Medical Verdicts

Why wasn’t bloody nipple discharge taken more seriously?

DUE TO BLOODY DISCHARGE from her left nipple, a woman in her thirties had a mammogram; results were suspicious for malignancy. Her surgeon’s examination and biopsy were negative.

Two years later she found a lump in her left breast. Ultrasonography suggested a benign mass at 9 o’clock. Her surgeon could not find a mass at 9 o’clock, but detected a mass at 7 o’clock. He ordered US-guided core biopsy of the 9 o’clock area, but not the 7 o’clock mass—she was instructed to return for removal of the 7 o’clock mass regardless of the biopsy’s outcome. She was impatient for the biopsy, and went to another surgeon. Biopsy results were negative for malignancy.

Months later, during right breast implant replacement, she had the left-sided mass excised. Pathology reported moderate to poorly differentiated infiltrating carcinoma. She underwent a left mastectomy, prophylactic right mastectomy, and chemotherapy.

PATIENT’S CLAIM Further evaluation of her original complaint of bloody nipple discharge by her surgeon would have led to earlier diagnosis.

PHYSICIAN’S DEFENSE The left breast mass was never biopsied because the patient didn’t return as instructed.

VERDICT A Pennsylvania defense verdict was returned.

Uterine artery severed, new mother dies; court mandates changes

THE UTERINE ARTERY WAS SEVERED during cesarean delivery in a 32-year-old woman, causing severe hemorrhage. The ObGyn repaired the uterine vessels in the OR. The patient was sent to the recovery room and then to the surgical ICU, where she was in severe hemorrhagic shock, hypotensive, tachycardic, and had minimal urine output with metabolic acidosis. Exploratory surgery revealed massive blood clots. A trauma surgeon, called in by the ObGyn, found an extensive hematoma and 2 to 3 L of blood in the retroperitoneum. The woman died within 24 hours of delivery.

PLAINTIFF’S CLAIM When repairing injuries that occurred during the cesarean, the ObGyn damaged retroperitoneal uterine arteries. Physicians in the recovery room and surgical ICU informed the ObGyn that the patient appeared to have internal bleeding, but he did not return her to the OR for over 6 hours. After consent for exploratory surgery was signed, the ObGyn left to deliver another baby. The recovery room’s OBIX Perinatal Data System monitors failed to accurately record the patient’s vital signs. Understaffing in the surgical ICU impaired treatment.

DEFENSE CLAIM The ObGyn’s responsibility for the patient was transferred to the recovery room’s attending doctor, who claimed he had discharged his responsibility when he recommended exploratory surgery. After viewing the patient’s chart in the surgical ICU, a surgeon told the ObGyn that immediate treatment was needed for internal bleeding. The hospital claimed staffing issues did not cause the patient’s death.

VERDICT The burden of a $5.2 million settlement was shared by the physicians and hospital. The hospital was mandated to 1) establish an annual lecture on patient safety; 2) purchase a maternal/neonatal simulator to train staff; and 3) change the default settings on all OBIX Perinatal Data System machines to prevent them from defaulting to record normal values for vital signs when the “add” button is pushed.

Severe pain and burns during biopsy and genital wart removal

BIOPSY AND GENITAL WART REMOVAL were performed on a 34-year-old woman without anesthesia. She screamed in pain when the ObGyn biopsied her labia. Pain increased when he removed warts using a trichloroacetic acid mixture. Acid ran into the patient’s vagina and onto her buttocks, causing second-degree burns.

PATIENT’S CLAIM The physician never offered anesthesia, nor did she refuse it. The acid should have been applied more discretely. The paper toweling used to clean up the acid was just moist and could not have caused the acid to spread.

PHYSICIAN’S DEFENSE The ObGyn stated he preferred not to use anesthesia because it might affect the pathology slide quality, but that he offered it to the patient, and she refused. He also claimed that he applied the acid carefully, and attributed the spread and burn to a nurse who brought wet paper towels to dry the patient.

VERDICT A Tennessee defense verdict was returned.

Why wasn’t bloody nipple discharge taken more seriously?

DUE TO BLOODY DISCHARGE from her left nipple, a woman in her thirties had a mammogram; results were suspicious for malignancy. Her surgeon’s examination and biopsy were negative.

Two years later she found a lump in her left breast. Ultrasonography suggested a benign mass at 9 o’clock. Her surgeon could not find a mass at 9 o’clock, but detected a mass at 7 o’clock. He ordered US-guided core biopsy of the 9 o’clock area, but not the 7 o’clock mass—she was instructed to return for removal of the 7 o’clock mass regardless of the biopsy’s outcome. She was impatient for the biopsy, and went to another surgeon. Biopsy results were negative for malignancy.

Months later, during right breast implant replacement, she had the left-sided mass excised. Pathology reported moderate to poorly differentiated infiltrating carcinoma. She underwent a left mastectomy, prophylactic right mastectomy, and chemotherapy.

PATIENT’S CLAIM Further evaluation of her original complaint of bloody nipple discharge by her surgeon would have led to earlier diagnosis.

PHYSICIAN’S DEFENSE The left breast mass was never biopsied because the patient didn’t return as instructed.

VERDICT A Pennsylvania defense verdict was returned.

Uterine artery severed, new mother dies; court mandates changes

THE UTERINE ARTERY WAS SEVERED during cesarean delivery in a 32-year-old woman, causing severe hemorrhage. The ObGyn repaired the uterine vessels in the OR. The patient was sent to the recovery room and then to the surgical ICU, where she was in severe hemorrhagic shock, hypotensive, tachycardic, and had minimal urine output with metabolic acidosis. Exploratory surgery revealed massive blood clots. A trauma surgeon, called in by the ObGyn, found an extensive hematoma and 2 to 3 L of blood in the retroperitoneum. The woman died within 24 hours of delivery.

PLAINTIFF’S CLAIM When repairing injuries that occurred during the cesarean, the ObGyn damaged retroperitoneal uterine arteries. Physicians in the recovery room and surgical ICU informed the ObGyn that the patient appeared to have internal bleeding, but he did not return her to the OR for over 6 hours. After consent for exploratory surgery was signed, the ObGyn left to deliver another baby. The recovery room’s OBIX Perinatal Data System monitors failed to accurately record the patient’s vital signs. Understaffing in the surgical ICU impaired treatment.

DEFENSE CLAIM The ObGyn’s responsibility for the patient was transferred to the recovery room’s attending doctor, who claimed he had discharged his responsibility when he recommended exploratory surgery. After viewing the patient’s chart in the surgical ICU, a surgeon told the ObGyn that immediate treatment was needed for internal bleeding. The hospital claimed staffing issues did not cause the patient’s death.

VERDICT The burden of a $5.2 million settlement was shared by the physicians and hospital. The hospital was mandated to 1) establish an annual lecture on patient safety; 2) purchase a maternal/neonatal simulator to train staff; and 3) change the default settings on all OBIX Perinatal Data System machines to prevent them from defaulting to record normal values for vital signs when the “add” button is pushed.

Severe pain and burns during biopsy and genital wart removal

BIOPSY AND GENITAL WART REMOVAL were performed on a 34-year-old woman without anesthesia. She screamed in pain when the ObGyn biopsied her labia. Pain increased when he removed warts using a trichloroacetic acid mixture. Acid ran into the patient’s vagina and onto her buttocks, causing second-degree burns.

PATIENT’S CLAIM The physician never offered anesthesia, nor did she refuse it. The acid should have been applied more discretely. The paper toweling used to clean up the acid was just moist and could not have caused the acid to spread.

PHYSICIAN’S DEFENSE The ObGyn stated he preferred not to use anesthesia because it might affect the pathology slide quality, but that he offered it to the patient, and she refused. He also claimed that he applied the acid carefully, and attributed the spread and burn to a nurse who brought wet paper towels to dry the patient.

VERDICT A Tennessee defense verdict was returned.

Why wasn’t bloody nipple discharge taken more seriously?

DUE TO BLOODY DISCHARGE from her left nipple, a woman in her thirties had a mammogram; results were suspicious for malignancy. Her surgeon’s examination and biopsy were negative.

Two years later she found a lump in her left breast. Ultrasonography suggested a benign mass at 9 o’clock. Her surgeon could not find a mass at 9 o’clock, but detected a mass at 7 o’clock. He ordered US-guided core biopsy of the 9 o’clock area, but not the 7 o’clock mass—she was instructed to return for removal of the 7 o’clock mass regardless of the biopsy’s outcome. She was impatient for the biopsy, and went to another surgeon. Biopsy results were negative for malignancy.

Months later, during right breast implant replacement, she had the left-sided mass excised. Pathology reported moderate to poorly differentiated infiltrating carcinoma. She underwent a left mastectomy, prophylactic right mastectomy, and chemotherapy.

PATIENT’S CLAIM Further evaluation of her original complaint of bloody nipple discharge by her surgeon would have led to earlier diagnosis.

PHYSICIAN’S DEFENSE The left breast mass was never biopsied because the patient didn’t return as instructed.

VERDICT A Pennsylvania defense verdict was returned.

Uterine artery severed, new mother dies; court mandates changes

THE UTERINE ARTERY WAS SEVERED during cesarean delivery in a 32-year-old woman, causing severe hemorrhage. The ObGyn repaired the uterine vessels in the OR. The patient was sent to the recovery room and then to the surgical ICU, where she was in severe hemorrhagic shock, hypotensive, tachycardic, and had minimal urine output with metabolic acidosis. Exploratory surgery revealed massive blood clots. A trauma surgeon, called in by the ObGyn, found an extensive hematoma and 2 to 3 L of blood in the retroperitoneum. The woman died within 24 hours of delivery.

PLAINTIFF’S CLAIM When repairing injuries that occurred during the cesarean, the ObGyn damaged retroperitoneal uterine arteries. Physicians in the recovery room and surgical ICU informed the ObGyn that the patient appeared to have internal bleeding, but he did not return her to the OR for over 6 hours. After consent for exploratory surgery was signed, the ObGyn left to deliver another baby. The recovery room’s OBIX Perinatal Data System monitors failed to accurately record the patient’s vital signs. Understaffing in the surgical ICU impaired treatment.

DEFENSE CLAIM The ObGyn’s responsibility for the patient was transferred to the recovery room’s attending doctor, who claimed he had discharged his responsibility when he recommended exploratory surgery. After viewing the patient’s chart in the surgical ICU, a surgeon told the ObGyn that immediate treatment was needed for internal bleeding. The hospital claimed staffing issues did not cause the patient’s death.

VERDICT The burden of a $5.2 million settlement was shared by the physicians and hospital. The hospital was mandated to 1) establish an annual lecture on patient safety; 2) purchase a maternal/neonatal simulator to train staff; and 3) change the default settings on all OBIX Perinatal Data System machines to prevent them from defaulting to record normal values for vital signs when the “add” button is pushed.

Severe pain and burns during biopsy and genital wart removal

BIOPSY AND GENITAL WART REMOVAL were performed on a 34-year-old woman without anesthesia. She screamed in pain when the ObGyn biopsied her labia. Pain increased when he removed warts using a trichloroacetic acid mixture. Acid ran into the patient’s vagina and onto her buttocks, causing second-degree burns.

PATIENT’S CLAIM The physician never offered anesthesia, nor did she refuse it. The acid should have been applied more discretely. The paper toweling used to clean up the acid was just moist and could not have caused the acid to spread.

PHYSICIAN’S DEFENSE The ObGyn stated he preferred not to use anesthesia because it might affect the pathology slide quality, but that he offered it to the patient, and she refused. He also claimed that he applied the acid carefully, and attributed the spread and burn to a nurse who brought wet paper towels to dry the patient.

VERDICT A Tennessee defense verdict was returned.

Delayed referral ends in (too) late diagnosis of colon cancer

CONSTIPATION AND ABDOMINAL PAIN prompted a 45-year-old woman to consult her primary care physician, who recommended a change in diet. Two months later, the patient returned to the doctor because her symptoms hadn’t resolved, but admitted that she hadn’t altered her diet. The doctor repeated her recommendation for dietary change.

A month later, when the symptoms had worsened, the physician referred the woman to a gastroenterologist, who performed a colonoscopy. The colonoscopy revealed a large mass in the colon, which was diagnosed as stage IV cancer. The woman ultimately died.

PLAINTIFF’S CLAIM The doctor was negligent in failing to diagnose the cancer promptly.

THE DEFENSE The patient was treated for the complaints she presented with at each visit, and a referral wasn’t warranted until it was given.

VERDICT $420,000 New York verdict.

COMMENT I shudder when I read cases that could reflect my own practice patterns. How many patients with abdominal pain do we temporize? And the delay in diagnosis was only a few months!

Student in “excellent” health collapses on basketball court

The summer before he was to start college, an 18-year-old student went to an internist for a physical exam and asked the physician to complete a form that the college required. The physician documented a “slight systolic murmur” on the form, followed by a question mark. The physical was otherwise unremarkable, and the physician signed the form, indicating that the young man was in “excellent” health and fit to participate in all college activities without restrictions.

Nearly 4 years later, the student—then a senior and a member of the college basketball team—collapsed and died during a game. The cause of death: sudden cardiac death related to hypertrophic cardiomyopathy (HCM).

PLAINTIFF’S CLAIM The physician found a slight systolic murmur—a condition often associated with HCM—that should have prompted her to order further tests. Additional testing would have resulted in an HCM diagnosis.

THE DEFENSE The doctor did order an electrocardiogram, but the patient failed to keep the appointment. During the 3½ years after the exam, 5 other health care providers cleared the young man for college athletics.

VERDICT $1.6 million Massachusetts jury award.

COMMENT Sometimes seemingly innocuous findings can signify serious problems. Lack of closing the loop on documentation and follow-up remains a common denominator in malpractice settlements.

Sources: MoreLaw Lexapedia. Available at: http://www.morelaw.com/verdicts/case.asp?n=&s=MA&d=43384. Accessed May 11, 2010; Hypertrophic Cardiomyopathy Association correspondence.

