Thoughts?

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Seems bizarre that they are obsessing over sepsis when the autopsy confirmed that it wasn’t sepsis. This sounds like something autoimmune like TTP based on the autopsy and reported lab abnormalities. It’s incredibly hard to fault the docs for sending him home the second time without clear life threatening abnormalities on labs for what turns out to be a zebra especially in a young otherwise healthy patient with symptoms that sound like typical viral syndrome. I do think it odd that they didn’t get a CXR, however, on a patient that they were obtaining blood cultures on, but there is a decent probability that it would’ve been normal.
 
Non pay walled link

Tough case. Seems strange too. Unsurprisingly the father latches onto sepsis (but seems unsupported by path. A renowned pathologist says it’s some weird zebra. Early ttp? Definitely doesn’t seem like forgoing abx was the critical error here. Maybe the nytimes should publish 1000 articles about benign self limited illnesses). Obviously he’s grieving, but I doubt he’ll get the closure he seeks from the malpractice case or his future career in advocacy. Unfortunately tragedies still happen in modern times and they’re not always preventable, even for the wealthy.
 
The general public doesn’t understand it is standard of care to miss the zebras. You can’t admit everybody until they’re feeling well. Also, it’s ridiculous there’s a lawsuit when even the autopsy is inconclusive. Unfortunately, bad things happen but it doesn’t mean it was somebody’s fault.
 
JacobMcCandles said:
The general public doesn’t understand it is standard of care to miss the zebras. You can’t admit everybody until they’re feeling well. Also, it’s ridiculous there’s a lawsuit when even the autopsy is inconclusive. Unfortunately, bad things happen but it doesn’t mean it was somebody’s fault.
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No, you see you’re just supposed to never miss anything while avoiding any imaging or admissions while billing maximum critical care and keeping door to doc times down with a smile. Then go back to playing anesthesiologist while you’re being an Orthopedic surgeon cardiologist neurologist and plastics specialist every weeknight and all hours on weekends.

Oh and don’t forget Dr. abc wants to be called for all his patients and the patients of Dr. xyz, he was very upset when his patient got admitted to the regular hospitalist service at 3am after he failed to answer the phone for two hours

It’s not that hard
 
Don't love that they name all the doctors involved including the intern and resident. Another uncritical quotation of the 200k/yr dying due to medical error "fact". Spend a lot of time talking about sepsis (which it isn't), have an ID doc saying that docs can't override sepsis alerts (despite sepsis requiring a suspected bacterial infection). Perpetuating the idea that if we just did more testing we'd come up with a definitive diagnosis on all the non-specific complaints that flood the ED. Failing to drive home the idea that some diseases have a very narrow window between looking benign and being deadly regardless of treatment and if you miss that window you will die and there's nothing anyone can do about it. Making passing reference to boarding, lack of RN staffing, struggles with the EMR while still writing an article at the behest of a plaintiff in an active lawsuit. The line about the dad (who's wealthy but describes himself as Calvinist) attending every deposition waiting for the doctor being deposed to "stop being defensive" and tell him what really happened is heartbreaking. I can't imagine his pain, but unless there's something seriously missing from the article, there's no peace in that path.

The damnable thing is as vaccines start going away, this is going to become more common (young healthy people dying after non-specific presentations).
 
JacobMcCandles said:
The general public doesn’t understand it is standard of care to miss the zebras. You can’t admit everybody until they’re feeling well. Also, it’s ridiculous there’s a lawsuit when even the autopsy is inconclusive. Unfortunately, bad things happen but it doesn’t mean it was somebody’s fault.
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Its always somebody’s fault unfortunately in the US. Natural death seems to be a foreign concept especially in younger people.

This would be easy to settle for a large sum. All you need is a bad outcome, not necessarily malpractice.
 
throway134 said:
No, you see you’re just supposed to never miss anything while avoiding any imaging or admissions while billing maximum critical care and keeping door to doc times down with a smile. Then go back to playing anesthesiologist while you’re being an Orthopedic surgeon cardiologist neurologist and plastics specialist every weeknight and all hours on weekends.

