How To Blow Your Defense

Abstract

To the EditorI was recently consulted by a medical malpractice attorney who asked for assistance in the defense of his client, a board-certified pulmonologist who had been managing a patient with very difficult steroid-dependent asthma. The patient also smoked cigarettes. The man, age 41, had acquired aseptic necrosis in both femoral heads requiring total hip replacements.The patient had suffered from asthma since the age of 6 months. He had had several hospitalizations for asthma and frequent trips to the emergency department for life-threatening attacks. He had been appropriately managed by this pulmonologist, with the use of inhaled short-acting as well as long-acting agonists, inhaled corticosteroids, leukotriene modifiers and, at times, bursts of systemic steroids to deal with exacerbations of asthma and/or associated acute and chronic sinusitis.The major issue in the plaintiff’s strategy was the fact that this pulmonologist had never done spirometry at any time during the management of this patient. Accordingly, the plaintiff argued that the patient never had asthma, which was one of the contentions of the medical expert hired by the plaintiff, also a board-certified pulmonologist. Fortunately, however, numerous measurements of peak flow during exacerbations, which demonstrated increases from low values up to the “personal best” level of approximately 450 to 500 L/min while in remission following corticosteroid treatment had been recorded. But why a simple spirogram was not done by the pulmonologist, as well as other pulmonary function tests, is beyond me. It certainly would have helped in this physician’s defense. Later, an allergist did perform spirometry, which showed severe airflow obstruction and air trapping with a normal diffusion test result.This is the fourth or fifth time I have been asked to defend a board-certified pulmonologist or internist in a similar malpractice action. The simple use of spirometry would have made the defense much easier.John Hutchinson introduced spirometry in 1846.1Hutchinson J On the capacity of the lungs, and on the respiratory functions, with a view of establishing a precise and easy method of detecting disease by the spirometer.Medico-Chirurgical Transactions (London). 1846; 29: 137-161Crossref PubMed Google Scholar Some time ago, noted physiologist Joseph Milic-Emili wrote on 150 years of blowing, citing the work of Hutchinson, who coined the term vital capacity, and Tiffeneau of Paris, who added the timed vital capacity (ie, FEV1) to spirometry.2Milic-Emilie J Marazzini L D'Angelo E 150 years of blowing: since John Hutchinson.Can Respir J. 1997; 4: 239-245Crossref Scopus (6) Google ScholarToday, the National Lung Health Education Program recommends spirometry for all smokers ≥ 45 years old and anyone with dyspnea on exertion, chronic cough, mucus hypersecretion, or wheeze.3Ferguson GT Enright PL Buist AS et al.Office spirometry for lung health assessment in adults: a consensus statement from the National Lung Health Education Program.Chest. 2000; 117: 1146-1161Abstract Full Text Full Text PDF PubMed Scopus (397) Google Scholar Certainly the patient had all of these. The National Asthma Education Program has recommended spirometry in the evaluation of asthmatics for more than a decade.4National Asthma Education Program Expert panel report: guidelines for the diagnosis and management of asthma. National Institutes of Health, Bethesda, MD1991Google Scholar Thus, spirometry has to become the standard of care.Physicians who treat asthma, COPD, and other pulmonary disorders for which steroids may be required will be well advised to “blow their defense” in the form of doing spirometry in conjunction with the initial patient assessment and for documentation of responses to therapy.The issue of aseptic necrosis of the femoral head has been commented on for some time.5Richards JM Santiago SM Klaustermeyer WB Aseptic necrosis of the femoral head in corticosteroids-treated pulmonary disease.Arch Intern Med. 1980; 140: 1473-1475Crossref PubMed Scopus (17) Google Scholar,6Freeman HJ Kwan WC Brief report: non-corticosteroid-associated osteonecrosis of the femoral heads in two patients with inflammatory bowel disease.N Engl J Med. 1993; 329: 1314-1316Crossref PubMed Scopus (36) Google Scholar,7Mirza R Chang C Greenspan A et al.The pathogenesis of osteonecrosis and the relationships to corticosteroids.J Asthma. 