Surreal: EM legend and Temple chair Robert McNamara loses $6.4 million lawsuit

[bougiecric]

http://bit.ly/LNRStV

Phila. jury renders $6.4 million plaintiffs’ verdict in medical malpractice, wrongful death case

6/7/2012 4:20 PM By Jon Campisi

A Philadelphia jury last week rendered a $6.4 million plaintiffs’ verdict in a medical malpractice and wrongful death case filed two years ago by the family of a man who died from a massive heart attack mere months after being released from a city hospital.

The jury’s decision came after a weeklong trial before Philadelphia Common Pleas Court Judge Rosalyn K. Robinson, court records show.

The litigation was initiated back on March 1, 2010, by Wyomissing, Pa. resident Frederick Nice, administrator of the estate of the late Derrick Harlem.

The defendants originally named in the case were Temple University Hospital, Temple University Health System, Temple University School of Medicine, Temple University Health System Foundation, Temple University and doctors Robert T. McNamara and Marsha W. Edwards.

Derrick Harlem was 38 years old at the time of his death on Nov. 12, 2009, court records show.

Nice, Harlem’s estate administrator, filed the civil action on behalf of Harlem’s five surviving children, who range in age from 1 to 8.

The children are Harlem’s beneficiaries and entitled to wrongful death and survival damages, the complaint stated.

According to the lawsuit, Harlem’s ordeal began back on May 31, 2009, when emergency medical personnel transported the man to Temple University Hospital’s emergency room with complaints of chest and shoulder pain.

Harlem, who the lawsuit stated had a history of atrial fibrillation, began to experience chest and shoulder pains while playing basketball earlier that day, the record shows.

While at the hospital, Harlem was assessed by resident physician Edwards and attending physician McNamara.

The lawsuit claimed that the doctors failed to order cardiac biomarkers and a lipid panel for Harlem, who at the time had an elevated white blood cell count.

Following further testing, Harlem was diagnosed with having pneumonia and syncope and discharged from Temple’s emergency department at about 9 that evening.

Exactly three months later, on Aug. 30, 2009, emergency medical personnel were called to the scene of a man having a seizure in North Philadelphia.

Upon arrival, the emergency workers found Harlem vomiting and spitting and coughing following a game of basketball, according to the lawsuit.

After suffering from a seizure and going into shock, medical workers took Harlem back to Temple University Hospital, where he was placed on mechanical ventilation.

The following evening, Harlem was diagnosed with an acute heart attack with cardiac arrest and anoxic brain injury.

Harlem went on to be treated for the heart problems, as well as for pneumonia and an infected abdominal wound.

He was discharged from Temple to a long-term care facility on Oct. 7, 2009.

Between that day and the date of his death on Nov. 12 of that year, Harlem remained ventilator-dependent and had to undergo numerous medical procedures, the lawsuit states.

The lawsuit claimed that the various defendants’ negligence led to Harlem’s ultimate demise. The suit contained counts of both negligence and corporate negligence.

The trial opened on May 21 and commenced with a jury verdict for the plaintiff’s on June 1, court records show.

Causal negligence was attributed to the three defendants who made it to trial: Temple University Hospital, and doctors McNamara and Edwards.

According to the verdict sheet, McNamara was found to be 88 percent negligent, Edwards was found to be 10 percent negligent and Temple was determined to be 2 percent negligent in Harlem’s death.

The verdict breakdown included $5,657,039.82 for total Survival Act and wrongful death damages plus $750,000 for pain and suffering, totaling $6,407,039.82.

The plaintiff in the case was represented by attorney Matthew A. Casey of the Philadelphia firm Ross Feller Casey LLP.

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[curious1x]

Any follow up with PCP between the initial Ed visit and the return 3 months later....
Probably not....bc there is no more self accountability in this country.

So what happens if I discharge some one with atypical cp, and a year later they die. My fault, bc I didn't get cards to cath the pt.

The medico legal environment here is just a joke any more.

 

[Flopotomist]

I would be very curious to see the transcript of the case and read what the plaintiffs expert witnesses felt the standard of care was here that was breeched.