Oh and don’t forget Dr. abc wants to be called for all his patients and the patients of Dr. xyz, he was very upset when his patient got admitted to the regular hospitalist service at 3am after he failed to answer the phone for two hours

It’s not that hard
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Another data point in the barrel of data points that show how done this field is.

Be perfect, fast, don't use resources...oh and satisfy the "customer." You can't min max all these successfully.

You have a target on your back and will be sniped at from multiple angles including liability, resource utilization, flow, interpersonal interactions.

EM is trash tier. The fact that med students continue to select into this field baffles me. The smoke and mirrors surrounding EM was exposed during COVID and there's SO MUCH information online and yet YOU STILL choose this. You deserve what you get I suppose.

I'm happy that I only have a handful more years going full-time at this.
 
Ugh...too long. I read most of it.
Understand why parents are absolutely mortified. Unfortunately this is a 1 in a million case. Maybe even less (one in two million?).
I would have gotten a chest xray on the second visit. Why save resources for a simple CXR?

I was more irritated than sad with this article. All of these nonsense statistics on how > 500,000 people die each year directly due to negligence, diagnostic errors > 5%, and other non-relevant or misleading claims and stats.

Without seeing the chart, there was certainly no gross malpractice at all. I'm not even sure if there was malpractice.

The standard of care line is also rubbish, pure rubbish for > 80% of the medical complaints that come into the ER.
 
JacobMcCandles said:
The general public doesn’t understand it is standard of care to miss the zebras. You can’t admit everybody until they’re feeling well. Also, it’s ridiculous there’s a lawsuit when even the autopsy is inconclusive. Unfortunately, bad things happen but it doesn’t mean it was somebody’s fault.
Click to expand...

+1.

We rarely get the right diagnosis because we rarely encounter people who have medical complaints that are within our area of expertise. That's why diagnostic errors are so frequent.
 
The Reddit crowd is amusingly different than the one on this site. We're the old jerks who have seen the "standard of care" degrade into mindless pan-testing. Did the kid *need* a CXR? Nah. Reasonable either way, and we don't have the information say otherwise based on that article. The younger crowd is ready to throw clinical judgment to the wolves.

Not nearly enough appreciation for the inane "sepsis alert", and the perspective of "the alert said he had sepsis, why not just order antibiotics?" either. That sort of diagnostic anchoring is just as likely to contribute to missed and delayed diagnoses of alternative conditions.
 
The article says there were some lab abnormalities. Would love to see what they were. I'll reserve opinion until I get the full details of the case, which I'll probably never have. Always hate lawsuits, but sometimes people do mess up. We're only human. Not saying the docs messed up in this case, but if labs were abnormal would be interested in seeing what they were.
 
thegenius said:
Ugh...too long. I read most of it.
Understand why parents are absolutely mortified. Unfortunately this is a 1 in a million case. Maybe even less (one in two million?).
I would have gotten a chest xray on the second visit. Why save resources for a simple CXR?
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Real question. In a young, previously healthy patient with normal respiratory mechanics (rate and effort),clear lungs, and a normal O2 sat in whom you're not chasing PTX, when was the last time the CXR provided actionable info?

What the kid really needed was good discharge instructions (come back if you're having trouble catching your breath at rest) and an understanding that this *looks* like a virus but we haven't found the cause and if things get worse come back again. Probably wouldn't have mattered but until he started hemorrhaging into his lungs it doesn't sound like any of the tests we do that would have been reasonable would have been useful.
 
I think the article said he was quite tachycardic on discharge. Frankly I’d have thrown in a trop and dimer the second time he was there. Almost sounds like a multisystem inflammatory syndrome. I’ve become really liberal with ordering labs/imaging. Patients love tests and helps keep my name out of the news. My job is not to clear the waiting room.
 
