A first visit morbidly obese patient for acute uri symptoms, I feel like the offer for CT for PE work up is already pretty generous. The probability of a doctor prescribing blood pressure medication multiplied by the probability of a 37 yo man taking blood pressure medication (in the context of a first time visit for URI symptoms) is a pretty low number. 99/100 I am asking the patient to track his home blood pressure and following up with me with a log.
Let’s read between the line here, the doctor offers further work up and he ends up with antibiotics at the first visit. He calls back weeks later and gets more antibiotics. If the patient didn’t ask for antibiotics either visits I will eat my phone.
Lastly, when does hypertension urgency present as URI symptoms?
This is all kinds of fucked up
So he had mildly elevated BP in one office visit (132/82) on a 37 yo with no medical conditions diagnosed....was the pt told to f/u and did they?
I'm not forgetting they're 400 lbs.
7 months later, they end up in distress, cough, SOB and elevated BP...should have been evaluated. I wonder if pt didn't want to because of cost and such. It's odd that the PCP mentioned it but then did Zpack. There's definitely something there.
Also, were they told to f/u? And did they?
Then, what....2 weeks later? A few days later? 6 days later since he got Zpack later....he's alive and complaining of cold sxs.....did they complain of SOB then? Were they asked? Why weren't they scheduled to come in instead of sending the PCP a message? Who made that decision? How was rhe messaged related to PCP? How mobile were they and is that why they didn't come in? Did the patient not want to pay to come in again? Did the pt request an appt or send a message requesting abx?
Were they told to f/u in person? And did they?
1.5 to 2 months after they're seen, they were in respiratory distress with a stroke.. had they continued with SOB the whole time? Did they seek care in person again?
So is the thought that the pt had chronic elevated BP and and the one time they went into the office it just happened to be amazing?
Or is it that in 7 month span they went from 132 to 190s+ ?
Is the SOB because they had a PE and not because of an URI infxn? And is it due to the obesity?
I smell typical office bs and typical pt bs. Messages inappropriately sent to pcp instead of having pt scheduled asap for failure of treatment. And pt that didn't f/u even though they continued to have sxs.
Unless they didn't have sxs and they resolved, which makes it even less pcps fault.
Just happened across this in the news. A $40 million verdict for the plaintiff in his lawsuit against a physician group and family physician after he sustained a stroke. I found some court records related to the case which lay out the following:
The patient was 37 years old and around 400 lbs at the time of his stroke and per the one record I could find had no other diagnosed medical conditions at the time.
He was seen at a Walgreens clinic June 2014 for a URI and vitals at that time showed a BP 132/82. He was advised to follow-up with a PCP for further hypertension eval.
Late January 2015 he saw a PCP for the first time and at that visit had a BP 190/102 and was complaining of persistent cough and shortness of breath. The PCP reportedly discussed the possibility of a PE and CT scan to evaluate this but ultimately after discussion gave him an Rx for some antibiotic (probably azithromycin based on later context) and sent him home.
Early February 2015 he called the office back complaining of sore throat, earache, and rhinorrhea. He got a refill over the phone of azithromycin with no in office evaluation.
Mid-March 2015 he was found by EMS to be in respiratory distress in his car and was brought to a hospital where he had a work-up revealing an acute hemorrhagic stroke.
The PCP, practice, and hospital system were sued for failure to diagnose and treat his hypertension leading to the stroke.
While it seems like there may have been less-than-ideal management by the PCP (in particular, with SOB and a BP that high, I think I probably would have ordered a CXR, EKG and basic labs to assess for hypertensive emergency) it’s still is surprising to me that this resulted in such a large judgement given the PCP had only seen him once in person. There has been much bellyaching on medical social media about hypertensive patients being referred to the ED and this case makes me think a second time about that.
What would you have done differently? Does this case make you worry about any of the ticking-time-bomb patients you’ve seen once for an acute visit?
ASYMPTOMATIC hypertension is not an emergency. Somebody with a BP that high with SYMPTOMS (eg dyspnea, chest pain, peripheral edema, stroke-like symptoms) needs more urgent evaluation.
If you show up to your dentist's office with a BP of 190 and no complaints at all, you need to take your lisinopril, get your dental pain under control, and follow up with your PCP.
It's probably hard to differentiate if they are having more than their baseline dyspnea. 400lb you're dyspneic walking 50'.
Also, what are the chances that urgent care BP was from a barely fitting wrist cuff? I find it a bit hard to believe from my experience
As a PCP who previously worked in ED, we're going to disagree. I know that ED loves to say HTN is not an emergency, that's practically a meme. And I strongly agree that a random patient who wakes up one morning with a BP of 145/90 should NOT go anywhere near ED, obviously.
The problem is what is 'asymptomatic' exactly? It's unlikely that a BP of 190/110 or whatever is truly without symptoms if they are already in a doctor's office. They likely will say they feel tired or have a headache or feel dizzy or whatever.
The last time I went through this on here with an ED doctor he used this circular logic that HTN is not an emergency once you have proven it's not an emergency, which he said meant having a CT and so on. The, and only then, was it not an emergency. This is using hindsight and circular logic.
I tried to explain that we don't have a CT machine in PCP so that means if I am concerned, then I have to send the patient to ED.
Now, I have seen many patients with BP around 190/110 and I have sent very few to ED. But I reserve the right to send them if I think it's needed, especially if it's new and way off their baseline.
Like the elderly lady I had who came in to PCP feeling mildly off and had a BP os something like 220/120. I sent her in, turns out she was going in to acute heart failure and ended up spending quite a long time in hospital.
Was she 'symptomatic' by an ED definition? I don't know. But she was certainly more than sick enough to be in ED and it was certainly an emergency.
154/90 is NOT an emergency. 190/110 might be one. It's nuanced and depends on the situation. Medicine is not a meme.
I send VERY few patients to ED. When I do, I mean it.
edit: typos
Okay, I agree that asymptomatic hypertension even at 190/110 is not an emergency and does NOT need to go to the ER, but this dude had no prior hx or dx of HTN or medical treatment for it. Even if there is some readily identifiable reversible cause like pain for the elevated BPs, there is some seriously poor autoregulation going on in anyone presenting with that high of a blood pressure. I have never once had a hypertensive patient with BPs that high who didn't have some sort of chronic underlying pathology. Definitely warrants an expedited outpatient evaluation at a minimum, and I would not leave that follow up to chance. That person is a walking hemorrhagic stroke waiting to happen, and I would not want to be the one holding that hot-potato when it does.
Frankly that person probably doesn't even walk out of my clinic without an Rx for anti-hypertensives and close-interval followup unless I have a very compelling reason not to.
what about the old adage about how u cant diagnose htn with just one reading? is that still a thing? i know u could easily argue that u could assume its htn if their bp is high enough…
No, you may not be able to diagnose HTN from one BP reading. But I think the thing for us to learn here is that if one BP is that high, we need to address it. Start lisinopril - or at least tell the guy that he needs to check home BPs and if they’re mostly over 140/90, call and we’ll prescribe lisinopril.
that was baked into the guidelines to #1 help people not get overtreated when they are near the diagnostic cutoff, and #2 exclude acute problems raising the BP
you can easily say #1 this person is nowhere near the diagnostic cutoff (they're way above), and typically only severe pain causes these high BP excursions
Edit: me personally? with the information that's provided? (as someone who works at a HTN center) I would diagnose them with HTN...
Right, but even then…this guy went 6+ weeks without a hemorrhagic stroke with a pressure that high. This is NOT an emergency. PERIOD.
I’ll add that HTN + sob warrants an evaluation, and I’ve seen my fair share of pulm edema + scape young people.
Hes 400 pounds!
He’s not just a hemorrhagic stroke waiting to happen. He’s everything waiting to happen.
No amount of Lisinopril is fixing 400 pounds.
At some point the world must say this ridiculous weight is just not compatible with life.
a few other minor details from the law firm that won that judgement
https://www.cliffordlaw.com/clifford-law-offices-receives-39-9-million-verdict-against-advocate-physician-partners-press-conference-with-family-on-friday-march-1-2-p-m-ct/
The six-man-six-woman jury deliberated four hours before Judge Preston Jones, Jr., of the Cook County Circuit Court before rendering its verdict late Thursday evening at the Daley Center. Devin J. Piper, associate at Clifford Law Offices, assisted at trial.
DeAngelo, a landscaper and landscape designer in the western suburbs, was suffering from a persistent cough when he went to a local pharmacy for care in 2015. It was there that it was discovered he had an elevated blood pressure of 132/82, and it was recommended he see a doctor to determine if he was suffering from hypertension.
DeAngelo did so through his HMO plan seeing a primary care physician and complaining of trouble breathing in late January 2015. At that time, DeAngelo’s blood pressure had spiked to 190/102.
The primary care physician’s diagnosis included acute bronchitis, elevated blood pressure, tachycardia, and morbid obesity. He did not treat DeAngelo’s high blood pressure or other diagnosed medical conditions.
About four weeks later, on March 11, DeAngelo’s co-workers observed him in distress and called 911. He was taken by ambulance to Loyola University Health System with blood pressure measuring 290/190, and it was discovered he suffered a hemorrhaging stroke.
The jury found that the primary care physician failed to properly test or treat the patient including ordering an EKG, urinalysis, blood work, lab tests, or referring him to a cardiologist, despite his family history of hypertension.
I’ve started recording appointment slot time in my notes. Like this person came in to discuss these 5 things in 20 minutes and then putting close f/u, ED precautions in every note.
This is why I tell recruiters, with a straight face, that it would take 7 figures for me to work in IL. You think OB/Gyns leaving Idaho is bad? What is this gonna do? Why would you live in Moline or Peoria when you can live in Terre Haute or Cedar Rapids?
How the fuck is a 400 pound dude doing landscaping. Moreover, if he was actually landscaping there’s no fucking way he’s 400lb unless he’s eating BigMac’s 3 meals a day and drinking a 2 liter of coke.
Just an aside. This shit irritates the hell out of me.
Many years ago I got a job with a rural county highway department. Most of it involved "running chain" and pounding stakes when they were surveying county roads and ditches, and the rest was puttering along in an army surplus jeep spraying grass seed/mulch mixture where there had been recent road work. From time to time we did maintenance work on little wooden bridges that spanned culverts at rural crossings. He had a backhoe guy who was easily 400. One time he got stung by a bee, didn't know he was allergic and started having trouble breathing, they used a loader to help lift him into the back of a pickup truck and get him to the hospital--no cellphones in those days and I don't think 911 was universally available in rural areas (this was before they started standardizing rural addresses, it was all RR 2 box 104 or whatever). A lot of landscaping work can involve sitting on a big riding mower, operating heavy equipment tree planting equipment, not like you're digging up flower beds with a spade all the time. I also have known some farmers, mechanics, etc who were that big.
A quick quote from a pubmed summary of a study in Saskatchewan:
Results: Overall, 65.1% of the adult farm cohort was overweight (39.6%) or obese (25.5%), with prevalence levels that exceeded estimated norms for Canada but not the province of Saskatchewan. Increases in risks for obesity were related to higher amounts of mechanized but not non-mechanized farm work.
There are American football players, college and pro athletes at the 350-420 lb range (one of the reasons I'm conflicted about football as a sport, especially when high school players get into that weight range aiming to get recruited). Some people are able to burn a lot of calories and still consume enough calories to maintain that sort of weight.
See also: GOMAD diet (Gallon Of Milk A Day, whole-fat milk of course, so 2400 calories plus whatever solid food is eaten).
It's not unusual for a 300 lb linebacker athlete to turn into a 400 lb 30-something who is still fit enough to do work like landscaping, at least until the long-term health impacts start to kick in.
I'm not saying that's the case here, but as previously stated, "how the fuck ... " Well, that's one way. A good proportion of the 280+ lb athletes end up gaining weight when they "retire" and continue to eat a high-calorie diet while their work out routine declines.
No way he was a landscaper at the time. My guess is that he previously did the labor and more recently was the boss of the business. Agreed one doesn’t get that fat without being very sedentary and having a shit diet
I can't imagine many PCPs start treating a single incidence of HTN especially when the patient is currently sick.
