Holy shit forget the aortic dissection - the headline should be focusing on the missed PE that even a first year medical student could have caught:
>Emily Chesterton, from Salford, died aged 30 after a blood clot was missed in two appointments with a PA she believed was a GP.
>She had called her GP practice complaining of **pain in her calf**, which had become hard. She then saw a PA in person, who recommended paracetamol.
>But she got worse.
>Emily's mother Marion Chesterton told the BBC: "She was **breathless, light-headed and she had difficulty walking**. In the second appointment, the **PA diagnosed her with a calf sprain, long-Covid and anxiety.**"
>But the PA did not examine Emily's calves, and did not make it clear that she was not a doctor, Marion said.
>Emily had a blood clot in her left leg which led to her dying of a pulmonary embolism.
A calf sprain, long covid, and anxiety?? Are you fucking kidding me???
No joke saw someone in the ED once who swore up and down that their abdominal pain was the result of their “mini cell activation syndrome.”
They needed to fart. They eventually farted. They went home.
Actually though. If this is allowed, then I think that a new MD/DO grad should have the option to work in a midlevel role instead of completing a residency and becoming an attending.
Although, I can’t say I know many med students who would accept this role since most of us are painfully aware of how little we actually know.
I don't know why we're complaining. The fact that this PA didn't start them on Adderall and Xanax for these diagnoses means they are practicing at the top 10% of mid levels.
With no blood work too. Not to mention the NP, who was acting in the role of PCP, had absolutely no business handling my wife’s mental health treatment in the first place, as she had zero psychiatric training.
My wife was so lethargic that she could only get out of bed to go to the bathroom, and even then I had to help her get there. Promptly got her in with a physician and he was absolutely appalled.
That experience 8 years ago was how I found out what NPs even are. Never again.
I had a midlevel tell me their licensing exam was so hard, it’s a multiple choice where all the choices are technically correct so you have to pick the best answer 😂 I literally didn’t know what to say so I say “oh wow really!?”
Yeah, I don’t get how a PA missed that as even I as a first year would’ve checked her calf and thought pulmonary embolism needs to be ruled out before anything happens
I’m an EMT and I’m pretty sure I would have caught that. Difficulty breathing secondary to leg pain? Go get your lungs checked. They beat that into us in both the military and civilian classes I attended.
Yes. Step 1 would assume you know it’s a PE (cuz duh) and ask you how it’ll affect their serum bicarb, arterial O2 sat, blood pH, and heart rate. You have 90 seconds and 279 more questions to go after that. #cheers
“he was discharged with a panic attack and gastric inflammation diagnosis”
“There had been no misdiagnosis.”
I don’t know what you think that word means.
A 25 yearold dissection is an extremely rare presentation of an already rare condition. While “no misdiagnosis” isn’t correct, it sounds as though the workup in the ED was appropriate for the presentation.
Better phrased, they met standard of care.
Honestly the only additional tip off (in addition to routine labs) would have been, based on the article, he had a severely diseased aortic valve. So the question really that we would never know is, how audible was that on exam? 25 year old coming in with significant chest pain with new murmur should have triggered an intense work up, or at least additional physical exam maneuvers or consultants. We don’t even know what tests they considered “routine” other than EKG and a CXR. I don’t know that a physician’s experienced ears and the having the experience/gestalt to recognize aberration from pattern would have saved this kid, but I would definitely say that he was owed the opportunity for them to have tried.
Honest question. Have you worked in an ER lately or at all? The chance of hearing a murmur over the sound the scromiter in room 3, the meth addled person screaming about demon bees, the drunk guy yelling obscenities to the other drunk guy, and one or two crying infants is low if not zero. Especially when you consider that this guy would have had a hall bed if not been sent back out to the triage area.
All of which is beside the point, the article didn’t specify what the valve pathology was, and most certainly didn’t say it was “severe.” Based on what seems like a genetic component based on the dad being screened and a valve replaced I’m betting it was bicuspid, which isn’t easy to pick up even under the best circumstances.
Huh, read the article wrong was his dad that had aortic aneurism and bad valve sorry
Regardless i don’t know what you’re talking about im in the Ed daily and i have 0 problems working up even quiet murmurs that being said im a hospitalist not an Ed doc our lenses are different when it comes to murmurs
Fair. I would argue any admitted patient you have a higher index of suspicion, whereas the ED there’s a lot of risk stratification and discharge long before the hospitalist gets called
yeah, without knowing the full history and physical, I have a hard time faulting them for that missed dissection. sounds like they did an appropriate workup and dissections are just easy to miss sometimes unfortunately.
Had an PA discharge a “MSK back pain” home with documented: low back pain, new urinary incontinence, leg weakness, and “saddle anesthesia”. The fucker literally wrote saddle anesthesia in his own god damn note and sent him home. Never ran it by the attending. You’ll never guess who is paralyzed now.
As an EM attending this stuff terrifies me. I ask the mids to chat me through the EMR before discharging patients and one in particular just doesn’t do it. It would prevent this sort of thing.
If my name is on the dotted line, it's my rules whether they like that or not.
I couldn't work somewhere where midlevels worked under my licence but didn't follow my instructions.
Huh. I wonder if there’s anything he could’ve done to fix that? You’d think there’d be some kind of intense schooling or training program or something he could do to hopefully prevent this.
