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PED-EM-L  June 1998

PED-EM-L June 1998

Subject:

Re: CT before LP in meningitis??? So what's your point, Richard?

From:

"Bartucci, Richard" <[log in to unmask]>

Reply-To:

Bartucci, Richard

Date:

Tue, 23 Jun 1998 19:06:00 +0200

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (207 lines)

        Counselor, my "perseverative" point is that even when an adequate
history is taken and a thorough physical examination is performed, the
physician attending upon such a case (and the institution in which such a
case is attended) still stands considerable risk of getting slammed with a
lawsuit should there be an adverse outcome, predicated chiefly on the same
principle whereby lottery tickets are purchased.
 
        Under the tort law conditions which presently obtain, the outlay of
a small amount of time and expense buys the plaintiff (and his attorney) a
chance for a pretty big payoff.  Not much expenditure, and much to win.  So
why not play your favorite number and see what happens?
 
        And as most of us who have been the targets of medical malpractice
suits can tell you, the fact that most such cases are decided in favor of
the physician defendant is just about no comfort whatsoever.  To paraphrase
the Duke of Wellington, there is nothing so terrible as a lawsuit
unsuccessfully defended except one in which the defendant has "won."
 
        "Rant?" "Rave?" "Perseverate?"  Counselor, awaken and inhale the
scent of the C-4 being packed around the foundations of civil society.  Even
professional politicians -- the most disconnected-from-reality cadre in our
population -- are beginning to perceive the need to roll back the last
half-century's worth of tort law tumescence in our legal system, and there
appears to be some development of tolerance to the anaesthetic effects of
the increasingly larger campaign contributions from America's trial lawyers.
 
 
        Pending genuine reform of liability law in the United States,
however, there must always be maintained the heightened sensitivity to the
fact that we are dealing with malignant litigiousness as well as the more
immediate problems of morbidity and mortality in every case we handle.
 
        Personally, I'd have to say that I *wouldn't* order a cranial CT
scan before performing a diagnostic puncture in the sort of case presently
under discussion (unless, of course, findings in history and physical
examination led me to believe that such a study was indicated -- at which
point I'd almost certainly be on the horn to the youngster's attending
physician, because the kid's either going to be admitted or get himself a
helicopter ride to one of the children's hospitals in Philadelphia).   This
notwithstanding, I'd certainly be feeling a cold draft blowing down the back
of my neck as I undertook the tap, no matter *how* benign the H&P might've
been.
 
        Like it or not, you boys with the "J.D." after your names have
managed to achieve the kind of broad "heightened sense of hazard" that
outfits like Abu Nidal and the Red Brigades could only dream of.  And if
those of us in the prey population are a little bit cranky about it, I guess
you'll just have to live with it.
 
                                -- Perseveratively,
                                   Rich Bartucci, D.O.
                                   Williamstown, N.J.
 ----------
From: Douglas Ragland
To: Multiple recipients of list PED-EM-L
Subject: Re: CT before LP in meningitis??? So what's your point, Richard?
Date: Monday, June 22, 1998 6:23PM
 
Richard - I am aware of two patients at my institution who herniated their
brain stems and died after undergoing LP for complaints of fever, headache
and vomiting.  One patient -- 3 years old -- had a history of VP shunt
placement as well as physical evidence of same on exam that was overlooked
by the doc.  The other, an adult, had focal neurologic findings (per nursing
staff) and no documented funduscopic exam.  The problem with the medical
care of these patients was NOT the failure to perform a CT first - it was
the failure to perform an adequate history and physical prior to LP.  Jay's
point is valid.
 
You can rant, rave and perseverate against the attorneys and the courts all
you want.  But you can't win in court if you allow the attorneys to make you
play by their rules.  If you do routine CT's before LP's, sooner or later
your going to have a bad outcome because of the delay in diagnosis and
treatment.  The same attorney who sues me for failing to perform a pre-LP CT
will sue you for doing one and delaying Dx/Tx! Personally, I'll take my
chances in court with a prompt LP after a careful (and carefully documented)
history and physical over a routine "pre-tap" CT any day!  Make the
attorneys play by your rules -- you won't always win, but you lose a lot
less often.
 
Douglas W. Ragland, M.D., J.D.
Department of Emergency Medicine
John C. Lincoln - North Mountain
E-mail: [log in to unmask]
Alternate E-mail:[log in to unmask]
 
 
 
 
 
 
 ------------------ Reply Separator --------------------
Originally From: "Bartucci, Richard" <[log in to unmask]>
Subject:  Re: CT before LP in meningitis???
Date: 06/22/98 12:39pm
 
 
Jay:
        Regrettably, what matters more in these circumstances tends to
be:
 
a) What a tort law judge is willing to admit into consideration in a
professional liability case,
 
b) What a member of the plaintiff's bar is likely to put before a jury,
and
 
c) What a juror is likely to excuse as a basis for his/her determination
to "stick it to the insurance company" when a child has sustained an
adverse outcome that can be even remotely and tenuously connected to a
diagnostic procedure.
 
        Inasmuch as these are all plotted along a line asymptotic with
infinity, how the hell do you dare say that something as "irresponsibly
minimal" as a careful history and a scrupulous physical examination be
relied upon when a clinician is trying to determine whether or not to
shove a needle into a child's intrathecal space?
 
        In the United States (much as I must bite back against the bile
that rises in my throat when I admit it), it's not sufficient to act as
if we are judged by a jury of our peers.  We must undertake to practice
medicine in a fog of "junk science," always aware of the fact that those
who'll be impanelled to judge the fitness of our decisions are actually
going to be a pack of befuddled idiots lacking even the intelligence
required to get out of jury duty.
 
        Life sucks, and the vigor of the suction keeps getting ratcheted
up.
 
                                -- Rich Bartucci, D.O.
                                   Williamstown, N.J.
 ----------
From: Jay Pershad, M.D.
To: Multiple recipients of list PED-EM-L
Subject: CT before LP in meningitis???
Date: Sunday, June 21, 1998 5:39PM
 
Karen Farbman wrote:
Does anyone routinely obtain a heat CT on teen-agers before the LP, as
our
adult
ED colleagues do?  Outlined in Annals of Emer Med this year is a
headache
CPG
which lists this as a guideline over age 14, I believe.
 -
 
Karen:
 
No, I personally don't get a CT iff:
 - No focal deficits on neurologic exam
 - Sharp discs
 - No altered sensorium
 - No suspicion of a coagulopathy or IC bleed or h/s/o SAH
 
All cases of meningitis have some elevation of their ICP (which causes
their
HA, emesis photophobia etc). Whether their CT shows edema or not, by
definition their opening pressures are going to be elevated! What one is
really determining with a CT is any focal pathology with "midline shift"
or
significant ICP elevation from diffuse cytotoxic cerebral edema (as in
fulminant meningitis). Both these situations, I believe, can be
discerned
with a careful neurologic examination and using the screening criteria I
mentioned above.
 
I am not aware, at least from the recent pediatric literature, any case
of
post mortem proven herniation following an LP in a patient with
suspected
meningitis who was clinically awake, without FND or papilledema.
Moreover,
was the herniation from meningitis or the LP???  I will have to check
the
older literature. Is there a threshold ICP beyond which the risk of
herniation increases?????
 
Which issue of Annals are you referring to? I think we will be getting a
whole lot of CT's if these CPG's are promulgated!!! My intuition makes
me
disagree with this CPG.
 
Hope this helps. Will report back if I find something on a literature
search.
Jay Pershad, M.D.
"We care for wee folks"
 
 
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The URL for the PED-EM-L Web Page is:
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