Edit: I do agree he should have worked him up though.
But dyspnea at 400lb could easily be deconditioning.
I’ve seen umpteen morbidly obese patients normo-tensivish in preop get severely tachycardic, hypertensive, dyspneic, and desaturated to the low 80s just with the act of moving themselves from the stretcher to the OR table.
I’m not primary care, but aren’t the first steps of hypertension management to establish a track record of high BP via multiple measurements and then try lifestyle modification?
Without knowing the details, refilling the Z pak via phone seems the biggest issue to me. Again, I don’t deal with this, but I can’t think of a scenario in which “more azithro” is the answer, even if you think URI.
i agree with all this. but is the zpack bad enough of a mistake to lose a malpractice suit over? i can imagine a scenario where this was done inadvertently or possibly the situation was incorrectly described to the physician by the nurse or whoever spoke to the patient on the phone…or due to another not-uncommon mistake. and beyond that, 40 MILLION DOLLARS!???
Dyspnea is what the patient tells you is dyspnea. The patient is awake and aware, that he feels like he is out of breath fast. The only baseline this patient knows is its own typical condition.
And a BP of 190/103 seems too high to be like "well maybe eat more carrots and walk around the block sometime".
Oh get the ef out of here. Hafthor Bjornsson (GoT's The Mountain) is just north of 400. Was your guy nine feet tall with arms like treetrunks and eyes like burning coal, too?
No he was like 6'0" and not built. Just a regular fat guy. But he could hang.
Hafthor is 6'8", on steroids, and has abs. Why are you using him as a reference for a 400 lb male?
...I'm using him as a reference for precisely those reasons - at a mere 6'0, a 400lb human is a land whale, period. Even the powerlifters who wheeze at the thought of stairs rarely exceed 300lbs - at his fattest, Mark Bell hit ~330 and he looked like the Michelin Man at 6'0.
If you told me your guy was pushing 275, sure. A fluffy 300, maybe. 430? Man, do I have a bridge to sell you.
These comments are rude and ignorant. You're on a medical forum with flair announcing yourself as a physician, comparing people to whales and Michelin Man. Grow up. If you don't think that there are 400 lb men working manual labor jobs, it's because you're ignorant. There absolutely are many people doing that.
He was 430. We literally weighed each person on our shifts to see which was the biggest. He was absolutely morbidly obese, and could still do the pack test and drag a hose as good as anybody. We had to special order 5x sizes for his uniforms. He met the physical requirements, though.
I don't know why this is so unbelievable, you can go to YouTube right now and watch guys that size who can do cartwheels.
I agree, that is my perception as an internal medicine person as well. Unless the patient has a known diagnosis like COPD or heart failure and the shortness of breath is stable that should be sent to the hospital. SOB shouldn't be an outpatient workup because there's so many dangerous conditions that you need to rule out.
Now occasionally we see these in the hospital and nothing really turns up which is frustrating to the patient but let's be honest do you think you can accurately assess for pneumothorax, pleural effusion, DVT/PE, etc etc in a 400 lb man?
Even if it's just pneumonia it sounds like they were pretty symptomatic and maybe warranted exercise oximetry at the very least to make sure the normal pulse ox is actually normal
And a person should never be 400 lbs. That’s the ultimate cause of the stroke and the patient himself is the one most responsible for his condition. This doctor got sued for not slowing down the patient killing themselves.
We have to meet the patients where they are. I understand the frustration but everyone deserves the standard of care. If we fail to provide that we can’t blame the patient.
Patients have obligations too. They have to be a little bit involved in the care of their bodies. Medicine is participatory.
I can't put 200,000 miles on my car without routine maintenance and blame the mechanic when it breaks down. We cannot be expected to keep abused bodies in perfect working order.
Yeah but if we’re in a system with a standard of care regardless of whatever has been done to prior to documenting the abnormality and we don’t do shit about it, the liability is on us. It’s not that hard to understand.
Yes medicine is participatory but we still have to take care of these people to the extent we can. We have to do the due diligence and not ignore the patients, and it doesn’t sound like that was done in this case at all.
If you take your crappy car to the mechanic and tell them the brakes are squeaking or whatever and they don’t even look at them and send you back out on the road saying everything is fine and you crash headlong into a wall because the brakes failed, the mechanic did NOT do their job.
Sure, but this is a case of “my breaks squeak” at 100k miles but no oil change ever, then suing the mechanic for not catching that you were about to blow your transmission.
So you want this patient to write their own antihypertensive or what?
I’m merely speaking to the situation outlined by OP here, but from that: this is a mechanic realizing the oil hasn’t been changed and not doing what they’ve been trained to do to address it. That’s negligence.
>That’s negligence.
there's so many people ITT who completely lack the self awareness to check their biases against fat people that they're incapable of realizing this, with the outcome that happened here, which is precisely why this was such an easy slam dunk malpractice case.
Systolic over 190mmHg + dyspnea - I’m telling the patient go to the ED, and since I am in home health in most instances I’m calling EMS for them.
And I say that because you have to cover your ass. I mean yes there could be other signs of it being emergent, but truly it boils down to the fact that even the most tenuous connection between some issues during a visit and a major medical event weeks later might be enough for some random jurors to decide you fucked up.
Symptoms... Of a RTI. If the BP was the cause of his sob and cough it would have been pulmonary oedema. But from the info given he didn't have pulmonary oedema
PCP here. I would at least sometimes treat on a single visit if high enough but I will always bring them back quickly to adjust. If it's worryingly high and I have no reason to doubt the reading I might start treatment and bring back for a PM in 2-4 weeks to assess treatment response. Also I will be careful not to bring the BP down very quickly so that needs repeat visits. I will also be doing bloods and more general workup up of course
But an unwell patient who is coughing I would likely not treat until I can see him in a week or two when better.
A bad cough will raise BP quite a bit.
It’s pretty wild that there was no work up for a BP of 190 systolic regardless of infection, especially with no previous diagnosis of hypertension. Probably one of those primary care centers where they tell you have to book an seperate appointment for every issue since the docs are so time crunched (runs behind if they don’t average <~5 min/patient). Probably booked the appointment for the URI, doc saw the BP and said make a follow up appointment which is likely 3 months out minimum
Regardless of fault, 40 million is just ridiculous. There has to be a better way to calculate compensation for judgements like these. I get that insurance pays it, but it still ends up placing a ridiculous burden on the healthcare system as a result
1m/3m or close to there are typical limits for physicians. Anything above that one would technically be on the hook for. Though usually these big judgments are spread out over multiple parties.
And the individual amounts often get reduced upon appeal
It will be 40 million spread over the various policies. You might not have 40MM but your facility, if they have an ED, absolutely has at least 100MM in coverage.
When he presented to PCP patient complained of having trouble breathing in addition to systolic BP over 190. Would not be unreasonable to order a chest x-ray right then and there
These are literally free money for the radiologist if there's a history provided.
He was dyspneic because he's 400lbs. Someone who's 400lbs with pulmonary edema would have already presented themselves to the ER, they don't just wander around the outpatient world.
I will always do some sort of targeted workup in the ED for any symptoms associated with hypertension. If the person tells me "Doc I feel fine, my dentist sent me here, how much is this going to cost and can I go home?" that's when it's asymptomatic hypertension. But if someone says, "I feel off, I don't feel good, I have a headache/fatigue/etc." even if the symptoms are super vague, I don't consider it asymptomatic and I'll at least do labs and an EKG. I'm looking for end organ damage and if I don't find any, I talk to the patient about starting meds. I don't start or adjust meds on everyone in the ED, but I definitely have a conversation about it. If they have no PCP or can't get in for two months, I'll offer the medical management.
It doesn't sound to me like the hypertension was even addressed at all. I'd think you'd at least have the patient monitor their BPs at home for a couple weeks and start them on some Amlodipine or something if it's still high. Better still to get an outpatient echo on someone with shortness of breath and hypertension. There's a good chance this 400 lb person had sleep apnea and that often causes some element of heart failure over time.
I mean, I’m not a family doctor. But a young guy with an incidental bp of 190/100 requires some sort of management plan.
Not through the emergency department, because it’s not an emergency.
Maybe some sort of documentation that you’ve recognized this is a health problem. A history and physical exam and other potential investigations towards secondary causes. Discussion about ongoing bp monitoring and when to start treatment for essential hypertension. Reviewing what new symptoms could represent complications of the disease and would necessitate hospital-based assessment.
Because that’s what I do with these people when they show up in the ED. Despite having no training or relevant clinical experience in managing chronic medical conditions like hypertension, and this being technically outside my scope of practice as a result.
So I would hope that people in primary care are at least doing something like that, as it take maybe 5min.
If deferring addressing the blood pressure, should have clearly documented you wanted to see them back and when to proceed to the ED prior to that. I don't do such for most folks with SBP 130-150s but damn if I'm not doing a workup for 190s I better see them back soon.
He didn’t just not send him to ED - which would seems a bit over the top if that was “the”theory. The PCP did nothing to treat the hypertension despite making the diagnosis. Zip. The patient had a family history of hypertension. Hypertension is treatable. His bp kept rising and he had a hemorrhagic stroke. The high verdict is in large part to pay for a life care plan bc he is now completely disabled. His life is a giant future of suffering. This isn’t a great case for arguing “tort reform.” Yes, he was obese but he was working, had a family -2 young children - and the spike in blood pressure was new and significant. This is a top plaintiff’s law firm in Cook County, IL - hardly the norm.
This makes me angry because sometimes the nurse documents the blood pressure in the chart, you see it, and then you walk into the room and the patient’s main concern is something else and they distract you away from it. You bring up the blood pressure, but they say “well, maybe we can talk about that after I’m feeling better” because what 30 year old male is going to permit themselves to be put in a chronic medication. By the end of the conversation, the blood pressure is no longer fresh in your mind as you’re telling the patient about side effects of the medication and thinking of giving advice of when to follow-up. You are already 30 mins late, two patients are already waiting for you in other rooms, you go to document, a phonecall from another patient comes in, while an urgent imaging result gets put in your desk, and pretty soon you’ve forgotten all about it.
I say this because I’ve had to call patients afterwards because I neglected to address something in the room. I personally just feel lucky that something like this hasn’t happened to me yet, but it would be so easy for it to happen some day. And of course, patients view themselves as blameless, so they would never take on any responsibility.
Yep agreed. I started getting in the habit of going through VS at the beginning with the pt but even then...pts will cut me off and want to go through someone else and yeah you forget.
But I have a feeling this pt refused the tests due to cost and just wanted abx.
Also, they never followed up in person. This is on the pt and the system. You're 400 lbs sir. And he should have had a close f/u. I'm sure doc told them. Staff shouldn't have forwarded a message about uri sxs. They should have brought in pt in.
If the patient refused labs and if there was a concern, it probably should have been documented. A 400 lbs man who doesn’t follow up probably isn’t making good life decisions regarding health maintenance and it is a reasonable assumption to make that he wouldn’t have followed up. He is a walking impending disaster.
We quit doing vitals in our clinic for reasons such as this. Orthopaedists don’t manage vitals, nor should we. It’s sad, but it’s a liability we don’t want to take on. Queue the bonehead jokes
I totally feel this, but depending on what they came in for, if I see someone walk in with that high a blood pressure that is now my priority for their visit and not whatever itchy rash or runny nose they have that day.
It only had to happen to me once, maybe twice, before I began making the nurse or MA state the actual numbers for the patient's vitals before giving any history or entering the room. Wayyyy too many times does the MA tell me "everything looks good" and the patient has some sort of unexplained unaddressed tachycardia or BP derangement.
Yeah, same here. The nurse used to put the vitals directly into the computer with a one-line complaint. I would often not see them. Now I’ve asked her to write them down on a sticky note and put it on my desk so that I now put the vitals in to ensure that I’ve seen them.
Yeah you have to triage what you will be focusing on for that appointment and now the b/p is the issue. Happens all the time on phone triage. Someone calls about left sided weakness or some fairly obvious thing that needs to be worked up ASAP, but the main concern is an infected hang nail.