Abnormal EKG with no follow-up, concludes with fatal MI

A 53-YEAR-OLD MAN WITH A HISTORY OF HEART DISEASE and cardiac symptoms went to his family physician of many years for a physical examination. The physician performed an electrocardiogram (EKG), which was normal, but the patient reported occasional chest pain. His physician referred him to a cardiologist for further evaluation. The cardiologist performed a stress test, which was normal.

Three years later, the patient had another physical exam and EKG. Although he reported no chest pain at this exam, he did mention heart palpitations, flutters, and skips. A computer reading revealed that the EKG was abnormal, with a possible inferior infarction. The patient’s physician nevertheless decided against a further work-up and did not refer him to a cardiologist.

Less than a month later, the man’s wife found him dead in bed. The death certificate cited myocardial infarction as the cause of death.

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

THE DEFENSE No information about the defense is available.

VERDICT $900,000 Virginia settlement.

COMMENT When faced with evidence of cardiac ischemia, prompt attention is indicated. Enough said.

Suicide attempt blamed on improper med management

A MAN WITH OBSESSIVE-COMPULSIVE DISORDER was prescribed fluoxetine by his psychiatrist as part of treatment. After several years, the psychiatrist discontinued the medication; the patient subsequently developed selective serotonin reuptake inhibitor (SSRI) discontinuation syndrome, including depression and suicidal ideation. The patient tried, unsuccessfully, to kill himself with a shotgun and ended up facing criminal charges of reckless endangerment.

The patient was transferred to the care of another psychiatrist, who prescribed higher doses of fluoxetine. The suicidal ideation stopped, but the patient complained of ongoing, disabling depression and distress related to his suicide attempt.

PLAINTIFF’S CLAIM The doctor failed to manage the patient’s medication properly. Discontinuing fluoxetine is known to cause the symptoms the patient experienced.

THE DEFENSE The plaintiff had told the first psychiatrist that he wanted to discontinue fluoxetine and had failed to report any concerns related to stopping the drug. SSRI discontinuation syndrome is rare, and the symptoms are difficult to detect.

VERDICT $911,000 New York verdict.

COMMENT Although I would quibble with the label discontinuation syndrome (sounds more like recurrent major depressive disorder), it’s very important to monitor patients carefully when starting treatment with an antidepressant, during changes in therapy, and after discontinuing a drug.

Delayed referral ends in (too) late diagnosis of colon cancer

CONSTIPATION AND ABDOMINAL PAIN prompted a 45-year-old woman to consult her primary care physician, who recommended a change in diet. Two months later, the patient returned to the doctor because her symptoms hadn’t resolved, but admitted that she hadn’t altered her diet. The doctor repeated her recommendation for dietary change.

A month later, when the symptoms had worsened, the physician referred the woman to a gastroenterologist, who performed a colonoscopy. The colonoscopy revealed a large mass in the colon, which was diagnosed as stage IV cancer. The woman ultimately died.

PLAINTIFF’S CLAIM The doctor was negligent in failing to diagnose the cancer promptly.

THE DEFENSE The patient was treated for the complaints she presented with at each visit, and a referral wasn’t warranted until it was given.

VERDICT $420,000 New York verdict.

COMMENT I shudder when I read cases that could reflect my own practice patterns. How many patients with abdominal pain do we temporize? And the delay in diagnosis was only a few months!

Student in “excellent” health collapses on basketball court

The summer before he was to start college, an 18-year-old student went to an internist for a physical exam and asked the physician to complete a form that the college required. The physician documented a “slight systolic murmur” on the form, followed by a question mark. The physical was otherwise unremarkable, and the physician signed the form, indicating that the young man was in “excellent” health and fit to participate in all college activities without restrictions.

Nearly 4 years later, the student—then a senior and a member of the college basketball team—collapsed and died during a game. The cause of death: sudden cardiac death related to hypertrophic cardiomyopathy (HCM).

PLAINTIFF’S CLAIM The physician found a slight systolic murmur—a condition often associated with HCM—that should have prompted her to order further tests. Additional testing would have resulted in an HCM diagnosis.

THE DEFENSE The doctor did order an electrocardiogram, but the patient failed to keep the appointment. During the 3½ years after the exam, 5 other health care providers cleared the young man for college athletics.

VERDICT $1.6 million Massachusetts jury award.

COMMENT Sometimes seemingly innocuous findings can signify serious problems. Lack of closing the loop on documentation and follow-up remains a common denominator in malpractice settlements.

Sources: MoreLaw Lexapedia. Available at: http://www.morelaw.com/verdicts/case.asp?n=&s=MA&d=43384. Accessed May 11, 2010; Hypertrophic Cardiomyopathy Association correspondence.

Abnormal EKG with no follow-up, concludes with fatal MI

A 53-YEAR-OLD MAN WITH A HISTORY OF HEART DISEASE and cardiac symptoms went to his family physician of many years for a physical examination. The physician performed an electrocardiogram (EKG), which was normal, but the patient reported occasional chest pain. His physician referred him to a cardiologist for further evaluation. The cardiologist performed a stress test, which was normal.

Three years later, the patient had another physical exam and EKG. Although he reported no chest pain at this exam, he did mention heart palpitations, flutters, and skips. A computer reading revealed that the EKG was abnormal, with a possible inferior infarction. The patient’s physician nevertheless decided against a further work-up and did not refer him to a cardiologist.

Less than a month later, the man’s wife found him dead in bed. The death certificate cited myocardial infarction as the cause of death.

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

THE DEFENSE No information about the defense is available.

VERDICT $900,000 Virginia settlement.

COMMENT When faced with evidence of cardiac ischemia, prompt attention is indicated. Enough said.

Suicide attempt blamed on improper med management

A MAN WITH OBSESSIVE-COMPULSIVE DISORDER was prescribed fluoxetine by his psychiatrist as part of treatment. After several years, the psychiatrist discontinued the medication; the patient subsequently developed selective serotonin reuptake inhibitor (SSRI) discontinuation syndrome, including depression and suicidal ideation. The patient tried, unsuccessfully, to kill himself with a shotgun and ended up facing criminal charges of reckless endangerment.

The patient was transferred to the care of another psychiatrist, who prescribed higher doses of fluoxetine. The suicidal ideation stopped, but the patient complained of ongoing, disabling depression and distress related to his suicide attempt.

PLAINTIFF’S CLAIM The doctor failed to manage the patient’s medication properly. Discontinuing fluoxetine is known to cause the symptoms the patient experienced.

THE DEFENSE The plaintiff had told the first psychiatrist that he wanted to discontinue fluoxetine and had failed to report any concerns related to stopping the drug. SSRI discontinuation syndrome is rare, and the symptoms are difficult to detect.

VERDICT $911,000 New York verdict.

COMMENT Although I would quibble with the label discontinuation syndrome (sounds more like recurrent major depressive disorder), it’s very important to monitor patients carefully when starting treatment with an antidepressant, during changes in therapy, and after discontinuing a drug.

Delayed referral ends in (too) late diagnosis of colon cancer

CONSTIPATION AND ABDOMINAL PAIN prompted a 45-year-old woman to consult her primary care physician, who recommended a change in diet. Two months later, the patient returned to the doctor because her symptoms hadn’t resolved, but admitted that she hadn’t altered her diet. The doctor repeated her recommendation for dietary change.

A month later, when the symptoms had worsened, the physician referred the woman to a gastroenterologist, who performed a colonoscopy. The colonoscopy revealed a large mass in the colon, which was diagnosed as stage IV cancer. The woman ultimately died.

PLAINTIFF’S CLAIM The doctor was negligent in failing to diagnose the cancer promptly.

THE DEFENSE The patient was treated for the complaints she presented with at each visit, and a referral wasn’t warranted until it was given.

VERDICT $420,000 New York verdict.

COMMENT I shudder when I read cases that could reflect my own practice patterns. How many patients with abdominal pain do we temporize? And the delay in diagnosis was only a few months!

Student in “excellent” health collapses on basketball court

The summer before he was to start college, an 18-year-old student went to an internist for a physical exam and asked the physician to complete a form that the college required. The physician documented a “slight systolic murmur” on the form, followed by a question mark. The physical was otherwise unremarkable, and the physician signed the form, indicating that the young man was in “excellent” health and fit to participate in all college activities without restrictions.

Nearly 4 years later, the student—then a senior and a member of the college basketball team—collapsed and died during a game. The cause of death: sudden cardiac death related to hypertrophic cardiomyopathy (HCM).

PLAINTIFF’S CLAIM The physician found a slight systolic murmur—a condition often associated with HCM—that should have prompted her to order further tests. Additional testing would have resulted in an HCM diagnosis.

THE DEFENSE The doctor did order an electrocardiogram, but the patient failed to keep the appointment. During the 3½ years after the exam, 5 other health care providers cleared the young man for college athletics.

VERDICT $1.6 million Massachusetts jury award.

COMMENT Sometimes seemingly innocuous findings can signify serious problems. Lack of closing the loop on documentation and follow-up remains a common denominator in malpractice settlements.

Sources: MoreLaw Lexapedia. Available at: http://www.morelaw.com/verdicts/case.asp?n=&s=MA&d=43384. Accessed May 11, 2010; Hypertrophic Cardiomyopathy Association correspondence.

Abnormal EKG with no follow-up, concludes with fatal MI

A 53-YEAR-OLD MAN WITH A HISTORY OF HEART DISEASE and cardiac symptoms went to his family physician of many years for a physical examination. The physician performed an electrocardiogram (EKG), which was normal, but the patient reported occasional chest pain. His physician referred him to a cardiologist for further evaluation. The cardiologist performed a stress test, which was normal.

Three years later, the patient had another physical exam and EKG. Although he reported no chest pain at this exam, he did mention heart palpitations, flutters, and skips. A computer reading revealed that the EKG was abnormal, with a possible inferior infarction. The patient’s physician nevertheless decided against a further work-up and did not refer him to a cardiologist.

Less than a month later, the man’s wife found him dead in bed. The death certificate cited myocardial infarction as the cause of death.

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

THE DEFENSE No information about the defense is available.

VERDICT $900,000 Virginia settlement.

COMMENT When faced with evidence of cardiac ischemia, prompt attention is indicated. Enough said.

Suicide attempt blamed on improper med management

A MAN WITH OBSESSIVE-COMPULSIVE DISORDER was prescribed fluoxetine by his psychiatrist as part of treatment. After several years, the psychiatrist discontinued the medication; the patient subsequently developed selective serotonin reuptake inhibitor (SSRI) discontinuation syndrome, including depression and suicidal ideation. The patient tried, unsuccessfully, to kill himself with a shotgun and ended up facing criminal charges of reckless endangerment.

The patient was transferred to the care of another psychiatrist, who prescribed higher doses of fluoxetine. The suicidal ideation stopped, but the patient complained of ongoing, disabling depression and distress related to his suicide attempt.

PLAINTIFF’S CLAIM The doctor failed to manage the patient’s medication properly. Discontinuing fluoxetine is known to cause the symptoms the patient experienced.

THE DEFENSE The plaintiff had told the first psychiatrist that he wanted to discontinue fluoxetine and had failed to report any concerns related to stopping the drug. SSRI discontinuation syndrome is rare, and the symptoms are difficult to detect.

VERDICT $911,000 New York verdict.

COMMENT Although I would quibble with the label discontinuation syndrome (sounds more like recurrent major depressive disorder), it’s very important to monitor patients carefully when starting treatment with an antidepressant, during changes in therapy, and after discontinuing a drug.

Patient sues drug companies: “HT caused my breast cancer”

A WOMAN IN HER LATE 50S took a combination of Premarin and Provera for 6 years to treat menopausal symptoms. She was then switched to Prempro for 4 years until she detected a lump in her breast. Her physician diagnosed invasive ductal breast cancer and the patient underwent a left mastectomy. Cancer spread to her lymph nodes; she underwent chemotherapy and radiation treatments. She sued the drug manufacturers.

PATIENT’S CLAIM Years of combination hormone therapy (HT) caused her breast cancer. The pharmaceutical companies failed to adequately test the drugs despite knowledge of their cancer-causing potential. If the defendants had begun cancer studies in the early 1980s when they first learned about the cancer risk, the risk would have been discovered before she began taking HT in 1991. She provided letters dated as early as 1976 from the FDA, independent researchers, and internal drug company scientists urging that cancer risk research be conducted. She claimed the defendants intentionally restricted the publication of medical data outlining the cancerous effects of combination HT to physicians and patients.

DEFENDANTS’ DEFENSE The FDA has reviewed the benefits and risks of HT for decades, always finding that the benefits outweighed the risks. Defendants cited 19 studies examining HT and breast cancer risk, the first published in 1959. The Women’s Health Initiative reaffirmed the increased risk of breast cancer, available in the labeling for Prempro in 1995. Labeling for Premarin and Provera included FDA-approved warnings of the breast cancer risk. The physician and patient were adequately warned of risks before use.

VERDICT $34.3 million verdict was returned, including $28 million in total punitive damages against the drug companies.

Was hypertension properly treated in this stroke victim?

AFTER HEAVY VAGINAL BLEEDING was diagnosed in a 49-year-old woman, her gynecologist prescribed medroxyprogesterone acetate. Several months later, she underwent a dilation and curettage for continued bleeding. A year later, her blood pressure (BP) was 140/94 mm Hg, which the physician believed was “white coat” hypertension. The woman returned 10 months later, still complaining of abnormal uterine bleeding, but she refused surgical options; the physician prescribed birth control pills. She returned for a routine exam a year later, when her BP was again elevated. The physician continued the patient’s oral contraceptive prescription and initiated treatment for high BP with triamterene. When the patient called to complain of excessive bleeding the next month, a nurse told her to take ibuprofen and call back if symptoms persisted. Shortly thereafter, the patient suffered a stroke. After rehabilitation, she regained use of her arms and legs, but suffered from foot drop and decreased fine motor skills.

PATIENT’S CLAIM The stroke was caused by uncontrolled hypertension and/or birth control pills. The physician should have initiated treatment the first time her BP was elevated, and it should have been checked more frequently. Birth control pills should have been discontinued when high BP was diagnosed because they are contraindicated in women older than 35 years whose BP is elevated.

