Med Mal Case: Hospitalist, Ischemic Leg

[bbc586]

60-year-old woman presents to the ED, diagnosed with DKA.

Hospitalist service called for admission.

Patient develops severe leg pain, very slow workup and failure to correlate the exam with radiology findings.

Vascular surgery consulted several days later, way too late to save the leg.

Records, expert witness opinions at the link.

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[rokshana]

So why wasn’t the pain management mid level named? She saw the pt 13 hours before and didn’t do anything

 

[Crayola227]

Not terribly interesting. What a screw up.

OTOH, this sort of thing happens all the time with trainwreck patients that are quite sick, and the lady sounds like one, and her legs were chronic. I can see how this happened, which isn't me defending the care whatsoever.

 

[wamcp]

Not terribly interesting. What a screw up.

OTOH, this sort of thing happens all the time with trainwreck patients that are quite sick, and the lady sounds like one, and her legs were chronic. I can see how this happened, which isn't me defending the care whatsoever.

I can also see how this played out. Sick comorbid patients are always sick patients and it’s a major medicolegal trap to become jaded to their complaints. Take them seriously.

They come in for “just DKA” but say they have back pain? Do a full exam and be quick on the trigger for MRI spine if any red flags.

Subjective leg weakness that’s bilateral? Don’t brush it off as “general weakness from XXX illness”. Check reflexes and screen the history for GBS...assess for myelopathy..how rapidly progressive are the symptoms, can this be aortic dissection...etc etc.
All of these “cannot miss” differentials must be on the back of your mind.

This is also why I call or ask ER to call consult for things asap upon admission, as a nocturnist, rather than be that lazy type who writes “consult XXX in the morning” because you are still on the hook for any delayed care issue. If you miss something that consultant could catch it in the morning rather than waiting a full day for their set of eyes.

 

[chessknt]

So why wasn’t the pain management mid level named? She saw the pt 13 hours before and didn’t do anything

Why did this expert witness name the new medical team for failing to act as well when they did? What a hack.

 

[Chemist0157]

Leg complaints first documented 8/19 AM. Exam findings are concerning. At #19, now 8/20 AM, the note says an US is pending. When was it ordered? Does not say. It was done later that morning but no report until later that evening. Vascular consult was called 8/21 AM. A pain management consult later that morning by an APRN...? Vascular surgery consult done by a resident a couple of hours after consult called. CTA done at noon, reported at 1430. Vascular surgeon saw her at 1800. Surgery soon after that and eventual amputation.

It does just seem all slow. Seems like a failure to appreciate exam findings for a more critical situation. I hesitate to Monday morning quarterback, but it would not have been unreasonable to call vascular just based on clinical symptoms and exam, even if patient noted some of it was chronic. Vascular could have been called that evening after the US returned. The US seemed really slow. I have to wonder if they were not expecting an urgent condition at all.

Why is the hospitalist being listed? Just because? Not sure what else he could have done...saw patient in the morning and called vascular.

Should the vascular attending not also be in the lawsuit? I feel like if the resident was concerned about limb ischemia, a vascular attending should have seen the patient sooner. 7 hours or so went by between resident and attending.

I can empathize as I tend to have a lot of ESRD patients with peripheral vascular disease. We have a low threshold to work up and to consult vascular early. At the same time, most people are just hanging out and waiting for surgery. They are not having acute and progressive weakness, paresthesias, and skin changes.

Medical team seems pretty boned.

 

[Crayola227]

My guess for why even the people who seemingly weren't the most leg-draggy of all (no pun intended) got named, is because there isn't good evidence that any one of them went "Holy crap this lady's leg might be acutely dying, and I'm treating this as emergent NOW," and did a good job documenting that and then putting in orders accordingly. Someone needed to pull the fire alarm, and it doesn't look like anyone did. The vascular surgeon is the only one that provided SOC in this metric.

 

[chessknt]

My guess for why even the people who seemingly weren't the most leg-draggy of all (no pun intended) got named, is because there isn't good evidence that any one of them went "Holy crap this lady's leg might be acutely dying, and I'm treating this as emergent NOW," and did a good job documenting that and then putting in orders accordingly. Someone needed to pull the fire alarm, and it doesn't look like anyone did. The vascular surgeon is the only one that provided SOC in this metric.