 

[Medicfletch]

There was a discussion regarding this on another forum including some transcripts, one of the key points from the expert was the Ed's failure to check lipids on this pt which they felt was standard of care. Excuse me? Lipids? When did this become Ed standard of care?

 

[EctopicFetus]

Obviously there is more to this.. Yes lipid panel cause the WBC is up.. dumbest thing I ever heard.. but the reporter probably got their Associates degree online.

Anyways, my practice.. come to the ED with chest pain.. if i send you home its cards follow up in 1-2 days. Why.. because of this crap. 20 with CP.. f/u with cards, struck in the chest with a baseball f/u cards and PCP.. Stabbed in chest.. f/u cards (kidding on that one).

The only complaint i have recieved was for a patient who I sent to hand surgery for a retained FB from a lac that happened on the job and not occ health.. Ugh.. the patient's supervsor should send them to occ health. Anyways I learned my lesson..

The med mal system is so broken its not funny. 38 years old.. without family history? without personal history? I mean come on.. if so then this is crap.. but in the jackpot med mal system they go for it.

I am sure there is more to the case BUT this still blows.

 

[strongboy2005]

The article makes it sound like an MI was missed on the first visit to the ED. If so, then was there at least an EKG done? Would like to know more details.

 

[southerndoc]

The article makes it sound like an MI was missed on the first visit to the ED. If so, then was there at least an EKG done? Would like to know more details.

The article makes it sound like we don't know if the patient had an MI on their first visit since serial cardiac markers weren't checked.

I routinely check lipid panels (non-fasting) on chest pains that are borderline risky. However, I only do it at my main hospital because the turnaround time is pretty quick and it's on our check box for orders (so it's easy to order). Once, and only once, did it change the disposition of a patient. A 28 year old with cardiac-sounding chest pain (pressure, radiation down arm) that ended up with an LDL of 300+ and an HDL of 15. Admitted to cards, second troponin was positive, and cath showed a stentable lesion.

Yes I realize how many lipid panels I've ordered that has cost the healthcare system money only to find that one case that it made a difference.

Thankfully my state has a gross negligence clause. It's not grossly negligent to skip a lipid panel on a chest pain patient while in the ED.

 

[Arcan57]

I was thinking that maybe we should start applying some CMS/JC practices to med mal. For example, the concept of "never" events. A missed MI is never worth $6.8 million, suing after an ED visit should never happen if the bad outcome occurs more than 30 days after the visit, etc. A lawyer's fee would be at risk if they can't prove that they followed best practices in prosecuting the suit (especially in the realm of expert witnesses), and what those practices are would be determined by an appointed panel of doctors. Malfeasance on the part of the client or expert witnesses would not let the lawyer off the hook.

Just a thought.

 

[Arcan57]

The article makes it sound like we don't know if the patient had an MI on their first visit since serial cardiac markers weren't checked.

I routinely check lipid panels (non-fasting) on chest pains that are borderline risky. However, I only do it at my main hospital because the turnaround time is pretty quick and it's on our check box for orders (so it's easy to order). Once, and only once, did it change the disposition of a patient. A 28 year old with cardiac-sounding chest pain (pressure, radiation down arm) that ended up with an LDL of 300+ and an HDL of 15. Admitted to cards, second troponin was positive, and cath showed a stentable lesion.

Yes I realize how many lipid panels I've ordered that has cost the healthcare system money only to find that one case that it made a difference.

Thankfully my state has a gross negligence clause. It's not grossly negligent to skip a lipid panel on a chest pain patient while in the ED.

It's not negligent at all. A non-fasting lipid panel has essentially no value in determining an emergent cause of anything (except maybe pancreatitis), and cholesterol can be effected by illness such that at my last hospital (prior to CMS mandating it for inpatients) fasting lipids were checked on ACS pts on their first post-hospital outpatient visit for improved accuracy. And if someone sounds like they have cardiac chest pain, then admit them. You should have admitted them regardless of their LDL or at least kept them around for a 2nd set prior to D/C.