PHYSICIAN’S DEFENSE The use of birth control pills was proper; the physician prescribed a low-dose combination medication commonly given to perimenopausal women to control abnormal bleeding. When high BP was first suspected, the physician commenced treatment.

VERDICT A defense verdict was returned.

Painful intercourse reported following incontinence surgery

EIGHT SURGERIES WERE PERFORMED to correct a 54-year-old woman’s cystocele, enterocele, and retrocele. The patient’s bladder, colon, and intestines had been pressing on her vaginal canal causing abdominal pain, painful intercourse, and urinary and fecal incontinence.

PATIENT’S CLAIM The procedures reduced the size of her vaginal opening and the length of her vaginal canal, causing constant pain as well as severe pain with intercourse. She was not informed that this was a risk of surgery.

PHYSICIAN’S DEFENSE The patient’s vaginal opening did shrink due to the release of pressure placed on the vaginal canal by the other organs, but it is still within normal range of vaginal size. The procedures resolved the patient’s incontinence issues.

VERDICT A defense verdict was returned.

Radiotherapy wrong for sarcoma; caused short bowel syndrome

FIBROIDS WERE MORCELLATED during a vaginal hysterectomy in a 56-year-old woman. The patient’s pathology report indicated endometrial stromal sarcoma (ESS). She underwent open surgery for staging and to remove any residual cancer cells that could be identified. The gynecologist referred her to a radiation oncologist. After receiving radiotherapy for 4 months, the patient complained of bowel-related symptoms. Three months later, she sought treatment closer to home for diarrhea and gastrointestinal problems. A surgeon diagnosed radiation-induced short bowel syndrome causing inadequate nutritional absorption. The patient underwent two operations, during which large sections of her bowel were removed, a permanent colostomy was placed. She then required total parenteral nutrition tube feedings.

PLAINTIFF’S CLAIM The radiation oncologist was negligent for recommending and administering radiotherapy because of its limited value in ESS. Hormonal therapy should have been used instead.

PHYSICIAN’S DEFENSE Radiotherapy was necessary because of the patient’s history and disease type. Morcellation during vaginal hysterectomy increased the risk of microscopic cancer cells remaining in the pelvis, supported by the finding of residual cancer cells during the second procedure. Radiotherapy was necessary to treat the residual cancer cells.

VERDICT A defense verdict was returned.

No response to alarm when fetal heart tones are lost

A WOMAN ATTEMPTED VAGINAL BIRTH after having one vaginal birth and one cesarean delivery in the past. Labor progressed slowly with inadequate contractions and lack of descent. After the mother pushed five or six times without progress, the OB left to deliver another baby. Because of lack of progression, the mother requested cesarean delivery, and the husband conveyed their concerns to the nursing staff. The nurses assured them that all was well but did not discuss the parents’ concerns with the OB or other hospital personnel. One hour later, the mother’s uterus ruptured, fetal heart tones were lost from the external fetal monitor, and an alarm sounded.

PLAINTIFF’S CLAIM The nursing staff failed to respond to the alarm immediately; when a response did come, a nurse allegedly stated with excitement that she was amazed that no one had responded. This statement was confirmed by the OB. After 9 minutes of signal loss, a fetal heartbeat of 60 was found, but it was severely bradycardic. The mother was rushed to the OR and the baby was delivered expeditiously. The child was born limp and without respiratory effort, and sustained hypoxic ischemic encephalopathy. At age 5, he had no purposeful movement of his extremities, could not communicate, and was wheelchair-bound, although he was not cognitively impaired.

DEFENDANTS’ DEFENSE The OB offered full policy limits before trial. The hospital claimed that the 9-minute delay in detecting the loss of fetal heart tone and seeking the OB’s intervention was not the proximate cause of the child’s handicaps.

VERDICT A $4.9 million Michigan verdict was reached.

Untreated postpartum infection necessitated hysterectomy

AN 18-YEAR-OLD WOMAN was discharged from the hospital two days after the vaginal birth of her healthy child, although she claimed to not feel well. When a hospital-employed nurse visited her the next day, the patient reported abdominal pain and cramping. Five days later, she returned to the hospital in extreme pain. She was diagnosed with severe Streptococcus A infection, air-lifted to another hospital, and treated with antibiotics for 5 days. A hysterectomy was later performed.

PLAINTIFF’S CLAIM The physician, visiting nurse, and hospital failed to diagnose and treat the infection in a timely manner, resulting in a hysterectomy. Laboratory tests taken before the patient’s hospital discharge showed an elevated white blood cell (WBC) count; the patient should have been prescribed antibiotics before leaving the hospital. The visiting nurse did not react appropriately when the patient reported pain. The hospital was responsible because the results of the WBC test were not entered into the patient’s chart.

DEFENDANTS’ DEFENSE The physician claimed that the elevated WBC count was not recorded in the patient’s medical chart with other lab values. The hospital claimed that a high WBC count is common after childbirth; the test is rarely performed at that time. The only reason it was performed was that the technology automatically recorded WBC when it evaluated hemoglobin and hemocrit. Abdominal cramping reported to the visiting nurse is normal 3 days after childbirth. The patient did not have an infection at discharge or at the time of the nurse’s visit.

VERDICT Suit against the physician was dismissed prior to jury deliberations. A $2.3 million verdict was returned against the hospital.

Did retained sponges lead to PID and gallbladder disease?

A 6-INCH VAGINAL LACERATION was discovered after a woman delivered a healthy baby. The ObGyn, who was covering for the patient’s regular ObGyn because of a snowstorm, could not repair the laceration in the delivery room. He packed the patient’s vagina with gauze sponges, and took her to the OR where he repaired the laceration. The next day, he removed sponges placed after surgery. The patient was discharged with instructions to follow-up with her regular ObGyn. Eight days after delivery, the patient complained to her ObGyn of severe abdominal pain and a foul odor. Antibiotics were prescribed, but she refused a vaginal examination because of the pain. Six weeks after delivery, four gauze sponges were removed from the patient’s vagina.

PLAINTIFF’S CLAIM The physician was negligent in leaving the sponges in her vagina. He should have conducted the follow-up himself because he delivered her child. The infection caused chronic pain from pelvic inflammatory disease (PID), and necessitated the removal of her gallbladder.

PHYSICIAN’S DEFENSE Retained sponges can occur in the absence of negligence. It was proper for the patient to return to her own physician for postoperative follow-up treatment. The patient’s PID and gallbladder problems were unrelated to the retained sponges.

VERDICT A defense verdict was returned. The defendant was granted costs and attorney fees exceeding $27,000.

Patient sues drug companies: “HT caused my breast cancer”

A WOMAN IN HER LATE 50S took a combination of Premarin and Provera for 6 years to treat menopausal symptoms. She was then switched to Prempro for 4 years until she detected a lump in her breast. Her physician diagnosed invasive ductal breast cancer and the patient underwent a left mastectomy. Cancer spread to her lymph nodes; she underwent chemotherapy and radiation treatments. She sued the drug manufacturers.

PATIENT’S CLAIM Years of combination hormone therapy (HT) caused her breast cancer. The pharmaceutical companies failed to adequately test the drugs despite knowledge of their cancer-causing potential. If the defendants had begun cancer studies in the early 1980s when they first learned about the cancer risk, the risk would have been discovered before she began taking HT in 1991. She provided letters dated as early as 1976 from the FDA, independent researchers, and internal drug company scientists urging that cancer risk research be conducted. She claimed the defendants intentionally restricted the publication of medical data outlining the cancerous effects of combination HT to physicians and patients.

DEFENDANTS’ DEFENSE The FDA has reviewed the benefits and risks of HT for decades, always finding that the benefits outweighed the risks. Defendants cited 19 studies examining HT and breast cancer risk, the first published in 1959. The Women’s Health Initiative reaffirmed the increased risk of breast cancer, available in the labeling for Prempro in 1995. Labeling for Premarin and Provera included FDA-approved warnings of the breast cancer risk. The physician and patient were adequately warned of risks before use.

VERDICT $34.3 million verdict was returned, including $28 million in total punitive damages against the drug companies.

Was hypertension properly treated in this stroke victim?

AFTER HEAVY VAGINAL BLEEDING was diagnosed in a 49-year-old woman, her gynecologist prescribed medroxyprogesterone acetate. Several months later, she underwent a dilation and curettage for continued bleeding. A year later, her blood pressure (BP) was 140/94 mm Hg, which the physician believed was “white coat” hypertension. The woman returned 10 months later, still complaining of abnormal uterine bleeding, but she refused surgical options; the physician prescribed birth control pills. She returned for a routine exam a year later, when her BP was again elevated. The physician continued the patient’s oral contraceptive prescription and initiated treatment for high BP with triamterene. When the patient called to complain of excessive bleeding the next month, a nurse told her to take ibuprofen and call back if symptoms persisted. Shortly thereafter, the patient suffered a stroke. After rehabilitation, she regained use of her arms and legs, but suffered from foot drop and decreased fine motor skills.

PATIENT’S CLAIM The stroke was caused by uncontrolled hypertension and/or birth control pills. The physician should have initiated treatment the first time her BP was elevated, and it should have been checked more frequently. Birth control pills should have been discontinued when high BP was diagnosed because they are contraindicated in women older than 35 years whose BP is elevated.

PHYSICIAN’S DEFENSE The use of birth control pills was proper; the physician prescribed a low-dose combination medication commonly given to perimenopausal women to control abnormal bleeding. When high BP was first suspected, the physician commenced treatment.

VERDICT A defense verdict was returned.

Painful intercourse reported following incontinence surgery

EIGHT SURGERIES WERE PERFORMED to correct a 54-year-old woman’s cystocele, enterocele, and retrocele. The patient’s bladder, colon, and intestines had been pressing on her vaginal canal causing abdominal pain, painful intercourse, and urinary and fecal incontinence.

PATIENT’S CLAIM The procedures reduced the size of her vaginal opening and the length of her vaginal canal, causing constant pain as well as severe pain with intercourse. She was not informed that this was a risk of surgery.

PHYSICIAN’S DEFENSE The patient’s vaginal opening did shrink due to the release of pressure placed on the vaginal canal by the other organs, but it is still within normal range of vaginal size. The procedures resolved the patient’s incontinence issues.

VERDICT A defense verdict was returned.

Radiotherapy wrong for sarcoma; caused short bowel syndrome

FIBROIDS WERE MORCELLATED during a vaginal hysterectomy in a 56-year-old woman. The patient’s pathology report indicated endometrial stromal sarcoma (ESS). She underwent open surgery for staging and to remove any residual cancer cells that could be identified. The gynecologist referred her to a radiation oncologist. After receiving radiotherapy for 4 months, the patient complained of bowel-related symptoms. Three months later, she sought treatment closer to home for diarrhea and gastrointestinal problems. A surgeon diagnosed radiation-induced short bowel syndrome causing inadequate nutritional absorption. The patient underwent two operations, during which large sections of her bowel were removed, a permanent colostomy was placed. She then required total parenteral nutrition tube feedings.

PLAINTIFF’S CLAIM The radiation oncologist was negligent for recommending and administering radiotherapy because of its limited value in ESS. Hormonal therapy should have been used instead.

PHYSICIAN’S DEFENSE Radiotherapy was necessary because of the patient’s history and disease type. Morcellation during vaginal hysterectomy increased the risk of microscopic cancer cells remaining in the pelvis, supported by the finding of residual cancer cells during the second procedure. Radiotherapy was necessary to treat the residual cancer cells.

VERDICT A defense verdict was returned.

No response to alarm when fetal heart tones are lost

A WOMAN ATTEMPTED VAGINAL BIRTH after having one vaginal birth and one cesarean delivery in the past. Labor progressed slowly with inadequate contractions and lack of descent. After the mother pushed five or six times without progress, the OB left to deliver another baby. Because of lack of progression, the mother requested cesarean delivery, and the husband conveyed their concerns to the nursing staff. The nurses assured them that all was well but did not discuss the parents’ concerns with the OB or other hospital personnel. One hour later, the mother’s uterus ruptured, fetal heart tones were lost from the external fetal monitor, and an alarm sounded.

PLAINTIFF’S CLAIM The nursing staff failed to respond to the alarm immediately; when a response did come, a nurse allegedly stated with excitement that she was amazed that no one had responded. This statement was confirmed by the OB. After 9 minutes of signal loss, a fetal heartbeat of 60 was found, but it was severely bradycardic. The mother was rushed to the OR and the baby was delivered expeditiously. The child was born limp and without respiratory effort, and sustained hypoxic ischemic encephalopathy. At age 5, he had no purposeful movement of his extremities, could not communicate, and was wheelchair-bound, although he was not cognitively impaired.

DEFENDANTS’ DEFENSE The OB offered full policy limits before trial. The hospital claimed that the 9-minute delay in detecting the loss of fetal heart tone and seeking the OB’s intervention was not the proximate cause of the child’s handicaps.

VERDICT A $4.9 million Michigan verdict was reached.

Untreated postpartum infection necessitated hysterectomy

AN 18-YEAR-OLD WOMAN was discharged from the hospital two days after the vaginal birth of her healthy child, although she claimed to not feel well. When a hospital-employed nurse visited her the next day, the patient reported abdominal pain and cramping. Five days later, she returned to the hospital in extreme pain. She was diagnosed with severe Streptococcus A infection, air-lifted to another hospital, and treated with antibiotics for 5 days. A hysterectomy was later performed.

PLAINTIFF’S CLAIM The physician, visiting nurse, and hospital failed to diagnose and treat the infection in a timely manner, resulting in a hysterectomy. Laboratory tests taken before the patient’s hospital discharge showed an elevated white blood cell (WBC) count; the patient should have been prescribed antibiotics before leaving the hospital. The visiting nurse did not react appropriately when the patient reported pain. The hospital was responsible because the results of the WBC test were not entered into the patient’s chart.

