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

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EctopicFetus said:
Great post birdstrike.. For the residents.. take note.. dont practice in states with terrible med mal environments. you can be the ones to make the change we need.
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Aside from Texas, what are the states with tort reform that are the safest for EM docs or any other physician for that matter?
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Thanks for the links Birdstrike. It would be interesting if someone did a graph of payouts per capita/medical tort index vs. plaintiff's bar PAC $.
 
BS, I'll admit I've had my head in the sand about that.

We, individual physicians, are paying for it. No doubt.
 
This is certainly good advice and has helped me defend cases in the past. You must give people a fixed timeframe for follow-up and a specific actionable plan to follow.

AmoryBlaine said:
Actually after hearing a med mal lecture I started doing this exactly even on simple cases. Migraine? "If you are not feeling better in 24 hours you need to be seen, if you cannot be seen by your PMD you should return to this ER."
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In regard to your earlier post about chest pain back on the first page of this thread, remember that you can cath everyone who has "clean" coronaries and a certain percentage of those people are still going to have MI's because it turns out that those 60 or 70% non-stentable lesions are the ones with plaque rupture and cause trouble. Indeed, in the McNamara case, the guy could easily have had negative components in the ED and in the hospital, and a negative stress test, and still had the same outcome three months down the road.

Remember folks – we will never attain perfection, nor is it expected of us by the system. You're only expected you to do what a reasonably prudent doctor with similar training would do in the same situation. Thorough charting which addresses the differential and thought process in high-risk diagnoses prevents some lawyer from coming back after-the-fact three or five years down the road and trying to paint a picture of you being some sort of lazy slob who didn't bother to even consider the critical life-threatening problems.
 
bartleby said:
This is certainly good advice and has helped me defend cases in the past. You must give people a fixed timeframe for follow-up and a specific actionable plan to follow.



In regard to your earlier post about chest pain back on the first page of this thread, remember that you can cath everyone who has "clean" coronaries and a certain percentage of those people are still going to have MI's because it turns out that those 60 or 70% non-stentable lesions are the ones with plaque rupture and cause trouble. Indeed, in the McNamara case, the guy could easily have had negative components in the ED and in the hospital, and a negative stress test, and still had the same outcome three months down the road.

Remember folks – we will never attain perfection, nor is it expected of us by the system. You're only expected you to do what a reasonably prudent doctor with similar training would do in the same situation. Thorough charting which addresses the differential and thought process in high-risk diagnoses prevents some lawyer from coming back after-the-fact three or five years down the road and trying to paint a picture of you being some sort of lazy slob who didn't bother to even consider the critical life-threatening problems.
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This case shows this statement to be false in the current environment.
Dr. McNamara is one of the finest I have ever encountered.
He did what was appropriate and got burned.
 
the is system is "designed" for what a prudent and reasonable physician would do in a similar situation. but it fails miserably. it fails bc of who the reasonable and prudent physician is.
once again i point everyone to the aaem website where expert testimonies are posted

https://ssl18.pair.com/aaemorg/expert/search.php?browse=all#results

the reasonable physician is a hired gun who is just trying to make a buck and is honestly a terrible person. i wish i could meet these people in person and tell them what sell outs they are.
mcnamara goes to bat for any physician as an defense expert if the academy asks and this is what he gets in return
 
i'm not a member of AAEM, can't get to list... i highly doubt anyone from there would object to this being public info? at least, semi public, as in you'd have to go looking for it.

this is an absolute travesty. whomever was the "expert" witness in this needs to be blackballed. i don't care who they are, this is absofugginlutely ridiculous.
 
inspirationmd said:
Aside from Texas, what are the states with tort reform that are the safest for EM docs or any other physician for that matter?
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Mississippi has sovereign immunity at any publically funded hospital, of which there are many within the state. The practice environment is pretty good as long as you are at one of those places. I never heard of any huge complaints at the private places. I trained there 4 years and moonlit at both kinds.
 
bartleby said:
This is certainly good advice and has helped me defend cases in the past. You must give people a fixed timeframe for follow-up and a specific actionable plan to follow.