1999; 36: 77-95Crossref PubMed Scopus (75) Google Scholar It is not clear, however, if aseptic necrosis in patients treated with corticosteroids represents a drug complication, a complication of the disease process, or both.6Freeman HJ Kwan WC Brief report: non-corticosteroid-associated osteonecrosis of the femoral heads in two patients with inflammatory bowel disease.N Engl J Med. 1993; 329: 1314-1316Crossref PubMed Scopus (36) Google Scholar,7Mirza R Chang C Greenspan A et al.The pathogenesis of osteonecrosis and the relationships to corticosteroids.J Asthma. 1999; 36: 77-95Crossref PubMed Scopus (75) Google Scholar It is interesting that in 1995, a Massachusetts Supreme Court ruling (Precort vs Frederic, 355 Mass 679) held that the risk of acquiring aseptic necrosis from long-term prednisone use was so negligible that the “informed consent” issue should not be used.Simple spirometry is a requirement for the initial evaluation of patients with both obstructive and restrictive ventilatory disorders. It is key to monitoring responses to therapy. The use of spirometry will also help avoid trips to the courthouse. So always remember to blow your defense! To the EditorI was recently consulted by a medical malpractice attorney who asked for assistance in the defense of his client, a board-certified pulmonologist who had been managing a patient with very difficult steroid-dependent asthma. The patient also smoked cigarettes. The man, age 41, had acquired aseptic necrosis in both femoral heads requiring total hip replacements.The patient had suffered from asthma since the age of 6 months. He had had several hospitalizations for asthma and frequent trips to the emergency department for life-threatening attacks. He had been appropriately managed by this pulmonologist, with the use of inhaled short-acting as well as long-acting agonists, inhaled corticosteroids, leukotriene modifiers and, at times, bursts of systemic steroids to deal with exacerbations of asthma and/or associated acute and chronic sinusitis.The major issue in the plaintiff’s strategy was the fact that this pulmonologist had never done spirometry at any time during the management of this patient. Accordingly, the plaintiff argued that the patient never had asthma, which was one of the contentions of the medical expert hired by the plaintiff, also a board-certified pulmonologist. Fortunately, however, numerous measurements of peak flow during exacerbations, which demonstrated increases from low values up to the “personal best” level of approximately 450 to 500 L/min while in remission following corticosteroid treatment had been recorded. But why a simple spirogram was not done by the pulmonologist, as well as other pulmonary function tests, is beyond me. It certainly would have helped in this physician’s defense. Later, an allergist did perform spirometry, which showed severe airflow obstruction and air trapping with a normal diffusion test result.This is the fourth or fifth time I have been asked to defend a board-certified pulmonologist or internist in a similar malpractice action. The simple use of spirometry would have made the defense much easier.John Hutchinson introduced spirometry in 1846.1Hutchinson J On the capacity of the lungs, and on the respiratory functions, with a view of establishing a precise and easy method of detecting disease by the spirometer.Medico-Chirurgical Transactions (London). 1846; 29: 137-161Crossref PubMed Google Scholar Some time ago, noted physiologist Joseph Milic-Emili wrote on 150 years of blowing, citing the work of Hutchinson, who coined the term vital capacity, and Tiffeneau of Paris, who added the timed vital capacity (ie, FEV1) to spirometry.2Milic-Emilie J Marazzini L D'Angelo E 150 years of blowing: since John Hutchinson.Can Respir J. 1997; 4: 239-245Crossref Scopus (6) Google ScholarToday, the National Lung Health Education Program recommends spirometry for all smokers ≥ 45 years old and anyone with dyspnea on exertion, chronic cough, mucus hypersecretion, or wheeze.3Ferguson GT Enright PL Buist AS et al.Office spirometry for lung health assessment in adults: a consensus statement from the National Lung Health Education Program.Chest. 