Your administrators are not looking out for you.

[tantacles]

Just wanted to post this thread for therapy / a warning.

I can't talk too much about this case as the hospital I was working at is in arbitration for this case. But here's the gist:

A patient I consulted on had an elective (though necessary) surgery done, and he subsequently became severely hypotensive (and tachycardic). I received a call asking me to go to bedside, and being a reasonable human and physician I am, I did. Given the patient's condition, I strongly advocated for the surgeon who performed the surgery to open the patient back up as this was 4 hours post-op.

When the surgeon decided not to, I got to writing. I wrote a note that essentially summarized my recommendations and made a strong case for the patient having internal bleeding.

The patient coded and died soon after that. And can you guess how much blood they found at the surgical site? Really. Guess. I can't tell you the answer because again, litigation.

And subsequently, I was reprimanded (not formally, don't worry) for writing a note that made the surgeon and the hospital "look bad." and "opened them up to liability."

But guess who's getting sued? Not me. The hospital and the surgeon.

So the way I see it: The reprimand was just the hospital and administration covering their asses even though that surgeon was clearly wrong. I'm convinced that had I not written that note, I would be the one being sued and have my license on the line.

And in case you're wondering, I have thought a lot about this case since it happened. Wondered what I could have done differently to advocate for this patient? Should I have screamed? Called another surgeon? Vomited on the surgical site to infect it so they were forced to open up the patient? For legal reasons, that last one is a joke. Don't come for me.

But the moral of the story: Write that note to discuss your findings if you see someone actively providing substandard care if you're involved with a patient's case. It might not save the patient, particularly if you're not being listened to, but it may save your medical license.

And trust your gut.

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[DrMetal]

And trust your gut.

You did all the right things. Who's reprimanding you for this, and by what twisted logic? And what did they expect you to do, beyond what you already did?

 

[tantacles]

You did all the right things. Who's reprimanding you for this, and by what twisted logic? And what did they expect you to do, beyond what you already did?

Oh, they expect me to be subservient and protect their bottom line. But w/e, I quit that job a while ago and am delighted not to be working there anymore.

 

[NewYorkDoctors]

the hospital and admin are just salty and you should enjoy milking their crocodile tears for all its worth. im glad you moved on. let them cry more. Cry cry me a river... you owe them nothing.

if you didnt document it, then they would have found a way to throw you under the bus. protect yourself first and foremost and these admins can go ... (thinking of euphemism) vacuum something very dirty, long, filthy, smelly.... obviously a janitors mop....


A vacuum is one of the few things that can simultaneously suck and blow. Hospital admins are another it seems.

Always be truthful but always document. Just like the meme goes (no pics no proof), no documentation it didnt happen.

 

[end stage fibro]

good on you an screw your admin

academic discussion: did you consider get a CT a/p to force the hand of the surgeon? I know it is the wrong step in management 99% of the time in this scenario. just curious...i've been in similar situations and it is incredibly frustrating not being able to do anything

 

[NewYorkDoctors]

or more to the point a FAST exam using a point of care U/S like the butterfly IQ? i mean I know not EVERYONE carries one ... but if I were in that situation as the intensivist consulting on a case, that's what I would have done to force the surgeons' hand. but again, I don't know the specific details of the case.

 

[DrMetal]

did you consider get a CT a/p to force the hand of the surgeon? I know it is the wrong step in management 99% of the time in this scenario.

I absolutely would've (you don't necessarily need it: the post op patient, hypotense, dropping Hgb, belly pain, that's enough . . .but if you can resuscitate him and get him in a scanner, why not?)

or more to the point a FAST exam using a point of care U/S like the butterfly IQ? i mean I know not EVERYONE carries one ... but if I were in that situation as the intensivist consulting on a case, that's what I would have done to force the surgeons' hand. but again, I don't know the specific details of the case.

Problem with bedside US is that no one 'believes' the result. I always go for the formal, or go straight to CT.

 

[NewYorkDoctors]

I absolutely would've (you don't necessarily need it: the post op patient, hypotense, dropping Hgb, belly pain, that's enough . . .but if you can resuscitate him and get him in a scanner, why not?)



