WhiteCoat

More on Perfect Medicine

Someone forwarded my the link to this story about a Connecticut woman who filed a multi-million-dollar lawsuit against a hospital and emergency physician for failing to diagnose pulmonary emboli which ultimately killed her husband.

According to the article, the patient went to Stamford’s Tully Hospital emergency department complaining of flank pain. The emergency physician performed a CT scan on the patient’s abdomen “without performing further testing” and then discharged the patient home.

Nine days later, the patient returned to the emergency department in critical condition with blood clots in both lungs. He died the following day.

It is hard to comment specifically about the case without knowing more facts. However, in general, pulmonary emboli are notoriously difficult to diagnose. We do a lot of chest CT scans looking for them, and a vast majority of the time the chest CT scans come back normal. Of course, after the negative result is known, then everyone accuses you of ordering an “unnecessary test” to look for a pulmonary embolism, but that’s another topic for later discussion. So in a patient who comes to the emergency department complaining of flank pain, a blood clot in the lungs is probably not going to be near the top of any reasonable physician’s differential diagnosis list. Flank pain is usually due to kidney problems and the kidneys are in your abdomen at about the level of your belly button. The pulmonary emboli that kill people lodge in the central parts of the lungs, in the center of the chest just to the sides of the heart. See the diagram.

The thing that really bothered me about the article was that the plaintiff’s attorney, Craig Yankwitt, from the Stamford law firm of Silver Golub & Teitell, was quoted as saying:

“They were simply not permitted to discharge without ruling out whether he was suffering from a life-threatening condition.”

This is ridiculous confabulated unsubstantiated calumny. And the purpose of this calumny is to try to bolster the retrospective claim that Mr. Yankwitt will try to use to make millions of dollars:

“Had they performed the additional testing, Mr. Hermann would still be¬†alive.”

There is no rule that a physician or hospital is “not permitted to discharge” a patient without ruling out whether the patient is suffering from a life-threatening condition. To require so would demand perfection in medicine: Doctors are not allowed to miss any life threatening conditions ever, regardless of how obscure or tangential the complaint. Think about if this really were the case.
You come to the emergency department with pain when you urinate and a little bit of blood in your urine. Sounds like a simple UTI … but wait, we are “simply not permitted to discharge you without ruling out whether you are suffering from a life-threatening condition.”
Your could have a pulmonary embolism. That is a life-threatening condition. According to Mr. Yankwitt, you can’t be discharged until a pulmonary embolism has been ruled out. We’ll have to do a CT scan of your chest before you can be discharged.
Kidney cancer is also a life-threatening condition. Add a CT scan of the abdomen and pelvis to the list of tests.
And you *could* be suffering from brain cancer. That’s a life-threatening condition. According to Mr. Yankwitt, you can’t be discharged until that potential life-threat is ruled out. May as well do a whole body CT scan and get it over with.
But wait, you *could* also be suffering from leukemia. That’s a life-threatening condition. We’ll need to get an oncology consult for a stat bone marrow biopsy just to “rule out” that life threat.
You could also have been poisoned by some unknown chemical. We should probably draw a few dozen tubes of blood and send them to the Mayo Clinic to rule out every possible poisoning “life threat.” Been exposed to any strychnine lately? We’ll have to test for that before we’re “permitted” to discharge you. Looks like you’ll be in the emergency department for a while until the tests come back.
Oh, and you *could* be suffering from a Naegleria fowleri infection. That’s verylife-threatening and it doesn’t show up on CT scan. We’ll call the neurosurgeons for a stat brain biopsy as soon as the oncologists are done with you.

By this time, we’ve increased your risks of cancer from all the extra radiation, have increased the risk of a bad outcome from performing surgical procedures, have left a hole in your brain, and have caused you to incur tens of thousands of dollars in extra testing … and we haven’t even scraped the surface of all the “life-threatening conditions” that we¬†allegedly must rule out before we are “permitted” to discharge you.