That is nonsense responding several hours earlier after days of symptoms wont change the outcome/harm the patient suffered. I mean the surgeon didn't activate an OR and take her to it in under an hour so why not sue him too?

 

[Crayola227]

That is nonsense responding several hours earlier after days of symptoms wont change the outcome/harm the patient suffered. I mean the surgeon didn't activate an OR and take her to it in under an hour so why not sue him too?

I mean, I did wonder if they had done anything different if the outcome would have been different, but proving that isn't what's necessary for these med-mal cases. Deviating from SOC is enough. You don't have to prove that she might have kept the leg if they had acted sooner, and that ergo, she lost the leg because they dallied. The dallying followed by a bad outcome, and the deviance from SOC creating the question of fault is enough.

 

[chessknt]

I mean, I did wonder if they had done anything different if the outcome would have been different, but proving that isn't what's necessary for these med-mal cases. Deviating from SOC is enough. You don't have to prove that she might have kept the leg if they had acted sooner, and that ergo, she lost the leg because they dallied. The dallying followed by a bad outcome, and the deviance from SOC creating the question of fault is enough.

You have to prove harm as a result of that deviation in order to prove malpractice. If I was a witness I would not be able to say that responding at 2pm instead of 8am on the third day resulted in harm that was not already there. This is like getting signout at 8AM and discovering at 10AM that the troponin at 6AM yesterday was 1000 and nobody got an EKG then getting sued because you didnt see it at 8AM.

 

[GoBuckeyes913]

This is a common case of missed diagnosis.
Ischemic limb is a clinical diagnosis, only getting a radiology study to confirm location of the clot. The only thing to do here is to learn from mistakes and apply it moving forward. Unfortunate outcome for all.

 

[Crayola227]

You have to prove harm as a result of that deviation in order to prove malpractice. If I was a witness I would not be able to say that responding at 2pm instead of 8am on the third day resulted in harm that was not already there. This is like getting signout at 8AM and discovering at 10AM that the troponin at 6AM yesterday was 1000 and nobody got an EKG then getting sued because you didnt see it at 8AM.

My point is in this case good luck convincing a jury that her leg was a goner anyway. If they want to believe there was a chance and those terrible doctors deprived her of it by not taking her complaints seriously enough....

 

[chessknt]

My point is in this case good luck convincing a jury that her leg was a goner anyway. If they want to believe there was a chance and those terrible doctors deprived her of it by not taking her complaints seriously enough....

And my point is that the medical 'expert' who lumped the new medical team (the one that contacted vascular the first day on service after getting the study which clinched the diagnosis) in with the old should be ashamed of doing so since it was solely a maneuver to spread more blame around and increase the settlement which I am sure was encouraged by the plaintiff's attorney.

 

[Lexdiamondz]

I can also see how this played out. Sick comorbid patients are always sick patients and it’s a major medicolegal trap to become jaded to their complaints. Take them seriously.

They come in for “just DKA” but say they have back pain? Do a full exam and be quick on the trigger for MRI spine if any red flags.

Subjective leg weakness that’s bilateral? Don’t brush it off as “general weakness from XXX illness”. Check reflexes and screen the history for GBS...assess for myelopathy..how rapidly progressive are the symptoms, can this be aortic dissection...etc etc.
All of these “cannot miss” differentials must be on the back of your mind.

This is also why I call or ask ER to call consult for things asap upon admission, as a nocturnist, rather than be that lazy type who writes “consult XXX in the morning” because you are still on the hook for any delayed care issue. If you miss something that consultant could catch it in the morning rather than waiting a full day for their set of eyes.

However, this is where solid clinical skills and sound clinical judgement come into play. Not everything needs a stat consult in the middle of the night & outside of academia, waking up an attending to do a consult at 2am for something that could easily wait till 8am is a sure-fire way to get you canned depending on the service you've managed to tick off.

That is nonsense responding several hours earlier after days of symptoms wont change the outcome/harm the patient suffered. I mean the surgeon didn't activate an OR and take her to it in under an hour so why not sue him too?

Except the plaintiff's expert witness will argue just that - and there are days of documentation of leg pain with nothing done about it and a patient with an AKA. There's no good defence for this even if, medically speaking, they likely wouldnt have saved the leg sooner.