Problem with bedside US is that no one 'believes' the result. I always go for the formal, or go straight to CT.

true of course need that radiology documentation. but if one saw ascites (presumed hemoperitoneum) and showed the surgeon and then documented the encounter, maybe things would have been different? or possibly not. something like the butterfly IQ has a HIPAA compliant image server. but unless the hospitals' quality control department signed off on it, it is unclear if they permit your personal images to enter the chart or not. but at least writing such an encounter occurred might have be admissible. one could write "based on this combination of clinical findings and a point of care U/S finding, I recommended for CTAP but the surgeon had to go to T-time."

 

[chessknt]

An immediate post-op abdomen FAST or CT is going to be borderline useless (one exception would be a CTA with a clear active bleeder but youll miss venous sources)--post-op changes are going to be blamed for almost everything unless they literally bled their entire circulating volume in to the abdomen. And doing a POCUS with a ****ty handheld not approved by biomed is a bad plan--get a formal radiology US done stat at bedside or use a cart biomed-approved device from the ER and do it yourself.

Was there a JP drain or something to indicate that was the case? If the surgeon won't take back for a re-exploration then you really can't do anything. Since it was elective you could try calling the on-call person but the chances of that person wanting to get involved in the case are 0.

 

[Splenda88]

Surgeons are never wrong.

Nurses at my hospital think surgeons went to different type of medical schools than internists. Surgeons are the "true" doctors.

 

[DrMetal]

Surgeons are never wrong.

Nurses at my hospital think surgeons went to different type of medicine schools than internists. Surgeons are the "true" doctors.

Yeah, especially Neurosurgeons, who go through an extensively long residency to learn how to NOT operate and NOT round on their patients.

 

[tantacles]

good on you an screw your admin

academic discussion: did you consider get a CT a/p to force the hand of the surgeon? I know it is the wrong step in management 99% of the time in this scenario. just curious...i've been in similar situations and it is incredibly frustrating not being able to do anything

Can't send a patient with BP 70/30 to CT. Did not, will never.

But also, I wasn't primary, so it wasn't mine to order.

 

[tantacles]

or more to the point a FAST exam using a point of care U/S like the butterfly IQ? i mean I know not EVERYONE carries one ... but if I were in that situation as the intensivist consulting on a case, that's what I would have done to force the surgeons' hand. but again, I don't know the specific details of the case.

What's funny is the intensivist responded. No ultrasound reported at that time.

 

[tantacles]

An immediate post-op abdomen FAST or CT is going to be borderline useless (one exception would be a CTA with a clear active bleeder but youll miss venous sources)--post-op changes are going to be blamed for almost everything unless they literally bled their entire circulating volume in to the abdomen. And doing a POCUS with a ****ty handheld not approved by biomed is a bad plan--get a formal radiology US done stat at bedside or use a cart biomed-approved device from the ER and do it yourself.

Was there a JP drain or something to indicate that was the case? If the surgeon won't take back for a re-exploration then you really can't do anything. Since it was elective you could try calling the on-call person but the chances of that person wanting to get involved in the case are 0.

No drain. It was supposed to be a routine procedure.

 

[bronx43]

Of course hospitals are going to protect their cash cows at all cost. Hospitals these days are basically just surgical centers that happens to also have inpatient units. Nonsurgical physicians are viewed as a necessary inconvenience so that admin can keep their hospital designation, while getting $20k a pop for a 90 min shoulder scope.
The admin know that their $500k salaries and bonuses come out of the OR fees. Everything else is a money loser or break even at best.

 

[NewYorkDoctors]

agreed. i was not saying rely on your $2k pocket fun times ultrasound. the point was if there was too much therapeutic inertia and you could get a good ultrasound exam in by an intensivist or surgeon or something skilled in it (understanding it's less sensitive and more specific) and found something very concerning like new ascites, pleural effusion, pericardial effusion, etc...., that might have been sufficient argument for the surgeon to get back in there. again hindsight is 20/20

i mean the hypotension is a big give away... and hypotension alone is grounds for a FALLS exam anyway to get the Weil shock classification by the intensivist.

i like to use my pocket ultrasound butterfly (i also use a philips lumify to get some nice crisp echo images) as an "extension of my stethoscope." For hospital patients ill mention it in my physical exam section, not bill for it, then get the appropriate formal study expedited. usually for "yep clinical history and physical exam shows its a big nothing burger" i wont go out of my way. but if there is just a sneaking suspicion something is up and subtle, then hey better than just feeling around and pretending to listen to something....

