Milwaukie ER overdose death

[coachB]

Yeah…my CT utilization rate is 32 percent in my group for ages 18-65 for non trauma patients. I’m in the top 20 percent of utilizers.

No one cares. I’m not changing my practice. I’ve been sued once for literally existing and responding to a code blue. Took one full year to be dropped without prejudice.

I don’t care about utilization. Patients in fact love tests and leave happier when they’ve been thoroughly checked out. And to be perfectly honest, when it’s really busy and im jumping from room to room, chances are my work ups are going to be more thorough as that’s when i know i can miss something. My LOS are still slightly below average so my through put is still okay.

But no one ever got in trouble for ordering that CT scan.

Except maybe the patient. Anticoagulated for the false positive PE. Malignancy. Iatrogenic harm from workup of that incidentaloma. Or maybe the other patient who experienced a delay in care because the scanner was in use.

And hopefully you meant with prejudice. That means the case cannot be refiled. If without prejudice, it can be refiled at a later date and you are not off the hook. Sounds counterintuitive, but that's how it's defined.

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[greatnt249]

Except maybe the patient. Anticoagulated for the false positive PE. Malignancy. Iatrogenic harm from workup of that incidentaloma. Or maybe the other patient who experienced a delay in care because the scanner was in use.

And hopefully you meant with prejudice. That means the case cannot be refiled. If without prejudice, it can be refiled at a later date and you are not off the hook. Sounds counterintuitive, but that's how it's defined.

The gist of what I was getting at was using your best clinical judgment to figure out what test to order and what you plan to do with those results, and that "saving the hospital money" is not really in my clinical decision-making equation. The problem is, "clinical decision-making" cannot simply be distilled into easy-to-follow algorithms for about 95% of medical practice, much to the chagrin of hospital administrators and insurance companies, and the other 5% where there is an algorithm/decision-making tree, there exists a sizeable portion of "practitioners" who don't seem to understand what patient population those guidelines were actually designed for.

 

[cyanide12345678]

Except maybe the patient. Anticoagulated for the false positive PE. Malignancy. Iatrogenic harm from workup of that incidentaloma. Or maybe the other patient who experienced a delay in care because the scanner was in use.

And hopefully you meant with prejudice. That means the case cannot be refiled. If without prejudice, it can be refiled at a later date and you are not off the hook. Sounds counterintuitive, but that's how it's defined.

6 years later, it doesn’t matter. Ohio statute of limitations is 1 year.

Hey…my job is to not miss life threatening issues. And i try not to. We all have patients where we think it’s going to be nothing and then you end up very surprised. It happens all the time. We can get sued and crucified in this specialty for missing things.

 

[cyanide12345678]

The gist of what I was getting at was using your best clinical judgment to figure out what test to order and what you plan to do with those results, and that "saving the hospital money" is not really in my clinical decision-making equation. The problem is, "clinical decision-making" cannot simply be distilled into easy-to-follow algorithms for about 95% of medical practice, much to the chagrin of hospital administrators and insurance companies, and the other 5% where there is an algorithm/decision-making tree, there exists a sizeable portion of "practitioners" who don't seem to understand what patient population those guidelines were actually designed for.

Yeah but even if you have algorithms, they are not 100 percent. Maybe 95 percent? Are you okay with missing 5 percent of things? Society isn’t. Your bosses probably aren’t.

I almost never scan kids. But adults who can make their own decisions and come in acting like they are dying and then everything comes back negative, yeah….id do that work up again every time.

 

[southerndoc]

Not justifying the care that this patient received, but we should all be mindful what we say around police. Proof that they keep their bodycams rolling with mics hot even when in the ER.

 

[BicepsTriceps]

Yeah…my CT utilization rate is 32 percent in my group for ages 18-65 for non trauma patients. I’m in the top 20 percent of utilizers.

No one cares. I’m not changing my practice. I’ve been sued once for literally existing and responding to a code blue. Took one full year to be dropped without prejudice.

