Midwest Medical Liability Management Association
Medical Liability Webinar
October 2012
Midwest Medical Liability Management Association
Midwest Medical Liability Management Association
Midwest Medical Liability Management Association
Midwest Medical Liability Management Association
Midwest Medical Liability Management Association
The Patient
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59 year old male
Postal worker
Hx. excision of left calcaneal exostosis
C/O recurrent pain left heel, increasing in severity
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Course of Treatment
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11/4/06 – initial evaluation
Pt. reported trial of different shoe types and padding
provided no pain relief. Requested surgical intervention.
Erythema circumferentially around the posterior superior
aspect of left heel.
Dorsalis pedis and posterior tibial pulses +2/4 bilat
Patellar and Achilles deep tendon reflexes +2/4 bilat
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Course of Treatment (continued)
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X-ray, L foot showed hypertrophic bone formation at the
posterior and superior aspect of calcaneus. Kager’s triangle
is intact and the Archilles tendon appears normal. Increased
soft tissue density is noted just posterior to the area of bone
hypertrophy.
Diagnosis = Left foot retrocalcaneal hypertrophy of bone with
pain
Plan = Left foot retrocalcaneal ostectomy
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Surgery scheduled for next day
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Course of Treatment (continued)
11/5/06 – Surgery
- Dx. L retrocalcaneal hypertrophy of bone
- Procedure: L retrocalcaneal partial ostectomy with partial
detachment and reattachment of the Achilles tendon with
internal fixation
- Pt. tolerated procedure and anesthesia well and left OR with all
VSS and good perfusion to the L foot.
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Course of Treatment (continued)
11/8/06: 3 days post-op SOAP Notes:
(S) Pt. presents for F/U of L foot- he had discomfort but not unbearable. Was Ibuprofen
taken during waking hours?
(O) & (A) Satisfactory progressive post-op healing. Sutures intact. 0 signs of infection.
(P) Sterile scrub done to L foot
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X-ray taken L foot, DP&LAT – Pt. wore lead apron
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X-ray reviewed
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EGS directed to L foot @ 300v X 15 MIN.
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Sterile dressing with polysporin powder applied to L foot
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BK cast applied to L foot with Fiberglass material
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Return to office 5-7 days
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Rx. Cephalexin 500mg. Disp. #40 (forty) Take 1 tab.Q6H w/food
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When was Ibuprofen prescribed?
Why was cephalexin prescribed?
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Course of Treatment (continued)
11/15/06: 1 week 3 days post-op
(S) Pt. presents for F/U of L foot surgery. Reports his foot feels good except
when it swells. He can feel it tight in the cast.
(O) & (A) Satisfactory progressive post-op healing. Cast intact.
(P) Diathermy directed to L heel through cast @ 50% X 15 min.
Cast checked-cast removed
Sterile scrub done to L foot
Sterile dressing with polysporin powder applied to L foot
Cast reapplied
Return to office 10 days
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Why diathermy through cast when cast was later removed?
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Course of Treatment (continued)
11/24/06: 2 weeks 5 days post-op
(S) Pt. presents for F/U L foot. Reports he only has discomfort when foot swells
(O) & (A) Satisfactory progressive post-op healing. Sutures intact. Cast intact.
(P) Cast removed
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Sterile scrub done to L foot
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EGS directed to L foot @ 200V X 15 min.
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Surgical site debrided
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Sterile dressing w/polysporin & zinc applied to L foot surgical site
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Cast applied with fiberglass
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Return to office 1 week
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Surgical site debrided, polysporin applied – why?
Were sutures removed?
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Course of Treatment (continued)
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Pt. returned weekly for next 2 weeks
Same documentation and same treatment
Weight bearing status?
Home instructions?
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Course of Treatment (continued)
12/16/06: 5 weeks 6 days post-op
(S) Pt. presents for F/U L foot surgery. Reports pain.
(O) & (A) Satisfactory progressive post-op healing.
(P) Sterile scrub done to L foot
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L foot examined
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Sterile dressing with polysporin applied to L foot surgical site with Desitin
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EGS directed to L foot @ 200V X 15 min.
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Pt. advised to take Motrin
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Pt. advised to wear open-backed shoes for right now
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Return to office Monday (3 days)
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Why was polysporin & sterile dsg. Applied at 6 wks. post-op?