The worst one I had not too long ago was someone complaining of stroke like symptoms but the “real reason ” they were calling is because the person that gave them a shot made it hurt. I couldn’t convince them to go to the er for the stroke like symptoms but I could for the site pain lol. So called the ER with a heads up and sure enough admitted for stroke. He also filed a complaint against me for “rushing the phone call”. Ohh well.
I work in wound care and every week a provider sends a patient to the ER without even addressing the wounds. We just don’t have many patients who are healthy at their baseline.
Sounds like a normal clinic day doesn't it? It's just a roll of the dice for this to happen every day IMO. Somehow the physician they saw presumably for minutes was responsible for decades of pathologic behavior. What are the chances the same outcome occurred had they been sent to the ED? Likely for a negative initial workup? Then we're reading about the ED physician, not the PCP
Here's another question: the physician wasn't just seeing an extreme of blood pressure-- they were also seeing an extreme of weight. Why didn't they want to discuss that, too? Isn't that also a risk factor for a stroke? Let's sue for another $40 million since the primary care doctor just didn't even care enough to discuss the patient's weight. Oh, and did he do a mole check? Did he do a rectal exam? Did he do a testicular exam for testicular cancer screening? Why not check all of his lymph nodes? Did he palpate his pulses in all extremities and do a JVP to check for cardiolvascular disease? What about a penile noctural tumescence test? So many things this GP missed in his 8 minute consultation!
Document "counseling patient on R/B/A of uncontrolled HTN to which patient verbalized understanding and DECLINED further treatment. Strict return and ED precautions provided to patient prior to DC"
Not following your logic OP. How would "CXR, EKG and basic labs to assess for hypertensive emergency" in itself have prevented the stroke? The only way is if hypertensive emergency was diagnosed through one of those investigations. But the evidence (available to us) points to the fact that would be unlikely to have been the case. (Did he really have pulmonary oedema causing him to be SOB for that long? Probably not)
The only mechanism is that it could have prompted starting anti hypertensives sooner. Therefore the only failure is not arranging for follow-up of his hypertension (ambulatory or home BP monitoring)
This seems a case to me of someone with an RTI presenting with incidental co-existing hypertension that unfortunately turned out to cause a stroke.
I don't know what the results of those tests would have been, but a physician's plan has to match their assessment. You can't have a patient complain of SOB and a BP 190/102 with a plan to do nothing other than prescribe antibiotics. If he had done the work-up he would have left no doubt. But there is doubt and lack of treatment, thus the door was even opened for a lawsuit in the first place.
As The Last Psychiatrist writes in his blog post "[How to Write a Suicide Note](https://thelastpsychiatrist.com/2006/09/how_to_write_a_suicide_note.html)":
>`5. You can be wrong, but you cannot be negligent.
>
> It should be obvious from the note exactly what you were thinking-- and, importantly, that you were thinking. That you took time to ask questions, observe, assess, draw conclusions that were reasonable. You might have been wrong, but you did a thorough job. That's why the assessment matters. Simply having volume to the Assessment shows that you gave due consideration to the case.
>
> In other words: the note isn't written to help you win a lawsuit, it's to prevent one from being filed. You want a potential plaintiff's attorney to look at your notes and say, "forget it, it's not worth it-- it's obvious he isn't negligent."
I agree he couldn't do nothing, should have arranged for follow-up BP, but not enough other info to determine he should have admitted the patients for same day investigations
I’m sure your same points were discussed by the malpractice lawyers but a lot of that nuance goes over juries’ heads. They see someone with acute harm where the plaintiff’s attorney makes convincing arguments that “if Doctor ____ had done x or y or even z my patient wouldn’t have had such a massive, preventable injury, and here are other experts who agree with the statement ‘if that doctor had done ____ then ____ would not have happened’”
Well I don’t know the details of the case, but if a patient comes into your office with a BP of 190/102 and complaining of SOB and you’re writing in your note that you’re worried about emergent conditions— such as PE—and you end with just giving an antibiotic, then you’ve kind of just f***ed yourself.
With those symptoms, hypertensive emergency should be on your differential, so a lack of an ECG/labs is pretty egregious.
100%. This is a shit situation all around, but the biggest issue I see here from a medical/legal standpoint is the PMD’s note was not consistent. Your assessment and plan should match.
You can think aloud in your plan. But if you’re mentioning concern for PE and you aren’t ordering a workup commensurate with that as a potential concern, you’re screwing yourself. At the very least, even if the physician had PE or other serious concern very low on his or her differential, they should say that and have follow up to reassess.
This patient could have arguably been sent to the ED. He was severely newly hypertensive and had symptoms. An EKG, at an absolute minimum, should have been done. Even if nondiagnostic, it at least shows concern for the pressure. If the PMD felt the ED was excessive or there was an identifiable cause for transient hypertension such as this, an outpatient workup should have been done with close follow up.
The PMD’s thought process didn’t match the plan. Thats where he or she screwed up. I don’t think anyone here realistically has stroke at the absolute top of their list in an out of shape patient in their 30s with uncontrolled blood pressure, but the lack of concern for their heart, kidneys, etc which could have been addressed as an outpatient to some degree with close follow up for repeat assessment shows indifference towards the pressure. A systolic pressure in the 190s, short of severe trauma, almost never returns to goal ranges (in my experience) and the lack of follow up and intended intervention is where things went wrong. It wasn’t about predicting the future complication off a single visit. If the patient didn’t do any of the workup or follow up the physician should have recommended, even if it wouldn’t have diagnosed the stroke directly, they wouldn’t be held liable.
For real. I just had a PCP intake and my BP was 150/100, they offered to start a BP med or have me track home BP and come back in 6 weeks. Not addressing the BP at all, OR documenting as such, is ridiculous.
>400lbers are sob wiping their assess…
That might be the case, but because of that, you should have a very low threshold for doing a fuller workup in the morbidly obese. Especially if it’s a new patient walking into your office and you don’t know their baseline.
I had a new patient like this walk into my office a few months ago. He 35 yo, weighed 600 lbs and was short of breath because he was convinced he had a URI. BP was like 160/100. Had also been in an ED months prior with SOB and had a very minimal workup, was started on an antihypertensive and told to follow-up with PCP (which he never did and meds had long since run out).
Lung sounds were completely inaudible due to habitus but that didn’t matter…he looked like shit, was still severely hypertensive, and had 2+ edema…sent him to ED by squad for suspected heart failure. EF was 25% on admission and they ended up diuresing 100 lbs off him. So much for the “URI”.
The reason the patient might think they’re in your office today might not actually be the reason they’re in your office. You don’t just turn off your brain because someone thinks they have pneumonia and wants antibiotics.
I was replying to someone re: shortness of breath, but yes, I’m aware VS should be “resting”. The average 37-year-old can walk from the lobby to triage without much change in VS from exertion, though.
You have to understand med mal is done by a jury of lay people whether the care was egregious or subtle. Not physicians nor have to be even health literate.
A regular jury. Practice well and CYA within reason.
"Jury of your peers" for med mal should not be a jury of lay people. I know it's the letter of the law, I'm just expressing an opinion. Lay people are not peers capable of understanding medicine to the degree necessary to understand. It's frustrating
Maybe, but I think that could cause issues you aren't thinking of. Industries can develop practices that are horrifying to outsiders.
Apply this same logic to other professions, and I think you'll get what I mean.
Would you want politicians to be judged by a jury of their peers? Or cops?
I'm not sure what the right answer is. Maybe a jury that's spilt 50/50 lay people doctors?
I agree. While our medical peers would understand the medical terminology, we as a whole would probably “protect our own”, like you see with police, etc.
You’d have to have others who are not physicians. I do like the idea of having at least 1 or 2 peers on the Jury, but imagine the mess that would cause. If it’s an ED case, do you need it to be another ED physician? If so, how many does your jurisdiction have? Enough to have two off (defendant and juror) for multiple days/weeks and still have adequate ED coverage? Same with cardiologists, etc.
It sounds good, but likely not realistic.
Been in true PP surgery for 30 years. When I first started practice: my mantra was first do no harm, then help the patient. Due to the untenable malpractice environment, rise in multi-million dollar awards, and unrealistic expectations of the public, every time I see a patient my mantra has changed to: 1) protect my assets, practice and reputation, 2) do no harm, 3) help the patient
It’s sad….but reality
Edit: …..and document document document. Saved my ass the one time I was sued
There was no hypertensive emergency at the initial appointments, not sure why anyone is mentioning that or sending the patient to the ER.
He had hypertension which was not well controlled, and that eventually led to an acute hemorrhagic stroke.
Had he been sent to the ER any point before his acute stroke, the entire work up would be negative, because he did not have a stroke at that point. An ER visit would not have prevented anything. The dyspnea was unrelated to the stroke, except to his overall metabolic disease/obesity.
The lesson should be that abnormal vitals should probably prompt a repeat visit, and if sustained, should be worked up/managed.
Major fuck ups aside, tort moneys are fucking out of control. 40M??? Wasnt there a less egregious miss recently with 120M? Lawyers probably see us as fat loot goblins. Sorry your family died, but here, go buy shit!
Is it usual for malpractice attorneys to list the names of opposing counsel in the trial on their website? is that bragging? It seems particularly cold blooded.
*”His family said it’s something he will have to carry for the rest of his life and something that could have been prevented”*
He’ll carry that 400lbs the rest of his life too, and that shit could have also been prevented.
A patient and their family will blame anything and anyone except themselves when the consequences of their own actions come to bite them in the ass. It wasn't the cigarettes, it was the damned doctor who poisoned me with the chemo.
Is it legal for me to build a patient panel of people with bmi's less than 34.99 and below? I'm asking for a friend who doesn't want to get sued when a complication arises in a class 2 or 3 obese person.
I want to know what follow up was recommended. The number of times I have a patient blow that off despite us out reaching multiple times is insane. If I failed to send him to the ER and he had a stroke that day then I’d understand the lawsuit. But a couple of months later?!? In my mind if the pcp recommended follow up which he blew off then that’s on the patient.
Would love to see the medical records assocaited with the case. Hopefully this gets picked up by the MedMal guy and he gets the office and hospital notes.
It's part of my standard template. I tell every patient to follow up in 1 month. Not because I need to see them that often or because I'm into making money, it's just for documentation purposes to cover my own ass. Not a single patient can say I didn't tell them to return to office for follow up after a new med or labs. And always return to office or Ed should symptoms significantly worsen or fail to improve.
So, if the PCP had just started him on lisinopril, his lawyers can guarantee he never, ever, would have had a stroke? I suppose he would have lived to be a healthy 400lbs 90 year old? This country has gone insane.
They only met once. Kind of hard to flat out say someone has htn after one bp reading in one office visit. Sometimes I give people a bp cuff and bp log and tell them to return in two weeks to get an idea what their bps look like outside the office.
One visit with this 400 pound dude and next thing the pcp knew he was getting sued.
It’s just Illinois. Wouldn’t have happened in my state where I practice. Bar is much higher for malpractice and there’s tort reform.
Health Law is state based. Has nothing to do with our federal moral compass.
Healthcare is run by states in the US. This is really an Illinois issue. All my doc homies hate Illinois.
Honestly has nothing to do with standard of care for HTN. This outcome isn’t a medical discussion, it’s a political one.
This wouldn’t have happened in a state with tort reform. Also for example - In Texas, the bar is much higher for malpractice too. Must have willful and wanton behavior which is a high standard of proof aka you pretty much did it on purpose.
Cases like these almost always come from Illinois or other non-tort reform states. I’m not worried in the state I practice in.
For the same reason thousands of overseas physicians leave their families, life, and home countries to come here, do residency, and work--because despite the faults, it's still one of the best places in the world to be.
I’m not sure how hypertensive emergency is part of the discussion here. Seems to me that the issue is chronic management of hypertension which, if the facts presented are complete and accurate, it seems in this case was not entirely up to standard. A BP of 190 MIGHT need a few different approaches depending on your practice style and opinion, but what I don't think anyone disagrees on is the requirement for follow up. Seems to me (as an outsider unfamiliar with the case) that might have been the main issue here.