DEFENDANTS’ DEFENSE The physician claimed that the elevated WBC count was not recorded in the patient’s medical chart with other lab values. The hospital claimed that a high WBC count is common after childbirth; the test is rarely performed at that time. The only reason it was performed was that the technology automatically recorded WBC when it evaluated hemoglobin and hemocrit. Abdominal cramping reported to the visiting nurse is normal 3 days after childbirth. The patient did not have an infection at discharge or at the time of the nurse’s visit.

VERDICT Suit against the physician was dismissed prior to jury deliberations. A $2.3 million verdict was returned against the hospital.

Did retained sponges lead to PID and gallbladder disease?

A 6-INCH VAGINAL LACERATION was discovered after a woman delivered a healthy baby. The ObGyn, who was covering for the patient’s regular ObGyn because of a snowstorm, could not repair the laceration in the delivery room. He packed the patient’s vagina with gauze sponges, and took her to the OR where he repaired the laceration. The next day, he removed sponges placed after surgery. The patient was discharged with instructions to follow-up with her regular ObGyn. Eight days after delivery, the patient complained to her ObGyn of severe abdominal pain and a foul odor. Antibiotics were prescribed, but she refused a vaginal examination because of the pain. Six weeks after delivery, four gauze sponges were removed from the patient’s vagina.

PLAINTIFF’S CLAIM The physician was negligent in leaving the sponges in her vagina. He should have conducted the follow-up himself because he delivered her child. The infection caused chronic pain from pelvic inflammatory disease (PID), and necessitated the removal of her gallbladder.

PHYSICIAN’S DEFENSE Retained sponges can occur in the absence of negligence. It was proper for the patient to return to her own physician for postoperative follow-up treatment. The patient’s PID and gallbladder problems were unrelated to the retained sponges.

VERDICT A defense verdict was returned. The defendant was granted costs and attorney fees exceeding $27,000.

Patient sues drug companies: “HT caused my breast cancer”

A WOMAN IN HER LATE 50S took a combination of Premarin and Provera for 6 years to treat menopausal symptoms. She was then switched to Prempro for 4 years until she detected a lump in her breast. Her physician diagnosed invasive ductal breast cancer and the patient underwent a left mastectomy. Cancer spread to her lymph nodes; she underwent chemotherapy and radiation treatments. She sued the drug manufacturers.

PATIENT’S CLAIM Years of combination hormone therapy (HT) caused her breast cancer. The pharmaceutical companies failed to adequately test the drugs despite knowledge of their cancer-causing potential. If the defendants had begun cancer studies in the early 1980s when they first learned about the cancer risk, the risk would have been discovered before she began taking HT in 1991. She provided letters dated as early as 1976 from the FDA, independent researchers, and internal drug company scientists urging that cancer risk research be conducted. She claimed the defendants intentionally restricted the publication of medical data outlining the cancerous effects of combination HT to physicians and patients.

DEFENDANTS’ DEFENSE The FDA has reviewed the benefits and risks of HT for decades, always finding that the benefits outweighed the risks. Defendants cited 19 studies examining HT and breast cancer risk, the first published in 1959. The Women’s Health Initiative reaffirmed the increased risk of breast cancer, available in the labeling for Prempro in 1995. Labeling for Premarin and Provera included FDA-approved warnings of the breast cancer risk. The physician and patient were adequately warned of risks before use.

VERDICT $34.3 million verdict was returned, including $28 million in total punitive damages against the drug companies.

Was hypertension properly treated in this stroke victim?

AFTER HEAVY VAGINAL BLEEDING was diagnosed in a 49-year-old woman, her gynecologist prescribed medroxyprogesterone acetate. Several months later, she underwent a dilation and curettage for continued bleeding. A year later, her blood pressure (BP) was 140/94 mm Hg, which the physician believed was “white coat” hypertension. The woman returned 10 months later, still complaining of abnormal uterine bleeding, but she refused surgical options; the physician prescribed birth control pills. She returned for a routine exam a year later, when her BP was again elevated. The physician continued the patient’s oral contraceptive prescription and initiated treatment for high BP with triamterene. When the patient called to complain of excessive bleeding the next month, a nurse told her to take ibuprofen and call back if symptoms persisted. Shortly thereafter, the patient suffered a stroke. After rehabilitation, she regained use of her arms and legs, but suffered from foot drop and decreased fine motor skills.

PATIENT’S CLAIM The stroke was caused by uncontrolled hypertension and/or birth control pills. The physician should have initiated treatment the first time her BP was elevated, and it should have been checked more frequently. Birth control pills should have been discontinued when high BP was diagnosed because they are contraindicated in women older than 35 years whose BP is elevated.

PHYSICIAN’S DEFENSE The use of birth control pills was proper; the physician prescribed a low-dose combination medication commonly given to perimenopausal women to control abnormal bleeding. When high BP was first suspected, the physician commenced treatment.

VERDICT A defense verdict was returned.

Painful intercourse reported following incontinence surgery

EIGHT SURGERIES WERE PERFORMED to correct a 54-year-old woman’s cystocele, enterocele, and retrocele. The patient’s bladder, colon, and intestines had been pressing on her vaginal canal causing abdominal pain, painful intercourse, and urinary and fecal incontinence.

PATIENT’S CLAIM The procedures reduced the size of her vaginal opening and the length of her vaginal canal, causing constant pain as well as severe pain with intercourse. She was not informed that this was a risk of surgery.

PHYSICIAN’S DEFENSE The patient’s vaginal opening did shrink due to the release of pressure placed on the vaginal canal by the other organs, but it is still within normal range of vaginal size. The procedures resolved the patient’s incontinence issues.

VERDICT A defense verdict was returned.

Radiotherapy wrong for sarcoma; caused short bowel syndrome

FIBROIDS WERE MORCELLATED during a vaginal hysterectomy in a 56-year-old woman. The patient’s pathology report indicated endometrial stromal sarcoma (ESS). She underwent open surgery for staging and to remove any residual cancer cells that could be identified. The gynecologist referred her to a radiation oncologist. After receiving radiotherapy for 4 months, the patient complained of bowel-related symptoms. Three months later, she sought treatment closer to home for diarrhea and gastrointestinal problems. A surgeon diagnosed radiation-induced short bowel syndrome causing inadequate nutritional absorption. The patient underwent two operations, during which large sections of her bowel were removed, a permanent colostomy was placed. She then required total parenteral nutrition tube feedings.

PLAINTIFF’S CLAIM The radiation oncologist was negligent for recommending and administering radiotherapy because of its limited value in ESS. Hormonal therapy should have been used instead.

PHYSICIAN’S DEFENSE Radiotherapy was necessary because of the patient’s history and disease type. Morcellation during vaginal hysterectomy increased the risk of microscopic cancer cells remaining in the pelvis, supported by the finding of residual cancer cells during the second procedure. Radiotherapy was necessary to treat the residual cancer cells.

VERDICT A defense verdict was returned.

No response to alarm when fetal heart tones are lost

A WOMAN ATTEMPTED VAGINAL BIRTH after having one vaginal birth and one cesarean delivery in the past. Labor progressed slowly with inadequate contractions and lack of descent. After the mother pushed five or six times without progress, the OB left to deliver another baby. Because of lack of progression, the mother requested cesarean delivery, and the husband conveyed their concerns to the nursing staff. The nurses assured them that all was well but did not discuss the parents’ concerns with the OB or other hospital personnel. One hour later, the mother’s uterus ruptured, fetal heart tones were lost from the external fetal monitor, and an alarm sounded.

PLAINTIFF’S CLAIM The nursing staff failed to respond to the alarm immediately; when a response did come, a nurse allegedly stated with excitement that she was amazed that no one had responded. This statement was confirmed by the OB. After 9 minutes of signal loss, a fetal heartbeat of 60 was found, but it was severely bradycardic. The mother was rushed to the OR and the baby was delivered expeditiously. The child was born limp and without respiratory effort, and sustained hypoxic ischemic encephalopathy. At age 5, he had no purposeful movement of his extremities, could not communicate, and was wheelchair-bound, although he was not cognitively impaired.

DEFENDANTS’ DEFENSE The OB offered full policy limits before trial. The hospital claimed that the 9-minute delay in detecting the loss of fetal heart tone and seeking the OB’s intervention was not the proximate cause of the child’s handicaps.

VERDICT A $4.9 million Michigan verdict was reached.

Untreated postpartum infection necessitated hysterectomy

AN 18-YEAR-OLD WOMAN was discharged from the hospital two days after the vaginal birth of her healthy child, although she claimed to not feel well. When a hospital-employed nurse visited her the next day, the patient reported abdominal pain and cramping. Five days later, she returned to the hospital in extreme pain. She was diagnosed with severe Streptococcus A infection, air-lifted to another hospital, and treated with antibiotics for 5 days. A hysterectomy was later performed.

PLAINTIFF’S CLAIM The physician, visiting nurse, and hospital failed to diagnose and treat the infection in a timely manner, resulting in a hysterectomy. Laboratory tests taken before the patient’s hospital discharge showed an elevated white blood cell (WBC) count; the patient should have been prescribed antibiotics before leaving the hospital. The visiting nurse did not react appropriately when the patient reported pain. The hospital was responsible because the results of the WBC test were not entered into the patient’s chart.

DEFENDANTS’ DEFENSE The physician claimed that the elevated WBC count was not recorded in the patient’s medical chart with other lab values. The hospital claimed that a high WBC count is common after childbirth; the test is rarely performed at that time. The only reason it was performed was that the technology automatically recorded WBC when it evaluated hemoglobin and hemocrit. Abdominal cramping reported to the visiting nurse is normal 3 days after childbirth. The patient did not have an infection at discharge or at the time of the nurse’s visit.

VERDICT Suit against the physician was dismissed prior to jury deliberations. A $2.3 million verdict was returned against the hospital.

Did retained sponges lead to PID and gallbladder disease?

A 6-INCH VAGINAL LACERATION was discovered after a woman delivered a healthy baby. The ObGyn, who was covering for the patient’s regular ObGyn because of a snowstorm, could not repair the laceration in the delivery room. He packed the patient’s vagina with gauze sponges, and took her to the OR where he repaired the laceration. The next day, he removed sponges placed after surgery. The patient was discharged with instructions to follow-up with her regular ObGyn. Eight days after delivery, the patient complained to her ObGyn of severe abdominal pain and a foul odor. Antibiotics were prescribed, but she refused a vaginal examination because of the pain. Six weeks after delivery, four gauze sponges were removed from the patient’s vagina.

PLAINTIFF’S CLAIM The physician was negligent in leaving the sponges in her vagina. He should have conducted the follow-up himself because he delivered her child. The infection caused chronic pain from pelvic inflammatory disease (PID), and necessitated the removal of her gallbladder.

PHYSICIAN’S DEFENSE Retained sponges can occur in the absence of negligence. It was proper for the patient to return to her own physician for postoperative follow-up treatment. The patient’s PID and gallbladder problems were unrelated to the retained sponges.

VERDICT A defense verdict was returned. The defendant was granted costs and attorney fees exceeding $27,000.

Delay in diagnosing blastomycosis cuts a young life short

COUGH, FEVER, AND FLU-LIKE SYMPTOMS for a week prompted a 25-year-old man to visit his physician, who prescribed an antibiotic. When the symptoms didn‘t improve after 3 days, the patient went to a local health care group, where a physician assistant continued the antibiotic, performed a tuberculosis test, and instructed the young man to return in 3 days.

At the return visit, the patient still had the cough and a fever of 101°F, as well as decreased breath sounds and bilateral pain in his lower lungs when reclining. Another physician assistant diagnosed pneumonia and prescribed a different antibiotic, but didn’t order chest radiographs or blood work—or measure oxygen saturation. He wrote the patient a 5-day excuse from work and told him to return if his condition worsened.

A few days later, the patient went to the emergency department, where he was diagnosed with a pulmonary blastomycosis infection. The infection was too far advanced to treat effectively, and the man died shortly thereafter.

PLAINTIFF’S CLAIM The physician assistants were negligent for not having radiographs or blood work done and not consulting the supervising physician. The supervising physician didn’t review the examination and treatment notes.

THE DEFENSE No negligence occurred; an earlier diagnosis wouldn’t have changed the outcome.

VERDICT $3.7 million Wisconsin verdict.

COMMENT This case sends shivers down my spine. I really get worried when huge verdicts are returned for failure to diagnose rare conditions. How many times a week do we treat patients for “bronchitis” or community-acquired pneumonia without getting a radiograph or oxygen saturation measurement—especially in a 25-year-old!

A drug overdose, with plenty of blame to go around

AN 85-YEAR-OLD WOMAN was admitted to a nursing home for a temporary stay after she broke her arm shoveling snow in her driveway. Her physician prescribed a medication, to be given once a week, for the woman’s rheumatoid arthritis. But because a nurse transcribed the order incorrectly, the patient was given the medication every day. After 17 days, she died of an overdose.

PLAINTIFF’S CLAIM The nurse was negligent in transcribing the order incorrectly, the doctor was negligent for signing the order without reading the nurse’s note, and the pharmacy was negligent for failing to discover the dosage error.

THE DEFENSE No information about the defense is available.

VERDICT $1 million Ohio settlement.

COMMENT The moral of this story: Don’t sign those nursing home orders on autopilot!

Unexamined mass isn’t benign after all

A PEA-SIZED MASS on a 34-year-old woman’s head was diagnosed as a sebaceous cyst. A physician assistant removed the mass, which was thrown away without being sent for pathologic examination. A year later, the mass reappeared and was identified as a sarcoma. The woman died a year later.

PLAINTIFF’S CLAIM The doctor and physician assistant were negligent in failing to diagnose the mass accurately and failing to send it for pathologic analysis.

THE DEFENSE The mass appeared normal and didn’t require examination.

VERDICT $1.5 million Texas settlement.

COMMENT I make it a policy to send all skin specimens—no matter how innocuous—for pathologic determination. I recently testified for a defendant in a case similar to this one (fortunately the physician won).

