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Tag Archives: Medical-Legal

Anna Brown And Appropriate Emergency Medical Care

I’m surprised that this case hasn’t gotten more press. A patient named Anna Brown was unhappy with the care she received at several hospital emergency departments. When she was discharged from the last emergency department, she refused to leave. Police were called and the patient was carried to a police car. She said that she couldn’t walk. Police took her to jail, carried her into the cell and left her laying on the floor. About an hour later, she was still laying there … dead. From the public’s point of view, the case appears outrageous. But as I read through the description of what happened and thought about what could have been done different, from a physician’s point of view, I’m not sure what else could have been done. Christine Byers wrote an excellent article describing events that took place, and then wrote a follow up article in which the hospital defended its care. I’m hoping that the St. Louis Post-Dispatch commends her for her work. She did a great job with the stories. Background A summary taken from Ms. Byers’ article shows that Anna Brown was admitted to the hospital for spraining her ankle while walking near a ditch. EKGs, blood tests, and lab work were performed. Ms. Brown was in the hospital from Sept 13 to Sept 15 and then discharged. She walked on crutches after her discharge.

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Joanne Doroshow At It Again

Why does the Huffington Post allow Joanne Doroshow to keep posting misinformation? For those of you who didn’t know, Ms. Doroshow is an attorney who is the executive director for New York Law School’s Center for Justice and Democracy. Attorney Doroshow’s latest blog post on HuffPo alleges that medical malpractice caps are an “attack on women” and therefore any Republican who votes for medical malpractice caps is risks alienating himself (or herself) from half of all the voters in the United States. Yeah. Half of Attorney Doroshow’s post cites opinions from others that the Republican party is engaging in “mass misogyny.” When she finally tries to justify her kindergarten logic, Attorney Doroshow quotes University of Buffalo law professor Lucinda Finley, stating that “[C]ertain injuries that happen primarily to women are compensated predominantly or almost exclusively through non-economic loss damages. These injuries include sexual or reproductive harm, pregnancy loss, and sexual assault injuries.” Let’s look at the legal arguments that Attorney Doroshow has adopted. Sexual or reproductive harm happens primarily to women. Is Attorney Doroshow attempting to argue that there are so many fewer lawsuits relating to testicular/prostate cancer, male urologic injuries, testicular torsion, and hernia-related injuries such that malpractice caps would be de facto misogynistic? I notice a deafening lack of statistics to support her assertions. Professor Finley’s article didn’t address the issue, either, but Professor Finley’s article wasn’t limited to medical malpractice caps — it discussed general caps on noneconomic damages. Pregnancy loss happens primarily to women. True. Women are the ones who get pregnant. But is Attorney Doroshow attempting to argue that only one parent is allowed to file a lawsuit on behalf of the child when there is a pregnancy-related loss? As an attorney, what is her legal basis for such a claim? How are malpractice caps on a “pregnancy loss” lawsuit discriminatory toward women? Sexual assault injuries happen primarily to women and are compensated predominantly or almost exclusively through non-economic loss damages. I agree that sexual assault injuries primarily happen to women. However, sexual assault injuries have little to do with medical malpractice caps. Sexual assault is a criminal issue. Often, victims of crimes receive compensation from a Crime Victims Compensation Fund. Caps on medical malpractice have nothing to do with sexual assault injuries – unless the physician is the one assaulting the patient. And even if a physician did sexually assault a patient, the litigation wouldn’t be a “medical malpractice” issue subject to malpractice caps, it would be a civil tort issue where malpractice caps do not apply. As further justification for how noneconomic medical malpractice damage caps are discriminatory toward women, Ms. Doroshow again cites Professor Finley, stating “[J]uries consistently award women more in noneconomic loss damages than men … [A]ny cap on noneconomic loss damages will deprive women of a much greater proportion and amount of a jury award than men.” There is no comment from Attorney Doroshow on why it is acceptable for juries to discriminate against men in awarding noneconomic damages. However, if legislatures take some action that would potentially neutralize the “discrimination,” Attorney Dorshow alleges the action would constitutes a sleight so severe to the female gender as to amount to instant political suicide. That is simple pig pen effluent. I agree that $250,000 caps on noneconomic damages are not fair to patients. I also think that we need to find some middle ground where patients can be fairly compensated for their injuries but where medical providers are not subject to bankruptcy from “super losses“. Joanne Doroshow’s attempts to scare people into opposing H.R. 5 through a campaign of misinformation is ...

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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 ...

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Demanding Perfection?

