Grand Rounds Recap 9.9.2020
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medical malpractice WITH dr. ryan
Medical Malpractice
In Emergency Medicine:
16.5% of those under 40 will be sued
75% over 55 years old will have been sued
The longer you practice the more likely you are to be sued
22% of cases are found in favor the plaintiff
Reasons you may be sued
They don’t like you
Failure to diagnose
Procedures performed improperly
Delays in treatment, consultation, admission
Weak medical record, inattentive follow up
Overlooked labs/testing/orders
Turnovers, poor discharge instructions
The “cost”
Time
It takes 45 months on average to get through the courts
Money
It costs about $100K, even if found not to be negligent
Stress
How to reduce the risk of a lawsuit
Spend time with the patient
Explain times and what to expect
Listen to the patient
Be happy
Apologize
This is not an admission of guilt
It has been shown that an admission of medical error will lead to a decrease likelihood that you will be sued
Criteria for a case to move forward
The physician had a duty
Had a relationship with the patient
In the ED: a patient walked through the front door of the emergency department
The physician breached the duty
Caused harm
Did not provide the best care or follow standard of care
There was harm to the patient
The harm was caused by the physician’s breach of duty
Affidavit of Merit
Designed to make plaintiffs prove that they have done their homework before filing a medical malpractice lawsuit
The physician expert must review the case and opine a standard of care breach
They must confirm that there was a breach of standard of care
Must review all of the available records and confirm that you are qualified and familiar with the applicable standard of care
Ohio 2008 Tort Reform
Non Economic loss awards:
Capped at $250k or 3x the amount of economic damages, not to exceed $350k per plaintiff
Exception: permanent and substantial physical functional injury - so that the patient can not independently care for self
Types of cases
Malpractice
1 year from discovery to file
For EM usually the occurrence date is the discovery
Wrongful death
2 years from discovery to file
Discovery is the date of death
180 day letter
Extends by 180 days the ability to file medical malpractice or wrongful death
Majority of these do not move on to lawsuits because most bad lawsuits are identified before the end date
Types of courts
Common Pleas
Located in each county in Ohio
Both criminal and civil matters
Trial by jury
Judges are elected
Non-teaching setting cases go here
Court of Claims
Located in Columbus, OH
Cannot sue state employee in a teaching setting
Defined as working with a resident
The hospital is the only defendant
Not reported to the National Practitioner’s Data Bank (so it is reported for all jobs applied for)
Single Judge
Appointment position
Trial by fact only not jury - the judge makes the decision
Separate trial for damages
With the same judge
Process will take YEARS
Case #1: “The Ankle”
60s year old presents after a trip and sprained ankle with negative XR
Family doc followed him up: continue what you're doing
Goes to Europe for 6 months
Follows up with family doc when returns
Goes to Ortho - XR negative again and now PT
Ankle still hurts
MRI shows torn Achilles tendon
The cases you don’t think you will get sued about are often the ones that are pursued
Case #2: “The Shoulder”
Patient arrived after a witnessed seizure: normal exam, R shoulder pain but XR negative
Another seizure with another normal exam and negative shoulder XR
Seized in the ED again after XR but no new XR was obtained
Fracture seen at next visit 1 week later
No further exam after 2nd seizure here
Need to document seizure precautions
Documenting and re-examining is important
Tubes and things WITH dr. hill
Tracheostomies
Check out our podcast with airway guru Dr. Carleton
Grab anesthetization
Progressively dilate until the tube can be passed
When placing the trach:
Should come from the side and rotate down when inserting with more force then you feel comfortable with
NG/NJ
NG
Not innocuous procedures - painful and stressful for the patient
Very important to prepare for the procedure before starting it
Afrin and lidocaine jelly are key - especially for a salem sump
Coat an NP airway to help open the walls and increase anesthesia
Put in warm water to soften up the tube
Wrap around the hand to help with memory and get the tube to follow
Positioning
Have them straight up with the stretcher back behind them
Past the nasal cavity have them swallow to help pull the tube into the esophagus
Be prepared to occlude the second port so you do not get vomit everywhere
Have them speak afterwards
If it is in airway they will not be able to speak normally
Dobhoff tubes:
~2% incidence of malposition in the tracheobronchial tree
Have a lead weighted tip to help get post-pyloric
Wire with some stiffness
On X-ray:
Should be below the diaphragm and then pool in the stomach
PEG/G/J
Feeding tube change questions to ask:
How long has it been out?
How long has it been in?
How big is it?
Where does it go and where is it supposed to be?
Is it mature?
Call a surgeon if it is <2-3 weeks
What kind of tube is it supposed to be?
Can search the EMR for the tube and what kind of tube it is
When to call surgery?
Within first month post op
Or if the wound does not appear well healed
Placed in a digestively specific location
The ostomy is no longer patent
Local infection/abscess near the ostomy tract
Types of Problems:
The ostomy is open and the tube is readily available
You need:
the correct tube, lube, toomey syringe
Who gets placement confirmation?