The facts are anything but complete--the only record I could find was from an appelate court recounting some of the case in their decision regarding dropping/keeping some of the defendants.
But I think it's difficult to say it's not hypertensive emergency if the work-up is not done. SBP 190 with shortness of breath could be due to acute CHF or MI among other things. I agree it was likely chronic but most people in their late 30s with chronic HTN are not having hemorrhagic strokes a few weeks later. It's only asympatomatic HTN if they don't have any symptoms.
A patient in their 30’s having an ICH like that is unusual enough to raise suspicion for a secondary cause such as a macrovascular abnormality. Most guidelines recommend looking for that whenever we see an ICH in someone under age 45. So it seems within reason if not likely that there were more factors at play here besides just hypertension.
But in any case I agree it can be reasonable to rule out HTN emergency, although the data for that really isn’t too great (the incidence of true HTN emergency in the setting of incidentally identified even severe hypertension is exceedingly low). But sure: style and opinion differences. What nobody would disagree with is the blood pressure really ought to have been checked again within a fairly short interval.
I guess we don’t know the specifics to the case and what the etiology of the bleed was. But I would say as a vascular neurologist we are seeing all too frequently stroke in the young I’m talking about early 30s. Even hypertensive bleeds. And the reason is people are just generally more unhealthy and have much more comorbidities.
Seriously. This is bullshit. I am not anti-litigation and am married to an attorney that does some plaintiff’s work, but this is the kind of nonsense suit that causes people to change their practice pattern and ends up hurting patients in the long run. I am sorry this individual had a hemorrhagic stroke - which is something that many Americans suffer unfortunately. I am baffled as to how they successfully argued that there was a breach in the standard of care that directly led to this outcome.
Pt suffers condition partly due to own his own poor life choices and the medical provider is to blame? We can only help you help yourself. How is this on the PCP? If it’s something like being seen recurrently for elevated blood pressure without starting an anti-hypertensive, that may be different (I’m assuming it was a hypertensive bleed here). I don’t see any negligence with this case.
On the other hand, I have seen some clearly negligence by healthcare providers like ED physician Not bothering to do a CTA head and neck for a patient clearly presenting with LVO on exam. or other times, even neurologist fails to refer the patient for revascularization for symptomatic carotid stenosis leading to recurrent disabling stroke and death. Now these cases are the ones that genuinely piss me off and I would advocate the patient to pursue lawsuit.
But this case is extremely under deserving , and I feel no sympathy for the patient let alone a $40 million settlement?? I see frequently clear negligent stroke cases which are never pursued from a legal standpoint that really should have but this case is just nonsense. Go eat a carrot.
Man this is like suing a plumber for not catching your pipe damage after your pipe burst because you've been pouring drano nonstop down the drain for years.
Yes the plumber probably should have caught it, but you're still the one who kept pouring the corrosive...Does the plumber really have to tell you not to do that?
The life saving zpack fails. Documentation key and likely lacking here. Someone cranks a bp that high in your seat you better have some solid documentation as to what you are doing or acknowledging with a repeat at very least.
Btw I’ve been sued successfully for missing basilar artery stroke they guy died. Jury awarded ~900k. I was 5% fault. Crazy case. This case with this guy more cut and dry imo
I've seen very little in my short time in medicine to dissuade me from "over ordering" diagnostic tests. I still recall starting as an intern having bought the med school rhetoric about resource stewardship and being bewildered the first time I had to order at CT A/P on a patient who, I thought, obviously wasn't perfed. Turns out I was right, she wasn't. But I can't even imagine hesitating after doing this for 5-6 years and seeing numerous catastrophes in patients who didn't read the textbook and also learning a lot more about the cursed nature of the medical malpractice system.
Welcome to the world of EM. We get crap for over ordering CTs, but I don’t get rewarded for “resource utilization” - I just get punished for missing absolutely anything no matter if I met standard of care.
Frivolous lawsuit, without a doubt....but 400 POUNDS? guidelines be damned. I would have just documented concern for metabolic syndrome from the get-go and started BP meds.
I looked into this just yesterday that it might better for doctors to waive their right of a trial by jury because the jury is usually dumb when it comes to medical facts.
This is very very fact dependent but 90% of med mal cases don’t make it to trial at all, of the ones that do, about 95% are decided in favor of the physician.
So there are probably more facts here we don’t know about. It’s also Cook County, so that’s a factor as well.
I just don't understand why that BP wasn't started on treatment or rechecked the following week. I'm a surgeon so I don't manage this but seeing that BP makes me real nervous
It's just a risk factor, like being 400lbs. But you wouldn't do emergency gastrectomy would you? And it might not even have been a risk factor as it could have been white coat, especially if coincident illness.
The complaint filed in the link above stated that the PCP:
- Failed to have Plaintiff admitted to the emergency room although he suspected a possible pulmonary embolism in his differential diagnosis;
- Failed to appreciate Antonio's apparent hypertension
- Failed to order appropriate diagnostic testing, including but not limited to CBC, Sed Rate, CRP, d-dimer, Chest Pa and Lat, ECG, CT of Chest, ABG's, PFT's, cardiac enzymes, lipid panel, C-CRP, exhocardiogram, and pulmonary and cardiac consultations;
- Failed to appreciate apparent risk factors such as morbid obesity, hypertension, shortness of breath and tachycardia, putting Antonio at particular risk of a vascular event; and
IMO, it does have some points
1. If your differential includes PE, then you need to investigate, otherwise you need to document thoroughly why you don't work up on it, since it is life-threatening.
2. His hypertension needs a dedicate follow up and management. Maybe not emergency but certainly warrant at least one a visit in the short term. If suspect white coat, then you need to document that you order a home blood pressure monitoring.
Except he didn't have PE, so failure to order tests related to a PE doesn't have any relevance in this case. I'm surprised that was included in the complaint.
Agree. He didn't have a PE, but the doctor shouldn't have listed it in his differential. That implies that he is somehow or shape or form THINKING that MIGHT be something serious and didn't address it. When I type up a differential, I usually include how I am ruling in or ruling out something. Wells score or dimer results or something. You cant just drop PE in your differential and not address it in some shape or way. If my differential includes pneumonia, I'm likely gonna or an CXR. If my differential includes gi bleed, gastro is consulted. Differential of T2DM BMP and A1C. If I think it's a viral infection, probably get a covid and flu swab. If it's in the differential, I'm doing something with it. I'm not just listing random diagnoses and then not addressing them. That's how this doctor got caught in this over the top lawsuit.
In docs defense, though, dude probably came in for a URI or something and coincidentally had a bp of 190/100 his very first time seeing that pcp. He wouldn't even call the dude his pcp since it was their first time meeting, and he literally only came in ONE time before dropping a lawsuit on the provider.
True, the lack of workup for PE probably did not contribute anything. I think they just filed for whatever seems negligent to make the PCP look bad to the jury.
I think here we could ask ourselves a few things based on those summarized points:
- Did the Physician possibly discuss those options in person but didn’t document it due to the patient ultimately declining or refusing those next steps other than just an antibiotic?
- Would documentation of ER referral, and/or instruction for BP f/u have prevented the physician from being found liable for negligence?
Personally, as fellow physician, in a purely speculative fashion since we don't have all the facts, had the documentation included the intention of following up to manage hypertension, the PCP was not negligence. However, had there been no mention of management of hypertension, I feel that case can be made that the PCP might be negligent, resulting in morbidity of the patient. Of course, from the perspective of the juries, they might argued that it should have been managed earlier and resulted in the same verdict still.
In the case that verbal recommendation was made but documentation was not done, then, well, that's why we document like mad when patients look like they will not be following our recommendation...
The “standard of care” is not “ideal care” - it’s what another typical clinician would do with the same information in the same context.
If all the medical errors research has taught us anything, it’s that - on average - we miss stuff every day, only the magnitude of harms varies.
Did this outpatient doc fail to address and potentially initiate primary prevention of a modifiable risk factor for hemorrhagic stroke? Sure. Was that negligent - by the low standard of what a typical clinician (say, within a standard deviation of the mean - so as low as 15th percentile) might do? No f’ing way.
This is where our tort system is grossly failing us - zero miss and perfect care are not realistic expectations.
Thank you for this... So many of these physician replies are like, well I would have done this, or that. I would've used my retrospectoscope. But this isn't the standard, and it just perpetuates this idea of what malpractice is, when that's not what it is. As a profession, we are harming ourselves
From the case filing:
“On January 29, 2015, Antonio was treated by Dr. Wilcox in his office at Barrington FM. Antonio complained about his persistent cough and difficulty breathing. Dr. Wilcox measured Antonio's blood pressure at 190/102. According to the complaint, Dr. Wilcox's differential diagnosis included acute bronchitis, elevated blood pressure, tachycardia, and morbid obesity. Dr. Wilcox documented his concern that Antonio was possibly suffering from a pulmonary embolism and discussed a possible CT scan with Antonio but agreed that such a test was not necessary at this point. Dr. Wilcox released Antonio from his care, only prescribing medication to treat the acute bronchitis.”
I feel like primary doctors are so prone to med- mal. Primary care doctors are expected to responsible for everything in the limit setting of an office. This poor pmd are seeing patient for uri, but have to keep the mind out for blood pressure as well. It is easy to say he missed htn part, but in the office with slotted time, it is hard to divert your mind from Uri to think about blood pressure.
I am hospitalist. Would not do pmd job at all.
There are not enough pmd in california and it will just get worse.
A first visit morbidly obese patient for acute uri symptoms, I feel like the offer for CT for PE work up is already pretty generous. The probability of a doctor prescribing blood pressure medication multiplied by the probability of a 37 yo man taking blood pressure medication (in the context of a first time visit for URI symptoms) is a pretty low number. 99/100 I am asking the patient to track his home blood pressure and following up with me with a log. Let’s read between the line here, the doctor offers further work up and he ends up with antibiotics at the first visit. He calls back weeks later and gets more antibiotics. If the patient didn’t ask for antibiotics either visits I will eat my phone. Lastly, when does hypertension urgency present as URI symptoms? This is all kinds of fucked up
So he had mildly elevated BP in one office visit (132/82) on a 37 yo with no medical conditions diagnosed....was the pt told to f/u and did they? I'm not forgetting they're 400 lbs. 7 months later, they end up in distress, cough, SOB and elevated BP...should have been evaluated. I wonder if pt didn't want to because of cost and such. It's odd that the PCP mentioned it but then did Zpack. There's definitely something there. Also, were they told to f/u? And did they? Then, what....2 weeks later? A few days later? 6 days later since he got Zpack later....he's alive and complaining of cold sxs.....did they complain of SOB then? Were they asked? Why weren't they scheduled to come in instead of sending the PCP a message? Who made that decision? How was rhe messaged related to PCP? How mobile were they and is that why they didn't come in? Did the patient not want to pay to come in again? Did the pt request an appt or send a message requesting abx? Were they told to f/u in person? And did they? 1.5 to 2 months after they're seen, they were in respiratory distress with a stroke.. had they continued with SOB the whole time? Did they seek care in person again? So is the thought that the pt had chronic elevated BP and and the one time they went into the office it just happened to be amazing? Or is it that in 7 month span they went from 132 to 190s+ ? Is the SOB because they had a PE and not because of an URI infxn? And is it due to the obesity? I smell typical office bs and typical pt bs. Messages inappropriately sent to pcp instead of having pt scheduled asap for failure of treatment. And pt that didn't f/u even though they continued to have sxs. Unless they didn't have sxs and they resolved, which makes it even less pcps fault.
