Everyone gets a CT now....

[Boatswain2PA]

Eye pain?  Conjunctivitis?   To the CT scanner you go.  Especially if you are only 17 years old.

Otherwise you could trigger an $11.3 MILLION DOLLAR AWARD because it just might be a one-in-a-million event (cerebral aneurysm) that ruptures FOUR MONTHS LATER.  https://madmimi.com/p/ab1fd9?fe=1&pact=23339-139014736-9685000803-a6c8173bf13bd15739694eda3be2f203b132e199

 

More information on the case, with testimony, from:  http://verdictsearch.com/verdict/wrong-diagnosis-caused-teens-brain-damage-plaintiff-alleged/
"One of the plaintiff's emergency room experts, Shalon Buchs, testified that had a CAT scan and other testing been performed on Arcadio, it would have discovered that he had a brain aneurysm behind his right eye. She testified that had the aneurysm been detected, treatment would have prevented it from bursting and causing his brain damage. She testified that the providers' failure to perform proper testing fell below the standard of care. "

CT the head of every 17 year old with conjunctivitis?  That's "standard of care"????

Oh, wait...apparently Shalom Buchs isn't a M.D. (like she is listed as on the above web-site), but rather a PA, and is on faculty at the University of Florida PA program.

The American College of Emergency Physicians now has away of censuring physicians who give grossly negligent testimony.  Dr. Peter Rosen (one of the founding father's of EM, and writer of a book that many of us in EM have used) was censured by ACEP for giving terrible testimony for a plaintiff (https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0ahUKEwjFltmdltrTAhVK7GMKHQI8BZcQFggnMAE&url=http%3A%2F%2Fwww.acepnow.com%2Farticle%2Facep-issues-public-censure%2F&usg=AFQjCNF3BcLL7qbWHk_RHAaAMIqCxFOxpQ&sig2=JpkqqgECNyR1RoWy-pASCg)

Can someone at the AAPA, PAFT, or SEMPA begin the process of creating a way to censure PAs who give grossly negligent testimony?


There may be a LOT more to this story than can be found on the internet (and I HOPE to  God there is!!), but if this was a clear-cut conjunctivitis (versus posterior eye pain without anterior redness/swelling) and we have a PA testifying that a CT is the "standard of care" for conjunctivitis....then this was negligent testimony and should be professionally censured.


This case led me to have a discussion with my attorney today about asset protection.  She isn't a MedMal expert so she is sending me to one of her partners.  I want to make sure my assets are structured in a way that if I were forced to declare bankruptcy due to an extraordinary MedMal case like this I wouldn't loose everything. Oh....  I thank GOD I live in a VERY MedMal friendly state, however all it takes is ONE lawsuit to make you loose everything you've worked for your entire life.

This case just solidifies the fact that there is no way in HELL I would practice in Florida, California, New York, Mass, Conn (or a few other states I'm sure).   

[sk732]

I suspect that the jury just saw a gibbled kid and got tunnel vision...conjunctivitis and cerebral aneursym are what I would consider very divergent DDx.  Complaining of headache and red eye, I might go looking a bit more that's for certain - red eye, not so much.  I can't see any of my radiologists, no matter how much money they'll make off the job, approving a CT angio for a 17 yo male with a red eye and no other complaints other than "Covering My Arse".

 

SK

[GetMeOuttaThisMess]

Anyone with altered vision, globe pain increased with eye movement, photophobia, and eye injection warrants further assessment (didn't read the article). I DO warn my conjunctivitis folks about periorbital cellulitis however. Anything lasting longer than six/seven days even without treatment needs further work up. The trifecta for bacterial conjunctivitis: loss of tarsal vessels, able to identify affected eye from 20', and purulent drainage.

[pvdude]

Anyone with altered vision, globe pain increased with eye movement, photophobia, and eye injection warrants further assessment (didn't read the article). I DO warn my conjunctivitis folks about periorbital cellulitis however. Anything lasting longer than six/seven days even without treatment needs further work up. The trifecta for bacterial conjunctivitis: loss of tarsal vessels, able to identify affected eye from 20', and purulent drainage.

When you say further assessment what are you referring to?

[DogLovingPA]

Eye complaints are already one my least favorite chief complaints. Now I hate them even more.

[GetMeOuttaThisMess]

When you say further assessment what are you referring to?

 

Check IOP's, slit lamp exam if available, and if not, send to ophthalmology.  CT scanning in some instances is not an unreasonable option.  You also have to consider vascular obstruction/inflammation.  Auscultate the eyeballs as well.  I don't know how many times I've auscultated the forehead listening for evidence of an AVM.  I don't want to derail what was the original premise of the thread.  My point is that one needs to consider all scenarios.  Months since time of assessment and bad outcome?  Show me how it was apparent at the time in which I saw the patient Mr./Ms. Attorney.

[EMEDPA]

I would think glaucoma would be higher on the ddx list than this zebra...

[Boatswain2PA]

GMOTM - There is no indication from published reports (that I have read) that there was any indication of anything BUT conjunctivitis.  The defense position was that the kid was correctly diagnosed and treated (for conjunctivitis), and the aneurysm was unrelated.  

