February, 2015 The goal of Medical Malpractice Insights is to improve patient safety, educate physicians and reduce the cost and stress of medical ma

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Med Mal Insights

February, 2015

The goal of Medical Malpractice Insights is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. Feedback from scores of readers across the country indicates this publication can help achieve that, and I thank you for the encouragement..

Every few weeks we quickly distill a few cases into a key teaching point or "Takeaway." Nothing fancy. Occasionally unconventional. Maybe even humorous. But always readable in about 3 minutes on whatever device you prefer.

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Charles A. Pilcher MD FACEP, Editor
Medical Malpractice Insights

Simple Complex

The simplest solutions are often the cleverest. They are also usually wrong.

Multiple risk factors deserve a thorough workup for endocarditis (SBE)

Don't over-simplify a complex case

Williams v University of Chicago
Facts: A 13 yo male presents with fever, backache, and headache. He has a history of transposition of the great vessels with surgical repair, recent stent placement, and prior endocarditis. No tests are done. He is diagnosed with a viral syndrome and sent home on ibuprofen. Two days later he returns with the same complaints, is admitted, and antibiotics are started. Blood cultures are positive for staph aureus. His hospital course is long and complicated, resulting in brain damage and left sided hemiparesis. 

Plaintiff: My heart defect and prior endocarditis made me high risk for repeat SBE. The first physician should have admitted me and obtained blood cultures. A cardiology consult should also have been obtained.

Defense: You're probably right. Let's settle
Result: Settlement for $17 million.
Takeaway: Patients with complex histories deserve more than simple evaluations. A teenager with a history of heart surgery, endocarditis and coronary artery stents is a bouquet of red flags. Save your simple assessments for straightforward patients. And, If you are not the PCP, consult him/her. eMedicine article ->

Aortic Dissectionjpg

I know. It says "Abdominal." Message is the same.

Aortic dissection in a teenager

It's possible. Think of it. Then rule it out or document your reasons for not doing so.

Crooks v Thomas Hospital - Alabama
Facts: A 17 yo male presents to the ED with headache and 6/10 pleuritic chest pain for 45 minutes. An EKG and CXR show only sinus bradycardia. He is sent home on ibuprofen and Tylenol with a dx of muscular strain. Six days later he sees his PCP who continues the ibuprofen. The teen dies 5 days later of pericardial tamponade due to thoracic aortic dissection (TAD).
Plaintiff: You failed to test for aortic dissection.
Defense: The care was reasonable.
Result: Verdict for the defense.
Takeaway: TAD can be a difficult diagnosis, especially in the young, in which case it is often associated with vasculitis, Marfan syndrome and Ehlers-Danlos syndrome. The standard of care is "what a reasonably competent and skilled physician with similar background in similar circumstances would have done." That said, one's Medical Decision Making should always include dissection and pulmonary embolus in patients with chest pain, the two most common causes of malpractice lawsuits in such patients. Juries are unpredictable in cases of aortic dissection. Don't take chances. eMedicine article ->

Bacterial Culture

Do test. Check results. Treat appropriately.

A system to follow up on cultures is critical

Antonucci v. Fond et al. - Rockland County, NY
Facts: An adult male undergoes an injection for a contrast MRI of the hip. Days later he has a culture done at the hospital to determine if an infection is present. Two days later he is briefly evaluated by his orthopedist and sent home; the positive culture is available but not considered. He returns to the hospital 2 days later with severe damage to his hip joint, is treated and requires a hip replacement 3 months later. 

Plaintiff: No one bothered to check the culture result. I have constant pain and you should have known I had a serious infection. My hip had to be replaced as a result. I am now disabled, can't enjoy my previous hobbies, and can't work in construction. 

Defense: Defense position unavailable. 

Result: A $2.3 million verdict after a 3 week trial.
Takeaway: When cultures are done, you must have a system in place to assure follow-up of the results. If you do not have a "culture nurse" or someone specifically assigned to this task, appoint one.

Finger pointing

When you may NOT be liable for your own malpractice

Sort of like the concept of original sin?

Anonymous v. Anonymous, Broward County, FL
Facts: A 44 yo woman driving a company car is involved in an MVC that aggravates a pre-existing disk problem. (The other driver is at fault and uninsured.) She is treated with epidural steroid injections, and several months later is diagnosed with adrenal insufficiency. The complication is attributed most likely to the injections. The patient's employer (who owned the company car) is sued. 

Plaintiff: I had complications from my treatments. Had I not been in the wreck driving your car, I would not have had to undergo these treatments. 

Defense: We don't like this, but the law clearly says that if a defendant harms someone, he/she is on the hook for all consequential damages. So I guess we better settle. 

Result: $2.4 million settlement against employer. 

Takeaway: This is a weird and undependable outcome, but is one of the rare "out clauses" for you and your insurer, should you be charged with malpractice. According to this patient's attorney, Andrew Rader, "Suppose I get in a car accident and go to the hospital with a broken left arm. In the hospital, they cut off my right arm. The original driver is still liable, because I wouldn’t have been in the hospital if it hadn’t been for the accident.” Despite substandard care and/or complications by subsequent caregivers, the original wrongdoer can be held responsible.

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Failure is the key to success; each mistake teaches us something.

Morihei Ueshiba