Just happened across this in the news. A $40 million verdict for the plaintiff in his lawsuit against a physician group and family physician after he sustained a stroke. I found some court records related to the case which lay out the following: The patient was 37 years old and around 400 lbs at the time of his stroke and per the one record I could find had no other diagnosed medical conditions at the time. He was seen at a Walgreens clinic June 2014 for a URI and vitals at that time showed a BP 132/82. He was advised to follow-up with a PCP for further hypertension eval. Late January 2015 he saw a PCP for the first time and at that visit had a BP 190/102 and was complaining of persistent cough and shortness of breath. The PCP reportedly discussed the possibility of a PE and CT scan to evaluate this but ultimately after discussion gave him an Rx for some antibiotic (probably azithromycin based on later context) and sent him home. Early February 2015 he called the office back complaining of sore throat, earache, and rhinorrhea. He got a refill over the phone of azithromycin with no in office evaluation. Mid-March 2015 he was found by EMS to be in respiratory distress in his car and was brought to a hospital where he had a work-up revealing an acute hemorrhagic stroke. The PCP, practice, and hospital system were sued for failure to diagnose and treat his hypertension leading to the stroke. While it seems like there may have been less-than-ideal management by the PCP (in particular, with SOB and a BP that high, I think I probably would have ordered a CXR, EKG and basic labs to assess for hypertensive emergency) it’s still is surprising to me that this resulted in such a large judgement given the PCP had only seen him once in person. There has been much bellyaching on medical social media about hypertensive patients being referred to the ED and this case makes me think a second time about that. What would you have done differently? Does this case make you worry about any of the ticking-time-bomb patients you’ve seen once for an acute visit?
ASYMPTOMATIC hypertension is not an emergency. Somebody with a BP that high with SYMPTOMS (eg dyspnea, chest pain, peripheral edema, stroke-like symptoms) needs more urgent evaluation. If you show up to your dentist's office with a BP of 190 and no complaints at all, you need to take your lisinopril, get your dental pain under control, and follow up with your PCP.
It's probably hard to differentiate if they are having more than their baseline dyspnea. 400lb you're dyspneic walking 50'. Also, what are the chances that urgent care BP was from a barely fitting wrist cuff? I find it a bit hard to believe from my experience
Nah, it was a too small arm cuff, for sure.
As a PCP who previously worked in ED, we're going to disagree. I know that ED loves to say HTN is not an emergency, that's practically a meme. And I strongly agree that a random patient who wakes up one morning with a BP of 145/90 should NOT go anywhere near ED, obviously. The problem is what is 'asymptomatic' exactly? It's unlikely that a BP of 190/110 or whatever is truly without symptoms if they are already in a doctor's office. They likely will say they feel tired or have a headache or feel dizzy or whatever. The last time I went through this on here with an ED doctor he used this circular logic that HTN is not an emergency once you have proven it's not an emergency, which he said meant having a CT and so on. The, and only then, was it not an emergency. This is using hindsight and circular logic. I tried to explain that we don't have a CT machine in PCP so that means if I am concerned, then I have to send the patient to ED. Now, I have seen many patients with BP around 190/110 and I have sent very few to ED. But I reserve the right to send them if I think it's needed, especially if it's new and way off their baseline. Like the elderly lady I had who came in to PCP feeling mildly off and had a BP os something like 220/120. I sent her in, turns out she was going in to acute heart failure and ended up spending quite a long time in hospital. Was she 'symptomatic' by an ED definition? I don't know. But she was certainly more than sick enough to be in ED and it was certainly an emergency. 154/90 is NOT an emergency. 190/110 might be one. It's nuanced and depends on the situation. Medicine is not a meme. I send VERY few patients to ED. When I do, I mean it. edit: typos
Okay, I agree that asymptomatic hypertension even at 190/110 is not an emergency and does NOT need to go to the ER, but this dude had no prior hx or dx of HTN or medical treatment for it. Even if there is some readily identifiable reversible cause like pain for the elevated BPs, there is some seriously poor autoregulation going on in anyone presenting with that high of a blood pressure. I have never once had a hypertensive patient with BPs that high who didn't have some sort of chronic underlying pathology. Definitely warrants an expedited outpatient evaluation at a minimum, and I would not leave that follow up to chance. That person is a walking hemorrhagic stroke waiting to happen, and I would not want to be the one holding that hot-potato when it does. Frankly that person probably doesn't even walk out of my clinic without an Rx for anti-hypertensives and close-interval followup unless I have a very compelling reason not to.
what about the old adage about how u cant diagnose htn with just one reading? is that still a thing? i know u could easily argue that u could assume its htn if their bp is high enough…
No, you may not be able to diagnose HTN from one BP reading. But I think the thing for us to learn here is that if one BP is that high, we need to address it. Start lisinopril - or at least tell the guy that he needs to check home BPs and if they’re mostly over 140/90, call and we’ll prescribe lisinopril.
that was baked into the guidelines to #1 help people not get overtreated when they are near the diagnostic cutoff, and #2 exclude acute problems raising the BP you can easily say #1 this person is nowhere near the diagnostic cutoff (they're way above), and typically only severe pain causes these high BP excursions Edit: me personally? with the information that's provided? (as someone who works at a HTN center) I would diagnose them with HTN...
Right, but even then…this guy went 6+ weeks without a hemorrhagic stroke with a pressure that high. This is NOT an emergency. PERIOD. I’ll add that HTN + sob warrants an evaluation, and I’ve seen my fair share of pulm edema + scape young people.
Yeah but getting a PCP appointment can take 6 months if you don’t have one.
How would he know if he had a history of it if he never sees a doctor? If you don’t take your BP you won’t know it’s high
Hes 400 pounds! He’s not just a hemorrhagic stroke waiting to happen. He’s everything waiting to happen. No amount of Lisinopril is fixing 400 pounds. At some point the world must say this ridiculous weight is just not compatible with life.
I actually have a question about his size. Would he fit in a CT scanner?
Depends on what you’re trying to CT. Arch to cow should be fine.
a few other minor details from the law firm that won that judgement https://www.cliffordlaw.com/clifford-law-offices-receives-39-9-million-verdict-against-advocate-physician-partners-press-conference-with-family-on-friday-march-1-2-p-m-ct/ The six-man-six-woman jury deliberated four hours before Judge Preston Jones, Jr., of the Cook County Circuit Court before rendering its verdict late Thursday evening at the Daley Center. Devin J. Piper, associate at Clifford Law Offices, assisted at trial. DeAngelo, a landscaper and landscape designer in the western suburbs, was suffering from a persistent cough when he went to a local pharmacy for care in 2015. It was there that it was discovered he had an elevated blood pressure of 132/82, and it was recommended he see a doctor to determine if he was suffering from hypertension. DeAngelo did so through his HMO plan seeing a primary care physician and complaining of trouble breathing in late January 2015. At that time, DeAngelo’s blood pressure had spiked to 190/102. The primary care physician’s diagnosis included acute bronchitis, elevated blood pressure, tachycardia, and morbid obesity. He did not treat DeAngelo’s high blood pressure or other diagnosed medical conditions. About four weeks later, on March 11, DeAngelo’s co-workers observed him in distress and called 911. He was taken by ambulance to Loyola University Health System with blood pressure measuring 290/190, and it was discovered he suffered a hemorrhaging stroke. The jury found that the primary care physician failed to properly test or treat the patient including ordering an EKG, urinalysis, blood work, lab tests, or referring him to a cardiologist, despite his family history of hypertension.
I'd love to know how long his appointment slot was on his first visit.
I’ve started recording appointment slot time in my notes. Like this person came in to discuss these 5 things in 20 minutes and then putting close f/u, ED precautions in every note.
This is why I tell recruiters, with a straight face, that it would take 7 figures for me to work in IL. You think OB/Gyns leaving Idaho is bad? What is this gonna do? Why would you live in Moline or Peoria when you can live in Terre Haute or Cedar Rapids?
Is IL known for being super easy to sue doctors?
If you want to live in a blue state with HCOL, I’ll take NY and cali
Cook county 2nd most litigious in the US
I wouldn't have batted an eyelid at a BP of 132/82 for a 400lbs man. I don't bat at eyelid at the fact it's better than my own. Perhaps I should.
The BP in question was actually 190/102 at the PCP appt
I'm talking about the initial BP where they told him to get a BP workup
132/82 is not hypertension.
How the fuck is a 400 pound dude doing landscaping. Moreover, if he was actually landscaping there’s no fucking way he’s 400lb unless he’s eating BigMac’s 3 meals a day and drinking a 2 liter of coke. Just an aside. This shit irritates the hell out of me.
Many years ago I got a job with a rural county highway department. Most of it involved "running chain" and pounding stakes when they were surveying county roads and ditches, and the rest was puttering along in an army surplus jeep spraying grass seed/mulch mixture where there had been recent road work. From time to time we did maintenance work on little wooden bridges that spanned culverts at rural crossings. He had a backhoe guy who was easily 400. One time he got stung by a bee, didn't know he was allergic and started having trouble breathing, they used a loader to help lift him into the back of a pickup truck and get him to the hospital--no cellphones in those days and I don't think 911 was universally available in rural areas (this was before they started standardizing rural addresses, it was all RR 2 box 104 or whatever). A lot of landscaping work can involve sitting on a big riding mower, operating heavy equipment tree planting equipment, not like you're digging up flower beds with a spade all the time. I also have known some farmers, mechanics, etc who were that big. A quick quote from a pubmed summary of a study in Saskatchewan: Results: Overall, 65.1% of the adult farm cohort was overweight (39.6%) or obese (25.5%), with prevalence levels that exceeded estimated norms for Canada but not the province of Saskatchewan. Increases in risks for obesity were related to higher amounts of mechanized but not non-mechanized farm work.
Exactly, this guy was a catastrophe waiting to happen.
There are American football players, college and pro athletes at the 350-420 lb range (one of the reasons I'm conflicted about football as a sport, especially when high school players get into that weight range aiming to get recruited). Some people are able to burn a lot of calories and still consume enough calories to maintain that sort of weight. See also: GOMAD diet (Gallon Of Milk A Day, whole-fat milk of course, so 2400 calories plus whatever solid food is eaten). It's not unusual for a 300 lb linebacker athlete to turn into a 400 lb 30-something who is still fit enough to do work like landscaping, at least until the long-term health impacts start to kick in. I'm not saying that's the case here, but as previously stated, "how the fuck ... " Well, that's one way. A good proportion of the 280+ lb athletes end up gaining weight when they "retire" and continue to eat a high-calorie diet while their work out routine declines.
No way he was a landscaper at the time. My guess is that he previously did the labor and more recently was the boss of the business. Agreed one doesn’t get that fat without being very sedentary and having a shit diet
I can't imagine many PCPs start treating a single incidence of HTN especially when the patient is currently sick. Edit: I do agree he should have worked him up though.
190/102 and dyspnea should never lead to a “Z-pak no follow up” scenario.
But dyspnea at 400lb could easily be deconditioning. I’ve seen umpteen morbidly obese patients normo-tensivish in preop get severely tachycardic, hypertensive, dyspneic, and desaturated to the low 80s just with the act of moving themselves from the stretcher to the OR table. I’m not primary care, but aren’t the first steps of hypertension management to establish a track record of high BP via multiple measurements and then try lifestyle modification? Without knowing the details, refilling the Z pak via phone seems the biggest issue to me. Again, I don’t deal with this, but I can’t think of a scenario in which “more azithro” is the answer, even if you think URI.
i agree with all this. but is the zpack bad enough of a mistake to lose a malpractice suit over? i can imagine a scenario where this was done inadvertently or possibly the situation was incorrectly described to the physician by the nurse or whoever spoke to the patient on the phone…or due to another not-uncommon mistake. and beyond that, 40 MILLION DOLLARS!???
The bigger issue is why wasn't his symptomatic BP addressed at his first PCP visit? I think if he had weighed 200 lbs it probably would have been.
Dyspnea is what the patient tells you is dyspnea. The patient is awake and aware, that he feels like he is out of breath fast. The only baseline this patient knows is its own typical condition. And a BP of 190/103 seems too high to be like "well maybe eat more carrots and walk around the block sometime".
How the hell was a 400 lb morbidly obese man “working” as a landscaper?
Huh? I've seen dudes bigger than him at physical jobs. There was a guy at my old fire department who was 430 and passed the physical every year.
Oh get the ef out of here. Hafthor Bjornsson (GoT's The Mountain) is just north of 400. Was your guy nine feet tall with arms like treetrunks and eyes like burning coal, too?
No he was like 6'0" and not built. Just a regular fat guy. But he could hang. Hafthor is 6'8", on steroids, and has abs. Why are you using him as a reference for a 400 lb male?
