March, 2022 Welcome to Medical Malpractice Insights - Learning from Lawsuits. If you're a first-time reader, sign up here (free) to receive each monthly issue in your inbox. Your story can save lives. Submit your story. Some of the best cases in this newsletter come from readers like you, whether from experience as an expert witness or having been sued yourself. Every med mal story has teaching points, and untold stories only lead to more patient harm. All cases are anonymized and no settlement amounts are disclosed to comply with confidentiality clauses common in pre-trial settlements. Click here to send your story. Is Med Mal Insights going to your junk folder? If so, add medmalinsights@pilchermd.com to your address book or contact list. That should white-list it and get it to your inbox. In the meantime, I'm working with MadMimi, my mailing partner, to see if there's a fix. In this issue: Documentation matters. ▪ SCFE: The case of the missing phone call
▪ SEA: Saved by the record
| ▪ | SCFE: The case of the missing phone call | | ▪ | SEA: Saved by the record | Plus an update on MMI's new Editorial Board. |  Click the image for the "Who's on first" skit. | SCFE: Who called whom and when? "Who?" "What?" and "I don't know." Another version of Abbott & Costello's classic skit "Who's on first" Facts: An 11 year old female feels a sudden px in her L hip while doing a flip turn during swimming practice. She sees her PCP a week later and is diagnosed with a "groin strain." The sx persist and she is re-examined by another PCP a few days later. The dx is changed to "adductor strain." A month later she feels a "pop" in her hip, falls, and is taken to the ED. An x-ray of her hip reveals a slipped capital femoral epiphysis (SCFE). Orthopedist A is allegedly contacted by phone and advises the EP that she can be seen in the office. The actual identity of Orthopedist A is not recorded. Surgery is done 4 days later by orthopedist B. Avascular necrosis (AVN) develops and the pt requires a total hip replacement. An attorney is contacted and a lawsuit is filed claiming delay in dx against the first 2 physicians and inappropriate delay in surgery against the EP and the two involved orthopedic surgeon(s).
Plaintiff: The first two doctors missed my diagnosis. They didn't even do an x-ray. The EP made the correct diagnosis but allowed Orthopedist A to convince him that immediate surgery was unnecessary. The EP testifies that he spoke with Orthopedist A but didn't record it. Phone records show that it was actually Orthopedist B with whom he spoke, so we're suing both of them.
Defense: Orthopedist A testifies that he was "on vacation" on the day of the ED phone call. Orthopedist B testifies that he wasn't called because "If I was called, I would have done immediate surgery." Avascular necrosis is possible no matter when surgery is done. Timing is a matter of debate.
Result: Because of all the unknowns in this case, the various parties agreed to settle for undisclosed amounts pre-trial.
Takeaways:
* If you speak with a consultant, identify him/her, what advice you were given and why you did or did not follow it.
* Share the agreed upon plan with the patient, e.g., "Dr. X recommends Y. He and I have discussed this and you should follow up according to our plan."
* One cannot prove when this SCFE actually occurred. It is possible that early x-rays would have been normal and that the SCFE found by the EP was a later subluxation of the epiphysis aggravated by the fall.
* Once SCFE is identified, surgical stabilization should be done ASAP. That said, the role of timing as a cause of complications like AVN remains a matter of debate.
* SCFE classically presents in an overweight adolescent with non-radiating, dull, aching pain in the hip, groin, thigh, or knee, and no history of trauma.
Reference: Slipped Capital Femoral Epiphysis Treatment & Management. Walter KD. Medscape eMedicine. Updated Dec 03, 2018. | Spinal epidural abscess (SEA): Saved by the documentation You're a doctor, not a prophet. Jury agrees. Facts: A 69 yo man presents to the ED with low back pain after lifting heavy objects out of his truck. An x-ray shows only DJD. He is discharged with pain meds to f/u with his PCP, which he does. Eight days later he returns to the ED with pain in the shoulder and back, rash on his arm and legs, and jaundice. A complete spinal MRI is done, showing lumbar discitis and a psoas abscess. He is admitted and treated with antibiotics. Two days later he develops left arm deficits and is transferred. A repeat MRI at the receiving hospital shows a cervical epidural abscess. Despite surgery the patient is left with permanent loss of use of his left arm. A lawsuit is filed claiming that his SEA should have been diagnosed earlier. The case goes all the way to a jury trial.
Plaintiff: The plaintiff's only significant claim was "You should have done the MRI on my first visit."
Defense: We did it on your second visit and it was normal. There was no indication for an MRI on the first visit. The diagnosis and our care were reasonable.
Result: Jury verdict for defense.
Takeaways:
* There was clearly no malpractice in this case. The plaintiff attorney appears to have limited medical knowledge.
* The transferring hospital could have repeated an MRI but it would not have changed the need for transfer and surgery. Thus, any negligence did not cause the patient harm, only a delay in diagnosis.
* SEA is rarely diagnosed on first presentation.
* SEA was considered, documented and supported by the ordering of a full spinal MRI - which was normal 2 days before transfer.
* The patient was treated appropriately for the psoas abscess.
* If SEA is suspected, a CRP and/or ESR has over 95% sensitivity in ruling it out. In this case, however, the test would be elevated due to the psoas abscess.