The more damning thing here though is the fact that they did get a diagnostic study suggesting ischaemia the day before and still didn't do anything. You can't plausibly deny knowning about a cold dying leg if you ordered a study yesterday that told you exactly that.

You have to prove harm as a result of that deviation in order to prove malpractice. If I was a witness I would not be able to say that responding at 2pm instead of 8am on the third day resulted in harm that was not already there. This is like getting signout at 8AM and discovering at 10AM that the troponin at 6AM yesterday was 1000 and nobody got an EKG then getting sued because you didnt see it at 8AM.

You may not be able to say that, perhaps, but an expert witness on retainer for the plaintiff's attorneys will likely say exactly that - and a jury will believe him/her.

 

[chessknt]

However, this is where solid clinical skills and sound clinical judgement come into play. Not everything needs a stat consult in the middle of the night & outside of academia, waking up an attending to do a consult at 2am for something that could easily wait till 8am is a sure-fire way to get you canned depending on the service you've managed to tick off.


Except the plaintiff's expert witness will argue just that - and there are days of documentation of leg pain with nothing done about it and a patient with an AKA. There's no good defence for this even if, medically speaking, they likely wouldnt have saved the leg sooner.

The more damning thing here though is the fact that they did get a diagnostic study suggesting ischaemia the day before and still didn't do anything. You can't plausibly deny knowning about a cold dying leg if you ordered a study yesterday that told you exactly that.



You may not be able to say that, perhaps, but an expert witness on retainer for the plaintiff's attorneys will likely say exactly that - and a jury will believe him/her.

Again my point is that the new hospitalist assumed care that day was named by the medical 'expert' as deviating from the standard of care when he/she did not. Just because a medical 'expert' says someone deviated from the standard of care does not make it so. Why are there no references that describe viability of 3 day dead limb compared to a 3 day +2 hour dead limb? As I reread the testimony the hospitalist consulted vascular surgery basically immediately after seeing the patient--how was the standard of care not followed in that case?

 

[DrMetal]

Again my point is that the new hospitalist assumed care that day was named by the medical 'expert' as deviating from the standard of care when he/she did not.

Just outta curiosity, is there any way to contest that? Can't you argue your were the new hospitalist that just picked up the patient, how could you be responsible for mistakes made 3 days before you came on service? This has always been my fear (picking up some train wreck, becoming implicated in some medical-legal mess). I guess it could happen to anyone. We pass around patients like hotcakes.

 

[wamcp]

Again my point is that the new hospitalist assumed care that day was named by the medical 'expert' as deviating from the standard of care when he/she did not. Just because a medical 'expert' says someone deviated from the standard of care does not make it so. Why are there no references that describe viability of 3 day dead limb compared to a 3 day +2 hour dead limb? As I reread the testimony the hospitalist consulted vascular surgery basically immediately after seeing the patient--how was the standard of care not followed in that case?

Day 1 admit: no patient report of leg pain. The attending and residents that day should be off the hook.

Day 2: new attending and new residents take over. Leg pain reported and exam was documented. NOTHING was done for this on day 2. This new attending is screwed.

Day 3: Ultrasound order finally placed. Result was reviewed. NOTHING further was done on day 3. The attending is STILL screwed.

Day 4: A third new attending takes over and two new residents. They order CTA and consult vascular after the imaging was done. They should be off the hook but I bet they will still get nailed by a sympathetic jury.

bascially the attending who took over on day 2 and stayed on service day 3 is 100% done, they have no real defense against their malpractice...the leg didn’t turn black until Day 4 so if vascular was consulted only 48 hours prior it would have been a potentially salvageable limb

 

[DrMetal]

Day 2: new attending and new residents take over. Leg pain reported and exam was documented. NOTHING was done for this on day 2. This new attending is screwed.
Day 3: Ultrasound order finally placed. Result was reviewed. NOTHING further was done on day 3. The attending is STILL screwed.

I don't think it's uncommon to wait a day (maybe half a day) to place the order for further imaging (yes, you could make the argument that US is very easy to get, non invasive etc). The problem is: we're in the era of 'cost-concious' or 'choosing wisely' medicine, which I happen to think is bullsht, for reasons like this case.

3 attendings in 4 days . . . that's just great. It's wonder stuff like this doesn't happen all of the time (probably does, it just doesn't manifest as a legal case).