EMdoc235 said:
I think the article said he was quite tachycardic on discharge. Frankly I’d have thrown in a trop and dimer the second time he was there. Almost sounds like a multisystem inflammatory syndrome. I’ve become really liberal with ordering labs/imaging. Patients love tests and helps keep my name out of the news. My job is not to clear the waiting room.
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I've got bad news but ordering labs and imaging isn't what keeps your name out of the news. Keeping your name out of the news would mean not seeing any patients. The number of patients you see is what directly correlates to your chances of getting sued. It's not if you do or don't order ridiculous stuff, it's not if you're a good or bad doctor, it's how many patients you see.
 
southerndoc said:
The article says there were some lab abnormalities. Would love to see what they were. I'll reserve opinion until I get the full details of the case, which I'll probably never have. Always hate lawsuits, but sometimes people do mess up. We're only human. Not saying the docs messed up in this case, but if labs were abnormal would be interested in seeing what they were.
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When I saw that and also saw that so far the cause of death has been inconclusive, I immediately think of things like a sodium of 134, ALT of 51, etc.
 
Arcan57 said:
Real question. In a young, previously healthy patient with normal respiratory mechanics (rate and effort),clear lungs, and a normal O2 sat in whom you're not chasing PTX, when was the last time the CXR provided actionable info?

What the kid really needed was good discharge instructions (come back if you're having trouble catching your breath at rest) and an understanding that this *looks* like a virus but we haven't found the cause and if things get worse come back again. Probably wouldn't have mattered but until he started hemorrhaging into his lungs it doesn't sound like any of the tests we do that would have been reasonable would have been useful.
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It's low. And I also consider a CXR to be an extremely low risk study for providing false negatives (or positives). And there is extremely low chance of producing annoying incidentalomas that you have to spend additional time mucking about documenting, arranging for follow-up, explaining to patients, etc.

So I don't spend much time deliberating over whether a CXR would be indicated or helpful. It's a test that will very rarely provide me with a lot of extra work.

Did that guy with a fever of 100.6 and HR 125 has a normal RR?

Another real question: How often are you surprised to find PNA in young patients whom you suspect have PNA and have respiratory symptoms and normal vitals? For me it's more often than anticipated AND it is rare (both can be true). And they often have normal O2 and a normal (or close to normal RR). I agree with the notion that pediatrics and young adults have excess capacity allowing them to have normal vitals despite having PNA.
 
JacobMcCandles said:
I've got bad news but ordering labs and imaging isn't what keeps your name out of the news. Keeping your name out of the news would mean not seeing any patients. The number of patients you see is what directly correlates to your chances of getting sued. It's not if you do or don't order ridiculous stuff, it's not if you're a good or bad doctor, it's how many patients you see.
Click to expand...
USucS claims they get sued at a fraction of general EM docs.. of course.. not published data. But they love spewing it. Even have it on their website i think.
 
EctopicFetus said:
USucS claims they get sued at a fraction of general EM docs.. of course.. not published data. But they love spewing it. Even have it on their website i think.
Click to expand...

TeamHealth said the same thing. Their rate of getting sued was 50% less. I remember something like 1/40,000 ER visits produce a lawsuit and they are much better. Nothing is published.

USUKS is just a terrible company
 
southerndoc said:
The article says there were some lab abnormalities. Would love to see what they were. I'll reserve opinion until I get the full details of the case, which I'll probably never have. Always hate lawsuits, but sometimes people do mess up. We're only human. Not saying the docs messed up in this case, but if labs were abnormal would be interested in seeing what they were.
Click to expand...
I swear it mentioned pancytopenia but I may have hallucinated that.
 
xaelia said:
The Reddit crowd is amusingly different than the one on this site. We're the old jerks who have seen the "standard of care" degrade into mindless pan-testing. Did the kid *need* a CXR? Nah. Reasonable either way, and we don't have the information say otherwise based on that article. The younger crowd is ready to throw clinical judgment to the wolves.

Not nearly enough appreciation for the inane "sepsis alert", and the perspective of "the alert said he had sepsis, why not just order antibiotics?" either. That sort of diagnostic anchoring is just as likely to contribute to missed and delayed diagnoses of alternative conditions.
Click to expand...
We have somehow managed to avoid someone adding a sepsis alert at my normal hospitals. Picked up some shifts with another part of our group to help out. Different health system. It was winter time. Every influenza patient had a sepsis alert. Wtf am I supposed to do with this information?
 
