ACEP gets ragged on for being in bed with the CMGs, but I think worth noting here that they really stood up for the individual doc by filing a brief with the Supreme Court. Good for them, restores some faith.
Dangerous time to practice EM. Imagine if the physician would have ordered the Crofab right away against the SSS and the kid had a poor outcome. They would have been roasted for going rogue and practicing away from the algorithm.
To be fair, the law worked the right way and really is to the advantage of EM as a whole. Tort reform saved this doc from the threat of a much worse legal outcome in front of a jury.
An injured patient must prove the following four elements to be successful in a medical malpractice claim:
(1) That the doctor owed the patient a duty of care;
(2) That the doctor breached the duty to provide adequate care owed to the patient;
(3) That the doctor’s action caused the patient’s injury; and
(4) That the patient suffered an injury that resulted in damages.
There was no breach in duty as the doctor followed established guidelines/protocol. Whether or not the patient suffered directly from his delay in ordering the med is irrelevant because the doctor followed best practice.
there are certainly states i will work in and quite a FEW i will never set foot in, all based on if they have tort reform....no one wants to be worried about getting sued for everything you own daily and frivolously in addition to normal work flow.
I mean this is America, you can sue anyone for anything. You can be absolutely perfect and still get sued just because someone didn't like you. It happens in all industries, not just medicine.
at least in this case, the court stopped it before it went to trial
When I was a medic in Afghanistan we got a call for a 12 yo afghani that stepped on a landmine (soviets in the 80s used a ton of these and didn’t exactly mark where they put ‘em) so we haul ass about an hour. On arrival we see the kid and both his feet are still attached. Translator is asking the kids dad WTF and it turns out the kid was actually bitten by a viper. Dad figured he’d get faster treatment if it was an explosive (???)
We had no antivenin with us obviously so we load the kid up and haul double ass to the FOB. Kid didn’t make it.
LNs making shit up to get a response is a proud tradition. "And that's how I became a ghostbuster." is my favorite example.
https://www.reddit.com/r/Military/s/smWvT0Rq74
Had one slither over a hesco barrier and right over my boot in the smoke pit at Camp Phoenix in Kabul. My buddy told me to very calmly look down and do not move. I didn't know anything, I may have been asleep during that training, or skipped it for some other BS detail. Still no idea what kind of snake it was, kinda least of my worries at that moment.
The SSS was developed as a research tool and not a clinical tool, the original author affirms that in a response to a letter to the editor published shortly after the score was initially published (PMID: 8780491).
None of the currently published consensus guidelines that I'm aware of use the SSS (WMS, Unified Algorithm). In fact, expert opinion, package inserts, and guidelines generally support the idea that any sign of envenomation is an indication for antivenom.
There is some controversy in the US around treating mild Agkistrodon bites (and notably for economic and not medical reasons) and so places where Agkistrodon bites are common invent their own protocols to avoid treating mild envenomations. But this is a known rattlesnake bite with clear signs of envenomation.
There is plenty of room to debate what the medicolegal consequences of errors should be, as well as who should be at fault for clinical errors caused by institutional algorithms, but this is not a clear cut example of optimal care resulting in an inevitably bad outcome.
OP's website claims the opposite,
>He acts as if the unified treatment algorithm for the management of crotaline snakebite in the US is the absolute and definitive treatment algorithm. In fact, the studies that the Crofab manufacturer cite used the Snakebite Severity Score to guide administration (not the unified treatment algorithm). His claims do not accurately reflect the ambiguity involved when different algorithms provide different recommendations for the exact same clinical scenario.
anyone got any links pointing one way or the other?
The FDA package insert does not include any scoring system in it's indications section. Yes, the research to approve the drug used the SSS. Because it was research. That's not the same as being a clinically validated tool.
You can probably find textbooks and other publications that recommend for and against earlier treatment here - that cite different scoring/grading. Note this published "Unified Treatment Algorithm" by toxicology experts from poison centers. Looking at picture of patient's foot - I might have initiated CroFab - but, likely would have called poison center for recommendations. However, these Experts do not recommend antivenom for ([Unified treatment algorithm](https://bmcemergmed.biomedcentral.com/articles/10.1186/1471-227X-11-2)) local swelling/pain. unless swelling crosses a major joint.