Desitin?
Why was patient instructed to return in 3 days?
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Course of Treatment (continued)
12/20/06: 6 weeks 3 days post-op
(S) Pt. presents for L foot surgery F/U. Reports no pain.
(O) & (A) Satisfactory progressive post-op healing
(P) Sterile scrub done to L foot
EGS directed to L foot @ 400V X 15 min.
Sterile dressing with Desitin and polysporin
applied to L foot surgical site
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“Satisfactory progressive post-op healing”, but still applying dressing?
No description of surgical site?
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Course of Treatment (continued)
12/23/06: 6 weeks 6 days post-op
(S) Pt. presents for F/U L foot surgery. Reports little pain.
(O) & (A) Satisfactory progressive post-op healing with capsulitis
(P) Sterile scrub done on L foot
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EGS directed L foot @ 400 V X 15 min.
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Sterile dressing with polysporin applied to L foot
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Return to office 1 week
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Return 3 days after previous visit-why such frequent visits at almost 7 weeks
post-op?
Still applying sterile dressing?
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Progress
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Pt.. Returned weekly for the next 6 weeks
No documentation of capsulitis
No wound description
Same treatment : surgical scrub, sterile dressing, ointment
Still obvious wound, but no documentation of such
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Progress
2/18/07
(S) Pt. reports increased drainage from L foot surgical site for 3-4-days. He also
has c/o increased pain. He stopped doing the stretching exercises due to pain.
(O) & (A) retrocalcaneal surgical scar with mild deshiscence of incision. Drainage
noted-mild erythema.
(P) L foot surgical site cleansed with H2O2.
EGS directed t L heel at 200 V X 15 mins.
Wound culture taken L heel. Sent to lab.
Pt. to use compresses on heel
To ease off on stretching
Rx Cephalexin 500 mg. Dispense #40 (forty), Take 1 tab. Q6H with food
RTC 1 week
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No documentation of systemic review?
(Notes getting better – foot getting worse?)
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Progress
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No mention of culture results in subsequent notes
Patient returned every 3-4 weeks for next 4 visits,
then weekly for the next 3 weeks.
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Progress
4/1/07
(S) Pt. presents for F/U L heel. Reports his heel has been hurting a lot and the wound
is open again.
(O) & (A) S/P L heel resection with wound dehiscence.
(P)EGS directed to L heel at 200 V X 15 mins.
Sterile scrub done to L heel
L heel examined
Cultures taken-sent to lab
Pt. should still soak foot
Rx Cipro 500 mg. Disp. #20 (Twenty), 1 Tab. BID with food.
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Dehiscence does not equal infection
Antibiotic changed to Cipro-why? Was Cephalexin d/c’d?
Now 5 months post op
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Progress
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Pt. seen every 3-4 days for next 3 visits.
Again, no mention of culture results in notes
4/14/04
(S) Pt. reports his foot is feeling much better
(O) & (A) L foot retrocalcaneal suture rejection site 90% cleared.
(P) Sterile scrub
EGS X 15 min. at 120 V
Sterile dressing with polysporin and zinc oxide to L foot
Rx Septra DS, #20, BID with food
RTC 4 days
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Antibiotic changed to Septra-why?
Are the Cipro and Cephalexin still being used?
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Progress
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Pt. seen every 3-4 days for next 4 visits
At visit on 5/2/07, the Podiatrist advised the patient “of the need for an X-ray to
evaluate osseous involvement in recurrence of pain.”
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Progress
5/6/07
(S) Pt. presents for F/U L heel- still draining and has “puffy” spot-blister-yesterday was biggerneed Rx for MRI written
(O) & (A) L retrocalcaneal resection
(P) Sterile scrub done
EGS directed to L heel at 250 V X 15 min.
L heel examined
C&S taken L ankle. Specimen sent to lab
Sterile dressing with polysporin to L heel
Rx Cephalexin 500 mg. #40, Take 1 tab q 6H with food.
Rx MRI L ankle, 3mm cuts, without contrast
RTC 3 days
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Still no description of culture results, but pt. prescribed Cephalexin
No mention of X-ray results?
No description of wound?
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Progress
Patient returned every 3 days for next
2 visits
Midwest Medical Liability Management Association
Progress
5/24/07
(S) Pt. presents for F/U L heel. Feels a little better
(O) & (A) L foot retrocalcaneal aspect resection
(P) Sterile scrub done to L ft.