JacobMcCandles said:
I've got bad news but ordering labs and imaging isn't what keeps your name out of the news. Keeping your name out of the news would mean not seeing any patients. The number of patients you see is what directly correlates to your chances of getting sued. It's not if you do or don't order ridiculous stuff, it's not if you're a good or bad doctor, it's how many patients you see.
Click to expand...
I think the data is even worse than "how many patients you see." Isn't it just "time in practice?" That's what I remember reading a few years ago.
 
TooMuchResearch said:
We have somehow managed to avoid someone adding a sepsis alert at my normal hospitals. Picked up some shifts with another part of our group to help out. Different health system. It was winter time. Every influenza patient had a sepsis alert. Wtf am I supposed to do with this information?
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Give 30 ml / kg, send a lactate and blood cultures, give IV antibiotics, admit, and bill 60 mins of 99291.

That’s what I’m going to do all the time now.
 
I DC tachycardic patients all the time. After searching for a reason ofc. And no I don't CTA them all. Are you supposed to admit every tachycardia person who feels well? I am already pretty conservative compared to my group with above avg admission and imaging rates. People don't understand the function of the ED. I can't wait to get out.
 
This case is a non event that should never change practice. This same pt comes to the ER 50 times a shift during the winter. Healthy, fever, tachy, looking good, exam benign, no source.

Medicine is not perfect. Humans are not perfect. These bad outcomes just happens. The only way to prevent this ever from happening is to pan lab all pts, blood cultures, admit for Obs. We would have worse outcomes if we try to prevent all bad outcomes/death.

Sepsis alert from someone that looks like the flu is just about the dumbest thing hospitals ever did. At Peek hysteria, I saw pts come back to the main ER with IV/Labs b/c triage had to start the sepsis protocol. I mean, when did we stop "doing no harm"
 
JacobMcCandles said:
I've got bad news but ordering labs and imaging isn't what keeps your name out of the news. Keeping your name out of the news would mean not seeing any patients. The number of patients you see is what directly correlates to your chances of getting sued. It's not if you do or don't order ridiculous stuff, it's not if you're a good or bad doctor, it's how many patients you see.
Click to expand...
There is some evidence that amount of tests is inversely associated with malpractice claims. Physician spending and subsequent risk of malpractice claims: observational study
(But certainly your point still stands.)

If they had gotten a chest x ray, there would be at least 2 less paragraphs in this article. Lawyers and the family are certainly noting the lack of that test. What it would have shown is a question without an answer and creates a large canvas for others to paint a story of "malpractice". For me, I dont put much thought into x rays. They're relatively cheap and fast. They're relatively low risk. They're a crowd pleaser. I dont order chest x rays on every person with a cough, but my threshold to do so is fairly low.

Nonetheless, I really feel for the family. I can only imagine the pain of losing a kid that young. I don't really blame the family for doing what they're doing. This was a brutally tragic case. But I also highly doubt there was any real malpractice. Seems like one of those cases where I am glad I wasn't the one that signed up for that patient.
 
WhatJobDoIPick said:
I DC tachycardic patients all the time. After searching for a reason ofc. And no I don't CTA them all. Are you supposed to admit every tachycardia person who feels well? I am already pretty conservative compared to my group with above avg admission and imaging rates. People don't understand the function of the ED. I can't wait to get out.
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I've encountered emergency physicians on reddit who say they NEVER discharge a tachycardic patient.
 
carbonizedeyesockets said:
There is some evidence that amount of tests is inversely associated with malpractice claims. Physician spending and subsequent risk of malpractice claims: observational study
(But certainly your point still stands.)

If they had gotten a chest x ray, there would be at least 2 less paragraphs in this article. Lawyers and the family are certainly noting the lack of that test. What it would have shown is a question without an answer and creates a large canvas for others to paint a story of "malpractice". For me, I dont put much thought into x rays. They're relatively cheap and fast. They're relatively low risk. They're a crowd pleaser. I dont order chest x rays on every person with a cough, but my threshold to do so is fairly low.
Click to expand...
I briefly scanned that study but it focused on obstetrics and specialties with hospital admissions. I didn’t dig deep into it but it looks like they used total hospital charges as using higher resources. It makes logical sense, at least to me, that patients with higher hospital charges are likely sicker and in the hospital longer so it makes sense there’s a higher likelihood of malpractice with them. I don’t really see how this study is applicable to EM.

