Yet another reason to stay away from Florida if you are a physician. The inspectors and health care agencies down there leave quite a bit to be desired.

The Florida Agency for Healthcare Administration cited an emergency department’s staff for failing to give “adequate care” to 13 week pregnant patient before she had miscarriage of twins.

The timeline of events for the patient was outlined in this article.

At 9:45 a.m. the patient came to the emergency department with pelvic pain and vaginal bleeding.
At 10:30 a.m., the patient was diagnosed with pain and bleeding, a urinalysis and a battery of blood tests ordered, but there was no test ordered that would have revealed her glucose level. There was also no discussion of whether to discontinue or maintain the patient’s insulin pump. Ultrasound tests were ordered, then changed, which “caused a delay.”
At 11:45 a.m., the patient was bleeding heavily and was “in obvious labor” according to state inspectors. The ultrasound scan showed both fetuses had normal heart rates. The state inspectors stated that the emergency physician “failed to initiate any immediate response to the ultrasound report, the patient’s continued labor pains and the profuse bleeding.”
At 12:25 p.m., the physician performed a pelvic exam and suctioned some large blood clots from the vaginal canal. The patient then “spontaneously aborted one of the fetuses.” Inspectors noted that the patient was not informed of any risks of performing a pelvic exam, nor did she give informed consent for the pelvic exam.
A second ultrasound was ordered.
By 2 p.m., the second ultrasound showed a normal heartbeat in the remaining fetus. At that point “the doctor took no steps to stop labor or maintain the second pregnancy.” Additionally, the emergency physician’s report showed that the second fetus had no heartbeat, which conflicted with the radiologist’s report.
At 4 p.m., the patient’s blood-sugar level was measured and found to be “critically low.” She then received orange juice and IV dextrose.
At 5:30 p.m., an obstetrician arrived and performed a pelvic exam. He ordered no additional procedures or medications.
At 6:15 p.m., the woman passed the second fetus.

The inspectors stated that the physician failed to monitor blood sugar levels, failed to respond to the patient’s bleeding and pain, and failed to intervene to stop her labor.

In eight of ten other cases that inspectors reviewed, the hospital was cited for failing to document the amount of the patient’s blood loss, failing to record vital signs, and failing to record other case information.

We need more information about the other cases, but even without extra information, I’m still calling out the inspector and the Florida Agency for Healthcare Administration. Many of these citations are uninformed and inappropriate.

#1 No discussion documented about whether to continue or discontinue the patient’s insulin pump.
Such discussions are rarely held in the emergency department. Should the patient’s blood glucose have been checked sooner? Probably. However, if a patient is not having symptoms suggestive of low blood glucose, how often should the glucose level be checked — especially with an unrelated complaint? Should hospitals be cited when glucose levels aren’t checked in a diabetic patient with an ankle sprain or laceration?

#2 The emergency physician “failed to initiate any immediate response to the ultrasound report, the patient’s continued labor pains and the profuse bleeding.”
How much bleeding was there? What were the patient’s vital signs? Notice how the report is vague about the findings? Also notice how the report doesn’t state what the emergency physician should have done, and only made vague accusations about what the emergency physician didn’t do? Expert testimony like this in court would be tossed. In state investigations, it is apparently normal procedure. The treatment of bleeding during a miscarriage is generally either letting the fetus pass or performing a D and C.

#3 The patient was not informed of the risks and benefits of performing the pelvic exam and did not give informed consent.
This citation is so far out in left field, that it makes me wonder whether the inspector knows anything about medicine. It also puts the emergency physician in a no-win situation. Let’s say that the patient doesn’t consent to a pelvic exam – even though she’s having vaginal bleeding. Then the physician would have been cited for failing to do the pelvic exam.
But the physician didn’t discuss the risks and benefits of pelvic exams? OK, oh wise state inspector … what are the risks and benefits that the physician egregiously failed to discuss? Again, you and your department allege error, but then fail to provide all of us other dangerous physicians with the proper procedures to use.
Then there was no consent on the chart. The concept of “implied consent” is well established. If a patient with a gyne problem is told that the physician wants to perform a gyne exam and she gets up in the stirrups, chances are pretty good that she has consented to the exam. But, oh wise state inspector … what procedures require consent and do not require consent? Educate all of us dangerous practitioners. While you’re at it, give us some shred of written documentation that supports your assertions.

#4 After the patient passed one fetus, “the doctor took no steps to stop labor or maintain the second pregnancy.” This has to be the nadir of medical misinformation. Most pre-med college students know that a fetus is not viable until roughly 24 weeks of gestation. If a woman is having labor with a gestation less than 20 weeks, it is called a miscarriage. There is no treatment to save the pregnancy. A 13 week fetus is never, and will never be, viable outside of the uterus — unless the patient is a lion or some other member of the animal kingdom with a short gestation.
So, oh wise state inspector, exactly how should medical personnel “intervene” to stop the labor of a patient who is 13 weeks pregnant? You’ve accused the medical staff of doing something wrong, what should they have done different?

To illustrate the problems in lay terms, imagine being arrested for failing to drive the correct speed. You aren’t told what the correct speed is, you just have to pay a fine because you weren’t driving the correct speed. You have to apologize and promise to drive the correct speed in the future in order to keep your driver’s license.
Or imagine that you were arrested for failing to properly raise your child. No allegation as to what you should have done different, only the assertion that what you are doing is wrong.
These are they types of allegations that the inspector is making against the medical staff in many of these instances.

I hope that everyone realizes the significant effect that “investigations” such as this have on the access to medical care in the communities.

Doctors are publicly accused of inappropriate medical care.
The public trusts that the publicized accusations are accurate … when they may not be accurate.
Public perception that medical care at a hospital or by a caregiver is “bad” then increases.
Hospitals then increase expenditures to correct the publicized “bad” care and to comply with inane and unsubstantiated governmental citations.
Fewer funds are then available to provide medical care.
More doctors leave the state or leave medicine entirely because they’re sick of the administrative burdens.
More hospitals close.
Less care is available.
Safety is paradoxically worsened because fewer providers are available to manage patients.

Oh and throw in some unjustified lawsuits as well. You know that if a governmental agency states that doctors “didn’t do anything” to stop a patient’s 13 week old miscarriage, however uneducated and inappropriate the statement may be, the patient is going to believe that she was wronged and will find a malpractice attorney to file a suit against the physician.

Don’t take this post as me advocating for less oversight of medical practice in the states. I fully believe that there needs to be oversight of medical care and that dangerous physicians need to either improve or have action taken against their licenses. Investigations need to be based in sound medical practice, though.

The issue I have here is that the investigator in this case made multiple vague unsubstantiated and medically inappropriate opinions about several providers’ care and those opinions were taken as fact when instead they should have been recognized largely as calumny. Based on the investigator’s calumny, the hospital was cited and the medical practitioners were publicly chastised. I’d bet that there was action taken against the providers at work as well.

By the way, if someone can get me a copy of this inspector’s actual report, I’d love to post it for further discussion.

Yep, between the “three strikes” rule, the criminalization of medicine, the high medical malpractice premiums, and the quality of the state inspections, doctors would be plum crazy to practice medicine in Florida right now.

Sorry, Senator Bill Nelson, things like this are going to drive doctors away from a state that “desperately needs more doctors.” Have fun rearranging the deck chairs on your Titanic, though.