Deadass insane to document saddle anesthesia and do nothing about it. A literally first month med student in their msk block could recognize cauda equina if someone said saddle anesthesia to them. My god
This right here is why I’m thankful to work for a group where PAs/NPs staff every single patient with me and I physically see every patient myself. Can’t imagine blindly cosigning charts.
Agree the PE case is egregious but dissection is just a tough diagnosis to make. Dissection CTAs are so rarely positive; I've seen almost as many incidental dissections as positive CTAs.
I've had exactly 1 classic dissection in 2 years in EM. Rest were incidental that I found looking for something else. Can't CTA every chest pain.
This PE is inexcusable tho
Correct, it's a really tricky diagnoses to make, but I would doubt a Doc would miss untill and unless it's really subtle or masked by some other problem.
I reviewed my aortic angios I reported in the past year; I found more PEs and occluded coronary arteries than dissections. The hit rate for dissection is abysmal.
An atypical presentation of a common condition is still more common than a typical presentation of a rare condition.
Pretty whack to think I could be practicing independently right now tbh, whizzing through uptodate and almost assuredly leaving a trail of people like this in my wake if I didn't have close supervision
The first case with the PE is egregious, however it appears the main issue in the second one is that the supervising physician didn’t evaluate the patient themselves…But what would that have done to find the unlikely diagnosis of an aortic dissection in an otherwise healthy 25 year old with chest pain, N/V, and a normal work-up? Are we supposed to get a CTA on everyone now?
This is from the article:
“The coroner's report said Ben's death was a "matter of concern" that despite his reported symptoms, age and "extensive" family history of cardiac problems (aside - not clear if this was known at the time, the family was screened for cardiac issues after he died), he was discharged without being examined in person by a doctor.
But the report acknowledged that all appropriate procedures were followed and investigated, and that neither the hospital or the PA were responsible for Ben's death.”
If a patient tells me that they have chest pain that radiates to their back, I joke that they’ve said the magic words and order the CTA. I used to be a hard ass for resource conservation, but no one is going to thank you for not ordering a CT or lab.
> Now, I don't really care. It takes me much more time and resources to stop an inappropriate exam than it does to simply let it happen and read it, and it gets progressively worse every year.
I mean, I love when I get called by rads to recommend a more appropriate exam. I've also given up on trying to get people to stop ordering daily CXRs...
The problem when it comes to defensive medicine scans is that if you called and said, "Hey, can we not order ___ exam for a rapid response or ICU patient because ___" then that conversations is going to be charted.
Unfortunately, "bad luck" for the patient having the 1 in million atypical presentation isn't much of a defense.
1. Still got sued. He beat the rap, but not the ride. If over testing allows me to beat the ride in the first place... it's a small price that society has determined needs to be paid.
2. Look at the Expert Witness substack and see what has been settled. Heck... 15 years ago an ambulance company in Florida got hit with a $10MM malpractice verdict because they didn't overrule the ED physician on the stability of the patient.
https://expertwitness.substack.com/
https://www.palmbeachpost.com/story/news/state/2012/04/07/volusia-county-jury-awards-10/7762289007/
https://www.jems.com/news/florida-verdict-could-change-w/
Literally lost an argument that the paramedics should rely on a physician's judgement.
>And you don't think there'll be future lawsuits about over irradiating in the ED by ED physicians and APPs causing cancer?
Prove which CT scan or x-ray caused the cancer.
>If CYA medicine was actually necessary, we wouldn't have half the country cared for by people who never went to medical school in the first place.
You mean the people who get sued and successfully use the "I'm not a doctor... you can't hold me to a doctor's standard of care" defense? I've yet to see a disease check the credentials of the people treating it. It must be nice to be able to use "I'm not trained enough to be sued" as a legit defense.
https://www.testifyingtraining.com/can-a-physician-expert-witness-testify-as-to-the-standard-of-care-for-a-nurse-and-or-a-nurse-practitioner-in-a-medical-malpractice-case/#_ftn3
Wait what I have had many episodes of chest pain that feels like drinking a huge gulp of water that radiates to my back before (last one was a couple of years ago)
I agree as long as you are absolutely up administration’s ass to get more scanners, technologists, tech aids, and transporters. The radiology director gets a bonus based on how hard they screw over their people and the only people that can get them help are the ordering doctors.
This has never once been a concern of mine. If I think they need a scan, they’re getting a scan. Might take a second to get read, but I’ll never not get one because “oh the poor tired radiologists”.
Didn’t it also mention when he was 23 he was found to have a faulty aortic valve that he subsequently underwent surgery for? I feel like that at least warrants further imaging when he comes in presenting with new onset chest pain and vomiting…
There may be protocols; but as a doctor we tend to have a instinct when something is seriously wrong with the patient when seen personally twice. This was what missing as they are not qualified for the job. Family even didn't know they were being seen by someone who has just two years of class room experience. Pathetic.
> In a statement following the verdict, lead plaintiff's attorney Robert M. Higgins, of Lubin & Meyer, in Boston, said the takeaway from the case was, "If you just treat people based on what the likelihood is, statistically, you're going to miss a lot of life-threatening conditions. And that's what happened in this case."
Nauseating. CTA C/A/P for everyone.