If they got a chest xray then those paragraphs would have been examining why he didn’t get a CT. If he had a CT then they would have been examining why they didn’t get something else. The point is…it’s always something.
 
TooMuchResearch said:
Just wanted to reply to myself noting that my last two discharges tonight were mildly tachycardic.
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I can imagine what my conversation with hospitalist would be.

Me - Dr. Internist, can you admit this 20 yr with the flu and tachy at 110?
Dr Internist - He must be really sick. Can you tell me more
Me - He looks great, eating/drinking, looks well hydrated, no medical issues, currently watching a football game
Dr Internist - so you want him admitted
Me - Yeah, he is tachy at 105 and I refuse to discharge him.

Hahahaha.... I would be the most hated ER doc in the hospital
 
Mount Asclepius said:
I would highly caution against routinely discharging unexplained tachycardia.

Research has shown that unexplained tachycardia has been present in a high percentage of patients who have died shortly after being discharged from the ED.

Unanticipated death after discharge home from the emergency department
Click to expand...

Rate of death in their study is estimated at 30 out of 100,000.

How many of the other 99,970 had tachycardia at discharge? No data – but, obviously, many. And they lived.

Not something to get hung up on as a "discharge block", just a reminder that abnormal vital signs ought to be 1) recognized, 2) have a bit of a thought.
 
xaelia said:
Rate of death in their study is estimated at 30 out of 100,000.

How many of the other 99,970 had tachycardia at discharge? No data – but, obviously, many. And they lived.

Not something to get hung up on as a "discharge block", just a reminder that abnormal vital signs ought to be 1) recognized, 2) have a bit of a thought.
Click to expand...
The post above you: blunt instrument, crayon
Your post: fine and refined. A fountain pen
 
Btw for anyone thinking that admission is some kind of panacea to risk: I know of multiple pending cases where the EP recognized that something was off, admitted the patient, the patient had a bad outcome inpatient, and the EP was named.

The field, and generally medicine, are trash.

Lurking students: for your own sake, choose a field that minimizes this risk and avoids you having to be beholden to a hospital. Derm, PM&R. Or a field where you generate so much money for the hospital that it doesn't matter what you do (Ortho). Don't fall for the same trap we did.
 
WhatJobDoIPick said:
Btw for anyone thinking that admission is some kind of panacea to risk: I know of multiple pending cases where the EP recognized that something was off, admitted the patient, the patient had a bad outcome inpatient, and the EP was named.

The field, and generally medicine, are trash.

Lurking students: for your own sake, choose a field that minimizes this risk and avoids you having to be beholden to a hospital. Derm, PM&R. Or a field where you generate so much money for the hospital that it doesn't matter what you do (Ortho). Don't fall for the same trap we did.
Click to expand...

Hi, it's me.
 
WhatJobDoIPick said:
The field, and generally medicine, are trash.
Click to expand...
Maybe it’s just me but I’m not sure if you’ve ever made a post where you didn’t voice your displeasure for EM and medicine in general. While medicine (and EM) has its warts and it’s easy to fall into a negative attitude around SDN, I look forward to the day where you finally practice what you preach and leave the field. I hope you find the happiness you’re looking for but you seem like a chronically unhappy person.
 
My only lawsuit in 25 years of practice was a pt I didn't even know.

ICU pt. Chronic medical issues. On pressors, Abx due to sepsis. Coded. Lucky me was called for the code. Pt died. I was named. We settled for relative chump change.

Lawyer said they would take it to trial if I wanted. Why would I want to spend the next 1-2 years in deposition. Yanked around for pre trial/trial meetings having to reschedule my shifts to just have them move the dates of these meetings?

ER is not very litigious if you are a competent doc working in a good medmal state like Tx.
 
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