I don't mean to go off on you but we need to stop the mission creep. We are sh
&ty primary care doctors and trying to act like we aren't is a recipe for trouble. And if there's somebody getting lipid panels on every chest pain pt, then there's going to be some jackass on the stand saying it's standard of care. #%$%@

 

[CraftyMed]

The points that stick out to me are:
1. chest pain
2. chest pain with radiation to the shoulder
3. exertional chest pain
4. no cardiac markers drawn at initial eval
5. diagnosed on discharge with pneumonia and syncope

I'm sure there's more to the story than just the article suggests, but I think I would have ordered cardiac markers on this guy. Do I think it would've changed the whole endpoint? No. Sadly, I did not see in the lawsuit his PCP or the Cardiologist that he should be following with his h/o AFib and the episode of chest pain.

I love my town, but I hate the malpractice environment.

 

[Cerberus]

Mind boggling.

 

[Hamhock]

It's not negligent at all. A non-fasting lipid panel has essentially no value in determining an emergent cause of anything (except maybe pancreatitis), and cholesterol can be effected by illness such that at my last hospital (prior to CMS mandating it for inpatients) fasting lipids were checked on ACS pts on their first post-hospital outpatient visit for improved accuracy. And if someone sounds like they have cardiac chest pain, then admit them. You should have admitted them regardless of their LDL or at least kept them around for a 2nd set prior to D/C.

I don't mean to go off on you but we need to stop the mission creep. We are sh
&ty primary care doctors and trying to act like we aren't is a recipe for trouble. And if there's somebody getting lipid panels on every chest pain pt, then there's going to be some jackass on the stand saying it's standard of care. #%$%@

Indeed, it's almost "negligent" to get the lipid panel. (yes, I know the definition of 'negligent'; just making a point)

HH

 

[Hamhock]

Has anyone ever requested a transcript of a case like this? How practical is it to do so?

HH

 

[EMFreakz]

More importantly for him, what's he going to do? Likely his insurance covers to 1mill. How is he going to pay this? This freaks me out about how to support a family.

 

[la gringa]

my understanding from a PI lawyer is that physicians who are sued in excess of coverage declare bankruptcy.... my group's internal lawyer says most of the time things are settled far in advance and the max from your med mal is the most they'd go for.

this went to a jury so... no telling where they got the number. anyone know how Temple is insured?

 

[RustedFox]

This just makes me so extraordinarily angry.

When is "enough" enough ? Awhile ago, if you ask me.

 

[sleepymed]

This lawsuit makes me so mad. Dr. McNamarra is a phenomenal doctor, I am sure we do not know all the details of the case, but they were able to spin it so that all anyone heard was orphaned children, orphaned children; and the other doctor that was named was a resident! I hate the nature of our practice of medicine in the states, but because of cases like this, I feel like our hand has been pushed into being more defensive in our practice, EVERYONE wants to cash in. I hate lawyers, there should be a special place in hell reserved for greasy, slimy, ambulance chasers.

Articles like this: http://www.personalinjuryjuryverdictnews.com/2012/06/misdiagnosis-results-in-6-4-million-award/

further enrage me. Enough is enough. We need to stand up for ourselves, people need to have personal accountability, an event that happens MONTHS after being discharged from the ED should not be considered a "missed" event. Argh.

So Mad. Sorry for the rambling, disjointed post, I'm functioning on very little sleep.

 

[TooMuchResearch]

This lawsuit makes me so mad. Dr. McNamarra is a phenomenal doctor, I am sure we do not know all the details of the case, but they were able to spin it so that all anyone heard was orphaned children, orphaned children; and the other doctor that was named was a resident! I hate the nature of our practice of medicine in the states, but because of cases like this, I feel like our hand has been pushed into being more defensive in our practice, EVERYONE wants to cash in. I hate lawyers, there should be a special place in hell reserved for greasy, slimy, ambulance chasers.

