down the street. Therefore, its MY FAULT the next time somebody slips on the ice and breaks their ankle because I KNEW there were prior injuries on that steep driveway and I failed to level out the driveway to make it safer.

Same BS logic used in the McDs case.

 

[gro2001]

The issue of medical mistakes should be discussed. Not for the purpose of placing blame but for the purpose of reducing this serious problem. Studies that I have seen estimate that 100,000 deaths occur each year as a result of medical mistakes (this does not count the mistakes that result in non-mortal injuries). Other studies suggest that medical mistakes is a top 10 killer in the U.S. Of course, no physician wants to make a mistake and is utterly devastated because of it as a consequence. I also know that medical mistakes are inevitable.

The IOM report you allude to defines medical ERROR (not mistake) as: "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim."

By this definition, physician sees a patient, diagnoses the problem correctly, performs the appropriate action correctly, but the patient still deteriorate. That is a medical error in the IOM report. If the patient dies, he becomes part of the 100k cited figure. Think of a potentially life saving surgery that just did not work, for example.

They further went on to classify errors as negligent or not (a very controversial part of the report, but will not go into that). So for example, it reported something around 40% of errors made in relation to surgery, but a very small proportion of them were considered negligent, because surgeries don't always work.

I think most people (even physicians) hear the 100k per year number, equate medical error with 'a mistake' and don't look into the details of definitions and how those numbers were generated and so come away with a very erroneous picture.

Incidentally, if you want to read the original, you can read it here: http://www.nap.edu/catalog.php?record_id=9728#toc
(click on each of the items in the table of contents; free access to the whole thing).

 

[odoreater]

Short of that locked down f/u appt, then yes you need to admit to obs for 24-48 hours, wait for blood cultures to be negative and document a decrease in bands before d/c home.

😕😕😕

 

[Arcan57]

If you have good follow-up its fine to d/c home with strict instructions to return ASAP for any changes. You need to draw a blood culture before d/c from the ER and there needs to be a good contact number documented in the chart for call backs for positive blood cultures. But that follow-up appointment better be iron-clad, none of this "call your PCP in the AM" stuff. Short of that locked down f/u appt, then yes you need to admit to obs for 24-48 hours, wait for blood cultures to be negative and document a decrease in bands before d/c home.

Clicked on the link from your signature. You realize that they were talking about PA residencies in that thread, not PAs applying to MD/DO residencies?

 

[Birdstrike]

.

 

[Socrates25]

Clicked on the link from your signature. You realize that they were talking about PA residencies in that thread, not PAs applying to MD/DO residencies?

The thread started out about PA residencies, but emedpa quickly changed course.

He went back later and changed his post. Thats why I copied/pasted his direct quote, which is unequivocally talking about PAs doing MD/DO residencies.

He's made other comments on that forum as well that show he thinks PAs should be able to do MD/DO residencies. He wont post them on SDN because he knows he would get roundly criticized.

It clearly shows that the PAs who "play nice" on SDN have their own secret agenda that they dont tell you about.

 

[Makati2008]

The thread started out about PA residencies, but emedpa quickly changed course.

He went back later and changed his post. Thats why I copied/pasted his direct quote, which is unequivocally talking about PAs doing MD/DO residencies.

He's made other comments on that forum as well that show he thinks PAs should be able to do MD/DO residencies. He wont post them on SDN because he knows he would get roundly criticized.

It clearly shows that the PAs who "play nice" on SDN have their own secret agenda that they dont tell you about.

Or could it show your an obvious liar who is anti np/pa and tolerates pas due to them not having the ability to go independent like nps.

PS- I know several of us that have no motives as your state otherwise why would I be in med school like 3 others I know on the board????

 

[Socrates25]

Or could it show your an obvious liar who is anti np/pa and tolerates pas due to them not having the ability to go independent like nps.

PS- I know several of us that have no motives as your state otherwise why would I be in med school like 3 others I know on the board????

Good for you. I still wont be "supervising" any midlevel, NP or PA.

