What would you do? A new book dissects “bouncebacks” in the emergency department, turning nightmare ED scenarios into Holmesian teaching cases.
The second installment of “Bouncebacks!” is now out with an all new format, and all new cases. All the cases are real with the actual ED chart, the contemporaneous nursing notes, the vital signs, the test results all laid out with the relevant time stamps. In each case the patient will return for an unscheduled ED follow-up visit and that bounceback visit is the beginning of a bad outcome that leads to a medical malpractice suit. The raw case presentation data is then integrated with the court transcripts, detailed medical analysis, expert witness testimony, and a legal analysis. What takes place over 2-5 years in real life is condensed into a chapter that reads in 10-15 minutes. The format mimics the TV series “Law and Order” where you get a look at the detectives working the case and making an arrest (that us, the EPs investigating a patients problem, treating them and making a disposition), and then the prosecutors go to trial (here it’s the legal analysis, court transcripts, expert witness analysis, and legal outcome).
The book is like an M&M (Morbidity and Mortality) Conference on steroids allowing unique insight to the cases and what went wrong. M&M, also known as Death and Doughnuts, is always a favorite during residency grand rounds (assuming its not your case) and this book brings it all back in full color. As each case unfolds you’ll hear echoes of your last shift, uncomfortable recollections of a patient you recently sent home, or maybe should have done an LP on, and now there is uncertainty buzzing in your head like a fly trapped against a window on a hot summer day. Pull up a comfy chair, and get some coffee while you delve into this non-fiction horror novel. Stephen King couldn’t cause a more ominous, profound sense of foreboding than Weinstock and Klauer do for their readers. With each case, you picture yourself trying to see 3 patients an hour, getting interrupted 10 times per patient visit, juggling lab critical values, fielding phone calls and paramedic runs, and in so doing missing a few key facts that change an “obvious” bronchitis into a sub-acute MI with failure, and a “benign” headache into a subarachnoid bleed.
Obviously, each case has a poor outcome for the patient because “damages” are necessary fuel for a legal action. This fact drives home the seriousness of every day medical decision-making and the responsibility we all bear providing emergency health care. Furthermore, these cases are NOT critically ill, obviously sick ones (those would all be admitted), but are instead relatively well appearing patients harboring a serious medical diagnosis needing prompt attention. They are the proverbial needle in the haystack. While it is true that most headaches ARE benign, and most people with a cough, sputum, and chest pain have bronchitis, these cases show just how subtle the clues to a more serious problem can be. As you read each case (with forewarning that its all going to blow up) you feel empathy for the physician who “missed” the diagnosis, and sympathy for the patient and family who faced the tragic result. It’s not easy to find a needle in a haystack, but if you don’t it may stab you!
Generally speaking, I think we spend too much time “teaching to the tort”, letting legal cases set the “standard of care”, and letting our fear of malpractice rob us of the joys of seeing and treating patients. Medico-legal fears cause some physicians to see their patients as “dangerous” or as the “enemy”. Having noted that, “Bouncebacks!” mitigates the damage by sharing personal backgrounds for the patients and humanizing them, and to be sure the plaintiff does NOT win every case (even though every outcome is bad). Teaching to the tort does have a role in medical education and “Bouncebacks!” does a good job. The book is particularly illuminating regarding the legal world which surrounds our practice. For most, that world is largely unknown (fortunately) since only about 1/15,000-20,000 ED cases result in a tort, and many of those do not go to court. You learn a lot about how an expert decides if the case is defendable and how the attorney puts the defense together. Sometimes very small details are critical to the legal outcome. Notable experts from our world weigh in as well including Greg Henry (you can hear his voice already), Bob Bitterman, Jerome Hoffman, Steve Colluciello, Dave Talan, and Amal Mattu to name just a few. The result is a very readable fast-paced expose of Emergency Medicine malpractice.
“The good doctor learns from their mistakes, and the great doctor learns from the mistakes of others”. If that is true, then “Bouncebacks!” is a must read.
Dr. Mallon is an Associate Professor of Emergency Medicine at the Keck School of Medicine at University of Southern California.
Disclosure: Two of the authors of Bouncebacks! Medical and Legal – Drs. Kevin Klauer and Greg Henry – are affiliated with Emergency Physicians Monthly as editors and writers.