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Had C difficile cleared before chemotherapy? ... and more

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Had C difficile cleared before chemotherapy?

THE DIAGNOSIS WAS BREAST CANCER for a 54-year-old woman. In May 2006, a surgeon performed a mastectomy and prescribed postoperative antibiotics.

In July, the patient became ill and was treated for Clostridium difficile infection. She began a course of chemotherapy in August, after telling her oncologist about the earlier infection. The patient later developed acute colitis and underwent emergency colectomy. She has a permanent ileostomy, has had 14 additional operations, and continues to suffer complications of severe colitis.

PATIENT’S CLAIM The surgeon was at fault for prescribing antibiotics after mastectomy. The oncologist was negligent in failing to test for C difficile before starting chemotherapy. The antibiotics caused C difficile infection. Because her immune system was compromised by chemotherapy, C difficile caused colitis.

PHYSICIANS’ DEFENSE The surgeon’s defense was not reported. The oncologist claimed he was not negligent; he questioned whether the patient had C difficile infection at all.

VERDICT The surgeon settled for an undisclosed amount before trial. A $4.5 million Oklahoma verdict was returned against the oncologist.

Uterine rupture and placental abruption found at C-section

A WOMAN WAS IN ACTIVE LABOR at 41 weeks’ gestation when admitted to the hospital. After 9 hours of labor, cesarean delivery was performed because the fetal heart-rate tracing showed tachycardia, with potential fetal distress.

At delivery, it was discovered that the uterus had ruptured and the placenta had abrupted. The child was asphyxic and bradycardic at birth. She suffered brain damage that resulted in severe cognitive deficits and cerebral palsy. At 5 years, she is unable to speak, walk, sit up, or feed herself.

PATIENT’S CLAIM Although the fetal heart-rate tracing showed fetal distress, several hours passed before cesarean delivery was performed. Oxytocin should not have been administered during labor because the drug is contraindicated in the presence of an abnormal fetal heart rate.

DEFENDANTS’ DEFENSE Hospital physicians and staff reacted properly and in a timely manner when the heart-rate tracing showed fetal distress. Uterine rupture and placental abruption could not have been foreseen.

VERDICT A $5.8 million Texas settlement was reached.

Fibrocystic mass becomes cancerous

A WOMAN UNDERWENT regular annual breast exams because of fibrocystic breast disease. Her primary care physician noted a breast mass in 1997, and continued to follow the mass. A biopsy in 1999 revealed fibrosis. In January 2002, breast cancer was diagnosed in the same mass, and the woman underwent mastectomy.

PATIENT’S CLAIM The physician was negligent in failing to diagnose breast cancer earlier. She had classic signs of cancer, including a persistent mass with changing symptoms.

PHYSICIAN’S DEFENSE The mass had been closely monitored, so that when changes were noted in December 2001, a referral was made and cancer diagnosed.

VERDICT A Louisiana defense verdict was returned.

Was mother’s labor monitored properly?

DURING DELIVERY, a woman experienced vaginal bleeding without pain or contractions. The nurses did not consider the bleeding excessive and did not detect any urgency to her labor until several hours later. The baby did not survive, and it was determined the mother suffered from vasa previa. She had been given a diagnosis of placenta previa at 15 weeks, but a sonogram at 20 weeks showed resolution.

PATIENT’S CLAIM The mother’s condition should have been monitored more closely. Vaginal bleeding during labor and delivery should have been responded to more urgently, given the history of placenta previa.

DEFENDANTS’ DEFENSE The hospital and the nurses claimed that the woman was properly treated.

VERDICT An Alabama defense verdict was returned.

Heart attack and death after epidural

AT AGE 34, A WOMAN WENT to the hospital for cesarean delivery of her third child. Within minutes of receiving epidural anesthesia, she became agitated and complained of difficulty breathing. She went into cardiopulmonary arrest, and resuscitation efforts were unsuccessful. The child survived.

ESTATE’S CLAIM A total spinal block occurred; the anesthesiologist failed to recognize and treat it in a timely manner.

PHYSICIAN’S DEFENSE Medications were properly administered; a total spinal block had not occurred. The patient had a history of Hodgkin’s lymphoma with chemotherapy, and radiation treatment of the chest. Autopsy indicated the cause of death was Castleman’s disease, a rare lymphoproliferative disease, which had not been diagnosed during her life.

VERDICT A $800,000 Virginia verdict was returned.

Retained sponge causes obstruction

AFTER CESAREAN DELIVERY, the nurses reported a complete sponge count. Immediately after surgery, the mother reported lower-left quadrant pain that resolved, then recurred. Several complaints to her ObGyn were dismissed. After 2.5 months, the ObGyn referred the patient to her primary care physician. An abdominal CT scan revealed a retained surgical sponge, with bowel perforation. The ObGyn attempted surgery, but the sponge was partially adhered to bowel. Colorectal surgeons had to resect two sections of small intestine to remove the infected sponge and abscess. She continues to have medical problems and has been hospitalized for an obstruction.

 

 

PATIENT’S CLAIM The nurses were negligent in failing to correctly count the sponges. The ObGyn was negligent for leaving the sponge in the patient’s abdomen, and for not responding to her complaints by determining the cause of her pain.

DEFENDANTS’ DEFENSE The nurses admitted liability but contended that the ObGyn was also at fault under the captain-of-the-ship doctrine. The ObGyn denied negligence, arguing that it was the nurses’ responsibility to count the sponges and that he acted properly by referring the patient to her primary care physician.

VERDICT The Pennsylvania jury found the hospital and nurses negligent and awarded a $525,000 verdict. A defense verdict was returned for the ObGyn.

Hypoxic ischemic encephalopathy

A WOMAN WENT TO THE HOSPITAL in labor. Her ObGyn was consulted by telephone at 10:20 pm. At 5:40 am, a positive scalp stimulation test indicated the fetus was healthy. The nurse called the ObGyn, who was en route to the hospital. At 6:04 am, the fetal heart rate dropped to 60 bpm. The nurse again contacted the ObGyn, and then called in a midwife, who took no effective action to complete delivery.

At 6:16 am, the covering physician was summoned, but the ObGyn arrived and took charge. When he saw that the fetal heart rate was still 60 bpm, he performed a central episiotomy and delivered the infant at 6:23 am using vacuum extraction. The infant suffered perinatal depression with hypoxic ischemic encephalopathy and brain damage.

PATIENT’S CLAIM The injuries were caused by continued low fetal heart rate. The hospital nurse, midwife, and covering physician were negligent in not reacting to the low fetal heart rate by performing emergency cesarean delivery. The ObGyn was negligent for not coming to the hospital earlier.

DEFENDANTS’ DEFENSE The hospital staff acted properly. The ObGyn was in touch with the hospital staff and came when labor became active. When he saw that the fetal heart rate was low, he saved the child’s life.

VERDICT A $7 million settlement was reached with the hospital; a defense verdict was returned for the ObGyn.

Incontinence or ovarian cancer?

A WOMAN IN HER 50s saw a urologist in November 2004 because of urinary incontinence. The urologist prescribed medication. During the next 2 years, there were additional examinations and treatment, but incontinence continued. In January 2007, a diagnosis of ovarian cancer was made. She died after the suit was filed.

ESTATE’S CLAIM Ovarian cancer should have been diagnosed in November 2004. The cancer could have been treated, and the patient would have survived. Incontinence is a symptom of that type of ovarian cancer.

PHYSICIAN’S DEFENSE The tests in November 2004 indicated that the decedent’s incontinence was from muscle weakness. Cancer did not develop until late 2006.

VERDICT A New York defense verdict was returned.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

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Had C difficile cleared before chemotherapy?

THE DIAGNOSIS WAS BREAST CANCER for a 54-year-old woman. In May 2006, a surgeon performed a mastectomy and prescribed postoperative antibiotics.

In July, the patient became ill and was treated for Clostridium difficile infection. She began a course of chemotherapy in August, after telling her oncologist about the earlier infection. The patient later developed acute colitis and underwent emergency colectomy. She has a permanent ileostomy, has had 14 additional operations, and continues to suffer complications of severe colitis.

PATIENT’S CLAIM The surgeon was at fault for prescribing antibiotics after mastectomy. The oncologist was negligent in failing to test for C difficile before starting chemotherapy. The antibiotics caused C difficile infection. Because her immune system was compromised by chemotherapy, C difficile caused colitis.

PHYSICIANS’ DEFENSE The surgeon’s defense was not reported. The oncologist claimed he was not negligent; he questioned whether the patient had C difficile infection at all.

VERDICT The surgeon settled for an undisclosed amount before trial. A $4.5 million Oklahoma verdict was returned against the oncologist.

Uterine rupture and placental abruption found at C-section

A WOMAN WAS IN ACTIVE LABOR at 41 weeks’ gestation when admitted to the hospital. After 9 hours of labor, cesarean delivery was performed because the fetal heart-rate tracing showed tachycardia, with potential fetal distress.

At delivery, it was discovered that the uterus had ruptured and the placenta had abrupted. The child was asphyxic and bradycardic at birth. She suffered brain damage that resulted in severe cognitive deficits and cerebral palsy. At 5 years, she is unable to speak, walk, sit up, or feed herself.

PATIENT’S CLAIM Although the fetal heart-rate tracing showed fetal distress, several hours passed before cesarean delivery was performed. Oxytocin should not have been administered during labor because the drug is contraindicated in the presence of an abnormal fetal heart rate.

DEFENDANTS’ DEFENSE Hospital physicians and staff reacted properly and in a timely manner when the heart-rate tracing showed fetal distress. Uterine rupture and placental abruption could not have been foreseen.

VERDICT A $5.8 million Texas settlement was reached.

Fibrocystic mass becomes cancerous

A WOMAN UNDERWENT regular annual breast exams because of fibrocystic breast disease. Her primary care physician noted a breast mass in 1997, and continued to follow the mass. A biopsy in 1999 revealed fibrosis. In January 2002, breast cancer was diagnosed in the same mass, and the woman underwent mastectomy.

PATIENT’S CLAIM The physician was negligent in failing to diagnose breast cancer earlier. She had classic signs of cancer, including a persistent mass with changing symptoms.

PHYSICIAN’S DEFENSE The mass had been closely monitored, so that when changes were noted in December 2001, a referral was made and cancer diagnosed.

VERDICT A Louisiana defense verdict was returned.

Was mother’s labor monitored properly?

DURING DELIVERY, a woman experienced vaginal bleeding without pain or contractions. The nurses did not consider the bleeding excessive and did not detect any urgency to her labor until several hours later. The baby did not survive, and it was determined the mother suffered from vasa previa. She had been given a diagnosis of placenta previa at 15 weeks, but a sonogram at 20 weeks showed resolution.

PATIENT’S CLAIM The mother’s condition should have been monitored more closely. Vaginal bleeding during labor and delivery should have been responded to more urgently, given the history of placenta previa.

DEFENDANTS’ DEFENSE The hospital and the nurses claimed that the woman was properly treated.

VERDICT An Alabama defense verdict was returned.

Heart attack and death after epidural

AT AGE 34, A WOMAN WENT to the hospital for cesarean delivery of her third child. Within minutes of receiving epidural anesthesia, she became agitated and complained of difficulty breathing. She went into cardiopulmonary arrest, and resuscitation efforts were unsuccessful. The child survived.

ESTATE’S CLAIM A total spinal block occurred; the anesthesiologist failed to recognize and treat it in a timely manner.

PHYSICIAN’S DEFENSE Medications were properly administered; a total spinal block had not occurred. The patient had a history of Hodgkin’s lymphoma with chemotherapy, and radiation treatment of the chest. Autopsy indicated the cause of death was Castleman’s disease, a rare lymphoproliferative disease, which had not been diagnosed during her life.

VERDICT A $800,000 Virginia verdict was returned.

Retained sponge causes obstruction

AFTER CESAREAN DELIVERY, the nurses reported a complete sponge count. Immediately after surgery, the mother reported lower-left quadrant pain that resolved, then recurred. Several complaints to her ObGyn were dismissed. After 2.5 months, the ObGyn referred the patient to her primary care physician. An abdominal CT scan revealed a retained surgical sponge, with bowel perforation. The ObGyn attempted surgery, but the sponge was partially adhered to bowel. Colorectal surgeons had to resect two sections of small intestine to remove the infected sponge and abscess. She continues to have medical problems and has been hospitalized for an obstruction.

 

 

PATIENT’S CLAIM The nurses were negligent in failing to correctly count the sponges. The ObGyn was negligent for leaving the sponge in the patient’s abdomen, and for not responding to her complaints by determining the cause of her pain.

DEFENDANTS’ DEFENSE The nurses admitted liability but contended that the ObGyn was also at fault under the captain-of-the-ship doctrine. The ObGyn denied negligence, arguing that it was the nurses’ responsibility to count the sponges and that he acted properly by referring the patient to her primary care physician.

VERDICT The Pennsylvania jury found the hospital and nurses negligent and awarded a $525,000 verdict. A defense verdict was returned for the ObGyn.

Hypoxic ischemic encephalopathy

A WOMAN WENT TO THE HOSPITAL in labor. Her ObGyn was consulted by telephone at 10:20 pm. At 5:40 am, a positive scalp stimulation test indicated the fetus was healthy. The nurse called the ObGyn, who was en route to the hospital. At 6:04 am, the fetal heart rate dropped to 60 bpm. The nurse again contacted the ObGyn, and then called in a midwife, who took no effective action to complete delivery.

At 6:16 am, the covering physician was summoned, but the ObGyn arrived and took charge. When he saw that the fetal heart rate was still 60 bpm, he performed a central episiotomy and delivered the infant at 6:23 am using vacuum extraction. The infant suffered perinatal depression with hypoxic ischemic encephalopathy and brain damage.

PATIENT’S CLAIM The injuries were caused by continued low fetal heart rate. The hospital nurse, midwife, and covering physician were negligent in not reacting to the low fetal heart rate by performing emergency cesarean delivery. The ObGyn was negligent for not coming to the hospital earlier.

DEFENDANTS’ DEFENSE The hospital staff acted properly. The ObGyn was in touch with the hospital staff and came when labor became active. When he saw that the fetal heart rate was low, he saved the child’s life.

VERDICT A $7 million settlement was reached with the hospital; a defense verdict was returned for the ObGyn.

Incontinence or ovarian cancer?

A WOMAN IN HER 50s saw a urologist in November 2004 because of urinary incontinence. The urologist prescribed medication. During the next 2 years, there were additional examinations and treatment, but incontinence continued. In January 2007, a diagnosis of ovarian cancer was made. She died after the suit was filed.

ESTATE’S CLAIM Ovarian cancer should have been diagnosed in November 2004. The cancer could have been treated, and the patient would have survived. Incontinence is a symptom of that type of ovarian cancer.

PHYSICIAN’S DEFENSE The tests in November 2004 indicated that the decedent’s incontinence was from muscle weakness. Cancer did not develop until late 2006.

VERDICT A New York defense verdict was returned.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Had C difficile cleared before chemotherapy?

THE DIAGNOSIS WAS BREAST CANCER for a 54-year-old woman. In May 2006, a surgeon performed a mastectomy and prescribed postoperative antibiotics.

In July, the patient became ill and was treated for Clostridium difficile infection. She began a course of chemotherapy in August, after telling her oncologist about the earlier infection. The patient later developed acute colitis and underwent emergency colectomy. She has a permanent ileostomy, has had 14 additional operations, and continues to suffer complications of severe colitis.

PATIENT’S CLAIM The surgeon was at fault for prescribing antibiotics after mastectomy. The oncologist was negligent in failing to test for C difficile before starting chemotherapy. The antibiotics caused C difficile infection. Because her immune system was compromised by chemotherapy, C difficile caused colitis.

PHYSICIANS’ DEFENSE The surgeon’s defense was not reported. The oncologist claimed he was not negligent; he questioned whether the patient had C difficile infection at all.

VERDICT The surgeon settled for an undisclosed amount before trial. A $4.5 million Oklahoma verdict was returned against the oncologist.

Uterine rupture and placental abruption found at C-section

A WOMAN WAS IN ACTIVE LABOR at 41 weeks’ gestation when admitted to the hospital. After 9 hours of labor, cesarean delivery was performed because the fetal heart-rate tracing showed tachycardia, with potential fetal distress.

At delivery, it was discovered that the uterus had ruptured and the placenta had abrupted. The child was asphyxic and bradycardic at birth. She suffered brain damage that resulted in severe cognitive deficits and cerebral palsy. At 5 years, she is unable to speak, walk, sit up, or feed herself.

PATIENT’S CLAIM Although the fetal heart-rate tracing showed fetal distress, several hours passed before cesarean delivery was performed. Oxytocin should not have been administered during labor because the drug is contraindicated in the presence of an abnormal fetal heart rate.

DEFENDANTS’ DEFENSE Hospital physicians and staff reacted properly and in a timely manner when the heart-rate tracing showed fetal distress. Uterine rupture and placental abruption could not have been foreseen.

VERDICT A $5.8 million Texas settlement was reached.

Fibrocystic mass becomes cancerous

A WOMAN UNDERWENT regular annual breast exams because of fibrocystic breast disease. Her primary care physician noted a breast mass in 1997, and continued to follow the mass. A biopsy in 1999 revealed fibrosis. In January 2002, breast cancer was diagnosed in the same mass, and the woman underwent mastectomy.

PATIENT’S CLAIM The physician was negligent in failing to diagnose breast cancer earlier. She had classic signs of cancer, including a persistent mass with changing symptoms.

PHYSICIAN’S DEFENSE The mass had been closely monitored, so that when changes were noted in December 2001, a referral was made and cancer diagnosed.

VERDICT A Louisiana defense verdict was returned.

Was mother’s labor monitored properly?

DURING DELIVERY, a woman experienced vaginal bleeding without pain or contractions. The nurses did not consider the bleeding excessive and did not detect any urgency to her labor until several hours later. The baby did not survive, and it was determined the mother suffered from vasa previa. She had been given a diagnosis of placenta previa at 15 weeks, but a sonogram at 20 weeks showed resolution.

PATIENT’S CLAIM The mother’s condition should have been monitored more closely. Vaginal bleeding during labor and delivery should have been responded to more urgently, given the history of placenta previa.

DEFENDANTS’ DEFENSE The hospital and the nurses claimed that the woman was properly treated.

VERDICT An Alabama defense verdict was returned.

Heart attack and death after epidural

AT AGE 34, A WOMAN WENT to the hospital for cesarean delivery of her third child. Within minutes of receiving epidural anesthesia, she became agitated and complained of difficulty breathing. She went into cardiopulmonary arrest, and resuscitation efforts were unsuccessful. The child survived.

ESTATE’S CLAIM A total spinal block occurred; the anesthesiologist failed to recognize and treat it in a timely manner.

PHYSICIAN’S DEFENSE Medications were properly administered; a total spinal block had not occurred. The patient had a history of Hodgkin’s lymphoma with chemotherapy, and radiation treatment of the chest. Autopsy indicated the cause of death was Castleman’s disease, a rare lymphoproliferative disease, which had not been diagnosed during her life.

VERDICT A $800,000 Virginia verdict was returned.

Retained sponge causes obstruction

AFTER CESAREAN DELIVERY, the nurses reported a complete sponge count. Immediately after surgery, the mother reported lower-left quadrant pain that resolved, then recurred. Several complaints to her ObGyn were dismissed. After 2.5 months, the ObGyn referred the patient to her primary care physician. An abdominal CT scan revealed a retained surgical sponge, with bowel perforation. The ObGyn attempted surgery, but the sponge was partially adhered to bowel. Colorectal surgeons had to resect two sections of small intestine to remove the infected sponge and abscess. She continues to have medical problems and has been hospitalized for an obstruction.

 

 

PATIENT’S CLAIM The nurses were negligent in failing to correctly count the sponges. The ObGyn was negligent for leaving the sponge in the patient’s abdomen, and for not responding to her complaints by determining the cause of her pain.

DEFENDANTS’ DEFENSE The nurses admitted liability but contended that the ObGyn was also at fault under the captain-of-the-ship doctrine. The ObGyn denied negligence, arguing that it was the nurses’ responsibility to count the sponges and that he acted properly by referring the patient to her primary care physician.

VERDICT The Pennsylvania jury found the hospital and nurses negligent and awarded a $525,000 verdict. A defense verdict was returned for the ObGyn.

Hypoxic ischemic encephalopathy

A WOMAN WENT TO THE HOSPITAL in labor. Her ObGyn was consulted by telephone at 10:20 pm. At 5:40 am, a positive scalp stimulation test indicated the fetus was healthy. The nurse called the ObGyn, who was en route to the hospital. At 6:04 am, the fetal heart rate dropped to 60 bpm. The nurse again contacted the ObGyn, and then called in a midwife, who took no effective action to complete delivery.

At 6:16 am, the covering physician was summoned, but the ObGyn arrived and took charge. When he saw that the fetal heart rate was still 60 bpm, he performed a central episiotomy and delivered the infant at 6:23 am using vacuum extraction. The infant suffered perinatal depression with hypoxic ischemic encephalopathy and brain damage.

PATIENT’S CLAIM The injuries were caused by continued low fetal heart rate. The hospital nurse, midwife, and covering physician were negligent in not reacting to the low fetal heart rate by performing emergency cesarean delivery. The ObGyn was negligent for not coming to the hospital earlier.

DEFENDANTS’ DEFENSE The hospital staff acted properly. The ObGyn was in touch with the hospital staff and came when labor became active. When he saw that the fetal heart rate was low, he saved the child’s life.

VERDICT A $7 million settlement was reached with the hospital; a defense verdict was returned for the ObGyn.

Incontinence or ovarian cancer?

A WOMAN IN HER 50s saw a urologist in November 2004 because of urinary incontinence. The urologist prescribed medication. During the next 2 years, there were additional examinations and treatment, but incontinence continued. In January 2007, a diagnosis of ovarian cancer was made. She died after the suit was filed.

ESTATE’S CLAIM Ovarian cancer should have been diagnosed in November 2004. The cancer could have been treated, and the patient would have survived. Incontinence is a symptom of that type of ovarian cancer.

PHYSICIAN’S DEFENSE The tests in November 2004 indicated that the decedent’s incontinence was from muscle weakness. Cancer did not develop until late 2006.

VERDICT A New York defense verdict was returned.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

References

We want to hear from you! Tell us what you think.

References

We want to hear from you! Tell us what you think.

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Had C difficile cleared before chemotherapy? ... and more
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Had C difficile cleared before chemotherapy? ... and more
Legacy Keywords
Malpractice;Medical malpractice;C difficile;chemotherapy;breast cancer;Clostridium difficile;verdict;settlement;defense;negligence;Medical Malpractice Verdicts;Settlements & Experts;Lewis Laska;uterine rupture;placental abruption;cesarean delivery;fibrocystic mass;vasa previa;placenta previa;cardiac arrest;retained sponge;hypoxic ischemic encephalopathy;vacuum extraction;incontinence;ovarian cancer;fetal heart-rate monitor;FHR;scalp stimulation test;sponge count;spinal block;Hodgkin's lymphoma
Legacy Keywords
Malpractice;Medical malpractice;C difficile;chemotherapy;breast cancer;Clostridium difficile;verdict;settlement;defense;negligence;Medical Malpractice Verdicts;Settlements & Experts;Lewis Laska;uterine rupture;placental abruption;cesarean delivery;fibrocystic mass;vasa previa;placenta previa;cardiac arrest;retained sponge;hypoxic ischemic encephalopathy;vacuum extraction;incontinence;ovarian cancer;fetal heart-rate monitor;FHR;scalp stimulation test;sponge count;spinal block;Hodgkin's lymphoma
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Inadequate differential proves fatal ... Death by fentanyl patch and methadone ... more

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Culture results go undiscussed, man suffers stroke

TWO WEEKS AFTER PROSTATE SURGERY, a 76-year-old man went to the ED because he was having trouble urinating. The ED physician catheterized the patient, ordered a urine culture, and discharged him.

The culture results, showing methicillin-resistant Staphylococcus aureus, were sent to a printer in the ED twice, as was the usual practice, but evidently no one saw them.

The patient returned to the ED 2 weeks after his initial visit with the same complaint of difficult urination and was seen by the same physician. The physician again discharged him with a catheter but without mentioning the culture results. Two days later, the patient suffered a stroke, which paralyzed his left side.

PLAINTIFF’S CLAIM The bacteria had spread from the patient’s urine to his bloodstream, sparking a cascade of events that led to the stroke.

THE DEFENSE No information about the defense is available.

VERDICT $2.25 million New Jersey settlement.

COMMENT The repeated missed opportunities to diagnose and treat this patient’s infection were regrettable—and costly.

Inadequate differential proves fatal

SHORTNESS OF BREATH led a 52-year-old woman to visit her medical group, where she was a long-time patient. The family practitioner who saw her noted tachycardia and ordered an electrocardiogram, which was abnormal. The physician also ordered a chest x-ray and, because the woman had a history of anemia, a complete blood count and a number of other blood tests. He subsequently called the patient at home to tell her that the blood tests were normal and she didn’t have anemia.

Three days later, the patient went to an urgent care center complaining of shortness of breath and tightness in her chest. A pulmonary embolism was diagnosed, and she was transferred to a hospital ED. Later that evening, a code blue was called and the patient was resuscitated. She died the following day.

PLAINTIFF’S CLAIM The doctor assumed that the patient had anemia and failed to develop a differential diagnosis. The patient had risk factors for pulmonary embolism—obesity and the use of an ethinyl estradiol-etonogestrel vaginal contraceptive ring—which should have prompted the doctor to consider that possibility. If he had done so, the pulmonary embolism would have been diagnosed and the patient’s death prevented.

THE DEFENSE The patient’s presentation wasn’t typical for pulmonary embolism, and there wasn’t any way to know whether an earlier diagnosis would have resulted in survival.

VERDICT $1.9 million California verdict.

COMMENT Although pulmonary embolism can be a challenging diagnosis to make, it needs to be considered carefully in all patients with shortness of breath, chest pain, or poorly defined pulmonary or cardiac symptoms.

The correct diagnosis comes too late

FLU-LIKE SYMPTOMS AND AN IRREGULAR HEART RATE prompted a man to go to the ED, where the physician diagnosed a viral infection, prescribed pain medication, and discharged him. The following day, a laboratory report indicating a staph infection was sent to an ED secretary, but the patient wasn’t told the results.