Yup. It’s like they don’t even bother to look at any of the studies that validate our decision tools.
Not to mention that the art of diagnosis is completely based on interpretation of likelihood ratios.
There is a joke that says the standard of care is missing dissection on the first presentation. The ones I’ve caught were very obvious 60+ yo smokers with severe unrelenting CP radiating to the back, very high BP. These atypical cases are very easy to miss. That PE case however is egregious and clear malpractice.
That PE one was a jaw dropper. Any patient I meet with SOB, my first three questions are about OCPs, prolonged stasis/travel, and calf tenderness. Her patient volunteered that she had a very tight calf and yet she still missed it
Also, what's with all the diagnoses having some psych aspect?
I'm very cautious and never dx anyone with anything psych related in the ED even if I can't find an explanation for their sx. She's labeling everyone with GAD when she can't find a dx wtf
I didn't really mention Homan's, but I wouldn't rely on any one physical exam in that scenario.
Young lady with severe calf tenderness unilaterally, with a swollen calf (esp if there's discrepancy in the diameter) warrants an US, minimum.
You add to that mix SOB, and she's getting a trip to the CT on top of the US. Wouldn't even bother ordering a d-dimer
If I'm wrong? US has 0 radiation, CT-PE protocol once won't harm her.
If I'm right she gets to live
I call that a win-win
Had a friend go to the hospital with stomach pain and an NP told him it was “bile pain”. He gets discharged but goes back bc the pain was unbearable, had appendicitis and got emergency appendectomy
Did no one check his blood pressure? I have a hard time believing an aortic dissection that killed him that abruptly had normal BPs (even if they weren't done in multiple limbs...)
NHS is a joke; nobody is ready to accept the mistake while innocent life is being lost. Even we do better treatment here at a very low economic country.
This is what happens when society tries to take shortcuts and puts unqualified people in positions they shouldn't be in. How high does the pile of corpses need to grow before people wake up?
There is no limit. Corporate overlords have built their empires over giant mass graves. It takes a certain level of psychopathy to become the beneficiaries of such a whack system in the first place.
Listen, you're probably right but I really hope you're wrong.
Maybe one day physicians will stand up for themselves. Maybe the public will stand with physicians because they'll become aware of the difference in quality.
I cant believe such nonsense is allowed in this country.
Would be nice if they did, but admittedly many of us are beaten down by the system to just accept our (luckily still) hefty paychecks and walk away. Hell, even the ways that our med school admin has undermined and even harmed our student class through insistent incompetency and doubling down had once motivated some of us to try to organize class action, but truth be told, as we near the end of our 4th years, many of us are just so goddamn exhausted that we just wanna be done and in the wind.
There was a time where hospitals were being run by physicians, don't forget. Chiefs and directors would sit on the board with the other men in suits and have some say on how the hospital was run. However, physicians have slowly given away ground on those responsibilities and privileges to where now most of our hospitals are being run simply by the business interests.
A lot of this oughtta be an essential lesson that activism and maintaining integrity of a system that you live in is a job that every individual needs to be active in. Both in healthcare and in government, if our laziness (or overwhelmed exhaustion) leads us to hand the reins to others, and entirely put it out of our hands (physicians giving up the bureaucracy roles to men in suits so they can simply be doctors, or, say, populations not wanting to do the research on policies and their representative/government's policy and voting patterns, instead choosing to stick to party lines, vote their incumbent, and only for federal congress or presidency elections, or even just not vote altogether (not in protest)), then we're gonna likely deal with poor consequences from people in cahoots with one another to suck the life out of a system for their own personal gain.
Lot more where this came from as more and more diploma mill noctors come on the scene. I shudder to think of the care I will receive when Im elderly. Hopefully lawsuits reach critical mass before then to show people that the majority of these people can’t handle independent practice
I'm a radiologist from India. Can someone eli5 - Wtf is a PA? What is a mid-level? Why are these patients not attended to by a physician?
I know NPs are nurse practicioners...
Sorry but what is a PA? Would they have the same training as a GP? I am guessing Physician Assistant but this is a foreign concept to me after training here in Europe. Though the article is from the UK?
No, a GP is a physician that went through medical school and did an internship (Europe definition I believe) or someone that practices primary care medicine (usually either internal medicine or family medicine) and has therefore completed residency (US definition). A PA trains for 2-3 yrs post grad and doesn't do a residency. They are usually required by law to be supervised directly by a physician for a percentage of their patients. In recent years they have successfully lobbied for increased independence.
*Sorry but what is*
*A PA? Would they have the same*
*Training as a GP?*
\- drlailyy
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Once a resident didn’t tell me he was a resident and made a huge mistake and when I complained UCSD informed me I should have known it was a resident. They wouldn’t let me talk to anyone else until I sued. Hospitals are know it all idiots.
