Malpractice Case against a PA. What do you guys think?

[nebero]

A GWINNETT COUNTY JURY AWARDS ER PATIENT $5 MILLION IN A MEDICAL MALPRACTICE CLAIM

 

Attorneys for Ellen Wadsworth brought a medical malpractice lawsuit after a physician's assistant at Houston Medical Center, misdiagnosed her as having cellulitis, a skin infection caused by bacteria, and failed to diagnose blockages in her arteries behind both knees.Ms. Wadworth, 61 at the time, was transported by ambulance to Houston Medical Center with complaints of pain in her feet. Ms. Wadworth told the triage nurse that her pain was an eight on a scale of one to 10. Gregory Howland, MD ruled out vein problems when he felt a weak pulse in her feet. He did not order an arterial ultrasound because he believed the pulse indicated that blood was flowing to her feet. Howland prescribed pain medication and antibiotics and was told to apply ice to only one leg.Ms. Wadworth was discharged from the emergency department, even though she couldn't walk. "She begged to be admitted. Her son begged for her to be admitted," said Virgil Adams, who represented Ms. Wadworth in the suit. "They said they never saw the doctor. They only saw a physician's assistant. The doctor stuck his head in the door and said, 'We don't admit people for cellulitis.' "Ms. Wadsworth returned to the hospital later that night, after she was found unresponsive in her home by her son. A blockage was found and both legs were amputated below the knees a few days later.Attorneys for Ms. Wadsworth argued that her legs could have been saved had tests been performed to detect a blockage in her arteries. Instead, Wadsworth was told she had what amounted to a skin rash, said Adams.The defense claimed that Wadsworth's blood clots weren't present when she first visited the emergency room the morning of Nov. 27, 2008, but had manifested after her initial discharge. According to the defense outline of the case in the pre-trial order, they "contend that Ellen Wadsworth's condition was completely different during the two emergency room visits and that her later condition was caused by subsequent events which were not present and were not foreseeable."Caroline Herrington, who also represents Ms. Wadworth said defense based its case on the idea that Howland did his duty because he checked for blockages in his physical examination. "The physician's assistant testified that as long as he could feel a pulse, that's all he had to do to rule that blockage out," Herrington said.The case went to trial before a Gwinnett County jury last week. Gwinnett County State Court Judge Joseph Iannazzone allowed the jury to decide whether the defendants were liable of gross negligence or ordinary negligence, which have different standards of proof under Georgia's 2005 tort reform law.A key point in the trial came when defense expert, vascular surgeon Dr. Daniel McDevitt, acknowledged during cross-examination that tests to determine whether there was an arterial blockage should have been done during Ms. Wadsworth's initial emergency room visit."Their own experts even testified on cross-examination that you can have a partial occlusion but still have a pulse," Adams said. "What blew up their whole defense was the evening of the next day, well after everyone had diagnosed the blockage in both legs, there's a doctor's report from the Medical Center of Central Georgia saying that she felt faint pulses on the top of the right foot and the back of her right ankle."After six days of testimony, the jury, composed of nine women and three men, awarded Ms. Wadworth $5 million. The presence of the pulse showed the jury that more testing should have been done to detect a blockage, Adams said.Gross Negligence v. Ordinary Negligence for Emergency Room Care:Georgia law requires clear and convincing evidence that a physician or health care provider showed gross negligence when providing emergency medical care, which is more difficult to prove than the preponderance of the evidence standard for ordinary negligence used in other medical-malpractice cases.Gross negligence means serious and perhaps wanton and even deliberate carelessness which must be proved by clear and convincing evidence. This increased burden of proof makes the successful handling of emergency room negligence cases extremely difficult.In this case, plaintiff's attorney persuaded the jury that the lower standard should be applied to Ms. Wadsworth because the law excludes non-urgent patients in stable condition from the definition of emergency medical care."A lot of defense attorneys argue that just because it happens in an emergency room, it's gross negligence, and that's not what the statute says," said Adams, referring to O.C.G.A. § 51-1-29.5. "The jury determined that the care-if you want to call it that-Ms. Wadsworth received was not emergency medical care."