The patient returned to the hospital 2 days later in a confused state. Tests revealed a staph infection and meningitis, for which the patient received antibiotics. A week later, the patient suffered a stroke, resulting in diminished cognitive ability, impaired vision, and right-sided motor deficits.

PLAINTIFF’S CLAIM The white blood cell count and C-reactive protein level measured at the patient’s first visit to the ED would have led to a diagnosis of bacterial infection. The patient should have been admitted to the hospital and given antibiotics at that time.

THE DEFENSE The original diagnosis was reasonable.

VERDICT Confidential settlement with the hospital. $900,000 net verdict against the physician in New Jersey.

COMMENT Lab reports gone awry and the lack of a fail-safe for abnormal tests result in a $900,000 judgment. Do you have adequate systems in place to avoid a communication failure like this one?

 

 

Slow response turns a bad situation into a disaster

A 66-YEAR-OLD MAN on warfarin therapy for chronic atrial fibrillation and a transient ischemic attack underwent lithotripsy for kidney stones. Three days after the lithotripsy, he went to the ED complaining of severe flank pain. A computed tomography (CT) scan of the abdomen showed a large retroperitoneal hematoma and prominent perinephric and pararenal hemorrhages.

The patient remained on a gurney in the hallway of the ED in deteriorating condition until he was admitted to the intensive care unit, by which time his condition was critical. He died the next day.

PLAINTIFF’S CLAIM The ED physician and admitting urologists failed to monitor and treat the patient’s active hemorrhage for 9 hours. They didn’t order coagulation studies or respond to signs of escalating hemorrhagic shock. They failed to seek timely consults from surgery and interventional radiology.

THE DEFENSE No information about the defense is available.

VERDICT $825,000 Virginia settlement.

COMMENT Preventing complications of anticoagulation is hard enough; the lack of a timely response in this case made a bad outcome disastrous.

Were steps taken quickly enough?

SEVERE LOWER ABDOMINAL PAIN prompted a 52-year-old woman to go to the ED. She said she hadn’t had a bowel movement in almost a week. The ED physician, in consultation with the attending physician, admitted her to the hospital and ordered intravenous fluids and a soap suds enema, which didn’t relieve the constipation. The patient’s vital signs deteriorated, and she was crying and restless.

When the attending physician saw the patient almost 3 hours after admission, she had a fever of 101.4°F. He ordered additional tests, a computed tomography (CT) scan, and antibiotics, but didn’t order them STAT.

About 1½ hours later, a house physician examined the patient, and, after speaking with the attending physician, transferred her to a step-down telemetry unit. About 1½ hours after the transfer, a nurse called the house physician to report that the patient’s condition was worsening. The house physician ordered pain relievers and a second enema but didn’t come to the hospital.

Because the patient wasn’t in the intensive care unit, no one checked on her again for 3½ hours. When the nurse did check, she found the patient pale, cold, and turning blue. The nurse called the house physician, who came to the hospital. The patient had a fever of 102.4°F and her blood pressure couldn’t be measured.

After speaking with the attending physician, the house physician had the patient admitted to the ICU and also ordered a STAT surgical consultation and CT scan. In the meantime, the patient went into cardiac arrest and couldn’t be revived. Death was caused by peritonitis with sepsis resulting from a large intestinal obstruction.

PLAINTIFF’S CLAIM The patient showed early signs of sepsis. She should have undergone testing sooner and been transferred to the ICU earlier.

THE DEFENSE The doctors claimed that all their actions were appropriate and that the actions suggested by the plaintiff wouldn’t have resulted in the patient’s survival.

VERDICT $3.8 million Pennsylvania verdict.

COMMENT Prompt evaluation and monitoring of this patient might have prevented death and a substantial verdict.

 

 

2 analgesic calamities: Death by fentanyl patch …

AFTER A WEEK OF INCREASING BACK PAIN, which had begun to shoot down his right leg, a 37-year-old man went to the ED. He was examined and given prescriptions for pain killers, including acetaminophen and hydrocodone, and muscle relaxants and discharged with instructions to return in 3 days for magnetic resonance imaging (MRI).

While he was at the hospital for the MRI, the patient returned to the ED because he was still in pain and his acetaminophen-hydrocodone prescription was running out. The ED physician prescribed a 0.75-mg fentanyl transdermal patch and instructed the patient to put it on his chest.

Three days later, the patient filled the prescription and applied the patch. The following day, his girlfriend found him dead in bed. Postmortem toxicology results showed a blood fentanyl level of 9.85 ng/mL, markedly higher than the therapeutic level. Respiratory failure caused by fentanyl toxicity was cited as the cause of death.

PLAINTIFF’S CLAIM The ED physician prescribed an excessive dose of fentanyl.

THE DEFENSE A defective patch or misuse of the patch caused the patient’s death.

VERDICT $1.2 million Indiana verdict.

… and methadone

A 36-YEAR-OLD MAN started treatment with a pain specialist for pain arising from a back problem, for which he had taken pain medication previously. The pain specialist prescribed methadone, 360 10-mg tablets. The prescription limited the patient to 2 tablets every 4 hours for a maximum dosage of 12 tablets (120 mg) per day.

Three days after the patient filled the prescription, he was found dead. An autopsy determined the cause of death to be drug toxicity from methadone. At the time the patient died, the bottle of methadone tablets contained 342 tablets, indicating that he had taken only 18 tablets, well within the maximum dosage authorized by the prescription.

PLAINTIFF’S CLAIM The prescribed methadone dosage was excessive for a patient just beginning to use the drug. A proper initial dosage is between 2.5 and 10 mg every 8 to 12 hours for a maximum of 30 mg per day.

THE DEFENSE No information about the defense is available.

VERDICT Confidential Utah settlement.

COMMENT These 2 cases have a common thread. The effects of opioids are often idiosyncratic. A plan for careful monitoring and follow-up should be prepared at initiation of treatment and when escalating the dosage.

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Culture results go undiscussed, man suffers stroke

TWO WEEKS AFTER PROSTATE SURGERY, a 76-year-old man went to the ED because he was having trouble urinating. The ED physician catheterized the patient, ordered a urine culture, and discharged him.

The culture results, showing methicillin-resistant Staphylococcus aureus, were sent to a printer in the ED twice, as was the usual practice, but evidently no one saw them.

The patient returned to the ED 2 weeks after his initial visit with the same complaint of difficult urination and was seen by the same physician. The physician again discharged him with a catheter but without mentioning the culture results. Two days later, the patient suffered a stroke, which paralyzed his left side.

PLAINTIFF’S CLAIM The bacteria had spread from the patient’s urine to his bloodstream, sparking a cascade of events that led to the stroke.

THE DEFENSE No information about the defense is available.

VERDICT $2.25 million New Jersey settlement.

COMMENT The repeated missed opportunities to diagnose and treat this patient’s infection were regrettable—and costly.

Inadequate differential proves fatal

SHORTNESS OF BREATH led a 52-year-old woman to visit her medical group, where she was a long-time patient. The family practitioner who saw her noted tachycardia and ordered an electrocardiogram, which was abnormal. The physician also ordered a chest x-ray and, because the woman had a history of anemia, a complete blood count and a number of other blood tests. He subsequently called the patient at home to tell her that the blood tests were normal and she didn’t have anemia.

Three days later, the patient went to an urgent care center complaining of shortness of breath and tightness in her chest. A pulmonary embolism was diagnosed, and she was transferred to a hospital ED. Later that evening, a code blue was called and the patient was resuscitated. She died the following day.

PLAINTIFF’S CLAIM The doctor assumed that the patient had anemia and failed to develop a differential diagnosis. The patient had risk factors for pulmonary embolism—obesity and the use of an ethinyl estradiol-etonogestrel vaginal contraceptive ring—which should have prompted the doctor to consider that possibility. If he had done so, the pulmonary embolism would have been diagnosed and the patient’s death prevented.

THE DEFENSE The patient’s presentation wasn’t typical for pulmonary embolism, and there wasn’t any way to know whether an earlier diagnosis would have resulted in survival.

VERDICT $1.9 million California verdict.

COMMENT Although pulmonary embolism can be a challenging diagnosis to make, it needs to be considered carefully in all patients with shortness of breath, chest pain, or poorly defined pulmonary or cardiac symptoms.

The correct diagnosis comes too late

FLU-LIKE SYMPTOMS AND AN IRREGULAR HEART RATE prompted a man to go to the ED, where the physician diagnosed a viral infection, prescribed pain medication, and discharged him. The following day, a laboratory report indicating a staph infection was sent to an ED secretary, but the patient wasn’t told the results.

The patient returned to the hospital 2 days later in a confused state. Tests revealed a staph infection and meningitis, for which the patient received antibiotics. A week later, the patient suffered a stroke, resulting in diminished cognitive ability, impaired vision, and right-sided motor deficits.

PLAINTIFF’S CLAIM The white blood cell count and C-reactive protein level measured at the patient’s first visit to the ED would have led to a diagnosis of bacterial infection. The patient should have been admitted to the hospital and given antibiotics at that time.

THE DEFENSE The original diagnosis was reasonable.

VERDICT Confidential settlement with the hospital. $900,000 net verdict against the physician in New Jersey.

COMMENT Lab reports gone awry and the lack of a fail-safe for abnormal tests result in a $900,000 judgment. Do you have adequate systems in place to avoid a communication failure like this one?

 

 

Slow response turns a bad situation into a disaster

A 66-YEAR-OLD MAN on warfarin therapy for chronic atrial fibrillation and a transient ischemic attack underwent lithotripsy for kidney stones. Three days after the lithotripsy, he went to the ED complaining of severe flank pain. A computed tomography (CT) scan of the abdomen showed a large retroperitoneal hematoma and prominent perinephric and pararenal hemorrhages.

The patient remained on a gurney in the hallway of the ED in deteriorating condition until he was admitted to the intensive care unit, by which time his condition was critical. He died the next day.

PLAINTIFF’S CLAIM The ED physician and admitting urologists failed to monitor and treat the patient’s active hemorrhage for 9 hours. They didn’t order coagulation studies or respond to signs of escalating hemorrhagic shock. They failed to seek timely consults from surgery and interventional radiology.

THE DEFENSE No information about the defense is available.

VERDICT $825,000 Virginia settlement.

COMMENT Preventing complications of anticoagulation is hard enough; the lack of a timely response in this case made a bad outcome disastrous.

Were steps taken quickly enough?

SEVERE LOWER ABDOMINAL PAIN prompted a 52-year-old woman to go to the ED. She said she hadn’t had a bowel movement in almost a week. The ED physician, in consultation with the attending physician, admitted her to the hospital and ordered intravenous fluids and a soap suds enema, which didn’t relieve the constipation. The patient’s vital signs deteriorated, and she was crying and restless.

When the attending physician saw the patient almost 3 hours after admission, she had a fever of 101.4°F. He ordered additional tests, a computed tomography (CT) scan, and antibiotics, but didn’t order them STAT.

About 1½ hours later, a house physician examined the patient, and, after speaking with the attending physician, transferred her to a step-down telemetry unit. About 1½ hours after the transfer, a nurse called the house physician to report that the patient’s condition was worsening. The house physician ordered pain relievers and a second enema but didn’t come to the hospital.

Because the patient wasn’t in the intensive care unit, no one checked on her again for 3½ hours. When the nurse did check, she found the patient pale, cold, and turning blue. The nurse called the house physician, who came to the hospital. The patient had a fever of 102.4°F and her blood pressure couldn’t be measured.

After speaking with the attending physician, the house physician had the patient admitted to the ICU and also ordered a STAT surgical consultation and CT scan. In the meantime, the patient went into cardiac arrest and couldn’t be revived. Death was caused by peritonitis with sepsis resulting from a large intestinal obstruction.

PLAINTIFF’S CLAIM The patient showed early signs of sepsis. She should have undergone testing sooner and been transferred to the ICU earlier.

THE DEFENSE The doctors claimed that all their actions were appropriate and that the actions suggested by the plaintiff wouldn’t have resulted in the patient’s survival.

VERDICT $3.8 million Pennsylvania verdict.

COMMENT Prompt evaluation and monitoring of this patient might have prevented death and a substantial verdict.

 

 

2 analgesic calamities: Death by fentanyl patch …

AFTER A WEEK OF INCREASING BACK PAIN, which had begun to shoot down his right leg, a 37-year-old man went to the ED. He was examined and given prescriptions for pain killers, including acetaminophen and hydrocodone, and muscle relaxants and discharged with instructions to return in 3 days for magnetic resonance imaging (MRI).

While he was at the hospital for the MRI, the patient returned to the ED because he was still in pain and his acetaminophen-hydrocodone prescription was running out. The ED physician prescribed a 0.75-mg fentanyl transdermal patch and instructed the patient to put it on his chest.

Three days later, the patient filled the prescription and applied the patch. The following day, his girlfriend found him dead in bed. Postmortem toxicology results showed a blood fentanyl level of 9.85 ng/mL, markedly higher than the therapeutic level. Respiratory failure caused by fentanyl toxicity was cited as the cause of death.

PLAINTIFF’S CLAIM The ED physician prescribed an excessive dose of fentanyl.

THE DEFENSE A defective patch or misuse of the patch caused the patient’s death.

VERDICT $1.2 million Indiana verdict.

… and methadone

A 36-YEAR-OLD MAN started treatment with a pain specialist for pain arising from a back problem, for which he had taken pain medication previously. The pain specialist prescribed methadone, 360 10-mg tablets. The prescription limited the patient to 2 tablets every 4 hours for a maximum dosage of 12 tablets (120 mg) per day.

Three days after the patient filled the prescription, he was found dead. An autopsy determined the cause of death to be drug toxicity from methadone. At the time the patient died, the bottle of methadone tablets contained 342 tablets, indicating that he had taken only 18 tablets, well within the maximum dosage authorized by the prescription.

PLAINTIFF’S CLAIM The prescribed methadone dosage was excessive for a patient just beginning to use the drug. A proper initial dosage is between 2.5 and 10 mg every 8 to 12 hours for a maximum of 30 mg per day.

THE DEFENSE No information about the defense is available.

VERDICT Confidential Utah settlement.

COMMENT These 2 cases have a common thread. The effects of opioids are often idiosyncratic. A plan for careful monitoring and follow-up should be prepared at initiation of treatment and when escalating the dosage.

Culture results go undiscussed, man suffers stroke

TWO WEEKS AFTER PROSTATE SURGERY, a 76-year-old man went to the ED because he was having trouble urinating. The ED physician catheterized the patient, ordered a urine culture, and discharged him.

The culture results, showing methicillin-resistant Staphylococcus aureus, were sent to a printer in the ED twice, as was the usual practice, but evidently no one saw them.

The patient returned to the ED 2 weeks after his initial visit with the same complaint of difficult urination and was seen by the same physician. The physician again discharged him with a catheter but without mentioning the culture results. Two days later, the patient suffered a stroke, which paralyzed his left side.

PLAINTIFF’S CLAIM The bacteria had spread from the patient’s urine to his bloodstream, sparking a cascade of events that led to the stroke.

THE DEFENSE No information about the defense is available.

VERDICT $2.25 million New Jersey settlement.

COMMENT The repeated missed opportunities to diagnose and treat this patient’s infection were regrettable—and costly.

Inadequate differential proves fatal

SHORTNESS OF BREATH led a 52-year-old woman to visit her medical group, where she was a long-time patient. The family practitioner who saw her noted tachycardia and ordered an electrocardiogram, which was abnormal. The physician also ordered a chest x-ray and, because the woman had a history of anemia, a complete blood count and a number of other blood tests. He subsequently called the patient at home to tell her that the blood tests were normal and she didn’t have anemia.

Three days later, the patient went to an urgent care center complaining of shortness of breath and tightness in her chest. A pulmonary embolism was diagnosed, and she was transferred to a hospital ED. Later that evening, a code blue was called and the patient was resuscitated. She died the following day.

PLAINTIFF’S CLAIM The doctor assumed that the patient had anemia and failed to develop a differential diagnosis. The patient had risk factors for pulmonary embolism—obesity and the use of an ethinyl estradiol-etonogestrel vaginal contraceptive ring—which should have prompted the doctor to consider that possibility. If he had done so, the pulmonary embolism would have been diagnosed and the patient’s death prevented.

THE DEFENSE The patient’s presentation wasn’t typical for pulmonary embolism, and there wasn’t any way to know whether an earlier diagnosis would have resulted in survival.

VERDICT $1.9 million California verdict.

COMMENT Although pulmonary embolism can be a challenging diagnosis to make, it needs to be considered carefully in all patients with shortness of breath, chest pain, or poorly defined pulmonary or cardiac symptoms.

The correct diagnosis comes too late

FLU-LIKE SYMPTOMS AND AN IRREGULAR HEART RATE prompted a man to go to the ED, where the physician diagnosed a viral infection, prescribed pain medication, and discharged him. The following day, a laboratory report indicating a staph infection was sent to an ED secretary, but the patient wasn’t told the results.

The patient returned to the hospital 2 days later in a confused state. Tests revealed a staph infection and meningitis, for which the patient received antibiotics. A week later, the patient suffered a stroke, resulting in diminished cognitive ability, impaired vision, and right-sided motor deficits.

PLAINTIFF’S CLAIM The white blood cell count and C-reactive protein level measured at the patient’s first visit to the ED would have led to a diagnosis of bacterial infection. The patient should have been admitted to the hospital and given antibiotics at that time.

THE DEFENSE The original diagnosis was reasonable.

VERDICT Confidential settlement with the hospital. $900,000 net verdict against the physician in New Jersey.

COMMENT Lab reports gone awry and the lack of a fail-safe for abnormal tests result in a $900,000 judgment. Do you have adequate systems in place to avoid a communication failure like this one?

 

 

Slow response turns a bad situation into a disaster

A 66-YEAR-OLD MAN on warfarin therapy for chronic atrial fibrillation and a transient ischemic attack underwent lithotripsy for kidney stones. Three days after the lithotripsy, he went to the ED complaining of severe flank pain. A computed tomography (CT) scan of the abdomen showed a large retroperitoneal hematoma and prominent perinephric and pararenal hemorrhages.

The patient remained on a gurney in the hallway of the ED in deteriorating condition until he was admitted to the intensive care unit, by which time his condition was critical. He died the next day.

PLAINTIFF’S CLAIM The ED physician and admitting urologists failed to monitor and treat the patient’s active hemorrhage for 9 hours. They didn’t order coagulation studies or respond to signs of escalating hemorrhagic shock. They failed to seek timely consults from surgery and interventional radiology.

THE DEFENSE No information about the defense is available.

VERDICT $825,000 Virginia settlement.

COMMENT Preventing complications of anticoagulation is hard enough; the lack of a timely response in this case made a bad outcome disastrous.

Were steps taken quickly enough?

SEVERE LOWER ABDOMINAL PAIN prompted a 52-year-old woman to go to the ED. She said she hadn’t had a bowel movement in almost a week. The ED physician, in consultation with the attending physician, admitted her to the hospital and ordered intravenous fluids and a soap suds enema, which didn’t relieve the constipation. The patient’s vital signs deteriorated, and she was crying and restless.

When the attending physician saw the patient almost 3 hours after admission, she had a fever of 101.4°F. He ordered additional tests, a computed tomography (CT) scan, and antibiotics, but didn’t order them STAT.

About 1½ hours later, a house physician examined the patient, and, after speaking with the attending physician, transferred her to a step-down telemetry unit. About 1½ hours after the transfer, a nurse called the house physician to report that the patient’s condition was worsening. The house physician ordered pain relievers and a second enema but didn’t come to the hospital.

Because the patient wasn’t in the intensive care unit, no one checked on her again for 3½ hours. When the nurse did check, she found the patient pale, cold, and turning blue. The nurse called the house physician, who came to the hospital. The patient had a fever of 102.4°F and her blood pressure couldn’t be measured.

After speaking with the attending physician, the house physician had the patient admitted to the ICU and also ordered a STAT surgical consultation and CT scan. In the meantime, the patient went into cardiac arrest and couldn’t be revived. Death was caused by peritonitis with sepsis resulting from a large intestinal obstruction.

PLAINTIFF’S CLAIM The patient showed early signs of sepsis. She should have undergone testing sooner and been transferred to the ICU earlier.

THE DEFENSE The doctors claimed that all their actions were appropriate and that the actions suggested by the plaintiff wouldn’t have resulted in the patient’s survival.

VERDICT $3.8 million Pennsylvania verdict.

COMMENT Prompt evaluation and monitoring of this patient might have prevented death and a substantial verdict.

 

 

2 analgesic calamities: Death by fentanyl patch …

AFTER A WEEK OF INCREASING BACK PAIN, which had begun to shoot down his right leg, a 37-year-old man went to the ED. He was examined and given prescriptions for pain killers, including acetaminophen and hydrocodone, and muscle relaxants and discharged with instructions to return in 3 days for magnetic resonance imaging (MRI).

While he was at the hospital for the MRI, the patient returned to the ED because he was still in pain and his acetaminophen-hydrocodone prescription was running out. The ED physician prescribed a 0.75-mg fentanyl transdermal patch and instructed the patient to put it on his chest.

Three days later, the patient filled the prescription and applied the patch. The following day, his girlfriend found him dead in bed. Postmortem toxicology results showed a blood fentanyl level of 9.85 ng/mL, markedly higher than the therapeutic level. Respiratory failure caused by fentanyl toxicity was cited as the cause of death.

PLAINTIFF’S CLAIM The ED physician prescribed an excessive dose of fentanyl.

THE DEFENSE A defective patch or misuse of the patch caused the patient’s death.

VERDICT $1.2 million Indiana verdict.

… and methadone

A 36-YEAR-OLD MAN started treatment with a pain specialist for pain arising from a back problem, for which he had taken pain medication previously. The pain specialist prescribed methadone, 360 10-mg tablets. The prescription limited the patient to 2 tablets every 4 hours for a maximum dosage of 12 tablets (120 mg) per day.

Three days after the patient filled the prescription, he was found dead. An autopsy determined the cause of death to be drug toxicity from methadone. At the time the patient died, the bottle of methadone tablets contained 342 tablets, indicating that he had taken only 18 tablets, well within the maximum dosage authorized by the prescription.

PLAINTIFF’S CLAIM The prescribed methadone dosage was excessive for a patient just beginning to use the drug. A proper initial dosage is between 2.5 and 10 mg every 8 to 12 hours for a maximum of 30 mg per day.

THE DEFENSE No information about the defense is available.

VERDICT Confidential Utah settlement.

COMMENT These 2 cases have a common thread. The effects of opioids are often idiosyncratic. A plan for careful monitoring and follow-up should be prepared at initiation of treatment and when escalating the dosage.

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Gravida in septic shock; were signs missed?

WITH SEVERE ABDOMINAL PAIN AND VOMITING at 14 weeks’ gestation, a 30-year-old woman was brought by ambulance to the hospital. After initial evaluation did not reveal a cause of her symptoms, she was transferred to the antepartum unit for observation.

The mother developed hypotension and a diagnosis of septic shock was made. Fetal cardiac activity ceased and the woman developed intestinal ischemia. She underwent an intestinal transplant several months later.

PATIENT’S CLAIM Both treating physicians and the nursing staff failed to react to her intermittently low blood pressure, and failed to diagnose or treat septic shock in a timely manner.

DEFENDANTS’ DEFENSE The patient was properly monitored and treated.

VERDICT A $11,500,000 Illinois verdict was returned against the hospital. A defense verdict was returned for both physicians.

Lethal outcome of ovarian cystectomy

A WOMAN IN HER 40s underwent ovarian cystectomy. During surgery, her gynecologist encountered dense adhesions that required bowel dissection. Later, the woman complained of severe abdominal pain, despite taking pain medication. A second gynecologist ordered an abdominal scan that showed fluid and possible bowel obstruction. Hospital staff ruled out pulmonary embolism. When her blood pressure dropped to dangerous levels, a surgeon recommended surgery. Preoperative testing found punctures in both large and small intestines. Before she could be given anesthesia, the woman suffered cardiac arrest, and was placed on a ventilator. The family asked that the ventilator be removed after three days, and she died.

ESTATE’S CLAIM The hospital staff and gynecologists were negligent in not ruling out bowel perforation as soon as the woman complained of severe abdominal pain after surgery.

DEFENDANTS’ DEFENSE Bowel perforation is a known complication of the surgery. There was no negligence; it was a complicated problem and the staff had progressively attempted to rule out various postsurgical issues.

VERDICT A $2.5 million Illinois settlement was reached.

Mother’s herpes infection transmitted in childbirth

A BABY BECAME ILL WITHIN 3 DAYS of birth and died several weeks later from a herpes virus infection. The mother had complained of burning pain during the office visits prior to delivery, and during labor and delivery.

PATIENT’S CLAIM Additional testing should have been performed when the mother complained of symptoms prior to birth. The child contracted the herpes virus during vaginal delivery; proper and timely diagnosis would have resulted in a cesarean delivery. The mother denied having sexual partners during her pregnancy.

PHYSICIAN’S DEFENSE Negative results of a Herpes Select Test 6 months before birth made follow-up testing unnecessary. She must have contracted the disease after testing had been performed. She had no symptoms that made the viral disease diagnosable at delivery. The child’s symptoms suggested transplacental transmission of herpes; a cesarean delivery would not have changed the outcome.

VERDICT A Nevada defense verdict was returned.

Home birth emergency

DURING A HOME BIRTH managed by a midwife, the baby was born after the mother pushed for 2 hours and 47 minutes. The child suffered brain damage.

PATIENT’S CLAIM The midwife was negligent in failing to send the mother to the nearest hospital after she had been pushing for 2 hours. The dangers associated with the lack of fetal heart rate monitoring had never been explained to them.

DEFENDANT’S DEFENSE The parents agreed to a home birth without use of fetal heart rate monitoring. They signed a detailed consent form, which advised them that emergencies could occur during delivery, and that the level and type of care would be less than at a hospital.

VERDICT A $1.9 million New Jersey settlement was reached.