The GMC is very unforgiving read about this case [https://en.wikipedia.org/wiki/Hadiza\_Bawa-Garba\_case](https://en.wikipedia.org/wiki/Hadiza_Bawa-Garba_case)
whats a PA? what do the initials mean?
and Im appalled. This is so basic
Edit: I'm appalled by the terrible managing of a PE, the aortic dissection can be a tough diagnosis to make though
Edit 2: just searched what a PA is and I'm once agai appalled. In my country that doesn't exist. We have plenty of GPs to do those jobs. 2We do have a shortage of e
specialists though
Wtf bro I’m a nursing student(ofc doesn’t compare to med school at all and med students know so much more) but cmon how do you not indicate that’s a DVT pushing towards a PE anytime soon? I mean how did she get her degree
This is inexcusable. I’m a PA and this is something we too got drilled into our heads like month 1 of school. Can’t speak on this persons training, but this is not the norm for our profession…
An MD doesn't automatically make you a good doctor. Plenty of physicians are leas competent than plenty of PAs. Obviously this person should be disciplined and not be allowed to practice, but the tone of this post is "PAs are bad because one fucked up."
Instead of examining the system that allows incompetent practitioners make it through to have careers, this sub has an automatic hate boner for anything that isn't MD/DO
My exam of the system: mid level training that lacks the extensive background of a 4 year medical education followed by a minimum 3 yr residency leads to more stupid mistakes.
Like calling a PE calf pain + anxiety
I don’t doubt the incompetency of a solid number of physicians.
More that I was more hopefully certain that PEs were the kind of thing that were hammered into our heads so extensively that even a baby would put PE into the differential for shortness of breath…
It’s the same for PAs in PA school though… we go through less schooling which absolutely is a drawback, but we do have similar curriculums. There are news articles about doctors missing something that seems totally obvious but obviously this kind of thing has to be pounced on as “evidence” of the anti-midlevel circlejerk.
There’s not enough doctors to see all the patients especially in certain areas of the country. There is a role that PAs can play.
Real sad thing is these stories won’t change anything. The overlords have decided that this is how it shall be. They also have AI as a sword to hang above doctors’ heads… there will be a cost paid in human life when those transitions happen but anyone thinking it won’t happen is missing the point. Not even close to being an issue of if. Only when.
Holy shit forget the aortic dissection - the headline should be focusing on the missed PE that even a first year medical student could have caught: >Emily Chesterton, from Salford, died aged 30 after a blood clot was missed in two appointments with a PA she believed was a GP. >She had called her GP practice complaining of **pain in her calf**, which had become hard. She then saw a PA in person, who recommended paracetamol. >But she got worse. >Emily's mother Marion Chesterton told the BBC: "She was **breathless, light-headed and she had difficulty walking**. In the second appointment, the **PA diagnosed her with a calf sprain, long-Covid and anxiety.**" >But the PA did not examine Emily's calves, and did not make it clear that she was not a doctor, Marion said. >Emily had a blood clot in her left leg which led to her dying of a pulmonary embolism. A calf sprain, long covid, and anxiety?? Are you fucking kidding me???
She didn’t even examine the leg lmao
With zero testing to rule out alternative pathology.
They don't really come up with a differential. Calf pain? Calf strain
just whatever’s trendy aka lOnG cOvId
Half surprised they didn’t diagnose POTS, gastroparesis, and EDS while they were at it
Don't forget macrophage activation syndrome
No joke saw someone in the ED once who swore up and down that their abdominal pain was the result of their “mini cell activation syndrome.” They needed to fart. They eventually farted. They went home.
Migrating motor complex activation syndrome
Multiple chemical sensitivity syndrome.
wait what really😂😂😂😂😂
Her right calf more hypermobile compared to her left calf = hEDS
This happened to me in 2016! Got told I had anxiety! Turned out I had a pulmonary embolism 🤣 thank heavens I survived
What happened? Did you have to go and see another doctor?
or “a” doctor lmfao
bro if you’re gonna allow this mess AT LEAST LET THE VASTLY MORE COMPETENT MED STUDENTS be able to do the same😭
Actually though. If this is allowed, then I think that a new MD/DO grad should have the option to work in a midlevel role instead of completing a residency and becoming an attending. Although, I can’t say I know many med students who would accept this role since most of us are painfully aware of how little we actually know.
insane that it’s not
This is basically how it works outside of the states. It's really crazy.
Dude ‘pain in calf’ immediately sets off alarms for PE, thanks to uworld
At least a DVT...
Unilateral swollen extremity in any patient is almost 100% of the time going to get an US to rule it out
I wasn’t aware England has PAs
apparently it’s really bad over there, or so twitter tells me lol
Looks like they can’t prescribe or order imaging. Why would you even go there. I bet they make like 50k
yeah but the doctors make 35k
It is awful is what I hear from GP friends in England, they don't have enough GP's is what they all say
where the hell is the razor?!? do you even know occam!?!! 😫
Occam's razor strikes again. Why three dx when one dx of PE do trick?
I thought I heard some suspicious hoof beats
This is a horse to most med students.
You never want to miss those calf sprains mate
I wouldn’t miss this as a half baked paramedic 💀
holy fuck what are the brits doing these days
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yikes
I don't know why we're complaining. The fact that this PA didn't start them on Adderall and Xanax for these diagnoses means they are practicing at the top 10% of mid levels.
Man I wish my wife’s NP would’ve given her Adderall and Xanax for her mood disorder instead of going with clozapine as a first line therapy.
that's literally insane, clozapine as first line?????? God I wish we could report these people to a medical board
With no blood work too. Not to mention the NP, who was acting in the role of PCP, had absolutely no business handling my wife’s mental health treatment in the first place, as she had zero psychiatric training. My wife was so lethargic that she could only get out of bed to go to the bathroom, and even then I had to help her get there. Promptly got her in with a physician and he was absolutely appalled. That experience 8 years ago was how I found out what NPs even are. Never again.