Articles like this: http://www.personalinjuryjuryverdictnews.com/2012/06/misdiagnosis-results-in-6-4-million-award/

further enrage me. Enough is enough. We need to stand up for ourselves, people need to have personal accountability, an event that happens MONTHS after being discharged from the ED should not be considered a "missed" event. Argh.

So Mad. Sorry for the rambling, disjointed post, I'm functioning on very little sleep.

But what good does a place in hell do for the living?

 

[dotcb]

Nonsense - what clearly happened in that courtroom was shenanigans. Causality? Proximate cause? That is seriously a raw deal.

I have ordered lipids on a chest pain case exactly never.

 

[Apollyon]

As has been said, there's something we're not getting. Strictly going on what was said, I wonder if there was a movement for JNOV (judgment non obstante veredicto - and that is correct, notwithstanding any idiots on SDN), or judgment notwithstanding the verdict, where the judge, as a matter of law, can overrule a jury decision, if the judge determines there's no way a reasonable jury could have arrived at that verdict.

 

[gman33]

This one hits really close to home.
Starting my residency tomorrow and kind of thinking I shouldn't even bother if this is the world I'm entering.

Besides the obvious bs part, what lessons should I try to learn about how to protect myself? I'm not talking about the medicine part, I mean the financial part.

Like don't practice in a place without tort limits, where to shelter my investments in case of this type of judgement, etc...

I know being a doc, especially in EM, means you are going to be sued multiple times.
It's just crazy how one case like this that you probably would never think about again can come back and ruin your life.

 

[EM_Rebuilder]

God Bless Texas...

Get involved with ACEP, go to the L&A Conference. Lobby for the passing of Tort Reform for all physicians...

I met with my House Member and Senators and asked them to support Tort Reforms; and yet I am in Texas where things are already good.

There are power in numbers.. support ACEP/NEMPAC.

 

[8654Marine]

Whoa, let's take a step back for a sec.

There must have been an "expert witness" for the plaintiff who made it very clear that an elevated WBC begets emergent lipid panel. That pneumonia beget cardiac enzymes.

This is obviously the "standard of care".

Remember folks, we are our worst enemy. The lawyers know and capitalize on this.

Know any other profession that charges $400-1000/hr for some great oral skills?

 

[AmoryBlaine]

The sad reality of life now is that MI is not just a dx for people over 45 who are obese.

Our standard of care is to never miss and MI, or something like this can happen.

I actually love the idea of high sensitivity trops (helpful if neg) and coronary CTs.

You come to the ER with chest pain, I don't care about your bill and I don't care about the radiation you get. At all. You are getting worked up unless you are very young and your story is terrible.

 

[deleted109597]

I don't care about the radiation you get. At all.

Until 5-10 years from now when the cancer rates skyrocket and we are at fault for that too. What we need is sensible reform, not testing everyone. Let me put it this way, at my shop we see an average of 140 pts/day. At least half have chest pain, and anyone who calls an ambulance with chest pain comes to my "chest pain center of excellence."
I cannot physically admit all of them. So my choice is to miss the MIs in the lobby, or the MIs I send home.

 

[doctorFred]

Sorry, but as somewhat of an aside, lipid panels? Are you people kidding me? You people order lipid panels in the ED? Forget about standard of care, I didn't even know that was a reasonable variant. Familial hypercholesterolemias are rare, lipid panels cost at least a hundred bucks, and we must see 15-20K chest pain complaints/year. The NNT on that one must be pretty high, and associated with a multi-million dollar cost.

Is it just me, or does anyone else think that lipid panels are the purview of internists?

 

[Hamhock]

Sorry, but as somewhat of an aside, lipid panels? Are you people kidding me? You people order lipid panels in the ED? Forget about standard of care, I didn't even know that was a reasonable variant. Familial hypercholesterolemias are rare, lipid panels cost at least a hundred bucks, and we must see 15-20K chest pain complaints/year. The NNT on that one must be pretty high, and associated with a multi-million dollar cost.

Is it just me, or does anyone else think that lipid panels are the purview of internists?

And I would like to point out the idea that traditional "cardiac risk factors" (eg lipids) are for CAD, not ACS.

