Learning from Lawsuits

They Missed ACS Three Times

This episode talks about the three different ways acute coronary syndrome can present and how to avoid missing unstable angina as a cause of chest pain.   Dr. Charles Piltcher and Katie Wyatt NP-C discuss takeaways that can keep each of us from making the same mistakes with our patients.

Did IV Calcium Kill This Hypocalcemic Patient?

A 33-year-old woman arrives at the emergency room struggling to breathe—her symptoms alarming, her condition urgent. What follows is a rapid series of events marked by uncertainty, communication gaps, and a critical moment that changes everything. In this episode of Learning from Lawsuits, we unpack a heartbreaking case involving abnormal electrolytes, unclear documentation, and a sudden cardiac arrest that occurred just minutes after medication was reportedly administered. With the medical record unable to confirm exactly what was given—and when—we explore how breakdowns in communication, documentation, and clinical clarity can lead to devastating outcomes. More importantly, we focus on what healthcare teams can learn from this case. How do we ensure accuracy in high-pressure moments? What safeguards can prevent medication errors? And how can teams better communicate when every second counts? This episode is a powerful reminder that patient safety often hinges not just on clinical knowledge—but on systems, clarity, and connection.

Missed Appendicitis-How are we still missing this?

In this episode, we unpack the case of a 40-year-old woman who came to the Emergency Department with right upper quadrant abdominal pain—an atypical presentation that led her care team away from considering appendicitis. Without the “classic” symptoms, the diagnosis was missed, and she was discharged home—only to return two days later with a ruptured appendix. We explore how cognitive biases, atypical presentation, and time pressures in the ED can impact clinical decision-making. More importantly, we discuss practical strategies to reduce diagnostic error: broadening differentials, recognizing atypical presentations, improving team communication, and strengthening safety-netting at discharge. This episode is a powerful reminder that uncommon presentations of common conditions can test even experienced clinicians—and that small shifts in thinking can make a life-saving difference.

Patient Dies in Jail After Being Evicted From ED

In this episode hosts Katie Wyatt NP-C and Charles Piltcher MD discuss a sad case of a patient who was taken to the ED by law enforcement for medical evaulation, and because of violence against the nuse and law enforcement officers, the patient was evicted to jail without medical exam. The patient had a cardiac arrest in the jail 30 minutes after arrival. Listen for the details and tips on how we can avoid situations like this in the future.

Seven Minutes Too Late: The Deadly Risk of Prone Restraints

This episode reviews a malpractice case where a psychiatric patient boarded in an ED for over 24 hours was restrained in a prone position, sedated, and left unmonitored, resulting in cardiac arrest and severe brain injury. We discuss failures in monitoring, documentation, restraint policies, and the broader problem of psychiatric boarding, plus lessons for clinicians to prevent similar outcomes. Many thanks to those of you who have donated to help cover the hard costs (about $1000/year) of Med Mal Insights. It means a lot to know that you appreciate the case stories and find them helpful. Donations are always welcome. Here's 3 ways to donate: * Zelle: Open your bank's Zelle app using your mobile device. Enter MMI-LFL mobile phone number 2069158593 * Venmo: Click this link to Venmo [https://email.cloud.secureclick.net/c/54759?id=179785.1146.1.556a7de450eff4073afc6683aefbaddb] * PayPal: Click PayPal [https://email.cloud.secureclick.net/c/54759?id=179785.1147.1.7a275017d9f787285eb48ef0febe1fd8] and select a donation amount 1. Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document. [https://email.cloud.secureclick.net/c/54759?id=179785.1148.1.e6145ba4a42fac9aa8fec4269395072b] Western Journal of Emergency Medicine, Vol 20 Issue 5 , July 22, 2019. 2. Resources on Behavioral Health Crowding and Boarding in the Emergency Department (ED) [https://email.cloud.secureclick.net/c/54759?id=179785.1149.1.6606905e763c1fbf5c8f9606a12bda84]Compiled by members of the ACEP Emergency Medicine Practice Committee, September 2019.