Delay in diagnosing blastomycosis cuts a young life short

COUGH, FEVER, AND FLU-LIKE SYMPTOMS for a week prompted a 25-year-old man to visit his physician, who prescribed an antibiotic. When the symptoms didn‘t improve after 3 days, the patient went to a local health care group, where a physician assistant continued the antibiotic, performed a tuberculosis test, and instructed the young man to return in 3 days.

At the return visit, the patient still had the cough and a fever of 101°F, as well as decreased breath sounds and bilateral pain in his lower lungs when reclining. Another physician assistant diagnosed pneumonia and prescribed a different antibiotic, but didn’t order chest radiographs or blood work—or measure oxygen saturation. He wrote the patient a 5-day excuse from work and told him to return if his condition worsened.

A few days later, the patient went to the emergency department, where he was diagnosed with a pulmonary blastomycosis infection. The infection was too far advanced to treat effectively, and the man died shortly thereafter.

PLAINTIFF’S CLAIM The physician assistants were negligent for not having radiographs or blood work done and not consulting the supervising physician. The supervising physician didn’t review the examination and treatment notes.

THE DEFENSE No negligence occurred; an earlier diagnosis wouldn’t have changed the outcome.

VERDICT $3.7 million Wisconsin verdict.

COMMENT This case sends shivers down my spine. I really get worried when huge verdicts are returned for failure to diagnose rare conditions. How many times a week do we treat patients for “bronchitis” or community-acquired pneumonia without getting a radiograph or oxygen saturation measurement—especially in a 25-year-old!

A drug overdose, with plenty of blame to go around

AN 85-YEAR-OLD WOMAN was admitted to a nursing home for a temporary stay after she broke her arm shoveling snow in her driveway. Her physician prescribed a medication, to be given once a week, for the woman’s rheumatoid arthritis. But because a nurse transcribed the order incorrectly, the patient was given the medication every day. After 17 days, she died of an overdose.

PLAINTIFF’S CLAIM The nurse was negligent in transcribing the order incorrectly, the doctor was negligent for signing the order without reading the nurse’s note, and the pharmacy was negligent for failing to discover the dosage error.

THE DEFENSE No information about the defense is available.

VERDICT $1 million Ohio settlement.

COMMENT The moral of this story: Don’t sign those nursing home orders on autopilot!

Unexamined mass isn’t benign after all

A PEA-SIZED MASS on a 34-year-old woman’s head was diagnosed as a sebaceous cyst. A physician assistant removed the mass, which was thrown away without being sent for pathologic examination. A year later, the mass reappeared and was identified as a sarcoma. The woman died a year later.

PLAINTIFF’S CLAIM The doctor and physician assistant were negligent in failing to diagnose the mass accurately and failing to send it for pathologic analysis.

THE DEFENSE The mass appeared normal and didn’t require examination.

VERDICT $1.5 million Texas settlement.

COMMENT I make it a policy to send all skin specimens—no matter how innocuous—for pathologic determination. I recently testified for a defendant in a case similar to this one (fortunately the physician won).

Delay in diagnosing blastomycosis cuts a young life short

COUGH, FEVER, AND FLU-LIKE SYMPTOMS for a week prompted a 25-year-old man to visit his physician, who prescribed an antibiotic. When the symptoms didn‘t improve after 3 days, the patient went to a local health care group, where a physician assistant continued the antibiotic, performed a tuberculosis test, and instructed the young man to return in 3 days.

At the return visit, the patient still had the cough and a fever of 101°F, as well as decreased breath sounds and bilateral pain in his lower lungs when reclining. Another physician assistant diagnosed pneumonia and prescribed a different antibiotic, but didn’t order chest radiographs or blood work—or measure oxygen saturation. He wrote the patient a 5-day excuse from work and told him to return if his condition worsened.

A few days later, the patient went to the emergency department, where he was diagnosed with a pulmonary blastomycosis infection. The infection was too far advanced to treat effectively, and the man died shortly thereafter.

PLAINTIFF’S CLAIM The physician assistants were negligent for not having radiographs or blood work done and not consulting the supervising physician. The supervising physician didn’t review the examination and treatment notes.

THE DEFENSE No negligence occurred; an earlier diagnosis wouldn’t have changed the outcome.

VERDICT $3.7 million Wisconsin verdict.

COMMENT This case sends shivers down my spine. I really get worried when huge verdicts are returned for failure to diagnose rare conditions. How many times a week do we treat patients for “bronchitis” or community-acquired pneumonia without getting a radiograph or oxygen saturation measurement—especially in a 25-year-old!

A drug overdose, with plenty of blame to go around

AN 85-YEAR-OLD WOMAN was admitted to a nursing home for a temporary stay after she broke her arm shoveling snow in her driveway. Her physician prescribed a medication, to be given once a week, for the woman’s rheumatoid arthritis. But because a nurse transcribed the order incorrectly, the patient was given the medication every day. After 17 days, she died of an overdose.

PLAINTIFF’S CLAIM The nurse was negligent in transcribing the order incorrectly, the doctor was negligent for signing the order without reading the nurse’s note, and the pharmacy was negligent for failing to discover the dosage error.

THE DEFENSE No information about the defense is available.

VERDICT $1 million Ohio settlement.

COMMENT The moral of this story: Don’t sign those nursing home orders on autopilot!

Unexamined mass isn’t benign after all

A PEA-SIZED MASS on a 34-year-old woman’s head was diagnosed as a sebaceous cyst. A physician assistant removed the mass, which was thrown away without being sent for pathologic examination. A year later, the mass reappeared and was identified as a sarcoma. The woman died a year later.

PLAINTIFF’S CLAIM The doctor and physician assistant were negligent in failing to diagnose the mass accurately and failing to send it for pathologic analysis.

THE DEFENSE The mass appeared normal and didn’t require examination.

VERDICT $1.5 million Texas settlement.

COMMENT I make it a policy to send all skin specimens—no matter how innocuous—for pathologic determination. I recently testified for a defendant in a case similar to this one (fortunately the physician won).

Improperly treated C difficile leads to total colectomy

A 66-YEAR-OLD MAN contracted Clostridium difficile during hospitalization for treatment of a foot infection. The treating physician prescribed a 7-day course of antibiotics rather than the 14-day course recommended by a hospital infectious disease specialist. On the day the patient was discharged from the hospital, the treating physician dictated a letter to the patient’s primary care physician, but misdated it with the previous year.

When the patient visited his primary care physician the following week, he was seen by an associate of his regular doctor. According to the patient, the associate said she hadn’t seen the letter that had been sent to his primary care physician. The associate then re-prescribed the cephalosporin antibiotic that had led to the patient’s C difficile illness in the first place.

When the patient went back to his primary care physician’s office 2 weeks later, a physician assistant (PA) told him to return to the hospital because he’d been ill since discharge. At the hospital, toxic megacolon and septicemia were diagnosed, and the patient underwent immediate surgery to remove his entire colon and perform an ileostomy.

PLAINTIFF’S CLAIM The doctor who treated the foot infection at the hospital was negligent in failing to follow up and properly transfer care of the patient to the primary care physician. The primary care physician and his associate were negligent in failing to treat the C difficile infection properly.

THE DEFENSE The doctor who treated the foot infection denied negligence and maintained that he’d acted properly in dictating the discharge letter to the primary care physician.

The primary care physician and his associate claimed that they hadn’t received the letter until more than 30 days after the patient was discharged. The plaintiff countered that the PA had told him he had cellulitis and osteomyelitis—something the PA couldn’t have known unless he’d seen the letter describing those diagnoses. The plaintiff also contended that neither the primary care physician nor his associate complained about the tardiness of the letter at the time they received it.

VERDICT $2.75 million Pennsylvania verdict.

COMMENT This case is a classic failure of our system for coordination and handoff of care. Although such problems are endemic, substantial malpractice judgments await the unwary.

For want of a timely transfusion, man bleeds to death

A MAN SUSPECTED OF HAVING GASTROINTESTINAL BLEEDING was admitted to a university medical center. He collapsed the next day. A resident informed the attending physician, who ordered a transfusion over the phone. The patient died of cardiac arrest from internal bleeding 6 hours after the transfusion was ordered, but before it was given.

PLAINTIFF’S CLAIM The blood bank had reported that the transfusion was ready 3 hours before the man collapsed; the attending physician, resident, and nurses were negligent in failing to administer the transfusion in a timely manner.

THE DEFENSE The attending physician claimed that he wasn’t required to come to the hospital for 24 hours after the patient was admitted and that the resident didn’t provide him with information that would have prompted him to come in and examine the patient. The resident maintained that he gave the attending physician all the necessary data and provided an accurate account of what had happened to the patient.

VERDICT $1.75 million New Jersey settlement.

COMMENT Speaking of coordination of care, understand the risks of working with residents, particularly when caring for a potentially unstable patient. I doubt many juries would be sympathetic to, “I wasn’t required to come to the hospital for 24 hours after admission.”

Improperly treated C difficile leads to total colectomy

A 66-YEAR-OLD MAN contracted Clostridium difficile during hospitalization for treatment of a foot infection. The treating physician prescribed a 7-day course of antibiotics rather than the 14-day course recommended by a hospital infectious disease specialist. On the day the patient was discharged from the hospital, the treating physician dictated a letter to the patient’s primary care physician, but misdated it with the previous year.

When the patient visited his primary care physician the following week, he was seen by an associate of his regular doctor. According to the patient, the associate said she hadn’t seen the letter that had been sent to his primary care physician. The associate then re-prescribed the cephalosporin antibiotic that had led to the patient’s C difficile illness in the first place.

When the patient went back to his primary care physician’s office 2 weeks later, a physician assistant (PA) told him to return to the hospital because he’d been ill since discharge. At the hospital, toxic megacolon and septicemia were diagnosed, and the patient underwent immediate surgery to remove his entire colon and perform an ileostomy.

PLAINTIFF’S CLAIM The doctor who treated the foot infection at the hospital was negligent in failing to follow up and properly transfer care of the patient to the primary care physician. The primary care physician and his associate were negligent in failing to treat the C difficile infection properly.

THE DEFENSE The doctor who treated the foot infection denied negligence and maintained that he’d acted properly in dictating the discharge letter to the primary care physician.

The primary care physician and his associate claimed that they hadn’t received the letter until more than 30 days after the patient was discharged. The plaintiff countered that the PA had told him he had cellulitis and osteomyelitis—something the PA couldn’t have known unless he’d seen the letter describing those diagnoses. The plaintiff also contended that neither the primary care physician nor his associate complained about the tardiness of the letter at the time they received it.

VERDICT $2.75 million Pennsylvania verdict.

COMMENT This case is a classic failure of our system for coordination and handoff of care. Although such problems are endemic, substantial malpractice judgments await the unwary.

For want of a timely transfusion, man bleeds to death

A MAN SUSPECTED OF HAVING GASTROINTESTINAL BLEEDING was admitted to a university medical center. He collapsed the next day. A resident informed the attending physician, who ordered a transfusion over the phone. The patient died of cardiac arrest from internal bleeding 6 hours after the transfusion was ordered, but before it was given.

PLAINTIFF’S CLAIM The blood bank had reported that the transfusion was ready 3 hours before the man collapsed; the attending physician, resident, and nurses were negligent in failing to administer the transfusion in a timely manner.

THE DEFENSE The attending physician claimed that he wasn’t required to come to the hospital for 24 hours after the patient was admitted and that the resident didn’t provide him with information that would have prompted him to come in and examine the patient. The resident maintained that he gave the attending physician all the necessary data and provided an accurate account of what had happened to the patient.

VERDICT $1.75 million New Jersey settlement.

COMMENT Speaking of coordination of care, understand the risks of working with residents, particularly when caring for a potentially unstable patient. I doubt many juries would be sympathetic to, “I wasn’t required to come to the hospital for 24 hours after admission.”

Improperly treated C difficile leads to total colectomy

A 66-YEAR-OLD MAN contracted Clostridium difficile during hospitalization for treatment of a foot infection. The treating physician prescribed a 7-day course of antibiotics rather than the 14-day course recommended by a hospital infectious disease specialist. On the day the patient was discharged from the hospital, the treating physician dictated a letter to the patient’s primary care physician, but misdated it with the previous year.

When the patient visited his primary care physician the following week, he was seen by an associate of his regular doctor. According to the patient, the associate said she hadn’t seen the letter that had been sent to his primary care physician. The associate then re-prescribed the cephalosporin antibiotic that had led to the patient’s C difficile illness in the first place.

When the patient went back to his primary care physician’s office 2 weeks later, a physician assistant (PA) told him to return to the hospital because he’d been ill since discharge. At the hospital, toxic megacolon and septicemia were diagnosed, and the patient underwent immediate surgery to remove his entire colon and perform an ileostomy.

PLAINTIFF’S CLAIM The doctor who treated the foot infection at the hospital was negligent in failing to follow up and properly transfer care of the patient to the primary care physician. The primary care physician and his associate were negligent in failing to treat the C difficile infection properly.

THE DEFENSE The doctor who treated the foot infection denied negligence and maintained that he’d acted properly in dictating the discharge letter to the primary care physician.

The primary care physician and his associate claimed that they hadn’t received the letter until more than 30 days after the patient was discharged. The plaintiff countered that the PA had told him he had cellulitis and osteomyelitis—something the PA couldn’t have known unless he’d seen the letter describing those diagnoses. The plaintiff also contended that neither the primary care physician nor his associate complained about the tardiness of the letter at the time they received it.

VERDICT $2.75 million Pennsylvania verdict.

COMMENT This case is a classic failure of our system for coordination and handoff of care. Although such problems are endemic, substantial malpractice judgments await the unwary.

For want of a timely transfusion, man bleeds to death

A MAN SUSPECTED OF HAVING GASTROINTESTINAL BLEEDING was admitted to a university medical center. He collapsed the next day. A resident informed the attending physician, who ordered a transfusion over the phone. The patient died of cardiac arrest from internal bleeding 6 hours after the transfusion was ordered, but before it was given.

PLAINTIFF’S CLAIM The blood bank had reported that the transfusion was ready 3 hours before the man collapsed; the attending physician, resident, and nurses were negligent in failing to administer the transfusion in a timely manner.

