I was sued for the first time yesterday. At least as far as I know it was the first time – these things don’t always arrive on your doorstep immediately. And to be precise, I wasn’t sued yesterday, and likely won’t be (at least not for this situation) for some time; regardless, it was yesterday that the seeds were sown.

Before I go any further, I should clarify a point or two about the practice of medicine, and specifically that of pediatrics. Even in the more “glamour” fields of allopathic medicine, the moments of true drama are not that common. Surgery? Far more time spent removing hemorrhoids and stitching the fragile, unwilling skin of middle-aged women over distended, trampoline-taut abdomens from which gallbladders have just been removed. The emergency department? True emergencies are outnumbered on a given day or night by patients who are eventually diagnosed with what is known in technical terms as a Big Bucket of Nothing. By a factor of ten to one. An ED doctor is less likely to spend three hours setting three broken bones than he is to pass the time watching three spectacularly drunk patients race their foul-smelling way to sobriety clustered in the same pungent room. Hell, when I worked at Charity Hospital in New Orleans, there was one room of the ED that was traditionally known as the Butt Pus Room. No further explanation needed. Kind of hard to imagine Clooney in there, isn’t it?

With this backdrop, consider now that pediatricians are the bottom-feeders of the medical profession. Snot-wipers. Veterinarians, to some of our colleagues (because our patients don’t talk…get it? Huh-huh, huh huh-huh). And to a certain degree, I can understand why my perspective on other doctors will always be a scenic view of their upturned nostrils; at least viewed in the traditional terms of western medicine, pediatrics is a remarkably passive field. The bulk of children’s healthcare lies in preventive measures: the slow and patient conversations that show up on no balance sheets, but rather in the family photos of the child who didn’t die in a swimming pool, the valedictorian who at age two didn’t find an open bottle of heart medication in Grandma’s purse lying open on the floor. Most children’s illnesses are going to get better regardless of what we do, and the biggest challenge is to reassure parents sufficiently that they do not feel the need to do something stupid trying to “fix” their kids. Like water for “constipated” one-month-olds – regardless of what you have heard, true constipation in an infant is a vanishingly rare occurrence, and there is a special place in Hell reserved for the companies that sell “Nursery Water” to prey on overzealous parents worried that Little Dylan turns purple in the face when he makes a poo. That’s the dirty little secret of my profession, namely that kids are just damn near unbreakable in a lot of ways, and that the number who truly need medical intervention is remarkably small. Correspondingly, the number of dramatic “hero” moments in pediatrics is even less than that in most other fields.

So yesterday, when the emergency department called to tell me that a little boy was being admitted to the ward with fever and abdominal pain, I wasn’t expecting much excitement. In a child less than a year old, most of the explanations for this revolve around fairly mundane stomach viruses and the like; while there were a couple of aspects of this child that puzzled the ED doctor, he wasn’t described to me as terribly ill. He had been seen in our emergency department the day before with the same symptoms, given an enema for constipation and sent home (a diagnosis I thought odd, but on which I didn’t dwell since a lot of detail gets lost in a quick description of recent events). I figured if it had been going on for this long, it could at least wait for me to use the bathroom and get a fresh cup of coffee from the break room.

There is a term some of my paramedic buddies use (maybe other people do as well, I don’t know), called the “Pucker Factor,” to describe the quick surge of adrenaline that clenches the stomach, shuts down non-urgent functions (like defecation) and makes minute detail stand out in hyper-reality during a true crisis. It’s known elsewhere as the “fight or flight mechanism,” but somehow it always comes back to the asshole in medicine – when the PF hits eight or nine, Gretzky himself couldn’t slip a turd past that sphincter. When I saw this child, I could have done naked squat-thrusts after a two-week rural Mexican vacation without a glimmer of worry, because he was clearly ill. And unfortunately, he had arrived in the slowest-moving part of the hospital in this condition, several floors away from the intensive care unit (don’t get me started on the dangerous shortsightedness of that little bit of hospital planning). Yet somehow, telephone calls that normally meet resistance (wrong numbers, phones not being answered, trying to fit into schedules for CT scan, etc.) went through effortlessly. Two nurses were nearby who happened to be among the most competent on our ward, and they executed our little dance with the machinery of hospitalization to perfection. In a relative eyeblink that still astonishes me, we had obtained a urine sample, prepared sedation medicines, taken him for his scan (where the medicines were actually not needed*), and wheeled him into the intensive care unit just as his blood pressure began to nose downward.

