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Legal problems for oncologists facing hematologic disorders: an increasing dilemma
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In recent months several of the editors of HemOnc Today have received increased requests for opinions in medical malpractice suits.
A lot of these malpractice allegations have been made against oncologists on call for their hematologist colleagues in their group practices. Many oncologists do not have hematology boards, or have combined hem/onc boards due to crossover of fellowship programs. Even when an oncologist might have passed a hematology board in the distant past, many spend a large majority of their time as solid tumor oncologists, yet occasionally take calls on weekends and vacations for what is a hematologic emergency. Frequently, oncologists might not be comfortable, or should not be comfortable, caring for these hematologic cases and may inadvertently make deadly mistakes, ultimately leading to a malpractice suit.
In this editorial, I will cite several examples, provided by our editors, that have resulted in malpractice litigation — litigation alleging hematologic misdiagnosis or mistreatment by oncologists.
Blood smears, thrombocytopenia
Oncologists frequently do not personally examine blood smears, an important diagnostic tool for any hematologist. Blood smears may be critical in several situations, but the most grievous example is in the evaluation of thrombocytopenic patients. These folk are frequently misdiagnosed as having immune thrombocytopenic pupura, yet instead of ITP, a blood smear would show that the patient in fact has thrombotic thrombocytopenic pupura. The failure to evaluate the blood smear results in failure to appreciate the sometimes subtle presence of schistocytes. Moreover, the ignoring of elevated LDH levels, and that the patient is not just thrombocytopenic but also anemic has been disastrous for several of our oncology colleagues and deadly for their patients.
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Several on-call oncologists have been litigation victims in the past few years in this arena. TTP is a medical emergency. It is easily treated, but about 80% of patients who aren’t treated die or end up with end-stage renal disease or brain infarction. The treatment calls for immediate plasma exchange. This should be performed rapidly, certainly within the first 24 hours, and is the accepted standard of care for TTP. Failure to so treat is recognized by the courts as evidence of malpractice.
Another common cause for malpractice suits involving thrombocytopenic patients relates to the failure to recognize heparin-induced thrombocytopenia. Physicians may encounter a thrombocytopenic patient who has recently had heparin and goes on to develop ischemic symptoms in various places, including the extremities. These patients may end up with amputations, gangrene, heart attacks, etc. The consultant sees the patient who two weeks prior was exposed to heparin during cardiac bypass or simply cardiac catheterization for diagnostic purposes. The patient developed heparin/platelet Factor IV antibodies, which may cause platelet and endothelial activation when heparin is re-administered. Such activation leads to “white” platelet-rich clots and catastrophic ischemia/infarctions. The failure to take a thorough patient history, obtain heparin antibody assays, and immediately stop heparin pharmaceuticals in this type of case is widely recognized in legal suits and is a frequent malpractice catastrophe.
Porphyria
Another diagnosis often missed, even by traditional hematologists, is porphyria. It can be potentially fatal and/or lead to chronic and mysterious episodes of severe (often abdominal) pain. Of the several types of porphyria, those producing neurovisceral problems (abdominal pain plus peripheral neuropathies including paralysis of respiratory muscles) are the most deadly. When patients present with these symptoms they are frequently worked up for all kinds of abdominal disorders, but to no avail. In addition, some porphyrias also may cause cutaneous rashes and blistering.
These cutaneous plus neurovisceral porphyrias (usually coproporphyria or protoporphyria) require fecal porphyrin assays for diagnosis, yet often only urinary assays are obtained. These miss the excessive excretion of (poorly water soluble) copro- or protoporphyrins. These diagnostic subtleties require specialty expertise. Failure of oncologists (and some hematologists as well as gastroenterologists) to obtain appropriate consultative advice has led to malpractice allegations, especially since the porphyrias are remittable when appropriately treated.
VTE in obese patients
Our editors also report several malpractice cases involving postoperative care of morbidly obese patients undergoing gastric bypass. The major danger of this procedure is postoperative thrombosis. Obese patients are at high risk for VTE and pulmonary embolism. Hematologists are frequently asked to give advice as to what kind of postoperative anticoagulation should be used in these patients. Anticoagulation should be liberal, and continuous heparin or enoxaparin (Lovenox, Sanofi Aventis) is standard treatment for the first few postoperative days.
The sole use of compression stockings is not sufficient and has been considered negligent by the courts in cases where patients have died with postoperative pulmonary embolism. In this regard, Lovenox, a very convenient anticoagulant, should not be used in patients presenting with significant renal insufficiency as the drug is mainly excreted by the kidneys. Since Lovenox dosing is by patient’s weight, morbidly obese patients are frequently given enormous amounts of the drug, which can be particularly dangerous if the patients have even mild (and unrecognized) renal insufficiency. Unfractionated heparin with rigorous PTT-based titration should be advised by hem/onc consultants in such cases. Not providing such advice has been recently deemed legally negligent.
Sickle cell disease
Finally, improper treatment of sickle cell disease, which is a common disease for hematologists but not for oncologists, is also a frequent malpractice allegation. Patients frequently present on weekends with painful crises, but chest pain is ignored. The chest pain actually represents an early symptom of acute chest syndrome. Although shortness of breath, fever and pulmonary infiltrates may rapidly follow, misdiagnosis of “pneumonia” often delays appropriate (and potentially lifesaving) exchange transfusion therapy.
Malpractice lawyers, particularly in locales with large black populations, have discovered this entity, and legal suits are burgeoning in these locales. I have personally been asked to opine in three fatal cases where the on-call consults were not usually called upon to treat sickling emergencies.
If there is any lesson to take away from these examples, it is for oncology-oriented physicians to obtain appropriate co-consultations on hematology-related cases even if it requires calling in practice partners that are not on call. Although this may be difficult in small practices, it could be the difference between diagnosing a treatable disease or suffering the outrageous slings and arrows of tort attorneys.