Want more evidence about how many people expect perfect outcomes in medical practice? Look no further than the Wall Street Journal: “What if the Doctor is Wrong?” by Laura Landro. As a substantive basis for the conclusion that initial treating physicians are “wrong” when they haven’t yet reached a diagnosis, Ms. Landro interviewed two patients who, in the midst of a workup, left the doctor who was trying to diagnose and treat their problems. Said patients then went to a “mecca” to have their workup completed where … amazingly … the problem is “discovered” and “properly” treated. Even though the initial provider in all likelihood would have done the same testing that the “mecca” performed after reviewing the results of the initial testing – had the patient stuck around long enough to have the testing performed. Even though the “standard of care” may have been to do things exactly the way that the initial provider was doing them. Nope, they’re wrong because they didn’t get to the answer sooner. When reading about all these “errors” I couldn’t help wondering: Did Ms. Landro have a neutral physician review the patients’ medical records to see whether the care provided to the patients was appropriate? Did Ms. Landro interview the initial treating physicians to determine what the next step in their treatment plans would have been? If so, she kind of left those points out of her article. I understand the idea that second opinions can be useful and I agree that misdiagnoses are sometimes made. Until we find a single test that is 100% sensitive and 100% specific for diseases such as cancer or complaints such as abdominal pain, there will always be misdiagnoses made. Even once a diagnosis has been made, there are disagreements about how to proceed with treatment. Some prefer one medication for treating certain types of cancer, some prefer another medication. Does that make one side “wrong” and the other side “right”? Hardly. The title of this article and the slant of this reporting make it appear as if doctors are “wrong” just because they don’t make a diagnosis after the first round of testing. Did Ms. Landro even explore how often the “meccas” get their diagnosis “wrong” on the first visit? Are the “meccas” that much better? If patients want to mortgage their house to get the tens or hundreds of thousands of dollars necessary for a “down payment” at MD Anderson (original link to WSJ article here) or some other “mecca” when they likely would have gotten similar testing done had they stuck with their initial providers, that’s free market medicine at work. When journalists imply that excluding diseases on a list of differential diagnoses in the midst of a workup or coming up with “inconclusive” results during testing is “wrong”, shouldn’t we start looking into journalistic malpractice? What if the Journalist is Wrong?

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Worst States For Medical Malpractice Risk

I just read an article in American Medical News about medical malpractice insurance costs. Included in the article was a small graphic about how much internists pay for medical malpractice insurance. Internists in Dade County, Florida paid medical malpractice insurance premiums that were 1400% higher than internists in the state of Minnesota. Illinois internists in Chicago paid more than 12 times as much in malpractice insurance premiums as their Minnesota counterparts. In other words, internists in select Florida and Illinois counties pay more for malpractice insurance in one month than internists in the state of Minnesota pay for an entire year. There are similar premium disparities for general surgeons and obstetricians, with Long Island, NY and Las Vegas NV also consistently being on the list for high malpractice premiums Does that mean that the Florida and Illinois physicians were 1200% to 1400% more negligent than doctors in Minnesota? Doubtful. It just means that Miami, FL; Chicago, IL; Las Vegas, NV; and Long Island, NY are places where insurance companies have determined that it is much more risky to practice medicine. When doctors search for the best states in which to practice medicine, they should consider the medical malpractice environment when making that decision. Given these statistics, doctors should not practice in Miami, Chicago, Las Vegas, or Long Island if they want to reduce their medical malpractice risk. Yet Florida lawmakers reach out to news stations and claim that the state “desperately needs more doctors.” Suing your way to better health care doesn’t work very well, does it, Senator Nelson?

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Healthcare Update — 10-03-2011

More medical news from around the web at the Satellite Edition of this week’s update on ER Stories … Australian emergency physician punches and slaps restrained patient who spat in his face. He was terminated from his position. A court held that the termination was unfair. Australian doctors considered going on strike after learning how the doctor was treated after the incident. When you read the comments section of articles describing patients who assault emergency department staff, many people seem to think that staff should accept abusive behavior due as being “part of the job.” Shouldn’t patients therefore accept abusive behavior from medical staff as being “part of the visit”? A view of medical malpractice reform misconceptions from physician-attorney William Sage. I disagree with several of his premises. For example, one question Dr. Sage asks “How likely is it, really, that ‘sinister forces’ outside [of medicine] are the reason why tens of millions of Americans lack access to services, or why even those who can afford it often get mediocre care at inflated prices?” Ask physicians who don’t provide care to patients with certain government insurance plans and who stop taking emergency call or stop performing certain procedures (such as brain neurosurgery) due to liability concerns. Ask doctors who won’t or can’t prescribe medications that are safe through billions of prescriptions because the FDA issues a black box warning that the drugs might have caused adverse reaction in one millionth of a percent of the people receiving them. Then ask patients who can’t afford to purchase certain drugs such as albuterol, colchicine, or (soon to be) Primatene Mist because drug companies jacked up their prices based upon a governmental technicality in approving the medications. Nah. No “sinister forces” here. Recent Massachusetts Medical Society survey shows many interesting findings. Specialties in critical short supply included internal medicine, urology and psychiatry. Primary care specialties had severe shortages for 6 straight years. More than half of physicians would be unwilling to participate voluntarily in either global payment programs or accountable care organizations. Oh – and “the fear of being sued continues to be a substantial negative influence on the practice of medicine, affecting access to and availability of physician services.” Nah. No “sinister forces” here, either. Another timely rebuttal to some assertions in Dr. Sage’s article. Study in Archives of Internal Medicine shows that 42% of physicians believe that their patients are receiving too much care. Guess what factor contributed to more aggressive care in 76% of cases. Click this link to find out. Hint: “Sinister force” alert. CMS coming out with bundled payment plans for 2012. Look for the pendulum of clinical care and testing to swing the other way. And look for more people to accuse “greedy doctors and hospitals” of limiting care in order to make more money when, in reality, the government is limiting care through underpayments to providers. Another reason that getting a ZeePack for your cough might not be a good idea (aside from the fact that it won’t work) … it might cause you to get Crohns disease or ulcerative colitis. Twelve percent of patients diagnosed with Crohns or UC had been prescribed three or more doses of antibiotics in the two years prior to their diagnosis. Only 7% of patients who had developed Crohns or UC had not been prescribed antibiotics. In other words, people prescribed frequent antibiotics were up to 50 percent more likely to get Crohn’s disease or ulcerative colitis within next two to five years. My guess is that they were more likely to get MRSA and C. difficile as well. Study abstract ...

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