Male Child Survived Rollover MVC

You hear the report from the medics at a scene of a male child, “between the ages of 8 and 14, involved in a rollover MVC, child was unrestrained, initially A&O x 3 but now becoming progressively more lethargic, not intubated, coming in 5 minutes”. Now after you change your shorts, you remember your trusty Broselow tape. But as you shake the dust off of the tape, you also remember something one of your pediatric colleagues said about the Broselow tape not being accurate anymore. 

Review by Randy Young, MD
Column organized by Evan Schwarz, MD
Division of Emergency Medicine
Washington University

Citation: Nieman CT, Manacci CF, et al. Use of the Broselow tape may result in the underresuscitaiton of children. Acad Emerg Med. Oct 2006; 13(10):1011-01019.

You hear the report from the medics at a scene of a male child, “between the ages of 8 and 14, involved in a rollover MVC, child was unrestrained, initially A&O x 3 but now becoming progressively more lethargic, not intubated, coming in 5 minutes”. Now after you change your shorts, you remember your trusty Broselow tape. But as you shake the dust off of the tape, you also remember something one of your pediatric colleagues said about the Broselow tape not being accurate anymore.


Well your colleague might in fact be correct. The Broselow tape was originally developed in the 1970’s by Dr. Jim Broselow, a family practice physician to help approximate children’s weight based on the child’s height. The system was widely adopted in emergency departments throughout the country due to its simplicity of a color-coded system used to divide children into weight categories.

Over the past three decades the prevalence of obesity in American children has increased at an alarming rate. The National Health and Nutritional Examination Survey (NHANES) III suggested that approximately 14% of US children are considered obese by body mass index standards. Even though previous studies have showed that a length based system used during resuscitation is better than when no calculation aids are used, the authors of this article believe that with the increase in obesity in US children that the current Broselow tape based off of the NHANES III data might underestimate the actual weight of children. Therefore it would provide inaccurate information for resuscitation purposes.

The authors designed a cross-sectional, descriptive study comparing actual and Broselow tape predicted cohorts in children underless than 12 years of age. The subjects consisted of a suburban cohort from eastern and western suburbs of Cleveland, Ohio and an urban cohort from Metrohealth Medical Center in Cuyahoga County. The authors evaluated the accuracy of the 2002A Broselow tape based on the NHANES III data and the 1998 tape based on the NHANES II data against actual weight. The biggest changes from the 1998 tape to the 2002A tape were alterations in the “orange and green zones” usually associated with school-aged children.


In total there were over 7,000 children used to evaluate each of the 1998 and 2002A tapes against actual weight. The length-based system estimated within 10% of the child’s actual weight in 55.3% (2002A tape) and 60% (1998 tape) of the children. This was in comparison to the 80% accuracy of a parent’s estimation of their child’s weight. This inaccuracy of weight predicted accurate drug dosages based on Broselow tape only 55-60% of the time with the system more likely to underestimate rather than overestimate drug dosages. In fact both tapes were 2 to 5 times more likely to underestimate than to overestimate drug dosages. Although for drugs based on lean body mass this effect might be negligible, certain lipophilic drugs used in resuscitation (e.g. midazolam, amiodarone) could be significantly underdosed. The length based system of the Broselow tape has also been used to estimate endotracheal tube size. Comparing the Broselow tape and the alternative age based system, the Broselow tape was more likely to estimate a smaller tube size than the age-based guidelines.

While there currently is no perfect system available for pediatric resuscitation, many of us still rely on the Broselow tape. While the authors of this article do not dissuade the use of the length-based guidelines, they do caution on the blind use of the tape especially when a child is obviously obese and may fall in with the one-third of children whom the Broselow tape underestimated actual body weight in.

For the full article please go to




  1. As I have advocated before, the number one issue is to “follow the money.” The single biggest difference between our health care system and numerous other systems is the huge administrative expense of our multitude of health care plans. It is estimated that there are well over ONE MILLION workers in the United States in the administrative side of health care finances. Just consider how many people in any private practice office that are devoted only to finances!
    If there were a system based on single payer, this would eliminate most of this overhead so that many extra dollars could be devoted to actually paying for health care. This is such a potentially huge savings that it could pay to insure everyone, without adding a cent to the budget. Amounts saved (this could be substantial) could be returned to caregivers (especially physicians) as incentive bonuses for supporting the transition to a new system.