According to plaintiff attorney Craig Yankwitt’s logic, we’d have to do this testing on every person who comes to the emergency department – even if it was for a hangnail – because we are “simply not permitted to discharge without ruling out whether [patients are] suffering from a life-threatening condition.”

When you wonder why physicians perform low yield testing and why defensive medicine abounds, think of plaintiff attorneys like Craig Yankwitt who perpetuate medically unjustified myths and who use hindsight bias as a means to become wealthy.

22 Responses to “More on Perfect Medicine”

  1. maribelchavez says:

    Well put – the only thing keeping people from understanding what you wrote is their greed or their need to blame someone even though reasonable care was given. The standards we sometimes hold the medical profession to are ridiculous. How do these attorneys sleep at night?

  2. Matt says:

    So you’re claiming that physicians perform low yield testing based on press releases from attorneys? And that press releases make them wealthy?

    Weird.

    “It is hard to comment specifically about the case without knowing more facts.”

    Should have stopped there. You don’t even have the entire contents of the email that’s driving you to do all these tests.

  3. Matt says:

    ” And the purpose of this calumny is to try to bolster the retrospective claim ”

    That doesn’t really make sense. An attorney’s email to a reporter will not be part of the evidence before the jury, and the jury is specifically instructed that the statements of the attorneys in court aren’t evidence. So how does it bolster the claim before the people who decide the validity of the claim?

    Love the word “calumny” though.

    • WhiteCoat says:

      Riiiiight.
      And a quote about an inappropriate medical standard published in a Stamford newspaper regarding a Stamford patient who died at a Stamford hospital which would be tried in Stamford courts would have no chance of tainting a Stamford jury pool. Silly me.
      The jury may be instructed not to consider statements outside court, but that doesn’t keep them from doing so. Now don’t think about the Cat in the Hat.
      If juries could randomly “disregard” any statements that a judge told them to disregard, there wouldn’t be much of a basis for mistrials, would there? The judge could just tell everyone to disregard evidence that shouldn’t have been heard.
      Got it, Sam-I-Am?

  4. Matt says:

    You really think a whole jury pool is going to be tainted based on one comment in one article which will likely not go to trial for at least another year? That the citizens of a city that size are all going to remember this little article, if they even read it? Wow.

    Better make sure that tinfoil hat is on tight – it’s windy today.

    • peter says:

      @Matt and the lawyer made this statement, not to help his case hevean forbid, but because……..um…….he liked the hot journalist?

  5. Griffin3 says:

    Whoa up, there. Dial back the level of … whatever.

    Matt: if the facts of the case were as stated: Patient goes in, complains of flank pain, is worked up for that, is discharged with pain of unknown origin. Comes back 9 days later with pulmonary embolism, and dies. Let’s take the facts presented in the article as gospel truth. Let’s also assume that the person has an clot, somewhere in their body, but not shown in the abdomen CT, that led to the pulmonary embolism.

    If that was the basic story: would you feel confident in taking this case to trial? What sort of story would you want to see to prove negligence, as the article asserts? What sort of facts, if they came to light, would make you think, whoa, this is not a case I can (should) win?

    Treat it like a case study. You guys seem to be already riled at each other from the language in these comments … but I think there is a basic schism in where you guys would draw the negligence line. And if we could pin it down, we could all get a little smarter.

    (honestly, my first thought on seeing this article, was, oo-whee, I wonder what matt has to say about this? Notoriety: its nearly as good a fame :-)

    • Matt says:

      I have no opinion on the facts of the case. As was noted, we lack the information (and I am certainly not qualified to opine on the medicine). I am remarking on the conclusion that the words of one attorney in one article drive testing or are able to taint a jury that hasn’t even been seated yet.

  6. Anonymous says:

    Show the CT scans to 2 other doctors chosen at random. If one of them sees a problem then the doc being sued is at fault and should pay up.

    Problem solved without needing a long ass rant.

    • D says:

      I don’t think you’re getting what he’s presented. There was no CT scan of the chest because it wasn’t appropriate. It wasn’t a misread study.

