IGX

Close elderly relative (81) goes in for an endoscopic ERCP procedure, and gets her innards perforated during the procedure. This is at Johns Hopkins, so not one of those Caribbean voodoo schools you guys all got your MDs from. They monitored for 24 hours to see if she would auto-correct, but no joy. They had to open her up wide to fix a 1 cm tear. She still has a bunch of drains coming out of her abdomen at all angles. Tough woman, but long hill to climb now.

They certainly didn't intend to poke a hole in her duodenum. Will they make right by all the extra costs to un-#$% their mistake? Time to lawyer up? Will the med insurance company handle this? I have no idea how these things play out.

Perforation is a potential risk with any endoscopic procedure. Should be covered by insurance I do not anticipate any need for adversarial proceedings. Complications are a risk with any procedure and as long as they are recognized and addressed there is really no departure from standard of care in my opinion. I hope she has a speedy recovery.

A lot will depend on the various Medicare expense caps and how close the whole thing (hospitalization and other procedures) takes her to it. I wish her a speedy recovery.

The Docs certainly have been up front about it. I just don't know how these things play out. Thanks.

I would hold off on the lawyer for now. From what you're saying the docs seem to be doing everything they can to correct this. Yeah, it's a fuck up, but these types of procedures come with risks. If the docs make everything right and she has no out of pocket expenses then all is well. If not, then I would get representation.

Here's to a speedy recovery. I hope all turns out well for her.

A good attorney would be able to answer this. Unlike guns, I don't care for lawyers personally but better to have and not need than need and not have. No need to go waiving your lawyer around and running your mouth, your attorney need not do anything at this point but advise as to the possible outcomes and what to expect if things did get ugly.

Lawyer here:

(caveat -- this does not constitute legal advice; it is information only. I am not your lawyer and you are not my client.)

If you are rich and have a lawyer on retainer, then sure, run it by him/her. If that doesn't describe you, Mr. Moneybags, then I don't think there's any reason to specifically consult a lawyer now. If there seems to be any funny business about compensation, or if the perforation leads to any other complications down the road, then it might be time to go have a talk.

If you do decide to go the lawyer route, remember that your lawyer isn't that much different than your car mechanic: he/she is performing a professional service for you. If you have friends who can offer recommendations, that's great. If not, your local county or state bar association probably has a lawyer referral service. You don't need to hire the first lawyer you talk to. If you don't get a good feeling for the lawyer, don't retain him/her. Remember that this is someone you are potentially going to spend a lot of time with: you don't need to love your lawyer like a brother, but you need to be able at least to tolerate him/her.

One further caveat: my practice is about as far from personal injury as you can get any still be a practicing lawyer. I do regulatory work for the gov't. This basically constitutes my boilerplate "so you think you should get a lawyer" spiel, and someone with more expertise might tell you different; if so you should probably listen to that.

What Sandman says. Unfortunate, but there is no such thing as a risk free procedure, even in experienced hands. In order for there to be malpractice, there needs to be a breach of the standard of care. Now, if they blew her off after the procedure, never acknowledged the possibility of a complication, failed to perform a workup to diagnose the complication - that would be a breach of the standard of care.

I hope she recovers smoothly.

Thanks for the comments

I'm bringing a naval aviation safety perspective to this whole misadventure. In the Nav, you start with the assumption that whatever occurred was preventable and go from there. Everything gets looked at, from the decision making in the moment, to the training, to facilities, etc. You do this even though everyone knows sometimes $%^ happens. The flip side is, the whole process is privileged and the results aren't used against anyone in a court of law.

Will the hospital look to learn from this? Some sort of formal post-mortem?

This didn't need to happen. For starters, no procedure = no perforation. So was the procedure needed? Desired? I hope they pause to ask those questions. I imagine at a minimum the data point will fuel the statistics behind the next study on the risks versus benefits of these sorts of things.

The patient in this case didn't have any symptoms of anything, but they thought they saw a mass on her liver in a scan for something else and needed to check it out. In talking to her family doctor, as we were trying to piece together why she was even getting something checked in the first place, he related that they'd seen something similar a few years ago and decided to just monitor back then. This didn't get passed to the treating doc down at Hopkins. No individual failure, a failure of the system. She'd been feeling fine.

Peritonitis in an 81 year old is a *really* bad thing. She played tennis and hiked and played catch with the grandkids and great-grandkids up until a few days ago. We're all wondering if she'll be home, much less eating, before Thanksgiving now.

I'm in charge of googling and doing the background research on things, and when I did after the fact, I saw that these procedures have a very high rate of complication (up to 8%) and now seem to be prescribed more for therapeutic reasons and less for diagnostic ones, due to that risk and the availability of other diagnostics. This was a purely diagnostic procedure.

Her diagnostic came back negative, to boot.

She didn't want anyone to worry about her, so she didn't tell *anyone* she was having the endoscopy. Arghh! If she had mentioned it, I'd have done the readahead and given her some more facts to chew on, and there'd be a lot less "what if-ing" and frustration going on now.