No need:
If it goes in easy with no resistance
Aspirates gastric contents easily
Insufflate air +Borborygmus
If none of these then confirm with gastrografin radiographs
The ostomy is not closed but its close
Dilate
Make sure it is a mature tract, gather supplies, temporize the tract you have
Supplies:
Get Foley catheters or red rubbers of ascending size
Get one size larger than your goal due to balloon needing to be inserted which is larger than the tube
Start with highest size and work down until one fits
After this insert progressively larger catheters until reaching the goal size
Should confirm radiographically
The tube is still in but “its not working”
You flush it and its working
Ask for reports of what is going on and what is needed to go through it
Tube does not flush
Unclog it only if a complicated tube placement to temporize until a replacement
Adjuncts
Alkalinized viokase
Soda
Otherwise just take the tube out and put a new one in
Will save a lot of time
Do not use central line wire to unclog
Can perforate a viscous
The tube is still in and needs to be replaced
PEG tubes
There are internal bolsters and external bolsters
Will stay in for 6 months before first change
Can be difficult to take them out - pull with some counter traction “modest force” may be required
Other complications
Localized burn, treat like a diaper rash
Barrier cream +/- anti-fungal cream
Granulation tissue
Stop the bleeding with silver nitrate
Buried bumper syndrome
Rubber bumper is lodged into the subcutaneous tissues
1-2 years post-placement
Presents with abdominal pain and erythema at the insertion site
Suprapubic catheters
Can be placed like a central line
<2 weeks=call urology
After first change = anyone can change
Clean the site and remove
Clean again and place the new catheter to same depth as previous
Bulb is stuck inflated
Attack the inflate deflate channel, maybe guidewire to help unclog
Can try to pop the balloon
Puncture it with a needle under ultrasound guidance after overinflation
Word Catheters
These usually have negative cultures
Marsupialization of the cavity to allow for drainage
1968 Use of catheter was published:
Place into the cavity and then instill 3-5ml of saline
VERY painful and difficulty for local anesthesia
Procedural sedation may be helpful
Incise on the mucosal surface and are deeper than a typical cutaneous abscess
Need a just right incision size
WoMan trial: word vs marsupialisation
By 2 weeks 19 of the word catheters fell out of the 82 placed
No outcome differences
Jacobi Ring
Loop drainage which remains in the cavity
Follow up with OB/GYN and they will remove it in a few weeks
Less pressure in the cavity with this option
racism in medicine WITH drs. mallory and unaka
Core values in medicine:
Teamwork, patient centeredness, compassion, respect, dignity
We miss the mark
Black and Latinx children spend more days in the hospital
Striking disparities in the morbidity and mortality of black men and women with CVD, stroke, diabetes
Black men have highest rate of prostate cancer deaths
Black mothers have the highest rate of premature births and are 3x more likely to die than their white counterparts from complications
Black children with appendicitis have half the rate of opioid analgesia than whites
Healthy black children have a 3.4x odds of dying within 30 days of surgery and 18% odds of developing complications compared to white children
How do we resolve the tension between these disparities and the core values of medicine?
Race? Historically this term allows the dignification of the division of humanity
Due to colonial enterprises of European powers
1767 - first classification into distinct races
Characteristics were stated: “inventive” vs “sly, lazy”
Human Genome project
No specific gene, trait, or characteristic that distinguishes all members of one race from all others
We are 99.9% the same as human beings
There is more variation within “race” groups than there is across racial groups
A true understanding of disease risk requires a thorough examination of root causes
Race and ethnicity are poorly defined terms that serve as flawed surrogates
Must move beyond and then find more proximal causes of disease
Race?
Ideology with social and political implications
Rooted in the social construct
A concept created or invented by individuals of a society culture or institution
Exists solely based on society’s acceptance of a specific concept
Racism
Umbrella concept that operations at many levels in the socioecological framework:
Intrapersonal
Internalized racism: acceptance of negative possible
Interpersonal
Personally mediated racism: prejudice, implicit/explicit bias
Institutional
Differential access to goods, services, opportunities
Systemic
The driver of inequalities
Ways in which societies foster racial discrimination via mutually reinforcing inequitable systems
Social determinants of Health
“Conditions that people live that shape health”
Direct connection between social determinants of health and structural racism
Housing Segregation
National Housing Act - Federal Housing Admin
Refusal to insure mortgages around black neighborhoods
Color coded maps: Red are least desirable are the black inner city neighborhoods
Red-Lining: systemic refusal of services by raising prices and mortgages
Illegal in 1968
Wells Fargo targeted black communities for subprime mortgages
Red-Lining
If population is 50% black then the homes have 50% less value
Devaluation of homes lead to decreased upward mobility of black children
Environmental Injustice
Disproportionate environmental burden rests on marginalized communities
Flint Water Crisis is a perfect example
Education
Brown vs Board of Education in 1954
Segregation is unconstitutional
School are still segregated by race and income
There are profound inequities in funding
White School districts get $23 billion more in funding
Community and social context
Roughly half of those fatally shot by police are white but minorities are shot at disproportionate rate compared to their rate in the population
Substance Use epidemics
Empathy and medicalization vs disregard and criminalization
Crack cocaine=black community and moral failure
Powdered cocaine=white community and more socially acceptable
100:1 Rule: 5 grams crack and 500 gram of powdered cocaine get same sentence
Opioid epidemic: public health crisis, impacted the suburban and rural white communities and framing the addiction as a disease
More resource allocation to help the epidemic
Racism in Health Care: abuse and mistreatment has resulted in a deep mistrust
Examples:
Dehumanization via grave robbing and public display
Eugenics
Intentional injection with harmful pathogens
Intentional exposure or intentional withholding of available treatments
Misuse of black prisoners
Antebellum time medial journals served as pro slavery propaganda, abuse was done to serve these ideas
Tuskegee Study: hundreds of Black men recruited - driven by dimorphism existed for syphilis
In 1932 by a public health service funded study
600 black men who were poor sharecroppers
They were never informed of being in experiment or of syphilis diagnosis
Treatment was withheld and PCN was std treatment in 1947
Conducted for 40 years!
