Money Minutes for Doctors #12 - Asset Protection

It is a fear that all physicians have at one time or another…how do I protect myself in the event of litigation? In this month’s edition of Money Minutes for Doctors, Katherine Vessenes, JD, CFP®, RFC, Founder and President of MD Financial Advisors, talks to us about the realities of legal actions against doctors as well as strategies of keeping oneself protected as much as practicable. Enjoy!!

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About Ms. Vessenes:

Ms. Vessenes works with over 300 physicians and dentists from Hawaii to Cape Cod. Her firm uses a team of experts to provide comprehensive financial planning to help doctors build their wealth and protect their wealth while reducing taxes now and in the future. Katherine is a longtime advocate for ethics in the financial services industry; and has written three books on the subject of investment strategies. She has received many honors and awards including: numerous tributes from Medical Economics as a top advisor for doctors, multiple 5-Star Advisor Awards, honored as a Top Woman in Finance, in addition to being selected to be on the CFP® Board of Ethics. Katherine can be reached at: Katherine@mdfinancialadvisors.com or 952-388-6317. Her website: www.mdfinancialadvisors.com.

Quick Summary:

  • Lawsuits are less common than you may think

  • You can do a lot as a physician to prevent a lawsuit

  • Almost universally the amount of a malpractice lawsuit is completely covered by the malpractice policy and rarely exceeds that amount

  • Residents and fellows are covered by their training program and do not need additional insurance

  • You can be sued for issues outside of malpractice and need to protect yourself in alternate ways, i.e. umbrella policy, which is recommended particularly as you progress in your career and your net value increases

    • Umbrella policies are fairly inexpensive and are in addition to your standard insurances

  • Most times medical malpractice is covered by your employer, be sure to look for this benefit in your contract as group policies are often less expensive than individual coverage

    • Generally not recommended to have additional malpractice beyond which your group covers, but may be of benefit in high risk specialties or if you own your practice.

    • May want your attorney to review your contract to be sure enough medical malpractice insurance is offered

  • Often dollar amount of the lawsuit is determined by the extent of your malpractice policy as determined in discovery (a formal part of the lawsuit)

  • Depending on the state in which you live, home ownership equity can be a source of protected asset in a law suit but be sure the asset is well insured!

    • Having a home equity line of credit on your home will show up as a lein and therefor offers protection in a lawsuit and is a better situation then owning your home outright

  • 401k/403b accounts are protected at federal level from law suits

  • IRA accounts are at slightly more risk than 401k/403b

  • The amount of protection to your Brokerage accounts varies by state

  • Having a spouses’ name on the account if it is a joint asset does not offer you significant asset protection. To place the asset soley in the spouses’ name offers protection but depends on the security in the relationship and generally is not helpful

  • The protection of placing an asset in an LLC/Corp depends on the asset, i.e. offers little protection for 401k/brokerage accounts/real estate

  • If a trust is constructed well it can offer protection

    • Accountants and attorneys are the most helpful to protect these assets and place them in LLC/trust etc.

  • Vehicles are vulnerable if you own them outright, if there is a loan or lein then less vulnerable

  • Savings accounts are vulnerable but some portion of the account value is protected by the state

  • Wills/trusts can be a great way to protect assets for future generations but needs to be done properly, consult an attorney!

  • Asset protection is best accomplished now, when you are sued it is too late! 

Treatment of Pneumothorax with a Portable Thoracic Vent

The Case

A 59 year-old male who underwent a same-day bronchoscopy with transbronchial biopsies taken for diffuse parenchymal lung disease presents later that afternoon to the Emergency Department with a chief complaint of shortness of breath.

Upon arrival he is noted to be mildly tachypneic with a respiratory rate of 22. He is not hypoxic and the remainder of his vital signs are within normal limits. Exam reveals diminished breath sounds in the left lung fields. An upright chest x-ray demonstrates a large left-sided pneumothorax (Figure 1).

Figure 1: Initial chest x-ray demonstrating large left-sided pneumothorax

Figure 1: Initial chest x-ray demonstrating large left-sided pneumothorax

Discussion

The conventional treatment of a spontaneous or iatrogenic pneumothorax is with a small-bore thoracostomy tube also known as a pigtail catheter. This usually requires connecting the patient to an underwater seal device such as a pleuravac, thereby necessitating admission to the hospital for monitoring. However, there are other devices available to treat this condition that can be deployed more rapidly and with similar success rates. In some cases, patients treated with these devices do not even require hospitalization.

