Shock rippled across emergency medicine when Peter Rosen, MD, arguably the father of the specialty, was censured by the American College of Emergency Physicians for violating its ethical guidelines on expert witness testimony. But no one was more stunned by the news than Dr. Rosen himself, who said his testimony was misrepresented and that ACEP's complaint review process was “unjust.”
The announcement was made in the September 2016 issue of ACEP Now without details, and ACEP declined to comment further. But in its public letter of censure dated July 25, 2016, obtained by Emergency Medicine News, ACEP said Dr. Rosen's deposition testimony against an ACEP member in a medical malpractice lawsuit, Johnson v. Omondi, was “false, misleading, and without medical foundation.” Dr. Rosen told EMN that his testimony was supported by medical evidence. “I think that what I testified to in the case was good medicine, and I would do it again,” Dr. Rosen said.
The case in question involved a 15-year-old high school football player named Shaquille Johnson, who had chest pain and was taken to the ED at Phoebe Putney Memorial Hospital in Albany, GA, on Dec. 29, 2007. (http://bit.ly/2lTjUie.) Shaquille had undergone arthroscopic knee surgery a week before, and his emergency physician, Price Paul Omondi, MD, gave him Toradol, and ordered an EKG and a chest x-ray. Interpreting Shaquille's test results as normal, Dr. Omondi diagnosed Shaquille with pleurisy and discharged him with a prescription for Naprosyn and instructions to return to the ED if his symptoms continued.
Two weeks later, Shaquille returned to the ED, where he died of bilateral pulmonary emboli, a condition that Dr. Omondi had ruled out based on Shaquille's age, normal vital signs, and positive reaction to Toradol. Shaquille's parents sued Dr. Omondi and Southwest Emergency Physicians for medical malpractice, and the case was dismissed twice until the Supreme Court of Georgia decided in 2013 that it should proceed to trial based on the depositions of Dr. Rosen and Steven Gabaeff, MD, witnesses for the Johnsons. Dr. Omondi shortly after that decided to settle the case; details of that were not released.
‘Out of Context’
It was William Sullivan, DO, JD, who brought the case to ACEP after reading about Dr. Omondi's case. He contacted Dr. Omondi's attorney to learn more, and submitted a 42-page complaint against Dr. Rosen to ACEP. Dr. Rosen said the examples that Dr. Sullivan and the board cited were taken out of context and not what he had said in his deposition.
Dr. Sullivan said Dr. Rosen had testified under oath that one to three percent of adolescent ED patients across the country have a pulmonary embolus. Dr. Rosen said he provided these numbers, but said he also added that the incidence varies depending on the population, the size of the ED, and the type of facility. According to the transcript, Dr. Rosen said Children's Hospital saw “many more [cases of PE] than just the routine emergency room.”
Dr. Rosen agreed in his testimony that PE is rare among pediatric patients, but the incidence should not be used as a justification for not investigating the possibility of PE in this patient. “[Shaquille]'s not just a child who's got chest pain; he is a patient who has lots of reasons why he might have a pulmonary embolism,” Dr. Rosen said.
Dr. Sullivan and ACEP also criticized Dr. Rosen for saying that an EKG, which Dr. Omondi ordered during Shaquille's ED visit, was useless care. Dr. Rosen later asserted that the “Q3T3” pattern in the EKG reading was a classic sign of PE. Dr. Sullivan said Dr. Rosen contradicted himself by saying that “these findings absolutely determine or are very suggestive of PE. On the other hand, he says, well, ‘The EKG doesn't matter.’” The transcript shows Dr. Rosen did say he didn't think an EKG was necessary in Shaquille's case, but also that Dr. Omondi did not interpret it correctly. Dr. Rosen said Shaquille had Q3 and T3 but not S1 patterns, which are not classic abnormalities of PE, but are consistent with left ventricular hypertrophy. Dr. Rosen said that can present with PE and its presence showed that the EKG was abnormal, and that had Dr. Omondi read it accurately, it should have prompted suspicion of PE and further workup.
Dr. Omondi, however, determined that the EKG was normal because he was looking for a cardiac problem that wasn't on the EKG, Dr. Rosen said in his testimony. “[Dr. Omondi] says in his notes these findings are very difficult to categorize and do not fit neatly into pulmonary etiology. And that's part of my problem with this case, is that an EKG was done, it was abnormal, it was misread as normal, and the thinking stopped as to what was going on with the young man that needed explanation,” he said.
“Maybe 20 years ago, we thought that the right heart changes ... would make a diagnosis of PE, but since then there have been enough studies done that showed that they are neither specific nor sensitive ... you can't rely on it,” Dr. Rosen said. “So rather than saying an EKG can help you make the diagnosis, [you say] it can show changes that are consistent with PE.”
Dr. Rosen's testimony on another diagnostic tool, D-dimer, also came under fire. Dr. Sullivan and ACEP said Dr. Rosen had said D-dimers were not elevated in post-surgical patients, and that that wasn't true. Dr. Rosen said that in his deposition, but also said the D-dimer released in any surgical patient was not “enough to trigger the definition of a positive D-dimer test in that laboratory.”
‘Not Fair to the Patient’
Dr. Rosen said he was not given the opportunity to question Dr. Sullivan or present his side of the case to ACEP's ethics committee or the board of directors. He said Dr. Sullivan testified during the ACEP hearing that he had not read all of Dr. Rosen's deposition, and based his arguments on the Georgia Supreme Court decision which did not contain Dr. Rosen's entire testimony. Dr. Rosen said the ACEP board members presiding over the case also said they did not read his complete deposition. “I ended up feeling that it didn't matter who I brought or what I said; they already made a decision to censure me, and I wasn't going to overturn it,” Dr. Rosen said.
Dr. Sullivan said he felt badly that Dr. Rosen was upset, but that he was not trying to “pick on” Dr. Rosen. “It's not about him. It's about his testimony.”
Dr. Rosen said ACEP's censure could deter other emergency physicians from testifying for plaintiffs in malpractice suits. “I think that it's wrong for ACEP to hold itself out as doctors never commit negligent practice,” he said. “What have I been doing for the last 45 years [but] trying to teach doctors how to practice better emergency medicine? And for them to say that whatever they do is OK is neither fair to the patient nor is it good for the society.”
Read a related interview with David Sklar, MD, about the difficulty of ED decision-making at http://bit.ly/EMNBreakingNews.
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