Overflowing optimism colliding with true life experience
You're not always smarter than the EKG computer
Young patients can have an MI too.
Anonymous v. anonymous - New York Facts: An overweight successful 34 yo male salesman with no prior heart history experiences chest pain for a few days. He presents to the ED with crushing chest pain radiating down his L arm and cold sweats. He is taken immediately to the treatment area and an EKG and blood work are interpreted as normal by the ED physician. The COMPUTER interpretation of the EKG is abnormal. The patient is admitted to an internist for 2 days and discharged without a cardiology consult, stress test or angiogram. Although the diagnosis is anxiety and stress, he is told to follow up with a cardiologist of his choice. He does so 3 times over the next 3 months, each time complaining of ongoing chest pain, helped by a prescription for NTG. The cardiologist never accesses the hospital record, relying only on his own evaluation. When the pain suddenly becomes excruciating, the patient’s wife calls 911. He returns to the original hospital, is diagnosed with a massive MI and transferred to a university hospital. He survives with significant myocardiopathy. He develops renal failure and becomes ineligible for a recommended heart transplant.
Plaintiff: You misread my EKG. My 3 experts and even your own defense agree that the EKG showed significant ischemia. I needed a coronary angiogram, which I would have gotten had you read the EKG correctly. That would have shown that I needed triple bypass surgery. Now I can barely walk, much less work.
Defense: The EKG was normal. I always disregard the computer reading. I have more experience. You saw a cardiologist as advised. The cardiologist did nothing.
Result: $6 million pre-trial settlement
Takeaway: Don’t ever think you’re smarter than the EKG computer without documenting your reason for disagreement. Remember that young people can have heart attacks (and PE’s and dissections.) In chest pain patients with equivocal findings, a stress EKG is mandatory. A coronary angiogram can be cost effective even if negative by providing reassurance, especially in a young patient worrying about a long “cardiac future.” And if you’re doing followup on a hospitalized patient, obtain and read the medical record.
Barium contraindicated in suspected perforated bowel
Failed handoff, missed communication, wrong test
Duque v. Hahnemann University Hospital et al. - Philadelphia, PA Facts: A 27 yo professional soccer player develops groin pain and undergoes surgery in 2009. He is discharged, but pain increases, despite increasing doses of pain medication over a 2 day period. He returns to the ED. His WBC is elevated, and a resident suspects bowel perforation. That resident leaves for the day without informing his replacement of the presumptive diagnosis. The latter orders a CT scan with barium contrast, and the perforation is confirmed. The perforation is repaired and abscesses drained during a second surgery. He is hospitalized for 18 days.
Plaintiff: Perforating my bowel was bad enough. Barium is contraindicated in bowel perforations. I developed adhesions and an infection and still have pain. Now I can't play professional soccer and I have to work as a consultant. [God forbid!]
Defense: This was a known risk of the surgery. Barium is not that bad. We did nothing wrong.
Result: $3.34 million jury verdict.
Takeaway: 1) Do a decent handoff when going off shift or transferring care. 2) Know the risks of drugs and contrast agents. 3) Don't use barium if you suspect a bowel perforation.
UpToDateOnline: Among other contraindications, barium should not be used in “known or suspected obstruction of the colon, known or suspected GI tract perforation, suspected tracheoesophageal fistula, obstructing lesions of small intestine, pyloric stenosis
Clearing the spine is good. Documenting that is better.
ED doc’s consistency trumps lack of documentation.
Rosebrock et al. v. Eastern Shore Emergency Physicians, LLC, et al., Maryland Facts: A nursing home staff member slips and falls on a wet floor at work and is taken to the ED on a backboard. The ED physician fails to record that patient has back pain, and she is discharged in just over an hour. On follow up 3 days later, another physician notes that patient has soreness in the hip, knee, and back. She worsens and sees a third physician 15 days later, at which time x-rays are taken revealing a compression (“burst”) fracture of L3 with nerve root impingement. The patient has a spinal fusion 6 days later and is discharged to rehab in 4 days. She then develops a surgical infection and is readmitted to the hospital. Eight days later she suffers an episode of VF resulting in anoxic brain injury and dies shortly thereafter.
Plaintiff: I arrived on a backboard and you did not properly clear my spine. Even if you did, there’s no record of it. You discharged me with a broken back. Everything went to hell thereafter. If you had diagnosed my fracture earlier and treated me appropriately, I wouldn’t have died.
Defense: You didn’t have any significant back pain. I saw no reason for x-rays. I see 5000-6000 patients a year and don’t remember you specifically. I treat several patients each shift who arrive on backboards and my habit/routine is identical with every single one. I do a spine exam on the backboard before removing a patient from it, and I do it “the same way, every single time, every day that I work.”
Result: Defense verdict, appealed by plaintiffs on grounds that the testimony regarding the ED physician’s “routine” was inadmissible. Appellate court denied appeal, ruling that the testimony regarding physician’s “habit” of clearing the spine could be allowed based on frequency, repetition, invariability and certainty, and “habit evidence” is allowed under Maryland court rules and does not require corroboration by others. The value of that evidence is up to the jury.
Takeaway: Having a routine to clear the spine of patients on backboards is good practice. Documenting that exam is better - and prevents lawsuits. (That said, we can still ask “How would this patient’s survival, and the absence of surgical complications and ultimate death, been assured had her surgery occurred immediately after the first ED visit?” The care was alleged to be sub-standard, but did that cause her death?)
For the truly bored, the Appellate Court decision can be read here.
Here’s a really "cock"-a-mamie story
Banks v. Bivins, Aikens et al. - Alabama Facts(or rather Facts?): Plaintiff Banks alleges to attorney John Graves that his penis was amputated during a circumcision performed by doctors Bivins and Aikens, specifying no date when this happened. Mr. Graves claims that he has tried for 2 whole weeks (!) to obtain his client's medical records, and when unsuccessful, files a lawsuit.
Plaintiff: This should never have happened.
Defense: "This" never did happen. Neither of us ever performed a circumcision on Mr. Banks or removed any tissue at all. Mr. Banks is lying.
Result: Case dismissed. Attorney Graves should have known his client's claims were false, but will be allowed to review 3000 to 4000 pages of patient’s medical records and submit an amended complaint within 30 days. (So far he has not.)
Takeaway: Justice cuts both ways. Attorneys must do their homework, including a detailed specification and factual description of the allegations. Attorney Graves and his firm will likely be sanctioned for irresponsible and unethical conduct. No action since July, 2014, when this case was reported.
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Charles A. Pilcher MD FACEP, Editor Medical Malpractice Insights
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