  2. Chris Louisell, M. D. on

    One issue that no one seems willing to talk about is frivilous use of the ER & 911 by people who do not pay anything for their health care. I’ve seen people having an MI drive themselves to the ER because they have no insurance . At the same time I’ve seen people on entitlement programs call 911 after stubbing their toe ! No linkage between use of a resource & payment for it, is a sure fire way to ensure massive waste and abuse. I firmly believe that everyone should have access to quality healthcare .However, there can be no ” rights ” without reponsibility.

  3. Scot DePue MD on

    I absolutely echo what Dr Louisell said. Between EMTALA and Medicaid, many people believe that ED care and transport are free, and thus, they devalue it to no worth whatsoever. I have seen parents call an ambulance for a 1 cm cut on the forehead of a child, then follow the ambulance in the family car. This system needs some personal accountability — a 20 dollar copay for an ambulance, 20 dollars for an ER visit, and 10 dollars for a prescription order (months worth) would be a good place to start.

  4. I have no doubt that I would have missed the diagnosis, and I’ve been practicing emergency medicine for over 30 years. This is just another one of those “there but for the grace of God go I” cases. It’s another confirmation of the old adages, that “”it’s better to be lucky than smart.”

    Both the work up and refer meet the Standard of Care in my community.

  5. Thomas H. Nelson, MD on

    By continuing to show Dr. UA his opportunities for improvement individually and thru peer review, he will improve or quit, and save you the grief of having to actually try to fire him. Make sure you stay strictly professional and document the counseling.

  6. William Wheeler on

    Thanks Dr. Henry for your article-good as always. I feel that one of the major contributors to our health care crisis is that people feel that they have the legar right to abuse their bodies and then have the legal right to live forever. They can smoke 3 packs a day for 30 years and then sue us when we miss their MI. What about a standard of care that patients need to live by? I feel that we need a health care system where your benefits are linked with how well you take care of yourself!

  7. Fred Kotalik, MD on

    Excellent thoughts and ideas by Dr Henry. I have been disgusted for years with the legal underpinnings of the practice of medicine. We over-test to a ridiculous/ludicrous point to “protect our ass” costing billions which has helped to dramatically escalate the cost of health care. Taking very small additional risk, we could treat and release many pts with little or no testing AND send home many pts, who are being put at risk by being hospitalized and further medicated and tested as they have little or no disease or no new disease. Under the current (and going nowhere mighty fast) medicolegal environment in the US of A, we can’t afford even a minimum of risk, so we will continue to CT Scan,MRI,US, get blood work, etc. even though the pt. doesn’t really need it.

  8. John D Lewis, MD, FACEP on

    Hopefully the winner of the current Presidential contest will appoint Dr Henry as Secretary of HHS!!

  9. Tom Scaletta, MD FAAEM on

    Three facets of emergency physician excellence are quality of care, patient/staff satisfaction and productivity. While I think quality and satisfaction are non-negotiable in top-tier ED, I am OK accepting a reasonable continuum regarding productivity. However, this only works when a meaningful productivity incentive is used.

    Consider an ED that pays and average of $160 per hour with an average patients per physician per hour of 2. Essentially, this means each case can be paid at $80. Then, doc seeing 1.5 patients-per-hour makes $120/h and a doc seeing 2.5 patients-per-hour makes $200/h.

    Actually, to prevent any cherry picking, I prefer linking the hourly rate linearly to charges billed per hour worked … again, with quality and satisfaction being non-negotiable. Now, a motivated and capable EP is happy working alongside Dr. UA. And, Dr. UA drifts to St. Elsewhere.

    Finally, to retain the best and brightest docs and to maximally satisfy the community, medical staff, and administrators, professional revenue must be fully returned to the docs after fair business expenses are deducted.

  10. I would have missed it-normal neuro, visual acuity-one would think retinal detachment, ‘visual’ migraine etc-but carotid dissection?
    The standard of care was met.
    To dissect the case a bit more-did the headache resolve? How severe was it. Did he have previous hx of such headaches? I rarely diagnose ppl with sinusitis based on CT scan thickening of sinuses-where I practice almost everyone has that without having clinical signs of sinusitis.