In regard to your earlier post about chest pain back on the first page of this thread, remember that you can cath everyone who has "clean" coronaries and a certain percentage of those people are still going to have MI's because it turns out that those 60 or 70% non-stentable lesions are the ones with plaque rupture and cause trouble. Indeed, in the McNamara case, the guy could easily have had negative components in the ED and in the hospital, and a negative stress test, and still had the same outcome three months down the road.

Remember folks – we will never attain perfection, nor is it expected of us by the system. You're only expected you to do what a reasonably prudent doctor with similar training would do in the same situation. Thorough charting which addresses the differential and thought process in high-risk diagnoses prevents some lawyer from coming back after-the-fact three or five years down the road and trying to paint a picture of you being some sort of lazy slob who didn't bother to even consider the critical life-threatening problems.
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I know, but this is part of the reason I like CCTA (or CTCA however you like). It will be very difficult for a lawyer to claim you didn't investigate ACS and the patient can go home.

I've made peace with this stuff over the course of my residency. No one can sue you for a big bill or for too many tests. I want to do my job and sleep at night. I know the data and the actual prevalence of diseases and I know that time and time again the American people have chosen to ignore them. I have worked with many attendings who are aggressive testers and I can name like 8 that are 10-30 years out who have never been sued.

We act like it's all a problem with trial lawyers, I agree that these people are scum in human form, but when the health care reform bill tried to pay doctors for end-of-life counseling the Tea Party screamed "death panels" until they were blue in the face. The problem runs deep and bipartisan.
 
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AmoryBlaine said:
No one can sue you for a big bill or for too many tests. I want to do my job and sleep at night.

We act like it's all a problem with trial lawyers, I agree that these people are scum in human form, but when the health care reform bill tried to pay doctors for end-of-life counseling the Tea Party screamed "death panels" until they were blue in the face. The problem runs deep and bipartisan.
Click to expand...

1. they can't sue but they will act all nice and grateful to your face (b/c they should be!) then curse out anyone they can speak to about their bill.

2. the tea partiers drive me insane. i have a few in my family, and you just can't argue health care logic with them. they're convinced that the gov't wants to kill off senior citizens.
 
la gringa said:
2. the tea partiers drive me insane. i have a few in my family, and you just can't argue health care logic with them. they're convinced that the gov't wants to kill off senior citizens.
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Liberals drive me insane. I have a few in my family. They think the answer is less freedom for greedy, self-serving capitalists, more handouts and higher taxes. They're convinced that just around the corner is a utopian society driven by government mandates.
 
la gringa we need to ration care.. aka kill off senior citizens.. I would say im a pretty conservative guy but the right is wrong on this
 
What this country needs in order to maintain good healthcare without breaking our bank is more rationing of care (direct money from futile care to effective interventions) and death panels (focus more on quality of life than on prolongation of it).
 
Jarabacoa said:
Liberals drive me insane. I have a few in my family. They think the answer is less freedom for greedy, self-serving capitalists, more handouts and higher taxes. They're convinced that just around the corner is a utopian society driven by government mandates.
Click to expand...

Be that as it may, we tried to pay doctors for end-of-life counseling and conservatives shot it down with mass hysteria. Liberals did not do this.

See also Santorum's bizarre claim that 10% of deaths in the Netherlands are euthanized old people. Really just odd.
 
Jarabacoa said:
Liberals drive me insane. I have a few in my family. They think the answer is less freedom for greedy, self-serving capitalists, more handouts and higher taxes. They're convinced that just around the corner is a utopian society driven by government mandates.
Click to expand...

whoa buddy, you just jumped off the cliff calling me a pan-liberal! though, i am admittedly a big tree hugger :love: mother nature always wins folks, we gotta be good to her... anyway...

i think it's hard to practice EM w/o having a liberal HEART at the core... with a partially conservative BRAIN with which to make some decisions.

rationing of care is absolutely needed, but not based solely on age. few things p!$$ me off more than seeing a terminally ill, almost always onc, patient who is dying in front of me but has no idea that they have a terminal illness! next in line is a demented gomer w/o a DNR. over-riding non-dnr gomer is usually SOMEONE who is profiting from the patient's suffering, which again irks me to no end.

