About Dr. Gustin
Dr. Gustin is residency-trained and board-certified in Emergency Medicine and Forensic Medicine and has been actively practicing in the fields of Emergency Medicine, Toxicology, and Forensic Medicine for more than 30 years. He has additional training and expertise in Medical, Occupational, and Environmental Toxicology and has Masters Degrees in Biochemistry, Metabolism and Nutrition, as well as Toxicology and Public Health. He is the primary founder of the American College of Forensic Medicine which currently has more than 2,000 members.
Dr. Gustin has reviewed thousands of medical malpractice, personal injury, criminal, and toxicology cases during his career. Dr. Gustin also has substantial testimony experience as an expert witness.
You can access Dr. Gustin's medical-legal experience by requesting a FREE phone or email consultation now. To review all the Services he offers, please click here.
Dr. Gustin's education, training, and experience qualifies him to evaluate and testify regarding a broad range of cases, in the following medical and toxicology specialty areas:
- Emergency Medicine, medical, surgical, pediatric
- Emergency Medical Ambulance Services (EMS)
- Trauma and Critical Care
- Forensic Toxicology
- Medical Toxicology and Poisoning (eg: accidental overdose, carbon monoxide poisoning, and all other product and drug exposures)
- Occupational and Environmental Toxicology
- Mechanisms and Forces of Injury in Criminal Cases
- Substance Abuse and Drug Addiction (Drug and Alcohol, including DUI)
- Electrical Injury
- Pharmaceutical Medicine (Drug-Drug interactions, Drug-Disease Interactions, Overdose, Unsafe poorly tested Drugs, Adverse Drug Reactions)
- Flight, Travel, and Wilderness Medicine
- Hospital Malpractice
- Public Health (eg: Legionnaire's Disease, Outbreak Diseases, Food Poisoning, and Waterborne Diseases)
- Legal Medicine (standard of care, evidence-based causation, medical ethics)
His primary areas of specialization are Emergency Medicine and Toxicology.
A partial list of cases Dr. Gustin has consulted on include: drugs of abuse including Methamphetamine, Cocaine, Opiates, and Alcohol, occupational chemical poisonings including toluene, benzene, isocyanates, other solvents, heavy metals including lead, carbon monoxide, and cyanide, occupational and travel-related infectious illness including Legionnaire's disease, MRSA, skin infections, bacterial enteritis, misdiagnosis and delayed treatments in the ER, civil rights cases, environmental exposure cases including contaminated water and sewage exposure.
Dr. Gustin's expert opinions will comply with ACEP (American College of Emergency Physicians) guidelines for Expert Witness Testimony: See: http://www.acep.org/practres.aspx?id=29446 ; the ACT (American College of Toxicology); and ACFE (American College of Forensic Examiners) Creed of Ethics. See: http://www.acfei.com/about_acfei/creed/
Office: 2928 Derby Street, Berkeley, CA 94705
Email: Click here to email Dr. Gustin
Ending Medical Malpractice Litigation
A Sensible Alternative to Our Broken System?
As every physician knows, our tort system is broken. Various solutions have been suggested over the years, only to fade away. But now, a promising new system for patient compensation in cases of medical error is being proposed in two states: Georgia and Florida. It makes sense for doctors and patients alike, and for our healthcare system as a whole.
The bills would, if passed, transform the current medical tort system into an administrative system for redress. Georgia's—the Patient Compensation Act in Georgia, SB 86—opens with the following game-changing text:
"Effective January 1, 2016, the cause of action under Georgia law for medical malpractice against a provider as defined in Code Section 51-13-2 is hereby repealed in its entirety."
A patient who is injured would seek a potential remedy via the Patient Compensation Act, which calls for the establishment of a "Patients' Compensation System."
That patient, via a patient advocate, would appeal to the system to investigate his or her injury. The full record would be reviewed by a rotating collection of medical experts in the relevant field. If this panel agreed that the injury was avoidable, the case would be referred to a compensation committee to make payment.
To qualify for compensation, the panel would, in the Georgia law's verbiage, use the following criteria:
"Medical injury" means a personal injury or wrongful death due to medical treatment, including a missed diagnosis, where all of the following criteria exist:
- The provider performed a medical treatment on the applicant;
- The applicant suffered a medical injury with damages;
- The medical treatment was the proximate cause of the damages; and
- Based on the facts at the time of medical treatment, one or more of the following:
- An accepted method of medical services was not used for treatment;
- An accepted method of medical services was used for treatment, but executed in a substandard fashion.