HH

 

[Hamhock]

Whoa, let's take a step back for a sec.

There must have been an "expert witness" for the plaintiff who made it very clear that an elevated WBC begets emergent lipid panel. That pneumonia beget cardiac enzymes.

This is obviously the "standard of care".

Remember folks, we are our worst enemy.

This is kinda what I was getting at with my question above about the transcript.

I'd like to know who the plantiff's expert witness was....and I'd like to read the testimony.

HH

 

[Khaos]

From what our group's lawyer has told us, we rarely pay more than the max our insurance pays. He says that you go up to the other lawyer, tell him that the max the insurance pays and that because of it you are going to ask for a new trial to re-try the case...usually instead of going to court again for a couple of years they agree to the max.

Second, when have lipids become emergent! They show risk, they do not indicate acute MI.

Last, I agree with personal accountability. Why didn't this guy follow up with his PCP. He has a h/o a.fib...did he follow up with his cardiologist?

 

[AmoryBlaine]

Until 5-10 years from now when the cancer rates skyrocket and we are at fault for that too. What we need is sensible reform, not testing everyone. Let me put it this way, at my shop we see an average of 140 pts/day. At least half have chest pain, and anyone who calls an ambulance with chest pain comes to my "chest pain center of excellence."
I cannot physically admit all of them. So my choice is to miss the MIs in the lobby, or the MIs I send home.

Well it's going to be very difficult to sue a doctor for a CT scan 10 years ago. I don't know about the statute of limitations but it may come into play here.

I agree that we need sensible reform, we all agree on that. The question is what you are going to do until that reform comes. We all know how we would practice if our entire country suddenly had an outbreak of sanity -- that's the easiest question in emergency medicine.

I'm not saying I admit every chest pain, but I take them very seriously. If you're 28, no risk factors, but you have a good story - sorry but you're getting admitted. If I get pushback I tell them to come listen to the description of this chest pain then blow it off. If that guy goes to a cardiologist with the same story, what do they do? The f***ing stress him is what they do. The point here is that none of us are missing MIs in the 52 year old obese diabetic smoker who is clutching his chest and sweating, but we are missing the atypical cases and getting burned for it. Until I am incentivized to control cost, I will not be controlling cost.

Call me a ***** if you like.

 

[Flopotomist]

A while ago, AAEM was listing on its website a "remarkable testimony" page where plaintiffs attorneys who gave testimony that was absurd (eg lipids in the ED) could be publically identified as giving testimony that was grossly incorrect. It is an imperfect system, but one step in the direction of policing ourselves.

If somebody sells out and says something like lipids are standard of care for chest pain in the ED, then they get to say it once in court, but for their NEXT case, the defense attorney could argue "Dr. Smith, weren't you identified by the American Academy of Emergency Medicine as giving testimony so egregious that you were publically rebuked by them in a previous case?"

Perhaps somebody should refer the witness in the above case to AAEM for review.

http://www.aaem.org/aaemtestimony/cases/2/

 

[Zback]

Perhaps somebody should refer the witness in the above case to AAEM for review.

http://www.aaem.org/aaemtestimony/cases/2/

This is what we need to see more of. If they would have this on the website, then publish it in their monthly magazine it would put a stop to some of these clowns getting on the stand and giving misleading information.

 

[Apollyon]

Last, I agree with personal accountability. Why didn't this guy follow up with his PCP. He has a h/o a.fib...did he follow up with his cardiologist?

Seriously - the guy was playing basketball! It's not like he was playing checkers with one of his kids, or sitting, nearly immobile, watching TV.

100% of people WILL die some time in their lives (proven with 100% specificity and sensitivity up until this very day, so far).

If we can't regulate morality, are we going to regulate physiology?

Or, perhaps, we should just collate a list:
1. playing basketball
2. having a threesome
3. ...

 

[JMC2010]

Dr. McNamara's personal malpractice will kick in to the tune of 1 million dollars. Then Temple will cover a certain percentage and finally the State of Pennsylvania Mcare fund will cover the rest of the cost. Your tax dollars at work...