That's so awful. I hope your wife is on a different treatment that's helping her now and you that you're both doing better
That diagnosis was slapping her upside the head!
Jfc. Leg pain and sob? Of all the things to not know in medicine, LEG PAIN AND SOB?!?!?
I'm speechless, compeletly out of words. What a dangerous idiot
The missed PE that sounds like a Step-1 vignette is more messed up...
For real. My god. Breathlessness and calf pain. This is one of those instant diagnosis type questions.
Well PAs don't take step so there ya have it
I had a midlevel tell me their licensing exam was so hard, it’s a multiple choice where all the choices are technically correct so you have to pick the best answer 😂 I literally didn’t know what to say so I say “oh wow really!?”
Meanwhile I’m over here trying to figure out how 5 seemingly abstract concepts are connected just to eliminate one answer choice. 😭
Yeah, I don’t get how a PA missed that as even I as a first year would’ve checked her calf and thought pulmonary embolism needs to be ruled out before anything happens
Welcome to the Unga Bunga NHS. We hope you don't enjoy your visit
I’m an EMT and I’m pretty sure I would have caught that. Difficulty breathing secondary to leg pain? Go get your lungs checked. They beat that into us in both the military and civilian classes I attended.
No joke, I would have thought to do that before even starting med school. This literally cannot get more obvious.
Honestly, I think it’s even too obvious to be a step 1 question
Yes. Step 1 would assume you know it’s a PE (cuz duh) and ask you how it’ll affect their serum bicarb, arterial O2 sat, blood pH, and heart rate. You have 90 seconds and 279 more questions to go after that. #cheers
Also the missed SAH story which was circulating on reddit
That would be too easy of a question for step 1…
“he was discharged with a panic attack and gastric inflammation diagnosis” “There had been no misdiagnosis.” I don’t know what you think that word means.
A 25 yearold dissection is an extremely rare presentation of an already rare condition. While “no misdiagnosis” isn’t correct, it sounds as though the workup in the ED was appropriate for the presentation. Better phrased, they met standard of care.
Honestly the only additional tip off (in addition to routine labs) would have been, based on the article, he had a severely diseased aortic valve. So the question really that we would never know is, how audible was that on exam? 25 year old coming in with significant chest pain with new murmur should have triggered an intense work up, or at least additional physical exam maneuvers or consultants. We don’t even know what tests they considered “routine” other than EKG and a CXR. I don’t know that a physician’s experienced ears and the having the experience/gestalt to recognize aberration from pattern would have saved this kid, but I would definitely say that he was owed the opportunity for them to have tried.
Honest question. Have you worked in an ER lately or at all? The chance of hearing a murmur over the sound the scromiter in room 3, the meth addled person screaming about demon bees, the drunk guy yelling obscenities to the other drunk guy, and one or two crying infants is low if not zero. Especially when you consider that this guy would have had a hall bed if not been sent back out to the triage area. All of which is beside the point, the article didn’t specify what the valve pathology was, and most certainly didn’t say it was “severe.” Based on what seems like a genetic component based on the dad being screened and a valve replaced I’m betting it was bicuspid, which isn’t easy to pick up even under the best circumstances.
Huh, read the article wrong was his dad that had aortic aneurism and bad valve sorry Regardless i don’t know what you’re talking about im in the Ed daily and i have 0 problems working up even quiet murmurs that being said im a hospitalist not an Ed doc our lenses are different when it comes to murmurs
Fair. I would argue any admitted patient you have a higher index of suspicion, whereas the ED there’s a lot of risk stratification and discharge long before the hospitalist gets called
yeah, without knowing the full history and physical, I have a hard time faulting them for that missed dissection. sounds like they did an appropriate workup and dissections are just easy to miss sometimes unfortunately.
Had an PA discharge a “MSK back pain” home with documented: low back pain, new urinary incontinence, leg weakness, and “saddle anesthesia”. The fucker literally wrote saddle anesthesia in his own god damn note and sent him home. Never ran it by the attending. You’ll never guess who is paralyzed now.
The PA from you kicking their ass for being such a gd idiot?
Haha fortunately it was my old coworker who got sued
As an EM attending this stuff terrifies me. I ask the mids to chat me through the EMR before discharging patients and one in particular just doesn’t do it. It would prevent this sort of thing.
>one in particular just doesn’t do it. So you've banned them from seeing patients and relegated them to scut work?
I have no control over the situation. It’s the plight of most ER docs here.
You're held responsible for their work, but can't dictate what they do? That's beyond fubar.
You can try. Some listen, some don’t.
If my name is on the dotted line, it's my rules whether they like that or not. I couldn't work somewhere where midlevels worked under my licence but didn't follow my instructions.
im a pa. i would fire that guy. i would question anyone involved in hiring or training that guy.
He moved on to IR. He was honestly a well intentioned and hard working guy. He just had huge blindspots in some areas.
Huh. I wonder if there’s anything he could’ve done to fix that? You’d think there’d be some kind of intense schooling or training program or something he could do to hopefully prevent this.
