Welcome to Talk EM, brought to you by the Emergency Medicine Institute where our goal is promoting clinical excellence. Our focus is for the advanced emergency medicine practitioners, nurse practitioners and physician assistants who work in the field, taking care of people who are really sick.

To anybody who’s ever worked on an ambulance, here’s my question: What’s the first rule of EMS?

What’s the first rule of being a paramedic or EMT? It’s scene safety. It’s always scene safety. You’ve got to take care of yourself. The worst case scenario is not that someone dies in a car accident. The worst-case scenario is you stop to help them and you get hit by a car; you die too. That’s the worst-case scenario.

This philosophy is sound as you practice medicine, either emergency medicine and urgent care or primary care medicine. You’ve got to take care of yourself, and what does that mean? It means medico legally. You have to take care of yourself spiritually, emotionally, physically, all that self-care stuff, but you also have to keep yourself out of trouble medico legally.

When I started teaching emergency medicine courses over twelve years ago, my goal was to teach extraordinary medicine, different ways to think and document. That was great, but I kept hearing people say, “John, you made me much safer in how I document and how I think.” That evolved into a performance improvement CME in medical malpractice defense, multiple lectures at national conferences, and doing medical malpractice defense claims. Now I defend PAs who are being sued.

We’re going to embark on a series on medical malpractice defense in the style of “The Art of War.” Sun Tzu wrote “The Art of War” 500 years before Christ to teach strategy. He says every battle is won before it is fought. It’s the same thing with medical malpractice. You have to think correctly, because the stakes are very high. “The Art of War” is kind of like the Dubin’s of EKG interpretation, but for strategic thinking. I mean it’s a mandatory text in a number of MBA programs.

I want to introduce to you this guy, his name’s Pete. Pete’s clearly a plumber. Pete is 41 years old, nice guy, good guy. If he was your neighbor, you’d like him. Two kids. He has a couple beers on a weekend, he doesn’t overdo it. Coaches T-ball. He’s just a good guy. Now you have to look in his eyes right now, and get to know Pete, because Pete’s going to be the guy in your jury. He’s going to be the guy on your jury, so your documentation has to be to Pete.

You have to get Pete to think you really cared about your patient, you were being thoughtful. It’s got to surround everything that you do on your medical chart, on your discharge instructions especially. You have to get Pete to like you. That’s how medical malpractice cases go away. Something bad can happen, but your documentation stops you from getting a certified letter. Pete is who you’ve got to be friends with, and the way you’re going to be friends with him is by your documentation.

Now, what do we need to know about Sun Tzu and “The Art of War?” You have to be proactive, not reactive, meaning that we have to now get our minds set to say, “I’m going to do everything I can to not get sued.” Take another minute or two on every single chart. If you see twenty patients in a day, yes, you have to take an extra thirty, forty minutes, to have much better documentation. I’d rather you see two less patients per day, but really cover your butt, than wing it.

Sun Tzu was a Chinese general, military strategist and philosopher, and he said that the general who wins the battle makes many calculations in his temple before the battle is fought. The general who loses makes but a few calculations beforehand. It is the exact same with medical malpractice defense. You have to start calculating risks. You have to start thinking about it; you have to be a student of it. If you are reactive, that means you are getting into trouble already, so you have to make many calculations before the battle is fought.

The Stakes of a Medical Malpractice Claim

If you want to know the stakes of a medical malpractice claim, here are the stakes. This is a true story of a thirty-year-old male. He was a valet, sent to the hospital for outpatient drug testing by his employer after a mild motor vehicle crash. Thirty minutes after he arrived, he became agitated and incoherent, and started thrashing about. The ED doc who just started his shift documented the patient was very agitated, and ordered Allopurinol 15 mg IV, some labs and a head CT. In the CT he went thought respiratory arrests and had some hypoxia during the event. He was admitted to the ICU, where he admitted he drank lots and lots of water to dilute his drug screen. Because of central pontine myelinolysis, he went into a coma and died the next day, so a lawsuit was served against the doc.

The first plaintiff expert stated on the stand he didn’t die of water toxemia, he died of Allopurinol given in an inappropriate route and excessive dose. During a cross examination, the plaintiff admitted that he only looked up Allopurinol on the PDR, he didn’t have first-hand knowledge of it. Understand that I wouldn’t use that 15 mg dose. It’s excessive dose, but it’s not crazy. The plaintiff also claimed that the patient was asked to drink water in the ED to produce a urine specimen, but they found the water that he drank to be in excess of about three gallons. All silly stuff, right?

The second emergency medicine expert, the emergency medicine physician, looked at the CT scan and said that CT scan clearly shows hypoxia. You guys know you can’t see hypoxia on a CT scan. While he was getting scanned, the patient had a hypoxia episode, but during the scan his O2 saturations ranged from 92 to 99 percent.

This was a case that dragged on for five years. Eventually they settled the case for about a quarter of a million dollars, but the stress it put on the ER doc broke him. Getting sued, especially if there’s a bad outcome, is deadly serious. This doctor committed suicide over it.

What does that mean as part of this series? You have to get good at protecting yourself and your documentation and your patient care. I’d like to help you with that journey if you will allow me. So, thank you for watching and reading, and understand that my whole goal is to give you real tools. This is part one.

I’d ask you a favor: please share this with other people. If you find this important, if the gravity of this hits you and says “Okay I really want to learn what he has to say,” I have strategies that will help you stay out of trouble medico legally. Good luck.

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