Episode I: The Phantom Menace
John Beuerle, M.D., M.S.Department of Emergency Medicine
University of Maryland Medical Center
It was a dark and stormy night . . .
• A 27 y.o. male presents to UMMC E.D. complaining of:– excessive somnolence and fatigue
– headache
– epigastric abdominal pain
– tinnitus
– B/L lower extremity
edema x 1 month
• PMHx: patient denies
• Rx: has been taking his uncle’smedications, but cannot recallmedication names or dosages(or even the name of his uncle)
• Allergies: “all NSAIDS”, Haldol, Zyprexa
• Physical Exam:
Eyes: bloodshot and “shifty”
Lungs: raspy breathing with a nervous cough
Heart sounds: “lubb-dubb-swish-bonk-flub”
Abdomen: soft and nontender,
large tattoo of Elvis Presley
Extremities: B/L LE edema
clogs on both feet
Diagnosis
• Somnolence and fatigue:– Patient quickly identified as an EM Intern on-
call in the MICU.
• Headache:– Secondary to excessive thinking during
medicine rotation.
• Tinnitus– Due to beeping from on-call pager.
Assessment (continued)
• Epigastric abdominal pain: – Indigestion from drug-rep. lunch earlier that day
• Progressive B/L LE edema x 1 month– Excessive bed-side rounding
Treatment
• Instructed to respond to on-call pages, PRN.
• Advised to adhere to resident work-hour limitations, but not to leave the hospital until “all the work is done.”
• Compression stockings for daily ICU rounds.
• Discharged back to the MICU in “more-or-less stable” condition.
Later that night . . .
“I just wanted to give youa heads up . . .”
• (0100) I was contacted by the ICU fellow who advised me that:– A 77 y.o. male is being transferred to UMMC for a G.I. bleed– E.T.A. 30 minutes
• (0108) Patient in room 7 codes– 3rd time today brief course of ACLS, defib. @ 200 Joules
return to sinus rhythm continue amiodarone gttp
• (0115) Nurse from IMC pages to advise me of a patient with temp of 99.2 F
• (0117) IMC pages me to evaluate patient for pulse ox. of 89%. Bedside evaluation identifies that the patient is disconnected from oxygen.
• (0128) Patient in room 7 codes again– False alarm, detached lead
• (0140) Son of patient in room 5 calls for an update on patient’s condition– Wishes to make patient DNR, although patient’s
daughter wants patient to be a “full code”
• (0152) Transfer patient with G.I. bleed arrives
New Patient Assessment
• HPI– Patient cognitively impaired, states “Okay,” to
most questions. – Does not know why he is here. No
complaints. – States, “I have to go to the bathroom.”– So I tell the patient, “I’ve had to go to the
bathroom since starting this rotation a month ago! …
“Why else would I be wearing this Foley leg bag?!!”– Patient says, … “Okay.”
• Notes from Transfer Summary:– 77 y.o. male transferred for G.I. bleeding– Seen by G.I. physician at outside hospital who
performed endoscopy, which found no evidence of upper GI bleeding
– Plan was to perform colonoscopy the next day
– Patient began to have multiple episodes of hematochezia.
• Notes from Transfer Summary (cont.):– Patient required multiple transfusions (7 units
PRBCs over 2 days).
– TRBC scan demonstrated evidence of small bowel source of bleeding, possibly proximal.
– Patient transferred to UMMC for “probable angiography and embolization of his gastrointestinal bleeding.”