[EMEDPA]

I'm sorry that this lady lost both legs but I imagine years of smoking probably contributed more to this than 1 relatively nl exam the day before the onnset of her clot. if this was tried by a "jury of peers" (medical professionals) the case would have been decided for the pa. with good pulses and intact cap refill most foplks would not do an ultrasound on this lady. sounds like the standard of care was met and they just didn't recognize that. acute arterial occlusion( I have seen a few) presents with a cold, numb extremity with poor to no cap. refill.

[nebero]

Just so you know, the jury was from the same county that awarded 3 million to the widow of Atlanta cop who died while having three way sex with another woman and a friend. In that case, the cardiologist was found at fault for not telling pt not to do anything strenuous.

[EMEDPA]

1. don't work in Georgia, check.

2. no 3 ways after bypass surgery, check.

[Just Steve]

2. no 3 ways after bypass surgery, check.

 

deal breaker...no bypass for me ;-)

[EMEDPA]

deal breaker...no bypass for me ;-)

yup, gotta go with the stents to preserve "3 way function".....:)

just remember what justin timerlake says to the ladies: " it's not gay in a 3 way, with a honey in the middle there's some leeway"

[CAdamsPAC]

yup, gotta go with the stents to preserve "3 way function".....:)

just remember what justin timerlake says to the ladies: " it's not gay in a 3 way, with a honey in the middle there's some leeway"

 

EMEDPA & Just Steve gettin their freak on in the PAF! ;-)

[jmj11]

Okay . . . sorry but I will digress from the three-way topic, but to talk about malpractice.

 

I saw a patient yesterday and let me briefly tell her story (only tangential to why I was seeing her).

 

At age 27 (few years ago) she had an abdominal hysterectomy. Apparently during the surgery her small bowel was nicked but not observed. She was closed up and went home. She became seriously ill over the next 24 hours, returned to the ER and was admitted to ICU for septicemia and was there for 18 days. She eventually had to go back to surgery and have a good portion of both small and large intestines removed and had a colostomy for two years and 2-3 subsequent surgeries for bowel revisions. She is now disabled due to continuing complications.

 

Okay, so I asked her . . . did you settle with the hospital or surgeon? She responded that her and her family met with a malpractice attorney in a large practice. They looked over her case and said that she didn't have a case because what happened to her was within the boundaries of a reasonable risks of surgery. I was really surprised considering all the flippant law suits that do seem to go through.

[True Anomaly]

A few things....

 

One, this article seems to have many factual errors, such as this confusing sentence: "ruled out vein problems when he felt a weak pulse in her feet. He did not order an arterial ultrasound because he believed the pulse indicated that blood was flowing to her feet."....and that no name of a PA was mentioned, only an MD name, which I assume is another factual error, or maybe it wasn't because they family said they never saw a doctor and this guy may actually be the PA instead....I mean, it's really confusing and shows poor journalistic skill.

 

Regardless, there is something in the article which I wasn't aware of, and actually quite scares me which hasn't been mentioned yet- that is that the decision came under another malpractice clause that's unrelated to emergency medicine. The plaintiff's attorney successfully convinced the jury that because the care that the plaintiff received was NOT emergency care, then they could pursue the part of the law that does not mention emergency care- that of gross negligence. Ergo, it's being held to the same standard as a primary care clinic, which is specifically set up to follow-up with their patient population unlike an ER is. Of course we can't view this specific patient (the one in the article) in front of us, so we can't say for certain whether she met the actual criteria for an emergent medical condition that needs to be stabilized, ie EMTALA, which is the reason we go to great lengths in the testing we do for patients in the ER. However, since the plaintiff's attorney acknowledged that this WASN'T an emergency case, then theoretically the ER practitioner shouldn't be held liable for not ordering the non-emergent test, and they should instead recommend referral as appropriate. It honestly worries me that the ER is then seen as a beefed-up primary care/specialty clinic that should handle anything and everything, and do it all immediately, when this just isn't feasible. I know this is only one county in one state, and I'm glad I don't work anywhere near that state/county, but still....