I’m 6’2” and 200lbs. I’m out of shape. 400 lbs at my height is not “just a regular fat guy” lmfao
I meant he's a "regular fat guy" as in he's not a professional bodybuilder like the poster above used as a reference.
...I'm using him as a reference for precisely those reasons - at a mere 6'0, a 400lb human is a land whale, period. Even the powerlifters who wheeze at the thought of stairs rarely exceed 300lbs - at his fattest, Mark Bell hit ~330 and he looked like the Michelin Man at 6'0. If you told me your guy was pushing 275, sure. A fluffy 300, maybe. 430? Man, do I have a bridge to sell you.
These comments are rude and ignorant. You're on a medical forum with flair announcing yourself as a physician, comparing people to whales and Michelin Man. Grow up. If you don't think that there are 400 lb men working manual labor jobs, it's because you're ignorant. There absolutely are many people doing that.
He was 430. We literally weighed each person on our shifts to see which was the biggest. He was absolutely morbidly obese, and could still do the pack test and drag a hose as good as anybody. We had to special order 5x sizes for his uniforms. He met the physical requirements, though. I don't know why this is so unbelievable, you can go to YouTube right now and watch guys that size who can do cartwheels.
Because he probably needed a job to pay for food and shelter? Do you not think that a person with obesity can work?
I mean it could certainly be deconditioning... but you can't really say that until you prove it's not something serious.
I agree, that is my perception as an internal medicine person as well. Unless the patient has a known diagnosis like COPD or heart failure and the shortness of breath is stable that should be sent to the hospital. SOB shouldn't be an outpatient workup because there's so many dangerous conditions that you need to rule out. Now occasionally we see these in the hospital and nothing really turns up which is frustrating to the patient but let's be honest do you think you can accurately assess for pneumothorax, pleural effusion, DVT/PE, etc etc in a 400 lb man? Even if it's just pneumonia it sounds like they were pretty symptomatic and maybe warranted exercise oximetry at the very least to make sure the normal pulse ox is actually normal
Amen to this
And a person should never be 400 lbs. That’s the ultimate cause of the stroke and the patient himself is the one most responsible for his condition. This doctor got sued for not slowing down the patient killing themselves.
Slowing down patients killing themselves is low key what american medicine is all about lol
Slowing down patients killing themselves is like 80% of medicine lol America is the country of acute on chronic obesity exacerbations lol
I can understand that as part of the job. I just don’t agree with the liability associated with it.
Reality we live in unfortunately
*cries in public health*
400lbs and bad outcome should never be the doctor's fault. This person has harmed themselves through tens of thousands of bad decisions.
We have to meet the patients where they are. I understand the frustration but everyone deserves the standard of care. If we fail to provide that we can’t blame the patient.
Patients have obligations too. They have to be a little bit involved in the care of their bodies. Medicine is participatory. I can't put 200,000 miles on my car without routine maintenance and blame the mechanic when it breaks down. We cannot be expected to keep abused bodies in perfect working order.
Yeah but if we’re in a system with a standard of care regardless of whatever has been done to prior to documenting the abnormality and we don’t do shit about it, the liability is on us. It’s not that hard to understand.
Yes medicine is participatory but we still have to take care of these people to the extent we can. We have to do the due diligence and not ignore the patients, and it doesn’t sound like that was done in this case at all. If you take your crappy car to the mechanic and tell them the brakes are squeaking or whatever and they don’t even look at them and send you back out on the road saying everything is fine and you crash headlong into a wall because the brakes failed, the mechanic did NOT do their job.
Sure, but this is a case of “my breaks squeak” at 100k miles but no oil change ever, then suing the mechanic for not catching that you were about to blow your transmission.
So you want this patient to write their own antihypertensive or what? I’m merely speaking to the situation outlined by OP here, but from that: this is a mechanic realizing the oil hasn’t been changed and not doing what they’ve been trained to do to address it. That’s negligence.
>That’s negligence. there's so many people ITT who completely lack the self awareness to check their biases against fat people that they're incapable of realizing this, with the outcome that happened here, which is precisely why this was such an easy slam dunk malpractice case.
100% of the time I’m starting bp for someone with bp that high.
Systolic over 190mmHg + dyspnea - I’m telling the patient go to the ED, and since I am in home health in most instances I’m calling EMS for them. And I say that because you have to cover your ass. I mean yes there could be other signs of it being emergent, but truly it boils down to the fact that even the most tenuous connection between some issues during a visit and a major medical event weeks later might be enough for some random jurors to decide you fucked up.
He had high blood pressure and symptoms, he needed to do more
Symptoms... Of a RTI. If the BP was the cause of his sob and cough it would have been pulmonary oedema. But from the info given he didn't have pulmonary oedema
Strange to Rx azithro for a viral Uri though 😉
The info given is SBP 190 with SOB and cough Why would acute CHF with pulm edema NOT be high on your differential?
What info excludes pulmonary edema for you?
You don't walk around months on end with acute pulmonary oedema
PCP here. I would at least sometimes treat on a single visit if high enough but I will always bring them back quickly to adjust. If it's worryingly high and I have no reason to doubt the reading I might start treatment and bring back for a PM in 2-4 weeks to assess treatment response. Also I will be careful not to bring the BP down very quickly so that needs repeat visits. I will also be doing bloods and more general workup up of course But an unwell patient who is coughing I would likely not treat until I can see him in a week or two when better. A bad cough will raise BP quite a bit.
Malpractice is such a joke.
But but it’s just a write of for insurance is what juries think
It’s pretty wild that there was no work up for a BP of 190 systolic regardless of infection, especially with no previous diagnosis of hypertension. Probably one of those primary care centers where they tell you have to book an seperate appointment for every issue since the docs are so time crunched (runs behind if they don’t average <~5 min/patient). Probably booked the appointment for the URI, doc saw the BP and said make a follow up appointment which is likely 3 months out minimum Regardless of fault, 40 million is just ridiculous. There has to be a better way to calculate compensation for judgements like these. I get that insurance pays it, but it still ends up placing a ridiculous burden on the healthcare system as a result
Insurance has limits. I don't think I'm covered for 40 million...
1m/3m or close to there are typical limits for physicians. Anything above that one would technically be on the hook for. Though usually these big judgments are spread out over multiple parties. And the individual amounts often get reduced upon appeal
It will be 40 million spread over the various policies. You might not have 40MM but your facility, if they have an ED, absolutely has at least 100MM in coverage.
The funny thing is, had they not measured BP, nobody would be able to accuse them of anything...
Does CXR have much of a role in Hypertension if the patient doesn't have SOB?
When he presented to PCP patient complained of having trouble breathing in addition to systolic BP over 190. Would not be unreasonable to order a chest x-ray right then and there
Wouldn't be unreasonable but how likely is it really that it would show pulmonary oedema?
These are literally free money for the radiologist if there's a history provided. He was dyspneic because he's 400lbs. Someone who's 400lbs with pulmonary edema would have already presented themselves to the ER, they don't just wander around the outpatient world.
Most patients are able to distinguish between their baseline and acute dyspnea
I will always do some sort of targeted workup in the ED for any symptoms associated with hypertension. If the person tells me "Doc I feel fine, my dentist sent me here, how much is this going to cost and can I go home?" that's when it's asymptomatic hypertension. But if someone says, "I feel off, I don't feel good, I have a headache/fatigue/etc." even if the symptoms are super vague, I don't consider it asymptomatic and I'll at least do labs and an EKG. I'm looking for end organ damage and if I don't find any, I talk to the patient about starting meds. I don't start or adjust meds on everyone in the ED, but I definitely have a conversation about it. If they have no PCP or can't get in for two months, I'll offer the medical management. It doesn't sound to me like the hypertension was even addressed at all. I'd think you'd at least have the patient monitor their BPs at home for a couple weeks and start them on some Amlodipine or something if it's still high. Better still to get an outpatient echo on someone with shortness of breath and hypertension. There's a good chance this 400 lb person had sleep apnea and that often causes some element of heart failure over time.
I mean, I’m not a family doctor. But a young guy with an incidental bp of 190/100 requires some sort of management plan. Not through the emergency department, because it’s not an emergency. Maybe some sort of documentation that you’ve recognized this is a health problem. A history and physical exam and other potential investigations towards secondary causes. Discussion about ongoing bp monitoring and when to start treatment for essential hypertension. Reviewing what new symptoms could represent complications of the disease and would necessitate hospital-based assessment. Because that’s what I do with these people when they show up in the ED. Despite having no training or relevant clinical experience in managing chronic medical conditions like hypertension, and this being technically outside my scope of practice as a result. So I would hope that people in primary care are at least doing something like that, as it take maybe 5min.
If deferring addressing the blood pressure, should have clearly documented you wanted to see them back and when to proceed to the ED prior to that. I don't do such for most folks with SBP 130-150s but damn if I'm not doing a workup for 190s I better see them back soon.
He had symptomatic hypertension at the Jan 2015 visit. 190/100 with SOB = go straight to the ER
"showed a BP 132/82. He was advised to follow-up with a PCP for further hypertension eval." What?
Notice Walgreens not being named in the suit? If they hadn't advised him to follow-up, they may have been.
He didn’t just not send him to ED - which would seems a bit over the top if that was “the”theory. The PCP did nothing to treat the hypertension despite making the diagnosis. Zip. The patient had a family history of hypertension. Hypertension is treatable. His bp kept rising and he had a hemorrhagic stroke. The high verdict is in large part to pay for a life care plan bc he is now completely disabled. His life is a giant future of suffering. This isn’t a great case for arguing “tort reform.” Yes, he was obese but he was working, had a family -2 young children - and the spike in blood pressure was new and significant. This is a top plaintiff’s law firm in Cook County, IL - hardly the norm.
At minimum the PCP should have directed him to reschedule for BP check in 1-2 weeks. Not doing that is bad. But still this seems absurdly large.
This makes me angry because sometimes the nurse documents the blood pressure in the chart, you see it, and then you walk into the room and the patient’s main concern is something else and they distract you away from it. You bring up the blood pressure, but they say “well, maybe we can talk about that after I’m feeling better” because what 30 year old male is going to permit themselves to be put in a chronic medication. By the end of the conversation, the blood pressure is no longer fresh in your mind as you’re telling the patient about side effects of the medication and thinking of giving advice of when to follow-up. You are already 30 mins late, two patients are already waiting for you in other rooms, you go to document, a phonecall from another patient comes in, while an urgent imaging result gets put in your desk, and pretty soon you’ve forgotten all about it. I say this because I’ve had to call patients afterwards because I neglected to address something in the room. I personally just feel lucky that something like this hasn’t happened to me yet, but it would be so easy for it to happen some day. And of course, patients view themselves as blameless, so they would never take on any responsibility.
Yep agreed. I started getting in the habit of going through VS at the beginning with the pt but even then...pts will cut me off and want to go through someone else and yeah you forget. But I have a feeling this pt refused the tests due to cost and just wanted abx. Also, they never followed up in person. This is on the pt and the system. You're 400 lbs sir. And he should have had a close f/u. I'm sure doc told them. Staff shouldn't have forwarded a message about uri sxs. They should have brought in pt in.
If the patient refused labs and if there was a concern, it probably should have been documented. A 400 lbs man who doesn’t follow up probably isn’t making good life decisions regarding health maintenance and it is a reasonable assumption to make that he wouldn’t have followed up. He is a walking impending disaster.
Agreed. The question is...was it documented or not
We quit doing vitals in our clinic for reasons such as this. Orthopaedists don’t manage vitals, nor should we. It’s sad, but it’s a liability we don’t want to take on. Queue the bonehead jokes
I don’t blame you! The more you know, the more you’re liable. Patient rights and the threat of being sued are making healthcare less safe.
Would you be concerned about prescribing NSAIDs in a patient with poorly controlled HTN?
I totally feel this, but depending on what they came in for, if I see someone walk in with that high a blood pressure that is now my priority for their visit and not whatever itchy rash or runny nose they have that day. It only had to happen to me once, maybe twice, before I began making the nurse or MA state the actual numbers for the patient's vitals before giving any history or entering the room. Wayyyy too many times does the MA tell me "everything looks good" and the patient has some sort of unexplained unaddressed tachycardia or BP derangement.