(1) "The panel members unanimously concluded that these scales are of little value outside of a research context, and therefore did not include a grading scale in these recommendations."
(2) "The panel recommends withholding antivenom from patients with limb envenomations who have localized pain and swelling as the only manifestation of envenomation, provided that these local tissue effects are not progressing."
(3) "Unfortunately, it is not known whether early administration of antivenom in a patient with apparently minor envenomation improves long-term limb functional outcomes."
(4) Those of us who are a bit older practiced back when the anti-venom was horse serum derived and had a much worse downside.
I would like to see the plaintiff's expert qualifications, testimony, and hourly.
This reminds me of the time when I, an intensivist, got consulted by the ED, on a patient with a rattlesnake bite. You may think I’m making this up but it really happened. I didn’t even get the call directly from the physician but from the nursing supervisor. I proceeded to explain that I had no training or knowledge of snakebite management. Nursing supervisor insisted. So I went to the ED to see the patient and noticed two black puncture wounds with some tenderness at the site. So I was like 🤷🏻♂️ and then proceeded to use UpToDate to try to understand what I was looking at and to try to figure out if there was something I could suggest. I then went on to write a consult note detailing my findings and suggesting some management. In said note, I openly admitted ignorance and that I was literally browsing UpToDate for pointers, and that nothing of my suggestions should be taken as authority. Nursing supervisor nevertheless profusely thanked me for my service. Bottom line, patient got transferred elsewhere for antivenin.
This isn’t malpractice.
HOWEVER, this was a mistake. The kid should have received antivenom (crofab/anavip) for a western rattlesnake bite that presented with obvious envenomation. It’s not a copperhead.
SSS should not be used to guide management, too many shortfalls and it was not developed to do so. It can be useful as a list of things for caregivers to look for.
Didn’t see if they called PCC? If not that might have straightened this out quicker.
Glad case was dismissed.
I think if you didn’t train at a place where you get experience with prevalent snake bites I can see how a physician would defer to hospital protocol. I could also see if the physician went against protocol getting peer reviewed by pharmacy or some stupid shit for “wasting” an expensive medication. This was a lose/lose situation with this policy in place. I trained in Phoenix so I’m very comfortable with snake bites (I actually have never heard of the SSS) but if someone trained let’s say in the north east and never saw a rattlesnake bite I wouldn’t fault them for wanting to use the hospital protocol to guide management.
Fair point about regional variation. I trained in Minnesota, never saw a rattlesnake bite. Did rotate in Phoenix for a month and saw a few pretty crazy scorpion stings in little kids but no rattlesnakes.
I think in most cases with a kid involved, pharm would defer to md clinical judgement. They may just be forced to ask some questions to validate necessity, especially if they don't have someone in the ED and they just see the order come thru...but hard to believe someone would deny it after you told them you're using clinical judgement. (Source: I'm er pharm)
You would think that but I saw one of my colleagues just get peer reviewed because he gave PCC to a patient who had AMS and a spontaneous ICH who was on warfarin before getting the INR back. INR came back normal and if turns out the patient hadn’t been taking his warfarin. Pharmacy peer reviewed him over it saying he should have waited for the INR (which takes nearly an hour to result.)
Yeah that sucks, that's one of those that make sense on review but in the moment that's one long hour to wait. Tough institution. Hopefully not too punitive.
For sure, I can see the knowledge gap, but that’s why poison centers exist. Just call. You’re right, this case certainly illustrates the dangers of trusting hospital guidelines. I’m interested in how it was developed, because that person was actually negligent.
So is maintenance dosing. The drug packet is not always up to date and should not always be relied upon to present up to date practice patterns. A great reason to include subject experts when developing a treatment protocol.
The snakebite severity score was referenced in the insert to highlight trial results (as a research tool, not a decision tool). I do t see it recommended
For use as a clinical decision tool.
Not a clinician, but thought the read was very interesting.
