2医生的职业规范:第一次开glimepiride,不是医生的失职。但在病人已出现过敏症状,在病人的恳求不要再开此类药物下,而且医生也同意是药物过敏(Allergic reaction to medication?),又开了同一class,分子结构非常近似的glipizide,这算不算失职?医生遇到病人过敏,首先要去除过敏原,而不是把病人以去除的过敏原,医生本身已怀疑的过敏原以另一种形式加进来。
3因果关系。SJS是一种罕见的疾病,除了严重的感染,就是药物引起。The ideal “ proof ” that an agent caused the skin eruption in a given patient is reappearance of the reaction upon re-exposure to
please read insert No.4. This is a legal document.
4 CONTRAINDICATIONS
AMARYL is contraindicated in patients with a history of a hypersensitivity reaction to: • Glimepiride or any of the product’s ingredients [see Warnings and Precautions (5.2)].
Sulfonamide derivatives: Patients who have developed an allergic reaction to sulfonamide derivatives may develop an allergic reaction to AMARYL. Do not use AMARYL in patients who have a history of an allergic reaction to sulfonamide derivatives.
Sulfonamide allergies — Concern regarding potential crossreactivity of sulfonamide antimicrobials (eg, sulfamethoxazole, sulfasalazine) and sulfonylureas, with an increased risk for allergic reactions to sulfonylureas in patients with a history of "sulfa allergies," appears to be unfounded and is no longer listed as a contraindication in the package insert for immediate-release glipizide. Although hypersensitivity to sulfonamides is still listed as a warning for glimepiride and a contraindication for gliclazideand glipizide extended release, most clinicians use sulfonylureas in patients with professed allergies to sulfonamide antimicrobials without any problems. (See "Sulfonamide allergy in HIV-uninfected patients", section on 'Between sulfonamide antimicrobials and nonantimicrobials'.)
这个案子法律的核心是negligence,大致有三个部分:1)是否医学上站得住脚,2)是否后面所有的injury都是这个original negligence造成. i.e. causation, 3)到底多少damages。
这个叫做“off label use”,医生不需要严格按照药厂所说的用药。例如分娩时候的诱导阶段,misoprostol是不能用的,根据手册,然而这个药每天都在临床使用中。这个off label不是对方的致命伤。作为原告,你要证明:a reasonable and prudent doctor won't use it under similar circumstances
通过网友的讨论,特别是各位专业人士给我提供了很多宝贵意见和建议,我衷心地感谢!这是我重新的思考。
1对病人的伤害,不再累述。
2医生的职业规范:第一次开glimepiride,不是医生的失职。但在病人已出现过敏症状,在病人的恳求不要再开此类药物下,而且医生也同意是药物过敏(Allergic reaction to medication?),又开了同一class,分子结构非常近似的glipizide,这算不算失职?医生遇到病人过敏,首先要去除过敏原,而不是把病人以去除的过敏原,医生本身已怀疑的过敏原以另一种形式加进来。
3因果关系。SJS是一种罕见的疾病,除了严重的感染,就是药物引起。The ideal “ proof ” that an agent caused the skin eruption in a given patient is reappearance of the reaction upon re-exposure to
the suspected agent. 这个医生的第二次给药已证实。
医学论文和法律案判决的逻辑不太一样。
can guess/argue/speculate, but it will not help you too much. Lawyers usually have a good taste whether the case worth their time or not.
你的律师也要请expert witness。对方当然也会有
医疗官司不好打。这个案子只有证明a->b->c每一步的因果关系,加上证明医生negligence,违反protocol,最后直接导致损害,赢的把握才大。
估计你顶从对方的保险公司拿到一小笔钱弥补你的medical expenses。因为不是永久损害,jury也不能亲眼看到你的惨状,不会同情心泛滥判给你天价赔偿
a lawyer. They are professional people on laws. Find a good lawyer and try. I have great sympathy on your family.
Again, 可以请老公公司的律师推荐 -- 律师们更容易知道谁好谁不好。
我是觉得你这个有官司打。老公受了5个月的苦,医疗账单50万(虽然不用你们付,但说明了情况的严重性),赔偿不会太少的。当然,貌似如今也没有当年麦当劳那种ridiculous的数目。但6位数应该可以有的吧?问律师吧,他们知道。
http://products.sanofi.us/amaryl/amaryl.pdf
one side effect of Glimepiride is SJS. Package insert (FDA document) said so.
I could not find the document for Glipizide
律师的角度是能否成案,医学的证据是用来辅助的。
4 CONTRAINDICATIONS
AMARYL is contraindicated in patients with a history of a hypersensitivity reaction to: • Glimepiride or any of the product’s ingredients [see Warnings and Precautions (5.2)].
