July 2023

Volume 17, Number 7                                                                                                                  July 2023

Cases

1. Worsening Sciatica
2. Medscape, Wayne Guglielmo, 4/17/23
3. Construction worker goes to ED with a long history of sciatica.
   1. As Dr. Bukata notes, prior diagnoses can be an impediment to a new diagnosis.
4. Complains of left foot pain (the same side as his sciatica), but pain is different.
   1. Is this a variation of the pain?
5. PA diagnoses exacerbation of sciatica.
6. Nurse’s note said the foot was turning purple and felt cool / PA had not read the nursing note.
   1. These findings don’t go along with the diagnosis of sciatica.
7. Six days later after discharge, the patient returns to ED with 9/10 pain.
8. Seen by NP who diagnosed exacerbation of sciatica.
9. Four days later PCP arranges US eval = DVT and arterial thrombosis left leg.
10. CT shows tissue to be necrotic — leg amputation.
11. PA, NP, and EP physician group sued / $20M at jury trial ($10M pain / $10M compensation.)
12. Discussion
    1. This was a type 1 reasoning error (the consequence of the associative nature of memory, which can lead to cognitive biases) as Dr. Klauer puts it.  These providers focused on what was easy and what they knew, which is what a person’s brain wants to do — but can be very wrong.
       1. Providers need to put the brakes on and think things through. 
          1. Example: If there is foot pain.  Is this compartment?  Is this vascular?  Rule those things out.  We’re “worst first” clinicians.
    1. Be careful of anchoring bias.  The first diagnosis in your mind results in a bias that this is the correct diagnosis — often ignoring information that is contrary to this diagnosis — this clinical presentation does not match with sciatica.
    1. As Dr. Lindor notes, a doctor’s job in the emergency room is not to diagnose the common things, but to rule out the dangerous things.
       1. Common things are common.  Need to consider the uncommon things.
    1. Exams for sciatica.
       1. Plain straight leg raise.  Causing pain if at just 30 degrees.
          1. Doesn’t need to be any higher.
       1. Crossed straight leg raise maneuver — low sensitivity but high specificity (in other words the test will miss a lot of cases of sciatic, but when it is positive it is highly likely the diagnosis is sciatica.
    1. Another issue is the idea of working collaboratively here with APPs.  The EP was providing “supervision,” but was everyone really working together?
    1. Dr. Klauer suggests valuing your own opinion with bounceback patients.  Do an evaluation first and then go consult the notes of the prior visit.  Don’t be biased by the prior visit diagnosis. 
    1. Nursing documentation was ignored here.  Read the nurses in the ED or perhaps must read them in trial.
       1. Dr. Lindor observes that it is imperative to always address nurse notes and counter any notes that you feel may be inexact — “at the time of my examination the child was not cyanotic as previously observed by nurse X and O2 saturation has been in the high 90s.”

2.  Another Leg Problem
3. Medscape, Leigh Page, April 6, 2023
4. Patient presents to the ED with non-traumatic lower leg pain.
5. PA evaluation — muscle strain, discharge.
6. Sees ortho the next day — compartment syndrome diagnosis.
7. Irreversible nerve damage and chronic regional pain syndrome.
8. Jury awarded $7M with supervising physician owing 40% (never saw patient / signed chart).
9. An update on numbers:
   1. 27 states no longer require supervision agreement for all or most NPs.
   1. 16 states have progressive practice authority (6 mo. to 4 yrs. experience).
   1. AAPA is pushing for elimination of a mandatory relationship with a specific physician — ND and RI have done so / CA and HI have eliminated mandatory chart review.
   1. Average payment in NP cases is increasing ($332,187 in 2022).
   1. Core concept – vicarious liability / respondent superior.
10. Discussion
    1. As Dr. Klauer points out, without defining what a signature means, it is left up to various interpretations (never saw the patient but signed the chart, saw the patient, discussed the patient??).
       1. There needs to be a definition underneath the signature showing involvement or non-involvement.  Is it QA? What is it?
       1. Does a supervising physician’s signature on the chart increase or decrease liability. 
       1. Dr. Bukata feels the overall responsibility in the emergency department remains with the physician. 
    1. Dr. Lindor notes that another issue arises with billing.  If a PA or NP does not have direct supervision, 85% of insurance can be billed to Medicare whereas if a physician is involved (case discussed at a minimum) or physician sees patient and writes a note, it is 100%.  During the pandemic PAs/NPs were paid 100% by Medicare.
    1. This is a training issue, a supervision issue, and a policy issue.