One such device is the Tru-Close thoracic vent. The Tru-Close (also referred to as a Thora-Vent) is a portable device that consists of an 11 or 13 French catheter connected directly to a small air chamber containing a one-way valve and self-sealing port.

Using either an over-the-wire Seldinger technique or a trocar for direct insertion, the catheter is inserted using local anesthetic and sterile technique into the affected side at the patient’s second intercostal space on the mid-clavicular line (similar in location to where one would needle decompress a tension pneumothorax). The entire device is then affixed to the chest wall with adhesive wings. It can be left to air seal or connected to suction if clinically indicated. Time to complete the entire procedure from beginning to end takes around one minute (a video with more information on The Tru-Close, as well as the procedure for placement can be found here).

The literature on the use of thoracic vent devices in treatment of pneumothorax is limited. In one study of 18 patients (15 with spontaneous pneumothorax and 3 with iatrogenic pneumothorax), 88.9% of patients (16/18) treated with a Tru-Close thoracic vent had complete lung re-expansion within 24 hours. All of the patients with spontaneous pneumothorax were discharged to follow up as an outpatient. There were no immediate complications, and most patients remained recurrence free during a three-year follow up period. It is important to note that in this study, the device was inserted under fluoroscopic guidance, something that is not readily available to most emergency physicians.  

In another study of 30 patients comparing thoracic vent devices to conventional intercostal tube drainage, the authors found that there was no significant difference in the rates of lung reexpansion or complications between the two groups. They did find that patients treated with the thoracic vent devices needed significantly less analgesics than patients treated in the conventional manner. Furthermore, 70% of patients treated with a thoracic vent were managed as an outpatient, whereas all patients treated with the conventional intercostal tube required admission. 

This literature suggests that in reliable, otherwise healthy patients who present with an uncomplicated spontaneous pneumothorax, the use of a thoracic vent device for lung reexpansion may be a good option that could potentially enable the patient to be discharged and managed as an outpatient provided they have close follow-up. Patients generally tolerate the device well as allows maximum ambulation while device in place.

Case Resolution

A Tru-Close thoracic vent is placed in the emergency department, and a repeat chest x-ray demonstrates rapid resolution of the pneumothorax (Figure 2). The patient is admitted to the medical service due to a persistent air leak. He has an uneventful hospital stay and is discharged on hospital day 3.

Figure 2: Interval resolution of left-sided pneumothorax after placement of a Tru-Close thoracic vent.

Figure 2: Interval resolution of left-sided pneumothorax after placement of a Tru-Close thoracic vent.

Faculty reviewer: Kristina McAteer


References

  1. Kim et al. “Effectiveness of Ambulatory Tru-Close Thoracic Vent for the Outpatient Management of Pneumothorax: A Prospective Pilot Study.”Korean J Radiol. 2017 May-Jun;18(3):519-525. doi: 10.3348/kjr.2017.18.3.519. Epub 2017 Apr 3.

  2. Roggla, et al. “The management of pneumothorax with the thoracic vent versus conventional intercostal tube drainage.” The Central European Journal of Medicine. 1996;108(11):330-3.

  3. Tsuchiya et al. “Outpatient Treatment of Pneumothorax with a Thoracic Vent: Economic Benefit.” Respiration. 2015;90(1):33-9. doi: 10.1159/000381958. Epub 2015 May 12.

  4. https://www.youtube.com/watch?v=HPIvp5TN51o

  5. https://www.uresil.com/pneumothroax.products/

Clinical Image of the Month: Lambl’s Excrescence

Welcome back to another Clinical Image of the Month from the case files of the Brown EM Residency.

 

HPI/ROS

A 77 y.o. female with PMHx significant for liver cirrhosis, COPD on 2L O2, fibromyalgia, depression, and GERD who presents to the ED for evaluation of abdominal and RLE pain after a mechanical fall. Patient denies head trauma and LOC and is not on blood thinners. Patient does report moderate ETOH use. Her mobility is quite limited by both her fibromyalgia as well as her underlying dyspnea which has previously been attributed to her COPD. She reports having episodes of diaphoresis for at least one to two years, which occur on a daily basis. She denies any clear fevers. She additionally denies any clear exertional chest pain or other associated complaints.