 

[wamcp]

I don't think it's uncommon to wait a day (maybe half a day) to place the order for further imaging (yes, you could make the argument that US is very easy to get, non invasive etc). The problem is: we're in the era of 'cost-concious' or 'choosing wisely' medicine, which I happen to think is bullsht, for reasons like this case.

3 attendings in 4 days . . . that's just great. It's wonder stuff like this doesn't happen all of the time (probably does, it just doesn't manifest as a legal case).

Nah man I disagree completely.
You would wait a day on this?

“She developed 10/10 right leg pain with paresthesias in her toes. Her pain worsened throughout the day, she developed weakness, and the leg was cool to the touch.”

 

[DrMetal]

Nah man I disagree completely.
You would wait a day on this?

No no, I would've ordered the US/CTA on admission just by looking at her train-wreck a$$, irrespective of her endorsement of any pain. These patients are too far gone, I usually never trust the words coming out of their mouth (sometimes they maximize their symptoms, sometimes they minimize). Many of them are too sick to know their left hand from the right. I always try to get objective evidence, and yeah I do it for CYA, to avoid cases like this!

The problem is, especially in residencies over the past 10 years, we're teaching this culture of hesitancy (don't do anything, b/c then you might have to do something else). And we teach: don't just order things for CYA (when in fact, that's exactly what we do, all the time in medicine, in real life!). So let's just teach it.

 

[chessknt]

Nah man I disagree completely.
You would wait a day on this?

“She developed 10/10 right leg pain with paresthesias in her toes. Her pain worsened throughout the day, she developed weakness, and the leg was cool to the touch.”

This is all retrospective framing too. I can easily see this from another perspective:

Poorly controlled diabetic with chronic LE pain complains of LE pain, given pain meds and not called by RN again. Would you order a CTA or ultrasound for every patient with chronic leg pain who has leg pain? If you have 26 patients are you running to the bedside every time you hear 10/10 pain?

 

[DrMetal]

Poorly controlled diabetic with chronic LE pain complains of LE pain, given pain meds and not called by RN again. Would you order a CTA or ultrasound for every patient with chronic leg pain who has leg pain? If you have 26 patients are you running to the bedside every time you hear 10/10 pain?

I'd transfer her to the COVID wing, to let the virus turn the glorious wheels of evolution.

 

[wamcp]

This is all retrospective framing too. I can easily see this from another perspective:

Poorly controlled diabetic with chronic LE pain complains of LE pain, given pain meds and not called by RN again. Would you order a CTA or ultrasound for every patient with chronic leg pain who has leg pain? If you have 26 patients are you running to the bedside every time you hear 10/10 pain?

I mean, yes, I would. If I am too busy I would scan instead of running to the bedside though. Like I never ignore pt complaining of headaches- if i have no time to check it out i get a stat cth. I have caught intracranial bleeds, as rare as it is. You just can’t miss these things in this litigious society.

Another example I have had 20 yo DKA pt come in still complaining of abd pain that the nurse claims is increased, and I go reexamine them to find their exam has changed from admission, then get a stat ct scan and discover perforated appendicitis. If i ignored it and ordered dilaudid from afar, assuming it’s “just abd pain from dka” which is statistically the most likely scenario, the pt could have ended up as a trainwreck with septic shock and die or intraabd abscesses that need perpetual drains and potential lawsuit

 

[wamcp]

This is all retrospective framing too. I can easily see this from another perspective:

Poorly controlled diabetic with chronic LE pain complains of LE pain, given pain meds and not called by RN again. Would you order a CTA or ultrasound for every patient with chronic leg pain who has leg pain? If you have 26 patients are you running to the bedside every time you hear 10/10 pain?

Also, 26 patients, geez i would never be in a job with that kind of volume. Totally unsafe.

 

[Mad Jack]

I know a guy who lost his leg in a similar scenario- complaining of leg pain that they brushed off and it turned out he had a dissecting AAA that compromised his left leg, ended up with a fairly high AKA

 

[FunnyDocMan1234]

Wow lol I can't believe some people are defending the primary team and saying how "I see how it could have happened" or using this case a reason to scan every single patient. Literally on day of admission the patient told the team she had 10/10 pain with parasthesias, nurses told the doctors about a cool extremity with thready pulse, and she literally was found down on the ground because her leg was so weak she fell. In what world does vascular surgery not get involved until 2 days after this series of events? If this case is really a reason for you to scan everyone then you're a doctor who probably should be scanning everyone for their own safety smh...