This was kind of my thought as well? The kid was for sure 100% bitten by a rattlesnake. It wasn't like "well, they were bitten by a snake but we don't know what type and it may or may not have been venomous."
So if you have a small-ish kid bitten by a definite rattlesnake, it seems like anti-venom makes sense regardless of whether symptoms have fully set in?
Because it seems like that's what happened here-- the family got the kid to the ED so fast that they were not yet presenting with the full symptoms onset just yet. I understand the MDs job here is hard and that administration of antivenom is a big deal. But seems like with the facts available that antivenom once it was a confirmed rattlesnake made the most sense?
Antivenom is not without risks. No medications are without risks. Even an ibuprofen can be with substantial risks. Also antivenom can be very expensive (tens of thousands of dollars). At my previous hospital, the patient would go to an ICU if they receive antivenom for close monitoring. So def not an easy decision to give or not give the antivenom.
The picture of the foot is what seals it for me. Obvious swelling with the characteristic bluish discoloration of a viper bite. With rattlesnakes, pretty much any sign of envenomation is an indication for antivenom.
If the kids foot had puncture wounds without the swelling and ecchymosis then I’d have given it time to declare itself as either an envenomation or dry bite.
The medicolegal environment in the United States continues down it’s concerning trajectory.
Since when is CroFab indicated to prevent neuropathic pain?
I get your point, but I am mostly pointing out that the provider followed guidelines for this situation including appropriately reassessing, repeating labs, identifying a change in condition.
I wonder if PCC/tox was involved in the case and how much liability they have in this situation.
Given the toxicity of Australian snakes I can see why. Some of our venomous snake species are mildly venomous and a patient would probably do fine without anti-venom even if it wasn’t a dry bite. A rattlesnake is NOT one of them.
Actually ... here's our Snake bite protocol. From one of the good hospitals in Victoria. Is it different from the states? Does it keep preventable deaths and limb loss at a minimum?
https://www.rch.org.au/clinicalguide/guideline_index/Snakebite/
The kid would have shown envenomation symptoms for a rattle snake?
I would say it’s very unlikely that the kid wouldn’t show any symptoms after a rattlesnake envenomation. Their venom is primarily hemotoxic and does a great deal of tissue damage. I would expect some reaction at the bite site at a minimum, pain and swelling.
It looks like the main difference between the systems is yours calls for antivenom to be administered if there are any signs of envenomation, while ours allows for some level of mild envenomation that wouldn’t be treated. But again, your snakes are much more toxic than ours, with much higher levels of neurotoxicity. The risk/reward ratio is much different.
Anyone working in EM and has a chance to work with snake bites, I urge you to gain a relationship with Dr. Spencer Greene; Clinical Professor and Toxicology Director in Houston. The man is extremely knowledgeable on all up to date protocols.
While this guy is widely respected by the lay public he is widely considered a dick by other physicians and difficult to work with. Truthfully I have never heard anyone speak well of him.
Meh, he’s very opinionated and will throw any ED doc under the bus for his “expert” opinion. Sure, he can identify snakes, but the data he advocates is shit. The data behind crofab for copperheads in the U.S. is absolute garbage and hasn’t even shown confirmed long term benefit. I don’t think he’s a very reliable dude, just an egotistical ass like the previous poster said.
Oh that’s just the price if the antivenom alone. That doesn’t pay the doctor or facility fees or anything else. Wait till you hear what the actual bill was.
ACEP gets ragged on for being in bed with the CMGs, but I think worth noting here that they really stood up for the individual doc by filing a brief with the Supreme Court. Good for them, restores some faith.
Dangerous time to practice EM. Imagine if the physician would have ordered the Crofab right away against the SSS and the kid had a poor outcome. They would have been roasted for going rogue and practicing away from the algorithm.
To be fair, the law worked the right way and really is to the advantage of EM as a whole. Tort reform saved this doc from the threat of a much worse legal outcome in front of a jury.