History
• PMHx: – Mental retardation, COPD, HTN, prostate
carcinoma, CVA with residual left hemiparesis
• Rx: – Ticlid, nortriptyline
• Allergies: – PCN
• Social Hx:– hx of ETOH abuse, quit several years ago– no smoking or illicit drug use
Physical Exam
• Vital signs:– HR 98, RR 18, BP 100/62, T 99 F
• HEENT: – pale mucous membranes
• Abdomen:– Soft and NTTP, +BS, well-healed midline surgical
scar, 1 episode of passing moderate amount (250 mL) of dark red blood per rectum during physical exam
• Neurologic:– Answers “Okay,” to most questions.– Does not follow most commands.– Mild right-sided weakness
Laboratory studies
(@ 1825)
11.9
9.7
28.5
87
140
3.6
119 29
14 1.5
207
14.6
1.238
ABG: pH 6.84 / HCO3 10 / pCO2 39 / pO2 342
Ca 5.7, Mg 1.2, P 4.8
EKG: normal sinus rhythm
CXR (AP): normal
MICU Course
• Gastroenterology consulted:– Endoscopy within last 48 hours revealed no
evidence of UGIB
– TRBC study demonstrated evidence of small bowel hemorrhage
– Colonoscopy unlikely to be diagnostically or therapeutically useful
– Recommend angiography and general surgery consult, IV Protonix, CBC Q4H and IV fluid / PRBC transfusions PRN
MICU Course
• General Surgery consulted:– TRBC studies do not identify specific area of
small bowel hemorrhage accurately enough to guide surgical small bowel resection
– Recommend angiography and Gastroenterology consultation
MICU Course
• Interventional Radiology consulted:– Angiography
• can be difficult in the setting of hypotension
• may not identify specific artery for embolization
• embolization may fail to control bleeding
• patient may not be stable enough for procedure
– Recommend general surgery and GI consult
MICU Course
• Patient continues to have several episodes of dark red blood per rectum
• Repeat vitals: – HR 106, RR 16, BP 98/60, T 98.8 F
• Repeat hemoglobin: 6.5 g/dL
• Patient received 2 Liters IVF and 2 units PRBCs
• Left femoral arterial line placed
Putting out the other fires . . .Patient in room 2 spikes afever to 102 F and becomeshemodynamically unstable.
E.D. calls to notify of2 additional patients requiring ICU beds.
Patient in room 7 has a 60-second run of VT, requiring cardioversion.
Code Blue on 13 East. Patient resuscitated, butnow requires an ICU bed.
IMC continues to pagewith various questions.
Meanwhile…
• G.I. bleed patient is getting worse.
• Re-contacted Interventional Radiology.
• Patient to go to the I.R. suite for angiography and embolization.
• EM Intern (that’s me) to accompany patient to I.R. “in case something goes wrong.”
IR Suite
• Patient transferred to the IR table• Angiography of the SMA and celiac
arteries show no evidence of active extravasation.
• sBP: 98 mmHg 78 mmHg• sBP: 78 mmHg 40 mmHg
IR Suite
• General surgery re-contacted to assess patient for emergent operative management
• Infusing 0.9% NaCl wide open, dopamine gttp
• Infusing PRBCs wide open
• RUE 16 gauge PIV extravasates
• Left subclavian central line and LUE 18 gauge PIV not infusing well
IR Suite
• General surgery attending and resident arrive.
• “What the hell is going on here!!”
• Patient gets intubated, and a right subclavian Cordis is placed.
• Patient taken emergently to the O.R. for exploratory laparotomy.
Operative Report
• (0045) Large amount of blood noted in the small and large bowel
• (0110) “There is an area of jejunum adherent to the anterior surface of the aorta.”
• (0130) Aorta cross-clamped just below the diaphragm.
• (0146) Large hole in what appears to be the anterior surface of an aortic graft that has developed a fistula with the jejunum.
Operative Report
• (0150) Patient continues to bleed from the aorta and proximal control is difficult to achieve
• (0200) pulseless VT begin CPR
• (0209) Resuscitative efforts fail
• Patient pronounced dead at 0210
Perioperative Ins & Outs• In
– Plasma: 10 Liters– 0.9% NaCl: 7 Liters– PRBCs: 12 units– FFP: 12 units– Platelets: 7 units
• Out– EBL: exsanguinated– Urine: 300 mL– NGT: 3,800 mL blood
What went wrong?
• Missing Information (PSHx)– Transfer Summary – Patient– No family
• Diagnostic / Therapeutic dilemmas
• Multiple specialties trying to punt– Cooperative team approach vs. “Punt Wars”
Where do we go from here?
Conclusions to be drawn:
• “You’re a bad PA.”
• “You are responsible for that man’s death.”
• “You shouldn’t be practicing medicine.”
• “The hospital is at fault.”
• “Where was the ICU attending?”
• “The resident should’ve picked this up.”
• “What was surgery / GI / IR THINKING?!”
• “I don’t want to go back to work.”
Take Home Points(Or, “Everything I ever needed to know about
medicine I learned in residency.”)
• The diagnosis is in the history.– “The eyes cannot see what the mind does not know.”– Study, review, share cases with colleagues.
• The physical exam both confirms what you already know, and reveals what you have forgotten to ask.– Be thorough, do not dismiss unexplained findings.
Take Home Points(Or, “Everything I ever needed to know about
medicine I learned in residency.”)
• A collaborative team approach is the only way to practice responsible medicine.
Isn’t it? . . . Hello?? . . . Is anyone out there?