 

[chessknt]

Wow lol I can't believe some people are defending the primary team and saying how "I see how it could have happened" or using this case a reason to scan every single patient. Literally on day of admission the patient told the team she had 10/10 pain with parasthesias, nurses told the doctors about a cool extremity with thready pulse, and she literally was found down on the ground because her leg was so weak she fell. In what world does vascular surgery not get involved until 2 days after this series of events? If this case is really a reason for you to scan everyone then you're a doctor who probably should be scanning everyone for their own safety smh...

Read a bit deeper--the primary team changed over 3x over 3 days and the third attending immediately involved vascular surgery after seeing the patient for the first time but still got named in the suit and a medical expert provided testimony that the third attending did not 'meet the standard of care' which is utter nonsense.

 

[Kaustikos]

Read a bit deeper--the primary team changed over 3x over 3 days and the third attending immediately involved vascular surgery after seeing the patient for the first time but still got named in the suit and a medical expert provided testimony that the third attending did not 'meet the standard of care' which is utter nonsense.

The third attending got screwed over because he's involved. Not necessarily his fault but it's what happened. Regardless, I wouldn't of hesitated to get the US and Vascular Surgery consult that morning. I'd actually rather call Vascular in the middle of the night for this than risk the leg going. Rather get yelled at by a fellow/attending from Vascular than risk the repercussions. BUT also, looking at the Calendar, this was on a weekend. She looks like a DKA presentation on a Friday evening/night. That explains the team changing/etc. I feel bad because the weekend is literally the best time for things like this to happen. Short-staffed - that US is not gonna get done that emergently, let alone the CTA - and residents/interns/attendings are covering or switching over. I'm not making excuses at all. In the end, the primary attending covering that weekend should've managed this better. The last attending got the dump and screwed over when they literally just walked into the mess.

 

[wamcp]

The third attending got screwed over because he's involved. Not necessarily his fault but it's what happened. Regardless, I wouldn't of hesitated to get the US and Vascular Surgery consult that morning. I'd actually rather call Vascular in the middle of the night for this than risk the leg going. Rather get yelled at by a fellow/attending from Vascular than risk the repercussions. BUT also, looking at the Calendar, this was on a weekend. She looks like a DKA presentation on a Friday evening/night. That explains the team changing/etc. I feel bad because the weekend is literally the best time for things like this to happen. Short-staffed - that US is not gonna get done that emergently, let alone the CTA - and residents/interns/attendings are covering or switching over. I'm not making excuses at all. In the end, the primary attending covering that weekend should've managed this better. The last attending got the dump and screwed over when they literally just walked into the mess.

I was an academic day hospitalist for a year right after finishing residency. There were some weekends that I was covering 3 resident teams, so like 50-60 patients that I'd be responsible for. And so I can definitely see how that situation could have happened even under my own watch with such high census. I agree with you that no excuses can be made - you must be thorough with every patient, especially the chronically ill, comorbid folks. The Day 2 attending in this med mal case should have been careful, even if they had a bajillion weekend patients to cover. They should have put in the work, do their own full assessment, and stay late for the patients' sake if necessary, or find another job if they can't handle it (which is what I personally did, never will I return to academics).

This is real life. Bad preventable outcomes absolutely can happen. Statistically, the 'cannot miss' bad stuff is more likely to happen to the sick population and we must never get jaded to that. Take patient complaints seriously.

 

[DrMetal]

This is all retrospective framing too. I can easily see this from another perspective:

Would you order a CTA or ultrasound for every patient with chronic leg pain who has leg pain?

Yeah, why not? At least the ultrasound first. Waste of resources? IDGAF. I'm not 'choosing wisely'? Also IDGAF. It's CYA medicine, and it's how we do things in 2020. Let's just admit it, and let's teach it!

What always surprises me is how much we perseverate and hesitate over getting non-invasive studies. It's a frickin ultrasound, I'm not suggesting we take her to the OR right this second for angiography.

Oh btw, nobody trusts the physical exam any more in medicine. You can't justify your lack of action/inaction, basesd on an 'abnormal/normal' physical exam. You're still getting sued.

Get your labs/rads.