2000; 117: 1146-1161Abstract Full Text Full Text PDF PubMed Scopus (397) Google Scholar Certainly the patient had all of these. The National Asthma Education Program has recommended spirometry in the evaluation of asthmatics for more than a decade.4National Asthma Education Program Expert panel report: guidelines for the diagnosis and management of asthma. National Institutes of Health, Bethesda, MD1991Google Scholar Thus, spirometry has to become the standard of care.Physicians who treat asthma, COPD, and other pulmonary disorders for which steroids may be required will be well advised to “blow their defense” in the form of doing spirometry in conjunction with the initial patient assessment and for documentation of responses to therapy.The issue of aseptic necrosis of the femoral head has been commented on for some time.5Richards JM Santiago SM Klaustermeyer WB Aseptic necrosis of the femoral head in corticosteroids-treated pulmonary disease.Arch Intern Med. 1980; 140: 1473-1475Crossref PubMed Scopus (17) Google Scholar,6Freeman HJ Kwan WC Brief report: non-corticosteroid-associated osteonecrosis of the femoral heads in two patients with inflammatory bowel disease.N Engl J Med. 1993; 329: 1314-1316Crossref PubMed Scopus (36) Google Scholar,7Mirza R Chang C Greenspan A et al.The pathogenesis of osteonecrosis and the relationships to corticosteroids.J Asthma. 1999; 36: 77-95Crossref PubMed Scopus (75) Google Scholar It is not clear, however, if aseptic necrosis in patients treated with corticosteroids represents a drug complication, a complication of the disease process, or both.6Freeman HJ Kwan WC Brief report: non-corticosteroid-associated osteonecrosis of the femoral heads in two patients with inflammatory bowel disease.N Engl J Med. 1993; 329: 1314-1316Crossref PubMed Scopus (36) Google Scholar,7Mirza R Chang C Greenspan A et al.The pathogenesis of osteonecrosis and the relationships to corticosteroids.J Asthma. 1999; 36: 77-95Crossref PubMed Scopus (75) Google Scholar It is interesting that in 1995, a Massachusetts Supreme Court ruling (Precort vs Frederic, 355 Mass 679) held that the risk of acquiring aseptic necrosis from long-term prednisone use was so negligible that the “informed consent” issue should not be used.Simple spirometry is a requirement for the initial evaluation of patients with both obstructive and restrictive ventilatory disorders. It is key to monitoring responses to therapy. The use of spirometry will also help avoid trips to the courthouse. So always remember to blow your defense! I was recently consulted by a medical malpractice attorney who asked for assistance in the defense of his client, a board-certified pulmonologist who had been managing a patient with very difficult steroid-dependent asthma. The patient also smoked cigarettes. The man, age 41, had acquired aseptic necrosis in both femoral heads requiring total hip replacements. The patient had suffered from asthma since the age of 6 months. He had had several hospitalizations for asthma and frequent trips to the emergency department for life-threatening attacks. He had been appropriately managed by this pulmonologist, with the use of inhaled short-acting as well as long-acting agonists, inhaled corticosteroids, leukotriene modifiers and, at times, bursts of systemic steroids to deal with exacerbations of asthma and/or associated acute and chronic sinusitis. The major issue in the plaintiff’s strategy was the fact that this pulmonologist had never done spirometry at any time during the management of this patient. Accordingly, the plaintiff argued that the patient never had asthma, which was one of the contentions of the medical expert hired by the plaintiff, also a board-certified pulmonologist. Fortunately, however, numerous measurements of peak flow during exacerbations, which demonstrated increases from low values up to the “personal best” level of approximately 450 to 500 L/min