APAS causes heart attack; fetal demise

7 MONTHS INTO HER FIRST PREGNANCY, a woman in her 20s suffered intrauterine fetal demise. A perinatologist determined that the mother has antiphospholipid syndrome (APAS), an immune system disorder that can cause excessive blood clotting, premature miscarriage, and heart attack. Although the perinatologist and Dr. A, the woman’s Family Practitioner (FP), received the report, neither told the woman.

When 6-weeks’ pregnant with a second child, the woman awoke with severe, crushing chest pain. Dr. B saw her in the emergency department, but did not order an ECG or cardiac enzyme blood test. After 7.5 hours, Dr. B diagnosed morning sickness or indigestion, or both, and was ready to discharge her. However, the woman, still in intense pain, expressed concern for her fetus. Dr. B sent her to another hospital 2 hours away.

Upon arrival, her chest pain had diminished but she reported radiating back and neck pain. Although the hospital’s protocol required ECG within 10 minutes of presentation with chest pain, no ECG was performed. A diagnosis of “gall bladder problems” was made.

 

 

Eighteen hours later, she was sent to a university hospital, where an ECG revealed that she had been experiencing a clot-induced heart attack for 44 hours. Approximately 40% of her heart muscle was damaged, and she was counseled to not continue the pregnancy because of cardiac dysfunction.

PATIENT’S CLAIM The perinatologist and Dr. A were negligent in not telling her that she has APAS. With that information, she could have taken medication to prevent a heart attack during her second pregnancy. Dr. B should have tested her for a heart attack when she reported chest pain. She will require at least two heart transplants during her lifetime.

PHYSICIANS’ DEFENSE The perinatologist claimed that messages were left for the patient on both her work and mobile phones, but she did not return the calls. The perinatologist also mailed a pamphlet on APAS and an additional lab form to the patient. Dr. A claimed that the perinatologist was solely responsible for follow-up regarding the test results. Dr. B claimed that a heart attack is very rare in a 24-year-old woman, and was very difficult to identify; several doctors at two hospitals missed the diagnosis.

VERDICT A New Mexico jury found all parties at fault: Dr. B, 47.5%; Dr. A, 35%; perinatologist, 10%; and patient, 7.5%. The jury awarded $9 million in general damages and established a patient compensation fund for future medical expenses. The plaintiff’s actual recovery was $1.8 million due to a state cap.

Bowel injury after hysterectomy

AN OBGYN PERFORMED laparoscopically assisted vaginal hysterectomy on a 55-year-old woman. After surgery, the woman’s condition deteriorated. The ObGyn consulted with a surgeon, who performed an exploratory laparotomy 2 days after initial surgery; he suspected a bowel perforation, but could not find it.

The patient was transferred to another hospital and 4 days later, an imaging study of the bowel revealed the injury and the bowel was repaired. She developed sepsis and necrosis, and a 44-cm section of bowel was resected. Her recovery was complex.

PATIENT’S CLAIM The ObGyn was negligent in not promptly identifying the bowel injury during the initial surgery. The surgeon was negligent for failing to find the bowel injury during exploratory surgery.

PHYSICIAN’S DEFENSE The injury did not occur during the initial surgery; the perforation found at the second hospital was fresh and unrelated to the previous procedures.

VERDICT A Louisiana defense verdict was returned for the ObGyn. The surgeon was found negligent, and the jury awarded $3,314,801.

Zavanelli maneuver; brachial plexus injury

SHOULDER DYSTOCIA was encountered during delivery, and her ObGyn attempted several procedures, including use of a vacuum extractor. Ultimately, he performed a Zavanelli maneuver, in which the fetal head is pushed back into the birth canal in order to deliver the child by cesarean delivery. The child suffered a brachial plexus injury, and does not have use of her right arm.

PATIENT’S CLAIM The mother was administered too much oxytocin by the delivery nurse, causing contractions to be too strong and come too fast, resulting in fetal distress. The ObGyn applied the vacuum extractor when the fetus was too high in the birth canal, resulting in too much traction on the fetus’ brachial nerves.

PHYSICIAN’S DEFENSE The fetus was in grave danger, and was at the proper stage of delivery when the maneuvers were attempted. The child would have suffered significant brain injury or death if the maneuvers had not been attempted.

VERDICT A Georgia defense verdict was returned.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

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Gravida in septic shock; were signs missed?

WITH SEVERE ABDOMINAL PAIN AND VOMITING at 14 weeks’ gestation, a 30-year-old woman was brought by ambulance to the hospital. After initial evaluation did not reveal a cause of her symptoms, she was transferred to the antepartum unit for observation.

The mother developed hypotension and a diagnosis of septic shock was made. Fetal cardiac activity ceased and the woman developed intestinal ischemia. She underwent an intestinal transplant several months later.

PATIENT’S CLAIM Both treating physicians and the nursing staff failed to react to her intermittently low blood pressure, and failed to diagnose or treat septic shock in a timely manner.

DEFENDANTS’ DEFENSE The patient was properly monitored and treated.

VERDICT A $11,500,000 Illinois verdict was returned against the hospital. A defense verdict was returned for both physicians.

Lethal outcome of ovarian cystectomy

A WOMAN IN HER 40s underwent ovarian cystectomy. During surgery, her gynecologist encountered dense adhesions that required bowel dissection. Later, the woman complained of severe abdominal pain, despite taking pain medication. A second gynecologist ordered an abdominal scan that showed fluid and possible bowel obstruction. Hospital staff ruled out pulmonary embolism. When her blood pressure dropped to dangerous levels, a surgeon recommended surgery. Preoperative testing found punctures in both large and small intestines. Before she could be given anesthesia, the woman suffered cardiac arrest, and was placed on a ventilator. The family asked that the ventilator be removed after three days, and she died.

ESTATE’S CLAIM The hospital staff and gynecologists were negligent in not ruling out bowel perforation as soon as the woman complained of severe abdominal pain after surgery.

DEFENDANTS’ DEFENSE Bowel perforation is a known complication of the surgery. There was no negligence; it was a complicated problem and the staff had progressively attempted to rule out various postsurgical issues.

VERDICT A $2.5 million Illinois settlement was reached.

Mother’s herpes infection transmitted in childbirth

A BABY BECAME ILL WITHIN 3 DAYS of birth and died several weeks later from a herpes virus infection. The mother had complained of burning pain during the office visits prior to delivery, and during labor and delivery.

PATIENT’S CLAIM Additional testing should have been performed when the mother complained of symptoms prior to birth. The child contracted the herpes virus during vaginal delivery; proper and timely diagnosis would have resulted in a cesarean delivery. The mother denied having sexual partners during her pregnancy.

PHYSICIAN’S DEFENSE Negative results of a Herpes Select Test 6 months before birth made follow-up testing unnecessary. She must have contracted the disease after testing had been performed. She had no symptoms that made the viral disease diagnosable at delivery. The child’s symptoms suggested transplacental transmission of herpes; a cesarean delivery would not have changed the outcome.

VERDICT A Nevada defense verdict was returned.

Home birth emergency

DURING A HOME BIRTH managed by a midwife, the baby was born after the mother pushed for 2 hours and 47 minutes. The child suffered brain damage.

PATIENT’S CLAIM The midwife was negligent in failing to send the mother to the nearest hospital after she had been pushing for 2 hours. The dangers associated with the lack of fetal heart rate monitoring had never been explained to them.

DEFENDANT’S DEFENSE The parents agreed to a home birth without use of fetal heart rate monitoring. They signed a detailed consent form, which advised them that emergencies could occur during delivery, and that the level and type of care would be less than at a hospital.

VERDICT A $1.9 million New Jersey settlement was reached.

APAS causes heart attack; fetal demise

7 MONTHS INTO HER FIRST PREGNANCY, a woman in her 20s suffered intrauterine fetal demise. A perinatologist determined that the mother has antiphospholipid syndrome (APAS), an immune system disorder that can cause excessive blood clotting, premature miscarriage, and heart attack. Although the perinatologist and Dr. A, the woman’s Family Practitioner (FP), received the report, neither told the woman.

When 6-weeks’ pregnant with a second child, the woman awoke with severe, crushing chest pain. Dr. B saw her in the emergency department, but did not order an ECG or cardiac enzyme blood test. After 7.5 hours, Dr. B diagnosed morning sickness or indigestion, or both, and was ready to discharge her. However, the woman, still in intense pain, expressed concern for her fetus. Dr. B sent her to another hospital 2 hours away.

Upon arrival, her chest pain had diminished but she reported radiating back and neck pain. Although the hospital’s protocol required ECG within 10 minutes of presentation with chest pain, no ECG was performed. A diagnosis of “gall bladder problems” was made.

 

 

Eighteen hours later, she was sent to a university hospital, where an ECG revealed that she had been experiencing a clot-induced heart attack for 44 hours. Approximately 40% of her heart muscle was damaged, and she was counseled to not continue the pregnancy because of cardiac dysfunction.

PATIENT’S CLAIM The perinatologist and Dr. A were negligent in not telling her that she has APAS. With that information, she could have taken medication to prevent a heart attack during her second pregnancy. Dr. B should have tested her for a heart attack when she reported chest pain. She will require at least two heart transplants during her lifetime.

PHYSICIANS’ DEFENSE The perinatologist claimed that messages were left for the patient on both her work and mobile phones, but she did not return the calls. The perinatologist also mailed a pamphlet on APAS and an additional lab form to the patient. Dr. A claimed that the perinatologist was solely responsible for follow-up regarding the test results. Dr. B claimed that a heart attack is very rare in a 24-year-old woman, and was very difficult to identify; several doctors at two hospitals missed the diagnosis.

VERDICT A New Mexico jury found all parties at fault: Dr. B, 47.5%; Dr. A, 35%; perinatologist, 10%; and patient, 7.5%. The jury awarded $9 million in general damages and established a patient compensation fund for future medical expenses. The plaintiff’s actual recovery was $1.8 million due to a state cap.

Bowel injury after hysterectomy

AN OBGYN PERFORMED laparoscopically assisted vaginal hysterectomy on a 55-year-old woman. After surgery, the woman’s condition deteriorated. The ObGyn consulted with a surgeon, who performed an exploratory laparotomy 2 days after initial surgery; he suspected a bowel perforation, but could not find it.

The patient was transferred to another hospital and 4 days later, an imaging study of the bowel revealed the injury and the bowel was repaired. She developed sepsis and necrosis, and a 44-cm section of bowel was resected. Her recovery was complex.

PATIENT’S CLAIM The ObGyn was negligent in not promptly identifying the bowel injury during the initial surgery. The surgeon was negligent for failing to find the bowel injury during exploratory surgery.

PHYSICIAN’S DEFENSE The injury did not occur during the initial surgery; the perforation found at the second hospital was fresh and unrelated to the previous procedures.

VERDICT A Louisiana defense verdict was returned for the ObGyn. The surgeon was found negligent, and the jury awarded $3,314,801.

Zavanelli maneuver; brachial plexus injury

SHOULDER DYSTOCIA was encountered during delivery, and her ObGyn attempted several procedures, including use of a vacuum extractor. Ultimately, he performed a Zavanelli maneuver, in which the fetal head is pushed back into the birth canal in order to deliver the child by cesarean delivery. The child suffered a brachial plexus injury, and does not have use of her right arm.

PATIENT’S CLAIM The mother was administered too much oxytocin by the delivery nurse, causing contractions to be too strong and come too fast, resulting in fetal distress. The ObGyn applied the vacuum extractor when the fetus was too high in the birth canal, resulting in too much traction on the fetus’ brachial nerves.

PHYSICIAN’S DEFENSE The fetus was in grave danger, and was at the proper stage of delivery when the maneuvers were attempted. The child would have suffered significant brain injury or death if the maneuvers had not been attempted.

VERDICT A Georgia defense verdict was returned.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Gravida in septic shock; were signs missed?

WITH SEVERE ABDOMINAL PAIN AND VOMITING at 14 weeks’ gestation, a 30-year-old woman was brought by ambulance to the hospital. After initial evaluation did not reveal a cause of her symptoms, she was transferred to the antepartum unit for observation.

The mother developed hypotension and a diagnosis of septic shock was made. Fetal cardiac activity ceased and the woman developed intestinal ischemia. She underwent an intestinal transplant several months later.

PATIENT’S CLAIM Both treating physicians and the nursing staff failed to react to her intermittently low blood pressure, and failed to diagnose or treat septic shock in a timely manner.

DEFENDANTS’ DEFENSE The patient was properly monitored and treated.

VERDICT A $11,500,000 Illinois verdict was returned against the hospital. A defense verdict was returned for both physicians.

Lethal outcome of ovarian cystectomy

A WOMAN IN HER 40s underwent ovarian cystectomy. During surgery, her gynecologist encountered dense adhesions that required bowel dissection. Later, the woman complained of severe abdominal pain, despite taking pain medication. A second gynecologist ordered an abdominal scan that showed fluid and possible bowel obstruction. Hospital staff ruled out pulmonary embolism. When her blood pressure dropped to dangerous levels, a surgeon recommended surgery. Preoperative testing found punctures in both large and small intestines. Before she could be given anesthesia, the woman suffered cardiac arrest, and was placed on a ventilator. The family asked that the ventilator be removed after three days, and she died.

ESTATE’S CLAIM The hospital staff and gynecologists were negligent in not ruling out bowel perforation as soon as the woman complained of severe abdominal pain after surgery.

DEFENDANTS’ DEFENSE Bowel perforation is a known complication of the surgery. There was no negligence; it was a complicated problem and the staff had progressively attempted to rule out various postsurgical issues.

VERDICT A $2.5 million Illinois settlement was reached.

Mother’s herpes infection transmitted in childbirth

A BABY BECAME ILL WITHIN 3 DAYS of birth and died several weeks later from a herpes virus infection. The mother had complained of burning pain during the office visits prior to delivery, and during labor and delivery.

PATIENT’S CLAIM Additional testing should have been performed when the mother complained of symptoms prior to birth. The child contracted the herpes virus during vaginal delivery; proper and timely diagnosis would have resulted in a cesarean delivery. The mother denied having sexual partners during her pregnancy.

PHYSICIAN’S DEFENSE Negative results of a Herpes Select Test 6 months before birth made follow-up testing unnecessary. She must have contracted the disease after testing had been performed. She had no symptoms that made the viral disease diagnosable at delivery. The child’s symptoms suggested transplacental transmission of herpes; a cesarean delivery would not have changed the outcome.

VERDICT A Nevada defense verdict was returned.

Home birth emergency

DURING A HOME BIRTH managed by a midwife, the baby was born after the mother pushed for 2 hours and 47 minutes. The child suffered brain damage.

PATIENT’S CLAIM The midwife was negligent in failing to send the mother to the nearest hospital after she had been pushing for 2 hours. The dangers associated with the lack of fetal heart rate monitoring had never been explained to them.

DEFENDANT’S DEFENSE The parents agreed to a home birth without use of fetal heart rate monitoring. They signed a detailed consent form, which advised them that emergencies could occur during delivery, and that the level and type of care would be less than at a hospital.

VERDICT A $1.9 million New Jersey settlement was reached.

APAS causes heart attack; fetal demise

7 MONTHS INTO HER FIRST PREGNANCY, a woman in her 20s suffered intrauterine fetal demise. A perinatologist determined that the mother has antiphospholipid syndrome (APAS), an immune system disorder that can cause excessive blood clotting, premature miscarriage, and heart attack. Although the perinatologist and Dr. A, the woman’s Family Practitioner (FP), received the report, neither told the woman.

When 6-weeks’ pregnant with a second child, the woman awoke with severe, crushing chest pain. Dr. B saw her in the emergency department, but did not order an ECG or cardiac enzyme blood test. After 7.5 hours, Dr. B diagnosed morning sickness or indigestion, or both, and was ready to discharge her. However, the woman, still in intense pain, expressed concern for her fetus. Dr. B sent her to another hospital 2 hours away.

Upon arrival, her chest pain had diminished but she reported radiating back and neck pain. Although the hospital’s protocol required ECG within 10 minutes of presentation with chest pain, no ECG was performed. A diagnosis of “gall bladder problems” was made.

 

 

Eighteen hours later, she was sent to a university hospital, where an ECG revealed that she had been experiencing a clot-induced heart attack for 44 hours. Approximately 40% of her heart muscle was damaged, and she was counseled to not continue the pregnancy because of cardiac dysfunction.

PATIENT’S CLAIM The perinatologist and Dr. A were negligent in not telling her that she has APAS. With that information, she could have taken medication to prevent a heart attack during her second pregnancy. Dr. B should have tested her for a heart attack when she reported chest pain. She will require at least two heart transplants during her lifetime.

PHYSICIANS’ DEFENSE The perinatologist claimed that messages were left for the patient on both her work and mobile phones, but she did not return the calls. The perinatologist also mailed a pamphlet on APAS and an additional lab form to the patient. Dr. A claimed that the perinatologist was solely responsible for follow-up regarding the test results. Dr. B claimed that a heart attack is very rare in a 24-year-old woman, and was very difficult to identify; several doctors at two hospitals missed the diagnosis.

VERDICT A New Mexico jury found all parties at fault: Dr. B, 47.5%; Dr. A, 35%; perinatologist, 10%; and patient, 7.5%. The jury awarded $9 million in general damages and established a patient compensation fund for future medical expenses. The plaintiff’s actual recovery was $1.8 million due to a state cap.

Bowel injury after hysterectomy

AN OBGYN PERFORMED laparoscopically assisted vaginal hysterectomy on a 55-year-old woman. After surgery, the woman’s condition deteriorated. The ObGyn consulted with a surgeon, who performed an exploratory laparotomy 2 days after initial surgery; he suspected a bowel perforation, but could not find it.

The patient was transferred to another hospital and 4 days later, an imaging study of the bowel revealed the injury and the bowel was repaired. She developed sepsis and necrosis, and a 44-cm section of bowel was resected. Her recovery was complex.

PATIENT’S CLAIM The ObGyn was negligent in not promptly identifying the bowel injury during the initial surgery. The surgeon was negligent for failing to find the bowel injury during exploratory surgery.

PHYSICIAN’S DEFENSE The injury did not occur during the initial surgery; the perforation found at the second hospital was fresh and unrelated to the previous procedures.

VERDICT A Louisiana defense verdict was returned for the ObGyn. The surgeon was found negligent, and the jury awarded $3,314,801.

Zavanelli maneuver; brachial plexus injury

SHOULDER DYSTOCIA was encountered during delivery, and her ObGyn attempted several procedures, including use of a vacuum extractor. Ultimately, he performed a Zavanelli maneuver, in which the fetal head is pushed back into the birth canal in order to deliver the child by cesarean delivery. The child suffered a brachial plexus injury, and does not have use of her right arm.

PATIENT’S CLAIM The mother was administered too much oxytocin by the delivery nurse, causing contractions to be too strong and come too fast, resulting in fetal distress. The ObGyn applied the vacuum extractor when the fetus was too high in the birth canal, resulting in too much traction on the fetus’ brachial nerves.

PHYSICIAN’S DEFENSE The fetus was in grave danger, and was at the proper stage of delivery when the maneuvers were attempted. The child would have suffered significant brain injury or death if the maneuvers had not been attempted.

VERDICT A Georgia defense verdict was returned.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

References

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Patient unaware of abnormal scans until it was too late ... For want of steroids, sight is lost ... more

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Patient unaware of abnormal scans until it was too late

A COMPUTED TOMOGRAPHY (CT) SCAN of a patient’s chest ordered by his physician revealed a cancerous nodule on the right lung. The physician’s office received the report but didn’t notify the patient of the finding. Nor was the patient informed of the CT report during a visit to the physician 2 months later, or during several visits the following year.

A second CT scan a year after the first showed a larger cancerous area in the lung. The patient and his wife went to the physician several days after the scan to discuss the results. While reviewing the patient’s chart, the doctor asked how long the man had been his patient and said, “We should have been on this a year ago.” He then left the office, and the building, without speaking further to the patient or his wife or explaining his departure. The patient tried unsuccessfully to get a copy of his medical records from the practice.

Two months later, the patient went to the emergency department (ED) with abdominal pain, shortness of breath, and dizziness. He was diagnosed with stage 4 lung cancer. The patient died about 7 weeks later.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $1 million South Carolina settlement.

COMMENT Fail-safes to assure the appropriate communication of abnormal test results are essential. I was pleased when my personal physician called recently concerning an abnormal lab test; too often timely communication doesn’t occur.

A cystic mass, then breast cancer

AFTER 6 MONTHS OF BREAST PAIN that became worse during menses, a 36-year-old woman, who had recently come to the United States from Iraq, consulted her family physician. The physician had been recommended because she was female, as the patient had requested, and, like the patient, was Iraqi.

The physician palpated the right breast and documented cystic fullness with no discrete masses or axillary nodes. She ordered a screening mammogram but was told by a radiologist that a 36-year-old woman could have screening mammography only if a mass was present. The physician changed the order to a diagnostic mammogram for a painful cystic mass. At the time of the mammogram, the patient told the technician that the lump came and went with her menstrual period. The results were reported as normal.

The physician continued to see the patient over the next 3 years for various health issues. At the patient’s final visit, the physician performed a clinical breast exam, which she documented as negative. The patient claimed that the physician hadn’t done any follow-up related to the right breast between her first visit and the final breast exam 3 years later.

Two years afterward, the now 41-year-old patient was diagnosed with cancer in her right breast after a mammogram, ultrasound, and biopsy. According to records at the hospital where she received the diagnosis, she’d discovered the lump 3 months earlier. The patient underwent a right mastectomy with chemotherapy and radiation and was cancer-free at the time of the trial.

PLAINTIFF’S CLAIM An ultrasound and biopsy should have been performed when the patient first consulted the family physician. The family physician didn’t perform any follow-up on the right breast until 3 years after she diagnosed the cystic fullness.

THE DEFENSE The family physician claimed that she tried twice to perform breast examinations during office visits in the 3 years she saw the patient, but the patient refused. The claim wasn’t documented. The patient’s cancer didn’t become palpable until after she left the doctor’s care. She had a fast-growing tumor, and the location of the cancerous mass differed from the area of cystic fullness the doctor originally discovered.

VERDICT $500,000 Illinois verdict.

COMMENT Failure to diagnose breast cancer continues to be a frequent and vexing allegation. Better documentation and follow-up could help obviate many of these claims.

 

 

 

For want of steroids, sight is lost

A 78-YEAR-OLD MAN was diagnosed with polymyalgia rheumatica (painful inflammation of the arteries, usually in the shoulders and hips) by his longtime primary care physician. The doctor treated the condition with low-dose steroids and monitored the patient’s erythrocyte sedimentation rate and C-reactive protein.

Two years after diagnosis, the patient complained to the physician of jaw pain and transient vision loss in the left eye. Three days later, he called the doctor to say that he had developed a headache. The physician lowered the steroid dosage but didn’t order blood tests or a biopsy. The following day the patient woke up and discovered he’d gone blind.

PLAINTIFF’S CLAIM The patient had giant cell arteritis and should have been treated with high-dose steroids. Starting treatment even one day earlier would have prevented blindness.

THE DEFENSE No information about the defense is available.

VERDICT $3 million Washington settlement.

COMMENT Timely diagnosis and appropriate treatment of temporal arteritis remain essential.

Sudden chest pain, sudden death, but not the usual suspects

SUDDEN ONSET OF CHEST PAIN brought a 41-year-old woman to the ED. Results of an electrocardiogram, chest radiograph, and lab tests were all normal. While in the ED, the patient developed diarrhea and was diagnosed with a gastrointestinal bleed.

She was admitted to the hospital, but no bed was available, so she remained in the ED, where she was found dead 7 hours later. Autopsy revealed a type A dissecting aorta to the level of the renal arteries.

PLAINTIFF’S CLAIM The ED physician failed to rule out all potential life-threatening causes of the chest pain and didn’t order a CT scan, which would have showed the aortic dissection.

DOCTOR’S DEFENSE Aortic dissection is a rare condition; the patient didn’t fit the profile of an individual at risk. A chest radiograph almost always reveals such abnormalities; no duty existed to rule out aortic dissection.

VERDICT $1.4 million Ohio verdict.

COMMENT Even though the details of this case are sketchy—and any death is a tragedy—I can’t help but sympathize with the defendant. While as physicians we should not chase zebras, we still have to consider the possibility of rare conditions.

Misdiagnosed cold foot leads to amputation

NUMBNESS IN HER RIGHT FOOT prompted 2 visits to the emergency department by a woman in her early 40s. The foot was cold and discolored. By the second visit, the patient was screaming with pain. A sprain was diagnosed without consulting a vascular surgeon, and the patient was sent home.

Ten days later, the patient had a computed tomography scan at another hospital, which found a blockage of the popliteal artery. Her right leg was amputated below the knee the following day and she was fitted with a prosthesis.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $1.25 million New Jersey settlement.

COMMENT I have seen a rash of cases in which peripheral vascular disease was inappropriately diagnosed. One wonders how an alert clinician could miss vascular disease and diagnose a sprain when faced with pain and a cold discolored foot.

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Patient unaware of abnormal scans until it was too late

A COMPUTED TOMOGRAPHY (CT) SCAN of a patient’s chest ordered by his physician revealed a cancerous nodule on the right lung. The physician’s office received the report but didn’t notify the patient of the finding. Nor was the patient informed of the CT report during a visit to the physician 2 months later, or during several visits the following year.

A second CT scan a year after the first showed a larger cancerous area in the lung. The patient and his wife went to the physician several days after the scan to discuss the results. While reviewing the patient’s chart, the doctor asked how long the man had been his patient and said, “We should have been on this a year ago.” He then left the office, and the building, without speaking further to the patient or his wife or explaining his departure. The patient tried unsuccessfully to get a copy of his medical records from the practice.

Two months later, the patient went to the emergency department (ED) with abdominal pain, shortness of breath, and dizziness. He was diagnosed with stage 4 lung cancer. The patient died about 7 weeks later.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $1 million South Carolina settlement.

COMMENT Fail-safes to assure the appropriate communication of abnormal test results are essential. I was pleased when my personal physician called recently concerning an abnormal lab test; too often timely communication doesn’t occur.

A cystic mass, then breast cancer

AFTER 6 MONTHS OF BREAST PAIN that became worse during menses, a 36-year-old woman, who had recently come to the United States from Iraq, consulted her family physician. The physician had been recommended because she was female, as the patient had requested, and, like the patient, was Iraqi.