 

[Redpancreas]

Couple points here.

1.) With something like DKA, residents and staff alike can let their guard down and be monotonous with the whole 1.) Treat DKA 2.) Consult DM educators 3.) Discharge. Felt that was a major reason for this missed case.

2. "The next day (August 19), she developed 10/10 right leg pain with paresthesias in her toes. Her pain worsened throughout the day, she developed weakness, and the leg was cool to the touch" -> Highly doubt this is what was documented. I am 90% sure the intern's note read "consult DM teaching, consider DC tomorrow". If
unilateral leg pain, parathesias, weakness, cool leg were brought to the team's attention, even the medical student knows who to call."

3.) Hep gtt should have been started in case of ALI on the 19th. There were likely no contraindications based on medical history. Start the Heparin gtt, call VS, ask them whatever imaging they want. I don't know why the IM team was messing around with ultrasounds and PAD. This becomes crazier when they're actually documenting cardinal signs of ALI in their note on the 20th. Some would have set up an OR slot right away with that US, others will want the CTA-run-off, etc. The whole imaging interpretation is outside IM's scope. Senior resident didn't have an idea of what they were doing, attending should have stepped in. Of course Vascular shouldn't have been sued. They acted the moment they saw the patient and were careful to document this was brought to our attn on the 21st.

 

[Redpancreas]

Wow lol I can't believe some people are defending the primary team and saying how "I see how it could have happened" or using this case a reason to scan every single patient. Literally on day of admission the patient told the team she had 10/10 pain with parasthesias, nurses told the doctors about a cool extremity with thready pulse, and she literally was found down on the ground because her leg was so weak she fell. In what world does vascular surgery not get involved until 2 days after this series of events? If this case is really a reason for you to scan everyone then you're a doctor who probably should be scanning everyone for their own safety smh...

Exactly, this was not chronic. The nurse told you about a pulseless extremity. This isn't a medical student who is doing a comprehensive, mostly irrelevant head-to-toe exam and reports that to you. This is a nurse who probably carries 3-4 patients and does pulse exams on every patient daily. He or she knows what's normal vs not-normal and likely had time to confirm that finding with another nurse before he/she called the scary doctor. That's an immediate indication to stop what you're doing, get the US, check the limb yourself, and if you can't find it you start heparin gtt and call vascular. Then a general surgery resident rotating on vascular will come up within an hour from the OR to make sure this is worth the chief's time and do the doppler exam him or herself. They will confirm potential ALI and will let their chief know. The chief will add the case to their list and text the case to the attending and they will page primary with what imaging they want (CTA). There wasn't even an AKI to slow down the CTA either. This should have been done on the 19th.

 

[cbrons]

Oh btw, nobody trusts the physical exam any more in medicine. You can't justify your lack of action/inaction, basesd on an 'abnormal/normal' physical exam. You're still getting sued.

These chronically sick obese gomers complain of any kind of localized pain they get a scan. I don't want to hear any non-sense about my "physical exam findings" when we're talking about a minimally cogitating 350-lb bag of sloppy protoplasm.

 

[end stage fibro]

What always surprises me is how much we perseverate and hesitate over getting non-invasive studies. It's a frickin ultrasound, I'm not suggesting we take her to the OR right this second for angiography.

Oh btw, nobody trusts the physical exam any more in medicine. You can't justify your lack of action/inaction, basesd on an 'abnormal/normal' physical exam. You're still getting sued.

Get your labs/rads.

These chronically sick obese gomers complain of any kind of localized pain they get a scan. I don't want to hear any non-sense about my "physical exam findings" when we're talking about a minimally cogitating 350-lb bag of sloppy protoplasm.

this cannot be emphasized enough. these patients are on a knife’s edge in terms of their physiology and that knife is ready to cut you. nobody wins prizes for tests they didn’t order. utilization review not gonna come to your aid in court.

 

[chessknt]

I wish news outlets would read this thread before the publish more hit pieces on medical costs and overtesting. This thread is like a primer on what is wrong in medical malpractice in this country.

 

[FunnyDocMan1234]

lol have you read the case? The majority of 3rd year medical students would have not managed to mess this up as badly as the teams did.

 

[chessknt]

lol have you read the case? The majority of 3rd year medical students would have not managed to mess this up as badly as the teams did.