THE DEFENSE The attending physician claimed that he wasn’t required to come to the hospital for 24 hours after the patient was admitted and that the resident didn’t provide him with information that would have prompted him to come in and examine the patient. The resident maintained that he gave the attending physician all the necessary data and provided an accurate account of what had happened to the patient.

VERDICT $1.75 million New Jersey settlement.

COMMENT Speaking of coordination of care, understand the risks of working with residents, particularly when caring for a potentially unstable patient. I doubt many juries would be sympathetic to, “I wasn’t required to come to the hospital for 24 hours after admission.”

Ureter was severed, reattached, obstructed

A WOMAN IN HER 60S underwent surgery to remove a large abdominal mass. The ObGyn resected a 7-cm portion of her ureter thinking it was a blood vessel. Realizing his mistake during the surgery, he contacted a urologist, who reattached the ureter. Later the patient was rehospitalized when she suffered a ureteral obstruction.

PATIENT’S CLAIM The ObGyn was negligent for failing to identify and protect the ureter, and to properly assess the area before resecting the mass. Also, ureteral obstructions were likely to reoccur.

PHYSICIAN’S DEFENSE The abdominal mass grossly distorted the patient’s anatomy so that the ureter was in front of the mass, which was an unusual presentation. Also, the injury is a known risk of this procedure.

VERDICT Michigan defense verdict.

Did retained cervical cup cause all her pain?

A 40-YEAR-OLD WOMAN was discharged the day after her ObGyn performed laparoscopic supracervical hysterectomy. Two months later, a KOH cervical cup was found in her vagina when she presented at the emergency room for hip pain. It was removed the next day.

PATIENT’S CLAIM The ObGyn failed to remove the cervical cup before her discharge after the original procedure. It compressed her S1 and S2 nerves as well as the pudendal nerve, causing constant pelvic pain. Its presence also changed her gait, resulting in pain and sciatica. Her primary care physician examined her six times following the surgery, but never performed a pelvic exam. It was negligent to leave the device inside her and to fail to find it in the weeks before it was removed.

PHYSICIAN’S DEFENSE The ObGyn admitted negligence for not removing the device at the end of the original procedure. He denied negligence in her follow-up care. Also, her pain was unrelated to the device.

VERDICT $63,500 California verdict against the ObGyn was reduced to no recovery due to a set-off by a confidential settlement with the hospital. The patient had sued the ObGyn, the hospital and its parent company, the device manufacturer, the primary care physician, and the assisting surgeon. The hospital settled before trial, and except for the ObGyn, cases against the other defendants were dismissed.

Sickle-cell mother ends up paralyzed

AFTER DELIVERY OF HER CHILD, a 22-year-old woman with sickle cell trait suffered a precipitous drop in blood pressure. When she was given phenylephrine, her blood pressure rose, and then dropped quickly to as low as 94/17. For nearly half an hour, nothing was done. When she was discharged from recovery, she was unable to move her legs. She remains paraplegic.

PATIENT’S CLAIM The paralysis was most likely caused by a drop in blood flow and proper perfusion in the area of the artery of Adam-kiewicz, resulting in a sludging and subsequent paralysis.

PHYSICIAN’S DEFENSE Not reported.

VERDICT Confidential District of Columbia settlement. During discovery, it was learned that a nurse, A, added a note at a later time saying that she had received approval to transfer the patient from another nurse, B, who had received approval from the anesthesiologist. Both nurse B and the anesthesiologist denied this claim, and the hospital filed a third-party claim against nurse A and her employer.

Fetal remains not kept for Muslim burial

A WOMAN EXPERIENCED PROBLEMS with her pregnancy at 17 to 18 weeks and went to the hospital. She was treated by a midwife, but suffered a miscarriage. The father viewed the remains and requested that they be returned to him so he and his wife could bury their child according to their Muslim beliefs. He returned to pick up the fetus, but the hospital no longer had the remains. The parents were unable to have a funeral.

PLAINTIFF’S CLAIM The hospital was negligent for failing to retain the remains as requested. As a result, the father suffered major depressive disorder and posttraumatic stress disorder.

HOSPITAL’S DEFENSE The plaintiff suffered no damage.

VERDICT $110,000 North Carolina verdict against the hospital.

Ureter was severed, reattached, obstructed

A WOMAN IN HER 60S underwent surgery to remove a large abdominal mass. The ObGyn resected a 7-cm portion of her ureter thinking it was a blood vessel. Realizing his mistake during the surgery, he contacted a urologist, who reattached the ureter. Later the patient was rehospitalized when she suffered a ureteral obstruction.

PATIENT’S CLAIM The ObGyn was negligent for failing to identify and protect the ureter, and to properly assess the area before resecting the mass. Also, ureteral obstructions were likely to reoccur.

PHYSICIAN’S DEFENSE The abdominal mass grossly distorted the patient’s anatomy so that the ureter was in front of the mass, which was an unusual presentation. Also, the injury is a known risk of this procedure.

VERDICT Michigan defense verdict.

Did retained cervical cup cause all her pain?

A 40-YEAR-OLD WOMAN was discharged the day after her ObGyn performed laparoscopic supracervical hysterectomy. Two months later, a KOH cervical cup was found in her vagina when she presented at the emergency room for hip pain. It was removed the next day.

PATIENT’S CLAIM The ObGyn failed to remove the cervical cup before her discharge after the original procedure. It compressed her S1 and S2 nerves as well as the pudendal nerve, causing constant pelvic pain. Its presence also changed her gait, resulting in pain and sciatica. Her primary care physician examined her six times following the surgery, but never performed a pelvic exam. It was negligent to leave the device inside her and to fail to find it in the weeks before it was removed.

PHYSICIAN’S DEFENSE The ObGyn admitted negligence for not removing the device at the end of the original procedure. He denied negligence in her follow-up care. Also, her pain was unrelated to the device.

VERDICT $63,500 California verdict against the ObGyn was reduced to no recovery due to a set-off by a confidential settlement with the hospital. The patient had sued the ObGyn, the hospital and its parent company, the device manufacturer, the primary care physician, and the assisting surgeon. The hospital settled before trial, and except for the ObGyn, cases against the other defendants were dismissed.

Sickle-cell mother ends up paralyzed

AFTER DELIVERY OF HER CHILD, a 22-year-old woman with sickle cell trait suffered a precipitous drop in blood pressure. When she was given phenylephrine, her blood pressure rose, and then dropped quickly to as low as 94/17. For nearly half an hour, nothing was done. When she was discharged from recovery, she was unable to move her legs. She remains paraplegic.

PATIENT’S CLAIM The paralysis was most likely caused by a drop in blood flow and proper perfusion in the area of the artery of Adam-kiewicz, resulting in a sludging and subsequent paralysis.

PHYSICIAN’S DEFENSE Not reported.

VERDICT Confidential District of Columbia settlement. During discovery, it was learned that a nurse, A, added a note at a later time saying that she had received approval to transfer the patient from another nurse, B, who had received approval from the anesthesiologist. Both nurse B and the anesthesiologist denied this claim, and the hospital filed a third-party claim against nurse A and her employer.

Fetal remains not kept for Muslim burial

A WOMAN EXPERIENCED PROBLEMS with her pregnancy at 17 to 18 weeks and went to the hospital. She was treated by a midwife, but suffered a miscarriage. The father viewed the remains and requested that they be returned to him so he and his wife could bury their child according to their Muslim beliefs. He returned to pick up the fetus, but the hospital no longer had the remains. The parents were unable to have a funeral.

PLAINTIFF’S CLAIM The hospital was negligent for failing to retain the remains as requested. As a result, the father suffered major depressive disorder and posttraumatic stress disorder.

HOSPITAL’S DEFENSE The plaintiff suffered no damage.

VERDICT $110,000 North Carolina verdict against the hospital.

Ureter was severed, reattached, obstructed

A WOMAN IN HER 60S underwent surgery to remove a large abdominal mass. The ObGyn resected a 7-cm portion of her ureter thinking it was a blood vessel. Realizing his mistake during the surgery, he contacted a urologist, who reattached the ureter. Later the patient was rehospitalized when she suffered a ureteral obstruction.

PATIENT’S CLAIM The ObGyn was negligent for failing to identify and protect the ureter, and to properly assess the area before resecting the mass. Also, ureteral obstructions were likely to reoccur.

PHYSICIAN’S DEFENSE The abdominal mass grossly distorted the patient’s anatomy so that the ureter was in front of the mass, which was an unusual presentation. Also, the injury is a known risk of this procedure.

VERDICT Michigan defense verdict.

Did retained cervical cup cause all her pain?

A 40-YEAR-OLD WOMAN was discharged the day after her ObGyn performed laparoscopic supracervical hysterectomy. Two months later, a KOH cervical cup was found in her vagina when she presented at the emergency room for hip pain. It was removed the next day.

PATIENT’S CLAIM The ObGyn failed to remove the cervical cup before her discharge after the original procedure. It compressed her S1 and S2 nerves as well as the pudendal nerve, causing constant pelvic pain. Its presence also changed her gait, resulting in pain and sciatica. Her primary care physician examined her six times following the surgery, but never performed a pelvic exam. It was negligent to leave the device inside her and to fail to find it in the weeks before it was removed.

PHYSICIAN’S DEFENSE The ObGyn admitted negligence for not removing the device at the end of the original procedure. He denied negligence in her follow-up care. Also, her pain was unrelated to the device.

VERDICT $63,500 California verdict against the ObGyn was reduced to no recovery due to a set-off by a confidential settlement with the hospital. The patient had sued the ObGyn, the hospital and its parent company, the device manufacturer, the primary care physician, and the assisting surgeon. The hospital settled before trial, and except for the ObGyn, cases against the other defendants were dismissed.

Sickle-cell mother ends up paralyzed

AFTER DELIVERY OF HER CHILD, a 22-year-old woman with sickle cell trait suffered a precipitous drop in blood pressure. When she was given phenylephrine, her blood pressure rose, and then dropped quickly to as low as 94/17. For nearly half an hour, nothing was done. When she was discharged from recovery, she was unable to move her legs. She remains paraplegic.

PATIENT’S CLAIM The paralysis was most likely caused by a drop in blood flow and proper perfusion in the area of the artery of Adam-kiewicz, resulting in a sludging and subsequent paralysis.

PHYSICIAN’S DEFENSE Not reported.

VERDICT Confidential District of Columbia settlement. During discovery, it was learned that a nurse, A, added a note at a later time saying that she had received approval to transfer the patient from another nurse, B, who had received approval from the anesthesiologist. Both nurse B and the anesthesiologist denied this claim, and the hospital filed a third-party claim against nurse A and her employer.

Fetal remains not kept for Muslim burial

A WOMAN EXPERIENCED PROBLEMS with her pregnancy at 17 to 18 weeks and went to the hospital. She was treated by a midwife, but suffered a miscarriage. The father viewed the remains and requested that they be returned to him so he and his wife could bury their child according to their Muslim beliefs. He returned to pick up the fetus, but the hospital no longer had the remains. The parents were unable to have a funeral.

PLAINTIFF’S CLAIM The hospital was negligent for failing to retain the remains as requested. As a result, the father suffered major depressive disorder and posttraumatic stress disorder.

HOSPITAL’S DEFENSE The plaintiff suffered no damage.

VERDICT $110,000 North Carolina verdict against the hospital.

Paps are “normal” despite bleeding and cervical cancer

A ROUTINE PAP SMEAR of a 27-year-old woman showed atypical squamous cells of undetermined significance. Over the next 3 years, the same gynecologist obtained annual Pap smears; pathologists and cytotechnologists interpreted these as being within normal limits. Then the patient reported postcoital bleeding to her gynecologist. Assuming the bleeding to be due to low estrogen associated with her oral contraceptive (OC), he switched her to another OC. Over the next 7 months, the patient reported on six occasions that she was still experiencing significant postcoital bleeding, tenderness during intercourse, and abdominal cramping. A Pap smear on one of those visits indicated no evidence of malignancy. Nine months after the change in OC, cervical cancer was diagnosed. Ten months later, the patient began radiation and chemotherapy because she was found to have metastatic cervical cancer of the rectum, pelvis, and colon. She died 9 months later at age 32.

PLAINTIFF’S CLAIM The first Pap smear actually showed evidence of a low-grade squamous intraepithelial lesion, so further testing was needed to rule out cervical cancer. When the patient reported postcoital bleeding, colposcopy and cervical biopsy should have been performed to determine whether she indeed had cervical cancer.

PHYSICIAN’S DEFENSE Not reported.

VERDICT $1.3 million Massachusetts settlement.

Ectopic pregnancy with IUD leads to fallopian tube removal

A FEW WEEKS AFTER IUD PLACEMENT, a 26-year-old woman reported to a hospital complaining of abdominal pain and bleeding. An ObGyn diagnosed an ectopic pregnancy, recommended removal of both fallopian tubes, and then proceeded to remove them.

PATIENT’S CLAIM It was negligent to perform nonemergent surgery when she was unable to consent to it.

PHYSICIAN’S DEFENSE The procedure was proper, as the patient was highly likely to have another ectopic pregnancy. Also, the patient could undergo in vitro fertilization if she wanted to become pregnant.

VERDICT Tennessee defense verdict.

Could retractors have caused right-leg femoral nerve neuropathy?

A 66-YEAR-OLD WOMAN with endometrial cancer underwent hysterectomy and surgical staging. Following the procedure, she suffered complete neuropathy of the femoral nerve in her right leg.

PATIENT’S CLAIM Retractors were used improperly during surgery, causing the injury.

PHYSICIAN’S DEFENSE The neuropathy was not a result of the type of retraction, but was probably due to the patient’s modified lithotomy position during surgery. Such an injury is a known risk of the procedure.

VERDICT $750,000 New York verdict. As the verdict was for all past pain and suffering, the court increased the judgment to $900,000 after the trial to include future pain and suffering.

Was retained clip the reason for kidney failure 12 years later?