while in remission following corticosteroid treatment had been recorded. But why a simple spirogram was not done by the pulmonologist, as well as other pulmonary function tests, is beyond me. It certainly would have helped in this physician’s defense. Later, an allergist did perform spirometry, which showed severe airflow obstruction and air trapping with a normal diffusion test result. This is the fourth or fifth time I have been asked to defend a board-certified pulmonologist or internist in a similar malpractice action. The simple use of spirometry would have made the defense much easier. John Hutchinson introduced spirometry in 1846.1Hutchinson J On the capacity of the lungs, and on the respiratory functions, with a view of establishing a precise and easy method of detecting disease by the spirometer.Medico-Chirurgical Transactions (London). 1846; 29: 137-161Crossref PubMed Google Scholar Some time ago, noted physiologist Joseph Milic-Emili wrote on 150 years of blowing, citing the work of Hutchinson, who coined the term vital capacity, and Tiffeneau of Paris, who added the timed vital capacity (ie, FEV1) to spirometry.2Milic-Emilie J Marazzini L D'Angelo E 150 years of blowing: since John Hutchinson.Can Respir J. 1997; 4: 239-245Crossref Scopus (6) Google Scholar Today, the National Lung Health Education Program recommends spirometry for all smokers ≥ 45 years old and anyone with dyspnea on exertion, chronic cough, mucus hypersecretion, or wheeze.3Ferguson GT Enright PL Buist AS et al.Office spirometry for lung health assessment in adults: a consensus statement from the National Lung Health Education Program.Chest. 2000; 117: 1146-1161Abstract Full Text Full Text PDF PubMed Scopus (397) Google Scholar Certainly the patient had all of these. The National Asthma Education Program has recommended spirometry in the evaluation of asthmatics for more than a decade.4National Asthma Education Program Expert panel report: guidelines for the diagnosis and management of asthma. National Institutes of Health, Bethesda, MD1991Google Scholar Thus, spirometry has to become the standard of care. Physicians who treat asthma, COPD, and other pulmonary disorders for which steroids may be required will be well advised to “blow their defense” in the form of doing spirometry in conjunction with the initial patient assessment and for documentation of responses to therapy. The issue of aseptic necrosis of the femoral head has been commented on for some time.5Richards JM Santiago SM Klaustermeyer WB Aseptic necrosis of the femoral head in corticosteroids-treated pulmonary disease.Arch Intern Med. 1980; 140: 1473-1475Crossref PubMed Scopus (17) Google Scholar,6Freeman HJ Kwan WC Brief report: non-corticosteroid-associated osteonecrosis of the femoral heads in two patients with inflammatory bowel disease.N Engl J Med. 1993; 329: 1314-1316Crossref PubMed Scopus (36) Google Scholar,7Mirza R Chang C Greenspan A et al.The pathogenesis of osteonecrosis and the relationships to corticosteroids.J Asthma. 1999; 36: 77-95Crossref PubMed Scopus (75) Google Scholar It is not clear, however, if aseptic necrosis in patients treated with corticosteroids represents a drug complication, a complication of the disease process, or both.6Freeman HJ Kwan WC Brief report: non-corticosteroid-associated osteonecrosis of the femoral heads in two patients with inflammatory bowel disease.N Engl J Med. 1993; 329: 1314-1316Crossref PubMed Scopus (36) Google Scholar,7Mirza R Chang C Greenspan A et al.The pathogenesis of osteonecrosis and the relationships to corticosteroids.J Asthma. 1999; 36: 77-95Crossref PubMed Scopus (75) Google Scholar It is interesting that in 1995, a Massachusetts Supreme Court ruling (Precort vs Frederic, 355 Mass 679) held that the risk of acquiring aseptic necrosis from long-term prednisone use was so negligible that the “informed consent” issue should not be used. Simple spirometry is a requirement for the initial evaluation of patients with both obstructive and restrictive ventilatory disorders. It is key to monitoring responses to therapy. The use of spirometry will also help avoid trips to the courthouse. So always remember to blow your defense!