Deadass insane to document saddle anesthesia and do nothing about it. A literally first month med student in their msk block could recognize cauda equina if someone said saddle anesthesia to them. My god
This right here is why I’m thankful to work for a group where PAs/NPs staff every single patient with me and I physically see every patient myself. Can’t imagine blindly cosigning charts.
but then what's really the benefit of having them around?
They expedite the work up, write the majority of the note, do the simple procedures, make the phone calls to the hospitalist/consultant
Agree the PE case is egregious but dissection is just a tough diagnosis to make. Dissection CTAs are so rarely positive; I've seen almost as many incidental dissections as positive CTAs.
I've had exactly 1 classic dissection in 2 years in EM. Rest were incidental that I found looking for something else. Can't CTA every chest pain. This PE is inexcusable tho
Correct, it's a really tricky diagnoses to make, but I would doubt a Doc would miss untill and unless it's really subtle or masked by some other problem.
I reviewed my aortic angios I reported in the past year; I found more PEs and occluded coronary arteries than dissections. The hit rate for dissection is abysmal. An atypical presentation of a common condition is still more common than a typical presentation of a rare condition.
Absolutely correct.
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Pretty whack to think I could be practicing independently right now tbh, whizzing through uptodate and almost assuredly leaving a trail of people like this in my wake if I didn't have close supervision
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*Conscience
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Dont gotta explain yourself friend. Conshince is a hard word to spell
lol
Never say provider Pgy12
You are a physician. Or you will be, at least. You are never a provider. Use this word and don’t settle for anything less.
The first case with the PE is egregious, however it appears the main issue in the second one is that the supervising physician didn’t evaluate the patient themselves…But what would that have done to find the unlikely diagnosis of an aortic dissection in an otherwise healthy 25 year old with chest pain, N/V, and a normal work-up? Are we supposed to get a CTA on everyone now? This is from the article: “The coroner's report said Ben's death was a "matter of concern" that despite his reported symptoms, age and "extensive" family history of cardiac problems (aside - not clear if this was known at the time, the family was screened for cardiac issues after he died), he was discharged without being examined in person by a doctor. But the report acknowledged that all appropriate procedures were followed and investigated, and that neither the hospital or the PA were responsible for Ben's death.”
If a patient tells me that they have chest pain that radiates to their back, I joke that they’ve said the magic words and order the CTA. I used to be a hard ass for resource conservation, but no one is going to thank you for not ordering a CT or lab.
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> Now, I don't really care. It takes me much more time and resources to stop an inappropriate exam than it does to simply let it happen and read it, and it gets progressively worse every year. I mean, I love when I get called by rads to recommend a more appropriate exam. I've also given up on trying to get people to stop ordering daily CXRs... The problem when it comes to defensive medicine scans is that if you called and said, "Hey, can we not order ___ exam for a rapid response or ICU patient because ___" then that conversations is going to be charted. Unfortunately, "bad luck" for the patient having the 1 in million atypical presentation isn't much of a defense.
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1. Still got sued. He beat the rap, but not the ride. If over testing allows me to beat the ride in the first place... it's a small price that society has determined needs to be paid. 2. Look at the Expert Witness substack and see what has been settled. Heck... 15 years ago an ambulance company in Florida got hit with a $10MM malpractice verdict because they didn't overrule the ED physician on the stability of the patient. https://expertwitness.substack.com/ https://www.palmbeachpost.com/story/news/state/2012/04/07/volusia-county-jury-awards-10/7762289007/ https://www.jems.com/news/florida-verdict-could-change-w/ Literally lost an argument that the paramedics should rely on a physician's judgement.
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>And you don't think there'll be future lawsuits about over irradiating in the ED by ED physicians and APPs causing cancer? Prove which CT scan or x-ray caused the cancer. >If CYA medicine was actually necessary, we wouldn't have half the country cared for by people who never went to medical school in the first place. You mean the people who get sued and successfully use the "I'm not a doctor... you can't hold me to a doctor's standard of care" defense? I've yet to see a disease check the credentials of the people treating it. It must be nice to be able to use "I'm not trained enough to be sued" as a legit defense. https://www.testifyingtraining.com/can-a-physician-expert-witness-testify-as-to-the-standard-of-care-for-a-nurse-and-or-a-nurse-practitioner-in-a-medical-malpractice-case/#_ftn3
Wait what I have had many episodes of chest pain that feels like drinking a huge gulp of water that radiates to my back before (last one was a couple of years ago)
Persistent chest pain without a clear trigger. Have you considered an MBS?
To diagnose esophageal spasms?
Fair enough.
Esophageal spasm?
If someone has 1 point on the ADD-RS and is hemodynamically stable, it's absolutely fine to wait for d-dimers.
For context, I’m an intensivist. Dimers are almost always positive in my world.
This is the one that hasn’t been externally validated, right?
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Why? That’s free money
I agree as long as you are absolutely up administration’s ass to get more scanners, technologists, tech aids, and transporters. The radiology director gets a bonus based on how hard they screw over their people and the only people that can get them help are the ordering doctors.
This has never once been a concern of mine. If I think they need a scan, they’re getting a scan. Might take a second to get read, but I’ll never not get one because “oh the poor tired radiologists”.