      And what a ridiculous standard. Medicine isn’t black and white and shouldn’t be treated as such.

  7. Marilyn says:

    If medicine were perfect my brother might not be paralyzed now.

    Went to ER, feeling strong malaise, a little weakness in limbs, slight temperature elevation (just 100 I think). Cough, but not incredibly productive. Hx includes heart attack and very mild (fully recovered) stroke, Type II diabetes.

    Sent home.

    Two days later, back in ER with more weakness, slight fever. While in ER, develops atrial fibrillation, collapses on floor.

    Final diagnosis? Pneumonia and septic shock. Neuro thinks AF threw clot that went to spine and, coupled with lack of perfusion from precipitous drop in blood pressure, damaged nerves. Now has axon demyelination.

    Do I expect that with his mild symptoms they would ever have thought pneumonia or septicemia?

    No. It is what it is and sometimes people fall through the cracks. We don’t all present in classic, textbook fashion.

  8. CJL says:

    Don’t know if anyone has seen this, but it’s worth watching (and relevant).

    http://www.ted.com/talks/lang/en/brian_goldman_doctors_make_mistakes_can_we_talk_about_that.html

  9. Well, how many other emergency medicine physicians would have done the same thing. If someone presented with flank pain and no shortness of breath it may be easy to do a CT scan and if normal send the patient home. Obviously, it depends but let’s say their only symptom was flank pain. How many times have we all don that as emergency medicine physicians?

  10. Someone says:

    Possibly a dumb question, but is it possible that the patient developed his PE after the initial ER visit, and the flank pain was due to something else?

  11. SeaSpray says:

    Darned if you do and darned if you don’t.

    I think the physician would win if your argument were presented in court.

    Could you just imagine the cost for each patient and doses of unnecessary radiation? I hope the radiation scare is wrong tho. Oh and then you can be sued for that if they become ill in the future. It’s just not fair. If the workup protocols are followed and documented …then how can the doc be held accountable?

    And if the Obama care is here to stay …in time they wouldn’t allow added expense anyway. The government will be too busy trying to cut state-of-the-art equipment, treatments and medications, etc., to compensate for the added financial burden.

  12. Scott says:

    I’ve been an ER doc for over 25 yrs. I’ve had patients with “flank pain” that had both PE and kidney stone in the differential. I’ve missed my share of PE’s, appreciate the difficulty of making the diagnosis, and without the facts, I am in no way being critical of the poor guy who discharged this patient, but I have seen a PE mimic a stone. That is not to say every negative stone study deserves a CT of the chest…….

  13. Skippy says:

    If it is in the diffrenetial, then should be ruled out. PE’s can present with flank pain, if you were unaware of this, add it tou your roledex. I screen with D-Dimer in low risk cases. By the way, upper abdominal pain can also be a PE. Damn PE, proof that PE is lawyers best friend. Good luck all.

  14. Ben Rush MD says:

    I say that every patient in the ED receive a consult with a trial lawyer prior to discharge to learn the real diagnosis before his condition gets too far advanced to salvage.

  15. Defense says:

    The standard is “what would a reasonable physician do?” My opinion is that this is multi-factorial.

  16. [...] pulmonary embolisms in a Greenwich man who came in complaining of flank pain. [Connecticut Post] White Coat analyzes what it would mean for emergency departments to hold on to patients until any possible [...]

  17. Ron Miller says:

    Everything you say is accurate. But let’s not get too excited about an out-of-context quote. Maybe he just meant an implied “that a reasonable prudent doctor should have ruled out.”

Leave a Reply


3 × = six

Popular Authors

  • Greg Henry
  • Rick Bukata
  • Mark Plaster
  • Kevin Klauer
  • Jesse Pines
  • David Newman
  • Rich Levitan
  • Ghazala Sharieff
  • Nicholas Genes
  • Jeannette Wolfe
  • William Sullivan
  • Michael Silverman

Subscribe to EPM