The physician palpated the right breast and documented cystic fullness with no discrete masses or axillary nodes. She ordered a screening mammogram but was told by a radiologist that a 36-year-old woman could have screening mammography only if a mass was present. The physician changed the order to a diagnostic mammogram for a painful cystic mass. At the time of the mammogram, the patient told the technician that the lump came and went with her menstrual period. The results were reported as normal.

The physician continued to see the patient over the next 3 years for various health issues. At the patient’s final visit, the physician performed a clinical breast exam, which she documented as negative. The patient claimed that the physician hadn’t done any follow-up related to the right breast between her first visit and the final breast exam 3 years later.

Two years afterward, the now 41-year-old patient was diagnosed with cancer in her right breast after a mammogram, ultrasound, and biopsy. According to records at the hospital where she received the diagnosis, she’d discovered the lump 3 months earlier. The patient underwent a right mastectomy with chemotherapy and radiation and was cancer-free at the time of the trial.

PLAINTIFF’S CLAIM An ultrasound and biopsy should have been performed when the patient first consulted the family physician. The family physician didn’t perform any follow-up on the right breast until 3 years after she diagnosed the cystic fullness.

THE DEFENSE The family physician claimed that she tried twice to perform breast examinations during office visits in the 3 years she saw the patient, but the patient refused. The claim wasn’t documented. The patient’s cancer didn’t become palpable until after she left the doctor’s care. She had a fast-growing tumor, and the location of the cancerous mass differed from the area of cystic fullness the doctor originally discovered.

VERDICT $500,000 Illinois verdict.

COMMENT Failure to diagnose breast cancer continues to be a frequent and vexing allegation. Better documentation and follow-up could help obviate many of these claims.

 

 

 

For want of steroids, sight is lost

A 78-YEAR-OLD MAN was diagnosed with polymyalgia rheumatica (painful inflammation of the arteries, usually in the shoulders and hips) by his longtime primary care physician. The doctor treated the condition with low-dose steroids and monitored the patient’s erythrocyte sedimentation rate and C-reactive protein.

Two years after diagnosis, the patient complained to the physician of jaw pain and transient vision loss in the left eye. Three days later, he called the doctor to say that he had developed a headache. The physician lowered the steroid dosage but didn’t order blood tests or a biopsy. The following day the patient woke up and discovered he’d gone blind.

PLAINTIFF’S CLAIM The patient had giant cell arteritis and should have been treated with high-dose steroids. Starting treatment even one day earlier would have prevented blindness.

THE DEFENSE No information about the defense is available.

VERDICT $3 million Washington settlement.

COMMENT Timely diagnosis and appropriate treatment of temporal arteritis remain essential.

Sudden chest pain, sudden death, but not the usual suspects

SUDDEN ONSET OF CHEST PAIN brought a 41-year-old woman to the ED. Results of an electrocardiogram, chest radiograph, and lab tests were all normal. While in the ED, the patient developed diarrhea and was diagnosed with a gastrointestinal bleed.

She was admitted to the hospital, but no bed was available, so she remained in the ED, where she was found dead 7 hours later. Autopsy revealed a type A dissecting aorta to the level of the renal arteries.

PLAINTIFF’S CLAIM The ED physician failed to rule out all potential life-threatening causes of the chest pain and didn’t order a CT scan, which would have showed the aortic dissection.

DOCTOR’S DEFENSE Aortic dissection is a rare condition; the patient didn’t fit the profile of an individual at risk. A chest radiograph almost always reveals such abnormalities; no duty existed to rule out aortic dissection.

VERDICT $1.4 million Ohio verdict.

COMMENT Even though the details of this case are sketchy—and any death is a tragedy—I can’t help but sympathize with the defendant. While as physicians we should not chase zebras, we still have to consider the possibility of rare conditions.

Misdiagnosed cold foot leads to amputation

NUMBNESS IN HER RIGHT FOOT prompted 2 visits to the emergency department by a woman in her early 40s. The foot was cold and discolored. By the second visit, the patient was screaming with pain. A sprain was diagnosed without consulting a vascular surgeon, and the patient was sent home.

Ten days later, the patient had a computed tomography scan at another hospital, which found a blockage of the popliteal artery. Her right leg was amputated below the knee the following day and she was fitted with a prosthesis.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $1.25 million New Jersey settlement.

COMMENT I have seen a rash of cases in which peripheral vascular disease was inappropriately diagnosed. One wonders how an alert clinician could miss vascular disease and diagnose a sprain when faced with pain and a cold discolored foot.

 

Patient unaware of abnormal scans until it was too late

A COMPUTED TOMOGRAPHY (CT) SCAN of a patient’s chest ordered by his physician revealed a cancerous nodule on the right lung. The physician’s office received the report but didn’t notify the patient of the finding. Nor was the patient informed of the CT report during a visit to the physician 2 months later, or during several visits the following year.

A second CT scan a year after the first showed a larger cancerous area in the lung. The patient and his wife went to the physician several days after the scan to discuss the results. While reviewing the patient’s chart, the doctor asked how long the man had been his patient and said, “We should have been on this a year ago.” He then left the office, and the building, without speaking further to the patient or his wife or explaining his departure. The patient tried unsuccessfully to get a copy of his medical records from the practice.

Two months later, the patient went to the emergency department (ED) with abdominal pain, shortness of breath, and dizziness. He was diagnosed with stage 4 lung cancer. The patient died about 7 weeks later.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $1 million South Carolina settlement.

COMMENT Fail-safes to assure the appropriate communication of abnormal test results are essential. I was pleased when my personal physician called recently concerning an abnormal lab test; too often timely communication doesn’t occur.

A cystic mass, then breast cancer

AFTER 6 MONTHS OF BREAST PAIN that became worse during menses, a 36-year-old woman, who had recently come to the United States from Iraq, consulted her family physician. The physician had been recommended because she was female, as the patient had requested, and, like the patient, was Iraqi.

The physician palpated the right breast and documented cystic fullness with no discrete masses or axillary nodes. She ordered a screening mammogram but was told by a radiologist that a 36-year-old woman could have screening mammography only if a mass was present. The physician changed the order to a diagnostic mammogram for a painful cystic mass. At the time of the mammogram, the patient told the technician that the lump came and went with her menstrual period. The results were reported as normal.

The physician continued to see the patient over the next 3 years for various health issues. At the patient’s final visit, the physician performed a clinical breast exam, which she documented as negative. The patient claimed that the physician hadn’t done any follow-up related to the right breast between her first visit and the final breast exam 3 years later.

Two years afterward, the now 41-year-old patient was diagnosed with cancer in her right breast after a mammogram, ultrasound, and biopsy. According to records at the hospital where she received the diagnosis, she’d discovered the lump 3 months earlier. The patient underwent a right mastectomy with chemotherapy and radiation and was cancer-free at the time of the trial.

PLAINTIFF’S CLAIM An ultrasound and biopsy should have been performed when the patient first consulted the family physician. The family physician didn’t perform any follow-up on the right breast until 3 years after she diagnosed the cystic fullness.

THE DEFENSE The family physician claimed that she tried twice to perform breast examinations during office visits in the 3 years she saw the patient, but the patient refused. The claim wasn’t documented. The patient’s cancer didn’t become palpable until after she left the doctor’s care. She had a fast-growing tumor, and the location of the cancerous mass differed from the area of cystic fullness the doctor originally discovered.

VERDICT $500,000 Illinois verdict.

COMMENT Failure to diagnose breast cancer continues to be a frequent and vexing allegation. Better documentation and follow-up could help obviate many of these claims.

 

 

 

For want of steroids, sight is lost

A 78-YEAR-OLD MAN was diagnosed with polymyalgia rheumatica (painful inflammation of the arteries, usually in the shoulders and hips) by his longtime primary care physician. The doctor treated the condition with low-dose steroids and monitored the patient’s erythrocyte sedimentation rate and C-reactive protein.

Two years after diagnosis, the patient complained to the physician of jaw pain and transient vision loss in the left eye. Three days later, he called the doctor to say that he had developed a headache. The physician lowered the steroid dosage but didn’t order blood tests or a biopsy. The following day the patient woke up and discovered he’d gone blind.

PLAINTIFF’S CLAIM The patient had giant cell arteritis and should have been treated with high-dose steroids. Starting treatment even one day earlier would have prevented blindness.

THE DEFENSE No information about the defense is available.

VERDICT $3 million Washington settlement.

COMMENT Timely diagnosis and appropriate treatment of temporal arteritis remain essential.

Sudden chest pain, sudden death, but not the usual suspects

SUDDEN ONSET OF CHEST PAIN brought a 41-year-old woman to the ED. Results of an electrocardiogram, chest radiograph, and lab tests were all normal. While in the ED, the patient developed diarrhea and was diagnosed with a gastrointestinal bleed.

She was admitted to the hospital, but no bed was available, so she remained in the ED, where she was found dead 7 hours later. Autopsy revealed a type A dissecting aorta to the level of the renal arteries.

PLAINTIFF’S CLAIM The ED physician failed to rule out all potential life-threatening causes of the chest pain and didn’t order a CT scan, which would have showed the aortic dissection.

DOCTOR’S DEFENSE Aortic dissection is a rare condition; the patient didn’t fit the profile of an individual at risk. A chest radiograph almost always reveals such abnormalities; no duty existed to rule out aortic dissection.

VERDICT $1.4 million Ohio verdict.

COMMENT Even though the details of this case are sketchy—and any death is a tragedy—I can’t help but sympathize with the defendant. While as physicians we should not chase zebras, we still have to consider the possibility of rare conditions.

Misdiagnosed cold foot leads to amputation

NUMBNESS IN HER RIGHT FOOT prompted 2 visits to the emergency department by a woman in her early 40s. The foot was cold and discolored. By the second visit, the patient was screaming with pain. A sprain was diagnosed without consulting a vascular surgeon, and the patient was sent home.

Ten days later, the patient had a computed tomography scan at another hospital, which found a blockage of the popliteal artery. Her right leg was amputated below the knee the following day and she was fitted with a prosthesis.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $1.25 million New Jersey settlement.

COMMENT I have seen a rash of cases in which peripheral vascular disease was inappropriately diagnosed. One wonders how an alert clinician could miss vascular disease and diagnose a sprain when faced with pain and a cold discolored foot.

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Wrongful birth claim: Child has a chromosomal disorder...and more

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Wrongful birth claim: Child has a chromosomal disorder

A WOMAN’S HUSBAND AND AN INTERPRETER came to her first prenatal appointment at 10 weeks’ gestation, as she spoke only Mandarin and the father’s English was limited. The ObGyn offered maternal serum sequential screening. At subsequent visits, with the husband and interpreter present, the mother saw a geneticist, genetic counselor, and nurse practitioner. At no time was additional genetic testing offered. At the 23-week visit, the husband was present, but the interpreter had not yet arrived; the ObGyn attempted to communicate through the husband.

The baby was born at term with cri-du-chat syndrome. The child is severely physically and mentally handicapped, and will require constant medical and attendant care for life.

PATIENT’S CLAIM The ObGyn did not offer amniocentesis or chorionic villus sampling (CVS), and failed to inform the parents that the chance of a 37-year-old woman having a child with a chromosomal aberration was 1.5%. The ObGyn did not obtain the woman’s signature waiving the presence of an interpreter at the 23-week visit. If the physician offered amniocentesis then, the parents did not understand. She would have terminated the pregnancy if she had been told the fetus had a severe chromosomal defect.

PHYSICIAN’S DEFENSE The ObGyn claimed to have offered amniocentesis at the 23-week visit, but it was declined. Proper care and treatment was provided.

VERDICT A $7 million Massachusetts settlement was reached.

Hematoma after biopsy; death

A 77-YEAR -OLD WOMAN underwent percutaneous biopsy of three right axillary lymph nodes. She developed a hematoma. She was sent to the hospital from the physician’s office because of the increasing size of the hematoma, low blood pressure, and pain, then admitted to the ICU for monitoring. She declined exploratory surgery to discover and repair the bleeding source. When her blood pressure and hemoglobin level dropped overnight, the physician again tried to persuade the woman to have surgery; she refused. The physician then undertook surgery on another patient.

An ICU resident and nurse subsequently obtained consent from the woman’s family. The surgeon was not told this for 4 hours, at which time the woman was taken immediately to the operating room. The surgeon repaired a severed axillary vein and punctured axillary artery.

The woman suffered two episodes of asystole during surgery. She later died of multiple organ failure.

ESTATE’S CLAIM The surgeon failed to take adequate measures to obtain surgical consent to repair the hematoma, and failed to perform surgery in a timely manner once consent was given.

PHYSICIAN’S DEFENSE The woman was awake, alert, and oriented both times she refused consent; her family could not be contacted without her authorization. Proper actions were taken when consent was obtained.

VERDICT An Illinois defense verdict was returned.

Epidural pump stolen—while in use

A WOMAN WAS GIVEN AN EPIDURAL during labor. While she slept, a newly hired physician assistant (PA) entered her room, disconnected the epidural pump, and stole it. The woman awoke but the PA assured her that everything was fine. Soon, she experienced significant labor pains and called the nurses, who paged an anesthesiologist to administer another epidural. Security personnel questioned the woman.

She gave birth to a healthy child.

PATIENT’S CLAIM The hospital failed to provide adequate security. Security personnel unduly questioned the woman before the second epidural was administered, delaying the procedure and increasing the length of time she was in pain.

DEFENDANTS’ DEFENSE The hospital claimed no responsibility for the theft; the PA’s actions were outside the scope of his employment, and his criminal behavior was unforeseeable.

VERDICT A Connecticut defense verdict was returned for the hospital. (The PA pleaded guilty to stealing the epidural pump, received 3 years’ probation, and lost his license.)

Ectopic pregnancy didn’t miscarry despite methotrexate

THINKING SHE WAS PREGNANT, a woman saw her ObGyn, Dr. A, who found no evidence of pregnancy, and suspected that she had miscarried. The next day, Dr. A’s office called the woman to return because of an elevated hCG level. A sonogram performed at the second visit did not reveal any signs of pregnancy.

Eleven days later, she went to the emergency department (ED) in excruciating pain. A sonogram revealed an ectopic pregnancy. Methotrexate was administered to terminate the pregnancy. The woman was advised to follow up with her ObGyn. Ten days later, blood tests continued to show an elevated hCG level, but Dr. A did not order further testing or follow up.

Two weeks later, the woman went to Dr. B, a different ObGyn, who ordered blood work to monitor her hCG. The next day, she went to the ED in great pain. The ED physician contacted Dr. B, who advised that the woman should be discharged with instructions to follow up with him. Nine days later, the woman saw Dr. B, who diagnosed and surgically removed a ruptured fallopian tube.

 

 

PATIENT’S CLAIM Neither physician properly monitored the patient after administration of methotrexate. The ectopic pregnancy continued, and caused rupture of the fallopian tube. Dr. B failed to respond properly to the call from the ED physician.

PHYSICIANS’ DEFENSE Dr. A admitted that the patient had not been properly monitored, but claimed that the lack of monitoring caused no harm. Dr. B denied any negligence.

VERDICT A Georgia defense verdict was returned for both physicians.

Uterine laceration during cesarean

A WOMAN BEGAN TO BLEED excessively in the recovery room after a nonemergent cesarean delivery. Blood pressure and blood oxygen saturation decreased, heart rate increased, and she passed large clots. The recovery room nurse notified the woman’s ObGyn, who ordered medication to constrict the uterus and diminish blood flow, but treatment was unsuccessful.

She was returned to the operating room, where the ObGyn repaired a low-segment uterine laceration. Blood was administered with additional uterotonics. After surgery, the woman was sent to the labor and delivery recovery room. When tests indicated that her hematocrit and hemoglobin level had decreased and she showed signs of a clotting difficulty, the ObGyn ordered additional blood products and fundal massage. Two hours later, the woman suffered cardiac arrest and was revived, but suffered significant brain damage. After six months, mechanical ventilation was withdrawn and she died.

ESTATE’S CLAIM The patient’s vital signs never returned to normal after uterine repair surgery. The ObGyn and anesthesiologist did not stabilize the patient, and failed to perform a hysterectomy to save her life. The nurses did not notify the ObGyn and anesthesiologist of unstable vital signs that signaled blood loss.

DEFENDANTS’ DEFENSE The anesthesiologist found the patient’s vital signs normal after repair of the laceration and left the woman in the care of the nursing staff and ObGyn. The ObGyn was not notified of unstable vital signs. The nurses asserted that they did not tell the ObGyn of the changes because they expected him to look at, review, and interpret the monitor. The physicians claimed that the arrest and death were due to an amniotic fluid embolism or amniotic fluid syndrome that was sudden, unpredictable, and difficult to treat.

VERDICT A $1,350,000 Virginia settlement was reached.

Was she discharged too early?

AN OBGYN PERFORMED total transvaginal hysterectomy on a 54-year-old patient, and discharged her the next day. Several hours later, she began to have severe abdominal pain, and was readmitted. The ObGyn prescribed IV antibiotics and ordered fluid management. When she continued to deteriorate, she was transferred to the ICU.

The next day, the ICU physician ordered diagnostic laparoscopy. A perforation of the sigmoid colon was found and repaired, but the woman continued to deteriorate. Nine days later, she was transferred to another hospital, where she died.

ESTATE’S CLAIM The ObGyn failed to find the perforation during hysterectomy. He did not properly follow-up with the patient after surgery, and improperly discharged her despite abnormal blood work and vital signs; elevated temperature and pulse rate; and an increase in her white blood cell count. Both physicians failed to diagnose and treat the perforation in a timely manner. Delay in diagnosis and treatment led to the woman’s death.

PHYSICIANS’ DEFENSE The physicians denied negligence.

VERDICT A $7 million North Carolina verdict was returned against the ObGyn. A defense verdict was returned for the ICU physician.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

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Wrongful birth claim: Child has a chromosomal disorder

A WOMAN’S HUSBAND AND AN INTERPRETER came to her first prenatal appointment at 10 weeks’ gestation, as she spoke only Mandarin and the father’s English was limited. The ObGyn offered maternal serum sequential screening. At subsequent visits, with the husband and interpreter present, the mother saw a geneticist, genetic counselor, and nurse practitioner. At no time was additional genetic testing offered. At the 23-week visit, the husband was present, but the interpreter had not yet arrived; the ObGyn attempted to communicate through the husband.

The baby was born at term with cri-du-chat syndrome. The child is severely physically and mentally handicapped, and will require constant medical and attendant care for life.

PATIENT’S CLAIM The ObGyn did not offer amniocentesis or chorionic villus sampling (CVS), and failed to inform the parents that the chance of a 37-year-old woman having a child with a chromosomal aberration was 1.5%. The ObGyn did not obtain the woman’s signature waiving the presence of an interpreter at the 23-week visit. If the physician offered amniocentesis then, the parents did not understand. She would have terminated the pregnancy if she had been told the fetus had a severe chromosomal defect.

PHYSICIAN’S DEFENSE The ObGyn claimed to have offered amniocentesis at the 23-week visit, but it was declined. Proper care and treatment was provided.

VERDICT A $7 million Massachusetts settlement was reached.

Hematoma after biopsy; death

A 77-YEAR -OLD WOMAN underwent percutaneous biopsy of three right axillary lymph nodes. She developed a hematoma. She was sent to the hospital from the physician’s office because of the increasing size of the hematoma, low blood pressure, and pain, then admitted to the ICU for monitoring. She declined exploratory surgery to discover and repair the bleeding source. When her blood pressure and hemoglobin level dropped overnight, the physician again tried to persuade the woman to have surgery; she refused. The physician then undertook surgery on another patient.

An ICU resident and nurse subsequently obtained consent from the woman’s family. The surgeon was not told this for 4 hours, at which time the woman was taken immediately to the operating room. The surgeon repaired a severed axillary vein and punctured axillary artery.

The woman suffered two episodes of asystole during surgery. She later died of multiple organ failure.

ESTATE’S CLAIM The surgeon failed to take adequate measures to obtain surgical consent to repair the hematoma, and failed to perform surgery in a timely manner once consent was given.

PHYSICIAN’S DEFENSE The woman was awake, alert, and oriented both times she refused consent; her family could not be contacted without her authorization. Proper actions were taken when consent was obtained.

VERDICT An Illinois defense verdict was returned.

Epidural pump stolen—while in use

A WOMAN WAS GIVEN AN EPIDURAL during labor. While she slept, a newly hired physician assistant (PA) entered her room, disconnected the epidural pump, and stole it. The woman awoke but the PA assured her that everything was fine. Soon, she experienced significant labor pains and called the nurses, who paged an anesthesiologist to administer another epidural. Security personnel questioned the woman.

She gave birth to a healthy child.

PATIENT’S CLAIM The hospital failed to provide adequate security. Security personnel unduly questioned the woman before the second epidural was administered, delaying the procedure and increasing the length of time she was in pain.

DEFENDANTS’ DEFENSE The hospital claimed no responsibility for the theft; the PA’s actions were outside the scope of his employment, and his criminal behavior was unforeseeable.

VERDICT A Connecticut defense verdict was returned for the hospital. (The PA pleaded guilty to stealing the epidural pump, received 3 years’ probation, and lost his license.)

Ectopic pregnancy didn’t miscarry despite methotrexate

THINKING SHE WAS PREGNANT, a woman saw her ObGyn, Dr. A, who found no evidence of pregnancy, and suspected that she had miscarried. The next day, Dr. A’s office called the woman to return because of an elevated hCG level. A sonogram performed at the second visit did not reveal any signs of pregnancy.

Eleven days later, she went to the emergency department (ED) in excruciating pain. A sonogram revealed an ectopic pregnancy. Methotrexate was administered to terminate the pregnancy. The woman was advised to follow up with her ObGyn. Ten days later, blood tests continued to show an elevated hCG level, but Dr. A did not order further testing or follow up.

Two weeks later, the woman went to Dr. B, a different ObGyn, who ordered blood work to monitor her hCG. The next day, she went to the ED in great pain. The ED physician contacted Dr. B, who advised that the woman should be discharged with instructions to follow up with him. Nine days later, the woman saw Dr. B, who diagnosed and surgically removed a ruptured fallopian tube.

 

 

PATIENT’S CLAIM Neither physician properly monitored the patient after administration of methotrexate. The ectopic pregnancy continued, and caused rupture of the fallopian tube. Dr. B failed to respond properly to the call from the ED physician.

PHYSICIANS’ DEFENSE Dr. A admitted that the patient had not been properly monitored, but claimed that the lack of monitoring caused no harm. Dr. B denied any negligence.

VERDICT A Georgia defense verdict was returned for both physicians.

Uterine laceration during cesarean

A WOMAN BEGAN TO BLEED excessively in the recovery room after a nonemergent cesarean delivery. Blood pressure and blood oxygen saturation decreased, heart rate increased, and she passed large clots. The recovery room nurse notified the woman’s ObGyn, who ordered medication to constrict the uterus and diminish blood flow, but treatment was unsuccessful.

She was returned to the operating room, where the ObGyn repaired a low-segment uterine laceration. Blood was administered with additional uterotonics. After surgery, the woman was sent to the labor and delivery recovery room. When tests indicated that her hematocrit and hemoglobin level had decreased and she showed signs of a clotting difficulty, the ObGyn ordered additional blood products and fundal massage. Two hours later, the woman suffered cardiac arrest and was revived, but suffered significant brain damage. After six months, mechanical ventilation was withdrawn and she died.

ESTATE’S CLAIM The patient’s vital signs never returned to normal after uterine repair surgery. The ObGyn and anesthesiologist did not stabilize the patient, and failed to perform a hysterectomy to save her life. The nurses did not notify the ObGyn and anesthesiologist of unstable vital signs that signaled blood loss.

DEFENDANTS’ DEFENSE The anesthesiologist found the patient’s vital signs normal after repair of the laceration and left the woman in the care of the nursing staff and ObGyn. The ObGyn was not notified of unstable vital signs. The nurses asserted that they did not tell the ObGyn of the changes because they expected him to look at, review, and interpret the monitor. The physicians claimed that the arrest and death were due to an amniotic fluid embolism or amniotic fluid syndrome that was sudden, unpredictable, and difficult to treat.

VERDICT A $1,350,000 Virginia settlement was reached.

Was she discharged too early?

AN OBGYN PERFORMED total transvaginal hysterectomy on a 54-year-old patient, and discharged her the next day. Several hours later, she began to have severe abdominal pain, and was readmitted. The ObGyn prescribed IV antibiotics and ordered fluid management. When she continued to deteriorate, she was transferred to the ICU.

The next day, the ICU physician ordered diagnostic laparoscopy. A perforation of the sigmoid colon was found and repaired, but the woman continued to deteriorate. Nine days later, she was transferred to another hospital, where she died.

ESTATE’S CLAIM The ObGyn failed to find the perforation during hysterectomy. He did not properly follow-up with the patient after surgery, and improperly discharged her despite abnormal blood work and vital signs; elevated temperature and pulse rate; and an increase in her white blood cell count. Both physicians failed to diagnose and treat the perforation in a timely manner. Delay in diagnosis and treatment led to the woman’s death.

PHYSICIANS’ DEFENSE The physicians denied negligence.

VERDICT A $7 million North Carolina verdict was returned against the ObGyn. A defense verdict was returned for the ICU physician.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Wrongful birth claim: Child has a chromosomal disorder

A WOMAN’S HUSBAND AND AN INTERPRETER came to her first prenatal appointment at 10 weeks’ gestation, as she spoke only Mandarin and the father’s English was limited. The ObGyn offered maternal serum sequential screening. At subsequent visits, with the husband and interpreter present, the mother saw a geneticist, genetic counselor, and nurse practitioner. At no time was additional genetic testing offered. At the 23-week visit, the husband was present, but the interpreter had not yet arrived; the ObGyn attempted to communicate through the husband.

The baby was born at term with cri-du-chat syndrome. The child is severely physically and mentally handicapped, and will require constant medical and attendant care for life.