BECAUSE OF A TUMOR on her left ovary, a woman’s left ovary and fallopian tube were removed. During surgery, Dr. A found and lysed adhesions around her right ovary. Seventeen months later, the patient underwent laparoscopy and lysis of adhesions as well as biopsy of the right ovary. Dr. B, who performed the procedure, did not note any clip on the left ureter. Three months after that, the patient underwent exploratory laparotomy with lysis of adhesions and right ovarian cystectomy and partial omentectomy—performed by Dr. C. Upon visual inspection, the left kidney appeared to be larger than the right kidney. When the patient complained of left-sided abdominal pain 10 years later, she underwent a CT urogram, which showed a chronically obstructed left kidney—probably related to a surgical clip obstructing the distal third of the left ureter. She was diagnosed with hydronephrosis of the left kidney, which was essentially nonfunctioning. The urologist believed the clip had been left there during the first surgery 12 years earlier.

PATIENT’S CLAIM Dr. A was negligent for placing the clip on the ureter, causing kidney damage.

PHYSICIAN’S DEFENSE Because of the statute of limitation and state of repose, Dr. A moved for dismissal and summary judgment, but the motions were denied. He also claimed that clipping the ureter during the first surgery would have caused immediate excruciating pain. However, he admitted that partial obstruction could occur without pain and in fact lead to total obstruction and death of the kidney years later.

VERDICT $450,000 Massachusetts arbitration award.

Nurses reassure new mother, who then dies from PE

A 25-YEAR-OLD WOMAN GAVE BIRTH to a healthy boy. She did not feel well during the week after hospital discharge. When she called her ObGyn’s office to discuss her complaints, the nurses reassured her. Ten days after delivery, she was taken to the emergency room, where she died from a pulmonary embolism.

PLAINTIFF’S CLAIM The physician and nurses failed to respond properly to the patient’s complaints, which were consistent with a pulmonary embolism.

PHYSICIAN’S DEFENSE The patient was monitored properly. An embolism is a sudden event.

VERDICT $867,273 Tennessee verdict. The physician group was found 70% at fault and the hospital 30% at fault.

Despite US results, birth delayed to 41 weeks

ULTRASONOGRAPHY SHOWED a shortened cervix, a subchorionic hematoma, and a choroid plexus cyst in the fetal brain during a patient’s prenatal care. The ObGyns induced labor at 41 weeks’ gestation and then performed emergent cesarean delivery. The child suffered birth asphyxia, thrombocytopenia, hypocalcemia, and cerebral palsy.

PATIENT’S CLAIM The ObGyns should have induced labor and/or performed cesarean delivery before 39 weeks’ gestation, but they failed to recognize the significance of the mother’s condition.

PHYSICIANS’ DEFENSE Not reported.

VERDICT $1.1 million Michigan settlement.

Sponge emerges 7 months after cesarean delivery

A LAPAROTOMY SPONGE was unknowingly left in the abdomen of a 29-year-old woman who underwent cesarean delivery. Seven months later, she was examined for a stitch abscess. Thinking he was removing a retained stitch, the surgeon pulled out a 12-inch sponge. She was awake at the time and experienced severe pain. The next day, she underwent laparotomy and drains were placed. She remained hospitalized for several days and drainage continued for another 6 days. The patient suffered no permanent injury; incisions for both operations were made at the same site, and she later gave birth without complication.

PATIENT’S CLAIM Leaving a sponge inside her was negligent.

PHYSICIAN’S DEFENSE The nurses who assisted in the surgery were responsible for the retained sponge.

VERDICT $110,410 Illinois verdict against the surgeon. Confidential settlement with the hospital prior to trial.

Would an earlier birth have saved this stillborn child?

WHEN 32 WEEKS’ PREGNANT, a 16-year-old patient repeatedly told her ObGyn she was experiencing bleeding. Later, she reported decreased fetal movement, but a sonogram indicated nothing abnormal. Twenty-three days later, her infant was delivered stillborn.

PATIENT’S CLAIM Placental abruption, which occurred 24 to 96 hours before delivery, caused the stillbirth. Because of her risk factors—bleeding, age, smoking, decreased fetal movement—labor should have been induced or a cesarean delivery performed earlier.

PHYSICIAN’S DEFENSE Ultrasonography did not indicate placental abruption, so delivery at that time was not warranted. An umbilical cord accident—which was unforeseeable and unpreventable—caused the stillbirth.

VERDICT Kentucky defense verdict.

Mother claims she wasn’t told test results for Down syndrome

A TRIPLE SCREEN BLOOD TEST ordered for a patient under prenatal care indicated that she had a 1:37 chance of giving birth to a child with Down syndrome. Six months later, her infant was born with Down syndrome.

PATIENT’S CLAIM The obstetrician failed to inform her that the triple screen test indicated a risk of having a child with Down syndrome. If she had known, she would have undergone an abortion.

PHYSICIAN’S DEFENSE The patient was informed three times of the test results. She was advised to undergo amniocentesis to obtain a definitive diagnosis, but she refused.

VERDICT Maryland defense verdict.

Paps are “normal” despite bleeding and cervical cancer

A ROUTINE PAP SMEAR of a 27-year-old woman showed atypical squamous cells of undetermined significance. Over the next 3 years, the same gynecologist obtained annual Pap smears; pathologists and cytotechnologists interpreted these as being within normal limits. Then the patient reported postcoital bleeding to her gynecologist. Assuming the bleeding to be due to low estrogen associated with her oral contraceptive (OC), he switched her to another OC. Over the next 7 months, the patient reported on six occasions that she was still experiencing significant postcoital bleeding, tenderness during intercourse, and abdominal cramping. A Pap smear on one of those visits indicated no evidence of malignancy. Nine months after the change in OC, cervical cancer was diagnosed. Ten months later, the patient began radiation and chemotherapy because she was found to have metastatic cervical cancer of the rectum, pelvis, and colon. She died 9 months later at age 32.

PLAINTIFF’S CLAIM The first Pap smear actually showed evidence of a low-grade squamous intraepithelial lesion, so further testing was needed to rule out cervical cancer. When the patient reported postcoital bleeding, colposcopy and cervical biopsy should have been performed to determine whether she indeed had cervical cancer.

PHYSICIAN’S DEFENSE Not reported.

VERDICT $1.3 million Massachusetts settlement.

Ectopic pregnancy with IUD leads to fallopian tube removal

A FEW WEEKS AFTER IUD PLACEMENT, a 26-year-old woman reported to a hospital complaining of abdominal pain and bleeding. An ObGyn diagnosed an ectopic pregnancy, recommended removal of both fallopian tubes, and then proceeded to remove them.

PATIENT’S CLAIM It was negligent to perform nonemergent surgery when she was unable to consent to it.

PHYSICIAN’S DEFENSE The procedure was proper, as the patient was highly likely to have another ectopic pregnancy. Also, the patient could undergo in vitro fertilization if she wanted to become pregnant.

VERDICT Tennessee defense verdict.

Could retractors have caused right-leg femoral nerve neuropathy?

A 66-YEAR-OLD WOMAN with endometrial cancer underwent hysterectomy and surgical staging. Following the procedure, she suffered complete neuropathy of the femoral nerve in her right leg.

PATIENT’S CLAIM Retractors were used improperly during surgery, causing the injury.

PHYSICIAN’S DEFENSE The neuropathy was not a result of the type of retraction, but was probably due to the patient’s modified lithotomy position during surgery. Such an injury is a known risk of the procedure.

VERDICT $750,000 New York verdict. As the verdict was for all past pain and suffering, the court increased the judgment to $900,000 after the trial to include future pain and suffering.

Was retained clip the reason for kidney failure 12 years later?

BECAUSE OF A TUMOR on her left ovary, a woman’s left ovary and fallopian tube were removed. During surgery, Dr. A found and lysed adhesions around her right ovary. Seventeen months later, the patient underwent laparoscopy and lysis of adhesions as well as biopsy of the right ovary. Dr. B, who performed the procedure, did not note any clip on the left ureter. Three months after that, the patient underwent exploratory laparotomy with lysis of adhesions and right ovarian cystectomy and partial omentectomy—performed by Dr. C. Upon visual inspection, the left kidney appeared to be larger than the right kidney. When the patient complained of left-sided abdominal pain 10 years later, she underwent a CT urogram, which showed a chronically obstructed left kidney—probably related to a surgical clip obstructing the distal third of the left ureter. She was diagnosed with hydronephrosis of the left kidney, which was essentially nonfunctioning. The urologist believed the clip had been left there during the first surgery 12 years earlier.

PATIENT’S CLAIM Dr. A was negligent for placing the clip on the ureter, causing kidney damage.

PHYSICIAN’S DEFENSE Because of the statute of limitation and state of repose, Dr. A moved for dismissal and summary judgment, but the motions were denied. He also claimed that clipping the ureter during the first surgery would have caused immediate excruciating pain. However, he admitted that partial obstruction could occur without pain and in fact lead to total obstruction and death of the kidney years later.

VERDICT $450,000 Massachusetts arbitration award.

Nurses reassure new mother, who then dies from PE

A 25-YEAR-OLD WOMAN GAVE BIRTH to a healthy boy. She did not feel well during the week after hospital discharge. When she called her ObGyn’s office to discuss her complaints, the nurses reassured her. Ten days after delivery, she was taken to the emergency room, where she died from a pulmonary embolism.

PLAINTIFF’S CLAIM The physician and nurses failed to respond properly to the patient’s complaints, which were consistent with a pulmonary embolism.

PHYSICIAN’S DEFENSE The patient was monitored properly. An embolism is a sudden event.

VERDICT $867,273 Tennessee verdict. The physician group was found 70% at fault and the hospital 30% at fault.

Despite US results, birth delayed to 41 weeks

ULTRASONOGRAPHY SHOWED a shortened cervix, a subchorionic hematoma, and a choroid plexus cyst in the fetal brain during a patient’s prenatal care. The ObGyns induced labor at 41 weeks’ gestation and then performed emergent cesarean delivery. The child suffered birth asphyxia, thrombocytopenia, hypocalcemia, and cerebral palsy.

PATIENT’S CLAIM The ObGyns should have induced labor and/or performed cesarean delivery before 39 weeks’ gestation, but they failed to recognize the significance of the mother’s condition.

PHYSICIANS’ DEFENSE Not reported.

VERDICT $1.1 million Michigan settlement.

Sponge emerges 7 months after cesarean delivery

A LAPAROTOMY SPONGE was unknowingly left in the abdomen of a 29-year-old woman who underwent cesarean delivery. Seven months later, she was examined for a stitch abscess. Thinking he was removing a retained stitch, the surgeon pulled out a 12-inch sponge. She was awake at the time and experienced severe pain. The next day, she underwent laparotomy and drains were placed. She remained hospitalized for several days and drainage continued for another 6 days. The patient suffered no permanent injury; incisions for both operations were made at the same site, and she later gave birth without complication.

PATIENT’S CLAIM Leaving a sponge inside her was negligent.

PHYSICIAN’S DEFENSE The nurses who assisted in the surgery were responsible for the retained sponge.

VERDICT $110,410 Illinois verdict against the surgeon. Confidential settlement with the hospital prior to trial.

Would an earlier birth have saved this stillborn child?

WHEN 32 WEEKS’ PREGNANT, a 16-year-old patient repeatedly told her ObGyn she was experiencing bleeding. Later, she reported decreased fetal movement, but a sonogram indicated nothing abnormal. Twenty-three days later, her infant was delivered stillborn.

PATIENT’S CLAIM Placental abruption, which occurred 24 to 96 hours before delivery, caused the stillbirth. Because of her risk factors—bleeding, age, smoking, decreased fetal movement—labor should have been induced or a cesarean delivery performed earlier.

PHYSICIAN’S DEFENSE Ultrasonography did not indicate placental abruption, so delivery at that time was not warranted. An umbilical cord accident—which was unforeseeable and unpreventable—caused the stillbirth.

VERDICT Kentucky defense verdict.

Mother claims she wasn’t told test results for Down syndrome

A TRIPLE SCREEN BLOOD TEST ordered for a patient under prenatal care indicated that she had a 1:37 chance of giving birth to a child with Down syndrome. Six months later, her infant was born with Down syndrome.

PATIENT’S CLAIM The obstetrician failed to inform her that the triple screen test indicated a risk of having a child with Down syndrome. If she had known, she would have undergone an abortion.

PHYSICIAN’S DEFENSE The patient was informed three times of the test results. She was advised to undergo amniocentesis to obtain a definitive diagnosis, but she refused.

VERDICT Maryland defense verdict.

Paps are “normal” despite bleeding and cervical cancer

A ROUTINE PAP SMEAR of a 27-year-old woman showed atypical squamous cells of undetermined significance. Over the next 3 years, the same gynecologist obtained annual Pap smears; pathologists and cytotechnologists interpreted these as being within normal limits. Then the patient reported postcoital bleeding to her gynecologist. Assuming the bleeding to be due to low estrogen associated with her oral contraceptive (OC), he switched her to another OC. Over the next 7 months, the patient reported on six occasions that she was still experiencing significant postcoital bleeding, tenderness during intercourse, and abdominal cramping. A Pap smear on one of those visits indicated no evidence of malignancy. Nine months after the change in OC, cervical cancer was diagnosed. Ten months later, the patient began radiation and chemotherapy because she was found to have metastatic cervical cancer of the rectum, pelvis, and colon. She died 9 months later at age 32.

PLAINTIFF’S CLAIM The first Pap smear actually showed evidence of a low-grade squamous intraepithelial lesion, so further testing was needed to rule out cervical cancer. When the patient reported postcoital bleeding, colposcopy and cervical biopsy should have been performed to determine whether she indeed had cervical cancer.

PHYSICIAN’S DEFENSE Not reported.

VERDICT $1.3 million Massachusetts settlement.

Ectopic pregnancy with IUD leads to fallopian tube removal

A FEW WEEKS AFTER IUD PLACEMENT, a 26-year-old woman reported to a hospital complaining of abdominal pain and bleeding. An ObGyn diagnosed an ectopic pregnancy, recommended removal of both fallopian tubes, and then proceeded to remove them.

