There’s No Sugarcoating this Verdict

Diabetes is one of several medical conditions that can lead to a myriad of problems. When you add substance abuse and schizophrenia, you have a perfect storm.

This Monster Claim℠ involves a middle-aged insulin-dependent diabetic whose family found him unresponsive and called 911 at 9:00 p.m. Paramedics found that the patient had low blood sugar. Because they had a hard time starting an IV, paramedics administered glucopaste and glucagon. When the patient arrived at the hospital, his blood sugar was 74. The man was given a sandwich and observed in the emergency department. One hour later, his blood sugar was 79, and then rose to 118 two hours later.

The patient was discharged to family members at 1:05 a.m. and went to bed at 3:00 a.m. Eight hours later, his family again found him unresponsive. The man was readmitted with extremely low blood sugar. The patient suffered severe brain damage, and he is now completely mentally incapacitated and requires custodial care.

Additional information surfaced during depositions and the trial. It’s unclear whether old records were reviewed at the time, but prior records indicated that the patient was seen for hypoglycemia two days previously, and also had a history of alcoholism, pancreatitis, schizophrenia, and non-compliance.

There were at least three physicians on duty at the time of the patient’s second visit. The first physician denied taking care of the patient. The other two physicians insisted that the first physician was the one primarily managing the patient. In addition, all three physicians opined that the patient had a history of non-compliance so, regardless of who was in charge, the patient was to blame. These issues were a plaintiff attorney’s dream and likely contributed to the huge verdict.

After a prolonged trial, the physicians were found to be 90% liable and the patient 10% liable. The court awarded over $20,000,000, which included past and future medical expenses, economic damages, and nearly $6,000,000 in past and future non-economic damages.

This case is a little different than most and the teachings are several-fold. We’ve all seen this patient – probably countless times – over the course of our careers.

In reviewing this case, we will discuss:

  1. Hypoglycemia management
  2. Issues involving hand-offs, supervision, and protocol-driven medicine
  3. Dealing with frequent emergency department utilizers and non-compliant patients

Understand the scope of the risk of recurrent hypoglycemic episodes

Let’s start by discussing the straightforward issues of hypoglycemia management. While there are many medications that treat diabetes, diabetics are typically divided into two categories: those treated with insulin and those treated with oral hypoglycemic agents. In reality, diabetes management is far more complex and can involve various combinations of medications, glycemic insulin pumps, and continuous monitoring.

While these innovative solutions have decreased the hyperglycemic complications of diabetes, several of the oral hypoglycemics – such as glipizide – have long half-lives. Therefore, hypoglycemic patients taking certain medications require prolonged observation. When treating hypoglycemia, it’s important to review the type of insulin the patient is taking as well as other diabetes medications, including Metformin, Sulfonylureas, SGLT2 inhibitors (such as Dapagliflozin and Empagliflozin) and Thiazolidinediones (such as Actos and Avandia).

There are a multitude of other factors that can contribute to hypoglycemia. Even medications not intended to treat diabetes can compound or cause hypoglycemia. These include Bactrim, beta-blockers, Haloperidol, MAO inhibitors, Pentamidine, Quinidine, and Quinine.

Another element that can contribute to hypoglycemia is liver disease. A diabetic alcoholic or one with liver disease has substantial risk for hypoglycemia because people with liver disease often have few glycogen stores.

Hypoglycemia can also arise from non-compliance, which in turn can be triggered by substance abuse involving alcohol and other drugs, or by psychiatric conditions like depression and schizophrenia. Recurrent visits involving hypoglycemia can be a sign that the patient doesn’t have the capacity to care for him or herself, or that he or she may be suicidal.

It is often easy to blame the non-compliant patient for his or her medical issues, and society even blames emergency departments for taking care of these patients when referring to these visits as “inappropriate” emergency department visits.

Shift work attitudes and protocol-driven medicine can lead to problems

Physician supervision can get confusing. Sometimes, misunderstandings involve nursing protocols. Other times, residents or medical students are part of the mix-up. And there are times when nurse practitioners and physicians assistants are part of the confusion. Protocol-driven care has been touted as a means to expedite care. However, with several physicians on duty, it can be difficult to pinpoint the physician in charge.

This confusion can be compounded during shift changes and on occasions when another physician is asked to pick up or handle the disposition of the patient. Hand-off reports can omit key parts of the case, including recent visits, concomitant medical issues, and social factors. A problematic hand-off might involve a comment such as, “All you need to do is check the CT” or “One more blood sugar and then you can discharge the patient.” Hand-offs should be closely evaluated, and it is prudent to review the chart and re-discuss the issues with the patient and family to ensure all thoughts and concerns are addressed.

Frequent emergency department utilizers and non-compliant patients create biases

Seeing the same patient time and again lulls emergency physicians and other providers into a state of complacency. It is important to regard every patient as though he or she may have an emergency. Indeed, the evaluation for a patient who returns to the emergency department should have increased attention to detail to ensure he or she doesn’t have a serious missed condition.

It is prudent to demonstrate additional concern for the well-being of the returning patient, including consulting social services and arranging for care or discussing substance abuse options. If you discharge the patient, it is advisable to assess suicidality and competence, and to make sufficient arrangements with family members and friends so that the patient can be observed.

Appropriate documentation might have prevented this case from being filed in the first place. This would include documentation of the discussion of the family’s observation, refusing referral for substance abuse, and the offer of further observation. Although I rarely comment on physician behavior and I don’t have access to all of the depositions and court transcripts, blaming the patient is a challenging position to be in and should typically be left to expert witnesses.

In conclusion, this case’s verdict is probably off the spectrum. Rather than dwell on this case, it’s best to learn to prevent future patient harm and medical malpractice cases. These are my quick takeaways:

  1. For diabetics with substance abuse, possible liver disease, or psychosocial issues, be careful to address observation and the continuum of care.
  2. In a busy emergency department and during hand-offs, make sure all information is communicated and there is proper oversight of care.
  3. For non-compliant patients and those with frequent revisits or unexpected return visits, spend additional time exploring the reasons for non-compliance. Look for other medical issues and assess for competence, the ability to care for oneself, social and medical support, and even depression and suicidality.
  4. Always document your attention to the well-being of the patient.
  5. Try to not get in a situation where you are overtly disagreeing with other physicians in the case. That is the job of the experts and attorneys.

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