It appears that we were just in time. Today, the boy is a puffy, bloated mess – overwhelming infection causes capillaries to leak fluid into what is referred to as the “third space” that is neither blood vessel nor cell. He looks a bit like a miniature version of the Michelin Man, but in his case it looks worse than it really is. I am as sure as I can be that he is going to be all right. I am also almost certain that someday I will discuss yesterday’s events in excruciating detail in a courtroom somewhere.

Why, you ask? Didn’t I do things right? Yes, as far as I know I did everything I needed to do and did it rapidly and well. It doesn’t matter. From the information I can gather, this child was mishandled in the emergency department two days ago, and one could argue that the same happened there yesterday. If that information is correct, one should reasonably expect a lawsuit, and unfortunately those have quite a blast radius. Typically, any doctor whose name appears in the chart will be included in the suit because it maximizes the number of pockets from which to pull money. It’s just how these things work, at least from the cases I have observed secondhand. Depending on the size of the lawsuit and whether the boy recovers completely, the hospital’s insurance carrier will probably settle out of court, and I will have a permanent black mark on my professional record. Oh, and the punch line of the story, the reason I am so confident of the outcome – what, one might idly ask, is the occupation of this child’s parents? They review medical charts for legal firms pressing malpractice suits.**

I’m not sure why I’m posting this, except as self-therapy really. I am proud of my performance yesterday afternoon, even if it was really nothing more than what I am supposed to do. The practice of anesthesia has been described as “long intervals of tedium punctuated by episodes of utter terror,” and there is some element of that to my job as well; yesterday gave me a reminder of exactly why I do what I do. Boogers and poo be damned, there are occasionally moments where all the chips really are on the table. And yet, by being in the middle of that rare, triumphant moment, I also put myself squarely in the path of an oncoming train. I am not complaining about that - there are people every day and everywhere who, in ways large and small, are caught in the gears of larger societal machinery through no fault of their own. And in degree, my situation is very small - I am not the prisoner on death row because he happened to be walking in the same neighborhood and happened to look like the murder suspect. I am just trying to wrap my mind around the off-kilter and vaguely unreal sense that the very actions which demonstrate my worth as a doctor will also be the ones that lead to professional dishonor. Perhaps one day this will be clear to me. Until then, I hope that I get to see that boy wave goodbye and walk to the exit elevators in the near future. Few of my moments are lived in such a way as to give them real importance, but there are exceptions. Sweet, ominous, strange exceptions.

* In some contexts, a “really well-behaved child” is not at all a good thing. In the frightening environment of a CT scanner, a one-year-old who is too sick to do anything but lie still definitely prompts a Pucker Factor escalation.

** Just to be clear, these are two very nice people who were polite and remarkably calm in a situation that would have turned me into a human puddle were it my child involved – and this at a time when they had every right to be angry enough to eat bark chips.

It's an outrage, SB, and I'm sorry to hear it. Our society has gone nuts, it seems.

I sincerely hope it works out to your best interest.

Jack

The practice of anesthesia has been described as “long intervals of tedium punctuated by episodes of utter terror,”

Major difference: anesthesiologists make tons more money than pediatricians.

I guess malpractice lawyers can also make a ton of money suing doctors. I hope the system recognizes your innocence. Nothing worse than guilt by association in my book.

At 17 he went to a well known emergency room with his mom complaining of dizziness, gait problems, and poor speech. The doctor on staff did an MRI and found a cyst on the left temporal lobe of his brain, which he never told the mom about in examination. He proceeded to question the patient as to whether he was on drugs (illegal ones) enough to aggravate the patient. He was released from the hospital and told to rest for the day. Everything appeared to be ok.

Fast forward 5 years. The door slams open and in comes my son, into my home. What’s wrong? Where is mom? Sleeping . . . Thump, thump, thump up the stairs. The bedroom door slams open. Take me the hospital now. What’s wrong ???? Take me to the hospital now. All the way to the hospital, "make them stop, make them stop."