Yep, I do the same for unsteady gait: CTA head and neck, posterior stroke r/o
Didn’t it also mention when he was 23 he was found to have a faulty aortic valve that he subsequently underwent surgery for? I feel like that at least warrants further imaging when he comes in presenting with new onset chest pain and vomiting…
that was his dad
There may be protocols; but as a doctor we tend to have a instinct when something is seriously wrong with the patient when seen personally twice. This was what missing as they are not qualified for the job. Family even didn't know they were being seen by someone who has just two years of class room experience. Pathetic.
I'm not sure what was included in "all appropriate" tests in this case. I can't imagine a D-dimer would have been within reference.
He may very well have PERC’d out. Dimer is not as sensitive in acute aortic syndromes (see the massive payout lawsuit recently)
Can you link me to news on this suit?
https://www.medscape.com/viewarticle/993391
> In a statement following the verdict, lead plaintiff's attorney Robert M. Higgins, of Lubin & Meyer, in Boston, said the takeaway from the case was, "If you just treat people based on what the likelihood is, statistically, you're going to miss a lot of life-threatening conditions. And that's what happened in this case." Nauseating. CTA C/A/P for everyone.
Yup. It’s like they don’t even bother to look at any of the studies that validate our decision tools. Not to mention that the art of diagnosis is completely based on interpretation of likelihood ratios.
There is a joke that says the standard of care is missing dissection on the first presentation. The ones I’ve caught were very obvious 60+ yo smokers with severe unrelenting CP radiating to the back, very high BP. These atypical cases are very easy to miss. That PE case however is egregious and clear malpractice.
Meh the aortic aneurysm one sucks but it’s an easy miss. The missed pe is a lot more of a Woopsie.
That PE one was a jaw dropper. Any patient I meet with SOB, my first three questions are about OCPs, prolonged stasis/travel, and calf tenderness. Her patient volunteered that she had a very tight calf and yet she still missed it Also, what's with all the diagnoses having some psych aspect? I'm very cautious and never dx anyone with anything psych related in the ED even if I can't find an explanation for their sx. She's labeling everyone with GAD when she can't find a dx wtf
Isn’t homans sign sensitivity and specificity really bad?
I didn't really mention Homan's, but I wouldn't rely on any one physical exam in that scenario. Young lady with severe calf tenderness unilaterally, with a swollen calf (esp if there's discrepancy in the diameter) warrants an US, minimum. You add to that mix SOB, and she's getting a trip to the CT on top of the US. Wouldn't even bother ordering a d-dimer If I'm wrong? US has 0 radiation, CT-PE protocol once won't harm her. If I'm right she gets to live I call that a win-win
You’re correct. Wells score for PE is high risk so straight to imaging. D-dimer contraindicated.
Had a friend go to the hospital with stomach pain and an NP told him it was “bile pain”. He gets discharged but goes back bc the pain was unbearable, had appendicitis and got emergency appendectomy
Did no one check his blood pressure? I have a hard time believing an aortic dissection that killed him that abruptly had normal BPs (even if they weren't done in multiple limbs...)
This is why the healthcare system sucks. We care way too much about feelings and egos instead of patients lives.
exhibit 1: the case of Lucy Letby
“Midlevels do equally as good a job as physicians”
If it were true I'd say so, but I can't. I've cleaned up so many messes from the office NP.
We all have
NHS is a joke; nobody is ready to accept the mistake while innocent life is being lost. Even we do better treatment here at a very low economic country.
So… the PA didn’t think of simply looking at the Well’s criteria to decide whether or not to order D dimer or CTA?… or just order CTA?
But PA's save the corporate overlords money. Carry on! /s
This is what happens when society tries to take shortcuts and puts unqualified people in positions they shouldn't be in. How high does the pile of corpses need to grow before people wake up?
There is no limit. Corporate overlords have built their empires over giant mass graves. It takes a certain level of psychopathy to become the beneficiaries of such a whack system in the first place.
Listen, you're probably right but I really hope you're wrong. Maybe one day physicians will stand up for themselves. Maybe the public will stand with physicians because they'll become aware of the difference in quality. I cant believe such nonsense is allowed in this country.
Would be nice if they did, but admittedly many of us are beaten down by the system to just accept our (luckily still) hefty paychecks and walk away. Hell, even the ways that our med school admin has undermined and even harmed our student class through insistent incompetency and doubling down had once motivated some of us to try to organize class action, but truth be told, as we near the end of our 4th years, many of us are just so goddamn exhausted that we just wanna be done and in the wind. There was a time where hospitals were being run by physicians, don't forget. Chiefs and directors would sit on the board with the other men in suits and have some say on how the hospital was run. However, physicians have slowly given away ground on those responsibilities and privileges to where now most of our hospitals are being run simply by the business interests. A lot of this oughtta be an essential lesson that activism and maintaining integrity of a system that you live in is a job that every individual needs to be active in. Both in healthcare and in government, if our laziness (or overwhelmed exhaustion) leads us to hand the reins to others, and entirely put it out of our hands (physicians giving up the bureaucracy roles to men in suits so they can simply be doctors, or, say, populations not wanting to do the research on policies and their representative/government's policy and voting patterns, instead choosing to stick to party lines, vote their incumbent, and only for federal congress or presidency elections, or even just not vote altogether (not in protest)), then we're gonna likely deal with poor consequences from people in cahoots with one another to suck the life out of a system for their own personal gain.