i think that there are enough medical, legal, and economic/stat type brains out there to come up with some better QOL measures... if you fall below certain cutoffs, only palliative treatments would be deemed appropriate and reimbursable. if you want more, you can pony up the cash. we can't keep hemorrhaging money to keep individuals w/ no characteristics of a human being alive indefinitely... i should calculate what a "grandma-gram" costs... basic labs, cxr, ct head, iv fluids, level 4-5 visit.

leading these changes need to be NH medical directors... with plans of care for their terminally ill patients. sending a patient with an unclear MS baseline to the ED for any and all MS changes is not really appropriate in many cases, is very expensive, and doesn't lead to any meaningful outcomes.

the fact that the EOL discussion visit reimbursement was struck down is really sad... even my supposedly educated family members were all up in arms that we were killing off old people. again, the "assessment" for rationing should be multifactorial... but age, as we all know, is a poor prognostic factor for just about anything.

signed,
glad she didn't have to do any grandma-grams or futile tonight, for once
 
Agree w/ La gringa.

I'll change it to mean COMPASSIONATE brain.

And RESPONSIBLE heart.

Saying lib or conservative really caricatures it.

I'd love to blame it on the lawyers, but I see too much complicity from society and the medical profession.
 
la gringa said:
i should calculate what a "grandma-gram" costs... basic labs, cxr, ct head, iv fluids, level 4-5 visit.
Click to expand...

I love this. I'm just letting you know that I'm stealing that. I'll be using it on my next shift.

As for the liberal vs. conservative thing I will say... ungh (sound of donning flame proof garment)... that the issue where conservatives were wrong in pushing the whole "death panel" scare concept is a drop in the ocean compared to the liberal misperception that you can give someone something for nothing and have them care about it. If you entitle someone to free housing they trash it. If you give them free healthy food they sell to buy cigarettes. If you give them Medicaid they call ambulances for rides to the ER for sore throats.
 
southerndoc said:
Caps were overturned by supreme court about two years ago.
Click to expand...

This is funny. Shows how who has money plays a role in what laws get made. In the industrial world there is a price per limb max you get. Guy lost two legs got 200k and disability. People die from threesomes or whatever in medicine and spouses are millionaires.
 
AmoryBlaine said:
Be that as it may, we tried to pay doctors for end-of-life counseling and conservatives shot it down with mass hysteria. Liberals did not do this.

See also Santorum's bizarre claim that 10% of deaths in the Netherlands are euthanized old people. Really just odd.
Click to expand...

Liberals did not do this because it was their legislation. Had it been republican legislation, they would have been just as obstructionist and confrontational.

While I agree that the government needs to stop promising the moon to every retired person, in addition to poor, stupid, lazy, etc., I really like the tea-party message. Look at the sinking Titanic that is the EU, Greece, etc. More government is clearly not the answer. The tea party message is smaller government, with focus on the constitution. The tea-party message is a drive towards an incentive-based society, rather than an entitlement based society. What is wrong with that?

The irony that I will grant you... many elderly people are just as guilty as anybody else with their idea of entitlement. I see it in my own parents. It is everywhere, and it is crushing our society.
 
la gringa said:
whoa buddy, you just jumped off the cliff calling me a pan-liberal! though, i am admittedly a big tree hugger :love: mother nature always wins folks, we gotta be good to her... anyway...
Click to expand...

I hate trees. I grew up in the desert and they just get in the way of the view. I cut them down and chop them up just for exercise. Endangered species laws are out of control. They are simply tools to rip property rights from the hands of land-owners and concentrate power into the hands of the government. The thought that a few inches of ocean rise over a hundred years is going to be catastrophic and that me driving a prius is going to change that is asinine.
 
Jarabacoa said:
I hate trees. I grew up in the desert and they just get in the way of the view. I cut them down and chop them up just for exercise. Endangered species laws are out of control. They are simply tools to rip property rights from the hands of land-owners and concentrate power into the hands of the government. The thought that a few inches of ocean rise over a hundred years is going to be catastrophic and that me driving a prius is going to change that is asinine.
Click to expand...