[mayceegreene]

I agree that this woman brought these problems on herself. But, if proper test were not given to her because she lacked insurance then that's different. Too bad the person who wrote this story was only as thorough as the doctor.

[rcdavis]

I agree that this woman brought these problems on herself. But, if proper test were not given to her because she lacked insurance then that's different. Too bad the person who wrote this story was only as thorough as the doctor.

 

I know of no ED in the country which makes EMERGENT Interventional or interrogatory procedure decisions based on insurance status. Matter of fact, most of the time, when I am conducting medical screening examinations ( which are required to be as thorough as necessary to rule out an emergent medical condition... X-rays, ultrasounds, labs, even surgery..) I am Blinded to the patient's insurance status. So I make these decisions based on my thinking and risk analysis, not financial considerations.

 

There are a few observations...

 

Extremely poorly reported... Experienced practitioners, myself included, cannot tell really what happened, or who was involved at what stage.

 

Extremely Unlikely that here were BILATERAL arterial obstructions occurring simultaneously... Much more likely there was a distal aortic or bifurcation occlusion which became emergently obstructed.. And the already compromised atherosclerotic leg arteries did not occlude, but failed to provide blood they no longer received thru direct or collateral flow, leading to bilateral lower extremely ischemic compromise...

 

The statement that pulses rule out OBSTRUCTION is true. The documented weak pulses imply significant , though not total, occlusion / advanced atherosclerosis or clot which is impeding adequate flow. I see this often

 

We also see this a lot of arterial or venous insufficiency caused skin changes and cellulitis.

 

The true issue is, was there an emergent medical condition?

 

In retrospect, arguably, despite lousy reporting, there was certainly critically severe (probably central) ischemic arterial disease. What is missing, for me, was a statement of how cool or cold the legs were. If she had such intractable pain which precluded her being able to walk, and cool/cold leg(s) with diminished pulses, then she should have had arterial dopplers and CT angio with run off... Emergently.

 

If the legs were warm, but diminished pulses only, then she still needed vascular w/u but maybe not Emergently.

 

The diagnosis was missed, obviously.

What is not clear is the THINKING involved behind the process supporting discharge.

 

A good take home is, before discharge, make sure that IN YOUR NOTES, you document what pathophysiology and alternate diagnoses you considered, and why you do not think they are present or emergent at time of discharge.

 

Generally juries will forgive you for being wrong, but not for missing the dx altogether ( which I think happened here).

 

True anomaly is right: what standard applies? If the case in downgraded from emergent to non emergent, how is it that the downgrader ( the emergency room practitioners) suddenly accrue the " non emergent" standards of care???

 

Regardless, maycee, I seriously doubt this woman's insurance status entered into the fray.

[RetNavyPAC]

 

The diagnosis was missed, obviously.

What is not clear is the THINKING involved behind the process supporting discharge.

 

A good take home is, before discharge, make sure that IN YOUR NOTES, you document what pathophysiology and alternate diagnoses you considered, and why you do not think they are present or emergent at time of discharge.

 

Generally juries will forgive you for being wrong, but not for missing the dx altogether ( which I think happened here).

 

I'll echo rcdavis' comments.

 

I've forgotten how many charts I've reviewed in Peer Review committee meetings where the documentation was absolute CRAP.

 

It's amazing how many PAs, NPs and MD/DOs in such a high-risk endeavor as emergency medicine do not document their THINKING.

 

Here is the most cogent and succinct thing I've ever read about this. It's from ACEPs Risk Management Curriculum: (emphasis mine)

 

"The importance of documentation is summed up [thusly]: “Use the history, risk factors, exam, test results and ED course to shape your differential diagnosis and medical reasoning into a compelling story so logical that any reasonable physician and every juror can only come to one conclusion – yours.”

