EM/Psych Malpractice Case re: suicidal patient [cross posted in psychiatry]

[bbc586]

A patient was seen for suicide concerns.

Her boyfriend broke up with her while she was driving, she tried to get out of the car making suicidal statements.

She was intoxicated.

Bf calls 911, patient seen in the ED by EM doc and psych social worker.

Cleared for discharge.

Dies 5 hours later.

Expert Witness Case #21

This case concerns a 24-year-old woman, Ms. C. She was in a vehicle with her boyfriend (Mr. D) who broke up with her as they were driving. She was intoxicated, made suicidal statements, and tried to jump out of the moving vehicle. Mr. D stopped the car, called 911, and Ms. S was taken to a...

expertwitness.substack.com

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[Birdstrike]

Meh...whatever...

 

[EM Junkie]

FYI to all the old docs that can’t cut it in the ED anymore, why don’t you do us all a favor and retire to the country.

Why do you find it necessary to hire yourself out to sleazy lawyers as an “expert witness” is beyond me. When you were practicing the ED physician still had a sleep room and saw 1PPH. Go screw your selves “expert witnesses”. Unless of course you work in defense of physicians only, then you’re ok in my book!

 

[Birdstrike]

A patient was seen for suicide concerns.

Her boyfriend broke up with her while she was driving, she tried to get out of the car making suicidal statements.

She was intoxicated.

Bf calls 911, patient seen in the ED by EM doc and psych social worker.

Cleared for discharge.

Dies 5 hours later.

Expert Witness Case #21

This case concerns a 24-year-old woman, Ms. C. She was in a vehicle with her boyfriend (Mr. D) who broke up with her as they were driving. She was intoxicated, made suicidal statements, and tried to jump out of the moving vehicle. Mr. D stopped the car, called 911, and Ms. S was taken to a...

expertwitness.substack.com

Doctor #1 gets sued for money by lawyers hired by people seeking money. Doctor calls insurance company who he's paid lots of money to defend doctor #1. Insurance company pays defense lawyer lots of money to defend doctor #1. Plaintiff's lawyer pay Doctor #2 lots of money to help get money from Doctor #1's insurance company. Result: Feeding frenzy over who can extract the most money from the insurance company who raises premiums on both Doctor #1 and #2. Doctor #1 and Doctor #2 go back to work to make more money to pay insurance company. Doctor #2 and Doctor #1 switch places. Cycle repeats

 

[dadaddadaBATMAN]

It's interesting that the social worker was sued for a settlement of $475,000 whereas the physician was sued for a settlement of $45,000. I would expect those numbers to be reversed. Makes me wonder if the social worker somehow really annoyed the family, or if they really do act as a good liability sink (I always wonder how much their determination really shields me). It is a little absurd that the social worker didn't even attempt to obtain collateral information on a suicidal patient who was contracting for safety.

the claim by the plaintiff that the patient's attempt to get out of the car was a "suicide attempt" is far from clear. As for the expert witnesses claim that "suicidal action mandates admission," I think I have discharged young cutters with "suicidal actions" and superficial wrist lacerations three times this month. That claim is nonsense, it depends on context, seriousness of attempt, etc.

It would be helpful to have some literature showing how often inpatient admissions actually prevent suicides, even if they were just estimates. My gestalt is that they may have use for adjustment disorders (temporary stimuli) but are probably useless for anything remotely chronic (95% of our SI patients).

 

[EM Junkie]

It is a little absurd that the social worker didn't even attempt to obtain collateral information on a suicidal patient who was contracting for safety.

I’m quite shocked how few of our social workers obtain collateral information on these, and act annoyed when I ask them if they have.

 

[RoyBasch]

I generally practice very defensively, but these types of psych cases give me no pause. These are truly random. Nobody can really predict which suicidal patients will succeed and which will not. There are so many malingerers and abusers obscuring the picture with the psych patient population.

I think the best we can do is simply provide the standard of care, which in most areas is to have the psych social worker see the patient and follow their disposition recommendation.

I think depression needs to be seen as a chronic disease which has a not insignificant mortality rate in the form of suicide. A decent percentage of these patients with long term depression/suicidality will eventually succeed, and that's the nature of a serious disease just like how a decent percentage of patients with heart failure will eventually die of cardiac complications despite aggressive treatment with medicines and procedures.

 

[turkeyjerky]

This case demonstrates that there is minimal protective utility in having the pysch social worker assess the patient and make recommendations. I cannot stand this practice, I hate taking signouts when it's "dispo per [person with frankly unclear qualifications, training and motivations]". MD stands for Makes Decisions. Their role is to obtain information and facilitate disposition, eg arranging for admission or followup. I cannot understand why we so often abdicate our responsibility to these patients.