The patient would not need a lawyer to propel his or her case forward; however, if desired, a lawyer could help the patient ensure that due process was followed.
The total pool of funds available for making payments would be less than the aggregate amount of funds doctors paid in professional liability premiums before enactment of the law. In other words, the system would not pay out more in the future than is currently being paid in by physicians. This term would keep costs stable for doctors—by statute—regardless of the number of claims.
The Patients' Compensation System would be a state-based entity and, similar to other state based entities—such as the Florida or Virginia Birth-Related Neurological Injury Compensation programs—payments would not be reportable to the National Practitioner Data Bank (NPDB).
Physicians would not need to purchase medical malpractice insurance, because they could not be sued. Instead, they would pay an annual contribution to administer the program. A family practitioner, for example, would pay $3900 per year; an orthopedic surgeon, $15,600 per year; and a spine surgeon, $17,500 per year. The specialists with the highest contribution rate, pediatric neurosurgeons, would pay $25,300 per year. These rates would be significantly below the current market rate for professional liability premiums—which typically cover only $1 million of liability.
How Physicians Would Benefit
In the Patients' Compensation System, there is no claim to defend. A doctor need only provide the patient's medical record. He or she may ignore any other procedural nuance, if desired. Alternatively, he or she may provide an explanation of care that was rendered.
And if the doctor wants to advocate for the patient, he or she may sit with the patient. If a doctor, for example, misses a critical diagnosis that could have easily be made, and that error cost the patient an extra month in the intensive care unit, the doctor could apologize to the patient and work with him or her in a nonadversarial setting to help the patient achieve reasonable compensation.
Furthermore, there would be no depositions, no cross-examinations, and no shutting down of a practice for 3 weeks to sit in a courtroom. Unlike the current system, there would be no reason to deny and defend.
In the Patients' Compensation System, the doctor incurs no personal financial liability for malpractice. In the current system, professional liability policies cover a limit for damages, usually $1 million. If a judgment exceeds this limit, the doctor is personally liable. This creates pressure on the doctor (and his or her insurer) to settle cases that might be defensible. Unlike in the current system, the doctor is fully "indemnified" for a patient's injury.
In the Patients' Compensation System, settlements and judgments reflecting payments to patients are not reportable to the NPDB. Because—unlike in the current system—payment would be made by the state-based system, such payment would not trigger reporting to the NPDB. As the statutory language states, "'Application' means a request for investigation by the Patients' Compensation System of an alleged occurrence of a medical injury and does not constitute a written demand for payment under any applicable state or federal law" (which might otherwise trigger reporting to the NPDB).
How Patients Would Benefit
In the Patients' Compensation System, all complaints would be reviewed. Currently, low-value claims are generally ignored by plaintiffs' attorneys because the cost of prosecuting such claims exceeds the estimated recovery. In contrast, because low-value claims would be heard under the Patients' Compensation System, more claims would be paid; in other words, more patients would have access to justice.
Payment would be made in months rather than years, as is common now. And the amount paid would be rational, reasonable, and predictable. Physicians would be able to speak openly and plainly about medical errors—enabling broad patient safety initiatives to be implemented.
The bill would allow a three-doctor panel to report any practitioner to the state licensing board who is an imminent danger to the public. A physician who poses such a risk would come to the attention of the board much sooner than under the status quo. Transparency is the starting point for fixing systemic safety problems related to those few physicians who are truly a danger to patients. A system cannot change what it cannot identify or measure.
How the Healthcare System Would Benefit
In the Patients' Compensation System, physicians would have no incentive to practice medicine defensively. Currently, if a doctor fails to order a particular test or imaging study and the patient has a bad outcome, that doctor is at risk for defending against a lawsuit that will last years and potentially bankrupt his or her life savings. Under this paradigm, defensive medicine is rational. As one emergency physician explained, "I will scan patients till they glow if it means avoiding even a day in court."
In the proposed system, doctors would be free to exercise their judgment. For example, if a person experiences a minor concussion, that individual will generally head to an emergency department. A minor concussion might be associated with brief loss of consciousness, nausea, headache, and other symptoms. On arrival in the emergency department, such a patient would ordinarily be neurologically intact. Best practices would include ordering an imaging study only for patients who either have or would be likely to develop an intracranial abnormality.
However, defensive medicine is often at odds with best practices—encouraging, in this hypothetical case, the ordering of an expensive scan and needlessly exposing the patient to radiation, whether or not the patient is deemed to be at risk.
In other words, resources could be saved without causing harm to patients. And patients who are unlikely to develop intracranial pathology would be spared radiation from an unnecessary imaging study.