PATIENT’S CLAIM The ObGyn did not offer amniocentesis or chorionic villus sampling (CVS), and failed to inform the parents that the chance of a 37-year-old woman having a child with a chromosomal aberration was 1.5%. The ObGyn did not obtain the woman’s signature waiving the presence of an interpreter at the 23-week visit. If the physician offered amniocentesis then, the parents did not understand. She would have terminated the pregnancy if she had been told the fetus had a severe chromosomal defect.

PHYSICIAN’S DEFENSE The ObGyn claimed to have offered amniocentesis at the 23-week visit, but it was declined. Proper care and treatment was provided.

VERDICT A $7 million Massachusetts settlement was reached.

Hematoma after biopsy; death

A 77-YEAR -OLD WOMAN underwent percutaneous biopsy of three right axillary lymph nodes. She developed a hematoma. She was sent to the hospital from the physician’s office because of the increasing size of the hematoma, low blood pressure, and pain, then admitted to the ICU for monitoring. She declined exploratory surgery to discover and repair the bleeding source. When her blood pressure and hemoglobin level dropped overnight, the physician again tried to persuade the woman to have surgery; she refused. The physician then undertook surgery on another patient.

An ICU resident and nurse subsequently obtained consent from the woman’s family. The surgeon was not told this for 4 hours, at which time the woman was taken immediately to the operating room. The surgeon repaired a severed axillary vein and punctured axillary artery.

The woman suffered two episodes of asystole during surgery. She later died of multiple organ failure.

ESTATE’S CLAIM The surgeon failed to take adequate measures to obtain surgical consent to repair the hematoma, and failed to perform surgery in a timely manner once consent was given.

PHYSICIAN’S DEFENSE The woman was awake, alert, and oriented both times she refused consent; her family could not be contacted without her authorization. Proper actions were taken when consent was obtained.

VERDICT An Illinois defense verdict was returned.

Epidural pump stolen—while in use

A WOMAN WAS GIVEN AN EPIDURAL during labor. While she slept, a newly hired physician assistant (PA) entered her room, disconnected the epidural pump, and stole it. The woman awoke but the PA assured her that everything was fine. Soon, she experienced significant labor pains and called the nurses, who paged an anesthesiologist to administer another epidural. Security personnel questioned the woman.

She gave birth to a healthy child.

PATIENT’S CLAIM The hospital failed to provide adequate security. Security personnel unduly questioned the woman before the second epidural was administered, delaying the procedure and increasing the length of time she was in pain.

DEFENDANTS’ DEFENSE The hospital claimed no responsibility for the theft; the PA’s actions were outside the scope of his employment, and his criminal behavior was unforeseeable.

VERDICT A Connecticut defense verdict was returned for the hospital. (The PA pleaded guilty to stealing the epidural pump, received 3 years’ probation, and lost his license.)

Ectopic pregnancy didn’t miscarry despite methotrexate

THINKING SHE WAS PREGNANT, a woman saw her ObGyn, Dr. A, who found no evidence of pregnancy, and suspected that she had miscarried. The next day, Dr. A’s office called the woman to return because of an elevated hCG level. A sonogram performed at the second visit did not reveal any signs of pregnancy.

Eleven days later, she went to the emergency department (ED) in excruciating pain. A sonogram revealed an ectopic pregnancy. Methotrexate was administered to terminate the pregnancy. The woman was advised to follow up with her ObGyn. Ten days later, blood tests continued to show an elevated hCG level, but Dr. A did not order further testing or follow up.

Two weeks later, the woman went to Dr. B, a different ObGyn, who ordered blood work to monitor her hCG. The next day, she went to the ED in great pain. The ED physician contacted Dr. B, who advised that the woman should be discharged with instructions to follow up with him. Nine days later, the woman saw Dr. B, who diagnosed and surgically removed a ruptured fallopian tube.

 

 

PATIENT’S CLAIM Neither physician properly monitored the patient after administration of methotrexate. The ectopic pregnancy continued, and caused rupture of the fallopian tube. Dr. B failed to respond properly to the call from the ED physician.

PHYSICIANS’ DEFENSE Dr. A admitted that the patient had not been properly monitored, but claimed that the lack of monitoring caused no harm. Dr. B denied any negligence.

VERDICT A Georgia defense verdict was returned for both physicians.

Uterine laceration during cesarean

A WOMAN BEGAN TO BLEED excessively in the recovery room after a nonemergent cesarean delivery. Blood pressure and blood oxygen saturation decreased, heart rate increased, and she passed large clots. The recovery room nurse notified the woman’s ObGyn, who ordered medication to constrict the uterus and diminish blood flow, but treatment was unsuccessful.

She was returned to the operating room, where the ObGyn repaired a low-segment uterine laceration. Blood was administered with additional uterotonics. After surgery, the woman was sent to the labor and delivery recovery room. When tests indicated that her hematocrit and hemoglobin level had decreased and she showed signs of a clotting difficulty, the ObGyn ordered additional blood products and fundal massage. Two hours later, the woman suffered cardiac arrest and was revived, but suffered significant brain damage. After six months, mechanical ventilation was withdrawn and she died.

ESTATE’S CLAIM The patient’s vital signs never returned to normal after uterine repair surgery. The ObGyn and anesthesiologist did not stabilize the patient, and failed to perform a hysterectomy to save her life. The nurses did not notify the ObGyn and anesthesiologist of unstable vital signs that signaled blood loss.

DEFENDANTS’ DEFENSE The anesthesiologist found the patient’s vital signs normal after repair of the laceration and left the woman in the care of the nursing staff and ObGyn. The ObGyn was not notified of unstable vital signs. The nurses asserted that they did not tell the ObGyn of the changes because they expected him to look at, review, and interpret the monitor. The physicians claimed that the arrest and death were due to an amniotic fluid embolism or amniotic fluid syndrome that was sudden, unpredictable, and difficult to treat.

VERDICT A $1,350,000 Virginia settlement was reached.

Was she discharged too early?

AN OBGYN PERFORMED total transvaginal hysterectomy on a 54-year-old patient, and discharged her the next day. Several hours later, she began to have severe abdominal pain, and was readmitted. The ObGyn prescribed IV antibiotics and ordered fluid management. When she continued to deteriorate, she was transferred to the ICU.

The next day, the ICU physician ordered diagnostic laparoscopy. A perforation of the sigmoid colon was found and repaired, but the woman continued to deteriorate. Nine days later, she was transferred to another hospital, where she died.

ESTATE’S CLAIM The ObGyn failed to find the perforation during hysterectomy. He did not properly follow-up with the patient after surgery, and improperly discharged her despite abnormal blood work and vital signs; elevated temperature and pulse rate; and an increase in her white blood cell count. Both physicians failed to diagnose and treat the perforation in a timely manner. Delay in diagnosis and treatment led to the woman’s death.

PHYSICIANS’ DEFENSE The physicians denied negligence.

VERDICT A $7 million North Carolina verdict was returned against the ObGyn. A defense verdict was returned for the ICU physician.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

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We want to hear from you! Tell us what you think.

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We want to hear from you! Tell us what you think.

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Did low amniotic fluid cause cerebral palsy?...and more

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Did low amniotic fluid cause cerebral palsy?

A BICORNUATE UTERUS and the infant’s breech position complicated a woman’s pregnancy. At her 39-week prenatal visit, testing showed a low amniotic fluid level, but the woman was sent home. Two days later, she went to the hospital in labor. Her ObGyn first allowed labor to proceed, then performed a cesarean delivery. The father recorded the birth on video camera. The baby was born “essentially lifeless” but with a weak heartbeat. The child was diagnosed with cerebral palsy.

PATIENT’S CLAIM A cesarean delivery should have been performed as soon as it was determined that the amniotic fluid level was low. During surgery, the ObGyn did not choose an incision location that would deliver the baby quickly. The recording evidenced that there was a delay in delivery.

PHYSICIAN’S DEFENSE Elective cesarean delivery was not necessary at the time of the patient’s last visit, as one is not performed before 40 weeks’ gestation. Cesarean delivery was appropriately performed. The baby had a good heart rate at birth. Brain damage was due to fetal inflammatory response syndrome.

VERDICT A $58 million Connecticut verdict was returned.

Death from meningitis after miscarriage

COMPLAINING OF VAGINAL BLEEDING, a woman in her 20s went to an emergency department. She was found to be about 12 weeks’ pregnant. An ObGyn diagnosed spontaneous abortion/miscarriage. Ultrasonography showed that fetal tissue had been expelled, and that no products of conception remained, only blood clots. The woman was given the option of 1) dilatation and curettage (D&C) or 2) letting the residual material expel without intervention. She chose the latter, and was discharged with instructions to return if her condition became worse. Three days later, the woman was admitted to another hospital with Group B streptococcal meningitis and a urinary tract infection. She died 2 days later.

ESTATE’S CLAIM A D&C should have been performed. Prophylactic antibiotics should have been prescribed, which would have stopped the infectious process and allowed the decedent to survive.

DEFENDANTS’ DEFENSE Prophylactic antibiotics were unnecessary because there were no signs or symptoms of infection when the woman was discharged. Prophylactic antibiotics would not have appropriately treated meningitis, and could have made the infection progress more rapidly by destroying the body’s infection-fighting process. There was no need for a D&C because ultrasonography identified no retained products of conception—indicating that there were no foreign substances to cause an infection.

VERDICT A Maryland defense verdict was returned.

Reduced fetal movement and severe brain damage

AT HER 39-WEEK PRENATAL VISIT, a woman reported that the baby wasn’t as active as usual. She was seen by a resident, who did not apply a fetal heart monitor or have the attending ObGyn examine the mother. She was sent home. Two days later, the mother realized the baby was not moving at all, and returned to the clinic. Emergency cesarean delivery was performed. The child has severe brain damage and cerebral palsy.

PATIENT’S CLAIM The resident failed to appropriately respond when the mother reported the baby was not active. The attending ObGyn should have been called, and the baby’s heart rate should have been monitored. It was later found that a clotting abnormality had developed, causing an inadequate supply of oxygen to the fetal brain. Proper response to the report of decreased movement would have resulted in the delivery of a healthy child.

PHYSICIANS’ DEFENSE Brain damage occurred prior to the mother’s 39th-week visit. This was apparent because of the child’s joint contractures, which, the defense argued, take a week or longer to develop. (The plaintiff countered that contractures were mild and that the infant was moving his arms and legs a short time after delivery.)

VERDICT A $4,821,000 Missouri verdict was returned.

Scalpel breaks during robotic surgery

ROBOT-ASSISTED LAPAROSCOPIC pelvic mass resection was performed on an obese 47-year-old woman. During surgery, the lower blade of an ultrasonic, vibrating scalpel dislodged. Dr. A spent 90 minutes searching for the blade, which he eventually found. The mass was removed and diagnosed as benign. During recovery, the patient became septic, went into acute renal failure, acute respiratory failure, and septic shock. A diagnosis of fecal peritonitis was made.

Dr. B assumed the care of the patient, and later found a colon perforation. Four days after the initial procedure, the patient underwent a colon resection. She was initially treated with a colostomy and then had a successful bowel reanastomosis 7 months after the injury.

PATIENT’S CLAIM Dr. A was negligent in applying too much pressure, dislodging the blade. Dr. A was also faulty in his search for the blade, which was the cause of bowel perforation. Both Drs. A and B were negligent in failing to discover the injury earlier.

 

 

PHYSICIAN’S DEFENSE The ultrasonic scalpel had a product defect that caused the lower blade to dislodge. The application of pressure wasn’t a factor; the 6-hour procedure had caused the robotic arm to overheat, weakening the metal and causing the blade to separate. Dr. A followed appropriate procedures when searching for the blade. The perforation did not occur until 3 days after surgery; it was diagnosed and treated in a timely manner. The removal of adhesions from the sigmoid colon weakened the bowel wall, leading to the perforation; this was a known risk of the procedure.

VERDICT A California defense verdict was reached.

Stroke during in vitro fertilization

DURING IN VITRO FERTILIZATION, a woman suffered a stroke to the right side of her brain, which initially paralyzed the left side of her body. She partially regained movement, but walks with a limp and has diminished dexterity in her right hand and diminished strength.

PATIENT’S CLAIM The ObGyn ignored warning signs of ovarian hyperstimulation syndrome (OHSS), and continued therapy. OHSS caused enlargement of the ovaries and leakage of fluid from the patient’s blood vessels into her abdomen. This leakage increased the viscosity of her blood, and enhanced the danger of blood clots. The ObGyn administered intravenous fluids, but did not prescribe an anticoagulant.

PHYSICIAN’S DEFENSE Stroke is a known complication of the surgery.

VERDICT A $1.5 million Virginia verdict was returned.

Umbilical cord in cervix; premature delivery

A WOMAN HAD AN ABNORMAL PAP smear during pregnancy. She was sent to a university hospital and placed on bed rest due to cervical incompetence. Tests indicated that the fetus was healthy. A month later, the baby was born 3 months’ premature. He weighed less than 2 lb at birth, and had brain damage and cerebral palsy.

PATIENT’S CLAIM A sonogram performed on the morning of the delivery showed the umbilical cord in the cervix and a low amniotic fluid level. An emergency cesarean delivery should have been performed. Delivery did not occur for another 12 hours; this delay caused oxygen deprivation and brain damage.

DEFENDANTS’ DEFENSE The hospital and physicians denied negligence.

VERDICT A $4,100,000 Maryland defense verdict was returned, but was reduced by the statutory cap on noneconomic damages to a net verdict of $3,605,000.

No ObGyn available for emergency cesarean

A WOMAN IN LABOR went to a hospital. When the fetal heart monitor indicated abnormalities, the only ObGyn on duty was busy in a scheduled elective procedure. The on-call resident was assisting with another surgery. After attempting to find another physician, the labor and delivery nurse waited 40 minutes before she put out a code that delivery was imminent. The resident then delivered the child, who was limp and discolored at birth. The child suffered physical and mental impairment, is confined to a wheelchair, and is unable to speak or to care for herself.

PATIENT’S CLAIM An ObGyn should have been available to perform emergency cesarean delivery. The resident was not skilled enough to attempt a high-risk birth. The nurse should not have waited so long to find a physician.

PHYSICIAN’S DEFENSE This is a teaching hospital; the resident was trained to perform delivery. The nurse attempted to find a physician, but all were occupied elsewhere.

VERDICT A $6,015,000 New Jersey verdict was returned against the resident’s university employer ($15,000), and the hospital, ObGyn, and nurse ($6 million).

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

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Did low amniotic fluid cause cerebral palsy?

A BICORNUATE UTERUS and the infant’s breech position complicated a woman’s pregnancy. At her 39-week prenatal visit, testing showed a low amniotic fluid level, but the woman was sent home. Two days later, she went to the hospital in labor. Her ObGyn first allowed labor to proceed, then performed a cesarean delivery. The father recorded the birth on video camera. The baby was born “essentially lifeless” but with a weak heartbeat. The child was diagnosed with cerebral palsy.

PATIENT’S CLAIM A cesarean delivery should have been performed as soon as it was determined that the amniotic fluid level was low. During surgery, the ObGyn did not choose an incision location that would deliver the baby quickly. The recording evidenced that there was a delay in delivery.

PHYSICIAN’S DEFENSE Elective cesarean delivery was not necessary at the time of the patient’s last visit, as one is not performed before 40 weeks’ gestation. Cesarean delivery was appropriately performed. The baby had a good heart rate at birth. Brain damage was due to fetal inflammatory response syndrome.

VERDICT A $58 million Connecticut verdict was returned.

Death from meningitis after miscarriage

COMPLAINING OF VAGINAL BLEEDING, a woman in her 20s went to an emergency department. She was found to be about 12 weeks’ pregnant. An ObGyn diagnosed spontaneous abortion/miscarriage. Ultrasonography showed that fetal tissue had been expelled, and that no products of conception remained, only blood clots. The woman was given the option of 1) dilatation and curettage (D&C) or 2) letting the residual material expel without intervention. She chose the latter, and was discharged with instructions to return if her condition became worse. Three days later, the woman was admitted to another hospital with Group B streptococcal meningitis and a urinary tract infection. She died 2 days later.

ESTATE’S CLAIM A D&C should have been performed. Prophylactic antibiotics should have been prescribed, which would have stopped the infectious process and allowed the decedent to survive.

DEFENDANTS’ DEFENSE Prophylactic antibiotics were unnecessary because there were no signs or symptoms of infection when the woman was discharged. Prophylactic antibiotics would not have appropriately treated meningitis, and could have made the infection progress more rapidly by destroying the body’s infection-fighting process. There was no need for a D&C because ultrasonography identified no retained products of conception—indicating that there were no foreign substances to cause an infection.

VERDICT A Maryland defense verdict was returned.

Reduced fetal movement and severe brain damage

AT HER 39-WEEK PRENATAL VISIT, a woman reported that the baby wasn’t as active as usual. She was seen by a resident, who did not apply a fetal heart monitor or have the attending ObGyn examine the mother. She was sent home. Two days later, the mother realized the baby was not moving at all, and returned to the clinic. Emergency cesarean delivery was performed. The child has severe brain damage and cerebral palsy.

PATIENT’S CLAIM The resident failed to appropriately respond when the mother reported the baby was not active. The attending ObGyn should have been called, and the baby’s heart rate should have been monitored. It was later found that a clotting abnormality had developed, causing an inadequate supply of oxygen to the fetal brain. Proper response to the report of decreased movement would have resulted in the delivery of a healthy child.

PHYSICIANS’ DEFENSE Brain damage occurred prior to the mother’s 39th-week visit. This was apparent because of the child’s joint contractures, which, the defense argued, take a week or longer to develop. (The plaintiff countered that contractures were mild and that the infant was moving his arms and legs a short time after delivery.)

VERDICT A $4,821,000 Missouri verdict was returned.

Scalpel breaks during robotic surgery

ROBOT-ASSISTED LAPAROSCOPIC pelvic mass resection was performed on an obese 47-year-old woman. During surgery, the lower blade of an ultrasonic, vibrating scalpel dislodged. Dr. A spent 90 minutes searching for the blade, which he eventually found. The mass was removed and diagnosed as benign. During recovery, the patient became septic, went into acute renal failure, acute respiratory failure, and septic shock. A diagnosis of fecal peritonitis was made.

Dr. B assumed the care of the patient, and later found a colon perforation. Four days after the initial procedure, the patient underwent a colon resection. She was initially treated with a colostomy and then had a successful bowel reanastomosis 7 months after the injury.

PATIENT’S CLAIM Dr. A was negligent in applying too much pressure, dislodging the blade. Dr. A was also faulty in his search for the blade, which was the cause of bowel perforation. Both Drs. A and B were negligent in failing to discover the injury earlier.

 

 

PHYSICIAN’S DEFENSE The ultrasonic scalpel had a product defect that caused the lower blade to dislodge. The application of pressure wasn’t a factor; the 6-hour procedure had caused the robotic arm to overheat, weakening the metal and causing the blade to separate. Dr. A followed appropriate procedures when searching for the blade. The perforation did not occur until 3 days after surgery; it was diagnosed and treated in a timely manner. The removal of adhesions from the sigmoid colon weakened the bowel wall, leading to the perforation; this was a known risk of the procedure.

VERDICT A California defense verdict was reached.

Stroke during in vitro fertilization

DURING IN VITRO FERTILIZATION, a woman suffered a stroke to the right side of her brain, which initially paralyzed the left side of her body. She partially regained movement, but walks with a limp and has diminished dexterity in her right hand and diminished strength.

PATIENT’S CLAIM The ObGyn ignored warning signs of ovarian hyperstimulation syndrome (OHSS), and continued therapy. OHSS caused enlargement of the ovaries and leakage of fluid from the patient’s blood vessels into her abdomen. This leakage increased the viscosity of her blood, and enhanced the danger of blood clots. The ObGyn administered intravenous fluids, but did not prescribe an anticoagulant.

PHYSICIAN’S DEFENSE Stroke is a known complication of the surgery.

VERDICT A $1.5 million Virginia verdict was returned.

Umbilical cord in cervix; premature delivery

A WOMAN HAD AN ABNORMAL PAP smear during pregnancy. She was sent to a university hospital and placed on bed rest due to cervical incompetence. Tests indicated that the fetus was healthy. A month later, the baby was born 3 months’ premature. He weighed less than 2 lb at birth, and had brain damage and cerebral palsy.

PATIENT’S CLAIM A sonogram performed on the morning of the delivery showed the umbilical cord in the cervix and a low amniotic fluid level. An emergency cesarean delivery should have been performed. Delivery did not occur for another 12 hours; this delay caused oxygen deprivation and brain damage.

DEFENDANTS’ DEFENSE The hospital and physicians denied negligence.

VERDICT A $4,100,000 Maryland defense verdict was returned, but was reduced by the statutory cap on noneconomic damages to a net verdict of $3,605,000.

No ObGyn available for emergency cesarean

A WOMAN IN LABOR went to a hospital. When the fetal heart monitor indicated abnormalities, the only ObGyn on duty was busy in a scheduled elective procedure. The on-call resident was assisting with another surgery. After attempting to find another physician, the labor and delivery nurse waited 40 minutes before she put out a code that delivery was imminent. The resident then delivered the child, who was limp and discolored at birth. The child suffered physical and mental impairment, is confined to a wheelchair, and is unable to speak or to care for herself.

PATIENT’S CLAIM An ObGyn should have been available to perform emergency cesarean delivery. The resident was not skilled enough to attempt a high-risk birth. The nurse should not have waited so long to find a physician.

PHYSICIAN’S DEFENSE This is a teaching hospital; the resident was trained to perform delivery. The nurse attempted to find a physician, but all were occupied elsewhere.

VERDICT A $6,015,000 New Jersey verdict was returned against the resident’s university employer ($15,000), and the hospital, ObGyn, and nurse ($6 million).

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Did low amniotic fluid cause cerebral palsy?

A BICORNUATE UTERUS and the infant’s breech position complicated a woman’s pregnancy. At her 39-week prenatal visit, testing showed a low amniotic fluid level, but the woman was sent home. Two days later, she went to the hospital in labor. Her ObGyn first allowed labor to proceed, then performed a cesarean delivery. The father recorded the birth on video camera. The baby was born “essentially lifeless” but with a weak heartbeat. The child was diagnosed with cerebral palsy.

PATIENT’S CLAIM A cesarean delivery should have been performed as soon as it was determined that the amniotic fluid level was low. During surgery, the ObGyn did not choose an incision location that would deliver the baby quickly. The recording evidenced that there was a delay in delivery.

PHYSICIAN’S DEFENSE Elective cesarean delivery was not necessary at the time of the patient’s last visit, as one is not performed before 40 weeks’ gestation. Cesarean delivery was appropriately performed. The baby had a good heart rate at birth. Brain damage was due to fetal inflammatory response syndrome.

VERDICT A $58 million Connecticut verdict was returned.

Death from meningitis after miscarriage

COMPLAINING OF VAGINAL BLEEDING, a woman in her 20s went to an emergency department. She was found to be about 12 weeks’ pregnant. An ObGyn diagnosed spontaneous abortion/miscarriage. Ultrasonography showed that fetal tissue had been expelled, and that no products of conception remained, only blood clots. The woman was given the option of 1) dilatation and curettage (D&C) or 2) letting the residual material expel without intervention. She chose the latter, and was discharged with instructions to return if her condition became worse. Three days later, the woman was admitted to another hospital with Group B streptococcal meningitis and a urinary tract infection. She died 2 days later.

ESTATE’S CLAIM A D&C should have been performed. Prophylactic antibiotics should have been prescribed, which would have stopped the infectious process and allowed the decedent to survive.

DEFENDANTS’ DEFENSE Prophylactic antibiotics were unnecessary because there were no signs or symptoms of infection when the woman was discharged. Prophylactic antibiotics would not have appropriately treated meningitis, and could have made the infection progress more rapidly by destroying the body’s infection-fighting process. There was no need for a D&C because ultrasonography identified no retained products of conception—indicating that there were no foreign substances to cause an infection.

VERDICT A Maryland defense verdict was returned.

Reduced fetal movement and severe brain damage

AT HER 39-WEEK PRENATAL VISIT, a woman reported that the baby wasn’t as active as usual. She was seen by a resident, who did not apply a fetal heart monitor or have the attending ObGyn examine the mother. She was sent home. Two days later, the mother realized the baby was not moving at all, and returned to the clinic. Emergency cesarean delivery was performed. The child has severe brain damage and cerebral palsy.

PATIENT’S CLAIM The resident failed to appropriately respond when the mother reported the baby was not active. The attending ObGyn should have been called, and the baby’s heart rate should have been monitored. It was later found that a clotting abnormality had developed, causing an inadequate supply of oxygen to the fetal brain. Proper response to the report of decreased movement would have resulted in the delivery of a healthy child.

PHYSICIANS’ DEFENSE Brain damage occurred prior to the mother’s 39th-week visit. This was apparent because of the child’s joint contractures, which, the defense argued, take a week or longer to develop. (The plaintiff countered that contractures were mild and that the infant was moving his arms and legs a short time after delivery.)

VERDICT A $4,821,000 Missouri verdict was returned.

Scalpel breaks during robotic surgery

ROBOT-ASSISTED LAPAROSCOPIC pelvic mass resection was performed on an obese 47-year-old woman. During surgery, the lower blade of an ultrasonic, vibrating scalpel dislodged. Dr. A spent 90 minutes searching for the blade, which he eventually found. The mass was removed and diagnosed as benign. During recovery, the patient became septic, went into acute renal failure, acute respiratory failure, and septic shock. A diagnosis of fecal peritonitis was made.

Dr. B assumed the care of the patient, and later found a colon perforation. Four days after the initial procedure, the patient underwent a colon resection. She was initially treated with a colostomy and then had a successful bowel reanastomosis 7 months after the injury.

PATIENT’S CLAIM Dr. A was negligent in applying too much pressure, dislodging the blade. Dr. A was also faulty in his search for the blade, which was the cause of bowel perforation. Both Drs. A and B were negligent in failing to discover the injury earlier.

 

 

PHYSICIAN’S DEFENSE The ultrasonic scalpel had a product defect that caused the lower blade to dislodge. The application of pressure wasn’t a factor; the 6-hour procedure had caused the robotic arm to overheat, weakening the metal and causing the blade to separate. Dr. A followed appropriate procedures when searching for the blade. The perforation did not occur until 3 days after surgery; it was diagnosed and treated in a timely manner. The removal of adhesions from the sigmoid colon weakened the bowel wall, leading to the perforation; this was a known risk of the procedure.