Reference: Epidural Abscess. Wallace MR. Medscape eMedicine. Updated: Jul 02, 2019. | Editorial Board Thanks to the dozens of readers who volunteered to join MMI's Editorial Board. Board members will provide input on pre-publication drafts of monthly stories and support MMI's mission to improve patient safety. Members were selected from a variety of backgrounds and bring with them experience in medical education, communications, patient safety and medical-legal issues. Please welcome the new Med Mal Insights Editorial Board:
* Patty Bartzak DNP RN is a Staff Nurse working at a level one trauma center in Massachusetts. She serves as a Nurse Expert Witness and has reviewed more than 70 cases in the past 7 years. She is a Board Member of the Academy of Medical-Surgical Nurses, and co-chaired the American Nurses Association Nursing Scope & Standards of Practice (2021). She is a peer editor for the Journal of Trauma Nursing and has published extensively on safe bedside nursing care.
* Antonio “Tony” Dajer MD is an emergency physician in NYC. He has chaired the QA committees for over 13+ years as an ED Medical Director and served as chair of Quality Assurance at NY Presbyterian - Lower Manhattan Hospital. He has done medical-legal consulting for 20 years, contributes to Discover Magazine's "Vital Signs" column, and tries to channel Charles Darwin's deep insights into the power of diversity in the natural world.
* John DeAngelis MD FACEP is an Emergency Physician, clinical researcher and assistant professor of Emergency Medicine in Rochester, NY. He completed a fellowship in Emergency Ultrasound and is active in weekly ultrasound QA and ultrasound education for fellows, residents, and medical students. His research interests include Pre-Hospital and Flight Ultrasound, POCUS in the ED, and the opioid epidemic. Current projects include Primary Investigator (PI) on a multi-center study and Co-PI on a trial funded by the CDC. He is a member of the NYACEP Research Committee, and the ACEP US Division Research sub-committee. Other academic interests include end of life care, vulnerable populations, and political advocacy.
* Eddie Decker RN is Director of Safety Engineering for HCA Healthcare in Nashville, TN. He has been involved in the care and improvement of human life for over two decades in a variety of healthcare settings. Originally planning to be a flight nurse, he was a med-surg and critical care nurse before realizing his passion was improving patient safety. He became interested in med mal cases while working as a hospital-based risk manager. Outside of work, Eddie enjoys adventures with his family and time spent in his garage woodshop.
* Zakeeya Kadwa MBBS is an emergency physician practicing in a community hospital in Cape Town, South Africa, seeing a mix of trauma, geriatrics and psychiatric patients. She believes that evidence-based practice, understanding and avoiding the common pitfalls we face daily, and educating one’s patients are the best ways to protect oneself from litigious outcomes. She believes that in an ideal world, doctors would no longer need malpractice insurance. Her special interests are in pain management and mental health care for providers but her ultimate goal is to teach young doctors about the joy of practicing emergency medicine. In her spare time she enjoys embroidery and reading novels and dreams of moving back to a small town where there is no such thing as traffic.
* Sajid Khan MD is a full time Emergency Physician and former Medical Director with over 15 years of experience working in a variety of settings. He is the author of How to Not Kill Your Patients: An ER Doctor's Guide to Life after Residency and The Ultimate Emergency Medicine Guide, a comprehensive review book that is the highest-rated and most up-to-date text for Emergency Medicine physicians preparing to take the written boards exam. He moderates the website myERdoctor.com and proceeds from his books and website support his charitable organization.
* Gita Pensa MD is an Emergency Physician and Associate Professor (Clinical) in the Department of Emergency Medicine at the Warren Alpert School of Brown University. She speaks nationally on the topics of physician litigation and litigation stress. Dr. Pensa is the creator of "Doctors and Litigation: The L Word," an open access podcast curriculum on the psychological and practical preparation required for physicians in malpractice litigation. She also is a coach for individual physician defendant wellness and performance at doctorsandlitigation.com. and has earned awards from RI ACEP and EMRA for her work.
* Lars-Kristofer Peterson MD FACEP FAAEM is an Attending Physician & Asst. Professor in the Departments of Medicine & Emergency Medicine at Cooper University Hospital in Camden, NJ. He specializes in critical care and neurocritical care and currently leads the medication safety and code blue/rapid response committees. He also chairs the critical care morbidity and mortality review for the critical care division and is vice-chair of the medical ethics committee. He appreciates that reading Med Mal Insights demystifies the medical malpractice process and provides a forum for impactful cases to improve patient safety and care quality.
* Don Talenti MD has been a full-time EP for 27 years and has served as Medical Director of a medium sized ED in New Jersey. Before medicine he was a research physiologist and worked with a major law firm assisting with asbestos litigation.Medical-legal issues have always been an interest, both as an expert witness as well as being on the wrong end of his own malpractice suit. He serves on his county’s special operations team for Hazmat, Swiftwater and other heavy rescues and is a member of a FEMA Urban Search and Rescue Task Forces in PA. He finds that MMI-LFL has made him pause more than once, and say “No way! They didn’t really do that, did they?” or “Crap, I would have discharged them too.” He also finds the recent "You Be The Expert" reader polls valuable and insightful.
* Stefani Vande Lune MD JD is an Emergency Medicine resident at Naval Medical Center Portsmouth in Virginia. Prior to joining the medical profession, she practiced intellectual property trial and appellate litigation in Washington, D.C. She continues to maintain an active license with the New York bar.
* Will Weber MD MPH is an Emergency Physician and faculty at Harvard / Beth Israel Deaconness. He cofounded the Medical Justice Alliance, a non-profit that trains volunteer physicians to provide expert medical testimony to ensure that those who are detained or incarcerated receive appropriate medical care. He developed Chart Decoder, a free application to help patients understand their medical records, and also serves on the Public Health and Injury Prevention Committee of the American College of Emergency Physicians. | About Medical Malpractice Insights - Learning from Lawsuits Mission: Our most egregious mistakes become lawsuits. By learning from them, we improve patient safety and reduce the cost and stress of repeated medical error.
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