I don’t care about utilization. Patients in fact love tests and leave happier when they’ve been thoroughly checked out. And to be perfectly honest, when it’s really busy and im jumping from roo

Yeah but even if you have algorithms, they are not 100 percent. Maybe 95 percent? Are you okay with missing 5 percent of things? Society isn’t. Your bosses probably aren’t.

I almost never scan kids. But adults who can make their own decisions and come in acting like they are dying and then everything comes back negative, yeah….id do that work up again every time.

You're 100% right.

Unfortunately this litigious society choose expensive, wasteful overly defensive medical care.

I'm hospitalist and I appreciate you fully working up these patient and I'd personally order useless tests left and right too because although I'm certain the patient doesn't have the pathology I'm ruling out society won't protect me for my medical judgement and my ass will be on fire for missing it in that weird 1% presentation by not pan scanning the patient.

I'm still young enough and I hope to God I work one day in a medical system that appreciates your education and judgement and protect you from frivolous suits and make you responsible only for clear cut malpractice or deviation of care.

Will this happen as society collapses and resources are more and more rare? 🤷🏻‍♂️

 

[GonnaBeADoc2222]

Except maybe the patient. Anticoagulated for the false positive PE. Malignancy. Iatrogenic harm from workup of that incidentaloma. Or maybe the other patient who experienced a delay in care because the scanner was in use.

Please lol.

Don't come to the ED with every tum tum ache and you won't get scanned.

 

[TooMuchResearch]

I’m curious how do you approach the “no wheelchair” dilemma?

Person is wheelchair bound but for unclear reasons. Like they can walk but use a wheelchair. EMS picks them up but leaves the wheelchair at home.

May or may not have ED social worker there that day but even if you do the social worker can not get a new wheel chair from insurance without a prior auth which takes 48 hours. So pt can’t leave but also Hospitalist won’t admit for inability to ambulate because they’ve already been seen by PT/OT and deemed unable to ambulate…the therapy necessary is a wheelchair.

So they board for 48 h in the ED awaiting prior auth for new wheel chair 🫠

Find a hospitalist who will admit.

 

[TooMuchResearch]

Yup and I’d argue they have some culpability if there’s a bad outcome but I realize that’s not how the legal system/QA process works.

I’ve seen some people who come in literally 100s of times a year for chest pain etc. You can’t troponin/dimer someone every day, but that one time someone doesn’t and it’s real…

I do it every time unless the patient doesn't want to. Yes I will explain that if the sxs are the same it's unlikely to be a heart attack or blood clot today. And then I proceed if that's what they want.

 

[TooMuchResearch]

How about multiple times in one shift lol?

Sure.

 

[TooMuchResearch]

Not justifying the care that this patient received, but we should all be mindful what we say around police. Proof that they keep their bodycams rolling with mics hot even when in the ER.

All the time.

 

[cyanide12345678]

You're 100% right.

Unfortunately this litigious society choose expensive, wasteful overly defensive medical care.

I'm hospitalist and I appreciate you fully working up these patient and I'd personally order useless tests left and right too because although I'm certain the patient doesn't have the pathology I'm ruling out society won't protect me for my medical judgement and my ass will be on fire for missing it in that weird 1% presentation by not pan scanning the patient.

I'm still young enough and I hope to God I work one day in a medical system that appreciates your education and judgement and protect you from frivolous suits and make you responsible only for clear cut malpractice or deviation of care.

Will this happen as society collapses and resources are more and more rare? 🤷🏻‍♂️

The one lawsuit where fortunately i had very very low stakes taught me how ridiculous our system is and just how easy it is for family to sue people.

The person where i was involved had left AMA where he was told he has ekg changes and is having heart related chest pain at pcp office. Refuses to go to ER. Pcp office draws a trop. He signs out AMA. Pcp office gets back trop next day which is elevated, call him again to go to ER, he finally goes many many hours after the phone call. Gets admitted for Nstemi - goes into cardiac arrest 4-5 hours after admission over night for his nstemi. Comes back. Goes to cath. Dies on table.