VERDICT A California defense verdict was reached.

Stroke during in vitro fertilization

DURING IN VITRO FERTILIZATION, a woman suffered a stroke to the right side of her brain, which initially paralyzed the left side of her body. She partially regained movement, but walks with a limp and has diminished dexterity in her right hand and diminished strength.

PATIENT’S CLAIM The ObGyn ignored warning signs of ovarian hyperstimulation syndrome (OHSS), and continued therapy. OHSS caused enlargement of the ovaries and leakage of fluid from the patient’s blood vessels into her abdomen. This leakage increased the viscosity of her blood, and enhanced the danger of blood clots. The ObGyn administered intravenous fluids, but did not prescribe an anticoagulant.

PHYSICIAN’S DEFENSE Stroke is a known complication of the surgery.

VERDICT A $1.5 million Virginia verdict was returned.

Umbilical cord in cervix; premature delivery

A WOMAN HAD AN ABNORMAL PAP smear during pregnancy. She was sent to a university hospital and placed on bed rest due to cervical incompetence. Tests indicated that the fetus was healthy. A month later, the baby was born 3 months’ premature. He weighed less than 2 lb at birth, and had brain damage and cerebral palsy.

PATIENT’S CLAIM A sonogram performed on the morning of the delivery showed the umbilical cord in the cervix and a low amniotic fluid level. An emergency cesarean delivery should have been performed. Delivery did not occur for another 12 hours; this delay caused oxygen deprivation and brain damage.

DEFENDANTS’ DEFENSE The hospital and physicians denied negligence.

VERDICT A $4,100,000 Maryland defense verdict was returned, but was reduced by the statutory cap on noneconomic damages to a net verdict of $3,605,000.

No ObGyn available for emergency cesarean

A WOMAN IN LABOR went to a hospital. When the fetal heart monitor indicated abnormalities, the only ObGyn on duty was busy in a scheduled elective procedure. The on-call resident was assisting with another surgery. After attempting to find another physician, the labor and delivery nurse waited 40 minutes before she put out a code that delivery was imminent. The resident then delivered the child, who was limp and discolored at birth. The child suffered physical and mental impairment, is confined to a wheelchair, and is unable to speak or to care for herself.

PATIENT’S CLAIM An ObGyn should have been available to perform emergency cesarean delivery. The resident was not skilled enough to attempt a high-risk birth. The nurse should not have waited so long to find a physician.

PHYSICIAN’S DEFENSE This is a teaching hospital; the resident was trained to perform delivery. The nurse attempted to find a physician, but all were occupied elsewhere.

VERDICT A $6,015,000 New Jersey verdict was returned against the resident’s university employer ($15,000), and the hospital, ObGyn, and nurse ($6 million).

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

References

We want to hear from you! Tell us what you think.

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"All in his head" Dx leaves boy limping for more than a year … When a migraine isn't a migraine ... more

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"All in his head" Dx leaves boy limping for more than a year … When a migraine isn't a migraine ... more

“All in his head” Dx leaves boy limping for more than a year

A 9-YEAR-OLD BOY developed pain in his ankle and a resulting limp. Despite several visits to his pediatrician at a local clinic and consultations with specialists, the limp became worse. A work-up in the emergency department (ED) led to a diagnosis of dystonia and a follow-up visit with a specialist.

The specialist, whose area of expertise wasn’t dystonia, concluded that the symptoms were “in the boy’s head” and changed the diagnosis to conversion disorder without consulting the ED records or the physician who diagnosed dystonia. The boy was admitted to a rehabilitation hospital, where, according to his parents, he underwent a bizarre and punitive behavior regimen. The physician in charge at the hospital ordered removal of the crutches the patient needed to walk and directed that the boy do sit-ups and push-ups whenever he fell or lost his balance.

When the boy hadn’t improved after 30 days in the rehabilitation hospital, the treatment team ordered that he return to school on the condition that the school be informed that the child had a psychiatric condition and could walk normally if he wanted to. The school staff was instructed to forbid the boy to use crutches and not to help him up if he fell.

The situation continued for a year despite repeated questions from the boy’s parents and visits to the clinic. The family was dissuaded from seeking additional testing on the grounds that it would further “medicalize” his condition. A blood test done more than a year after the limp started confirmed the original diagnosis of dystonia.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $890,000 Ohio verdict

COMMENT Although many unusual symptoms do have a psychiatric basis, in this case, poor communication and follow-up resulted in an almost $900,000 verdict.

When a migraine isn’t a migraine

WEAKNESS, LOSS OF BALANCE, AND HEARING LOSS prompted a 45-year-old woman to visit the emergency department (ED). An ED physician diagnosed a migraine headache and discharged her.

Five days later the woman returned to the ED with similar complaints, including imbalance, facial droop, dizziness, and weakness in the left arm. She was admitted to the hospital, where she had a stroke and died 5 days later.

PLAINTIFF’S CLAIM The ED doctor diagnosed a migraine headache and discharged the patient from the hospital when she really had a transient ischemic attack. The patient should have been referred for a neurologic evaluation, which would have revealed cardiomyopathy, which often shows no symptoms before precipitating a massive stroke.

THE DEFENSE No information about the defense is available.

VERDICT $3 million Illinois settlement.

COMMENT Faced with the hectic pace of practice, we need to carefully evaluate even the most routine complaints such as headache and perform a careful general physical, which in this case might have disclosed a murmur and raised the index of suspicion.

 

 

Confusion over warfarin Rx ends badly

A 48-YEAR-OLD MAN who had suffered a patellar tendon rupture to the left knee underwent bilateral patellar tendon repair by an orthopedic surgeon; long leg cylinder casts were applied to both legs. The patient started taking 5 mg warfarin the following day.

Two days later he was transferred to a skilled nursing facility for physical therapy and warfarin adjustment and assigned a primary care physician. During his stay in the nursing facility, the patient’s blood tests never showed a therapeutic warfarin level. He saw the orthopedist, who prescribed 4 to 6 more weeks of warfarin therapy and scheduled a return appointment for 2 weeks later.

The day after the patient saw the orthopedist, his primary care physician increased the warfarin dose to 6 mg. When a blood test 3 days later showed a nontherapeutic level, she increased the dose to 7 mg.

Twelve days later, the leg casts were removed and knee immobilizers applied. The doctor who removed the casts recommended that the patient keep taking warfarin for at least 6 more weeks until removal of the knee immobilizers and the start of range of motion exercises. The patient was given a prescription to take to the skilled nursing facility to continue warfarin at the discretion of the primary care physician. That same day, the primary care doctor ordered by telephone that the patient continue to receive the same dose of warfarin.

The patient was discharged home 2 days later with orders for physical therapy and a blood draw for prothrombin time/international normalized ratio (INR). Physical therapy began 3 days before the blood draw was to be performed. The blood draw was actually done a day later than ordered and one day after the patient had taken his last dose of warfarin.

The home health nurse notified the orthopedist that the patient had taken his last dose of warfarin and faxed him the results of the blood test, showing an INR of 1.3. Six days later, the nurse contacted the orthopedist again about the exhausted warfarin supply. The orthopedist told the nurse to get in touch with the primary care physician who had followed the patient during his stay at the skilled nursing facility. The nurse left a voice-mail message on the phone of the primary care physician’s nurse. Twenty-five days later, the patient suffered an embolism in his main pulmonary artery and died.

PLAINTIFF’S CLAIM The home health agency and physicians were negligent in failing to properly monitor the patient’s warfarin therapy.

THE DEFENSE The home health nurse acted properly in contacting the doctor. The orthopedist claimed that he had no duty to monitor the patient’s warfarin therapy because that was the responsibility of an internist. The primary care physician claimed that she wasn’t responsible for monitoring the warfarin after the patient was discharged from the skilled nursing facility.

VERDICT $76,760.12 net California verdict against the primary care physician with confidential post-trial settlement. The orthopedist received a defense verdict.

COMMENT Another example of lack of coordination of care, noncompliance, and inadequate follow-up. Although we can only partially improve adherence, we should shoulder responsibility for coordinated care!

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“All in his head” Dx leaves boy limping for more than a year

A 9-YEAR-OLD BOY developed pain in his ankle and a resulting limp. Despite several visits to his pediatrician at a local clinic and consultations with specialists, the limp became worse. A work-up in the emergency department (ED) led to a diagnosis of dystonia and a follow-up visit with a specialist.

The specialist, whose area of expertise wasn’t dystonia, concluded that the symptoms were “in the boy’s head” and changed the diagnosis to conversion disorder without consulting the ED records or the physician who diagnosed dystonia. The boy was admitted to a rehabilitation hospital, where, according to his parents, he underwent a bizarre and punitive behavior regimen. The physician in charge at the hospital ordered removal of the crutches the patient needed to walk and directed that the boy do sit-ups and push-ups whenever he fell or lost his balance.

When the boy hadn’t improved after 30 days in the rehabilitation hospital, the treatment team ordered that he return to school on the condition that the school be informed that the child had a psychiatric condition and could walk normally if he wanted to. The school staff was instructed to forbid the boy to use crutches and not to help him up if he fell.

The situation continued for a year despite repeated questions from the boy’s parents and visits to the clinic. The family was dissuaded from seeking additional testing on the grounds that it would further “medicalize” his condition. A blood test done more than a year after the limp started confirmed the original diagnosis of dystonia.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $890,000 Ohio verdict

COMMENT Although many unusual symptoms do have a psychiatric basis, in this case, poor communication and follow-up resulted in an almost $900,000 verdict.

When a migraine isn’t a migraine

WEAKNESS, LOSS OF BALANCE, AND HEARING LOSS prompted a 45-year-old woman to visit the emergency department (ED). An ED physician diagnosed a migraine headache and discharged her.

Five days later the woman returned to the ED with similar complaints, including imbalance, facial droop, dizziness, and weakness in the left arm. She was admitted to the hospital, where she had a stroke and died 5 days later.

PLAINTIFF’S CLAIM The ED doctor diagnosed a migraine headache and discharged the patient from the hospital when she really had a transient ischemic attack. The patient should have been referred for a neurologic evaluation, which would have revealed cardiomyopathy, which often shows no symptoms before precipitating a massive stroke.

THE DEFENSE No information about the defense is available.

VERDICT $3 million Illinois settlement.

COMMENT Faced with the hectic pace of practice, we need to carefully evaluate even the most routine complaints such as headache and perform a careful general physical, which in this case might have disclosed a murmur and raised the index of suspicion.

 

 

Confusion over warfarin Rx ends badly

A 48-YEAR-OLD MAN who had suffered a patellar tendon rupture to the left knee underwent bilateral patellar tendon repair by an orthopedic surgeon; long leg cylinder casts were applied to both legs. The patient started taking 5 mg warfarin the following day.

Two days later he was transferred to a skilled nursing facility for physical therapy and warfarin adjustment and assigned a primary care physician. During his stay in the nursing facility, the patient’s blood tests never showed a therapeutic warfarin level. He saw the orthopedist, who prescribed 4 to 6 more weeks of warfarin therapy and scheduled a return appointment for 2 weeks later.

The day after the patient saw the orthopedist, his primary care physician increased the warfarin dose to 6 mg. When a blood test 3 days later showed a nontherapeutic level, she increased the dose to 7 mg.

Twelve days later, the leg casts were removed and knee immobilizers applied. The doctor who removed the casts recommended that the patient keep taking warfarin for at least 6 more weeks until removal of the knee immobilizers and the start of range of motion exercises. The patient was given a prescription to take to the skilled nursing facility to continue warfarin at the discretion of the primary care physician. That same day, the primary care doctor ordered by telephone that the patient continue to receive the same dose of warfarin.

The patient was discharged home 2 days later with orders for physical therapy and a blood draw for prothrombin time/international normalized ratio (INR). Physical therapy began 3 days before the blood draw was to be performed. The blood draw was actually done a day later than ordered and one day after the patient had taken his last dose of warfarin.

The home health nurse notified the orthopedist that the patient had taken his last dose of warfarin and faxed him the results of the blood test, showing an INR of 1.3. Six days later, the nurse contacted the orthopedist again about the exhausted warfarin supply. The orthopedist told the nurse to get in touch with the primary care physician who had followed the patient during his stay at the skilled nursing facility. The nurse left a voice-mail message on the phone of the primary care physician’s nurse. Twenty-five days later, the patient suffered an embolism in his main pulmonary artery and died.

PLAINTIFF’S CLAIM The home health agency and physicians were negligent in failing to properly monitor the patient’s warfarin therapy.

THE DEFENSE The home health nurse acted properly in contacting the doctor. The orthopedist claimed that he had no duty to monitor the patient’s warfarin therapy because that was the responsibility of an internist. The primary care physician claimed that she wasn’t responsible for monitoring the warfarin after the patient was discharged from the skilled nursing facility.

VERDICT $76,760.12 net California verdict against the primary care physician with confidential post-trial settlement. The orthopedist received a defense verdict.

COMMENT Another example of lack of coordination of care, noncompliance, and inadequate follow-up. Although we can only partially improve adherence, we should shoulder responsibility for coordinated care!

“All in his head” Dx leaves boy limping for more than a year

A 9-YEAR-OLD BOY developed pain in his ankle and a resulting limp. Despite several visits to his pediatrician at a local clinic and consultations with specialists, the limp became worse. A work-up in the emergency department (ED) led to a diagnosis of dystonia and a follow-up visit with a specialist.

The specialist, whose area of expertise wasn’t dystonia, concluded that the symptoms were “in the boy’s head” and changed the diagnosis to conversion disorder without consulting the ED records or the physician who diagnosed dystonia. The boy was admitted to a rehabilitation hospital, where, according to his parents, he underwent a bizarre and punitive behavior regimen. The physician in charge at the hospital ordered removal of the crutches the patient needed to walk and directed that the boy do sit-ups and push-ups whenever he fell or lost his balance.

When the boy hadn’t improved after 30 days in the rehabilitation hospital, the treatment team ordered that he return to school on the condition that the school be informed that the child had a psychiatric condition and could walk normally if he wanted to. The school staff was instructed to forbid the boy to use crutches and not to help him up if he fell.

The situation continued for a year despite repeated questions from the boy’s parents and visits to the clinic. The family was dissuaded from seeking additional testing on the grounds that it would further “medicalize” his condition. A blood test done more than a year after the limp started confirmed the original diagnosis of dystonia.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $890,000 Ohio verdict

COMMENT Although many unusual symptoms do have a psychiatric basis, in this case, poor communication and follow-up resulted in an almost $900,000 verdict.

When a migraine isn’t a migraine

WEAKNESS, LOSS OF BALANCE, AND HEARING LOSS prompted a 45-year-old woman to visit the emergency department (ED). An ED physician diagnosed a migraine headache and discharged her.

Five days later the woman returned to the ED with similar complaints, including imbalance, facial droop, dizziness, and weakness in the left arm. She was admitted to the hospital, where she had a stroke and died 5 days later.

PLAINTIFF’S CLAIM The ED doctor diagnosed a migraine headache and discharged the patient from the hospital when she really had a transient ischemic attack. The patient should have been referred for a neurologic evaluation, which would have revealed cardiomyopathy, which often shows no symptoms before precipitating a massive stroke.

THE DEFENSE No information about the defense is available.

VERDICT $3 million Illinois settlement.

COMMENT Faced with the hectic pace of practice, we need to carefully evaluate even the most routine complaints such as headache and perform a careful general physical, which in this case might have disclosed a murmur and raised the index of suspicion.

 

 

Confusion over warfarin Rx ends badly

A 48-YEAR-OLD MAN who had suffered a patellar tendon rupture to the left knee underwent bilateral patellar tendon repair by an orthopedic surgeon; long leg cylinder casts were applied to both legs. The patient started taking 5 mg warfarin the following day.

Two days later he was transferred to a skilled nursing facility for physical therapy and warfarin adjustment and assigned a primary care physician. During his stay in the nursing facility, the patient’s blood tests never showed a therapeutic warfarin level. He saw the orthopedist, who prescribed 4 to 6 more weeks of warfarin therapy and scheduled a return appointment for 2 weeks later.

The day after the patient saw the orthopedist, his primary care physician increased the warfarin dose to 6 mg. When a blood test 3 days later showed a nontherapeutic level, she increased the dose to 7 mg.

Twelve days later, the leg casts were removed and knee immobilizers applied. The doctor who removed the casts recommended that the patient keep taking warfarin for at least 6 more weeks until removal of the knee immobilizers and the start of range of motion exercises. The patient was given a prescription to take to the skilled nursing facility to continue warfarin at the discretion of the primary care physician. That same day, the primary care doctor ordered by telephone that the patient continue to receive the same dose of warfarin.

The patient was discharged home 2 days later with orders for physical therapy and a blood draw for prothrombin time/international normalized ratio (INR). Physical therapy began 3 days before the blood draw was to be performed. The blood draw was actually done a day later than ordered and one day after the patient had taken his last dose of warfarin.

The home health nurse notified the orthopedist that the patient had taken his last dose of warfarin and faxed him the results of the blood test, showing an INR of 1.3. Six days later, the nurse contacted the orthopedist again about the exhausted warfarin supply. The orthopedist told the nurse to get in touch with the primary care physician who had followed the patient during his stay at the skilled nursing facility. The nurse left a voice-mail message on the phone of the primary care physician’s nurse. Twenty-five days later, the patient suffered an embolism in his main pulmonary artery and died.

PLAINTIFF’S CLAIM The home health agency and physicians were negligent in failing to properly monitor the patient’s warfarin therapy.

THE DEFENSE The home health nurse acted properly in contacting the doctor. The orthopedist claimed that he had no duty to monitor the patient’s warfarin therapy because that was the responsibility of an internist. The primary care physician claimed that she wasn’t responsible for monitoring the warfarin after the patient was discharged from the skilled nursing facility.

VERDICT $76,760.12 net California verdict against the primary care physician with confidential post-trial settlement. The orthopedist received a defense verdict.

COMMENT Another example of lack of coordination of care, noncompliance, and inadequate follow-up. Although we can only partially improve adherence, we should shoulder responsibility for coordinated care!

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Pelvic injury from the McRoberts maneuver?…and more

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Pelvic injury from the McRoberts maneuver?…and more

Pelvic injury from the McRoberts maneuver?

DURING PRENATAL CARE, a woman repeatedly complained of severe discomfort, and requested a cesarean delivery. The ObGyn’s charts did not note her complaints.

A first-year resident and nurse covered for the ObGyn because he did not arrive at the hospital for hours after the mother notified him she was in labor. When shoulder dystocia was encountered, the resident used the McRoberts maneuver. The ObGyn arrived a minute before the birth. The baby weighed 10 lbs. The mother suffered symphysis pubis diastasis, required several surgeries, and now uses a cane to walk.

PATIENT’S CLAIM The ObGyn was negligent in not arriving in time to deliver the baby. The mother’s pelvis was injured during the McRoberts maneuver. The baby’s size was not properly estimated.

PHYSICIAN’S DEFENSE The use of the resident’s care was appropriate, as this was a teaching hospital.

VERDICT A $5.5 million New York verdict was returned.

Cancer Dx “not timely”; additional tx required

IN JUNE 2000, AN OBGYN PALPATED a pelvic mass in a postmenopausal woman. After ultrasonography (US) in August 2000, the ObGyn told the woman that a uterine fibroid had been found but no further testing was needed. In December 2001, US revealed that the mass had enlarged, but no further testing was done. In May 2002, the patient reported fatigue, distention of her abdomen, and an increase in the frequency of urination.

In July 2002, the ObGyn removed a 3-lb malignant uterine tumor during hysterectomy. A second staging surgery was performed, and the patient underwent chemotherapy.

PATIENT’S CLAIM An earlier diagnosis would have reduced the amount of treatment required. The ObGyn should have reacted immediately when the mass was first palpated in June 2000 and found on US in August 2000, as postmenopausal women do not develop uterine fibroids. A gynecologic oncologist should have been present at the hysterectomy to perform concurrent staging.

PHYSICIAN’S DEFENSE The patient failed to report symptoms that suggested cancer for 10 months; a prompt response was made when symptoms were revealed. It was appropriate to accept the results of US regarding a uterine fibroid.

VERDICT A $1.25 million New York verdict was returned.

Abnormal thickness of fetal nuchal fold

WHEN A 31-YEAR-OLD WOMAN was 18 weeks’ pregnant, she underwent ultrasonography, which was reportedly normal. The child was born with Down syndrome.

PATIENT’S CLAIM The ObGyn and radiologist failed to detect an abnormal thickness in the fetal nuchal fold—often a sign of Down syndrome.

PHYSICIANS’ DEFENSE The sonogram was properly analyzed. A thickened fold is an unreliable indicator of Down syndrome.

VERDICT A $1.7 million New Jersey settlement was returned.

Ovary retained; cancer recurs; death

A WOMAN UNDERWENT SURGERY for ovarian cancer in July 2004. She died of ovarian cancer in 2008 at age 59.

ESTATE’S CLAIM The gynecologist did not tell the patient that only one ovary was removed, or that a pathologist had not found the second ovary in the specimen. Ovarian cancer developed in the retained ovary a few years later. She would have undergone additional surgery had she known the second ovary was still there.

PHYSICIAN’S DEFENSE Both ovaries were removed in July 2004. The left ovary was not found during an autopsy performed on the decedent.

VERDICT A $1.967 million Pennsylvania verdict was returned.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

5 birth injuries, $54 million in verdicts and settlements

1. Severe birth asphyxia: cerebral palsy and seizures

AFTER A NORMAL PREGNANCY, a woman went to the hospital in labor. Her ObGyn, Dr. A, went off duty at 4 PM and was replaced by Dr. B, a practice partner who delivered five other babies between 11 PM and 2:15 AM.

At 9:40 PM, the fetus was occiput posterior. At 12:31 AM, Dr. B attempted manual rotation; no exam was recorded in the chart. By 2:30 AM, the fetus had returned to the occiput posterior position, and Dr. B again tried manual rotation. Then he left to take a nap while the mother’s epidural was reinforced. There was a delay in achieving a satisfactory epidural, and Dr. B was not called back to the bedside until 4 AM. He decided to perform a cesarean delivery when the fetal heart monitor showed an increased baseline with persistent variable decelerations.

Although Dr. B had called Dr. A earlier to elicit her help with the cesarean, she had gone back to bed and was not prepared to assist. During a 30-minute delay, the electronic fetal monitor was disconnected and never reconnected. A nurse checked the fetal heart rate with ultrasonography, and reported that it was normal; however, there was no copy in the chart.

The incision was made at 4:33 AM, and the baby was delivered at 5:06 AM. The infant was born without a heart rate or respiration (Apgar scores, all 0). A neonatologist was not available for resuscitation; a neonatal nurse practitioner arrived 7 minutes after delivery. The baby finally had a heart rate 24 minutes after delivery. The child suffered severe birth asphyxia, causing athetoid and spastic cerebral palsy and seizures.

PATIENT’S CLAIM The ObGyn failed to deliver the baby in a timely manner. The fetus was not continuously monitored with a fetal scalp electrode. The nurse violated several hospital policies.

DEFENDANTS’ DEFENSE The baby suffered an acute, total cord occlusion minutes before birth; this was unpredictable and the injuries could not have been prevented.

VERDICT At the end of the discovery period, the defendants’ attorney withdrew and new attorneys sought to name new experts. While these issues were pending, the matter was settled for a Washington total of $20 million. The mother settled with the hospital for $9.85 million. Although the doctors’ group had $5 million in insurance coverage, the plaintiff demanded that the insurance company pay in excess of limits due to potential bad-faith claims. The insurance company ultimately paid $10.15 million.

2. Profound metabolic acidosis after emergent delivery

WHEN A WOMAN WAS 2 CM DILATED and 99% effaced, she was given dinoprostone and oxytocin to begin induction and augment labor. Oxytocin was continued even though her pattern of contractions showed tachysystole. An intrauterine pressure catheter that had been placed to assess contractions was removed. Monitoring revealed an elevated fetal heart rate at 170 to 180 bpm. Ten minutes before birth, the fetal heart tracing ended; a sonogram showed fetal bradycardia and prompted an emergency vacuum extraction.

The baby was floppy at birth, did not cry, and was intubated and transferred to the NICU. Apgar scores were 1, 3, and 5 at 1, 5, and 10 minutes. The umbilical cord gas had a venous pH of 6.637, indicative of profound acidosis. Ongoing hypoxia and anoxia resulted in massive and irreversible brain injury. An EEG at 5 days confirmed the presence of encephalopathy due to perinatal asphyxia. The child will require specialized treatment and attendant care for life.

PATIENT’S CLAIM Oxytocin was never stopped or reduced throughout labor and delivery. The ObGyn failed to promptly deliver the baby. No internal scalp electrode was used to directly monitor the fetus; the intrauterine pressure catheter was never replaced.

DEFENDANTS’ DEFENSE The ObGyn and hospital denied negligence or causation, claiming that there was a sudden placental abruption 10 minutes before birth that caused perinatal asphyxia.

VERDICT A $6.95 million District of Columbia settlement was returned.

3. Breech 2nd twin has cerebral palsy

PREGNANT WITH TWINS and in early labor, a woman went to the hospital, where a nurse midwife administered dinoprostone. The labor and delivery nurses only monitored one fetal heart rate during most of the labor period. The mother’s contraction pattern was indicative of tachysystole, and the twin who was being monitored showed a decelerating heart rate. The ObGyn arrived minutes before the birth unprepared for delivery, and a nurse delivered a healthy first child.

The second child’s heart rate dropped to 90 bpm, and the baby shifted to a breech position; the ObGyn tried manual rotation but was unsuccessful. After 20 minutes, cesarean delivery was performed. The boy was born with signs of metabolic acidosis and suffered a seizure 2 hours later. He was given a diagnosis of cerebral palsy and is fed through a tube, cannot speak, and requires skilled nursing care.

PATIENT’S CLAIM The ObGyn and nurses were negligent in only monitoring one fetus, and for failing to perform cesarean delivery in a timely manner.