[kidnid]

i would do a doppler U/S to r/o DVt ............ cos she reported 8/10 pain, esp in one leg !....... just to cover my rear end .....:;;D:

[Contrarian]

^^ Yep^^....

Simply because I have caught significant occlusions on a hunch when patients have come into the clinic with even milder presentations and complaints...

[Cideous]

5 million will buy a lot of smokes......she will be good for a while.

[Cideous]

I'll echo rcdavis' comments.

 

I've forgotten how many charts I've reviewed in Peer Review committee meetings where the documentation was absolute CRAP.

 

It's amazing how many PAs, NPs and MD/DOs in such a high-risk endeavor as emergency medicine do not document their THINKING.

 

Here is the most cogent and succinct thing I've ever read about this. It's from ACEPs Risk Management Curriculum: (emphasis mine)

 

"The importance of documentation is summed up [thusly]: “Use the history, risk factors, exam, test results and ED course to shape your differential diagnosis and medical reasoning into a compelling story so logical that any reasonable physician and every juror can only come to one conclusion – yours.”

 

 

 

 

In a perfect world this would be great...except we live and work in a world where productivity is > all. How many patients per hour can you see and still write these grand essays of pre litigation? Not many and anyone who says different is lying. Time does not lie and crafting these wonderful documentaries on every patient will win you a one way trip to the administrators office to explain your "lack of production". Welcome to Corporate Medicine *tm

[RetNavyPAC]

In a perfect world this would be great...except we live and work in a world where productivity is > all. How many patients per hour can you see and still write these grand essays of pre litigation? Not many and anyone who says different is lying. Time does not lie and crafting these wonderful documentaries on every patient will win you a one way trip to the administrators office to explain your "lack of production". Welcome to Corporate Medicine *tm

 

 

I respectfully disagree Cideous and please - easy with the snark. Unhappily it seems (forgive me if I assume too much) you live in an EM world where productivity is the overarching goal but happily, and luckily I suppose, I don't. Don't misconstrue this as a claim that productivity is unimportant in a busy ED. But wouldn't you agree that a balance must be struck with the proper and clear documentation of the (assumed) quality of care?

 

My corpsmen & medics and I could see 400-500 people a day on a MedCAP in a village in Afghanistan - mostly because we didn't have to document anything.

 

And I daresay I don't write 'grand essays of pre-litigation'. And I don't necessarily document thinking on every single patient. Mostly the medium-risk patients - because generally we're sending home the low-risk and admitting the high-risk aren't we? It's those ones in between that are the most vexing (EM is a tri-chotomy rather than the traditional 'sick, not sick' approach). I'll continue to maintain that, whatever acuity level of patient that you're seeing, it's good practice to try to make your charts as 'bullet-proof' as possible.

[RetNavyPAC]

In a perfect world this would be great...except we live and work in a world where productivity is > all. How many patients per hour can you see and still write these grand essays of pre litigation? Not many and anyone who says different is lying. Time does not lie and crafting these wonderful documentaries on every patient will win you a one way trip to the administrators office to explain your "lack of production". Welcome to Corporate Medicine *tm

 

 

I respectfully disagree Cideous and please - easy with the snark. Unhappily it seems (forgive me if I assume too much) you live in an EM world where productivity is the overarching goal but happily, and luckily I suppose, I don't. Don't misconstrue this as a claim that productivity is unimportant in a busy ED. But wouldn't you agree that a balance must be struck with the proper and clear documentation of the (assumed) quality of care?

 

My corpsmen & medics and I could see 400-500 people a day on a MedCAP in a village in Afghanistan - mostly because we didn't have to document anything.

 

And I daresay I don't write 'grand essays of pre-litigation'. And I don't necessarily document thinking on every single patient. Mostly the medium-risk patients - because generally we're sending home the low-risk and admitting the high-risk aren't we? It's those ones in between that are the most vexing (EM is a tri-chotomy rather than the traditional 'sick, not sick' approach). I'll continue to maintain that, whatever acuity level of patient that you're seeing, it's good practice to try to make your charts as 'bullet-proof' as possible.