  11. Glenn Saperstein on

    With the information that has been provided, I would agree with Dr. Palmer, that this does in fact meet the Standard of Care, in my community as well.

  12. Tough case and bad luck with several red herrings. I would want a little more info such as the vision changes improved or resolved completely? How bad was the headache and what was the onset like? Runny nose and productive cough are a bit misleading. To diagnose sinusitis there is supposed to be 4 days of purulent drainage but here we have a CT scan with sphenoid sinusitis (there are still a few people left that think all those whould be admitted for IV antibiotics – I have seen some very severe complications from sphenoid sinusitis) and some other symptoms to go with it (including the type of headache the patient is experiencing). I doubt I would have picked this up or will if I see one now and I think the doc did due dilligence with CT scan, but this would have been one that made me nervous needing to invoke 2 diagnoses and without a better feeling about the answer. I would be an expert for the defense not the prosecution. The patient had a bad outcome but I don’t think it is the doctors fault.

  13. David Kaminski on

    I don’t know what I would have done within the ED with this patient, but I must admit – while reading the case presentation I was anticipating a carotid dissection. If a CVA with any ongoing symptoms is suspected, I will consider admission for further evaluation, including carotid U/S. I don’t usually order carotid U/S’s out of the ED itself. In turn, I think the standard of care was met, as the case presentation says there were no neurologic findings on exam and close follow up to address the leading issues on the diff. dx was arranged.

    My second ‘big issue’ question is: Even if faulted for an incomplete work up, why should the physician be liable? This issue of liability is strange to me. The physician didn’t cause the dissection, he didn’t start the process, he didn’t assault the man and do harm. He attempted to treat the patient with all good intention. Why should he be liable ? I know the law defines this, but I think the criteria for liability and the responsibility forced upon health care providers is inappropriate.

  14. Mike McCormack on

    I think a negative exam and a non contributory CT scan would have made it very difficult to diagnose this condition,The standard was met.

  15. Perumunda Sharma, MD. on

    This is a clear example to show that one always has to be vigilant for the ‘zebras’ that show up in the ED. A sharp sudden headache is mostly vascular in origin. Having said that, it is our responsibility to rule out life-threatening or severe debilitating conditions like SAH, other intra-cerebral bleeds, temporal arteritis, carotid dissection and aortic arch dissection that extends to the carotids or vertebrals.
    A carotid ultrasound should have been done before discharge.
    I had a similar case about two years ago in a 55 year old male. This person did not have visual symptoms but only sudden one-sided headache. I ordered an ultrasound and it did show the carotid dissection.

  16. Perumunda Sharma, MD. on

    Addendum to my comment.
    I understand that the patient was discharged with the diagnosis “sinusitis and acute visual changes”. We have to be extremely cautious to send someone out of the ED with such diagnosis. Sinusitis does not cause acute visual changes.

  17. alexander kuehl MD, MPH,FACEP, FACS, on

    Unless most every headache is going to get a carotid ultrasound , the standard was met.

    Dr Sharma’s comment about ruling out the truly bad possible diagnoses is well taken; that is why some risk management consultants recommend a spiral CT for any undiagnosed chest pain case.

  18. David Hoyer, MD FAAEM on

    Excellent article on how to manage this disease that we do see in the ED but is not well covered in the EM literature. Responding to the above Comment, the hard copy of EPMonthly had a photo of a penile ulcer that is currently missing from the above article.

  19. Christian mannsfeld on

    TIA = admission and further evaluation. I certainly would have missed the dissection, but it would have been revealed by the inpatient work-up.

  20. alexander kuehl MD, MPH,FACEP, FACS, on

    I totally agree that tax-adavantage employee based health care makes no sense and should be discouraged.

    What I believe few health planners are willing to accept is that PAs and NPs already are delivering much of the primary, emergency and urgent care in the rural US; and could do most of it nationwide at a third the cost and a quarter of the post high school education.