EKG, MRI, etc later, the child-man signs himself into the psychiatric ward for voices that will not stop. And oh by the way the cyst is 1mm bigger. What cyst???? Zxyprexa makes the voices go away and 1 week later the hospital is ready to release him to the police as he had a seizure and hurt someone. We meet with the doctor and I start asking questions. How do you know the voices have stopped if he comes off of meds? Silence. Don't you think, it may be wise to keep him a few more days, take him off of meds and see? Silence. They keep him 3 more days and the voices do come back. So the doctor puts him back on meds. We meet with the doctor after 3 days. May we have a prescription for the Zyxpreza? Ok. May we have a letter detailing what you have discovered? Plain sheet of paper - typed out one paragraph and signed - no letterhead. Thank you and the police take away my son. Their was not a rug big enough this man could have swept us under

Two months latter, a neuro-psychiatrist from a major university hospital brings about a sleep deprived and caffeine induced seizure in a young man while hooked up to another machine. Diagnosis? Complex Partial Seizure caused by a lesion on the left temporal lobe, the same cyst a half a dozen doctors said was benign. One can be violent under such a seizure and appear to cognizant and not be cognizant. I am grateful for one good 80 year old psychiatrist who had the time to find out what happened one night and why it happened. I can not sue the idiot in the hospital because there is a statute of limitations for him and his accomplice who questioned my son, without his attorney's presence for the police. I can though hold them both in contempt though for violating their oath.

Sometimes bad things happen to good people. I can not tell you why it does; but, we are not bad people, my son is not a bad person, and I am sure you are not a bad person. However it may look, just know that you did the best you could do under the circumstance. It could be that without your presence, their child may have died and I would keep that close to you.

I have often times wondered what would have happened if I had not been adamant and the hospital had released him the first time without meds? What would have happen if we had not found this neuro-psychiatrist? What would have happened if years ago, they had diagnosed it correctly? I do not know sawbones. I do know that one good man made a difference and I can fix the rest in time.

And I do not have words to apologize on behalf of my profession for your experience with your son. There are times, especially in my area, when "watchful waiting" is the best answer, but after a certain point there is no more excuse for such. Your story illustrates as much as mine does how little sense there is to the system we have for "righting" (as if there really were such thing in a situation like this) medical wrongs. It makes me wonder sometimes if we weren't better off when such symptoms would be written off to "evil spirits"; sometimes the cloud of mystery and superstition around a sequence of events is preferable to the parade of if-only's that make us wonder what might have been.

Good luck, mercy, and grace to you and your son. That bourbon we've talked about sounds mighty nice right now.

True about the pay - it's part of why anesthesiologists get sued more often.

And thank you, but there won't be any recognition of innocence by the system. That's all right - I know my place in this story, and I'll be (mostly) able to sleep peacefully with the knowledge. That's enough, I think.

I don't know just what to think, really. If ever a parent of a child had grounds to sue, this was the situation (based on events in the ED the previous day and yesterday before I examined him). I don't want that right to go away in the slightest, as it is a restraint on doctors when the normal checks of ethics and common decency fail. I just wish it were arranged in a more rational way.

Thanks for your thoughts.

we don't have any control over what those cards are, only how we play em. ya did good. maybe ya did the best that anybody coulda done with those cards. but we'll never know. that kind of knowledge is reserved for the gods and they ain't talkin. but you can sleep quiet knowing ya did a good job. and whether or not this little boy survives isn't up to you either, it was a quick shuffle and you only had time for a glance at the cards and then you had to lead em out. after you replayed the hand in your mind's eye, you fell like you did as good a job as you could have under the circumstances. that little boy (and his parents) was lucky you were the guy. they're still lucky yer the guy. there's a reason we all admire policemen and firemen and doctors (yeah, even pediatricians). the suit shouldn't happen. in a perfect world it wouldn't. in this country, famously vulnerable to 'market forces', the legal profession is broken, the insurance industry is broken and, yes, the medical profession is busted as well. something's got to change. in the meantime, remember why you became a doctor. if you can't remember, wait til that little boy waves to you. you'll remember then.