Did you read my earlier posts? Everyone who touched the case got sued (except the surgeon) even the doctor who took over and immediately recognized a problem and lead to the patient getting treated got sued. The medical 'expert' even points a finger at the person who was responsible for the patient on the order of hours before she was diagnosed as not meeting the 'standard of care.'

 

[DrMetal]

Everyone who touched the case got sued (except the surgeon) even the doctor who took over and immediately recognized a problem and lead to the patient getting treated got sued.

It is possible to get 'unnamed' in a lawsuit? For instance, can the above physician make the case that he wasn't at fault (he caught the mistake and corrected it) . . . .or it just a lost cause?

 

[chessknt]

It is possible to get 'unnamed' in a lawsuit? For instance, can the above physician make the case that he wasn't at fault (he caught the mistake and corrected it) . . . .or it just a lost cause?

My understanding is that you can. This happens commonly with residents when the defense argues that the trainers should.not be held independently responsible and should be removed from the suit. I have no idea how often that works.

 

[wamcp]

It is possible to get 'unnamed' in a lawsuit? For instance, can the above physician make the case that he wasn't at fault (he caught the mistake and corrected it) . . . .or it just a lost cause?

You can but from what i have heard it is still on your “record” and still needs to be explained if you change jobs, and sometimes you pay out of pocket to get yourself dropped from the suit

 

[DrMetal]

You can but from what i have heard it is still on your “record” and still needs to be explained if you change jobs, and sometimes you pay out of pocket to get yourself dropped from the suit

It's pretty nuts to think that you could be named for rounding on a patient for even just a day (cross cover, for instance) . . .even if you're the good doctor who caught and corrected the mistake. I wonder if you can counter-sue the lawyers for defamation (or if the threat of such a suit would get them to remove you).

What a stupid profession we're in. No frickin common sense.

 

[turkeyjerky]

You can but from what i have heard it is still on your “record” and still needs to be explained if you change jobs, and sometimes you pay out of pocket to get yourself dropped from the suit

You shouldn't have to pay out of pocket, defense costs come from your malpractice insurance. It is definitely still on your record though and needs to be reported on all hospital applications and such.

 

[wamcp]

You shouldn't have to pay out of pocket, defense costs come from your malpractice insurance. It is definitely still on your record though and needs to be reported on all hospital applications and such.

One hospitalist’s name was listed as attending of record on day of admission but never saw the patient or knew pt existed. Pt sued. He was named along with all other doctors in the EMR that seemed to involve the pt. Our hospital system’s legal team wouldn’t try to get him dropped from the suit immediately and would let the case progress further- not sure the particulars but apparently it had to do with saving money (less hours billed). He had to hire his own attorney out of pocket to convince the pt’s legal team to get him dropped

 

[turkeyjerky]

One hospitalist’s name was listed as attending of record on day of admission but never saw the patient or knew pt existed. Pt sued. He was named along with all other doctors in the EMR that seemed to involve the pt. Our hospital system’s legal team wouldn’t try to get him dropped from the suit immediately and would let the case progress further- not sure the particulars but apparently it had to do with saving money (less hours billed). He had to hire his own attorney out of pocket to convince the pt’s legal team to get him dropped

Interesting. My guess is that he would've been dropped eventually regardless. But definitely need to advocate for yourself and make sure your attorney is representing your interests.

 

[tantacles]

You can but from what i have heard it is still on your “record” and still needs to be explained if you change jobs, and sometimes you pay out of pocket to get yourself dropped from the suit

Nah, it's not on your record. This happened to me as a resident when I was in the CICU. A patient who was transferred from an outside hospital to the floor coded and I responded to the code. The patient later died (my best guess was that she had an undiagnosed PE), and I was initially named in the lawsuit. Reported immediately to my legal department. Was later unnamed in the suit. Never showed up anywhere because I am not party in the suit.

 

[90sportsfan]

Nah, it's not on your record. This happened to me as a resident when I was in the CICU. A patient who was transferred from an outside hospital to the floor coded and I responded to the code. The patient later died (my best guess was that she had an undiagnosed PE), and I was initially named in the lawsuit. Reported immediately to my legal department. Was later unnamed in the suit. Never showed up anywhere because I am not party in the suit.

I have to admit, as a medical student this is pretty daunting to hear. I can imagine that as a resident a situation like what you described in the ICU is pretty common to encounter, as are patients as described in the malpractice case in the original post.