  21. Dennis Williams on

    He was seen by the ophthalmologist within ONE hour and deteriorated. In my facility you can’t get an inpatient ophth consult in one hour. He most certainly would have had the same outcome had he been admitted for “TIA” (don’t know how you come up with this diagnosis on initial presentation) vs. the appropriate referral. The d/c diagnosis was sinusitis “and” visual changes. Not sinusitis “with” visual changes. As Dr. Palmer stated, “but for the grace of God, there go I”. His visual changes were improving and negative neuro exam. The workup and referral met standard of care.

  22. Stephen Scherr on

    I think the standard of care was definitely met. The ED physician addressed the headache complaint appropriately, addressed his upper respiratory complaints appropriately, and got the patient excellent Ophthalmologic consultation in a reasonable time period to address the eye complaints. To suggest the converse that anyone presenting to the ED with those complaints (without other neurological findings or complaints)now requires a carotid ultrasound or CT angiogram with contrast as the “standard of care” is ridiculous. The patient’s lawsuit is a classic case of “retrospective scope” medicine, and we should not support or feed that mentality. I believe the care was exemplary and met or exceeded the standard of care in my community. I concur with Dr Palmer’s comments above. And as an aside, of the 4 opportunities I have had to push TPA in stroke, 2 of the 4 cases ended up being carotid artery dissections presenting with hemiplegia with ALOC or aphasia, with large MCA blood clots.

  23. Based on the information available, it appears that the standard of care was met. Looking back, the diagnosis of TIA is correct, and I agree would require admission, but I doubt that I would have made that diagnosis based on the info available at the time of presentation. Furthermore, the pateint deteriorated within an hour of discharge while at the ophthalmologist having his complaint investigated. The outcome was inevitable. If the CVA occurred 2-3 days later, and no follow up provided………perhaps a different story.

  24. Monday morning quarterbacking…..hate it!! But it is necessary evil in our profession. Like others that have written, I needed more inofrmation about this pt. However, having read this, I will be sure to listen carefully to the carotids of my future headache pt’s. But this is a Dx could still escape me and others. It dont think it is a reasonable standard to ultrasound every headache to catch this zebra…..but I promise it will now cross my mind. As a constant student of our profession, would love to know what people infinitely smarter than me suggest!!

  25. Evan Weinstein on

    I echo many of the commments previously made, but would add a couple. The first is that patients have to be put into the position to have to pay for the convience of being seen in the ED. Had a cold for a week, don’t feel like waiting for your PMD, fine come to the ED, but just like overnight shipping from LL Bean costs more, your choice to come to the ED should cost you. Also, hospitals, and ED administrators have to realize that we must protect the funds used to pay for the people who truly belong in the ED, thus it is ok to tell the pt “This is not an appropriate use of the ED”, or standing behind their docs who don’t think an emergency ultrasound is needed for the patient with years of pelvic pain, when the pt gets mad and writes a complaint letter.

  26. Evan Weinstein MD, EMTP, FAAEM on

    I think the key has to do with what the wine does for the Reader. If it is part of an enjoyable activity that leads to winding down, then it is fine. If the alcohol is used as a sedative, that is more of an issue. The question then is, can the sleep schedule or shift schedule be changed in such a way to lead to being more reliably tired?

  27. Jessica Racusin on

    The patient complained of a headache. This was worked up appropriately with a head CT. He had ophthalmic complaints and was seen with in ONE HOUR by an ophthalmologist. His neuro exam was normal and symptoms were improving, and he was stable. In determining liability isn’t part of it what a “reasonable physician” would do? This is certainly what any ED doc I know would do. We can’t be expected to do every single possible test for every possible rare diagnosis every single time. We already drive our health care costs up with defensive medicine. This patient recieved good care. And what if he had been admitted with a neuro consult? Would that have prevented him from having a bad outcome within ONE HOUR? Extremely doubtful. It was a tragic outcome but it’s nobody’s fault, unfortunately sometimes bad things happen with nobody to blame.

  28. David Milstein on

    Would like to know if any pulses were checked by the EP or ophthalmologist and whether there was any asymmetry noted in the palpated carotid pulses or if bruits were ever noted. We still check those things don’t we? Other than these questions, the EP met the standard of care. Even if the diagnosis had been made in the ED, the ischemic event would have occurred anyway as part of the natural history of this cf this patient’s condition. ‘S’ happens. Don’t smoke.

  29. I agree that the ED physician met the standard of care in this case. I probably would have missed this diagnosis too.