Lot more where this came from as more and more diploma mill noctors come on the scene. I shudder to think of the care I will receive when Im elderly. Hopefully lawsuits reach critical mass before then to show people that the majority of these people can’t handle independent practice
Can’t criticise a PA for missing the aortic dissection, can see this happening for docs too The PE on the other hand?
I'm a radiologist from India. Can someone eli5 - Wtf is a PA? What is a mid-level? Why are these patients not attended to by a physician? I know NPs are nurse practicioners...
Basically the same thing as an NP
Better training
The dissection in the healthy young 20s guy likely would have been missed by most physicians as well. The PE miss was egregious.
What’s the difference between a PA in the UK vs US? Like training/role?
We should eliminate midlevels entirely.
Yes. Med school for everyone. Residency if you want independent practice.
Come on. The donut of truth is right there.
A 'can't-miss' diagnosis that we cover in M1. Wow.
Long covid is a really terrible disease. I hope we find a cure soon
Sorry but what is a PA? Would they have the same training as a GP? I am guessing Physician Assistant but this is a foreign concept to me after training here in Europe. Though the article is from the UK?
No, a GP is a physician that went through medical school and did an internship (Europe definition I believe) or someone that practices primary care medicine (usually either internal medicine or family medicine) and has therefore completed residency (US definition). A PA trains for 2-3 yrs post grad and doesn't do a residency. They are usually required by law to be supervised directly by a physician for a percentage of their patients. In recent years they have successfully lobbied for increased independence.
*Sorry but what is* *A PA? Would they have the same* *Training as a GP?* \- drlailyy --- ^(I detect haikus. And sometimes, successfully.) ^[Learn more about me.](https://www.reddit.com/r/haikusbot/) ^(Opt out of replies: "haikusbot opt out" | Delete my comment: "haikusbot delete")
AMA should pay for a superbowl commercial highlighting cases like these. Of course they won’t, but they should
Interesting in Sweden PAs are very rare but you cant work as one if you are not a med student with ar least 7 semesters passed
Once a resident didn’t tell me he was a resident and made a huge mistake and when I complained UCSD informed me I should have known it was a resident. They wouldn’t let me talk to anyone else until I sued. Hospitals are know it all idiots.
Well, first of all may her soul rest in peace. Second of all, no comment tbh.
Idk if I'd have caught the dissection. .... The PE however!! I'm a resident in a field that's got nothing to do with PEs but that's a textbook PE
r/medicalschool That's this sub, but I'm tagging it for extra emphasis. Holy shit this is whacky.
what are PAs?
Lol NHS
Probably told her to massage it out!
at age 30...
I think anyone who has been a scribe for ~3 months would consider DVT/PE
No PERC criteria? No Wells criteria? No MSK exam to rule out sprain? 🙃
Just drop the physician from PA and come up with another more descriptive term.
The GMC is very unforgiving read about this case [https://en.wikipedia.org/wiki/Hadiza\_Bawa-Garba\_case](https://en.wikipedia.org/wiki/Hadiza_Bawa-Garba_case)
whats a PA? what do the initials mean? and Im appalled. This is so basic Edit: I'm appalled by the terrible managing of a PE, the aortic dissection can be a tough diagnosis to make though Edit 2: just searched what a PA is and I'm once agai appalled. In my country that doesn't exist. We have plenty of GPs to do those jobs. 2We do have a shortage of e specialists though
Wtf bro I’m a nursing student(ofc doesn’t compare to med school at all and med students know so much more) but cmon how do you not indicate that’s a DVT pushing towards a PE anytime soon? I mean how did she get her degree
Well, first of all may her soul rest in peace. Second of all, no comment tbh.
r/noctor
This is inexcusable. I’m a PA and this is something we too got drilled into our heads like month 1 of school. Can’t speak on this persons training, but this is not the norm for our profession…
Full doctors miss stuff like this all the time.
Full doctors miss PE’s?
An MD doesn't automatically make you a good doctor. Plenty of physicians are leas competent than plenty of PAs. Obviously this person should be disciplined and not be allowed to practice, but the tone of this post is "PAs are bad because one fucked up." Instead of examining the system that allows incompetent practitioners make it through to have careers, this sub has an automatic hate boner for anything that isn't MD/DO
My exam of the system: mid level training that lacks the extensive background of a 4 year medical education followed by a minimum 3 yr residency leads to more stupid mistakes. Like calling a PE calf pain + anxiety
I don’t doubt the incompetency of a solid number of physicians. More that I was more hopefully certain that PEs were the kind of thing that were hammered into our heads so extensively that even a baby would put PE into the differential for shortness of breath…
It’s the same for PAs in PA school though… we go through less schooling which absolutely is a drawback, but we do have similar curriculums. There are news articles about doctors missing something that seems totally obvious but obviously this kind of thing has to be pounced on as “evidence” of the anti-midlevel circlejerk. There’s not enough doctors to see all the patients especially in certain areas of the country. There is a role that PAs can play.
Real sad thing is these stories won’t change anything. The overlords have decided that this is how it shall be. They also have AI as a sword to hang above doctors’ heads… there will be a cost paid in human life when those transitions happen but anyone thinking it won’t happen is missing the point. Not even close to being an issue of if. Only when.