 

[docB]

I'm really sorry for Dr. McNamara. For this to happen to someone who has been such a fantastic educator for so many physicians is a travesty. The med mal system is clearly out of control and is an overwhelming negative for society. I hope that this can be appealed, reduced or otherwise changed.

 

[circulus vitios]

Know any other profession that charges $400-1000/hr for some great oral skills?

 

[deleted109597]

Well it's going to be very difficult to sue a doctor for a CT scan 10 years ago. I don't know about the statute of limitations but it may come into play here.

I bet 3 weeks ago you would have said it would be difficult to sue for an MI months after beeing seen in the ED for pneumonia as well. Also, statute for what? Did people sue tobacco companies decades after they quit smoking? What about those mesothelioma commercials you see on tv? This is civil law, not criminal law.

I'm not saying I admit every chest pain, but I take them very seriously. If you're 28, no risk factors, but you have a good story - sorry but you're getting admitted. If I get pushback I tell them to come listen to the description of this chest pain then blow it off. If that guy goes to a cardiologist with the same story, what do they do? The f***ing stress him is what they do. The point here is that none of us are missing MIs in the 52 year old obese diabetic smoker who is clutching his chest and sweating, but we are missing the atypical cases and getting burned for it. Until I am incentivized to control cost, I will not be controlling cost.

Call me a ***** if you like.

No reason to call you names. On the flip side, I practice in a great place for sensible medicine. I just wish I could get some of my colleages to do the same. 28, no family history, not obese, nonsmoker? You can go home with an EKG and a CXR. 50, with known CAD but two negative trops at 6 hours of pain, and currently pain free? You can stress next week (still not a great study either). EKG changes, positive (or trending positive) trops, sure, no question about admit, because those people need a cath.
My state's standard for malpractice is willful and wanton.

 

[Tiger26]

The sad reality of life now is that MI is not just a dx for people over 45 who are obese.

Our standard of care is to never miss and MI, or something like this can happen.

I actually love the idea of high sensitivity trops (helpful if neg) and coronary CTs.

You come to the ER with chest pain, I don't care about your bill and I don't care about the radiation you get. At all. You are getting worked up unless you are very young and your story is terrible.

I'm with AB on this one--it's like being able to order a cath from the ED.

 

[southerndoc]

lipid panels cost at least a hundred bucks, and we must see 15-20K chest pain complaints/year

So do rapid streps.

 

[RustedFox]

The sad reality of life now is that MI is not just a dx for people over 45 who are obese.

Our standard of care is to never miss and MI, or something like this can happen.

I actually love the idea of high sensitivity trops (helpful if neg) and coronary CTs.

You come to the ER with chest pain, I don't care about your bill and I don't care about the radiation you get. At all. You are getting worked up unless you are very young and your story is terrible.

Yep. I recently reached this conclusion as well with regard to radiation and CTs and such.

Its either the patients' DNA getting cooked, or my malpractice record being cooked.

Eff them. Until "they" realize that they are free to go die in a ditch without our help... they can have it "their way". I no longer give a ****. Light 'em up.

I'm "paying" (with my taxes, which are extraordinarily high, comparatively) for the privilege of treating these patients.... at great financial risk to myself ?

Nope. Your cancer is not my problem when you wish to sue me for poor customer service. They can have it their way... right into glioblastomaland.

 

[xaelia]

CCTA in our low-risk group that rules out with two sets is pure patient harm.

The risk-group was so low in those studies that their 30-day outcomes would already have been brilliant. The false positives and interventions from those scans are going to hurt more folks than they help. See: overdiagnosis of pulmonary embolism and complications from anticoagulation.

Makes the chart look pretty in case of bad outcome, though. It's sad that everyone outside of academics and Texas has to practice such absurdity. Don't just blame the lawyers - blame the industry-sponsored literature that pushes the requirement for diagnostic imaging and the professional societies that establish this as the "standard of care".