I probably could sue for the way the last hospital handled my son's case. I could have had him autopsied. I could have gone through his medical records and laid bare all the stupid errors that I know were made. I could have. I didn't. I know he got far better care in Chicago. I know at least some of what they did wrong in New York. I would never recommend the NY hospital to anyone (and have warned a friend against it) with what my son had. I just can't imagine dragging myself through a court case that won't bring him back anyway. There may be people in that medical team crossing their fingers and hoping they make it to the two year mark, and I hope at least one of them is really worried.

A lot of us laymen feel we should sue any time our expectations are dashed. Any time we lose the crapshoot that is life. My brother sued when my sister in law died during a routine procedure, but that's because the doctor did something so awful that the hospital staff involved took to sending my brother anonymous tips about the incident. My mother in law began a lawsuit in the death of her husband, because the ER forgot to x ray his hip after they admitted him for a severe fall, never noticed the fracture, and he bled to death during physical therapy. But the law firm dropped the case-- lack of evidence of malpractice, they said.

I know you believe that everyone should have the right to sue in genuine moments of malpractice, but that there are times when mistakes are made that shouldn't be sued for, or that lawyers set up suits so that even the innocent are harmed by them. The thing is, for us laymen, there's no way to know who exactly did what wrong. We are stuck trusting the lawyers just like we're stuck trusting the doctors on what to do. And insurance companies are worse than useless in this and other regards.

I had doctors at the NY hospital tell me to my face that it was my son's responsibility to be aware of the meds and procedures, and the protocols for his illness. Considering the meds they put him on made him hallucinate, I'm not sure how they expected him to accomplish this feat. We kept a notebook at his bedside and whoever was with him would write down what the nurses did, what doctors said, everything we can think of. It's a hell of a souvenir. But not very enlightening. I've since learned that some of the studies that informed their protocols had populations of around ten. TEN. That's the big N, not the arms. And they were carried out in China.

Who knows, maybe I'll change my mind in the next year. I have time. I suppose I could just call the hospital and ask for his records. That ought to make them rethink their policy with acute leukemia.

Sawbones:

You do not have to apologize for your profession. It was the two men who were the issue and not the profession. They could not get rid of us fast enough and they tried hard; but, I persisted and insisted. I had the presence of mind and knew my son would have died in jail if he had another seizure there and was unattended and off meds.

My first attorney is going to be sentenced soon for contributing to the death of a heroin-whore by buying her heroin, his usage of crack-cocaine, his possession of crack-cocaine, and his running a drug house. The most he can get is 15 years. My son hopes he ends up by him. This man deliberately went out of his way to cause us harm.

We fired our first attorney because we caught him in a lie, a lie about a plea bargain. At the last Hearing, he fired his first attorney and hired a second attorney. Why? He did not like the first attorney's recommendation on a plea bargain. We all wondered if the first attorney than ran into the judge's chambers to have an exparte conversation and lie to the judge about his client like he did with us.

As I used to tell the ex, with over a million of you lawyers in the US, you just have to know that somebody is going to sue somebody for something, just because they can.

Part of the damn problem is all of the settlements of course. If insurance companies would show some balls, and actually take some of the obviously frivolous suits to court (not that this instance is one), we'd see a lot less lawsuits. It's become, as you say, a race to the bottom of the deepest pockets the plaintiffs can find.

Then of course there's the "throw enough shit at the wall and some of it is bound to stick" mentality so prominent with the PI lawyers compounding the problem, and that's where you get dragged in.

You were there? Your name is on one of the charts? Fine, then we'll sue Dr. Sawbones too, he's got insurance. They'll settle with us. Who wants to take on the parents of a baby who almost died on the table? Sympathetic jury might cost them millions. They'll just cut us a check for a few hundred grand and make it go away. But it doesn't go away completely, as you pointed out. It's a mark on your record. It's disgusting.

As far as the proximity of the ED to the ICU, there's another example of the problem. You don't want to go into detail here, and that's understandable. But it's worse than that. You (and others) also are encouraged to keep your mouth(s) shut in the real world, and for the same reasons. You tell the Hospital Admin that it's a disaster waiting to happen, just trying to help. Paperwork (paper trail) is filed, and maybe the problem is addressed, ...and maybe it isn't.

Next thing you know, the disaster does happen, and the whistle blower becomes the plaintiff's star witness. So you don't blow the whistle.