 

[dgdg]

Always do your best for your patient and document it, regardless of other's opinions or interests.
Legally, if it isn't documented, it didn't happen.
When the music stops, no one is going to find a chair for you.

 

[Crayola227]

Just wanted to post this thread for therapy / a warning.

I can't talk too much about this case as the hospital I was working at is in arbitration for this case. But here's the gist:

A patient I consulted on had an elective (though necessary) surgery done, and he subsequently became severely hypotensive (and tachycardic). I received a call asking me to go to bedside, and being a reasonable human and physician I am, I did. Given the patient's condition, I strongly advocated for the surgeon who performed the surgery to open the patient back up as this was 4 hours post-op.

When the surgeon decided not to, I got to writing. I wrote a note that essentially summarized my recommendations and made a strong case for the patient having internal bleeding.

The patient coded and died soon after that. And can you guess how much blood they found at the surgical site? Really. Guess. I can't tell you the answer because again, litigation.

And subsequently, I was reprimanded (not formally, don't worry) for writing a note that made the surgeon and the hospital "look bad." and "opened them up to liability."

But guess who's getting sued? Not me. The hospital and the surgeon.

So the way I see it: The reprimand was just the hospital and administration covering their asses even though that surgeon was clearly wrong. I'm convinced that had I not written that note, I would be the one being sued and have my license on the line.

And in case you're wondering, I have thought a lot about this case since it happened. Wondered what I could have done differently to advocate for this patient? Should I have screamed? Called another surgeon? Vomited on the surgical site to infect it so they were forced to open up the patient? For legal reasons, that last one is a joke. Don't come for me.

But the moral of the story: Write that note to discuss your findings if you see someone actively providing substandard care if you're involved with a patient's case. It might not save the patient, particularly if you're not being listened to, but it may save your medical license.

And trust your gut.

Yeah, but I will say, if you are a resident in this situation, Lord help you.

 

[Crayola227]

You did all the right things. Who's reprimanding you for this, and by what twisted logic? And what did they expect you to do, beyond what you already did?

It's the way you document it.

There is, what I consider reality, and then there is, how you present that reality.

 

[Crayola227]

Oh, they expect me to be subservient and protect their bottom line. But w/e, I quit that job a while ago and am delighted not to be working there anymore.

Ah, was gonna say, well I know for a resident this can spell doom and was wondering what would make an attending immune....but it seems you didn't stick around before the hospital soured on you for this or more such incidents.

I'm not saying you did wrong, and of course if it's your license or someone else's and you did the right thing, protect yours.... but, if in the hospital's view you could have taken some artistic license to try to make the other guy not look so bad.... or hell, if the lawsuit would be on you but you didn't **** up and it wouldn't go as far, rather than be on the guy who did and will lose...

This happened to me as a resident because I was naive and actually from a big picture standpoint didn't understand how my truthful and accurate note about what happened was a giant blaring sign for how the attending committed massive malpractice.

I was informed and then subsequently told to adjust the note to be less damning while an addendum further softening the edges was added, effectively saying "well the resident is totally wrong it didn't happen that way" (it did though). Couldn't completely erase what I had said since the EMR saves some edits.

There were a few other times I was dumb enough to point out that the emperor wasn't wearing any clothes.

Have to be careful because yes, you are expected to have a reputation for honesty as a physician, but too much honesty is also not a desired characteristic.

 

[Crayola227]

What's funny is the intensivist responded. No ultrasound reported at that time.

But if the patient is basically actively dying and you're trying to directly intervene on that, can't you place that order despite that?

 

[LoudBark]

Can't send a patient with BP 70/30 to CT. Did not, will never.

But also, I wasn't primary, so it wasn't mine to order.

If you had let's say stabilized the patient with fluids +/- blood +/- pressors..........you would not on your own been able to order a CT in an emergent situation and only the surgeon can do that? Are you at an academic hospital? Have never seen a community hospital setting where the hospitalist if a consultant on a surgery patient does not have free reign to order an urgent / emergent study or procedure on their own and only the surgeon could order it.