Terminated after public outcry and press leak
National Research Act - protection of human subjects and established the IRB
Human Radiation Experiments: 1944-94 with >2000 experiments funded by the government
Blacks were over represented in these studies
In Cincinnati done on poor and black cancer patients without consent for the first 5 years
Blacks were 62% of the study subjects
25% of patients died within 2 months of radiation and 75% in 1 year
The Violence Initiative: 1992 study to identify biologically or genetically predisposed to violence in the inner city
3 experiments on children took place over 3 years
“It is proper to focus on blacks and other minorities”
Excluded white children
All participants were from impoverished families
Incentivized with money for parents and children
Undergo exhaustive psych testing and could not take any meds
Given IV fenfluramine (fen-phen)
Prior to this was never given to children <12
Identified subjects via department of probation records
A true invasion of the criminal justice system
Study design perpetuated the stereotype of black body/men as perpetrators of violence
Race based medicine today
Sickle Cell Disease
Myth of black disease: not an African disease
Evolutionary adaptation to malaria exposure higher in regions with malaria,
Mediterranean and Indian subcontinent
SCD: 1 in 365 black individuals, prevalence of 90,000
CF: 1 in 2500 white children, prevalence of 30,000
Mean NIH funding
$812 per person in SCD vs $2807 in CF
Publications 2008-2018
926 in SCD vs 1594 in CF
No federally supported centers for SCD care
CF has >120 comprehensive centers with national patient registries to help evaluation guidelines
Kidney disease and eGFR
Race is not a biological entity but is used in eGFR calculations
GFR is used with race based factor since 2009
This is based on assumption that blacks have higher GFR due to higher muscle mass
Increase in eGFR by ~16%
This affects the:
Timing of nephrology referrals
Medication dosing
When listed for renal transplant
When dialysis is initiated
Clinical trial eligibility
The case for diversity in medicine
The population in the US is increasingly diverse
Research shows that patients do better with a diverse physician workforce
Black patients have overall better outcomes when treated by black doctors
By 2043 the majority of population will not be white
Harvard Implicit Association Test
Providers with stronger implicit bias demonstrated poorer patient provider communication
31 studies found evidence of pro-white or light skin and anti black bias among variety of health care providers
Concordance: black newborns more likely to survive when cared for by black doctors
1.8million birth records between 1992 to 2015
3x more likely to die when cared for white doctors
Black men seen by black physicians were more likely to engage with the physician
2017 New York Times collection of stories to share earliest experiences with racism, some as early as kindergarten
RESUSCITATION of a 29 week neonate WITH pem fellows and faculty
Important to warm the infant
Warmers
Typically will have 2 power switches:
One must be on to turn the who device on
One on the front to turn the actual warmer on
If resuscitating then just turn it up to max
Put it on manual and turn the warmer up to 100%
Sides come down and the warmer will swivel
Transwarmer: is a plastic “warm pack” that can warm the baby from underneath
Under 30 weeks put the baby in a bag
A plastic bag will help with warming
Important to dry them off
At 29 weeks the concern for need for intubation is high due to poor lung development
Can require high pressures due to under development of the lungs
Bagging may not help due to this
NRP
Compressions are way down as the airway is most important as is oxygenation
Need to be very aggressive in the airway and breathing part
LMA or oral airway if feel like bagging is not effective
Intubation
Main driver for airway intubation is the heart rate,
Saturation will be low for minutes after delivery
Want a preductal saturation = taken on the R arm
Bradycardia: should fix the airway to fix the heart rate
Should feel for a pulse in the umbilical stump
The additionally helps keep the hands away from the airway
Medications
Do not need medications as you do not want to take away the drive they have left
Access options:
IO
In prematurity can hand screw it into the femur
ETT
Can give medications through this
Umbilical Vein Cannulation
14 gauge into the umbilical vein and give drugs while someone holds it
Can do this with a deeper line as well
Try to do it as sterile as possible
Vein is biggest and is at about the 12 o'clock position
Cut the stump about 2 cm above the skin and get a good grip of the tissue
Advance until you get flash