Their case was that cardiology should have taken him to cath sooner.

But let’s face it…He was an adult who made his decision to leave AMA and understood the consequences - except when the consequences happened, family came running in for a payday.

Moral of the story - if someone makes a bad decision, leaves AMA and dies, you can still be sued because somehow it’s still your responsibility. And depending on your malpractice insurance, they may do a settlement that will stay with you forever. It’s a broken system.

 

[GonnaBeADoc2222]

The one lawsuit where fortunately i had very very low stakes taught me how ridiculous our system is and just how easy it is for family to sue people.

The person where i was involved had left AMA where he was told he has ekg changes and is having heart related chest pain at pcp office. Refuses to go to ER. Pcp office draws a trop. He signs out AMA. Pcp office gets back trop next day which is elevated, call him again to go to ER, he finally goes many many hours after the phone call. Gets admitted for Nstemi - goes into cardiac arrest 4-5 hours after admission over night for his nstemi. Comes back. Goes to cath. Dies on table.

Their case was that cardiology should have taken him to cath sooner.

But let’s face it…He was an adult who made his decision to leave AMA and understood the consequences - except when the consequences happened, family came running in for a payday.

Moral of the story - if someone makes a bad decision, leaves AMA and dies, you can still be sued because somehow it’s still your responsibility. And depending on your malpractice insurance, they may do a settlement that will stay with you forever. It’s a broken system.

My experience has taught me that patients and families are frivolous and greedy.

You can be sued for merely being tangentially involved in the care of a patient who was managed by a specialist.

You can even be sued for not doing a thing, even when you did it, and it is clearly documented.

I've consulted on a case where the accusation was the doc didn't do "x." On reading the documentation, "x" was clearly done. I said to the plaintiffs attorney "are you aware that 'x' was done and clearly stated?" Their response "oh no I didn't see that. What page is it on?"

No response from me.

 

[DocEspana]

yes all of this is horrible.

but is no one bothered by the fact that Milwaukee is spelled "incorrectly"? I have (since) found out that Milwaukie is the correct spelling of the Oregon city, but also.... that just means that they all made a typo 170 years ago at the founding of the city and are too embarrassed to fix it now.

 

[BoardingDoc]

yes all of this is horrible.

but is no one bothered by the fact that Milwaukee is spelled "incorrectly"? I have (since) found out that Milwaukie is the correct spelling of the Oregon city, but also.... that just means that they all made a typo 170 years ago at the founding of the city and are too embarrassed to fix it now.

Meh, the entire state of Idaho is named based on a lie. Settlers were looking for a Native American name for the new state. Some guy suggested Idaho, saying it was a Native American word meaning "gem of the mountains." Spoiler alert, he made all that up. Totally made up word. It wound up getting used as the name for a ship in the region though which then wound up as the state's name through somewhat informal assimilation. State's still called Idaho though.

https://history.idaho.gov/wp-content/uploads/2018/09/howidahogotitsname.pdf

 

[DocEspana]

Meh, the entire state of Idaho is named based on a lie. Settlers were looking for a Native American name for the new state. Some guy suggested Idaho, saying it was a Native American word meaning "gem of the mountains." Spoiler alert, he made all that up. Totally made up word. State's still called Idaho though.

https://history.idaho.gov/wp-content/uploads/2018/09/howidahogotitsname.pdf

Somehow this bothers me less because it's total BS out of left field from a dude and is actually a funny story. This name is just so barely off that it keeps triggering the "spell check" on my head every time I see it.

 

[Apollyon]

yes all of this is horrible.

but is no one bothered by the fact that Milwaukee is spelled "incorrectly"? I have (since) found out that Milwaukie is the correct spelling of the Oregon city, but also.... that just means that they all made a typo 170 years ago at the founding of the city and are too embarrassed to fix it now.

I might venture that's not a typo, per se. In 1850, there was still variable spelling of place names and such. Think of "Pittsburg" vs "Pittsburgh". I don't think this is some embarrassing error.