 

[tantacles]

If you had let's say stabilized the patient with fluids +/- blood +/- pressors..........you would not on your own been able to order a CT in an emergent situation and only the surgeon can do that? Are you at an academic hospital? Have never seen a community hospital setting where the hospitalist if a consultant on a surgery patient does not have free reign to order an urgent / emergent study or procedure on their own and only the surgeon could order it.

You’re correct, but the patient didn’t stabilize, so it’s a moot point.

 

[tantacles]

Ah, was gonna say, well I know for a resident this can spell doom and was wondering what would make an attending immune....but it seems you didn't stick around before the hospital soured on you for this or more such incidents.

I'm not saying you did wrong, and of course if it's your license or someone else's and you did the right thing, protect yours.... but, if in the hospital's view you could have taken some artistic license to try to make the other guy not look so bad.... or hell, if the lawsuit would be on you but you didn't **** up and it wouldn't go as far, rather than be on the guy who did and will lose...

This happened to me as a resident because I was naive and actually from a big picture standpoint didn't understand how my truthful and accurate note about what happened was a giant blaring sign for how the attending committed massive malpractice.

I was informed and then subsequently told to adjust the note to be less damning while an addendum further softening the edges was added, effectively saying "well the resident is totally wrong it didn't happen that way" (it did though). Couldn't completely erase what I had said since the EMR saves some edits.

There were a few other times I was dumb enough to point out that the emperor wasn't wearing any clothes.

Have to be careful because yes, you are expected to have a reputation for honesty as a physician, but too much honesty is also not a desired characteristic.

Yeah, idgaf. I’d rather be faulted because I knew what the patient had and stated it honestly than faulted because I killed someone and pretended to be oblivious.

 

[tantacles]

Resolution: settled. I was not party to the final lawsuit.

 

[DrMetal]

Resolution: settled. I was not party to the final lawsuit.

Just curious: how did the suit come about in the first place? Family seek an attorney, or the other way around? Were you deposed, and was it the content of your deposition that swayed them to exclude you from the suit?

 

[tantacles]

Just curious: how did the suit come about in the first place? Family seek an attorney, or the other way around? Were you deposed, and was it the content of your deposition that swayed them to exclude you from the suit?

I was never included in the suit; only the organization was sued. I was deposed, but the organization settled with the family prior to my scheduled date.

I believe the family sought counsel and was advised to sue for wrongful death, but I wasn't privy to the insider portion of it, so I can't say for sure.

 

[TransformerInWestVirginia]

Oh, they expect me to be subservient and protect their bottom line. But w/e, I quit that job a while ago and am delighted not to be working there anymore.

guaranteed the hospital ****-ministrators make this face when people decide to leave their **** hole hospital

 

[dozitgetchahi]

guaranteed the hospital ****-ministrators make this face when people decide to leave their **** hole hospital

View attachment 373509

My perception is that it’s more like “bored Pikachu face”.

At my first crappy rheumatology job, the hospital admin treated me like total garbage. I once overheard my office manager announce to my staff “I’ll have to talk to the recruiter and see if they’ve found a new rheumatologist yet”. After that and many other bull**** moves by admin, I promptly left. That was almost 3 years ago, and they still haven’t found a replacement rheumatologist yet. With an attitude like that…gee I wonder why.

 

[dozitgetchahi]

Yeah, idgaf. I’d rather be faulted because I knew what the patient had and stated it honestly than faulted because I killed someone and pretended to be oblivious.

Exactly. Because in that context, the situation will go like this:

1) Lawsuit is filed
2) Hospital will look for anyone, including its own employees, to throw under the bus to escape liability.
3) If it looks like it can be blamed on you, it will be.
4) If your notes look like you were oblivious, you may indeed be the person the hospital chooses to blame.
5) You will probably get fired in the process

You definitely will not “win” by trying to make the hospital look better. Whether or not you were honest in your note, you’ll likely be fired. But you may escape being made a party to the lawsuit, board complaints, whatever. Much better to *just* be looking for another job than defending against a lawsuit and board investigation etc.