The Patients' Compensation System would create an environment in which defensive medicine would not be needed. If this goal were achieved, the healthcare system would save a fortune.
Challenges to Passing the Bills
Those who benefit from the status quo will fight tooth and nail against change. This includes the trial bar, even though they will have a potential role to play in ensuring that patients' rights are preserved. Plaintiffs' lawyers will argue, for example, that state constitutions guarantee patients trial by jury, and the Patients' Compensation System removes that right.
Of course, old habits die hard. But trial lawyers would not have to risk their money going long on cases that might deliver zero payout. Plaintiffs' lawyers could assist patients without incurring any risk whatsoever, because they would be paid per transaction. Real estate attorneys, for example, have done quite well with such a model.
Whether the Patients' Compensation System is constitutional is beyond the scope of this article, but experts who have reviewed the proposed law firmly believe it passes constitutional muster.
What do patients say about a payment system as an alternative to litigation? A Georgia statewide survey by McLaughlin & Associates in August 2013 noted that 63% of participants support "reforming the current medical malpractice system" and 61% favor replacing the current medical malpractice system with a Patients' Compensation System.[4-6] There is an appetite on the part of the public to scrap what we currently have and try something new.
Dangers of Atarax (Hydroxyzine, Vistaril)
Physicians should take certain precautions in prescribing the first-generation antihistamine hydroxyzine to minimize the drug’s risk for potentially fatal heart arrhythmias, the European Medicines Agency (EMA) announced recently.
Hydroxyzine (Atarax, Vistaril) is approved in the European Union (EU) for treating anxiety disorders, sleep disorders, and pruritus as well as premedicating patients before surgery, with the indications varying by individual EU nation. Similar indications are approved in the United States. It is also used off label as an antiemetic/antinausea agent in the United States for adults.
The EMA’s Pharmacovigilance Risk Assessment Committee (PRAC) reviewed the safety of hydroxyzine at the request of Hungarian drug regulators, who were worried about adverse cardiac effects. PRAC confirmed a small but definite risk for QT interval prolongation and torsades de pointes, which can trigger ventricular fibrillation. However, the committee determined that clinicians could continue to prescribe the drug under the following conditions:
- Prescribe hydroxyzine at the lowest effective dose for the shortest time possible.
- Hydroxyzine must not be used by patients with known risk factors for heart arrhythmias or who are taking drugs that increase the risk for QT prolongation.
- The maximum daily dose should not exceed 100 mg in adults and 2 mg per kg of body weight in children weighing up to 40 kg.
- Hydroxyzine is not recommended for the elderly, but if clinicians believe that its use is unavoidable, the maximum daily dose for this age group should be 50 mg.
PRAC also recommended the continued monitoring of hydroxyzine to ensure that these precautions protect the public.
The committee’s recommendations now go to another EU regulatory body, the Co-ordination Group for Mutual Recognition and Decentralised Procedures-Human, for further action. This agency represents individual EU member states, each of which approves drugs for marketing within its borders.
Another Statin Side Effect
Statins are one of the most popular drugs. They reduce serum lipids implicated in producing cardiac and vascular disease. Statins have side effects and are well-known, such as liver disease and muscle pain. Now a new side effect has been discovered.
Statin therapy significantly elevates the risk of developing cataracts severe enough to warrant surgery, suggests analyses of two distinct cohorts, one from Canada and another from the US.
For now, the possibility of such a risk from statins and its potential mechanisms should be explored in prospective trials, "especially in light of increased statin use for primary prevention of cardiovascular disease and the importance of acceptable vision in old age, when cardiovascular disease is common," according to the report, published in the December 2014 issue of the Canadian Journal of Cardiology with lead author Dr Stephanie J Wise (University of British Columbia, Vancouver).
"However, because the relative risk is low and because cataract surgery is effective and well tolerated, this association should be disclosed but not be considered a deterrent to use of statins when warranted for cardiovascular risk reduction," they write.
"For those of us who have prescribed high doses of statins for almost 3 decades, there is certainly no epidemic of cataracts among our longtime lipid-clinic patients," write Drs Steven E Gryn and Robert A Hegele (Western University, London, ON) in an accompanying editorial in the same journal.
"Nevertheless, if the findings of Wise et al are confirmed, physicians might need to factor in this potential risk when discussing statin use with patients," they continue.