    That being said, I am reminded of several memorable patients I have diagnosed in the past with “zebra” conditions based upon the answer to a single intern-level question: “Is there anything different about this [headache/abdominal pain/back pain/etc.] from your typical [headaches/abdominal pains/back pains/etc.]? I had a young obese female patient with a history of migraines, chronic pain, and possible narcotic overuse, who came in to my ED with a headache that was “different” than her typical migraines (no “aura”, did not respond to typical migraine treatment either at home or in the ED, and was bilateral rather than unilateral). It turned out she had an acute parenchymal ICH – thankfully picked up on CT scan after she failed to respond to her typical ED treatment regimen. Perhaps the patient described in the case above would have raised more “red flags” if he had said, “This is the worst headache of my life!”, or “This is different from any headache I’ve ever had before”, or “This headache came on with a thunderclap!” A single additional question in the H&P has saved my bacon more than once!

  30. Based on the patient’s history and lack of findings on physical exam and imaging,
    the work-up that this patient received was appropriate. There was no mention of treatment and if the headache was completely resolved prior to leaving the ED but I assume the patient appeared well. I am impressed that the patient was seen so soon by an ophthalmologist! The question is: What else could the EP have done to diagnose the patient’s condition ? I do not think that there was enough evidence to justify an MRA at the time of his visit to his ED. Zebras will always continue to bafffle us in ED as medicine is not perfect. The ED in this situation practiced within the standard of care.

  31. Agree with Dr. Kuehl, as the case is presented, standard of care met (I assume the history and ROS was more complete than presented). The more common concern (an more likely) would be retinal detachment. The evaluation process was entirely appropriate (i.e., the next step is an Ophthalmology evaluation). Within the time-line presented, it would not be reasonable to expect any different outcome. The cause/effect was not related to his visit but due to the natural course of the disease.

    I would have likely missed this diagnosis as well. However, I think that if the patient did not have any eye pathology to explain his symptoms, and the clot dislodges a day later (for example), the case becomes less black and white (i.e., the outcome may have been more preventable, but that would require a more detailed review of the patient’s encounter).

  32. Robert J. Geller, D.O. on

    I agree that the standard of care was met. I am sure I would have missed this diagnosis as well. From the H&P I have no idea how you could diagnosis of a carotid dissection.

    Robert J. Geller, D.O.

  33. Jim Mensching, DO, FACEP, FAAEM on

    A true zebra given the presentation and final diagnosis. Truly, there but for the grace of God go I. Thankfully the standard of care is based not on doing the absolute best but what a reasonable ED physician would do under similar clinical circumstances. Remember that attempting to prove a negative can expose patients to unintended iatrogenic morbidities (i.e. radiation exposure, dye reaction, procedrual complications, etc.). Either way I’m sure the physician will be paying out on this one.

  34. Robert Oliver, M.D. on

    My colleague diagnosed a similar case in our ED 10 years ago because he had seen one at Stanford in residency.With only one eye working and normal funduscopic exam one thinks of cortical events, migraine and the like. Two separate sets of complaints-the URI and the headache with visul changes. The treatment of URI as described was not to our standard. The examination and documentation of neck pulses, temporal artery pulses may have saved a suit or found the dissection. the headache workup should also have included an LP for bleed to find the 2-8% whose CT’s are nondiagnostic. This patient was in the throes of his disease no matter how quickly he moved to U/S and TPA as it cannot be done in less than an hour.

  35. Ricardo Machado on

    I have seen 3 carotid dissections in my career and I wonder as time goes by how many I have missed. This is an elussive diagnosis and easily missed because of the none specific findings that may initially present with it. Not to mention the people that have minimal symptoms and never seek care and heal spontaneously. Without anterior neck pain or history of trauma it is a difficult diagnosis not to add the significant amount of people that present with high dissections that are not seen with ultrasound or even CT angio, have had 2 of those. The presentation was far from classic and the workup was reasonable. It was an unfortunate outcome but bad outcome does not equate malpractice. Standard of care was met.

  36. Tom Richardson, M.D. on

    I think 98% of ED docs would have done exactly what this doctor did, including me, and that is what you base a “standard” on, not what an academician who has time to look at every “zebra” such as “House” would do. If you find it, you look like a genious, but if you don’t, you shouldn’t be held to blame.

