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One In A Million

March 12, 2014

A small case with big implications almost escaped my notice this week.  On March 10th the Boston Globe reported a case in which a family sued after a 23-year -old man died after being diagnosed with a lung infection.

According to the Globe, the young man went to one of the Boston Emergency Rooms complaining of cough, fever, and chest pains.  OK, stop right there all you armchair diagnosticians.  What does this man most likely have?  99.999% of the time a patient with these complaints has a bad cold.  Bronchitis at worst.  The chances of this young man having a heart problem is very very small.  So Doctor Liang (that’s the doctor who got sued) is doing his shift in the ER.  Maybe it’s busy, maybe he has a headache, maybe some drunk just spit at him, whatever.  In any case, he sees this kid, takes one look at him, sees that he has some community acquired infectious process (ie, cold or flu), gives him antibiotics even though such things are almost always viruses, and sends him home.  Easy Button.  Any other doctor in any other ER would have done the same thing, given these symptoms.  And they would have been correct.

Unfortunately for poor Dr. Liang, lightning has struck and Zebras are galloping around Fenway Park.  The kid doesn’t have a cold.  He has viral myocarditis.  Here’s what the American Heart Association says about viral myocarditis:

“Viral myocarditis has been recognized as a cause of congestive heart failure for >50 years, but it is still a challenging disease to diagnose and treat.  The history and clinical features are often nonspecific, and practical serological markers are not available during the acute phase of the disease. Even after proper diagnosis, no clinically proven treatment exists to inhibit the development of subsequent dilated cardiomyopathy (DCM) and, in some cases, death.”  (Circulation. 2009; 119: 2615-2624)

So it has non-specific symptoms, no markers are available, and you can’t treat it anyway.  Awesome.  The European Heart Journal calls it one of the most difficult diagnoses in all of cardiology (Eur. Heart J (208) 29(17): 2073-2082).  Same Eur. Heart J says that the incidence of viral myocarditis isn’t even known because it’s so misdiagnosed.  The only way to diagnose it is heart muscle biopsy.  The virus that causes it could be one of several common viruses that up to 90% of people in the world get with nothing worse than a day off from work.

So let’s go back to our case.  Young man, fever, cough.  The Globe article, being rather one-sided, says the doctor only saw the guy for 5 minutes and never did an EKG.  Ok, so maybe that’s true.  Maybe he should have examined him more closely.  Might have heard an abnormal heart sound, maybe not.  Maybe he should have done an EKG.  Might have been normal, might have been not.  Liang got caught by a patient with a disease that difficult to see and impossible to treat.  It could have happened to any doctor.

Well, the jury didn’t think so.  They awarded the family $4.8 million dollars and concluded that it was Dr. Liang’s fault.  The implications of this settlement are sobering.   This sort of thing is exactly what we doctors are talking about when we talk about cover-your-ass (CYA) medicine.  Any one of us could have a case like this at any time.  Just at a time when we are supposed to be cutting unnecessary costs we have to do EKGs, myocardial biopsies and cardiology consults on every 23-year-old who comes in complaining of cough and fever?  That’s what this verdict implies.  I feel terribly for the family of the young man, I do.  I also feel terribly for Dr. Liang, who will absolutely practice CYA medicine for the rest of his life.


From → Healthcare

  1. I’m thinking. Here is the problem. Having been a runner and seen/know of/been in running races where young people die in their prime and its always been heart related (some thing that happens to 1 out of 2.6 million people), I would have had him checked out for the heart. The reason is based on my experiences. I think that does kind of hit at the heart of medical educational fallacy. If you experience it, then you can diagnose it. If you don’t experience it, then you can’t take care of it. I actually had an internist like this, told me they couldn’t diagnose something and sent me to a specialist who said we can’t either.

  2. Susan Nowak permalink

    Read your article with interest. The very same story occurred with my 29 year old son. I am a nurse (ER) and as the PA suggested a pulled muscle from coughing, I insisted on bloodwork and an EKG. The chest pain and just the way this kid looked gave me a gut feeling something was very wrong with him. He ended up being helicoptered out and put under the care of a heart transplant team. I say all ER staff should at least know about signs and symptoms of viral myocarditis…..

    • Susan – thanks for reading! I agree that all ER staff should know about the signs and symptoms of myocarditis. The problem is those signs and symptoms are so non-specific, and viral myocarditis is so rare. Yes, it should be a thought in the back of the ER staff’s mind, but we’ll never get anywhere on health care reform and get ahold on costs if you take people to court over it.

  3. My personal issue with these kinds of articles is that we don’t have the facts. We have the authors opinion on the facts, maybe. Misinformation is the key in these articles about miscarriages in the med-mal/pi practice areas.

    I worked in the er for many years and the fact is that some docs do a complete history and physical on every patient and some are lazy and don’t. A quick look at the vitals and triage note, a few words and off to the next patient. The hardships of the shift and the difficulties of the other patients should never affect the care the next patient gets.