 

[pseudoknot]

I think it's potentially overreacting to go from a case where, although we really have no clue what happened, possibly involved a guy with exertional pain being sent out without a troponin, to saying that we have to CTA everyone. Troponins really have made a huge difference in the detection rate. If that wasn't run, it's a very different scenario than if it was. (I realize it wouldn't have made a medical difference here, from the sounds of it, but it may have legally.)

 

[deleted109597]

Troponins really have made a huge difference in the detection rate.

Yes, of ACS. This case, again, is about CAD. Troponins don't detect that.

 

[Hamhock]

So do rapid streps.

A waste of a test also.

These should not be sent from the ED, either.

HH

 

[pseudoknot]

Yes, of ACS. This case, again, is about CAD. Troponins don't detect that.

Right, as I said, I don't think it would have made a difference medically. I'm just saying that not getting a troponin in the initial visit could have been seen as a deviation from the standard of care. On the other hand before this thread I've never heard of ordering lipid panels in the ED, and I have no idea why you would do such a thing.

 

[VA Hopeful Dr]

A waste of a test also.

These should not be sent from the ED, either.

HH

They should if you're going to treat for strep. If you're going to send them back to me (FP) without antibiotics (which I'd prefer anyway), then I'm with you.

 

[link2swim06]

From what our group's lawyer has told us, we rarely pay more than the max our insurance pays. He says that you go up to the other lawyer, tell him that the max the insurance pays and that because of it you are going to ask for a new trial to re-try the case...usually instead of going to court again for a couple of years they agree to the max.

Second, when have lipids become emergent! They show risk, they do not indicate acute MI.

Last, I agree with personal accountability. Why didn't this guy follow up with his PCP. He has a h/o a.fib...did he follow up with his cardiologist?

Plus ridiculously high dollar lawsuits like this almost always get over turned/greatly reduced by the appellate court even if they do go back to court.

 

[deleted109597]

They should if you're going to treat for strep. If you're going to send them back to me (FP) without antibiotics (which I'd prefer anyway), then I'm with you.

No they shouldn't. If you decide to treat based on Centor criteria, then treat. Otherwise don't treat. You can treat strep with lollipops for all I care, but the test is expensive, and the culture is worse.
And, important for this thread, we spend far more money testing and treating strep than we save in preventing rheumatic fever (since we don't have a rheumatogenic strain in the US). But we do it to prevent lawsuits and increase our Press Ganey.

 

[xaelia]

No they shouldn't. If you decide to treat based on Centor criteria, then treat. Otherwise don't treat. You can treat strep with lollipops for all I care, but the test is expensive, and the culture is worse.
And, important for this thread, we spend far more money testing and treating strep than we save in preventing rheumatic fever (since we don't have a rheumatogenic strain in the US). But we do it to prevent lawsuits and increase our Press Ganey.

The NNT to prevent a single case of rheumatic fever in the continental U.S. will be at least >100,000, and many would say >1,000,000. The NNT to prevent PTA is probably more like ~5000. And I don't know your NNT to cover other rare causes of pathologic pharyngitis, such as fusobacterium, but I'm sure it's very high.

Hard to quantify the direct cost harms to each individual - and, at least, if you're giving amox or pen G, it's a cheap medicine on an individual basis. Billing the patient for your strep testing/culture is significant. So, aggregate costs are high, the antimicrobial resistance harms are non-negligible, allergic reaction harms are small but non-zero, and antibiotic-associated diarrheal harms are not uncommon. Why do we do this again?

 

[GeneralVeers]

No they shouldn't. If you decide to treat based on Centor criteria, then treat. Otherwise don't treat. You can treat strep with lollipops for all I care, but the test is expensive, and the culture is worse.
And, important for this thread, we spend far more money testing and treating strep than we save in preventing rheumatic fever (since we don't have a rheumatogenic strain in the US). But we do it to prevent lawsuits and increase our Press Ganey.

Exactly. There is little utility in the rapid strep (sensitivity of 80%??) but people expect it to be done. If you don't do the little swab thing and send the test, people assume that your care has fallen below standards.

Americans assume that more tests = better care.