This article about scary malpractice cases from Cracked.com will give all the docs out there some new stories to tell at dinner parties. Totally bizarre cases and funny commentary that comes with a language warning.
 Archive for June, 2009Scary Malpractice CasesWednesday, June 10th, 2009Two Thoughts on Health ReformWednesday, June 10th, 2009I don’t always agree with Uwe Reinhardt’s insights into the health care system, but he is so incredibly spot on with this quote that I had to post it.
A central concept of medical systems in many other countries is “social solidarity,” not irrational demand for the best medical care someone else can pay for. The US is going to have to emulate another functioning system if it is going to survive. The German model deserves some consideration. —— In addition, Alexander sent me a link to an Investor’s Business Daily editorial about how Oregon is working on health care reform. Oregon has compiled a list of 680 treatments for medical conditions and has ranked them in order of importance. Oregon will only pay for the top 503 on the list. Treatment for everything below number 503 must be paid out of pocket. Patients with broken toes, cracked ribs, and liver cancer are out of luck – they’re all ranked below number 503. However, treatments for obesity, schizophrenia, pathologic gambling and sexually transmitted diseases are fully covered. I foresee such a system as a way that health care spending will eventually be curtailed in this country. Liver cancer isn’t covered because not a lot of patients get liver cancer. Therefore, their collective voices are relatively small. When treatment is expensive and relatively few patients are affected, the treatments will be cut. Collectively, patients will receive more care for less expensive conditions that affect more people, but to keep things budget-neutral, patients who have less common diseases will receive less care. Even though Oregon admits that malignant neoplasms are a leading cause of death in anyone 11 years old and older (report pages PT4-PT11), it won’t pay for the care of “ill-defined malignant neoplasms” (#612). Doesn’t say anything about “well-defined” neoplasms, either. Refusing to pay for treatment of malignant neoplasms is great for saving money, but it is essentially a death sentence if you develop an ill-defined malignant neoplasm. Just hope to God that any neoplasm you get is benign. Those are still covered … unless you have a benign neoplasm of the eyelid (#516), kidney (#529), nasal cavities (#539), bone (#540), genital organs (#577 and 603), breast (#638), skin (#646), or digestive system (#656) – then you’re still SOL. Also note how many of the things that will not be reimbursed are conditions with “no or minimally effective treatments or no treatment necessary.” Who determines whether a treatment is “minimally effective”? Why the same entities that pay for the treatments, of course: U.S. to Compare Medical Treatments It’s the Golden Rule: He who has the gold makes the rules. Healthcare Policy Roundup June 9, 2009Tuesday, June 9th, 2009One way to get rid of your chest pain … threaten the nurses and hospital staff with a knife in the emergency department. Police will come and shoot you dead. Quote from the director of Calgary’s three emergency departments: “We have huge numbers of very sick patients essentially left behind in hallways and on ambulance stretchers for long periods of time, and across the country, in every major Canadian city, in every large urban emergency room, you have patients who are deteriorating or having adverse events as a result of these delays to care.” Canadian ED overcrowding isn’t due to non urgent patients clogging the EDs according to this study. Instead, the study author, a 25 year old master’s student, states that overcrowding is “rooted in insufficient physical and human resources and poor integration within and between hospitals.” Before the problem of ED overcrowding can be cured, he suggests “determin[ing] the purpose of EDs in order to best serve the patients, health care professionals, communities and the country.” Good advice. Sutter Roseville Medical Center is at risk of losing federal funding after a patient “walked away from the emergency room … and hanged himself in a wooded area 500 yards away.” CMS alleged that the hospital did not adequately screen the patient under EMTALA. Part of me wonders whether this action is somehow related to Suter’s decision to close another emergency department in its system. I may be wrong, but I just get the impression that there’s more than meets the eye going on here. Ten previously blogged about how his group had been surreptitiously ousted by hospital administration. This article shows that having a good relationship with hospital staff can save your job. When Mercy San Juan Medical Center tried to fire their current emergency docs and hire docs from California Emergency Physicians, the hospital staff got up in arms and the deal fell through. One way to cut state Medicaid costs … address high utilizers. This New Hampshire editorial states that frequent “ER” users only represented 5% of the Medicaid population, but those users accounted for 41% of the total Medicaid “ER” visits in the state during 2006. Another way to cut state Medicaid costs … stop providing services. North Carolina Medicaid recipients may soon feel the “bite” of budget deficits as state legislators propose to cut payments for dental visits by 50%. Think this through, folks. It’s not like people with cavities will just go away. Where do you think people with dental problems will end up? Receiving that nice inexpensive care in state emergency departments. I’ll bet that the state Medicaid costs