But, I just learned something, that is akin to "Main Street" in Dog River (on "Corner Gas"). Main Street is not named after being the central concourse, but, Josiah Main, an early settler. That's fiction, but this is fact: the Town of Carrollton, New York. I thought it was originally "the Town of Carroll", then got, somewhat goofily, renamed to "the Town of Carrollton", or in other words, the Town of the Town of Carroll. NO!!!! Denied! Dissed and dis-missed!! Carrollton was named after Guy Carrollton Irvine, who was, indeed, an early settler. Go figure!

 

[DocEspana]

I might venture that's not a typo, per se. In 1850, there was still variable spelling of place names and such. Think of "Pittsburg" vs "Pittsburgh". I don't think this is some embarrassing error.

But, I just learned something, that is akin to "Main Street" in Dog River (on "Corner Gas"). Main Street is not named after being the central concourse, but, Josiah Main, an early settler. That's fiction, but this is fact: the Town of Carrollton, New York. I thought it was originally "the Town of Carroll", then got, somewhat goofily, renamed to "the Town of Carrollton", or in other words, the Town of the Town of Carroll. NO!!!! Denied! Dissed and dis-missed!! Carrollton was named after Guy Carrollton Irvine, who was, indeed, an early settler. Go figure!

It still *feels* wrong. But I did appreciate the knowledge especially because I do know where Carrollton is (due to some distant family in Jamestown that we still visit occasionally) and that's cool and never realized that.

 

[Apollyon]

It still *feels* wrong. But I did appreciate the knowledge especially because I do know where Carrollton is (due to some distant family in Jamestown that we still visit occasionally) and that's cool and never realized that.

At my last job, I drove through at moderate speed every time I went to work! True story, you know you're rural when the wildlife you see on the road is a bear!

And, I remember when Homeland Security put in the license plate skimmers right in the middle of town. 219 is a drug pipeline like I-95 is a gun pipeline.

 

[RustedFox]

At my last job, I drove through at moderate speed every time I went to work! True story, you know you're rural when the wildlife you see on the road is a bear!

And, I remember when Homeland Security put in the license plate skimmers right in the middle of town. 219 is a drug pipeline like I-95 is a gun pipeline.

Two-Nine-Teen.

Oh, dear Lord.

Right thru rural PA... my childhood...
So many memories.
Bro. I might cry.

But for real; 219 is a drug superhighway. A lot of central PA was hit hard by the opioid epidemic. Meth is there, but not so popular. Or at least, that's the way it was last I was there.

 

[Zebra Hunter]

How about multiple times in one shift lol?

lol I have no problem discharging these patients immediately after an EKG and vitals as long as there has been no change in their symptoms and there has been a long history of malingering that has been documented.

 

[xaelia]

I wish general society understood the sheer number of people with just mild personality disorders (not severe psychiatric illness) that we see on a regular basis in the ED. Family and friends are shocked when I talk about many patients and high utilizers of the ED.

It is much more difficult to hold folks against their will/administer medical treatment against their will here in NZ, which makes for some rather interesting situations when coming from training in the U.S.

For example, routinely we have folks coming in for paracetamol (acetaminophen) overdoses above the treatment line – who just peace out while waiting for results, or leave even after NAC has started. Up to them – we're here to help if they want it.

Holding someone under the Mental Health Act requires significant impairment, not just repeated demonstrative supra-therapeutic overdoses. Much different than the almost capricious (and of questionable effectiveness) holds we can exert in the U.S.

 

[Zebra Hunter]

It is much more difficult to hold folks against their will/administer medical treatment against their will here in NZ, which makes for some rather interesting situations when coming from training in the U.S.

For example, routinely we have folks coming in for paracetamol (acetaminophen) overdoses above the treatment line – who just peace out while waiting for results, or leave even after NAC has started. Up to them – we're here to help if they want it.

Holding someone under the Mental Health Act requires significant impairment, not just repeated demonstrative supra-therapeutic overdoses. Much different than the almost capricious (and of questionable effectiveness) holds we can exert in the U.S.