DEFENDANTS’ DEFENSE The ObGyn claimed he was not informed of the decelerations shown on the fetal monitor, nor of the mother’s rapidly progressing labor. The hospital maintained that the nurses had given the ObGyn proper information and that the injuries to the infant had occurred after the ObGyn’s arrival. The mother’s weight of 322 pounds made monitoring difficult during labor and delivery.

VERDICT A $21,573,993 Pennsylvania verdict was returned against the hospital; a defense verdict was returned for the physician.

4. Shoulder dystocia, uterine tachysystole complicate vaginal delivery

WITH MILD PRE-ECLAMPSIA and vaginal spotting, a woman was admitted to a hospital’s L&D unit. Dinoprostone was administered, but the fetus was unengaged. Oxytocin was added to induce labor. Labor was complicated by repeated tachysystole; prolonged dilation; prolonged descent; severe, prolonged decelerations; and tachycardia. Uterine tachysystole continued for extended periods. Vaginal delivery was complicated by shoulder dystocia, which took 2 minutes to resolve. The child was delivered without a heart rate or respirations. A heartbeat was obtained a minute after delivery, and Apgar scores were 0, 2, and 2. The child was given a diagnosis of hypoxic ischemic encephalopathy, cerebral palsy, and a seizure disorder.

PATIENT’S CLAIM The L&D nurses and physicians were negligent in failing to properly monitor labor progression, fetal heart rate, and oxytocin management. They failed to communicate with the woman’s ObGyn, and did not exercise the proper chain of command. The physicians failed to recommend a cesarean delivery when labor became complicated.

DEFENDANTS’ DEFENSE The patient’s treatment was appropriate. Brain damage did not occur during labor and delivery.

VERDICT A $3.55 million Idaho verdict was returned.

5. Fetus transverse; oxytocin given

A WOMAN ARRIVED AT THE HOSPITAL after her membranes ruptured. A first-year resident failed to realize that the fetus was in a transverse position, and, with the attending physician’s approval, ordered oxytocin. When vaginal bleeding began, it was suspected that the placenta had detached. An hour later, after vaginal bleeding increased and late decelerations were noted on the fetal heart monitor, cesarean delivery was performed. The child was given a diagnosis of cerebral palsy and other complications, and died at 16 months of age.

ESTATE’S CLAIM The use of oxytocin is contraindicated for a baby in a transverse position. The fetus’ position indicated a need for a cesarean delivery. Placental detachment was not promptly addressed, leading to fetal oxygen deprivation.

DEFENDANTS’ DEFENSE The fetus appeared to be fine under all objective criteria until a “softball-sized” clot emerged from the mother’s vagina. The attending physician came to the mother’s bedside at that time. Umbilical cord blood gases showed no evidence of acidosis. A fetal brain injury occurred prior to the mother’s arrival at the hospital.

VERDICT A $2.5 million Pennsylvania verdict was returned.

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Pelvic injury from the McRoberts maneuver?

DURING PRENATAL CARE, a woman repeatedly complained of severe discomfort, and requested a cesarean delivery. The ObGyn’s charts did not note her complaints.

A first-year resident and nurse covered for the ObGyn because he did not arrive at the hospital for hours after the mother notified him she was in labor. When shoulder dystocia was encountered, the resident used the McRoberts maneuver. The ObGyn arrived a minute before the birth. The baby weighed 10 lbs. The mother suffered symphysis pubis diastasis, required several surgeries, and now uses a cane to walk.

PATIENT’S CLAIM The ObGyn was negligent in not arriving in time to deliver the baby. The mother’s pelvis was injured during the McRoberts maneuver. The baby’s size was not properly estimated.

PHYSICIAN’S DEFENSE The use of the resident’s care was appropriate, as this was a teaching hospital.

VERDICT A $5.5 million New York verdict was returned.

Cancer Dx “not timely”; additional tx required

IN JUNE 2000, AN OBGYN PALPATED a pelvic mass in a postmenopausal woman. After ultrasonography (US) in August 2000, the ObGyn told the woman that a uterine fibroid had been found but no further testing was needed. In December 2001, US revealed that the mass had enlarged, but no further testing was done. In May 2002, the patient reported fatigue, distention of her abdomen, and an increase in the frequency of urination.

In July 2002, the ObGyn removed a 3-lb malignant uterine tumor during hysterectomy. A second staging surgery was performed, and the patient underwent chemotherapy.

PATIENT’S CLAIM An earlier diagnosis would have reduced the amount of treatment required. The ObGyn should have reacted immediately when the mass was first palpated in June 2000 and found on US in August 2000, as postmenopausal women do not develop uterine fibroids. A gynecologic oncologist should have been present at the hysterectomy to perform concurrent staging.

PHYSICIAN’S DEFENSE The patient failed to report symptoms that suggested cancer for 10 months; a prompt response was made when symptoms were revealed. It was appropriate to accept the results of US regarding a uterine fibroid.

VERDICT A $1.25 million New York verdict was returned.

Abnormal thickness of fetal nuchal fold

WHEN A 31-YEAR-OLD WOMAN was 18 weeks’ pregnant, she underwent ultrasonography, which was reportedly normal. The child was born with Down syndrome.

PATIENT’S CLAIM The ObGyn and radiologist failed to detect an abnormal thickness in the fetal nuchal fold—often a sign of Down syndrome.

PHYSICIANS’ DEFENSE The sonogram was properly analyzed. A thickened fold is an unreliable indicator of Down syndrome.

VERDICT A $1.7 million New Jersey settlement was returned.

Ovary retained; cancer recurs; death

A WOMAN UNDERWENT SURGERY for ovarian cancer in July 2004. She died of ovarian cancer in 2008 at age 59.

ESTATE’S CLAIM The gynecologist did not tell the patient that only one ovary was removed, or that a pathologist had not found the second ovary in the specimen. Ovarian cancer developed in the retained ovary a few years later. She would have undergone additional surgery had she known the second ovary was still there.

PHYSICIAN’S DEFENSE Both ovaries were removed in July 2004. The left ovary was not found during an autopsy performed on the decedent.

VERDICT A $1.967 million Pennsylvania verdict was returned.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

5 birth injuries, $54 million in verdicts and settlements

1. Severe birth asphyxia: cerebral palsy and seizures

AFTER A NORMAL PREGNANCY, a woman went to the hospital in labor. Her ObGyn, Dr. A, went off duty at 4 PM and was replaced by Dr. B, a practice partner who delivered five other babies between 11 PM and 2:15 AM.

At 9:40 PM, the fetus was occiput posterior. At 12:31 AM, Dr. B attempted manual rotation; no exam was recorded in the chart. By 2:30 AM, the fetus had returned to the occiput posterior position, and Dr. B again tried manual rotation. Then he left to take a nap while the mother’s epidural was reinforced. There was a delay in achieving a satisfactory epidural, and Dr. B was not called back to the bedside until 4 AM. He decided to perform a cesarean delivery when the fetal heart monitor showed an increased baseline with persistent variable decelerations.

Although Dr. B had called Dr. A earlier to elicit her help with the cesarean, she had gone back to bed and was not prepared to assist. During a 30-minute delay, the electronic fetal monitor was disconnected and never reconnected. A nurse checked the fetal heart rate with ultrasonography, and reported that it was normal; however, there was no copy in the chart.

The incision was made at 4:33 AM, and the baby was delivered at 5:06 AM. The infant was born without a heart rate or respiration (Apgar scores, all 0). A neonatologist was not available for resuscitation; a neonatal nurse practitioner arrived 7 minutes after delivery. The baby finally had a heart rate 24 minutes after delivery. The child suffered severe birth asphyxia, causing athetoid and spastic cerebral palsy and seizures.

PATIENT’S CLAIM The ObGyn failed to deliver the baby in a timely manner. The fetus was not continuously monitored with a fetal scalp electrode. The nurse violated several hospital policies.

DEFENDANTS’ DEFENSE The baby suffered an acute, total cord occlusion minutes before birth; this was unpredictable and the injuries could not have been prevented.

VERDICT At the end of the discovery period, the defendants’ attorney withdrew and new attorneys sought to name new experts. While these issues were pending, the matter was settled for a Washington total of $20 million. The mother settled with the hospital for $9.85 million. Although the doctors’ group had $5 million in insurance coverage, the plaintiff demanded that the insurance company pay in excess of limits due to potential bad-faith claims. The insurance company ultimately paid $10.15 million.

2. Profound metabolic acidosis after emergent delivery

WHEN A WOMAN WAS 2 CM DILATED and 99% effaced, she was given dinoprostone and oxytocin to begin induction and augment labor. Oxytocin was continued even though her pattern of contractions showed tachysystole. An intrauterine pressure catheter that had been placed to assess contractions was removed. Monitoring revealed an elevated fetal heart rate at 170 to 180 bpm. Ten minutes before birth, the fetal heart tracing ended; a sonogram showed fetal bradycardia and prompted an emergency vacuum extraction.

The baby was floppy at birth, did not cry, and was intubated and transferred to the NICU. Apgar scores were 1, 3, and 5 at 1, 5, and 10 minutes. The umbilical cord gas had a venous pH of 6.637, indicative of profound acidosis. Ongoing hypoxia and anoxia resulted in massive and irreversible brain injury. An EEG at 5 days confirmed the presence of encephalopathy due to perinatal asphyxia. The child will require specialized treatment and attendant care for life.

PATIENT’S CLAIM Oxytocin was never stopped or reduced throughout labor and delivery. The ObGyn failed to promptly deliver the baby. No internal scalp electrode was used to directly monitor the fetus; the intrauterine pressure catheter was never replaced.

DEFENDANTS’ DEFENSE The ObGyn and hospital denied negligence or causation, claiming that there was a sudden placental abruption 10 minutes before birth that caused perinatal asphyxia.

VERDICT A $6.95 million District of Columbia settlement was returned.

3. Breech 2nd twin has cerebral palsy

PREGNANT WITH TWINS and in early labor, a woman went to the hospital, where a nurse midwife administered dinoprostone. The labor and delivery nurses only monitored one fetal heart rate during most of the labor period. The mother’s contraction pattern was indicative of tachysystole, and the twin who was being monitored showed a decelerating heart rate. The ObGyn arrived minutes before the birth unprepared for delivery, and a nurse delivered a healthy first child.

The second child’s heart rate dropped to 90 bpm, and the baby shifted to a breech position; the ObGyn tried manual rotation but was unsuccessful. After 20 minutes, cesarean delivery was performed. The boy was born with signs of metabolic acidosis and suffered a seizure 2 hours later. He was given a diagnosis of cerebral palsy and is fed through a tube, cannot speak, and requires skilled nursing care.

PATIENT’S CLAIM The ObGyn and nurses were negligent in only monitoring one fetus, and for failing to perform cesarean delivery in a timely manner.

DEFENDANTS’ DEFENSE The ObGyn claimed he was not informed of the decelerations shown on the fetal monitor, nor of the mother’s rapidly progressing labor. The hospital maintained that the nurses had given the ObGyn proper information and that the injuries to the infant had occurred after the ObGyn’s arrival. The mother’s weight of 322 pounds made monitoring difficult during labor and delivery.

VERDICT A $21,573,993 Pennsylvania verdict was returned against the hospital; a defense verdict was returned for the physician.

4. Shoulder dystocia, uterine tachysystole complicate vaginal delivery

WITH MILD PRE-ECLAMPSIA and vaginal spotting, a woman was admitted to a hospital’s L&D unit. Dinoprostone was administered, but the fetus was unengaged. Oxytocin was added to induce labor. Labor was complicated by repeated tachysystole; prolonged dilation; prolonged descent; severe, prolonged decelerations; and tachycardia. Uterine tachysystole continued for extended periods. Vaginal delivery was complicated by shoulder dystocia, which took 2 minutes to resolve. The child was delivered without a heart rate or respirations. A heartbeat was obtained a minute after delivery, and Apgar scores were 0, 2, and 2. The child was given a diagnosis of hypoxic ischemic encephalopathy, cerebral palsy, and a seizure disorder.

PATIENT’S CLAIM The L&D nurses and physicians were negligent in failing to properly monitor labor progression, fetal heart rate, and oxytocin management. They failed to communicate with the woman’s ObGyn, and did not exercise the proper chain of command. The physicians failed to recommend a cesarean delivery when labor became complicated.

DEFENDANTS’ DEFENSE The patient’s treatment was appropriate. Brain damage did not occur during labor and delivery.

VERDICT A $3.55 million Idaho verdict was returned.

5. Fetus transverse; oxytocin given

A WOMAN ARRIVED AT THE HOSPITAL after her membranes ruptured. A first-year resident failed to realize that the fetus was in a transverse position, and, with the attending physician’s approval, ordered oxytocin. When vaginal bleeding began, it was suspected that the placenta had detached. An hour later, after vaginal bleeding increased and late decelerations were noted on the fetal heart monitor, cesarean delivery was performed. The child was given a diagnosis of cerebral palsy and other complications, and died at 16 months of age.

ESTATE’S CLAIM The use of oxytocin is contraindicated for a baby in a transverse position. The fetus’ position indicated a need for a cesarean delivery. Placental detachment was not promptly addressed, leading to fetal oxygen deprivation.

DEFENDANTS’ DEFENSE The fetus appeared to be fine under all objective criteria until a “softball-sized” clot emerged from the mother’s vagina. The attending physician came to the mother’s bedside at that time. Umbilical cord blood gases showed no evidence of acidosis. A fetal brain injury occurred prior to the mother’s arrival at the hospital.

VERDICT A $2.5 million Pennsylvania verdict was returned.

READ A RELATED ARTICLE

Pelvic injury from the McRoberts maneuver?

DURING PRENATAL CARE, a woman repeatedly complained of severe discomfort, and requested a cesarean delivery. The ObGyn’s charts did not note her complaints.

A first-year resident and nurse covered for the ObGyn because he did not arrive at the hospital for hours after the mother notified him she was in labor. When shoulder dystocia was encountered, the resident used the McRoberts maneuver. The ObGyn arrived a minute before the birth. The baby weighed 10 lbs. The mother suffered symphysis pubis diastasis, required several surgeries, and now uses a cane to walk.

PATIENT’S CLAIM The ObGyn was negligent in not arriving in time to deliver the baby. The mother’s pelvis was injured during the McRoberts maneuver. The baby’s size was not properly estimated.

PHYSICIAN’S DEFENSE The use of the resident’s care was appropriate, as this was a teaching hospital.

VERDICT A $5.5 million New York verdict was returned.

Cancer Dx “not timely”; additional tx required

IN JUNE 2000, AN OBGYN PALPATED a pelvic mass in a postmenopausal woman. After ultrasonography (US) in August 2000, the ObGyn told the woman that a uterine fibroid had been found but no further testing was needed. In December 2001, US revealed that the mass had enlarged, but no further testing was done. In May 2002, the patient reported fatigue, distention of her abdomen, and an increase in the frequency of urination.

In July 2002, the ObGyn removed a 3-lb malignant uterine tumor during hysterectomy. A second staging surgery was performed, and the patient underwent chemotherapy.

PATIENT’S CLAIM An earlier diagnosis would have reduced the amount of treatment required. The ObGyn should have reacted immediately when the mass was first palpated in June 2000 and found on US in August 2000, as postmenopausal women do not develop uterine fibroids. A gynecologic oncologist should have been present at the hysterectomy to perform concurrent staging.

PHYSICIAN’S DEFENSE The patient failed to report symptoms that suggested cancer for 10 months; a prompt response was made when symptoms were revealed. It was appropriate to accept the results of US regarding a uterine fibroid.

VERDICT A $1.25 million New York verdict was returned.

Abnormal thickness of fetal nuchal fold

WHEN A 31-YEAR-OLD WOMAN was 18 weeks’ pregnant, she underwent ultrasonography, which was reportedly normal. The child was born with Down syndrome.

PATIENT’S CLAIM The ObGyn and radiologist failed to detect an abnormal thickness in the fetal nuchal fold—often a sign of Down syndrome.

PHYSICIANS’ DEFENSE The sonogram was properly analyzed. A thickened fold is an unreliable indicator of Down syndrome.

VERDICT A $1.7 million New Jersey settlement was returned.

Ovary retained; cancer recurs; death

A WOMAN UNDERWENT SURGERY for ovarian cancer in July 2004. She died of ovarian cancer in 2008 at age 59.

ESTATE’S CLAIM The gynecologist did not tell the patient that only one ovary was removed, or that a pathologist had not found the second ovary in the specimen. Ovarian cancer developed in the retained ovary a few years later. She would have undergone additional surgery had she known the second ovary was still there.

PHYSICIAN’S DEFENSE Both ovaries were removed in July 2004. The left ovary was not found during an autopsy performed on the decedent.

VERDICT A $1.967 million Pennsylvania verdict was returned.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

5 birth injuries, $54 million in verdicts and settlements

1. Severe birth asphyxia: cerebral palsy and seizures

AFTER A NORMAL PREGNANCY, a woman went to the hospital in labor. Her ObGyn, Dr. A, went off duty at 4 PM and was replaced by Dr. B, a practice partner who delivered five other babies between 11 PM and 2:15 AM.

At 9:40 PM, the fetus was occiput posterior. At 12:31 AM, Dr. B attempted manual rotation; no exam was recorded in the chart. By 2:30 AM, the fetus had returned to the occiput posterior position, and Dr. B again tried manual rotation. Then he left to take a nap while the mother’s epidural was reinforced. There was a delay in achieving a satisfactory epidural, and Dr. B was not called back to the bedside until 4 AM. He decided to perform a cesarean delivery when the fetal heart monitor showed an increased baseline with persistent variable decelerations.

Although Dr. B had called Dr. A earlier to elicit her help with the cesarean, she had gone back to bed and was not prepared to assist. During a 30-minute delay, the electronic fetal monitor was disconnected and never reconnected. A nurse checked the fetal heart rate with ultrasonography, and reported that it was normal; however, there was no copy in the chart.

The incision was made at 4:33 AM, and the baby was delivered at 5:06 AM. The infant was born without a heart rate or respiration (Apgar scores, all 0). A neonatologist was not available for resuscitation; a neonatal nurse practitioner arrived 7 minutes after delivery. The baby finally had a heart rate 24 minutes after delivery. The child suffered severe birth asphyxia, causing athetoid and spastic cerebral palsy and seizures.

PATIENT’S CLAIM The ObGyn failed to deliver the baby in a timely manner. The fetus was not continuously monitored with a fetal scalp electrode. The nurse violated several hospital policies.

DEFENDANTS’ DEFENSE The baby suffered an acute, total cord occlusion minutes before birth; this was unpredictable and the injuries could not have been prevented.

VERDICT At the end of the discovery period, the defendants’ attorney withdrew and new attorneys sought to name new experts. While these issues were pending, the matter was settled for a Washington total of $20 million. The mother settled with the hospital for $9.85 million. Although the doctors’ group had $5 million in insurance coverage, the plaintiff demanded that the insurance company pay in excess of limits due to potential bad-faith claims. The insurance company ultimately paid $10.15 million.

2. Profound metabolic acidosis after emergent delivery

WHEN A WOMAN WAS 2 CM DILATED and 99% effaced, she was given dinoprostone and oxytocin to begin induction and augment labor. Oxytocin was continued even though her pattern of contractions showed tachysystole. An intrauterine pressure catheter that had been placed to assess contractions was removed. Monitoring revealed an elevated fetal heart rate at 170 to 180 bpm. Ten minutes before birth, the fetal heart tracing ended; a sonogram showed fetal bradycardia and prompted an emergency vacuum extraction.

The baby was floppy at birth, did not cry, and was intubated and transferred to the NICU. Apgar scores were 1, 3, and 5 at 1, 5, and 10 minutes. The umbilical cord gas had a venous pH of 6.637, indicative of profound acidosis. Ongoing hypoxia and anoxia resulted in massive and irreversible brain injury. An EEG at 5 days confirmed the presence of encephalopathy due to perinatal asphyxia. The child will require specialized treatment and attendant care for life.

PATIENT’S CLAIM Oxytocin was never stopped or reduced throughout labor and delivery. The ObGyn failed to promptly deliver the baby. No internal scalp electrode was used to directly monitor the fetus; the intrauterine pressure catheter was never replaced.

DEFENDANTS’ DEFENSE The ObGyn and hospital denied negligence or causation, claiming that there was a sudden placental abruption 10 minutes before birth that caused perinatal asphyxia.

VERDICT A $6.95 million District of Columbia settlement was returned.

3. Breech 2nd twin has cerebral palsy

PREGNANT WITH TWINS and in early labor, a woman went to the hospital, where a nurse midwife administered dinoprostone. The labor and delivery nurses only monitored one fetal heart rate during most of the labor period. The mother’s contraction pattern was indicative of tachysystole, and the twin who was being monitored showed a decelerating heart rate. The ObGyn arrived minutes before the birth unprepared for delivery, and a nurse delivered a healthy first child.

The second child’s heart rate dropped to 90 bpm, and the baby shifted to a breech position; the ObGyn tried manual rotation but was unsuccessful. After 20 minutes, cesarean delivery was performed. The boy was born with signs of metabolic acidosis and suffered a seizure 2 hours later. He was given a diagnosis of cerebral palsy and is fed through a tube, cannot speak, and requires skilled nursing care.

PATIENT’S CLAIM The ObGyn and nurses were negligent in only monitoring one fetus, and for failing to perform cesarean delivery in a timely manner.

DEFENDANTS’ DEFENSE The ObGyn claimed he was not informed of the decelerations shown on the fetal monitor, nor of the mother’s rapidly progressing labor. The hospital maintained that the nurses had given the ObGyn proper information and that the injuries to the infant had occurred after the ObGyn’s arrival. The mother’s weight of 322 pounds made monitoring difficult during labor and delivery.

VERDICT A $21,573,993 Pennsylvania verdict was returned against the hospital; a defense verdict was returned for the physician.

4. Shoulder dystocia, uterine tachysystole complicate vaginal delivery

WITH MILD PRE-ECLAMPSIA and vaginal spotting, a woman was admitted to a hospital’s L&D unit. Dinoprostone was administered, but the fetus was unengaged. Oxytocin was added to induce labor. Labor was complicated by repeated tachysystole; prolonged dilation; prolonged descent; severe, prolonged decelerations; and tachycardia. Uterine tachysystole continued for extended periods. Vaginal delivery was complicated by shoulder dystocia, which took 2 minutes to resolve. The child was delivered without a heart rate or respirations. A heartbeat was obtained a minute after delivery, and Apgar scores were 0, 2, and 2. The child was given a diagnosis of hypoxic ischemic encephalopathy, cerebral palsy, and a seizure disorder.

PATIENT’S CLAIM The L&D nurses and physicians were negligent in failing to properly monitor labor progression, fetal heart rate, and oxytocin management. They failed to communicate with the woman’s ObGyn, and did not exercise the proper chain of command. The physicians failed to recommend a cesarean delivery when labor became complicated.

DEFENDANTS’ DEFENSE The patient’s treatment was appropriate. Brain damage did not occur during labor and delivery.

VERDICT A $3.55 million Idaho verdict was returned.

5. Fetus transverse; oxytocin given

A WOMAN ARRIVED AT THE HOSPITAL after her membranes ruptured. A first-year resident failed to realize that the fetus was in a transverse position, and, with the attending physician’s approval, ordered oxytocin. When vaginal bleeding began, it was suspected that the placenta had detached. An hour later, after vaginal bleeding increased and late decelerations were noted on the fetal heart monitor, cesarean delivery was performed. The child was given a diagnosis of cerebral palsy and other complications, and died at 16 months of age.

ESTATE’S CLAIM The use of oxytocin is contraindicated for a baby in a transverse position. The fetus’ position indicated a need for a cesarean delivery. Placental detachment was not promptly addressed, leading to fetal oxygen deprivation.

DEFENDANTS’ DEFENSE The fetus appeared to be fine under all objective criteria until a “softball-sized” clot emerged from the mother’s vagina. The attending physician came to the mother’s bedside at that time. Umbilical cord blood gases showed no evidence of acidosis. A fetal brain injury occurred prior to the mother’s arrival at the hospital.

VERDICT A $2.5 million Pennsylvania verdict was returned.

READ A RELATED ARTICLE

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Compartment syndrome Dx delayed... Failure to suspect endocarditis ends in heart surgery and memory deficit

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Compartment syndrome Dx delayed... Failure to suspect endocarditis ends in heart surgery and memory deficit
 

Delayed diagnosis renders dominant hand and wrist useless

A WOMAN HOSPITALIZED WITH RESPIRATORY SYMPTOMS was treated and released 4 days later. She returned by ambulance the next day and was readmitted for chronic obstructive pulmonary disease and respiratory failure. She had a history of tobacco use. It turned out she had suffered a myocardial infarction. After a cardiac consultation, she was started on 3 anticoagulants, including enoxaparin.

When her condition failed to improve after 4 days, she was transferred to another hospital. Before the transfer, bruising and slight swelling were observed on the patient’s left side and chest, and a physician reportedly ordered that the enoxaparin be discontinued. The plaintiff received another dose of enoxaparin just after she arrived at the second hospital and 3 more doses before the drug was discontinued 2 days later. On the day after admission, the patient’s right forearm, her dominant arm, was noted to be swollen, firm, and painful; her torso was bruised. No immediate evaluation was performed.

An orthopedic consultation the following day led to a diagnosis of compartment syndrome. Emergency surgery resulted in loss of muscle and nerves in the arm and chronic pain. The patient also developed anemia, hypovolemic shock, and retroperitoneal hemorrhage requiring a number of blood transfusions. The patient lost almost all function in her right wrist and hand.

PLAINTIFF’S CLAIM The defendants were negligent in failing to promptly diagnose compartment syndrome and subsequent hemorrhaging.

THE DEFENSE No negligence occurred.

VERDICT $1.525 million Ohio verdict.

COMMENT Subtle and nonspecific findings make compartment syndrome a challenging diagnosis. The combination of extremity pain, swelling, and bruising in the context of anticoagulation should trigger consideration of this condition.

Failure to suspect endocarditis ends in heart surgery and memory deficit

GENERAL ACHES, FATIGUE, AND OCCASIONAL FEVER of 102.5°F led a 43-year-old woman to seek treatment at a local clinic. The nurse practitioner who examined her suspected influenza. Six days later the patient returned, complaining that her symptoms were making it difficult to care for her 4 children. She didn’t have a fever at the time. The nurse practitioner suggested that the woman might want to go to the local hospital for an examination; she also said she could prescribe oral antibiotics to see if they helped. The patient chose the antibiotics.