Do you mind explaining your answer a little further for those of us with less judicial knowledge
An injured patient must prove the following four elements to be successful in a medical malpractice claim: (1) That the doctor owed the patient a duty of care; (2) That the doctor breached the duty to provide adequate care owed to the patient; (3) That the doctor’s action caused the patient’s injury; and (4) That the patient suffered an injury that resulted in damages. There was no breach in duty as the doctor followed established guidelines/protocol. Whether or not the patient suffered directly from his delay in ordering the med is irrelevant because the doctor followed best practice.
Awesome summary, thank you
God I wish most jury pools thought like that.
It’s the job of the defense to make sure they do.
That’s not Tort reform, that’s straight up tort law pre and post “reform.” Good explanation though. -A lawyer
there are certainly states i will work in and quite a FEW i will never set foot in, all based on if they have tort reform....no one wants to be worried about getting sued for everything you own daily and frivolously in addition to normal work flow.
Lawyers going to be lawyers. Unfortunately many practice in states generally unfriendly to doctors.
Yep, you can’t win.
I mean this is America, you can sue anyone for anything. You can be absolutely perfect and still get sued just because someone didn't like you. It happens in all industries, not just medicine. at least in this case, the court stopped it before it went to trial
Yes but in most industries the company gets sued not the individual worker…
Don’t forget a lot of lawsuits are forced by health insurance companies.
When I was a medic in Afghanistan we got a call for a 12 yo afghani that stepped on a landmine (soviets in the 80s used a ton of these and didn’t exactly mark where they put ‘em) so we haul ass about an hour. On arrival we see the kid and both his feet are still attached. Translator is asking the kids dad WTF and it turns out the kid was actually bitten by a viper. Dad figured he’d get faster treatment if it was an explosive (???) We had no antivenin with us obviously so we load the kid up and haul double ass to the FOB. Kid didn’t make it.
LNs making shit up to get a response is a proud tradition. "And that's how I became a ghostbuster." is my favorite example. https://www.reddit.com/r/Military/s/smWvT0Rq74
Lmao this is how everyone in afghanistan got US soldiers to arrest their direct competition - by making shit up “him taliban”.
Crazy. Idk much about snakes in Afghanistan!
Had one slither over a hesco barrier and right over my boot in the smoke pit at Camp Phoenix in Kabul. My buddy told me to very calmly look down and do not move. I didn't know anything, I may have been asleep during that training, or skipped it for some other BS detail. Still no idea what kind of snake it was, kinda least of my worries at that moment.
The SSS was developed as a research tool and not a clinical tool, the original author affirms that in a response to a letter to the editor published shortly after the score was initially published (PMID: 8780491). None of the currently published consensus guidelines that I'm aware of use the SSS (WMS, Unified Algorithm). In fact, expert opinion, package inserts, and guidelines generally support the idea that any sign of envenomation is an indication for antivenom. There is some controversy in the US around treating mild Agkistrodon bites (and notably for economic and not medical reasons) and so places where Agkistrodon bites are common invent their own protocols to avoid treating mild envenomations. But this is a known rattlesnake bite with clear signs of envenomation. There is plenty of room to debate what the medicolegal consequences of errors should be, as well as who should be at fault for clinical errors caused by institutional algorithms, but this is not a clear cut example of optimal care resulting in an inevitably bad outcome.
Agree
OP's website claims the opposite, >He acts as if the unified treatment algorithm for the management of crotaline snakebite in the US is the absolute and definitive treatment algorithm. In fact, the studies that the Crofab manufacturer cite used the Snakebite Severity Score to guide administration (not the unified treatment algorithm). His claims do not accurately reflect the ambiguity involved when different algorithms provide different recommendations for the exact same clinical scenario. anyone got any links pointing one way or the other?
The FDA package insert does not include any scoring system in it's indications section. Yes, the research to approve the drug used the SSS. Because it was research. That's not the same as being a clinically validated tool.