Here's another example of emedpa's double tongue:

http://www.physicianassistantforum.com/forums/showthread.php/35742-You-handle-the-easy-ones...

Paula: P.S. Yup, we need to be physician associates and out from under.
Emedpa: it's a work in progress....

I can play this game all day long.

 

[Makati2008]

Good for you. I still wont be "supervising" any midlevel, NP or PA.

Here's another example of emedpa's double tongue:

http://www.physicianassistantforum.com/forums/showthread.php/35742-You-handle-the-easy-ones...

Paula: P.S. Yup, we need to be physician associates and out from under.
Emedpa: it's a work in progress....

I can play this game all day long.

Physician associate is the better name IMHO.It's attitude like yours that made me go back to med school lol.

I am against MLPs not being supervised by a physician point blank but they are an intricate part of healthcare that isn't going anywhere so deal with it bro.

 

[Socrates25]

Clicked on the link from your signature. You realize that they were talking about PA residencies in that thread, not PAs applying to MD/DO residencies?

Here's another emedpa quote that shows his true colors:

http://www.physicianassistantforum..../35528-Creating-a-Sub-specialty-Certification

This thread is in reference to subspecialty certification for PAs.

Emedpa: "I agree but wouldn't be even more important if we were independent like np's? we would need an objective criteria to say we were specialists in our given field, right?"

 

[Socrates25]

Here's yet another representative quote from another PA on that forum, who is one of the main posters on that board:

http://www.physicianassistantforum....-Creating-a-Sub-specialty-Certification/page2

jmj11: "I think this conversation just went down a rabbit hole, down which I am not even tempted to go. Ironically this whole thing is about seeking autonomy and the whole point is assuring lateral mobility. If you want to move in any direction you want to go, you can. But the industry wants you to prove that you have the skill set in those far corners. It is limiting and restrictive to PAs to declare to them that they can not move into specialties but must stay in the narrow scope of primary care. The autonomy that I want is owning my own specialty clinic and playing with the big-boys, like all PAs should have the right to do. But the insurance companies say, if you declare yourself to be a specialist, then you need some standard of proof. It is no different than what ACLS does for PAs in acute settings."


There you have it from the horse's mouth. This PA wants to be equivalent to a board certified neurologist with a subspecialty certification in headache management.

 

[Makati2008]

Here's yet another representative quote from another PA on that forum, who is one of the main posters on that board:

http://www.physicianassistantforum....-Creating-a-Sub-specialty-Certification/page2

jmj11: "I think this conversation just went down a rabbit hole, down which I am not even tempted to go. Ironically this whole thing is about seeking autonomy and the whole point is assuring lateral mobility. If you want to move in any direction you want to go, you can. But the industry wants you to prove that you have the skill set in those far corners. It is limiting and restrictive to PAs to declare to them that they can not move into specialties but must stay in the narrow scope of primary care. The autonomy that I want is owning my own specialty clinic and playing with the big-boys, like all PAs should have the right to do. But the insurance companies say, if you declare yourself to be a specialist, then you need some standard of proof. It is no different than what ACLS does for PAs in acute settings."


There you have it from the horse's mouth. This PA wants to be equivalent to a board certified neurologist with a subspecialty certification in headache management.[/QUOTE

So you point out one rogue out of the thousands of PAs that are currently practicing, big deal. The AAPA is AGAINST autonomy of our profession(they were even against the bridge program where a PA could become a Physician through a 3year program.)

I will give you this though, if that guy is truly that blinded by hubris then his local medical board should snatch his license for impersonating a Physician. I am a firm believer in you need those two didactic years to truly understand how it is to be a doc after being through the fire

 

[deleted6669]

Or could it show your an obvious liar who is anti np/pa and tolerates pas due to them not having the ability to go independent like nps.

PS- I know several of us that have no motives as your state otherwise why would I be in med school like 3 others I know on the board????

ding, ding, ding we have a winner.
look at the time stamp on my post for that thread. if it had been altered it would not have a time stamp immediately after the op's question.
QED socrates is guilty of lying to advance his own agenda.