will increase if they go this route. Funding issues causing problems with access to Connecticut hospitals as well. Connecticut hospitals lost $156 million in the last quarter of 2008 and $200 million in the first quarter of 2009. The state is underfunding its Medicaid program and hospital emergency departments are “busier than ever,” with uninsured patients making up 45% of hospital emergency department visits. Some hospitals are now requesting payment in advance for elective procedures. Want to reduce your risk of malpractice? Be nice. “Developing a rapport with the patient — is any physician’s best protection from eventually being sued by that patient.” One thing I don’t get – was this doc so busy that he couldn’t take off his surgical mask before posing for a picture in the article? Or is a surgical mask hanging around the neck the new fashion statement for surgeons? A House Subcommittee recently approved a bill that would limit the Feres Doctrine for armed service members. Currently, members of the military and their families cannot sue the military for negligent medical care – regardless of how egregious the care was. The Carmelo Rodriguez Military Medical Accountability Act was named after a sergeant in the military whose bleeding buttocks lesion was repeatedly misdiagnosed as being a wart or a birthmark. Sgt. Rodriguez died from metastatic melanoma. I agree that doctors should be responsible for egregious care, but if we turn the armed services court system into another civilian medical malpractice system, how many military docs will leave? Another point of view from Walter Olson at Point of Law here. Fast care, free care, quality care – pick any two. Physician’s Reciprocal Insurers, a med mal carrier that insures 25% of New York’s physicians has one foot in bankruptcy court and the other foot on a banana peel. State mandated insurance premium rate freezes appear to be partly to blame. How could this happen if insurers are raking in the money and are really responsible for the medical malpractice crisis? The Trial of a WhiteCoat – Part 3Monday, June 8th, 2009The wind blasted me in the face walking from train station to Vinny’s office. Vinny wanted me to meet him there so we could prepare for my deposition the following week. Even though I had spoken to Vinny on the phone a few times, we still hadn’t met and I was trying to imagine what he looked like. I printed up a map of the area before I left home and I kept pulling it out of my pocket to make sure I was going in the right direction. People pushed by me as I slowed down to look at the map and get my bearings. If this ever happens again, I’m not scheduling a meeting late in the afternoon when everyone’s leaving work. Don’t roll your eyes at me lady. Do I have a camera around my neck? I’m not some tourist, you know. Walking down the street trying to avoid being knocked over by everyone else walking up the street to the train station, I noticed how some of the biggest buildings have some of the smallest building numbers. I could play this game with my kids all day … I spy with my little eye … something that is one shade darker than concrete, covered by pigeon droppings, written in 6 point type, and is underneath an awning in the shadows. Right! It’s the building number! Vinny’s building had security screening personnel who were apparently all disgruntled former TSA employees. I had to show picture ID and state the name of the person I was coming to see. Then they had to call the person to verify that I really was supposed to be there. I got a sticker ID that I had to wear at all times while in the building. This wasn’t an ordinary ID sticker, though. It turned red after being exposed to the air so you couldn’t use it again the following day. The waiting room of Vinny’s office was smaller than I expected. Contemporary design with a glass motif. Old golf magazines and law journals were scattered about the end tables. There was a constant background din of the secretary answering the phone and transferring calls to different offices. “Smith, Jones, Brown, White, Schmidt, and Rubenschlager, how can I help you?” I kept hearing the same greeting over and over again. Literally a call or a transfer came in every 30 seconds while I was sitting there. Sometimes after a night shift and little sleep I’ll answer our home phone “Emergency department, can I help you?” I meant to ask her if she ever answered her home phone the way she does at the office, but she was still in the middle of a call when Vinny walked out of the door. “Hi, are you doctor WhiteCoat? I’m Vinny.” Whoa. Absolutely nothing like I expected. I was expecting an older heavy set balding guy in a designer suit with a Rolex watch rattling around on his wrist. Vinny was young – maybe a little older than me – thin, tall, glasses, and a full head of wavy brown hair. He was wearing a white dress shirt with the sleeves rolled up. No watch at all. So the insurance company’s “go to guy” is a modern day Atticus Finch. Interesting. We spent several hours going through the medical records and making sure I knew all of the pertinent facts in the case. He also threw a lot of questions at me and showed me how the plaintiff’s attorney would try to trip me up when he asked them. He also showed me how to answer the questions so that I wouldn’t get tripped up. I also got to meet the attorney working on my case with Vinny. I had received many letters from Louise over the previous year. Most just advised me of what had happened in court hearings and what the plaintiff’s attorney was doing. Louise was in her mid-30s and thin. Her shoulder length blonde hair was gathered back into a ponytail using a scrunchee. Some of her hair had come out of