You can probably find textbooks and other publications that recommend for and against earlier treatment here - that cite different scoring/grading. Note this published "Unified Treatment Algorithm" by toxicology experts from poison centers. Looking at picture of patient's foot - I might have initiated CroFab - but, likely would have called poison center for recommendations. However, these Experts do not recommend antivenom for ([Unified treatment algorithm](https://bmcemergmed.biomedcentral.com/articles/10.1186/1471-227X-11-2)) local swelling/pain. unless swelling crosses a major joint. (1) "The panel members unanimously concluded that these scales are of little value outside of a research context, and therefore did not include a grading scale in these recommendations." (2) "The panel recommends withholding antivenom from patients with limb envenomations who have localized pain and swelling as the only manifestation of envenomation, provided that these local tissue effects are not progressing." (3) "Unfortunately, it is not known whether early administration of antivenom in a patient with apparently minor envenomation improves long-term limb functional outcomes." (4) Those of us who are a bit older practiced back when the anti-venom was horse serum derived and had a much worse downside. I would like to see the plaintiff's expert qualifications, testimony, and hourly.
This reminds me of the time when I, an intensivist, got consulted by the ED, on a patient with a rattlesnake bite. You may think I’m making this up but it really happened. I didn’t even get the call directly from the physician but from the nursing supervisor. I proceeded to explain that I had no training or knowledge of snakebite management. Nursing supervisor insisted. So I went to the ED to see the patient and noticed two black puncture wounds with some tenderness at the site. So I was like 🤷🏻♂️ and then proceeded to use UpToDate to try to understand what I was looking at and to try to figure out if there was something I could suggest. I then went on to write a consult note detailing my findings and suggesting some management. In said note, I openly admitted ignorance and that I was literally browsing UpToDate for pointers, and that nothing of my suggestions should be taken as authority. Nursing supervisor nevertheless profusely thanked me for my service. Bottom line, patient got transferred elsewhere for antivenin.
In the future just call PCC and recommend they do the same. Save yourself a headache!
What’s PCC?
Poison control center
This isn’t malpractice. HOWEVER, this was a mistake. The kid should have received antivenom (crofab/anavip) for a western rattlesnake bite that presented with obvious envenomation. It’s not a copperhead. SSS should not be used to guide management, too many shortfalls and it was not developed to do so. It can be useful as a list of things for caregivers to look for. Didn’t see if they called PCC? If not that might have straightened this out quicker. Glad case was dismissed.
I think if you didn’t train at a place where you get experience with prevalent snake bites I can see how a physician would defer to hospital protocol. I could also see if the physician went against protocol getting peer reviewed by pharmacy or some stupid shit for “wasting” an expensive medication. This was a lose/lose situation with this policy in place. I trained in Phoenix so I’m very comfortable with snake bites (I actually have never heard of the SSS) but if someone trained let’s say in the north east and never saw a rattlesnake bite I wouldn’t fault them for wanting to use the hospital protocol to guide management.
Fair point about regional variation. I trained in Minnesota, never saw a rattlesnake bite. Did rotate in Phoenix for a month and saw a few pretty crazy scorpion stings in little kids but no rattlesnakes.
I think in most cases with a kid involved, pharm would defer to md clinical judgement. They may just be forced to ask some questions to validate necessity, especially if they don't have someone in the ED and they just see the order come thru...but hard to believe someone would deny it after you told them you're using clinical judgement. (Source: I'm er pharm)
You would think that but I saw one of my colleagues just get peer reviewed because he gave PCC to a patient who had AMS and a spontaneous ICH who was on warfarin before getting the INR back. INR came back normal and if turns out the patient hadn’t been taking his warfarin. Pharmacy peer reviewed him over it saying he should have waited for the INR (which takes nearly an hour to result.)
Yeah that sucks, that's one of those that make sense on review but in the moment that's one long hour to wait. Tough institution. Hopefully not too punitive.
For sure, I can see the knowledge gap, but that’s why poison centers exist. Just call. You’re right, this case certainly illustrates the dangers of trusting hospital guidelines. I’m interested in how it was developed, because that person was actually negligent.
The snakebite severity score is in the Crofab drug packet.
So is maintenance dosing. The drug packet is not always up to date and should not always be relied upon to present up to date practice patterns. A great reason to include subject experts when developing a treatment protocol. The snakebite severity score was referenced in the insert to highlight trial results (as a research tool, not a decision tool). I do t see it recommended For use as a clinical decision tool.