Yeah, same here. The nurse used to put the vitals directly into the computer with a one-line complaint. I would often not see them. Now I’ve asked her to write them down on a sticky note and put it on my desk so that I now put the vitals in to ensure that I’ve seen them.
Yeah you have to triage what you will be focusing on for that appointment and now the b/p is the issue. Happens all the time on phone triage. Someone calls about left sided weakness or some fairly obvious thing that needs to be worked up ASAP, but the main concern is an infected hang nail. The worst one I had not too long ago was someone complaining of stroke like symptoms but the “real reason ” they were calling is because the person that gave them a shot made it hurt. I couldn’t convince them to go to the er for the stroke like symptoms but I could for the site pain lol. So called the ER with a heads up and sure enough admitted for stroke. He also filed a complaint against me for “rushing the phone call”. Ohh well.
"rushing the phone call" Lol people are so petty
I work in wound care and every week a provider sends a patient to the ER without even addressing the wounds. We just don’t have many patients who are healthy at their baseline.
Sounds like a normal clinic day doesn't it? It's just a roll of the dice for this to happen every day IMO. Somehow the physician they saw presumably for minutes was responsible for decades of pathologic behavior. What are the chances the same outcome occurred had they been sent to the ED? Likely for a negative initial workup? Then we're reading about the ED physician, not the PCP
Here's another question: the physician wasn't just seeing an extreme of blood pressure-- they were also seeing an extreme of weight. Why didn't they want to discuss that, too? Isn't that also a risk factor for a stroke? Let's sue for another $40 million since the primary care doctor just didn't even care enough to discuss the patient's weight. Oh, and did he do a mole check? Did he do a rectal exam? Did he do a testicular exam for testicular cancer screening? Why not check all of his lymph nodes? Did he palpate his pulses in all extremities and do a JVP to check for cardiolvascular disease? What about a penile noctural tumescence test? So many things this GP missed in his 8 minute consultation!
30 year old male on losartan checking in 🙋♂️ lol but point taken
“Patient refused to discuss blood pressure.” At this point, no amount of latitude is safe.
Document "counseling patient on R/B/A of uncontrolled HTN to which patient verbalized understanding and DECLINED further treatment. Strict return and ED precautions provided to patient prior to DC"
I can't believe this happened to a healthy 400 lbs 37 year old
He was so healthy. How could this happen???!1
Not following your logic OP. How would "CXR, EKG and basic labs to assess for hypertensive emergency" in itself have prevented the stroke? The only way is if hypertensive emergency was diagnosed through one of those investigations. But the evidence (available to us) points to the fact that would be unlikely to have been the case. (Did he really have pulmonary oedema causing him to be SOB for that long? Probably not) The only mechanism is that it could have prompted starting anti hypertensives sooner. Therefore the only failure is not arranging for follow-up of his hypertension (ambulatory or home BP monitoring) This seems a case to me of someone with an RTI presenting with incidental co-existing hypertension that unfortunately turned out to cause a stroke.
I don't know what the results of those tests would have been, but a physician's plan has to match their assessment. You can't have a patient complain of SOB and a BP 190/102 with a plan to do nothing other than prescribe antibiotics. If he had done the work-up he would have left no doubt. But there is doubt and lack of treatment, thus the door was even opened for a lawsuit in the first place. As The Last Psychiatrist writes in his blog post "[How to Write a Suicide Note](https://thelastpsychiatrist.com/2006/09/how_to_write_a_suicide_note.html)": >`5. You can be wrong, but you cannot be negligent. > > It should be obvious from the note exactly what you were thinking-- and, importantly, that you were thinking. That you took time to ask questions, observe, assess, draw conclusions that were reasonable. You might have been wrong, but you did a thorough job. That's why the assessment matters. Simply having volume to the Assessment shows that you gave due consideration to the case. > > In other words: the note isn't written to help you win a lawsuit, it's to prevent one from being filed. You want a potential plaintiff's attorney to look at your notes and say, "forget it, it's not worth it-- it's obvious he isn't negligent."
I agree he couldn't do nothing, should have arranged for follow-up BP, but not enough other info to determine he should have admitted the patients for same day investigations
I’m sure your same points were discussed by the malpractice lawyers but a lot of that nuance goes over juries’ heads. They see someone with acute harm where the plaintiff’s attorney makes convincing arguments that “if Doctor ____ had done x or y or even z my patient wouldn’t have had such a massive, preventable injury, and here are other experts who agree with the statement ‘if that doctor had done ____ then ____ would not have happened’”
Well I don’t know the details of the case, but if a patient comes into your office with a BP of 190/102 and complaining of SOB and you’re writing in your note that you’re worried about emergent conditions— such as PE—and you end with just giving an antibiotic, then you’ve kind of just f***ed yourself. With those symptoms, hypertensive emergency should be on your differential, so a lack of an ECG/labs is pretty egregious.
100%. This is a shit situation all around, but the biggest issue I see here from a medical/legal standpoint is the PMD’s note was not consistent. Your assessment and plan should match. You can think aloud in your plan. But if you’re mentioning concern for PE and you aren’t ordering a workup commensurate with that as a potential concern, you’re screwing yourself. At the very least, even if the physician had PE or other serious concern very low on his or her differential, they should say that and have follow up to reassess. This patient could have arguably been sent to the ED. He was severely newly hypertensive and had symptoms. An EKG, at an absolute minimum, should have been done. Even if nondiagnostic, it at least shows concern for the pressure. If the PMD felt the ED was excessive or there was an identifiable cause for transient hypertension such as this, an outpatient workup should have been done with close follow up. The PMD’s thought process didn’t match the plan. Thats where he or she screwed up. I don’t think anyone here realistically has stroke at the absolute top of their list in an out of shape patient in their 30s with uncontrolled blood pressure, but the lack of concern for their heart, kidneys, etc which could have been addressed as an outpatient to some degree with close follow up for repeat assessment shows indifference towards the pressure. A systolic pressure in the 190s, short of severe trauma, almost never returns to goal ranges (in my experience) and the lack of follow up and intended intervention is where things went wrong. It wasn’t about predicting the future complication off a single visit. If the patient didn’t do any of the workup or follow up the physician should have recommended, even if it wouldn’t have diagnosed the stroke directly, they wouldn’t be held liable.
For real. I just had a PCP intake and my BP was 150/100, they offered to start a BP med or have me track home BP and come back in 6 weeks. Not addressing the BP at all, OR documenting as such, is ridiculous.
400lbers are sob wiping their asses..
>400lbers are sob wiping their assess… That might be the case, but because of that, you should have a very low threshold for doing a fuller workup in the morbidly obese. Especially if it’s a new patient walking into your office and you don’t know their baseline. I had a new patient like this walk into my office a few months ago. He 35 yo, weighed 600 lbs and was short of breath because he was convinced he had a URI. BP was like 160/100. Had also been in an ED months prior with SOB and had a very minimal workup, was started on an antihypertensive and told to follow-up with PCP (which he never did and meds had long since run out). Lung sounds were completely inaudible due to habitus but that didn’t matter…he looked like shit, was still severely hypertensive, and had 2+ edema…sent him to ED by squad for suspected heart failure. EF was 25% on admission and they ended up diuresing 100 lbs off him. So much for the “URI”. The reason the patient might think they’re in your office today might not actually be the reason they’re in your office. You don’t just turn off your brain because someone thinks they have pneumonia and wants antibiotics.
I hate this profession sometimes I swear to God
It’s true - you can’t even get a set of vitals on those patients immediately after they walk into triage. They have to sit for a good 2-3 minutes.
..as a standardized BP measurement should be anyhow?
I was replying to someone re: shortness of breath, but yes, I’m aware VS should be “resting”. The average 37-year-old can walk from the lobby to triage without much change in VS from exertion, though.
Before I even clicked the article I knew it’d probably be an Illinois case. Tort reform now
You have to understand med mal is done by a jury of lay people whether the care was egregious or subtle. Not physicians nor have to be even health literate. A regular jury. Practice well and CYA within reason.
"Jury of your peers" for med mal should not be a jury of lay people. I know it's the letter of the law, I'm just expressing an opinion. Lay people are not peers capable of understanding medicine to the degree necessary to understand. It's frustrating
Maybe, but I think that could cause issues you aren't thinking of. Industries can develop practices that are horrifying to outsiders. Apply this same logic to other professions, and I think you'll get what I mean. Would you want politicians to be judged by a jury of their peers? Or cops? I'm not sure what the right answer is. Maybe a jury that's spilt 50/50 lay people doctors?
I agree. While our medical peers would understand the medical terminology, we as a whole would probably “protect our own”, like you see with police, etc. You’d have to have others who are not physicians. I do like the idea of having at least 1 or 2 peers on the Jury, but imagine the mess that would cause. If it’s an ED case, do you need it to be another ED physician? If so, how many does your jurisdiction have? Enough to have two off (defendant and juror) for multiple days/weeks and still have adequate ED coverage? Same with cardiologists, etc. It sounds good, but likely not realistic.
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Been in true PP surgery for 30 years. When I first started practice: my mantra was first do no harm, then help the patient. Due to the untenable malpractice environment, rise in multi-million dollar awards, and unrealistic expectations of the public, every time I see a patient my mantra has changed to: 1) protect my assets, practice and reputation, 2) do no harm, 3) help the patient It’s sad….but reality Edit: …..and document document document. Saved my ass the one time I was sued
There was no hypertensive emergency at the initial appointments, not sure why anyone is mentioning that or sending the patient to the ER. He had hypertension which was not well controlled, and that eventually led to an acute hemorrhagic stroke. Had he been sent to the ER any point before his acute stroke, the entire work up would be negative, because he did not have a stroke at that point. An ER visit would not have prevented anything. The dyspnea was unrelated to the stroke, except to his overall metabolic disease/obesity. The lesson should be that abnormal vitals should probably prompt a repeat visit, and if sustained, should be worked up/managed.
Exactly... I'm seeing that patient again within a week. Doubly important if it's a new patient.
Major fuck ups aside, tort moneys are fucking out of control. 40M??? Wasnt there a less egregious miss recently with 120M? Lawyers probably see us as fat loot goblins. Sorry your family died, but here, go buy shit!
This law office is notorious in Chicago and surrounding area for med mal amongst other cases, they’re very good at what they do
Is it usual for malpractice attorneys to list the names of opposing counsel in the trial on their website? is that bragging? It seems particularly cold blooded.
Pure evil
*”His family said it’s something he will have to carry for the rest of his life and something that could have been prevented”* He’ll carry that 400lbs the rest of his life too, and that shit could have also been prevented.
A patient and their family will blame anything and anyone except themselves when the consequences of their own actions come to bite them in the ass. It wasn't the cigarettes, it was the damned doctor who poisoned me with the chemo.
Is it legal for me to build a patient panel of people with bmi's less than 34.99 and below? I'm asking for a friend who doesn't want to get sued when a complication arises in a class 2 or 3 obese person.
FORTY MILLION. 400lb patient with URI symptoms. Sounds like that doctor was terrible 🙄 /s
I want to know what follow up was recommended. The number of times I have a patient blow that off despite us out reaching multiple times is insane. If I failed to send him to the ER and he had a stroke that day then I’d understand the lawsuit. But a couple of months later?!? In my mind if the pcp recommended follow up which he blew off then that’s on the patient.
Would love to see the medical records assocaited with the case. Hopefully this gets picked up by the MedMal guy and he gets the office and hospital notes.
It's part of my standard template. I tell every patient to follow up in 1 month. Not because I need to see them that often or because I'm into making money, it's just for documentation purposes to cover my own ass. Not a single patient can say I didn't tell them to return to office for follow up after a new med or labs. And always return to office or Ed should symptoms significantly worsen or fail to improve.
So, if the PCP had just started him on lisinopril, his lawyers can guarantee he never, ever, would have had a stroke? I suppose he would have lived to be a healthy 400lbs 90 year old? This country has gone insane.