    The hurdles these cases must jump over are profound: plaintiff’s attorney’s investigation, expert witness, medical tribunal, trial, jury verdict, judges decision on reducing or eliminating the verdict, appeal, etc…

    Healthcare providers make mistakes and patients get hurt, that’s why doctors and nurses carry insurance.

    • Thanks for reading! Totally agree I don’t have all the facts on this case. But neither are the vast majority of people reading about it. Conclusions can be drawn and precedents set on very little established fact, unfortunately.

      • I whole-heartedly agree people make snap decisions without the facts, basing their conclusions of an article that they may have read or in some cases a series of articles and flashes in the national media. One perfect example of this is the case involving Stella Liebeck, most don’t remember her name, but the case dubbed the Hot coffee case brings back anti-plaintiff/frivolous law suit memories, but the truth is surprising. I wrote an article on it which you can see here on my facebook:

  4. steveofcaley permalink

    Thank you. I am troubled by the comment: “The reason is based on my experiences. I think that does kind of hit at the heart of medical educational fallacy. If you experience it, then you can diagnose it. If you don’t experience it, then you can’t take care of it.”
    I cannot agree with that statement. There is really no “it” in medicine, as much as we wish to create an “it” out of pathology and disease. Disease is philosophically nominal – it does not exist as an entity, but in a person. Understanding a disease process is not simply experiential – even a name-able symptom is particular to the person experiencing it. It is the ability to understand the symptoms within the individual that is the challenge of diagnosis.
    The term “it” is also used for the concept of diagnosis. A diagnosis is not merely a constellation of names of symptoms and signs – it is an entirely different level of reality to proceed in the treatment of that identified disease.
    I have very good chops for diagnosing zebras where there are zebras, and horses where there are horses – in layman’s terms, I have very good diagnostic skills. I have not missed the obvious in 20 years, and have been baffled only once or twice. I have diagnosed appendicitis in a person whose spinal cord was ruptured at C5, rendering most of his body entirely insensate. How does one do that? One sees through what is, to what is behind. If that sounds mystical, it is because medicine is a human service that can never be divorced from human experience.
    Schopenhauer said that the living self-interest is “to live, and live well.” The service of the desire to live well, is our duty as physicians. We are only human, too.

    • Yes, Steve. And that was my point. Doctors are only human. There is a early-closure bias that we all have, in which 5 minutes into an exam we think we know exactly what the problem is. This is based on experience, and, as humans, things we see all the time are much more likely to pop into our heads than very unusual things.

  5. william reichert,md permalink

    This case, if reported accurately , points out a interesting conviction taking hold in medicine.
    The suggestion is that if doctors followed “evidence. based. medicine” then quality would be assured. But in this case where is thepublished. evidence to state. that the er. doc
    failed to comply with the evidence.? In real life , in my experience as an expert witness,
    most malpractice cases. arise from situations not examined with careful controlled experiments.
    Where is the evidecne published (not produced by an “expert” testifying for the plaintiff)
    stating what. should have been done that would produce a better outcome and at what cost?

    • Dr. Reichert – the EBM argument actually took hold a long time ago and has been declining in favor among clinicians even as it becomes a favorite of policy-makers and legislators. In the case of viral myocarditis, my understanding is that it’s so rare that no large database of evidence really exists or can easily be compiled. I suspect the publication you’re looking for doesn’t exist.

      • William Reichert permalink

        To SHirie Leng:
        Yes. Exactly right. The “publication (of the evidence to correctly treat this situation) does not exist.”
        The vast majority of medical decisions are not based on “evidence”. Yet, the jury awarded the plaintiff a large sum based on the testimony of “experts” who themselves did not have the evidence
        or the science to fairly judge the ER doctor. So in fact in this case, the standard of care is not
        science or evidence but is created by the jury at trial after hearing the opinions of paid experts whose opinions are necessarily biased by the source of the fees they receive for their testimony.
        Despite the clear lack of evidence for most of medical decisions and medical quandaries
        that appear in real life, the media, the regulators and the public choses to believe
        in evidence based medicine. And , as in this case under discussion, it does not exist.
        It is like a rainbow in a rain shower. Looks beautiful from afar, but up close, disappears.

    • We have a pretense that “evidence-based medicine” is something other than a rehashing of an old dictum, minus the comprehension and understanding underlying that.
      “For the Law permits as medicine everything that has been verified by experiment, although it cannot be explained by analogy.” I recommend the memorization of that quote. That, to me, summarizes the balance of subjective ratiocination against ‘evidence-based medicine.’ The speaker was our colleague doctor Maimonides; and has been in print for eight hundred years.
      We may command our doctors to be perfect, or face punishment. King Canute of Britain commanded the tides not to rise in his empire without his consent. It was said that he angrily ordered the disobedient surf to be whipped. What one wishes, and what one gets, may differ.

  6. Thanks! It’s an important issue, one to which I do not have answers.

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