Can Residents/Attendings comment on how common it is for Internal Medicine residents to be named on lawsuits (which is different from being sued). It was my understanding that residents being named on lawsuits was pretty rare, although in reading these posts, I must admit, it is a little nerve-wracking because it seems like it could be very common.

Is being initially named on a lawsuit something that can be expected over the course of an Internal Medicine residency or is it rare? I ask because I know deaths and bad outcomes will happen.

 

[Clean7795]

There are a lot of misconceptions in this thread. Acute ischemic limb is a clinical diagnosis. The fact that ultrasound was ordered & waited on is already a major delay in care. This is the equivalent of having an exertional chest pain patient + elevated troponin + ischemic ECG changes but waiting a few days for a coronary CTA and cardiac MR before thinking to call cardiology.

This med mal case does not encourage over investigating, rather it is a prime example of a modern physician lacking the clinical skills to diagnose "do not miss" diagnoses because they've gotten too used to radiology and subspecialists do the heavy lifting for them. Vascular should have been immediately consulted in a case where there are pulseless, cold legs.

 

[ReviewOfSystems]

There are a lot of misconceptions in this thread. Acute ischemic limb is a clinical diagnosis. The fact that ultrasound was ordered & waited on is already a major delay in care. This is the equivalent of having an exertional chest pain patient + elevated troponin + ischemic ECG changes but waiting a few days for a coronary CTA and cardiac MR before thinking to call cardiology.

This med mal case does not encourage over investigating, rather it is a prime example of a modern physician lacking the clinical skills to diagnose "do not miss" diagnoses because they've gotten too used to radiology and subspecialists do the heavy lifting for them. Vascular should have been immediately consulted in a case where there are pulseless, cold legs.

I actually disagree with this. You can have a high clinical suspicion for ischemic limb on exam, yes, and I suppose even diagnose it on exam w/ ABI/auscultation, but practically speaking you need imaging to confirm and to determine where the problem is objectively and anatomically. Vascular (at least where I work) will not take the patient anywhere without imaging, and to me this makes sense; I would think they need to see the imaging to determine the procedural plan of action. In your cardiac example, the abnormal trop and EKG are objective and sufficient measures of an MI, so of course no other testing is needed to get cardiology on board. You should be able to get a STAT arterial ultrasound or CTA and hound the radiologist to read it in order to get the results in < 1hr. Usually, that time is not going to make or break the limb, but if you want an abundance of precaution or your STAT imaging is not so STAT, you can call ahead to vascular to inform them of the consult and to let them know STAT imaging is pending.

 

[Crayola227]

I think where they are correct is that they should have consulted vascular in addition to ordering the imaging, and to state they were concerned about acute ischemic limb.

 

[Clean7795]

I actually disagree with this. You can have a high clinical suspicion for ischemic limb on exam, yes, and I suppose even diagnose it on exam w/ ABI/auscultation, but practically speaking you need imaging to confirm and to determine where the problem is objectively and anatomically. Vascular (at least where I work) will not take the patient anywhere without imaging, and to me this makes sense; I would think they need to see the imaging to determine the procedural plan of action. In your cardiac example, the abnormal trop and EKG are objective and sufficient measures of an MI, so of course no other testing is needed to get cardiology on board. You should be able to get a STAT arterial ultrasound or CTA and hound the radiologist to read it in order to get the results in < 1hr. Usually, that time is not going to make or break the limb, but if you want an abundance of precaution or your STAT imaging is not so STAT, you can call ahead to vascular to inform them of the consult and to let them know STAT imaging is pending.

CTA is for treatment planning. 95%+ of acute CLI diagnoses can be made purely on clinical examination alone and in fact often the clinical exam is often superior to the CTA (for acute CLI) due to artifact from severe atherosclerotic disease making the diagnosis on imaging alone unclear.

You are also correct in that vascular surgery absolutely should not take to OR without imaging because they need imaging for treatment planning. But vascular must be consulted as soon as the diagnosis of "pulseless cold leg" is made because either they must come see the patient (in cases where they don't trust your physical exam or if it's a complex case), or CTA must be ordered immediately for treatment planning while they prepare the OR.

Ultrasound does not fit anywhere in that decision-making tree and because it does not add to patient care.