Vital signs are stable. Patient had a right hip XR which revealed a displaced and mildly angulated femoral neck fracture with moderate override and no other acute osseous or articular abnormality. An incidental finding was seen on the CT abdomen and pelvis, partially shown below:

 

CT A/P

Abdomen

Lower chest: Cardiomegaly. Arteriosclerosis of the aorta and coronary arteries. There is left ventricular apical bulbous morphology suggesting old MI. A 21 x 11 mm thrombus is seen in the LV apex. Moderate bilateral pleural effusions with associated relaxation atelectasis. Large hiatal hernia.

Cardiology was consulted for the LV thrombus. In the Emergency Department, an echocardiogram which showed severely reduced LV function (EF25%), moderately reduced RV function and redemonstrated the LV apical thrombus. Additionally, a mobile mass on the aortic valve was noted.

 

Echocardiogram 2D Complete

  • Left ventricle is mildly dilated and global systolic function is severely reduced

  • There is a fixed non-mobile 10mm X 15mm thrombus at the LV apex

  • Right ventricle is dilated with moderately reduced systolic function

  • Inadequate coaptation of the mitral leaflets resulting in moderate-to-severe mitral insufficiency

  • There is a thin 8mm-long mobile echodensity on the aortic side of the aortic valve of unclear etiology, unusual appearance for endocarditis or thrombus.

  • Sclerodegenerative valve disease with mild aortic insufficiency

  • Mild pulmonary hypertension

  • Biatrial enlargement

Cardiology suspected that her cardiomyopathy was secondary to alcohol abuse, but due to the mobile mass on the aortic valve, there was suspicion for endocarditis. Blood cultures were drawn, patient was started on IV antibiotics, and a heparin drip.

Throughout her inpatient stay, the patient remained afebrile and blood cultures were negative. What’s the diagnosis?

 

LAMBL’S EXCRESCENCE

Lambl’s excrescences (LE) are thin, filiform strands of connective tissue found on the closure lines of valves.  Minor endothelial damage promotes thrombus formation and deposition of layers of mucopolysaccharide matrix. They are often seen as an incidental finding on transesophageal echocardiogram and are more commonly observed on the mitral valve than the aortic valve.

In one prospective review of healthy volunteers undergoing TEE, there were similar rates of cardioembolic disease between groups with LEs and those without. Additionally, they observed that aspirin and warfarin use did not alter prevalence or cardioembolic risk of LEs. In another study, LE were seen in up to 39% of elderly patients undergoing TEE for suspected cardiogenic embolic stroke. While they are typically small (1x10mm) they have the potential of embolization, with case reports attributing larger LEs to stroke or MI.

In the absence of clear evidence that they cause cardioembolic disease, Lambl’s excrescences as an isolated, incidental finding do not warrant prophylactic antithrombic therapy. More research is needed to determine the clinical significance of LEs.

 

Case Conclusion

The patient received a TEE two days later to further evaluate this and it was determined to be Lambl's excrescence, not endocarditis. Further ischemic workup was recommended by cardiology with nuclear stress test and medical optimization as an outpatient.

 

Faculty Reviewer: Dr. Alyson McGregor

 

References

  1. Chu A, Aung TT, Sahalon H, Choksi V, Feiz H. Lambl’s Excrescence Associated with Cryptogenic Stroke: A Case Report and Literature Review. Am J Case Rep. 2015; 16:876-81.

  2. Nakahira J, Sawai T, Kutsumata T, Imanaka H Minami T. Lambl’s excrescence on aortic valve detected by transesophageal echocardiography. Anesth Analg. 2008 June;106(6):1639-40.

  3. Roldan CA, Schevchuck O, Tolstrun K, Roldan PC, Macias L, Qualls CR, Greene ER, Hayek R, Charlton GA, Sibbitt WL Jr. Lambl’s Excrescences: Association with Cerebrovascular Disease and Pathogenesis. Cerebrovasc Dis. 2015;40(1-2): 18-27.