  37. David Shumway MD on

    I would have probably missed this one also. There are some questions I would have paid attention to. Why was the patient blind in his left eye? The patient seemed to be a vasculopath, so were there any carotid studies to review in the past? My sense of urgency for opthalomogic referral would also be within the timeline as in this case. To have provided documentation that carotid pulses and bruies were checked would strengthen the argument that all appropriate areas were examined. The finding of a sharp left sided headache with right vision symptoms does make me think vascular. Hopefully notes on the ED record would reflect the complexity of decision making and consideration of pertinant negatives. One could wonder whether giving TPA was the right thing to do, and how and when the diagnosis of carotid disection was actually made. Doing untrasounds within the ED is out of the question at my place. Standard of care met!

  38. Standard of care met. The emergent opthalmology referral was appropriate for the best tentative diagnosis. Acute bacterial sinusitis unlikely based on duration of sxs.

  39. Standard of Care met. ED MD did everything that could reasonably be expected at first visit and then some — ophthal eval w/i 1 hr!! Well done. Unfortunately pt had several comorbidities that clouded his sx at initial presentation. And IF further testing had been pursued while in the ED ie, cerebral MRA, it would not have affected outcome. The ED MD did what any ED MD would have done in similar circumstances. As is often the case, progression of disease w observation over time makes the cause more apparent.

  40. How many ischemic strokes present with headaches anyway? The money-grubbing family and lawyer met their standard, albeit low.

  41. Treating Physician on

    What is missing from the case presentation is that the patient had a history of the same visual disturbance several years ago and was seen by the same ophthamologist for this, and was told to return to his office immediately if it ever occurred again. His vision in that eye was 20/20 when I assessed him. During the trial, it was learned that he had had some sort of retinal edema that first time.

  42. Recently I had a similar case, but fortunately, it already had been suspected by the patient’s ophthalmologist and was sent to me for confirmation with emergency MRA. However, this case had distinct neuro signs including a constricted pupil and intermittent ptosis on the affected side.

    I would have to say that without neurological findings I would find it very difficult to make the diagnosis in the case presented. So I would have to say that the case presented met the standard of care.

  43. Critical care time includes: attending to the patient, reviewing labs, old records, family inquiry/discussion, consult discussion time with other physicians, giving orders and documenting the patient encounter.
    Scott, thanks for the excellent article on wound repair documentation. This was in this months EM Monthly. I think our group can improve critical care documentation. This may help.
    Bill D., I hope you don’t mind, I “borrowed” your copy of EM Monthly.

  44. T Clark Simpson MD on

    I have been in EM for over 10 years and the work-up was complete and thorough. If anything the work-up was exhaustive. I have no doubt that I would have missed this. The EP should not be held liable for this.

  45. money wasting paramedic on

    Dr. Henry says, “EMS is the largest hoax ever foisted on the American people.” Why is it that you wonder why we pay the costs for fire departments and EMS sytems to keep up their ACLS cards, you wonder why we go beyond the level of EMT-I and do more than carry a defibrillator? What about the costs for your RN’s to keep their ACLS cards current? Do ER RN’s need ACLS cards? No. We are at least out on the streets without a MD barking down our neck to push this or that so we need to know what the current standards are for ACLS. Stop wasting money on renewing your RN’s cards. We sometimes have long transport times, over 45 minutes to an hour until we get to an appropriate ER and practicing at a level above EMT-I is needed. We fly long distances with patients and they need a high level of care throughout transport- this is still under the EMS umbrella which according to you is “a so-called necessary healthcare expenditure.”

    Do the ER’s need to be stacked with high dollar MD’s in order to operate efficiently? No. PA’s are efficient enough to run an ER as long as they have an MD in the back office to sign off on their orders. Where is your data or study to say MD’s are an absolute necessity in an ER. You are nothing more than a corridor to the OR if it’s bad enough and we could save billions in high dollar salaries if we limit the unnecessary staff in ER’s. In fact, we are starting to take patients directly to the OR or cath lab instead of stopping in the ER because ER docs aren’t able to handle the case anyway.