Sulfonamide derivatives: Patients who have developed an allergic reaction to sulfonamide derivatives may develop an allergic reaction to AMARYL. Do not use AMARYL in patients who have a history of an allergic reaction to sulfonamide derivatives.
最重要的文件在我们身边
Contraindications
Glipizide is contraindicated in patients with:
Known hypersensitivity to glipizide or any of the product‘s ingredients. Hypersensitivity to sulfonamide derivatives。https://www.drugs.com/pro/glipizide-er.html
Sulfa药物过敏的病人,两种药都不能开。我会很快联系律师。谢谢各位!
Listed hypersensitivity reactions. 问题在于第二次。找律师吧,上面有人说了,律师要请expert witness的
首先,美国法律里medical malpractice案子是否可以赢,不完全看是否医学上是否站得住脚,要看陪审团喜欢原告多一点还是被告多一点。总体来说在全美国范围内,statistically speaking, medical malpractice案子里面原告输的比例远高于被告。
这个案子的医学核心是:如果在明知道一个病人对sulfa "过敏"的情况下,一个reasonable doctor是否应该不使用某种药。目前药看是否这个病人的“allergy”属于什么严重程度的。如果是严重过敏反应,那么对于某一种药看来不可以用,其他的临床上经常用。
以下摘抄于UPTODATE,是医生的案头书,类似红宝书:
Sulfonamide allergies — Concern regarding potential crossreactivity of sulfonamide antimicrobials (eg, sulfamethoxazole, sulfasalazine) and sulfonylureas, with an increased risk for allergic reactions to sulfonylureas in patients with a history of "sulfa allergies," appears to be unfounded and is no longer listed as a contraindication in the package insert for immediate-release glipizide. Although hypersensitivity to sulfonamides is still listed as a warning for glimepiride and a contraindication for gliclazideand glipizide extended release, most clinicians use sulfonylureas in patients with professed allergies to sulfonamide antimicrobials without any problems. (See "Sulfonamide allergy in HIV-uninfected patients", section on 'Between sulfonamide antimicrobials and nonantimicrobials'.)
这个案子法律的核心是negligence,大致有三个部分:1)是否医学上站得住脚,2)是否后面所有的injury都是这个original negligence造成. i.e. causation, 3)到底多少damages。
第一个法律核心就是最开始的那一段UPTODATE上面的摘抄:要看到底是什么药,到底是什么样的过敏,既往是严重过敏,还是普通小皮疹:不是只要“过敏”就不能用的。要看什么药,既往是什么样的过敏反应。
第二个法律核心就是看causation。
由于喝水呛咳导致水入内耳,耳鼻喉医生两次在耳鼓膜上钻孔,吸出内耳的水
and:
一位老教授看了以后,又让全科会诊,但仍没有给一个明确诊断。又做了皮肤活检,结果是不寻常药疹。三个月后,皮肤仍慢慢地恶化。于是我们又在教学医院住院了一周,当时医生怀疑是皮肌炎,又重新做了CT,MRI,肌肉活检,肌电图,免疫生化检查。肌肉活检并不支持皮肌炎。医生给了3天的IVIG(静脉免疫球蛋白。我老公对IVIG非常敏感,皮肤开始好转,体力逐渐恢复,吞咽也基本正
以上这两点初看起来不大符合causation。初一眼看,不容易和最开始的negligence联系在一起。这些后续的事情,如何与开始吃的那几次药联系起来?
第三个法律核心其实就是一个lien的问题。你说花了50万,我怀疑这些钱是out of pocket,是不是?如果是,那么还有大量的钱由公司的保险出。如果这个50万说的只是保险公司的EOB,那么绝大多数都被保险公司出了,对不?这个保险,typically属于ERISA lien,这个lien很可怕。基本上你官司赢得钱,要尽数还给health insurance company,因为美国最高法院的几个判例。
另外还有一个问题就是noneconomic damages cap.如果你所在州有CAP,例如在加州,你的精神损失费封顶在25万。打官司要多少钱?你这个案子我初步估计大约8万-10万,如果输了官司,你要负责出被告的8万-10万,这个在加州叫做CCP998。对你非常不利,因为这个打输了赔被告(CCP998)的钱,不是你的律师出,是你出。在其他大州,都有类似的法律出现,于是对于原告就非常不利。总体来说,这个属于可以试试看的情况但不是很看好。
这个叫做“off label use”,医生不需要严格按照药厂所说的用药。例如分娩时候的诱导阶段,misoprostol是不能用的,根据手册,然而这个药每天都在临床使用中。这个off label不是对方的致命伤。作为原告,你要证明:a reasonable and prudent doctor won't use it under similar circumstances
专家!专家!