We found out right before they were taking her into the OR for the repair, when they finally called the emergency contacts. I spent two hours wandering the parking garages at Hopkins with her car keys in my hand, pressing the HORN button and waiting for a beep from somewhere.

</whining>

nafod wrote:Thanks for the comments

I'm bringing a naval aviation safety perspective to this whole misadventure. In the Nav, you start with the assumption that whatever occurred was preventable and go from there. Everything gets looked at, from the decision making in the moment, to the training, to facilities, etc. You do this even though everyone knows sometimes $%^ happens. The flip side is, the whole process is privileged and the results aren't used against anyone in a court of law.

Will the hospital look to learn from this? Some sort of formal post-mortem?

This didn't need to happen. For starters, no procedure = no perforation. So was the procedure needed? Desired? I hope they pause to ask those questions. I imagine at a minimum the data point will fuel the statistics behind the next study on the risks versus benefits of these sorts of things.

The patient in this case didn't have any symptoms of anything, but they thought they saw a mass on her liver in a scan for something else and needed to check it out. In talking to her family doctor, as we were trying to piece together why she was even getting something checked in the first place, he related that they'd seen something similar a few years ago and decided to just monitor back then. This didn't get passed to the treating doc down at Hopkins. No individual failure, a failure of the system. She'd been feeling fine.

Will the hospital learn from the post-mortem? Good question, it seems to me that in our litigious world, sweeping things under the rug is more prudent than digging into all the possible reasons why something went wrong. After all, an attorney could use this self generated info against them in a suit. I don't know this to be true but I'm suspicious.

Was the treatment necessary? Again I wonder what's behind the reason to do the procedure: simple prudence, an opportunity to bill Medicare, fear of malpractice?

Info not passed down to Hopkins? I've heard of this again and again, how can it still be a problem in our hyper connected world?

Between insurance companies, hospital administrators, and a circling army of lawyer warriors, it's got to be tough to be a doctor right now.

DrDonkeyLove wrote:

nafod wrote:Thanks for the comments

I'm bringing a naval aviation safety perspective to this whole misadventure. In the Nav, you start with the assumption that whatever occurred was preventable and go from there. Everything gets looked at, from the decision making in the moment, to the training, to facilities, etc. You do this even though everyone knows sometimes $%^ happens. The flip side is, the whole process is privileged and the results aren't used against anyone in a court of law.

Will the hospital look to learn from this? Some sort of formal post-mortem?

This didn't need to happen. For starters, no procedure = no perforation. So was the procedure needed? Desired? I hope they pause to ask those questions. I imagine at a minimum the data point will fuel the statistics behind the next study on the risks versus benefits of these sorts of things.

The patient in this case didn't have any symptoms of anything, but they thought they saw a mass on her liver in a scan for something else and needed to check it out. In talking to her family doctor, as we were trying to piece together why she was even getting something checked in the first place, he related that they'd seen something similar a few years ago and decided to just monitor back then. This didn't get passed to the treating doc down at Hopkins. No individual failure, a failure of the system. She'd been feeling fine.

Will the hospital learn from the post-mortem? Good question, it seems to me that in our litigious world, sweeping things under the rug is more prudent than digging into all the possible reasons why something went wrong. After all, an attorney could use this self generated info against them in a suit. I don't know this to be true but I'm suspicious.

Was the treatment necessary? Again I wonder what's behind the reason to do the procedure: simple prudence, an opportunity to bill Medicare, fear of malpractice?

Info not passed down to Hopkins? I've heard of this again and again, how can it still be a problem in our hyper connected world?

Between insurance companies, hospital administrators, and a circling army of lawyer warriors, it's got to be tough to be a doctor right now.

+1

One thing I've learned and relearned, is the only true continuity of knowledge across the span of the medico-industrial complex is the family. Listen carefully and ask lots of questions.

Yes. We have a formal morbidity and mortality process to review complications. I'm not sure gi docs do. In any case m&m is not discoverable allowing us to look frankly at the cause.
As far as the reason for the test. Way more info would be needed. What specific endoscopy was being done. 8% perforation would be well out of the standard and would likely get your privileges pulled at most hospitaks

This they do anything other than just ercp?

SAR wrote:Yes. We have a formal morbidity and mortality process to review complications. I'm not sure gi docs do. In any case m&m is not discoverable allowing us to look frankly at the cause.
As far as the reason for the test. Way more info would be needed. What specific endoscopy was being done. 8% perforation would be well out of the standard and would likely get your privileges pulled at most hospitaks

It wasn't 8% perforation, it was 8% medium/major complications of various sorts. Far fewer perforations.

It was just the ercp. They take a sample from inside the liver after driving by the gall bladder. Sounds complicated and tricky to me.