EGS directed too L heel at 200 V X 15 mins.
L heel examined
C&S results discussed with Pt. from 5-06-07
C&S taken, Specimen sent to lab.
ID specialist discussed with Pt. if problem persists
Sterile dressing with polysporin to L heel
RTC 3 days
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No mention of MRI results
Discussed culture results, but no mention of what the results were
Was antibiotic prescribed?
Finally thinks of ID consult-was “discussion” enough?
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Progress
Returned every 3-7 days over the next 2 months
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6/3/07 – Septra DS ordered
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6/8/07 – More cultures taken
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6/15/07 – Pt. reported he saw ID doctor and he started new antibiotic -Zyvox. (ID
doctor recommended removal of hardware from heel)
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6/27/07 – Another culture taken-no mention of results. No acknowledgement of ID
doctor’s recommendation to remove hardware .
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7/11/07 – Another culture taken – no mention of culture results – chasing cultures
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7/21/07 – 1st mention of systemic symptoms
- PT. not admitted. Why?
- Pt. not following with ID. Why?
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7/23/07 – Finally sent to hospital
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Subsequent Treatment
Hospital
• Hardware removed in ED
• Admitted
• Surgical debridement
• ID consult
• Bone cultures + for MRSA
• IV antibiotics started
Post Discharge
• 6 wks. Home IV Vancomycin & oral Rifampin
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Lawsuit
Allegations against podiatrist:
• Negligence in managing post-operative infection
• Failure to prescribe the correct antibiotics
• Failure to refer to specialist in a timely manner
• Failure to remove hardware after the infectious disease specialist
recommended that it be removed
(Continued)
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Problems for Defense
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Failure to perform appropriate examination
- No description of wound
- No rationale for prescribing antibiotics
- No mention of C&S results in progress notes
- No rationale for not adhering to ID recommendations
Failure to timely refer to specialist
Failure to treat appropriately
- Multiple cultures were + for MRSA, but was never addressed by
podiatrist
- Did not follow the recommendations of the infectious disease
specialist (hardware removal & antibiotic)
- Infection developed into osteomyelitis
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Outcome
Settled during mediation
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Common Allegations in Infection Claims
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Failure to perform appropriate examination
Failure to obtain appropriate diagnostic testing: (X-rays, lab work, cultures)
Failure to timely refer to specialist
Failure to timely treat
Failure to diagnose infection
Failure to document the wound condition and size
Failure to document the treatment plan
Failure to timely admit to hospital
Failure to treat appropriately (antibiotics)
Failure to reappoint or follow up in a timely fashion
Midwest Medical Liability Management Association
APMA National Convention
Presented by PPI with cooperation and credit to
APMA National Convention
Aug 16-19, 2012 Washington DC
Midwest Medical Liability Management Association
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25% of Diabetics will have an ulcer.
Currently, the standard is to call a wound chronic if it is still open > 4
weeks.
We are seeing more ulcers as Diabetics are living longer and we se
more end stage Disease.
There is a 5 year survival rate for people following a leg amputation.
With any neuropathy caused ulcer, there is a 45% 5 year survival
rate.
Midwest Medical Liability Management Association
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There is an 8 fold increased chance of infection for
ulcers older than 30 days.
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You need to convert a chronic wound to an acute
wound for it to heal.
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24% of Foot Ulcer patients go to the hospital.
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Treat the Infection First: Patient Can Die!
2. Treat Vascular Status next.
3. Function and Structure come next.
4. Cosmetic consideration should come last.
1.
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Remove hyperkeratosis
• Remove Necrosis to healthy margins
• Curette the base, remove undermining
• Remove Fiber
• Wet to Moist no longer used; now the standard is on of the synthetic,
such as Calcium Alginates, Foams, Collagens, Hydrocolloids or
Hydrogels.
• Consider taking two wound margin samples on a serious case. Send
one to micro and the other to Pathology for confirmation if clean
margins. Results may cause a change in treatment plan.
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Midwest Medical Liability Management Association
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Negative pressure is becoming the standard of care.
Off Loading is standard of care but can be inadequate.