Same reason nobody saw Kitty Genovese get brutalized,
nobody wants to get involved, ...and sometimes it's hard to blame them. Our legal system can be a sausage grinder.

Keep up the good work Doc. It's why you do what you do.

Thanks for doing the good thing, I am glad you are in a career that you can contribute to humanity in tangible ways that will reward you with good feelings and sense of accomplishment forever. I mean this. As a lowly consulting accountant, I can tell you the idea of actual life saving & parent calming, even among mostly zit popping, sounds pretty damned good.

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Now then, about the reasons physicians get sued....

(1) I will let others fill in the blanks about greedy or needy parents, and sub human plaintiff lawyers.

(2) There really is incompetence in the medical profession, horror stories abound every one has one (think about that, everyone has experienced medical malpractice or knows someone who has), and instead of self-policing and cleaning it up, the industry generally puts on a defensive front and covers up/protects their own mistakes to a hysterical degree. Chicken/eggs arguments can ensue here, but that is the reality now. Thus we have lawyers willing to play the role of predator to thin the weak from the herd.

(3) God complex. The western medical industry places itslef in the role of God, a role many physicians actively cultivate, although they would not use that exact language. They put their patients in the role of utter dependency, and often enforced ignorance. The industry is slowly learning on this point, but until the industry stops pretending to be all-powerful, patients will get pissed off when the little dog occasionally pulls back the curtain.

(4) High fees. No chicken/egg here, the cost of health care has little to do with the cost of malpratice insurance, that is just one pass through proven by studies to be only indirectly related. Docs get paid a lot of money. As a result, when they fuck up, they get sued. Same goes for stockbrokers. Risk is directly proportional to reward.

(5) Medical industrial complex. Let's face it, the business is subject to Wal-Mart corporate thinking and Wal-Mart sized profits as a result. Health care corporations chose a business model that implicitly increases the odds of getting sued. Including not having enough staff, not having enough qualified staff, having a poorly designed building, and encouraging a culture of low-touch, high-speed calculated risk taking and triage based on a Wal Mart human value system. It is a calculated risk to get sued so I shed no tears when it happens.

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You seem like a good person and have a healthy perspective on all this. Hope this isn't too tough on you. Until you docs agiate to reform your side of the equation, we are stuck with the trial lawyers.

[fyi: I count among my close friends an Ob, Er doc, icu nurse, and anesthesiologist]

I'm guessing that your lawyer--meaning the lawyer eventually hired for you by your malpractice carrier, would prefer that you not post such notes. While they may not be prejudicial in and of themselves, variance from them in testimony can result in cross examination to impeach your credibility. Te less said, the less material for impeaching you.

All of which demonstrates anew that the focus should be on treatment and not litigation-preparation.

Failures in the duty to perform to the minimum standards set by your profession do sometimes result in great injuries that will require social intervention to ameliorate. Tort liability and insurance risk-sharing do perform that function, but how much distraction from the very purpose of medicine should the tort-insurance system be allowed to create?

We've brewed up a medical industry and a medical liability litigation industry to countervail against it in hopes of establishing workable standards to protect patients. The professional organizations that could enforce those standard instead of the courts--in fact, should enforce those standards because that is the very definition of a profession, have morphed into defensive bastions that do less and less enforcement because they see the field as preempted by litigators.

Worse, the gray line where a mistake passes into a tort is processed through a courtroom procedure into something that attaches fault as an onus on the practicing professional. The focus is turned negative, even to the extent that the press entertains its readers with such stories with their morning coffee.

At the bottom is the question: what is human nature best served by: penalties or some kind of more charitable process for both the injured patient and the professional?

the QM panel on Hillary's health care reform initiative was to do away with malpractice insurance. Instead, they proposed "negative outcome" insurance. They wanted to remove the mechanism for corrective action against a surgeon from the courts, and the lawyers, and all the money - not litigation, but remediation. They wanted to remove the financial incentive (and mitigate the professional incentive) to cover up mistakes, and instead have a process for referring the physician for appropriate corrective action.

Good thing the Republican patsies for the insurance industry shot that idea down, huh?

Good luck, Sawbones.

Accolades....the realities of Medicine and health care have never been said better!