Her symptoms improved over the next week but then reappeared, prompting her to return to the clinic with complaints of headache, muscle aches, fatigue, chest tightening, an unproductive cough, and night sweats so severe she had to wrap herself in a towel to avoid soaking her bed. Although she was still having regular periods, a physician told her she was probably premenopausal. He also told her that overweight people often sweat at night and attributed her fatigue to her 4 children. He prescribed rizatriptan on the theory that the headaches might be migraines. Because the woman didn’t have a fever at the time of the visit and had just finished a course of antibiotics, the physician said he was sure that she didn’t have an infection.

After 6 days with no improvement, the patient went to a hospital emergency department (ED) for a complete checkup because she was planning to drive to Arizona with her family and wanted to make sure she was all right before leaving. The ED physician ordered scans, a spinal tap, and blood tests; he diagnosed a viral infection.

Three days later, the patient went to the clinic, accompanied by her entire family, to find out the results of the blood tests. She still had symptoms and had developed a swollen, tender sternum. The nurse practitioner noted a positive culture result for Streptococcus veridans on the test report; she allegedly told the patient, in the presence of her 10-year-old son, that it must be a skin contaminant. She advised the patient to go on vacation and have additional blood work if she didn’t feel better.

The nurse practitioner gave the patient another pack of oral antibiotics in case she had a lingering low-grade infection. The patient also received another prescription for rizatriptan and an acetaminophen and oxycodone prescription for pain.

 

 

 

The nurse practitioner claimed that she suggested that the patient could stop by the hospital for a blood test before leaving on vacation, but the patient denied that the nurse made the suggestion, and no notes supported the claim. The oral antibiotics relieved the patient’s symptoms only temporarily. The family cut short their vacation so the patient could return to the clinic, where she received another ineffectual antibiotic. When her condition continued to deteriorate, her husband took her to the ED of a larger hospital in the area.

The ED physician diagnosed subacute endocarditis, which was confirmed by subsequent tests. Testing also identified a bicuspid aortic valve, which increased the patient’s susceptibility to endocarditis. She was started on appropriate intravenous antibiotics and improved initially.

The patient subsequently noticed red patches on her hand and forearm. She also experienced problems with mental processing. She returned to the hospital, where a scan showed increased vegetative growth on her aortic valve. Pieces of the growth were breaking off, causing embolic injury to the patient’s brain, hand, and other areas of her body. The patient underwent open heart surgery to replace the aortic valve and prevent further embolic injury. She continues to suffer from significant short-term memory loss and will require warfarin for the rest of her life to prevent blood clotting.

PLAINTIFF’S CLAIM The patient should have been referred earlier for a complete workup, and the nurse practitioner should have taken seriously the culture showing S veridans. The nurse practitioner was mistaken in thinking that S veridans was found on the skin. Had she looked it up, which she should have done, she would have discovered that the organism is the most common bacterial cause of subacute endocarditis.

The patient had the classic symptoms of subacute endocarditis. The delay in diagnosis allowed bacteria to build up on her aortic valve, forming a biofilm barrier that inhibited the effect of the IV antibiotics and the body’s natural defenses and precipitated the embolic injury.

THE DEFENSE The patient was responsible for the delay in diagnosis, especially in light of the fact that she had a nursing background. Any negligence on the part of the nurse practitioner had no effect on the outcome.

VERDICT $1 million Washington settlement.

COMMENT Subacute bacterial endocarditis remains a challenging diagnosis with potentially devastating consequences. Be on the alert for this subtle masquerader.

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Delayed diagnosis renders dominant hand and wrist useless

A WOMAN HOSPITALIZED WITH RESPIRATORY SYMPTOMS was treated and released 4 days later. She returned by ambulance the next day and was readmitted for chronic obstructive pulmonary disease and respiratory failure. She had a history of tobacco use. It turned out she had suffered a myocardial infarction. After a cardiac consultation, she was started on 3 anticoagulants, including enoxaparin.

When her condition failed to improve after 4 days, she was transferred to another hospital. Before the transfer, bruising and slight swelling were observed on the patient’s left side and chest, and a physician reportedly ordered that the enoxaparin be discontinued. The plaintiff received another dose of enoxaparin just after she arrived at the second hospital and 3 more doses before the drug was discontinued 2 days later. On the day after admission, the patient’s right forearm, her dominant arm, was noted to be swollen, firm, and painful; her torso was bruised. No immediate evaluation was performed.

An orthopedic consultation the following day led to a diagnosis of compartment syndrome. Emergency surgery resulted in loss of muscle and nerves in the arm and chronic pain. The patient also developed anemia, hypovolemic shock, and retroperitoneal hemorrhage requiring a number of blood transfusions. The patient lost almost all function in her right wrist and hand.

PLAINTIFF’S CLAIM The defendants were negligent in failing to promptly diagnose compartment syndrome and subsequent hemorrhaging.

THE DEFENSE No negligence occurred.

VERDICT $1.525 million Ohio verdict.

COMMENT Subtle and nonspecific findings make compartment syndrome a challenging diagnosis. The combination of extremity pain, swelling, and bruising in the context of anticoagulation should trigger consideration of this condition.

Failure to suspect endocarditis ends in heart surgery and memory deficit

GENERAL ACHES, FATIGUE, AND OCCASIONAL FEVER of 102.5°F led a 43-year-old woman to seek treatment at a local clinic. The nurse practitioner who examined her suspected influenza. Six days later the patient returned, complaining that her symptoms were making it difficult to care for her 4 children. She didn’t have a fever at the time. The nurse practitioner suggested that the woman might want to go to the local hospital for an examination; she also said she could prescribe oral antibiotics to see if they helped. The patient chose the antibiotics.

Her symptoms improved over the next week but then reappeared, prompting her to return to the clinic with complaints of headache, muscle aches, fatigue, chest tightening, an unproductive cough, and night sweats so severe she had to wrap herself in a towel to avoid soaking her bed. Although she was still having regular periods, a physician told her she was probably premenopausal. He also told her that overweight people often sweat at night and attributed her fatigue to her 4 children. He prescribed rizatriptan on the theory that the headaches might be migraines. Because the woman didn’t have a fever at the time of the visit and had just finished a course of antibiotics, the physician said he was sure that she didn’t have an infection.

After 6 days with no improvement, the patient went to a hospital emergency department (ED) for a complete checkup because she was planning to drive to Arizona with her family and wanted to make sure she was all right before leaving. The ED physician ordered scans, a spinal tap, and blood tests; he diagnosed a viral infection.

Three days later, the patient went to the clinic, accompanied by her entire family, to find out the results of the blood tests. She still had symptoms and had developed a swollen, tender sternum. The nurse practitioner noted a positive culture result for Streptococcus veridans on the test report; she allegedly told the patient, in the presence of her 10-year-old son, that it must be a skin contaminant. She advised the patient to go on vacation and have additional blood work if she didn’t feel better.

The nurse practitioner gave the patient another pack of oral antibiotics in case she had a lingering low-grade infection. The patient also received another prescription for rizatriptan and an acetaminophen and oxycodone prescription for pain.

 

 

 

The nurse practitioner claimed that she suggested that the patient could stop by the hospital for a blood test before leaving on vacation, but the patient denied that the nurse made the suggestion, and no notes supported the claim. The oral antibiotics relieved the patient’s symptoms only temporarily. The family cut short their vacation so the patient could return to the clinic, where she received another ineffectual antibiotic. When her condition continued to deteriorate, her husband took her to the ED of a larger hospital in the area.

The ED physician diagnosed subacute endocarditis, which was confirmed by subsequent tests. Testing also identified a bicuspid aortic valve, which increased the patient’s susceptibility to endocarditis. She was started on appropriate intravenous antibiotics and improved initially.

The patient subsequently noticed red patches on her hand and forearm. She also experienced problems with mental processing. She returned to the hospital, where a scan showed increased vegetative growth on her aortic valve. Pieces of the growth were breaking off, causing embolic injury to the patient’s brain, hand, and other areas of her body. The patient underwent open heart surgery to replace the aortic valve and prevent further embolic injury. She continues to suffer from significant short-term memory loss and will require warfarin for the rest of her life to prevent blood clotting.

PLAINTIFF’S CLAIM The patient should have been referred earlier for a complete workup, and the nurse practitioner should have taken seriously the culture showing S veridans. The nurse practitioner was mistaken in thinking that S veridans was found on the skin. Had she looked it up, which she should have done, she would have discovered that the organism is the most common bacterial cause of subacute endocarditis.

The patient had the classic symptoms of subacute endocarditis. The delay in diagnosis allowed bacteria to build up on her aortic valve, forming a biofilm barrier that inhibited the effect of the IV antibiotics and the body’s natural defenses and precipitated the embolic injury.

THE DEFENSE The patient was responsible for the delay in diagnosis, especially in light of the fact that she had a nursing background. Any negligence on the part of the nurse practitioner had no effect on the outcome.

VERDICT $1 million Washington settlement.

COMMENT Subacute bacterial endocarditis remains a challenging diagnosis with potentially devastating consequences. Be on the alert for this subtle masquerader.

 

Delayed diagnosis renders dominant hand and wrist useless

A WOMAN HOSPITALIZED WITH RESPIRATORY SYMPTOMS was treated and released 4 days later. She returned by ambulance the next day and was readmitted for chronic obstructive pulmonary disease and respiratory failure. She had a history of tobacco use. It turned out she had suffered a myocardial infarction. After a cardiac consultation, she was started on 3 anticoagulants, including enoxaparin.

When her condition failed to improve after 4 days, she was transferred to another hospital. Before the transfer, bruising and slight swelling were observed on the patient’s left side and chest, and a physician reportedly ordered that the enoxaparin be discontinued. The plaintiff received another dose of enoxaparin just after she arrived at the second hospital and 3 more doses before the drug was discontinued 2 days later. On the day after admission, the patient’s right forearm, her dominant arm, was noted to be swollen, firm, and painful; her torso was bruised. No immediate evaluation was performed.

An orthopedic consultation the following day led to a diagnosis of compartment syndrome. Emergency surgery resulted in loss of muscle and nerves in the arm and chronic pain. The patient also developed anemia, hypovolemic shock, and retroperitoneal hemorrhage requiring a number of blood transfusions. The patient lost almost all function in her right wrist and hand.

PLAINTIFF’S CLAIM The defendants were negligent in failing to promptly diagnose compartment syndrome and subsequent hemorrhaging.

THE DEFENSE No negligence occurred.

VERDICT $1.525 million Ohio verdict.

COMMENT Subtle and nonspecific findings make compartment syndrome a challenging diagnosis. The combination of extremity pain, swelling, and bruising in the context of anticoagulation should trigger consideration of this condition.

Failure to suspect endocarditis ends in heart surgery and memory deficit

GENERAL ACHES, FATIGUE, AND OCCASIONAL FEVER of 102.5°F led a 43-year-old woman to seek treatment at a local clinic. The nurse practitioner who examined her suspected influenza. Six days later the patient returned, complaining that her symptoms were making it difficult to care for her 4 children. She didn’t have a fever at the time. The nurse practitioner suggested that the woman might want to go to the local hospital for an examination; she also said she could prescribe oral antibiotics to see if they helped. The patient chose the antibiotics.

Her symptoms improved over the next week but then reappeared, prompting her to return to the clinic with complaints of headache, muscle aches, fatigue, chest tightening, an unproductive cough, and night sweats so severe she had to wrap herself in a towel to avoid soaking her bed. Although she was still having regular periods, a physician told her she was probably premenopausal. He also told her that overweight people often sweat at night and attributed her fatigue to her 4 children. He prescribed rizatriptan on the theory that the headaches might be migraines. Because the woman didn’t have a fever at the time of the visit and had just finished a course of antibiotics, the physician said he was sure that she didn’t have an infection.

After 6 days with no improvement, the patient went to a hospital emergency department (ED) for a complete checkup because she was planning to drive to Arizona with her family and wanted to make sure she was all right before leaving. The ED physician ordered scans, a spinal tap, and blood tests; he diagnosed a viral infection.

Three days later, the patient went to the clinic, accompanied by her entire family, to find out the results of the blood tests. She still had symptoms and had developed a swollen, tender sternum. The nurse practitioner noted a positive culture result for Streptococcus veridans on the test report; she allegedly told the patient, in the presence of her 10-year-old son, that it must be a skin contaminant. She advised the patient to go on vacation and have additional blood work if she didn’t feel better.

The nurse practitioner gave the patient another pack of oral antibiotics in case she had a lingering low-grade infection. The patient also received another prescription for rizatriptan and an acetaminophen and oxycodone prescription for pain.

 

 

 

The nurse practitioner claimed that she suggested that the patient could stop by the hospital for a blood test before leaving on vacation, but the patient denied that the nurse made the suggestion, and no notes supported the claim. The oral antibiotics relieved the patient’s symptoms only temporarily. The family cut short their vacation so the patient could return to the clinic, where she received another ineffectual antibiotic. When her condition continued to deteriorate, her husband took her to the ED of a larger hospital in the area.

The ED physician diagnosed subacute endocarditis, which was confirmed by subsequent tests. Testing also identified a bicuspid aortic valve, which increased the patient’s susceptibility to endocarditis. She was started on appropriate intravenous antibiotics and improved initially.

The patient subsequently noticed red patches on her hand and forearm. She also experienced problems with mental processing. She returned to the hospital, where a scan showed increased vegetative growth on her aortic valve. Pieces of the growth were breaking off, causing embolic injury to the patient’s brain, hand, and other areas of her body. The patient underwent open heart surgery to replace the aortic valve and prevent further embolic injury. She continues to suffer from significant short-term memory loss and will require warfarin for the rest of her life to prevent blood clotting.

PLAINTIFF’S CLAIM The patient should have been referred earlier for a complete workup, and the nurse practitioner should have taken seriously the culture showing S veridans. The nurse practitioner was mistaken in thinking that S veridans was found on the skin. Had she looked it up, which she should have done, she would have discovered that the organism is the most common bacterial cause of subacute endocarditis.

The patient had the classic symptoms of subacute endocarditis. The delay in diagnosis allowed bacteria to build up on her aortic valve, forming a biofilm barrier that inhibited the effect of the IV antibiotics and the body’s natural defenses and precipitated the embolic injury.

THE DEFENSE The patient was responsible for the delay in diagnosis, especially in light of the fact that she had a nursing background. Any negligence on the part of the nurse practitioner had no effect on the outcome.

VERDICT $1 million Washington settlement.

COMMENT Subacute bacterial endocarditis remains a challenging diagnosis with potentially devastating consequences. Be on the alert for this subtle masquerader.

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The Journal of Family Practice - 60(8)
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Missed aortic aneurysm proves fatal ... Too-late cancer Dx blamed on neglected x-ray findings... More

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Missed dissecting aortic aneurysm proves fatal

A 43-YEAR-OLD MAN was admitted to the hospital complaining of severe chest pain, shortness of breath, sweating, and dry mouth. After being seen by several physicians, the patient suffered an aortic dissection, which caused bleeding in the wall of the aorta, an aortic rupture, and bleeding into the pericardium. He died 2 days later.

PLAINTIFF’S CLAIM The defendants failed to order tests to rule out a dissecting aortic aneurysm and did not include aortic dissection in the differential diagnosis. They failed to provide appropriate drug therapy to decrease cardiac impulse and lower the systolic blood pressure. They did not obtain an emergency cardiac consultation or admit the patient to a cardiovascular surgical intensive care unit.

THE DEFENSE The defendants denied negligence and claimed that nothing they did or failed to do contributed to the patient’s death.

VERDICT $250,000 Michigan settlement.

COMMENT Just yesterday, a malpractice lawyer presented me with a case very similar to this one: a patient with unexplained chest pain who died of a dissecting aneurysm. Remember, not all chest pain is caused by coronary artery disease.

Too-late cancer Dx blamed on neglected x-ray findings

A LONG-TERM CIGARETTE SMOKER IN HER 50s saw a physician in 2001 for symptoms of pneumonia. The doctor prescribed antibiotics and referred her to another facility for a chest radiograph.

Five days later, she returned to the physician’s office, where she was seen by another internist in the practice. The internist noted that the chest radiograph showed parenchymal densities in the right lung. Parenchymal densities had also showed up on 2 previous chest radiographs, but were more prevalent on the latest film. The internist advised the patient to finish her antibiotic regimen; he did not prescribe further tests or treatment.

Over the following 40 months, doctors in the patient’s medical group examined her 8 times. Each time she complained of impaired respiration. The internist believed that the symptoms were caused by asthma.

In 2004, the patient was diagnosed with stage IV cancer of the right lung, which had spread to her bones and was untreatable. She died several weeks later.

PLAINTIFF’S CLAIM A proper diagnosis in 2001 would have allowed the cancer to be cured. A computed tomography scan should have been performed and a pulmonologist consulted at that time.

THE DEFENSE Findings from the radiograph from 2001 did not necessitate further action. Because the patient’s cancer had metastasized before that radiograph, treatment then (or later) would not have changed the outcome.

VERDICT $850,000 New York verdict.

COMMENT Careful follow-up and diagnosis of chest radiograph abnormalities is paramount.

Yes, it was a stroke

WEAKNESS, NUMBNESS, AND TINGLING IN HIS RIGHT ARM prompted a 56-year-old man to visit his primary care physician. The physician sent the patient to the emergency department (ED) for testing because he believed the man was experiencing stroke-like symptoms. As the patient and his wife drove to the hospital, the physician faxed the patient’s medical records to the ED.

When the patient’s wife tried to give ED employees the physician’s orders for tests and tell them of the doctor’s concern about a stroke, they told her that all the beds were full and she should sit down and wait.

The patient was eventually evaluated as a low-priority patient with numbness in his right hand. The examining doctor ordered radiographs of the right wrist and discharged the patient with a diagnosis of carpal tunnel syndrome.

Twenty minutes later, a nurse left a message telling the patient to return to the hospital for the stroke-related tests that had been ordered by his primary care physician. An ED physician other than the one who first examined the patient performed the tests—except for a test of blood flow to the brain. The physician diagnosed stroke-like symptoms and requested a consultation with another physician, which never happened. The patient was discharged about 6 hours after his first discharge.

About 16 hours later, the patient suffered a stroke. Subsequent testing revealed an obstruction in the left carotid artery. The stroke resulted in permanent neurologic injury.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE The defendants denied negligence and disputed the extent of the patient’s injuries.

VERDICT $1.123 million Maryland verdict.

COMMENT Coordination of care remains critical, particularly between our outpatient offices and the busy ED.

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Missed dissecting aortic aneurysm proves fatal

A 43-YEAR-OLD MAN was admitted to the hospital complaining of severe chest pain, shortness of breath, sweating, and dry mouth. After being seen by several physicians, the patient suffered an aortic dissection, which caused bleeding in the wall of the aorta, an aortic rupture, and bleeding into the pericardium. He died 2 days later.

PLAINTIFF’S CLAIM The defendants failed to order tests to rule out a dissecting aortic aneurysm and did not include aortic dissection in the differential diagnosis. They failed to provide appropriate drug therapy to decrease cardiac impulse and lower the systolic blood pressure. They did not obtain an emergency cardiac consultation or admit the patient to a cardiovascular surgical intensive care unit.

THE DEFENSE The defendants denied negligence and claimed that nothing they did or failed to do contributed to the patient’s death.

VERDICT $250,000 Michigan settlement.

COMMENT Just yesterday, a malpractice lawyer presented me with a case very similar to this one: a patient with unexplained chest pain who died of a dissecting aneurysm. Remember, not all chest pain is caused by coronary artery disease.

Too-late cancer Dx blamed on neglected x-ray findings

A LONG-TERM CIGARETTE SMOKER IN HER 50s saw a physician in 2001 for symptoms of pneumonia. The doctor prescribed antibiotics and referred her to another facility for a chest radiograph.

Five days later, she returned to the physician’s office, where she was seen by another internist in the practice. The internist noted that the chest radiograph showed parenchymal densities in the right lung. Parenchymal densities had also showed up on 2 previous chest radiographs, but were more prevalent on the latest film. The internist advised the patient to finish her antibiotic regimen; he did not prescribe further tests or treatment.

Over the following 40 months, doctors in the patient’s medical group examined her 8 times. Each time she complained of impaired respiration. The internist believed that the symptoms were caused by asthma.

In 2004, the patient was diagnosed with stage IV cancer of the right lung, which had spread to her bones and was untreatable. She died several weeks later.

PLAINTIFF’S CLAIM A proper diagnosis in 2001 would have allowed the cancer to be cured. A computed tomography scan should have been performed and a pulmonologist consulted at that time.

THE DEFENSE Findings from the radiograph from 2001 did not necessitate further action. Because the patient’s cancer had metastasized before that radiograph, treatment then (or later) would not have changed the outcome.

VERDICT $850,000 New York verdict.

COMMENT Careful follow-up and diagnosis of chest radiograph abnormalities is paramount.

Yes, it was a stroke

WEAKNESS, NUMBNESS, AND TINGLING IN HIS RIGHT ARM prompted a 56-year-old man to visit his primary care physician. The physician sent the patient to the emergency department (ED) for testing because he believed the man was experiencing stroke-like symptoms. As the patient and his wife drove to the hospital, the physician faxed the patient’s medical records to the ED.

When the patient’s wife tried to give ED employees the physician’s orders for tests and tell them of the doctor’s concern about a stroke, they told her that all the beds were full and she should sit down and wait.

The patient was eventually evaluated as a low-priority patient with numbness in his right hand. The examining doctor ordered radiographs of the right wrist and discharged the patient with a diagnosis of carpal tunnel syndrome.

Twenty minutes later, a nurse left a message telling the patient to return to the hospital for the stroke-related tests that had been ordered by his primary care physician. An ED physician other than the one who first examined the patient performed the tests—except for a test of blood flow to the brain. The physician diagnosed stroke-like symptoms and requested a consultation with another physician, which never happened. The patient was discharged about 6 hours after his first discharge.

About 16 hours later, the patient suffered a stroke. Subsequent testing revealed an obstruction in the left carotid artery. The stroke resulted in permanent neurologic injury.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE The defendants denied negligence and disputed the extent of the patient’s injuries.

VERDICT $1.123 million Maryland verdict.

COMMENT Coordination of care remains critical, particularly between our outpatient offices and the busy ED.

Missed dissecting aortic aneurysm proves fatal

A 43-YEAR-OLD MAN was admitted to the hospital complaining of severe chest pain, shortness of breath, sweating, and dry mouth. After being seen by several physicians, the patient suffered an aortic dissection, which caused bleeding in the wall of the aorta, an aortic rupture, and bleeding into the pericardium. He died 2 days later.

PLAINTIFF’S CLAIM The defendants failed to order tests to rule out a dissecting aortic aneurysm and did not include aortic dissection in the differential diagnosis. They failed to provide appropriate drug therapy to decrease cardiac impulse and lower the systolic blood pressure. They did not obtain an emergency cardiac consultation or admit the patient to a cardiovascular surgical intensive care unit.

THE DEFENSE The defendants denied negligence and claimed that nothing they did or failed to do contributed to the patient’s death.

VERDICT $250,000 Michigan settlement.

COMMENT Just yesterday, a malpractice lawyer presented me with a case very similar to this one: a patient with unexplained chest pain who died of a dissecting aneurysm. Remember, not all chest pain is caused by coronary artery disease.

Too-late cancer Dx blamed on neglected x-ray findings

A LONG-TERM CIGARETTE SMOKER IN HER 50s saw a physician in 2001 for symptoms of pneumonia. The doctor prescribed antibiotics and referred her to another facility for a chest radiograph.

Five days later, she returned to the physician’s office, where she was seen by another internist in the practice. The internist noted that the chest radiograph showed parenchymal densities in the right lung. Parenchymal densities had also showed up on 2 previous chest radiographs, but were more prevalent on the latest film. The internist advised the patient to finish her antibiotic regimen; he did not prescribe further tests or treatment.

Over the following 40 months, doctors in the patient’s medical group examined her 8 times. Each time she complained of impaired respiration. The internist believed that the symptoms were caused by asthma.

In 2004, the patient was diagnosed with stage IV cancer of the right lung, which had spread to her bones and was untreatable. She died several weeks later.

PLAINTIFF’S CLAIM A proper diagnosis in 2001 would have allowed the cancer to be cured. A computed tomography scan should have been performed and a pulmonologist consulted at that time.

THE DEFENSE Findings from the radiograph from 2001 did not necessitate further action. Because the patient’s cancer had metastasized before that radiograph, treatment then (or later) would not have changed the outcome.

VERDICT $850,000 New York verdict.

COMMENT Careful follow-up and diagnosis of chest radiograph abnormalities is paramount.

Yes, it was a stroke

WEAKNESS, NUMBNESS, AND TINGLING IN HIS RIGHT ARM prompted a 56-year-old man to visit his primary care physician. The physician sent the patient to the emergency department (ED) for testing because he believed the man was experiencing stroke-like symptoms. As the patient and his wife drove to the hospital, the physician faxed the patient’s medical records to the ED.

When the patient’s wife tried to give ED employees the physician’s orders for tests and tell them of the doctor’s concern about a stroke, they told her that all the beds were full and she should sit down and wait.

The patient was eventually evaluated as a low-priority patient with numbness in his right hand. The examining doctor ordered radiographs of the right wrist and discharged the patient with a diagnosis of carpal tunnel syndrome.

Twenty minutes later, a nurse left a message telling the patient to return to the hospital for the stroke-related tests that had been ordered by his primary care physician. An ED physician other than the one who first examined the patient performed the tests—except for a test of blood flow to the brain. The physician diagnosed stroke-like symptoms and requested a consultation with another physician, which never happened. The patient was discharged about 6 hours after his first discharge.

About 16 hours later, the patient suffered a stroke. Subsequent testing revealed an obstruction in the left carotid artery. The stroke resulted in permanent neurologic injury.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE The defendants denied negligence and disputed the extent of the patient’s injuries.

VERDICT $1.123 million Maryland verdict.

COMMENT Coordination of care remains critical, particularly between our outpatient offices and the busy ED.

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