the ponytail and kept falling in her face, so she repeatedly pushed her hair back behind her ears. Every time she leaned forward, the hair flopped out again. She wore a sharp blue suit. It was easy to tell that Louise wanted to get down to business. She seemed to get annoyed when Vinny went off on tangents not related to the case. I could tell that she was a perfectionist. She would get frustrated on the spot if I did something she didn’t like. “NO! Repeat after me. ‘The patient didn’t have signs of sepsis when he arrived in the emergency department, so there was no reason to initially suspect it.’” Louise had a thing for her pen, too. She chewed on the end, doodled intermittently as I talked, and would slam the pen on her pad of paper to make a point. Normally I do little things just to irritate people like Louise to try to get them to loosen up. Louise seemed like she was wound so tight that she’d use the chewed up pen to stab me in the jugular if I gave her a reason, so I just smiled and nodded my head when she talked. After a few hours of preparation, I felt pretty confident – both in the care I provided and in my ability to deal with the plaintiff’s attorney’s questions. “Want to get some dinner?” Vinny asked both of us. WTF Moment #388Sunday, June 7th, 2009Mom brings in her 2 year old child at 11:30 PM last night after she noticed a lump to the child’s kugelsack (“kugel” = “ball” in German – check out the video at the link before it gets pulled down) two days ago while bathing him. Ended up being a small hernia. No big deal. Why did she wait until 11:30 at night? She was working until 11:00 PM and brought him right after work. OK, seems reasonable. Why did she bring him to the emergency department on a Saturday night instead of taking him to their primary care physician on Monday? She got freaked out after talking to co-workers. One told her it was probably cancer. Note to parents: Diagnoses made by non medical personnel who haven’t examined your children are worth just a little less than what you pay for them. Transporting Morbidly Obese PatientsSaturday, June 6th, 2009Obese Woman Dragged From Home, Hauled Away After Death A 750 pound woman dies at home. According to police and the coroner’s office, there is no truck big enough to transport her to the morgue, so police call the towing company, they drag her out of her apartment on a mattress and load her onto a pickup truck to bring her to the morgue. According to witnesses, the tow truck drivers threw a piece of carpet over her instead of a sheet. I’m assuming the reason for this is because not too many tow truck drivers or coroners carry extra large clean sheets in the backs of their vehicles, but that is purely speculation on my part. Family members and neighbors were appalled. It was “like putting a cow up there,” said the deceased’s boyfriend. They don’t treat [dead dogs] that way,” stated a neighbor. Supposedly the fire department has equipment that will handle patients up to 1000 pounds, but no one knew that. Assuming that the fire department didn’t have the equipment available, what would the family have done to get the patient to the morgue? If people allow themselves to get so obese that traditional transport mechanisms won’t work, then what duties should providers have? [Thanks to Alexander for the link] UPDATE JUNE 8, 2009 Newest EMTALA Violation?Friday, June 5th, 2009
One of the issues that sparked the blogfight between Scalpel and Nurse K was the “InQuickER” concept at the Emory Adventist Hospital Emergency Department in Smyrna, Georgia. According to Emory’s web site, if you pay a $24.99 fee, you can reserve an “appointment” in the emergency department up to 12 hours in advance. You still have to pay for all of your care, but the $25 fee gets you on the “preferred” list. If you aren’t seen within 15 minutes of your appointment time by a physician or a physician’s assistant, you won’t pay for your services. To “Hold My Place In Line“, all you have to do is enter your symptoms, your name, an e-mail address, and your payment information. EMTALA requires that emergency departments provide a screening exam and that the screening examination be performed in a nondiscriminatory manner. If Emory Adventist Hospital is cherry picking patients who have computers with internet connections, who have credit cards, and who can pay a $25 fee to get “In QuickEr”, wouldn’t that be considered just a lit-tle “discriminatory”? Be interesting to see whether CMS jumps in if a patient who couldn’t afford the $25 copay had to sit longer at the back of the line and experienced a bad outcome. If we are going to enforce this overbearing law, we have to do so uniformly. Blogfight!Thursday, June 4th, 2009The Trial Of A WhiteCoat – Part 2Thursday, June 4th, 2009When I considered blogging about my malpractice case, I just figured that the posts would be of interest to a few. Not the case. The interest in this case has been incredible. Thanks to Kevin MD, Walter Olson at Overlawyered, GruntDoc, Shadowfax, Eric Turkewitz at NY PI Law Blog, Medicine Think, Law.com, Scienceroll, whomever “Stumbled Upon” my post, and any others I may have missed. —————————– I checked the attorney out online at Martindale.com and researched him on our state web site. I also had a couple of friends who are lawyers get some information about him. He had a very good reputation. That’s good news. One friend told me that he was the “go to guy” that the insurance company used to handle complex cases. That worried me. I know that I’m looking at the care I provided from my own skewed perspective, but I thought that everyone did a pretty darn good job treating this patient. Why did the insurers want a “big gun” for this