3. $13.5M Award from EP and His Group
4. Idaho Capital Sun, Audrey Duttin, February 9, 2023.
5. Both the EP and his group were sued.  Second largest malpractice jury award in Idaho.  Idaho has a $400,000 cap on non-economic damages — but there is an exception for injuries that arise out of “willful or reckless misconduct” and the jury found this to be the case.
6. The case goes back to the early morning of March 29th, 2016. The patient had severe headache and vomiting and became progressively more confused according to the lawsuit.  The patient arrived at the hospital by ambulance and within 11 minutes a doctor was examining the patient.  The patient had recently had sinus congestion, nausea, vomiting, dizziness and ringing in the ears.  The CT scan was read by a radiologist who noted no intracranial process.  The patient improved somewhat in the emergency department. He was going to be admitted for benign positional vertigo.
   1. This really can’t be the diagnosis in this case given that classically it is taught that spells last seconds to a few minutes. 
7. Because of persisting concern an MRI was ordered three hours later.  By then another clinician found the patient to be delirious without meaningful interactions.  It took another four to five hours for the patient to be seen by another doctor and an MRI was ordered but the machine was not available for hours.  Finally on receiving the MRI it showed a stroke and a torn artery in his neck.  Despite surgery his condition deteriorated to the point that he had an irreparable brain injury with impaired movement, was on disability and could no longer work.
8. The ED group “specifically denied any and all allegations of responsibility and liability.”  They also noted that at no time were they guilty of negligence or improper treatment. The injuries were a result of complications not poor medical care in the emergency department. The jury found that the emergency doctor as a member of an emergency group was reckless in failing to meet standards for medical care which caused the patient’s injuries.   The emergency physicians plan to appeal.
9. Discussion
   1. Fault often falls on the first physician of record.
   1. As Dr. Lindor comments, it’s all about how physicians and providers treat people.
      1. The family of the patient in question did not think he was cared for by the providers and physicians during the initial presentation.
         1. Dr. Klauer discusses different perceptions between physicians and patients/the patient’s loved ones.
            1. Physicians are very busy and time flies while patients and their loved ones may endure hours of just waiting.  Time feels very different between the two.

4.  Barking Cough of Croup Isn’t
5. A 7 Y/O boy presented during the middle of the night. He had awoken sobbing, felt warm and short of breath. Triage vital signs noted a temperature of 39.4 C, a heart rate of 135, a respiratory rate of 36 and a pulse ox of 95 on room air.  He was seen by a PA who was under the supervision of a board-certified emergency physician. 
6. The EP note indicated that dexamethasone was given, and a test was positive for Influenza type B.  Shared decision making resulted in Tamiflu not being given.  Patient was discharged.
7. The next day he remained febrile and complained of having SOB. While in his mother’s lap he had a cardiac arrest.  Paramedics briefly resuscitated him, but he arrested again in the ED but was not able to be resuscitated.
8. Autopsy reveals Influenza group B and necrotizing pneumonia caused by Group A strep.
9. The plaintiffs asserted that there was a departure from acceptable standards of medical care and that the patient was inappropriately discharged without the benefits of a radiographic evaluation of his chest, initiation of antibiotic therapy and a whole set of vital signs upon discharge.
10. Discussion
    1. This is another case of trying to fit a square peg into a round hole.
    1. Croup is generally under 5 years of age.
    1. Consider diagnostics that suggest other things.  Dr. Klauer believes this could have been avoidable.
    1. A jury of lay people would have been shocked by the patient not being given flu medicine.
    1. Bacterial pneumonia can follow viral pneumonia.
    1. What were the vitals?  Documentation is necessary.
    1. The tests led the physicians down the wrong path.  Physicians need to think twice.
    1. A seal-bark cough is so distinguishable from anything else.  Without this cough, a diagnosis of croup is hard to make.  A severe cough and a croupy cough are quite different.
    1. With patients like this, improvement needs to be demonstrated.  If no improvement is made, care needs to be escalated.  Observe longer or admit.  Don’t try to rush this type of patient out quickly.
    1. What is meant when a test is “within normal limits?”
       1. 95% of the people will fit within this range (2.5% will be off the lower limit and still be normal for a particular patient and 2.5% will be above the 95% range — but the patient will still be normal.  Normal patients can have lab tests slightly above or below the normal lists and still be normal.

5. An Eight-Day Old Febrile Infant
6. Medscape, Wayne Guglielmo, 5/8/23
7. An FP saw the infant at a clinic — crying, lack of appetite, and fever.
8. FP has concerns that the child is being overfed.
9. Arranges for a County nurse to see the patient at home the next day.
10. The visiting nurse called the FP’s office the next day and said the child needed to be seen immediately.
11. He was seen that afternoon and was taken down the hall to the ED.
12. Child was suspected of having a critical bowel obstruction and was transferred by helicopter to another hospital.
13. There the doctors noted the child to be acidotic and in respiratory failure.
14. He was then sent to a children’s hospital where the meningitis diagnosis was made.
15. The lawsuit claimed the collective failure of the doctors to make the diagnosis was the cause of the child’s permanent brain injury.
16. A jury found that the second hospital was totally responsible.
17. $17M with $7.5M going to future care.
18. Discussion
    1. There is a very specific approach to a febrile infant of this age — a septic evaluation is required that includes a lumbar puncture — it’s very straightforward in the ED setting.

• One-Month Old with Distended Abdomen
• KITV TV, Honolulu, May 30, 2023
• Healthy newborn presented to the Tripler Army Medical Center ED with a distended, tight abdomen and had turned blue from the waist down.
• On arrival she stopped breathing and had to be resuscitated.
• Transferred to another hospital the next day — surgery — volvulus diagnosed.
• Alleged 19-hour delay with failure to do needed tests.
• Lost 70-95% of small bowel — feeding tube at current age (6 YO).  Neurologically devastated.
• U.S. District Court judge awards $29,479,308.
• Discussion
  • When in doubt, kids like this get imaging (US is fast and safe). 
  • The clock is running in cases like this and care needs to be expedited
  • Upon closer examination of the case, Dr. Lindor notes that due to relative instability upon arrest, the physicians didn’t feel comfortable doing upper GI.  It’s a little more nuanced than the initial presentation.

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Rachel Lindor, MD                             Kevin Klauer, DO, EJD                                 Rick Bukata, MD