• Given enough time, we all have cases in which things go horribly wrong.
• It doesn’t take a hero to take credit when things to right.
• It takes a hero to step in and help out when things are going wrong.
Episode II: Attack of the Clones
. . . 3 years later . . .
“Looks like yer being sued now, don’cha know.”
What to do when you’ve been named in a law suit:
(a) Tear up the paper and hope it goes away. (b) Move to another country. (c) Change your name to “Unspecified PA” (d) Get drunk. (e) Call the patient up (if they aren’t already dead) and tell them
they’ve got some nerve naming you in a law suit. (f) Go back and change the medical record to reflect the type of
excellent medical care and thoughtful decision-making you know you did but forgot to document.
What has already occurred? You’ve (probably) treated the patient. Patient or their representative has decided to
seek reimbursement for damages incurred by your professional actions (or lack thereof).
They have obtained legal counsel. The medical records have already been obtained
and reviewed. A lawsuit has been prepared, claiming
allegations against you (usually, failure to meet the standard of care).
You have been served legal notice of the lawsuit (summons).
What should I do next?
Do not respond on your own. Do not contact the patient / family. Do not contact the plaintiff’s law firm. Do not talk about details of the case with anyone except your
attorney.
Notify your malpractice insurance carrier, who will provide legal counsel.
Do they even have a case?
Elements of a case
1. Duty to Act
2. Breach of duty failure to conform to standard of care
3. Proximate Cause
4. Damages
What happens next?
Responsive pleading (“Standard of care was met.”)
Discovery
Discovery
Detailed review of the medical record Medical documentation is the most important evidence in the case PA, nursing, physician documentation Dates and times Progress notes Consultant’s notes Be factual, avoid inflammatory documentation. Never, never, NEVER attempt to alter documentation after you’ve been
notified of a lawsuit.
Discovery
Review of the medical literature
Deposition of expert witnesses
Determining standard of care
Interrogatory
Written questions and answers from both sides
Your attorney typically prepares this, with your assistance.
Deposition
Verbal question-and-answer session(s)
The deposition is not: a search for the truth an opportunity to thoroughly explain yourself an opportunity to educate others a time to vent
Deposition Why are medical providers so bad at
depositions? We want to explain ourselves. We need to vent. We want to educate others. We want to expound on an answer to
demonstrate our knowledge. We want to be expunged of guilt. We want to provide evidence/rationale for
why we are good clinicians.
Deposition
PAs/doctors are from Mars. Attorneys are from . . .
Medicine is a collaborative process. Litigation is an adversarial process.
Deductive (PA/physician) reasoning: Fact + fact + fact = conclusion
Inductive (attorney) reasoning: Conclusion is proven by a certain subset of select
facts
hell.
How to Give a Good Deposition
Rule #1: Arrive prepared. Review case thoroughly Prepare answers Arrive well fed and well hydrated Arrive with your attorney
How to Give a Good Deposition
Rule #2: Speak as little as possible. Do not speak unless answering a direct question. Answer only the question being asked. Answer ONLY the question being asked. Do not answer an implied question. Think through your answer before speaking. Speak slowly. Correct yourself if necessary.
How to Give a Good Deposition
Plaintiff’s attorney: “PA Smith, please tell us what happened on the day Ms. Jones died in your Emergency Department.”
PA: “Ms. Jones arrived by ambulance in significant respiratory distress. She was quickly evaluated and initiated on 100% supplemental oxygen by nonrebreather. An IV was established and she was given a dose of enalapriland nitroglycerin, since examination revealed that she was in fulminant pulmonary edema. An EKG showed…”
How to Give a Good Deposition
Plaintiff’s attorney: “PA Smith, please tell us what happened on the day Ms. Jones died in your Emergency Department.”
PA: “Many things happened. Could you be more specific?”
Attorney: “What was the first thing that happened?”
PA: “I awoke in the morning.”
How to Give a Good Deposition
Attorney: “I’m not interested in what you had for breakfast, PA Smith! Please confine your answers to the medical case at hand.”
PA thinks: Is it a question? No. (remains silent)
Attorney: “Did Ms. Jones enter your E.R. in an ambulance that day?”
PA: “No.”
How to Give a Good Deposition
Attorney: “It says on page four of the medical record that Ms. Jones arrived by ambulance. Are you saying that’s not true?”
PA: “Ms. Jones was transported to the hospital by ambulance, but she did not enter the E.R. in an ambulance since ambulances are not allowed inside of the E.R. The ambulance was parked outside and she was brought into the E.R. on a stretcher by the ambulance crew.”