case? I’m sure it’s not like he or his firm were hurting for business. So I called “Vinny” and we talked on the phone for a while. I liked him almost immediately. Very down to earth. Knows his stuff. He did seem a little high strung at times. I could hear the tenor in his voice go up when he told me things to do and things not to do from that point forward. Vinny promised to keep me informed about any developments in the case. A few months later I got a large packet in the mail from Vinny’s law firm. There were a bunch of detailed questions called “interrogatories” from the other attorney that I had to answer under oath. I had no idea what the heck some of them had to do with the case. It didn’t matter, I still had to answer them. Vinny asked me to write out answers to the questions I could answer and then told me that he would put them into a “legal” format once he got them back from me. He told me not to worry about things I didn’t know – leave the questions blank. More information would come out as the litigation progressed and we could supplement the answers later. I started to research answers to some of the questions in order to justify each of the actions I took. This time Vinny told me to relax and to let the experts do that. Easy for him to say. Vinny’s firm and the insurance company contacted me with the name of an expert that they had chosen to review the case. Everyone seemed impressed with his credentials. He was from a teaching program and his curriculum vitae was reportedly quite large. Hey, great, so if his testimony isn’t that good he can roll up his “CV” and smack the plaintiff’s expert around with it. Or we can use the CV for a doorstop during trial. Go for it. The attorney sent the expert with the 5 pound CV a copy of all the medical records. Then the attorney, the insurance representative, and the expert with the 5 pound CV had a meeting to discuss my care. Other experts would review the care by the other doctors. This expert was focusing just on my care. I got a letter a couple of weeks later summarizing their discussions. The expert thought my care was negligent. I got mad. It seemed like the expert started with the ultimate diagnosis and worked backwards to focus in on what I should have done to begin with. “Dr. WhiteCoat didn’t appreciate how sick this patient really was.” Had he read through the chart, he would have seen that wasn’t the case at all. I called 4 consults on the patient in a few hours, resuscitated him from shock, and ruled out many life threatening illnesses. Yes, it took me a little longer to get to the diagnosis, but I did make it. The expert was criticizing me because he knew the zebra diagnosis before he even got the medical records and I didn’t think of the zebra diagnosis right off the bat. The expert gave several reasons why he thought what I did was wrong, completely criticized my thought processes, and listed another few things that I should have done differently. No basis for his opinions, mind you. Just a bunch of “shoulda, woulda, couldas.” By the time I finished reading that letter I was close to sustaining one of those fractures that occur when you accidentally fall on the floor. I went back into research mode. I analyzed each of the expert’s statements and wrote a fourteen page letter to my attorney and my insurance company rebutting each of the expert’s statements. I stated that the expert’s opinions were “unsupported by any medical literature” and I attached copies of several articles and textbook passages supporting my care. If “Dr. 5 pound CV” practices medicine in the same manner he reviews cases,” I wrote, “he is jeopardizing the health and safety of [his] patients.” I got a small amount of satisfaction when the insurance company agreed to get the opinion of another expert. But before the insurance company would consult another expert, I had to agree to abide by whatever opinion the expert rendered. Fine. This time I’m learning more about the expert before he gets his hands on the medical records. We agreed on expert #2. His CV wasn’t as big. He was the assistant director of an emergency medicine residency program in a large city. They sent him another set of medical records and they had another meeting. A few weeks later I got a call from Vinny describing the meeting. He made some small talk. He finished his sentence by adding “… he believes that you exceeded the standard of care.” You bastard. That was a perfectly good pair of underwear I had on. OK, I can breathe again. Thought I was going this journey alone for a second, there. Vinny told me not to expect to hear much from him until it was time to schedule depositions. He owes me one set of Jockey shorts. |
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ED Issues the Public Doesn’t Think About
Thursday, June 11th, 2009Down side of working in a trauma center near a music venue: drunks.
I used to work in a trauma center near a large music venue and the staff would plan its schedule around what band was playing there that weekend. Ditto for all the ambulance services. Jimmy Buffet and OzzFest were the worst. Documenting skin color on someone painted up to look like Lily Munster is challenging.
The hospital administration used to complain to the owners of the venue and about every month someone would show up in the ED and give us 50-100 free tickets to one of the shows. Developed an enjoyment of Tom Petty’s music because of those tickets.
Never did get offered tickets to Jimmy Buffet or OzzFest, though.
Guess the music venue owners figured if all the docs and nurses were at the concerts, the hospital would have trouble staffing the EDs to treat all the drunks.
Posted in News Commentary, Random Thoughts | 4 Comments »