19/20 "red painful eyes" are quickly ruled out for things like scleritis, endophthalmitis, periorbital cellulitis, foreign body/abrasion, iritis, or posterior abscess.

1/20 need deeper reflection and perhaps further testing like a CT, but these are not the classic conjunctivitis.  The vision loss/flashers, headache/posterior eye pain, painful EOM, proptosis.....those are the rare (maybe 1/50 "red painful eye") patients who need CT.  Even then I'm not looking for an aneurysm, I'm looking for an abscess, so probably wouldn't do a CTA that would be necessary to find an unruptured aneurysm.  

Furthermore, the adverse outcome came FOUR MONTHS LATER.  It obviously wasn't EMERGENT, so wasn't appropriate to testify that it was standard of care to find the aneurysm in the EMERGENCY department. 

 

 

I suspect that the jury just saw a gibbled kid and got tunnel vision...conjunctivitis and cerebral aneursym are what I would consider very divergent DDx.  Complaining of headache and red eye, I might go looking a bit more that's for certain - red eye, not so much.  I can't see any of my radiologists, no matter how much money they'll make off the job, approving a CT angio for a 17 yo male with a red eye and no other complaints other than "Covering My Arse".

 

SK

You're in Canada, right?  You guys don't get sued.

[GetMeOuttaThisMess]

I was commenting on certain ocular presentations with "eye pain" that might warrant further assessment that could include red eyes.  I don't doubt that the conjunctivitis could be an incidental presentation that could have been totally unrelated to the aneurysm, EXCEPT for the comment of eye pain.  Everyone that walks into my snot/cough clinic thinks that a red eye is "pink eye" (including staff I might add).  My comment is not so much directly related to this specific incident but more as a reminder to new folks that eye "pain" is one of those key phrases that should give each of us pause.

[sk732]

 

You're in Canada, right?  You guys don't get sued.

 

I got served about a year out of school on a case from my orthopedic trauma rotation...

 

SK

[HJK]

Whatever the PA did or it was, how are things changed 4 months later directly related one ED visit? Would the PA be off the hook if referred to someone lese to follow? It just baffles me.

[Boatswain2PA]

Whatever the PA did or it was, how are things changed 4 months later directly related one ED visit? Would the PA be off the hook if referred to someone lese to follow? It just baffles me.

Exactly.  Our medical malpractice system is out of control.

 

ACEP has initiated a system to censure EPs who give negligent testimony, as it appears MAY HAVE been done in this case by a PA.

 

Can someone in AAPA/PAFT/SEMPA look into creating such a system for PAs?  

 

Nobody wants to protect poor providers or actual malpractice, but cases like this (if it IS as it appears in these articles) are examples of how some medical providers are part of a predatory system that adversely affects health care for everyone.

 

I hope some organization can investigate her testimony and, if appropriate, sanction her so she can never testify again.  That is the case for Dr. Peter Rosen.  A world renowned expert in EM.

 

 

I got served about a year out of school on a case from my orthopedic trauma rotation...

 

SK

What was the result of that?  

 

Of course, "you guys 'never' get sued" is an exaggeration....but there is MUCH less medical litigation up there.  I believe that is due to a higher standard of proof, right? 

[sk732]

Exactly.  Our medical malpractice system is out of control.

 

ACEP has initiated a system to censure EPs who give negligent testimony, as it appears MAY HAVE been done in this case by a PA.

 

Can someone in AAPA/PAFT/SEMPA look into creating such a system for PAs?  

 

Nobody wants to protect poor providers or actual malpractice, but cases like this (if it IS as it appears in these articles) are examples of how some medical providers are part of a predatory system that adversely affects health care for everyone.

 

I hope some organization can investigate her testimony and, if appropriate, sanction her so she can never testify again.  That is the case for Dr. Peter Rosen.  A world renowned expert in EM.

 

 

What was the result of that?  

 

Of course, "you guys 'never' get sued" is an exaggeration....but there is MUCH less medical litigation up there.  I believe that is due to a higher standard of proof, right? 

 

My lawyer got me dropped - I was a student, observing the case at that time and wasn't scrubbed in or even hands on...this was a typical "shotgun" litigation, as even the OR cleaners who were listed on the OR Rota were named.  I was giggling a bit, I have to say, since the senior resident on my team was a knobber.  IIRC, there were two hospitals sued, one ER doc, our ortho team and a our vascular team, and all the ortho ward nurses at our hospital.  Dude was blaming us for his own failings in looking after himself...

 

I think the thing here is higher burden of proof but also judges here have a low tolerance for frivolity as well.  Having said that, if there is clear cut negligence, with a number of years of lost livelihood and such, you'll get 7 -8 figure settlements.  As I don't trust my employer one iota when it comes to my insurance (I've yet to be shown a binder in the 6 years/two employers since I've been out of the military), I have my own private coverage.  I lucked out in the case I got named in - I was an employee of The Crown and on duty at the time, so I had a Justice Dept lawyer appointed and had to walk on eggshells for 6 months for the next pile of disclosure and shyte to take place and the legal f*&kings off to occur.  Even when you're sure you're going to be let off, it grates on you like fingernails on a chalk board.

 

SK