That sounds so much better than the way we do it here. I’m so tired of 8-10 psych holds in the ER wasting resources and beds for the questionable efficacy of psych detention. It’s such an obnoxiously paternal way of dealing with the matter and puts us at increased risk medicolegally when these patients are discharged or elope due to us having the “responsibility” to force these patients to not kill themselves by putting them under detention. It also leads to so much abuse of the system due to no one wanting to be the one to discharge these patients.

 

[Angry Birds]

The police recordings here are going to hang that doctor.

Personally, I have learned to take seriously the concerns of other staff, EMS, police, etc. as I take it as another datapoint, especially if I know I’m biased against the patient.

“Doc, are you sure?” “Doc, the patient doesn’t look right…”

I take these words very seriously.

 

[hoot504]

The police recordings here are going to hang that doctor.

Personally, I have learned to take seriously the concerns of other staff, EMS, police, etc. as I take it as another datapoint, especially if I know I’m biased against the patient.

“Doc, are you sure?” “Doc, the patient doesn’t look right…”

I take these words very seriously.

Absolutely. At the end of the day we're paid for our skills, knowledge, and judgement. Part of exercising good judgement is listening and taking seriously if need be the concerns of others. I can say for sure that nurses have saved my bacon many a time just by sharing their concerns, things they saw/heard when I wasn't in the room, etc.

 

[Porfirio]

I ask police to turn off the body cams or leave the room.

HIPAA laws

 

[TrailRun]

this happened to me for the first time a few months ago. The cop actually seemed to whisper (I think into his lapel) "this conversation is being recorded" or something similar. Took me a few seconds to register what he said. They brought in an elderly confused driver and were asking me if he was intoxicated or on drugs (wasn't). Patient gave me permission to talk to the police so I thought I was helping his case by saying he wasn't, but in retrospect shouldn't have provided any info. But I like the approach above, requesting cameras off to protect HIPAA

 

[Iamnew2]

Absolutely. At the end of the day we're paid for our skills, knowledge, and judgement. Part of exercising good judgement is listening and taking seriously if need be the concerns of others. I can say for sure that nurses have saved my bacon many a time just by sharing their concerns, things they saw/heard when I wasn't in the room, etc.

I agree. Particularly when legalistic issues come up, if things ever come up for a malpractice case and the doctor ignored the staff, sometimes that can bite you in the butt. A different point of view sometimes is helpful

 

[southerndoc]

I ask police to turn off the body cams or leave the room.

HIPAA laws

HIPAA does not apply to police officers.

For a quick reference: Safeguarding Patient Privacy—HIPAA And The Police Body Camera | JD Supra

 

[gruemd]

HIPAA does not apply to police officers.

For a quick reference: Safeguarding Patient Privacy—HIPAA And The Police Body Camera | JD Supra

Yeah, but I basically always ask them to wait in the hall and close the (glass) door unless it's a violent criminal, and then they're usually handcuffed to the bed. There are a whole lot of "I didn't take anything" patients that turn into "Okay what I actually took was x, y, z" patients once I tell the patient I legally can't tell the cops jack and I just want to take care of them. The police are there for police interests, I find that those rarely overlap with medical interests.

 

[TooMuchResearch]

this happened to me for the first time a few months ago. The cop actually seemed to whisper (I think into his lapel) "this conversation is being recorded" or something similar. Took me a few seconds to register what he said. They brought in an elderly confused driver and were asking me if he was intoxicated or on drugs (wasn't). Patient gave me permission to talk to the police so I thought I was helping his case by saying he wasn't, but in retrospect shouldn't have provided any info. But I like the approach above, requesting cameras off to protect HIPAA

They routinely try to remain in the room when I evaluate the patient because they're "not allowed to leave" but ask the nurses to keep an eye while they go to their vehicle or the bathroom. Unless I need police backup for a violent or agitated person, I won't evaluate a patient with police in the room.