    There are questions as to why people call EMS for stupid things like stubbed toes or little cuts to the forehead. There is nothing more frustrating than getting called at 3am for a person with a swollen toe but do you know what their reason is for calling us? The reason is because these 24 hour nurse lines you set up tell the patient that they need to call 911. That is why these people are following us in their car because they think they have to because the ER nurse lines make them think that is their only option. So take a minute to bash your ER systems before you bash those of us that are out here performing an honest, LOW paying duty that not a whole lot of people want to do. Choose your words carefully next time you decide to criticize the prehospital profession.

  46. tough case …I’m sure I’d of missed it too. truly a zebra….how many headaches do we see every day…one thing I do on all my headaches is listen for a bruit…was this done….so much pressure to make the diagnosis, avoid excessive radiation, contain costs…what’s a doc to do with such and unusual presentation…to make this diagnosis one would have to be very lucky on a currently asymptomatic patient. You certainly met the standard of care in my book…hope your documentation was good. The med mal situation in this country is so out of control it disgusts me, bad outcome does not equal malpractice in other countries, only in the US

  47. I just graduated residency in July. Started my first job in August. And I’m scared as heck that I’m going to get sued. Pt’s and families get upset by every little thing. It’s like I have malicious intentions or I’m out to get them. I can already see myself burning out and getting fed up with this crap! I think 99.9% of ER Physicians would have missed this diagnosis. I think 80% of ER physicians would NOT have gotten this patient to an ophthalmologist the SAME DAY! I agree that standard of care has been met. And yes unfortunately in the USA, a bad outcome or delayed dx or an unexpected event = malpractice law suit. As if our medcial infrastructure doesn’t have enough problems as it is.

  48. I think the ER docs met the standard of care. A few years ago, I went to the ER because I’d been suffering from a terrible headache. I had a lot of the symptoms this patient had. The doctor did a cat scan and said I had a major sinus infection. He gave me antibiotics, pain medication for the headache and sent me home. I’m still here, so I guess he was!

  49. Cheryl Vinikoor on

    Does your ED stock amps of D10? We have not found a source and pull it from the IV bag. Otherwise we are teaching D12.5 diluted from D25 except for infants. Thanks

  50. William Sullivan, DO JD on

    I don’t want to give away the answer before the verdict is published, although I think that everyone is right on with their comments.
    This was an actual case taken from a jury verdict reporter.
    It is amazing that the doctor sued in this case is here to comment on the case as well. Hopefully these comments show you that you are practicing good medicine, doc.
    I’d be happy to e-mail a copy of the case as it was reported in the jury verdict reports to anyone that is interested. Just e-mail me at
    By the way, if any of you have any plaintiff or defense expert depositions you’d like the EPM readers to weigh in on, e-mail them to me at the address above. I’ll read through them and summarize them and we’ll put them in print.
    Next month I’m going to look at a different aspect of how we determine the standard of care.

  51. Sherry Schaden on

    The rotating shifts are keeping your body clock in permanent disarray. Visit your doctor and get an Rx for Sonata. It’s very short-acting, safe for long-term use and works consistently. Give up the wine at bedtime. I knew someone whose wine after a shift turned into an 8 oz gulp of vodka.
    You could also sleep as best as you can without the wine and use Provigil. It’s approved for shift work but is very expensive.
    Your insomnia is caused by your shift work…it’s not your fault. It’s OK to take a medication if you cannot change your schedule.

  52. This was a weird Zebra !!! I think the doctor did a good job and met standard of care. I would have sent that patient home too, follow up ophthalmology in the same day… (that’s unheard in my side of the tracks), CT with normal brain, no mention of neck pain and non-focal neuro exam. This was a very low punch. Now, to complete the legality of this case. The doc had a “duty”, which was fulfilled with he saw the patient, there was not “bridge of that duty”. Then we have a negative outcome (“harm”), but when it comes to “causality”, the doc didn’t cause the disection and going even further, the plaintiff has now to prove that the embolic event was caused by the failure to diagnosed. The natural history of this disease is to dislodge a clot, even with a heparin drip.
    So, I don’t think is fare.

  53. While reading this post meaning you said for annuity is a real one. Annuity is a serious of periodic payments. If you’re a salaried physician, your income is an annuity, or if you’ve won the lottery. Well said!

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