You echo my thoughts entirely. The modern environmentalist movement is an intellectual failure. Our fundamental problem is that we have too many people in the world and we are making more of them all the time. Short of killing off 2/3 of the people forcing the remainder to adapt a subsistence hunter/gatherer existence devoid of technology, there is nothing we can do. Given that we can't do anything to stop the destruction of Earth (assuming it's real) then all environmental regulations are now designed to increase the scope of government.
 
docB said:
I love this. I'm just letting you know that I'm stealing that. I'll be using it on my next shift.

As for the liberal vs. conservative thing I will say... ungh (sound of donning flame proof garment)... that the issue where conservatives were wrong in pushing the whole "death panel" scare concept is a drop in the ocean compared to the liberal misperception that you can give someone something for nothing and have them care about it. If you entitle someone to free housing they trash it. If you give them free healthy food they sell to buy cigarettes. If you give them Medicaid they call ambulances for rides to the ER for sore throats.
Click to expand...

glad you like my grandma-gram, it just slipped out of my mouth one day and the nurses loved it, so i keep using it.

i'm in no way saying that either side is CORRECT... the truth is in the middle, as usual.
 
doctorFred said:
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?
Click to expand...

Where I trained a lipid panel was ordered on every chest pain. So it is the standard of care some places.

Remember the NNS trumps the NNT every single time.
 
AmoryBlaine said:
Many docs are dropped from lawsuits and the suit ends up being against the hospital. Settlements >$1M are pretty rare. Also the vast majority of med mal cases never really leave the starting gate.
Click to expand...


Is it possible to purchase additional insurance above the typical $1 million/$3 million? I wonder if this is a double-edged sword though because if the limits are higher, I assume the lawyers would go after a higher settlement.
 
GeneralVeers said:
You echo my thoughts entirely. The modern environmentalist movement is an intellectual failure. Our fundamental problem is that we have too many people in the world and we are making more of them all the time. Short of killing off 2/3 of the people forcing the remainder to adapt a subsistence hunter/gatherer existence devoid of technology, there is nothing we can do. Given that we can't do anything to stop the destruction of Earth (assuming it's real) then all environmental regulations are now designed to increase the scope of government.
Click to expand...

I came to the same conclusion some time over the past year.
I'd love to think that there were things I could do to preserve the earth for future generations, but I just don't see it happening.

The population is way out of control and there is no stopping that.
I could think of some ways, but they will never happen.
 
Old_Mil said:
Where I trained a lipid panel was ordered on every chest pain. So it is the standard of care some places.

Remember the NNS trumps the NNT every single time.
Click to expand...

What did you do with that information in the EMERGENCY department? Who followed up on that lab? Was it fasting? Did you start statins on people with an isolated elevated lipid panel from the ED (hope not!)

If a lab is not going to change management in the ED, why order it?
 
have never ordered a lipid panel from the ED nor seen another provider do it.

this is from a large residency that saw a lot of "primary care" as well as the 2 community spots we rotated in in one state, and 3 different community hospitals under 3 different system umbrellas, in 3 more states. 2 of the total of 4 were near, but not in, PA.
 
Yes - I agree that from an EM standpoint you should NOT order tests that won't change your management.

In this case, I don't want to be discussing non-fasting lipids with low risk chest pain patients as I'm discharging patients for their follow-up.

Flopotomist said:
What did you do with that information in the EMERGENCY department? Who followed up on that lab? Was it fasting? Did you start statins on people with an isolated elevated lipid panel from the ED (hope not!)

If a lab is not going to change management in the ED, why order it?
Click to expand...
 
la gringa said:
have never ordered a lipid panel from the ED nor seen another provider do it.
.
Click to expand...

Lipid panels for chest pain in the ED are nonsense.

I have ordered a lipid panel once: Crazy alcoholic dude in complete withdrawl and pancreatitis who we intubated with propofol and had on a propofol drip for days.

HH
 
dotcb said:
Yes - I agree that from an EM standpoint you should NOT order tests that won't change your management.