And, in patients at high CV risk, "the prevention of CVD, stroke, and their associated morbidity and mortality vastly outweighs the risk of cataracts. Even among lower-risk patients, for whom the benefit/risk ratio is less dramatic, most patients would still probably prefer having to undergo earlier non–life-threatening cataract surgery over suffering a major vascular event."
Ecstasy Use Increases Dramatically
As Emergency Departments swell while suffering the repercussions of the Affordable Healthcare Act, our nation's youth increase their use of mind-altering drugs, in particular, Ecstasy (Mollys).
The number of emergency department (ED) visits related to the use of Ecstasy (MDMA) (3,4-methylenedioxymethamphetamine) has increased by a staggering 128% in just 6 years, new research shows.
Also known as Ecstasy or Molly, a new report from the Substance Abuse and Mental Health Services Administration (SAMHSA) shows that MDMA-related visits among individuals younger than 21 years jumped from 4460 in 2005 to 10,176 in 2011.
In addition, 33% of ED visits involving MDMA use in this patient population also involved alcohol use.
"These findings raise concerns about the increase in popularity of this potentially harmful drug, especially in young people. Ecstasy is a street drug that can include other substances that can render it even more potentially harmful. We need to increase awareness about this drug's dangers and take other measures to prevent its use," Peter Delany, MD, SAMSHA's director of the Center for Behavioral Health and Statistics and Quality, said in a release.
MDMA has both stimulant and hallucinogenic properties. Although it is usually taken by mouth, it can also be snorted or smoked. The drug produces feelings of increased energy and euphoria and distorts users' sense and perception of time.
The report authors also note that the drug can produce a variety of negative health effects, including anxiety and confusion, that can last a week or longer. In addition, it has been associated with hypertension, as well as renal and cardiac failure.
The increase in this population is "a cause for concern due to the serious health risks involved with Ecstasy use and the higher potential for abuse when Ecstasy is mixed with alcohol," the report authors write.
The full report is available on the SAMSHA Web site.
Elevated Glucose in the ER
Over the past few years advancements have been made in the approach to, and management of, elevated blood glucose. In the emergency room, elevated blood glucose (hyperglycemia) is commonly encountered. Often times, patients who present with unrelated problems are coincidentally found to have elevated blood glucose. Many emergency physicians dismiss this finding as a chronic finding and therefore, do not investigate further. But this is a mistake that often results in an adverse patient outcome, and later a medical-legal inquiry and possibly a medical malpractice lawsuit.
Elevated blood glucose can be a tip-off that there are serious metabolic abnormalites present. A detailed investigation is warranted in the ER because many of these patients are asymptomatic and will not seek follow-up medical care until they become symptomatic, by which time their condition may be far advanced. The following review article on the approach to hyperglycemia in the ER is current and represents the standard of care approach to these patients.
Read more: Elevated Glucose in the ER
FDA Revises AMBIEN guidelines
Ambien is the most common sleeping medication at the present time. Unfortunately, although Ambien is usually quite effective at facilitating sleep, it also has been found to have several disturbing side effects, including tolerance, addiction, and somambulism. Recently the FDA has revised its dosing guidelines on how the medication should be used. The news brief follows:
Read more: FDA Revises AMBIEN guidelines
Problems With Ambien
Ambien (zolpidem) is currently the most commonly used sleeping medication on the market. Most physicians believe, unknowingly, that it can be prescribed with impunity. This is not the case. Ambien has many side effects that have resulted in a big increase in visits to emergency departments.
Read more: Problems With Ambien
Amitiza for Opioid-induced Constipation
The FDA finally approved a new drug which ameliorates the severe constipation that accompanies the use of Opiates. Constipation is one of the main side effects that causes individuals to stop Opiate medication prematurely without any other option for their pain. This addition to treatment with opiates is a notable advancement.
Read more: Amitiza for Opioid-induced Constipation
Zithromax and Sudden Death
At one time or another, most of us have taken the antibiotic, Zithromax. It is one of the most commonly prescribed medications for conditions including bronchitis, pharyngitis, sinusitis, and others. The discussion that follows has to do with Zithromax's side-effects, some of which are potentially life-threatening. Recently, I have seen a case in my emergency room of sudden cardiac arrest secondary to the cardiac effects of Zithromax. The FDA has recently warned of this phenomenon.
Read more: Zithromax and Sudden Death
2013 Review of Food Poisoning
The following article on food poisoning and foodborne outbreak disease was obtained from a recent issue of emedicine #175569. It is an overview that covers major topics and issues. It does not address travel medicine. But it would have direct relevance to community acquired disease, assessments for such diseases, and surveillance.
Read more: 2013 Review of Food Poisoning