Medical Malpractice Bulletin – June, 2016

Perspective: What is pain and suffering worth?

By Charles A. Pilcher MD FACEP

I have occasionally been asked to opine on whether or not a patient experienced pain and suffering as a result of a traumatic injury or a medical procedure with a bad outcome. As I understand it, the presence of pain and suffering has an impact on the amount of a settlement. In a case where pain and suffering is one of the issues, the key points are always time frame and the level of awareness. The shorter the time frame and the less the level of consciousness, the harder it is to determine the amount of pain and suffering. Continue->

Debate continues regarding risks and benefits of tPA for stroke

An article in Stroke in February, 2016, reviewed the science behind a variety of inclusion/exclusion criteria for using tPA for stroke. The review garnered considerable attention among those who believe the value of the treatment is being overstated. tPA is certainly not the miracle drug the manufacturer and its champions would lead us to believe. The treatment time window is narrow and the ratio between number needed to treat (NNT) and the number needed to harm is unacceptable if the choice were not between death and lifelong disability. As one commenter said at the conclusion of his review of the study:

It is frankly impossible to estimate any of the magnitudes of benefit or harms from the practices endorsed by this new guideline, but it is safe to assume the purported current benefit of tPA is certainly the ceiling. Likewise, as the original contraindications were intended to improve the safety margin of tPA, the anticipated harms must be greater. This is not the sort of work that improves the lives of our patients. We do not need to expand the use of tPA; rather, we ought to be pursuing research that helps us narrow the treatment cohort to those with the stroke syndromes and comorbidities with the ideal risk/benefit profile.

Diagnostic error remains the achilles heel of medicine

Diagnostic errors continue to be the source of approximately 1/3 of medical malpractice lawsuits. These are errors involving “thought processes” as opposed to other issues such as technical competence or procedural error. Although the Institute of Medicine recently published an extensive white paper on this topic, the problem is not new. An article by Croskerry in Academic Medicine in 2003 summarizes the problem much more succinctly than the IOM report and recommends solutions. One of those solutions is “metacognition” which could be described as “knowing that you don’t know” and reflecting on the thinking process. Croskerry focuses on cognitive biases, an area previously discussed in this Bulletin, but which is worth reviewing since it is a feature of almost every med mal lawsuit.

Is it renal colic or an abdominal aortic aneurysm

Fewer lawsuits result from missing a ruptured/dissecting abdominal aortic aneurysm (AAA) than from missing a thoracic aortic dissection (TAD). In fact, in 35 years of reviewing med mal cases, the only AAA near miss I’ve encountered is one I almost missed myself, for the common reason that it presents similar to renal colic due to a kidney stone. In the chest, physicians err by ruling out the common MI and failing to consider the equally serious alternative. The differential diagnosis in chest pain should always include TAD. The differential in abdominal pain should always include AAA. An article in JAAPA covers the topic of AAA nicely.


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