In this case, I don't want to be discussing non-fasting lipids with low risk chest pain patients as I'm discharging patients for their follow-up.
Click to expand...

I suppose hyperlidemia could bump the TIMI risk score into the "non low risk" category thus admitting the patient.

Sent from my PC36100 using SDN Mobile
 
napster said:
I suppose hyperlidemia could bump the TIMI risk score into the "non low risk" category thus admitting the patient.
Click to expand...

Yep. It's those few times that I order them.

I'm not sure what the turnaround times are in your labs (since someone said who will follow up on it), but in our ED we get lipids back quickly. Haven't timed it exactly but I'd say less than 45 minutes.

If a patient does have dyslipidemia and I discharge them, yes, I do write for a statin.
 
GeneralVeers said:
You echo my thoughts entirely. The modern environmentalist movement is an intellectual failure. Our fundamental problem is that we have too many people in the world and we are making more of them all the time. Short of killing off 2/3 of the people forcing the remainder to adapt a subsistence hunter/gatherer existence devoid of technology, there is nothing we can do. Given that we can't do anything to stop the destruction of Earth (assuming it's real) then all environmental regulations are now designed to increase the scope of government.
Click to expand...

Sheesh, how depressingly defeatist. Just because our specific example of government is not functioning does not mean the functions of government to protect the greater good are inappropriate. Is it really so terrible to have regulations restricting the amount of toxic material dumped into the ecosystem?

Obviously, this is where the "free Americans" culturally differ from the "euro-style Socialists", but individuals left to their own devices act selfishly and destructively more frequently than not. When the consequences of poor choices are felt individually (of which we really don't have any more in the U.S., re: personal responsibility), sure, go ahead. When the consequences of poor choices mean arsenic in the water supply, I'm less enthusiastic. There is clearly some debate regarding the contributing factors and magnitude of global climate change, but - why wouldn't you want to err on the side of minimzing your personal impact?
 
Jarabacoa said:
Liberals did not do this because it was their legislation. Had it been republican legislation, they would have been just as obstructionist and confrontational.

While I agree that the government needs to stop promising the moon to every retired person, in addition to poor, stupid, lazy, etc., I really like the tea-party message. Look at the sinking Titanic that is the EU, Greece, etc. More government is clearly not the answer. The tea party message is smaller government, with focus on the constitution. The tea-party message is a drive towards an incentive-based society, rather than an entitlement based society. What is wrong with that?

The irony that I will grant you... many elderly people are just as guilty as anybody else with their idea of entitlement. I see it in my own parents. It is everywhere, and it is crushing our society.
Click to expand...

Um, no.

Liberals proposed this legislation and conservatives obstructed it. Liberals proposed something we all think is a good idea: compensation for EOL conversations and conservatives lied about it - "death panels." You aren't even really making an argument here are you? Conservatives would not have proposed legislation like this.

Respectfully, the Tea Party has no message. When you ask them what they want they say "cuts and smaller government." When you ask them what exactly they want to cut they say "NPR." They are no less entitled than anyone else.

We all like to focus on the most abusive people in the social welfare system, they exist and they piss us all off but an indictment of them is not a final rebuke on the whole system.
 
xaelia said:
Sheesh, how depressingly defeatist. Just because our specific example of government is not functioning does not mean the functions of government to protect the greater good are inappropriate. Is it really so terrible to have regulations restricting the amount of toxic material dumped into the ecosystem?

Obviously, this is where the "free Americans" culturally differ from the "euro-style Socialists", but individuals left to their own devices act selfishly and destructively more frequently than not. When the consequences of poor choices are felt individually (of which we really don't have any more in the U.S., re: personal responsibility), sure, go ahead. When the consequences of poor choices mean arsenic in the water supply, I'm less enthusiastic. There is clearly some debate regarding the contributing factors and magnitude of global climate change, but - why wouldn't you want to err on the side of minimzing your personal impact?
Click to expand...

totally agree... why not make choices to use less gasoline? recycle? organize errands to minimize fuel consumption? carpool? take only pictures and leave only footprints? i guess those things are just engrained in my being, they aren't hard and DO make an impact if enough people do them!

larger scale environmental issues... who other than the gov't is going to come up with rules and enforce them? corporations have shown time and time again that they will harm people and the earth for profit. no one else stepped up soooo... same reason gov't runs so many other things, like healthcare. you can't depend on humans to reliably make good decisions for themselves, much less others, yet we all want everything to be perfect. sighhhhh
 
+1 for sensible environmentalism.