You're very unlikely, in the case of an 81 year-old patient, to recover damages even with gross malpractice. The reason is that a dollar settlement wouldn't be very high (perhaps $250K) vs a child or a young adult with a well-compensated job. The attorney pays his expenses out of pocket and then collects a percentage of any winnings as payment. Litigation expenses could easily break $100K and the case could take 4-5 years to go to trial. Finally, the physician typically wins 75%+ cases (defense verdict), at least in emergency medicine. There are very few attorneys who'd be willing to spend that kind of time and money on a case with such a low potential payout (remember that John Edwards made his money on alleged botched deliveries).
When you factor in the fact that perforation is a small but well-recognized risk of an endcoscopic procedure, I find it extremely unlikely that any attorney would recommend pursuing an action. This is just an unfortunate occurrrence (I am certainly not trying to minimize your's and your family's anguish), but not really a preventable action.
You can't really look at this from any aviation perspective, though that's been advocated in the past (safety checklists and the like). As has been pointed out numerous times previously, flying is safer than driving. If planes dropped out of the sky at even a 1% rate, it would be banned. Unfortunately, real-life medicine isn't like that and never will be.

LG Elf Ftr/Wizard 7/17 wrote:You're very unlikely, in the case of an 81 year-old patient, to recover damages even with gross malpractice. The reason is that a dollar settlement wouldn't be very high (perhaps $250K) vs a child or a young adult with a well-compensated job. The attorney pays his expenses out of pocket and then collects a percentage of any winnings as payment. Litigation expenses could easily break $100K and the case could take 4-5 years to go to trial. Finally, the physician typically wins 75%+ cases (defense verdict), at least in emergency medicine. There are very few attorneys who'd be willing to spend that kind of time and money on a case with such a low potential payout (remember that John Edwards made his money on alleged botched deliveries).
When you factor in the fact that perforation is a small but well-recognized risk of an endcoscopic procedure, I find it extremely unlikely that any attorney would recommend pursuing an action. This is just an unfortunate occurrrence (I am certainly not trying to minimize your's and your family's anguish), but not really a preventable action.
You can't really look at this from any aviation perspective, though that's been advocated in the past (safety checklists and the like). As has been pointed out numerous times previously, flying is safer than driving. If planes dropped out of the sky at even a 1% rate, it would be banned. Unfortunately, real-life medicine isn't like that and never will be.

Will you repeat the question?

Andy79 wrote:Will you repeat the question?

Summary for you: your carcass ain't worth anything.

LG Elf Ftr/Wizard 7/17 wrote:

Andy79 wrote:Will you repeat the question?

Summary for you: your carcass ain't worth anything.

You don't no nuthin'

Yup. I did a dozen or so in training. What part of intestine got perfed?

It does seem odd that they'd go to ercp for a mass.

SAR wrote:Yup. I did a dozen or so in training. What part of intestine got perfed?

The duodenum. Above the diaphragm? They were worried about fluid interfering with the lungs, I know.

Another relative asked the doctor what they were doing in the first place. They went through the billiary duct (?) into the liver to scrape some samples from the inside. Didn't make sense to me, but I'm not a doctor. They may be filtering the story, who knows.

Duodenum is the first part of the small intestine. The common bike duct empties into it. You use a side viewing scope and cannulate the duct. From there you can squirt dye and look at the plumbing if the pancreas and the liver. You can also stick a little brush up there and get some cells. ( there's other interventions and such as well)
Depending on what symptoms she had and what work up she had an ercp may or may not have been an appropriate test. Impossible to determine without knowing all her data. However whenever you do a medical test, you have to know in advance what you intend to do w the results. In this case I'm curious if anyone asked this question " if this 81 year old has a malignancy do we intend to aggressively treat it?" And if anyone explained to her " the purpose of this test is to find a cancer. If we find one do you want aggressive treatment?" If treatment wasn't appropriate then doing a diagnostic procedure to find something is also inappropriate. ( with a few exceptions).

SAR wrote:Depending on what symptoms she had and what work up she had an ercp may or may not have been an appropriate test. Impossible to determine without knowing all her data. However whenever you do a medical test, you have to know in advance what you intend to do w the results. In this case I'm curious if anyone asked this question " if this 81 year old has a malignancy do we intend to aggressively treat it?" And if anyone explained to her " the purpose of this test is to find a cancer. If we find one do you want aggressive treatment?" If treatment wasn't appropriate then doing a diagnostic procedure to find something is also inappropriate. ( with a few exceptions).

Whether or not Medicare will pay for it, and how much, is a big exception

Not for a lot of docs

So they released my MIL from the hospital yesterday, and she is home for the first time in over 9 months. Still has a fistula in her small intestine and so will need a major surgery to repair, but she exceeded a hell of a lot of expectations in not kicking the bucket. They'll fix it in the fall.

I got to be a single parent for the entire school year while my wife focused her time and energies on her mom. An interesting exercise - I've got a better appreciation for my wife when I deployed all those times.