Use: total Contact Cast (there are kits available called ITCC);
crutches for the young; if the patient is able to use adequately, a rollabout is to be used, but these can be dangerous. Patients could find
fault if you suggested something that is a challenge to them.
Use cam walkers, rocker type, such as air cast; ½ shoes; short shoes
to float toes if necessary. Be creative.
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NOTE: 82% of people in a removable Cam
walker remove it and walk without it.
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It may be necessary to use cable ties around the
Cam walker or to wrap it with Coban so the
patient is less likely to remove it.
Midwest Medical Liability Management Association
Look for 50% improvement in sq mm by 4 weeks, many feel if
not 25% healed by two weeks, you need to make changes in:
off loading, vascularity, bacteria burden, dressings, etc.
• The rule of 1mm a week of healing has been an old standard;
for large wounds and unusual wounds this may not apply.
• If not healed in 4 weeks, you need assistance with advanced
wound healing techniques.
• Only Dermagraft and Apligraf have pre-marketing approval from
the FDA. Others like Theraskin which is a less costly choice)
has a 510K status (under study).
• There is an art to billing these dressings and as you know some
require reapplications.
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Midwest Medical Liability Management Association
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Go to www.Footlaw.com and browse the sight.
The new trial attorney push is Diabetic foot ulcers that lead to
amputation.
Read the Blogs and cases and see top 10 reasons
Podiatrists are sued.
#7 is Diabetic Complications
#2 is RSDS/CRPS
Read about the Podiatrist who did not treat the heel pain
conservatively; had an $85,000 settlement.
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Wonder who the 21 Podiatrists are that
offer their services to this firm? They only
charge $800 to $1,200 to look at a case.
Midwest Medical Liability Management Association
Download and look at this paper from
www.podiatrytoday.com
“Consensus Recommendations on Advancing the Standard of Care For
Treating Neuropathic Foot Ulcers In Patients with Diabetes” - 2010
It is 24 pages long, but an easy pdf download. Very informative document.
Midwest Medical Liability Management Association
Midwest Medical Liability Management Association
DISCHARGING A PATIENT
Occasionally you encounter a patient that you know could be troublesome. It may be best to discharge them
from your care. Those displaying confrontational behavior or who are insistent on receiving treatment or
procedures you know are not in their best interest are dangerous from a liability standpoint, and great care
should be taken prior to performing any procedure; especially surgery. In the event you feel you must
continue to treat such patients obtaining second opinions prior to surgery is a good idea. Having support
going in can be very helpful in the event the patient becomes disgruntled...legitimately or not. Provided you
aren’t abandoning a patient, there is no obligation to treat them. If you are concerned to the extent you feel
you’re going to be at risk you may wish to recommend they continue treatment with another doctor. To
properly discharge a patient from your care you must take the following steps.
1.
2.
3.
4.
Be certain they are notified in writing
Advise them of the reason you are recommending they seek treatment elsewhere
Offer to continue necessary care until they have found another doctor, or for thirty-days (30); whichever
is shorter
Offer to recommend the names of other doctors in the area
A sample letter used to discharge a patient is on the following page.
The following is a sample letter used to discharge a patient.
Dear M. ______________
I find it necessary to inform you that I am withdrawing from further professional treatment of you
for the reason that you have persisted in refusing to follow my medical advice and
treatment. You are suffering from a very serious disease and your failure to follow my advice
jeopardizes your health.
Since your condition requires medical attention, I suggest that you place yourself under the care
of another physician without delay. If you so desire, I will be available to attend you for a
reasonable time after you have received this letter, but in no event for more than 30-days.
This should give you ample time to select a physician of your choice from the many competent
practitioners in this area. With your approval, I will make available to the physician your case
history and information regarding the diagnosis and treatment which you have received from
me.
Very truly yours,
**You may substitute the appropriate reason for that which is highlighted above. It may be that they are demanding
treatment you feel is inappropriate, they seem dissatisfied with the way your practice operates, refuse to pay for
treatment, etc.
Any questions in this regard should be directed to our Risk Manager...Jim Olsen at:
800 955-2840 or jdonlm@cablespeed.com
Midwest Medical Liability Management Association
Midwest Medical Liability Management Association
“Your company continues to be financially sound. The total number of
Insureds had dropped to 90 members, but we are now back up to 95. The
Board’s efforts continue to be toward finding a way for the Company to
market in Michigan. We have approached, and have been in negotiations
with two different companies. We hope to have news in this regard soon.