Also, how is government's keeping the costs of fuel artificially low any less of an "expansion of the scope of government" than emissions restrictions?
 
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AmoryBlaine said:
Um, no.

Liberals proposed this legislation and conservatives obstructed it. Liberals proposed something we all think is a good idea: compensation for EOL conversations and conservatives lied about it - "death panels." You aren't even really making an argument here are you? Conservatives would not have proposed legislation like this.

Respectfully, the Tea Party has no message. When you ask them what they want they say "cuts and smaller government." When you ask them what exactly they want to cut they say "NPR." They are no less entitled than anyone else.

We all like to focus on the most abusive people in the social welfare system, they exist and they piss us all off but an indictment of them is not a final rebuke on the whole system.
Click to expand...
Disagree. While EOLs and rationing (which I am for) were definitely taken to some bizarre place and labeled them death panels.

Re tea party.. I am not one but they are spot on. NO Obamacare, There is way more but since you wanted something specific. A lot of it is broad but that doesnt take away from the importance of it.

Identify constitutionality of every new law
Reject emissions trading
Demand a balanced federal budget
Simplify the tax system
Audit federal government agencies for waste and constitutionality
Limit annual growth in federal spending
Repeal the healthcare legislation passed on March 23, 2010
Pass an 'All-of-the-Above' Energy Policy
Reduce Earmarks
Reduce Taxes
Click to expand...
http://en.wikipedia.org/wiki/Tea_Party_movement
 
EctopicFetus said:
Disagree. While EOLs and rationing (which I am for) were definitely taken to some bizarre place and labeled them death panels.

Re tea party.. I am not one but they are spot on. NO Obamacare, There is way more but since you wanted something specific. A lot of it is broad but that doesnt take away from the importance of it.


http://en.wikipedia.org/wiki/Tea_Party_movement
Click to expand...

They simply do not want to balance the federal budget, they want to talk about balancing the federal budget. The distinction is critically important.

I want to bench press 350 pounds, but I don't have a serious plan to get there. I want to be a billionaire but I don't have a business plan to do so.

Time and time again Tea Partiers have been asked exactly how they would balance the budget and time and time again they say they would lower taxes, increase military spending, and make tiny cuts in programs that liberals like (NPR, NEA, etc). This will not balance the budget. So saying this is one of their positions is just silly.
 
AmoryBlaine said:
Respectfully, the Tea Party has no message. When you ask them what they want they say "cuts and smaller government." When you ask them what exactly they want to cut they say "NPR." They are no less entitled than anyone else.
Click to expand...

What is your message? How would you cut the federal deficit other than making government smaller?
 
la gringa said:
totally agree... why not make choices to use less gasoline? recycle? organize errands to minimize fuel consumption? carpool? take only pictures and leave only footprints? i guess those things are just engrained in my being, they aren't hard and DO make an impact if enough people do them!

larger scale environmental issues... who other than the gov't is going to come up with rules and enforce them? corporations have shown time and time again that they will harm people and the earth for profit. no one else stepped up soooo... same reason gov't runs so many other things, like healthcare. you can't depend on humans to reliably make good decisions for themselves, much less others, yet we all want everything to be perfect. sighhhhh
Click to expand...

http://www.youtube.com/watch?v=HlTxGHn4sH4

This is why I have a problem with large scale environmental issues. They create an extremely inefficient bureaucracy whose ultimate purpose is simply to obstruct development of resources.

If everyone in the USA stopped driving, how much of a decrease in global warming would that cause? Prove it.

Your other points about local conservation are just that...local issues, best dealt with locally.

I have seen the madness of environmental bureaucracy first hand. You haven't. If you did, you wouldn't hold the opinions you do.
 
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