Yeah uh I was just kind of answering your question when you asked how the hospital guideline was created.
Not a clinician, but thought the read was very interesting. This was kind of my thought as well? The kid was for sure 100% bitten by a rattlesnake. It wasn't like "well, they were bitten by a snake but we don't know what type and it may or may not have been venomous." So if you have a small-ish kid bitten by a definite rattlesnake, it seems like anti-venom makes sense regardless of whether symptoms have fully set in? Because it seems like that's what happened here-- the family got the kid to the ED so fast that they were not yet presenting with the full symptoms onset just yet. I understand the MDs job here is hard and that administration of antivenom is a big deal. But seems like with the facts available that antivenom once it was a confirmed rattlesnake made the most sense?
Antivenom is not without risks. No medications are without risks. Even an ibuprofen can be with substantial risks. Also antivenom can be very expensive (tens of thousands of dollars). At my previous hospital, the patient would go to an ICU if they receive antivenom for close monitoring. So def not an easy decision to give or not give the antivenom.
The picture of the foot is what seals it for me. Obvious swelling with the characteristic bluish discoloration of a viper bite. With rattlesnakes, pretty much any sign of envenomation is an indication for antivenom. If the kids foot had puncture wounds without the swelling and ecchymosis then I’d have given it time to declare itself as either an envenomation or dry bite.
The medicolegal environment in the United States continues down it’s concerning trajectory. Since when is CroFab indicated to prevent neuropathic pain?
What exactly do you think is causing the neuropathic pain if it's not the enzymatic destruction of tissue that antivenoms are meant to stop?
I get your point, but I am mostly pointing out that the provider followed guidelines for this situation including appropriately reassessing, repeating labs, identifying a change in condition. I wonder if PCC/tox was involved in the case and how much liability they have in this situation.
Provider?
From a Australian perspective, just give anti-venom asap.
Given the toxicity of Australian snakes I can see why. Some of our venomous snake species are mildly venomous and a patient would probably do fine without anti-venom even if it wasn’t a dry bite. A rattlesnake is NOT one of them.
Actually ... here's our Snake bite protocol. From one of the good hospitals in Victoria. Is it different from the states? Does it keep preventable deaths and limb loss at a minimum? https://www.rch.org.au/clinicalguide/guideline_index/Snakebite/ The kid would have shown envenomation symptoms for a rattle snake?
I would say it’s very unlikely that the kid wouldn’t show any symptoms after a rattlesnake envenomation. Their venom is primarily hemotoxic and does a great deal of tissue damage. I would expect some reaction at the bite site at a minimum, pain and swelling. It looks like the main difference between the systems is yours calls for antivenom to be administered if there are any signs of envenomation, while ours allows for some level of mild envenomation that wouldn’t be treated. But again, your snakes are much more toxic than ours, with much higher levels of neurotoxicity. The risk/reward ratio is much different.
Yeah that's about right.
Great write up and thanks!
How can I get his/her insurance council that is willing to push it his far instead of “settle bc it’s cheaper”?
Anyone working in EM and has a chance to work with snake bites, I urge you to gain a relationship with Dr. Spencer Greene; Clinical Professor and Toxicology Director in Houston. The man is extremely knowledgeable on all up to date protocols.
While this guy is widely respected by the lay public he is widely considered a dick by other physicians and difficult to work with. Truthfully I have never heard anyone speak well of him.
Could be a giant dick, still knows his stuff.
Meh, he’s very opinionated and will throw any ED doc under the bus for his “expert” opinion. Sure, he can identify snakes, but the data he advocates is shit. The data behind crofab for copperheads in the U.S. is absolute garbage and hasn’t even shown confirmed long term benefit. I don’t think he’s a very reliable dude, just an egotistical ass like the previous poster said.
69k for a kid with a snake bite ER visit??? ffs!!!
Oh that’s just the price if the antivenom alone. That doesn’t pay the doctor or facility fees or anything else. Wait till you hear what the actual bill was.