And no, it doesn't matter that the ED doc settled for a lower amount than the SW. We all understand that this was a BS case, but it's still gonna follow him/her around for the rest of their career.

 

[GeneralVeers]

Anyone know the rate of psych patients discharged from the ED who actually commit suicide within 30 days?

 

[DrDrummer]

It would be helpful to have some literature showing how often inpatient admissions actually prevent suicides, even if they were just estimates. My gestalt is that they may have use for adjustment disorders (temporary stimuli) but are probably useless for anything remotely chronic (95% of our SI patients).

If anything, there is some data (not high-quality, and nobody will ever RCT this particular question) that compelled or less than entirely voluntary admits may actually increase the risk for suicide attempt / completion.

 

[GeneralVeers]

If anything, there is some data (not high-quality, and nobody will ever RCT this particular question) that compelled or less than entirely voluntary admits may actually increase the risk for suicide attempt / completion.

Well generally the people who WANT to stay in a dirty, crowded, noisy ER and have their rights taken away are people there for secondary gain. I discharge tons of homeless meth heads every week with their daily complaint of suicidality.

 

[bravotwozero]

This case demonstrates that there is minimal protective utility in having the pysch social worker assess the patient and make recommendations. I cannot stand this practice, I hate taking signouts when it's "dispo per [person with frankly unclear qualifications, training and motivations]". MD stands for Makes Decisions.

Some places have tele psych. The person on the other end of that screen is usually an MD who 'makes decisions'. This may be a way to go if one doesn't want the social worker.

 

[RustedFox]

See...

We all need to remember ONE THING here.

The goal of Plaintiff's Council is only ONE THING....


Just "to get to suit".


Once there, their only goal is to shake the tree and see how many coconuts fall.

It's a win, then. Whether two coconuts or ten coconuts... They're still drinking coconut milk.

Doesn't matter if right or wrong. They shook the tree.

 

[emergentmd]

What a stupid case. I have discharged worse and its just whoever ends up having the hot potato. I have seen pts come tot he ER multiple times, cleared by SW and Psychiatry, keeps coming back saying they want to kill themselves.

 

[CliveStaples]

Medical Malpractice has very little to do with clinical medicine and a lot to do with the stars aligning. These stars are called

"sympathetic victim" "family with means" "family is upset"

 

[Brigade4Radiant]

Honestly it doesn’t really matter what you do if you have bad outcomes then there was a case and it may just fall against you.

 

[WilcoWorld]

I could definitely see myself either admitting or discharging this patient. My decision would depend on several factors that it's hard to glean from an EMR unless the doc named in the suit really knows how to write a chart.
With that in mind I try to write charts with this order of priority:

1 - To help the next doc take good care of the patient.
2 - To keep myself from getting sued.
3 - To keep the coders out of my inbox.
Occasionally, I write for...
4 - To make people who read my charts laugh instead of crying at the absurdity of medicine.

 

[Mbekweni]

I could definitely see myself either admitting or discharging this patient. My decision would depend on several factors that it's hard to glean from an EMR unless the doc named in the suit really knows how to write a chart.
With that in mind I try to write charts with this order of priority:

1 - To help the next doc take good care of the patient.
2 - To keep myself from getting sued.
3 - To keep the coders out of my inbox.
Occasionally, I write for...
4 - To make people who read my charts laugh instead of crying at the absurdity of medicine.

The quotation marks around psych charts are always a joy to your colleague when the patient comes back in a week.

 

[thegenius]

This case demonstrates that there is minimal protective utility in having the pysch social worker assess the patient and make recommendations. I cannot stand this practice, I hate taking signouts when it's "dispo per [person with frankly unclear qualifications, training and motivations]". MD stands for Makes Decisions. Their role is to obtain information and facilitate disposition, eg arranging for admission or followup. I cannot understand why we so often abdicate our responsibility to these patients.

And no, it doesn't matter that the ED doc settled for a lower amount than the SW. We all understand that this was a BS case, but it's still gonna follow him/her around for the rest of their career.

Technically there is nothing stopping you, the MD, from doing all of the work to determine if there is a psychiatric emergency, and if so, provide whatever stabilizing treatment necessary prior to discharge. Invariably, if there is a psychiatric emergency, I suspect the standard of care in the ED is to consult a psychiatrist to help provide stabilizing treatment.