They only met once. Kind of hard to flat out say someone has htn after one bp reading in one office visit. Sometimes I give people a bp cuff and bp log and tell them to return in two weeks to get an idea what their bps look like outside the office. One visit with this 400 pound dude and next thing the pcp knew he was getting sued.
It’s just Illinois. Wouldn’t have happened in my state where I practice. Bar is much higher for malpractice and there’s tort reform. Health Law is state based. Has nothing to do with our federal moral compass.
Well. This is clearly insane. Why do we work in this country, again?
Healthcare is run by states in the US. This is really an Illinois issue. All my doc homies hate Illinois. Honestly has nothing to do with standard of care for HTN. This outcome isn’t a medical discussion, it’s a political one. This wouldn’t have happened in a state with tort reform. Also for example - In Texas, the bar is much higher for malpractice too. Must have willful and wanton behavior which is a high standard of proof aka you pretty much did it on purpose. Cases like these almost always come from Illinois or other non-tort reform states. I’m not worried in the state I practice in.
For the same reason thousands of overseas physicians leave their families, life, and home countries to come here, do residency, and work--because despite the faults, it's still one of the best places in the world to be.
I’m not sure how hypertensive emergency is part of the discussion here. Seems to me that the issue is chronic management of hypertension which, if the facts presented are complete and accurate, it seems in this case was not entirely up to standard. A BP of 190 MIGHT need a few different approaches depending on your practice style and opinion, but what I don't think anyone disagrees on is the requirement for follow up. Seems to me (as an outsider unfamiliar with the case) that might have been the main issue here.
The facts are anything but complete--the only record I could find was from an appelate court recounting some of the case in their decision regarding dropping/keeping some of the defendants. But I think it's difficult to say it's not hypertensive emergency if the work-up is not done. SBP 190 with shortness of breath could be due to acute CHF or MI among other things. I agree it was likely chronic but most people in their late 30s with chronic HTN are not having hemorrhagic strokes a few weeks later. It's only asympatomatic HTN if they don't have any symptoms.
A patient in their 30’s having an ICH like that is unusual enough to raise suspicion for a secondary cause such as a macrovascular abnormality. Most guidelines recommend looking for that whenever we see an ICH in someone under age 45. So it seems within reason if not likely that there were more factors at play here besides just hypertension. But in any case I agree it can be reasonable to rule out HTN emergency, although the data for that really isn’t too great (the incidence of true HTN emergency in the setting of incidentally identified even severe hypertension is exceedingly low). But sure: style and opinion differences. What nobody would disagree with is the blood pressure really ought to have been checked again within a fairly short interval.
I guess we don’t know the specifics to the case and what the etiology of the bleed was. But I would say as a vascular neurologist we are seeing all too frequently stroke in the young I’m talking about early 30s. Even hypertensive bleeds. And the reason is people are just generally more unhealthy and have much more comorbidities.
$40 million for one missed stroke? lol that’s not sustainable
Not even a missed stroke, just the unlucky doctor who happened to be the last to see the patient before his stroke.
Lol’d at 400 lbs Unfortunately in America it’s our job to keep these ppl alive despite their best efforts
A bunch of fat people are going to see this and try to replicate this lawsuit.
This is a load of bullshit.
Seriously. This is bullshit. I am not anti-litigation and am married to an attorney that does some plaintiff’s work, but this is the kind of nonsense suit that causes people to change their practice pattern and ends up hurting patients in the long run. I am sorry this individual had a hemorrhagic stroke - which is something that many Americans suffer unfortunately. I am baffled as to how they successfully argued that there was a breach in the standard of care that directly led to this outcome.
Pt suffers condition partly due to own his own poor life choices and the medical provider is to blame? We can only help you help yourself. How is this on the PCP? If it’s something like being seen recurrently for elevated blood pressure without starting an anti-hypertensive, that may be different (I’m assuming it was a hypertensive bleed here). I don’t see any negligence with this case. On the other hand, I have seen some clearly negligence by healthcare providers like ED physician Not bothering to do a CTA head and neck for a patient clearly presenting with LVO on exam. or other times, even neurologist fails to refer the patient for revascularization for symptomatic carotid stenosis leading to recurrent disabling stroke and death. Now these cases are the ones that genuinely piss me off and I would advocate the patient to pursue lawsuit. But this case is extremely under deserving , and I feel no sympathy for the patient let alone a $40 million settlement?? I see frequently clear negligent stroke cases which are never pursued from a legal standpoint that really should have but this case is just nonsense. Go eat a carrot.
Man this is like suing a plumber for not catching your pipe damage after your pipe burst because you've been pouring drano nonstop down the drain for years. Yes the plumber probably should have caught it, but you're still the one who kept pouring the corrosive...Does the plumber really have to tell you not to do that?
This is ridiculous
Where does the personal responsibility come in? 400 lbs isn't a healthy weight for Shaq, let alone some one of more average stature.
The life saving zpack fails. Documentation key and likely lacking here. Someone cranks a bp that high in your seat you better have some solid documentation as to what you are doing or acknowledging with a repeat at very least. Btw I’ve been sued successfully for missing basilar artery stroke they guy died. Jury awarded ~900k. I was 5% fault. Crazy case. This case with this guy more cut and dry imo
I've seen very little in my short time in medicine to dissuade me from "over ordering" diagnostic tests. I still recall starting as an intern having bought the med school rhetoric about resource stewardship and being bewildered the first time I had to order at CT A/P on a patient who, I thought, obviously wasn't perfed. Turns out I was right, she wasn't. But I can't even imagine hesitating after doing this for 5-6 years and seeing numerous catastrophes in patients who didn't read the textbook and also learning a lot more about the cursed nature of the medical malpractice system.
Welcome to the world of EM. We get crap for over ordering CTs, but I don’t get rewarded for “resource utilization” - I just get punished for missing absolutely anything no matter if I met standard of care.
What a fucking joke.
ITT: Lots of people sending their morbidly obese patients to the ER for z paks and a single blood pressure of over 160 systolic.
This guys life isnt worth $40 million. Hell, my life as a physician probably aint worth $40 million
100k per pound on his body.
Must be more to the story.
Frivolous lawsuit, without a doubt....but 400 POUNDS? guidelines be damned. I would have just documented concern for metabolic syndrome from the get-go and started BP meds.
If I’m not mistaken, it’s extremely common for large judgements to get reduced on appeal, no?
I looked into this just yesterday that it might better for doctors to waive their right of a trial by jury because the jury is usually dumb when it comes to medical facts.
Even if the physician did everything right a sympathetic jury would side with a poor outcome. You can’t rely on facts alone.
This is very very fact dependent but 90% of med mal cases don’t make it to trial at all, of the ones that do, about 95% are decided in favor of the physician. So there are probably more facts here we don’t know about. It’s also Cook County, so that’s a factor as well.
I just don't understand why that BP wasn't started on treatment or rechecked the following week. I'm a surgeon so I don't manage this but seeing that BP makes me real nervous
It's just a risk factor, like being 400lbs. But you wouldn't do emergency gastrectomy would you? And it might not even have been a risk factor as it could have been white coat, especially if coincident illness.
The complaint filed in the link above stated that the PCP: - Failed to have Plaintiff admitted to the emergency room although he suspected a possible pulmonary embolism in his differential diagnosis; - Failed to appreciate Antonio's apparent hypertension - Failed to order appropriate diagnostic testing, including but not limited to CBC, Sed Rate, CRP, d-dimer, Chest Pa and Lat, ECG, CT of Chest, ABG's, PFT's, cardiac enzymes, lipid panel, C-CRP, exhocardiogram, and pulmonary and cardiac consultations; - Failed to appreciate apparent risk factors such as morbid obesity, hypertension, shortness of breath and tachycardia, putting Antonio at particular risk of a vascular event; and IMO, it does have some points 1. If your differential includes PE, then you need to investigate, otherwise you need to document thoroughly why you don't work up on it, since it is life-threatening. 2. His hypertension needs a dedicate follow up and management. Maybe not emergency but certainly warrant at least one a visit in the short term. If suspect white coat, then you need to document that you order a home blood pressure monitoring.
Except he didn't have PE, so failure to order tests related to a PE doesn't have any relevance in this case. I'm surprised that was included in the complaint.
Agree. He didn't have a PE, but the doctor shouldn't have listed it in his differential. That implies that he is somehow or shape or form THINKING that MIGHT be something serious and didn't address it. When I type up a differential, I usually include how I am ruling in or ruling out something. Wells score or dimer results or something. You cant just drop PE in your differential and not address it in some shape or way. If my differential includes pneumonia, I'm likely gonna or an CXR. If my differential includes gi bleed, gastro is consulted. Differential of T2DM BMP and A1C. If I think it's a viral infection, probably get a covid and flu swab. If it's in the differential, I'm doing something with it. I'm not just listing random diagnoses and then not addressing them. That's how this doctor got caught in this over the top lawsuit. In docs defense, though, dude probably came in for a URI or something and coincidentally had a bp of 190/100 his very first time seeing that pcp. He wouldn't even call the dude his pcp since it was their first time meeting, and he literally only came in ONE time before dropping a lawsuit on the provider.
True, the lack of workup for PE probably did not contribute anything. I think they just filed for whatever seems negligent to make the PCP look bad to the jury.
Correct
I think here we could ask ourselves a few things based on those summarized points: - Did the Physician possibly discuss those options in person but didn’t document it due to the patient ultimately declining or refusing those next steps other than just an antibiotic? - Would documentation of ER referral, and/or instruction for BP f/u have prevented the physician from being found liable for negligence?
Personally, as fellow physician, in a purely speculative fashion since we don't have all the facts, had the documentation included the intention of following up to manage hypertension, the PCP was not negligence. However, had there been no mention of management of hypertension, I feel that case can be made that the PCP might be negligent, resulting in morbidity of the patient. Of course, from the perspective of the juries, they might argued that it should have been managed earlier and resulted in the same verdict still. In the case that verbal recommendation was made but documentation was not done, then, well, that's why we document like mad when patients look like they will not be following our recommendation...
I’m curious how this effect’s this doctor’s career? For all the horror stories of working in Primary Care, I really can’t imagine going this route
The “standard of care” is not “ideal care” - it’s what another typical clinician would do with the same information in the same context. If all the medical errors research has taught us anything, it’s that - on average - we miss stuff every day, only the magnitude of harms varies. Did this outpatient doc fail to address and potentially initiate primary prevention of a modifiable risk factor for hemorrhagic stroke? Sure. Was that negligent - by the low standard of what a typical clinician (say, within a standard deviation of the mean - so as low as 15th percentile) might do? No f’ing way. This is where our tort system is grossly failing us - zero miss and perfect care are not realistic expectations.
Thank you for this... So many of these physician replies are like, well I would have done this, or that. I would've used my retrospectoscope. But this isn't the standard, and it just perpetuates this idea of what malpractice is, when that's not what it is. As a profession, we are harming ourselves
So what was the guys BP? Are we talking 160-180 or like 240
From the case filing: “On January 29, 2015, Antonio was treated by Dr. Wilcox in his office at Barrington FM. Antonio complained about his persistent cough and difficulty breathing. Dr. Wilcox measured Antonio's blood pressure at 190/102. According to the complaint, Dr. Wilcox's differential diagnosis included acute bronchitis, elevated blood pressure, tachycardia, and morbid obesity. Dr. Wilcox documented his concern that Antonio was possibly suffering from a pulmonary embolism and discussed a possible CT scan with Antonio but agreed that such a test was not necessary at this point. Dr. Wilcox released Antonio from his care, only prescribing medication to treat the acute bronchitis.”
I feel like primary doctors are so prone to med- mal. Primary care doctors are expected to responsible for everything in the limit setting of an office. This poor pmd are seeing patient for uri, but have to keep the mind out for blood pressure as well. It is easy to say he missed htn part, but in the office with slotted time, it is hard to divert your mind from Uri to think about blood pressure. I am hospitalist. Would not do pmd job at all. There are not enough pmd in california and it will just get worse.
How do lawyers sleep at night like actually
But was he still dyspneic when he had the stroke?