How to Give a Good Deposition Rule # 3: No sneak previews.
Be aware of your body language. Remain calm and focused. Don’t fidget. Do not respond to provocation.
Attorney: “You must be either incredibly stupid or incompetent to have missed that diagnosis, PA Smith.”
PA thinks: Is it a question? No. (remains silent)
How to Give a Good Deposition Rule #4: Take frequent breaks.
Do not allow yourself to become: Tired Irritable Hungry Frustrated Impatient
How to Give a Good Deposition For attorneys, time is money. So,… Don’t be in a rush. This is on either the
attorney’s or their client’s dime. Take all the time you need. This is time well spent.
Statistics California is a good place to practice
medicine. Statute of limitations is one year from the
time of plaintiff’s discovery of damages. $250K cap on non-economic damages > 80% of medical malpractice lawsuits are
closed with no indemnity payout If a case goes to trial, juries favor the
defense in > 80% of cases.
Settlement
Whether to settle or not is usually at the discretion of your insurance provider.
What if I don’t want to settle? Speak with your attorney / insurance carrier. Reconsider your decision. Hire a private attorney to represent you, incurring all risks and
expenses. Speak with your professional organization(s). Reconsider your decision.
Episode III:
Revenge
of the
Sith
Trial and Testimony
Be prepared. It is not a search for truth. It is not about right and wrong. The most important part of your testimony is getting the jury to
like you. Be professional, conscientious, empathetic, honest, and kind. (The jury
must identify with you.) Do not be arrogant, angry, condescending, cynical, quick to blame others,
or overly technical.
Trial and Testimony
Make eye contact with the jury. Show empathy for the plaintiff. Reiterate your caring, concerned approach to
the patient. Do not ramble. Do not lie. Do not blame others. Remain calm and professional. Be prepared for the ambush. Know when to tell your story.
Decision
It is a legal (not medical) judgement. May have very little to do with your quality of medical
care. May not be logical. May not be fair. Does not reflect your competency as a clinician.
Judgement Compensatory Damages
Economic (expenses incurred or anticipated) Lost wages, or lost earning potential Medical and life care expenses
Non-economic (pertain to the injury itself) Physical and psychological harm Pain and suffering Reduced enjoyment of life
Punitive Damages (wanton and reckless conduct)
Payout Malpractice Insurance
How much is enough? What if the judgement exceeds my coverage? What happens when there are multiple parties
involved?
Episode IV: A New Hope
Life During and After a Lawsuit
• Recognize and discuss your feelings.
Conclusions to be drawn:
• “You’re a bad PA.”
• “You are responsible for that man’s death.”
• “You shouldn’t be practicing medicine.”
• “The hospital is at fault.”
• “Where was the ICU attending?”
• “The resident should’ve picked this up.”
• “What was surgery / GI / IR THINKING?!”
• “I don’t want to go back to work.”
Life During and After a Lawsuit
• Recognize and discuss your feelings.
• Don’t be afraid to ask for help.
• Get enough sleep. Keep a routine.
• Manage stress through:– Vacation, Exercise, Family, Hobbies
• Evaluate your clinical practice, but don’t obsess about it.
Take Home Points, part 2(Or, “Everything I ever needed to know about
malpractice defense I learned in kindergarten.”)
• Take care of everyone and every thing.– The best way to protect yourself from malpractice
litigation is to take good care of your patients.– Always treat patients with respect. – Explain what you are doing. – Tell patients what they can expect.– Avoid surprises.
• Practice good penmanship.– If it’s not documented, it didn’t happen.– If it’s not documented, the plaintiff’s attorney will tell
the jury what did happen.
Take Home Points, part 2(Or, “Everything I ever needed to know about
malpractice defense I learned in kindergarten.”)
• Say “Hello,” “Goodbye,” and “Thank you.”– Introduce yourself.– If possible, sit down.– Take the time to listen.– Keep your patient advised about what is happening.– Talk to your patient before they leave.– Ask if they have any other questions.– Good discharge instructions are critical!
Take Home Points, part 2(Or, “Everything I ever needed to know about
malpractice defense I learned in kindergarten.”)
• Do your best to be a good person.– Treat people with kindness and consideration.– Learn new things.– Make friends (with your patients, colleagues, and the
jury if necessary).– If you’re going to have a temper tantrum, don’t do it in
public.– Do your best.– If you do something wrong, apologize.– Set a good example for others to follow.– Always wash your hands.
Good luck.