Our premiums have remained the same for several years in spite of
increased costs. Thus the importance of obtaining new members to
enable us to keep our premiums very competitive and to retain further
profits to continue to build policyholder funds.”
Midwest Medical Liability Management Association
Midwest Medical Liability Management Association
Since some PPI members will read this who have never been to a risk seminar, certain definitions are necessary:
Incident - Doctor receives a request for records or has an unhappy patient. You should call Jim Olsen, 1-800-955-2840.
NOI - A legal Notice of Intent from a patient that they are going to file a malpractice claim against a doctor.
Claim - The patient has actually filed a claim against a doctor.
As of 8/1/12 PPI has 3 claims, 1 NOI and 1 incident as pending cases.
The incident involves a patient’s death following surgery, yet to be determined, but we believe unrelated to the surgery.
One of the claims involves the death of a patient immediately following surgery; the other involves a patient losing toes
and part of foot and claiming negligence on the part of our doctor. The third claim relates to a poor result following
bunion surgery.
The NOI alleges improper implant surgery.
We remind you that for all procedures requiring the use of a consent form after 1/1/11 must have used our approved
form or a $2500 deductible may apply to any claim.
Midwest Medical Liability Management Association
We appreciate you participating in our first webinar. We trust the information was
useful and the method of presentation was convenient. Do let us know if you had
any trouble with accessing the webinar. Your input will aid us in improving future
presentations.
To confirm that you have carefully reviewing the information we’ll ask that you
complete the following questionnaire. We’ll ask some questions that will determine
whether the points we attempted to make were understood. It is not difficult, but will
confirm that our message got through.
Again, you comments and input will be appreciated. Simply follow the instructions
on the screen.
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Follow the instructions on the screen. If you have any trouble contact us at:
jdonlm@cablespeed.com
Midwest Medical Liability Management Association
1.
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3.
4.
What was patient’s diagnosis and treatment?
Name three allegations against doctor.
List three problems the defense faced.
What is the most common cause of lawsuits?
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Have you attended 1 or more of our annual risk management meetings?
Do you prefer the Webinar format or an annual meeting?
Comments:
Midwest Medical Liability Management Association
1) Ulcers that stagnate do so because of which following potential causes:
a) Vascular issues
b) Lack of offloading
c) The patient's nutritional status, smoking, obesity, and deconditioning
d) Bacterial burden
e) All of the above
2) When writing the first orders for managing an acute fetid foot, the most
important priority is:
a) Determine if pt needs just medial rays versus a total trans met amp.
b) Planning for scar position
c) Get ID consult and do an aggressive I&D
d) Get vascular/cardiology consult if no palpable pulses
e) None of above
Midwest Medical Liability Management Association
3) What is the most inadequate off loading management technique you could
recommend to a neuropathic patient with a forefoot ulcer who cannot stay on crutches?
a) Pad on foot
b) Air cast cam walker with plazitote and felt off loading for surface
c) TCC commercial type or office created
d) Tell patient to not walk too much and use their heel and anterior muscle group
and float his/her forefoot
e) Try 4 wheel roll-about if the patient has the strength for this and agility that they
can maneuver the cart and they live on one floor in the home.
f) Flat surgical shoe with no off loading, or padding.
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4) These are ideas about wound healing that are appearing in Publications and
National Meetings. Select all below that makes sense to you.
a) You need to change a number of your approaches to getting the wound healed
if it is not progressing steadily.
b) An ulcer that was 20x30mm on Nov 1st and now is 300mm in size Dec.1st is
good progress.
c) Consider referral to wound center or second opinion from fellow PPI insured
etc if you are managing an unhealed ulcer for more than 60-90 days.
d) There are law firms searching for amputation claims involving Podiatrists.
e) All of the above
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1. True or False; it is permissible to discharge a patient from your
care provided you are not abandoning the patient?
2. When discharging a patient the proper procedure, or requirements
include:
a.
b.
c.
d.
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There are no questions for this section of the presentation as it was to inform the
participants of the state of their sponsored malpractice insurer. Please proceed
to the next section concerning claims.
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1. Define the following:
1. Incident
2. NOI
3. Claim or Suit
2. What should you do in the event you receive notice of any of the
above?