PATIENT’S CLAIM It was negligent to perform nonemergent surgery when she was unable to consent to it.

PHYSICIAN’S DEFENSE The procedure was proper, as the patient was highly likely to have another ectopic pregnancy. Also, the patient could undergo in vitro fertilization if she wanted to become pregnant.

VERDICT Tennessee defense verdict.

Could retractors have caused right-leg femoral nerve neuropathy?

A 66-YEAR-OLD WOMAN with endometrial cancer underwent hysterectomy and surgical staging. Following the procedure, she suffered complete neuropathy of the femoral nerve in her right leg.

PATIENT’S CLAIM Retractors were used improperly during surgery, causing the injury.

PHYSICIAN’S DEFENSE The neuropathy was not a result of the type of retraction, but was probably due to the patient’s modified lithotomy position during surgery. Such an injury is a known risk of the procedure.

VERDICT $750,000 New York verdict. As the verdict was for all past pain and suffering, the court increased the judgment to $900,000 after the trial to include future pain and suffering.

Was retained clip the reason for kidney failure 12 years later?

BECAUSE OF A TUMOR on her left ovary, a woman’s left ovary and fallopian tube were removed. During surgery, Dr. A found and lysed adhesions around her right ovary. Seventeen months later, the patient underwent laparoscopy and lysis of adhesions as well as biopsy of the right ovary. Dr. B, who performed the procedure, did not note any clip on the left ureter. Three months after that, the patient underwent exploratory laparotomy with lysis of adhesions and right ovarian cystectomy and partial omentectomy—performed by Dr. C. Upon visual inspection, the left kidney appeared to be larger than the right kidney. When the patient complained of left-sided abdominal pain 10 years later, she underwent a CT urogram, which showed a chronically obstructed left kidney—probably related to a surgical clip obstructing the distal third of the left ureter. She was diagnosed with hydronephrosis of the left kidney, which was essentially nonfunctioning. The urologist believed the clip had been left there during the first surgery 12 years earlier.

PATIENT’S CLAIM Dr. A was negligent for placing the clip on the ureter, causing kidney damage.

PHYSICIAN’S DEFENSE Because of the statute of limitation and state of repose, Dr. A moved for dismissal and summary judgment, but the motions were denied. He also claimed that clipping the ureter during the first surgery would have caused immediate excruciating pain. However, he admitted that partial obstruction could occur without pain and in fact lead to total obstruction and death of the kidney years later.

VERDICT $450,000 Massachusetts arbitration award.

Nurses reassure new mother, who then dies from PE

A 25-YEAR-OLD WOMAN GAVE BIRTH to a healthy boy. She did not feel well during the week after hospital discharge. When she called her ObGyn’s office to discuss her complaints, the nurses reassured her. Ten days after delivery, she was taken to the emergency room, where she died from a pulmonary embolism.

PLAINTIFF’S CLAIM The physician and nurses failed to respond properly to the patient’s complaints, which were consistent with a pulmonary embolism.

PHYSICIAN’S DEFENSE The patient was monitored properly. An embolism is a sudden event.

VERDICT $867,273 Tennessee verdict. The physician group was found 70% at fault and the hospital 30% at fault.

Despite US results, birth delayed to 41 weeks

ULTRASONOGRAPHY SHOWED a shortened cervix, a subchorionic hematoma, and a choroid plexus cyst in the fetal brain during a patient’s prenatal care. The ObGyns induced labor at 41 weeks’ gestation and then performed emergent cesarean delivery. The child suffered birth asphyxia, thrombocytopenia, hypocalcemia, and cerebral palsy.

PATIENT’S CLAIM The ObGyns should have induced labor and/or performed cesarean delivery before 39 weeks’ gestation, but they failed to recognize the significance of the mother’s condition.

PHYSICIANS’ DEFENSE Not reported.

VERDICT $1.1 million Michigan settlement.

Sponge emerges 7 months after cesarean delivery

A LAPAROTOMY SPONGE was unknowingly left in the abdomen of a 29-year-old woman who underwent cesarean delivery. Seven months later, she was examined for a stitch abscess. Thinking he was removing a retained stitch, the surgeon pulled out a 12-inch sponge. She was awake at the time and experienced severe pain. The next day, she underwent laparotomy and drains were placed. She remained hospitalized for several days and drainage continued for another 6 days. The patient suffered no permanent injury; incisions for both operations were made at the same site, and she later gave birth without complication.

PATIENT’S CLAIM Leaving a sponge inside her was negligent.

PHYSICIAN’S DEFENSE The nurses who assisted in the surgery were responsible for the retained sponge.

VERDICT $110,410 Illinois verdict against the surgeon. Confidential settlement with the hospital prior to trial.

Would an earlier birth have saved this stillborn child?

WHEN 32 WEEKS’ PREGNANT, a 16-year-old patient repeatedly told her ObGyn she was experiencing bleeding. Later, she reported decreased fetal movement, but a sonogram indicated nothing abnormal. Twenty-three days later, her infant was delivered stillborn.

PATIENT’S CLAIM Placental abruption, which occurred 24 to 96 hours before delivery, caused the stillbirth. Because of her risk factors—bleeding, age, smoking, decreased fetal movement—labor should have been induced or a cesarean delivery performed earlier.

PHYSICIAN’S DEFENSE Ultrasonography did not indicate placental abruption, so delivery at that time was not warranted. An umbilical cord accident—which was unforeseeable and unpreventable—caused the stillbirth.

VERDICT Kentucky defense verdict.

Mother claims she wasn’t told test results for Down syndrome

A TRIPLE SCREEN BLOOD TEST ordered for a patient under prenatal care indicated that she had a 1:37 chance of giving birth to a child with Down syndrome. Six months later, her infant was born with Down syndrome.

PATIENT’S CLAIM The obstetrician failed to inform her that the triple screen test indicated a risk of having a child with Down syndrome. If she had known, she would have undergone an abortion.

PHYSICIAN’S DEFENSE The patient was informed three times of the test results. She was advised to undergo amniocentesis to obtain a definitive diagnosis, but she refused.

VERDICT Maryland defense verdict.

Sterilized woman skips f/u HSG test, becomes pregnant

A 31-YEAR-OLD MOTHER OF THREE underwent a hysteroscopic tubal sterilization procedure because she wanted to avoid pregnancy. She neglected to return 3 months later for a hysterosalpingogram (HSG) to determine whether the procedure was effective. A few months after that, she discovered she was pregnant.

PATIENT’S CLAIM The physician was negligent for failing to inform her that postoperative testing was necessary, and importantly, to confirm her inability to become pregnant. He also failed to advise her to use alternative contraceptive methods.

PHYSICIAN’S DEFENSE The patient was told several times that the HSG test was needed and important, and that she should use alternative contraception. Also, five appointments were scheduled for her to have the HSG test, but each time she either canceled or failed to come for the test.

VERDICT Connecticut defense verdict.

Preeclampsia leads to infant’s death and 24/7 care for mother

A WOMAN AT 30 WEEKS’ GESTATION complained of headaches to her ObGyn during a routine examination. Her blood pressure, although within normal limits, was above her baseline level, and a dipstick urine demonstrated proteinuria. The next morning, she had a seizure and was taken to the hospital. Preeclampsia was diagnosed. An emergent cesarean delivery was performed. The infant, who suffered neurologic impairments, died at 18 months. The mother was hospitalized for 7 months due to hypoxia-induced neurologic injuries, sepsis, lung problems, a ministroke, and a second hypoxic episode. Wheelchair-bound, she is speech-impaired and requires 24-hour care.

PATIENT’S CLAIM The ObGyn’s failure to diagnose preeclampsia was negligent.

PHYSICIAN’S DEFENSE The patient showed no signs of preeclampsia. Despite protein in her urine and elevated blood pressure, the levels were not in a range indicating preeclampsia.

VERDICT South Carolina defense verdict.

Did emboli in utero from deceased twin cause other twin’s postnatal problems?

A WOMAN PREGNANT WITH TWINS was admitted to the hospital because of premature contractions. Tests performed 3 weeks later indicated the intrauterine demise of one twin. The other twin showed signs of distress 8 days later and was delivered by cesarean later that day. The infant experienced hypoxic-ischemic brain damage, which caused severe mental retardation, cerebral palsy, and spastic quadriparesis.

PATIENT’S CLAIM Prior to delivery, emboli of thromboplastin material from the deceased fetus traveled to the surviving fetus, contributing to that fetus’s injuries. The delivery should have been performed sooner.

PHYSICIAN’S DEFENSE The plaintiff’s proposed theory for the injuries was not supported scientifically.

VERDICT All defendants except the hospital settled for a total of $1.5 million prior to trial. A $4 million Florida verdict against the hospital for injuries to the surviving twin was reduced to $2.95 million.

Was excessive force applied in case of shoulder dystocia?

THE OBGYN WHO HAD PROVIDED ALL PRENATAL CARE encountered shoulder dystocia during the infant’s delivery. The problem was resolved with the McRoberts maneuver with suprapubic pressure, the Wood’s screw maneuver, and attempted delivery of the posterior arm. Born with a severe left brachial plexus injury, the child underwent surgery but still has limited use of his left arm and hand.

PATIENT’S CLAIM Among relatives present at the delivery were two nurses. They testified at the trial that the physician used excessive downward lateral traction and also allowed a nurse to apply fundal pressure.

PHYSICIAN’S DEFENSE Shoulder dystocia was unexpected, excessive traction was not used, and once dystocia was evident, fundal pressure was not used.

VERDICT $80,000 Illinois settlement with the hospital prior to trial. Although the jury delivered a defense verdict for the physician, a $1,000,000/$200,000 high/low agreement was in place.

Sterilized woman skips f/u HSG test, becomes pregnant

A 31-YEAR-OLD MOTHER OF THREE underwent a hysteroscopic tubal sterilization procedure because she wanted to avoid pregnancy. She neglected to return 3 months later for a hysterosalpingogram (HSG) to determine whether the procedure was effective. A few months after that, she discovered she was pregnant.

PATIENT’S CLAIM The physician was negligent for failing to inform her that postoperative testing was necessary, and importantly, to confirm her inability to become pregnant. He also failed to advise her to use alternative contraceptive methods.

PHYSICIAN’S DEFENSE The patient was told several times that the HSG test was needed and important, and that she should use alternative contraception. Also, five appointments were scheduled for her to have the HSG test, but each time she either canceled or failed to come for the test.

VERDICT Connecticut defense verdict.

Preeclampsia leads to infant’s death and 24/7 care for mother

A WOMAN AT 30 WEEKS’ GESTATION complained of headaches to her ObGyn during a routine examination. Her blood pressure, although within normal limits, was above her baseline level, and a dipstick urine demonstrated proteinuria. The next morning, she had a seizure and was taken to the hospital. Preeclampsia was diagnosed. An emergent cesarean delivery was performed. The infant, who suffered neurologic impairments, died at 18 months. The mother was hospitalized for 7 months due to hypoxia-induced neurologic injuries, sepsis, lung problems, a ministroke, and a second hypoxic episode. Wheelchair-bound, she is speech-impaired and requires 24-hour care.

PATIENT’S CLAIM The ObGyn’s failure to diagnose preeclampsia was negligent.

PHYSICIAN’S DEFENSE The patient showed no signs of preeclampsia. Despite protein in her urine and elevated blood pressure, the levels were not in a range indicating preeclampsia.

VERDICT South Carolina defense verdict.

Did emboli in utero from deceased twin cause other twin’s postnatal problems?

A WOMAN PREGNANT WITH TWINS was admitted to the hospital because of premature contractions. Tests performed 3 weeks later indicated the intrauterine demise of one twin. The other twin showed signs of distress 8 days later and was delivered by cesarean later that day. The infant experienced hypoxic-ischemic brain damage, which caused severe mental retardation, cerebral palsy, and spastic quadriparesis.

PATIENT’S CLAIM Prior to delivery, emboli of thromboplastin material from the deceased fetus traveled to the surviving fetus, contributing to that fetus’s injuries. The delivery should have been performed sooner.

PHYSICIAN’S DEFENSE The plaintiff’s proposed theory for the injuries was not supported scientifically.

VERDICT All defendants except the hospital settled for a total of $1.5 million prior to trial. A $4 million Florida verdict against the hospital for injuries to the surviving twin was reduced to $2.95 million.

Was excessive force applied in case of shoulder dystocia?

THE OBGYN WHO HAD PROVIDED ALL PRENATAL CARE encountered shoulder dystocia during the infant’s delivery. The problem was resolved with the McRoberts maneuver with suprapubic pressure, the Wood’s screw maneuver, and attempted delivery of the posterior arm. Born with a severe left brachial plexus injury, the child underwent surgery but still has limited use of his left arm and hand.

PATIENT’S CLAIM Among relatives present at the delivery were two nurses. They testified at the trial that the physician used excessive downward lateral traction and also allowed a nurse to apply fundal pressure.

PHYSICIAN’S DEFENSE Shoulder dystocia was unexpected, excessive traction was not used, and once dystocia was evident, fundal pressure was not used.

VERDICT $80,000 Illinois settlement with the hospital prior to trial. Although the jury delivered a defense verdict for the physician, a $1,000,000/$200,000 high/low agreement was in place.

Sterilized woman skips f/u HSG test, becomes pregnant

A 31-YEAR-OLD MOTHER OF THREE underwent a hysteroscopic tubal sterilization procedure because she wanted to avoid pregnancy. She neglected to return 3 months later for a hysterosalpingogram (HSG) to determine whether the procedure was effective. A few months after that, she discovered she was pregnant.

PATIENT’S CLAIM The physician was negligent for failing to inform her that postoperative testing was necessary, and importantly, to confirm her inability to become pregnant. He also failed to advise her to use alternative contraceptive methods.

PHYSICIAN’S DEFENSE The patient was told several times that the HSG test was needed and important, and that she should use alternative contraception. Also, five appointments were scheduled for her to have the HSG test, but each time she either canceled or failed to come for the test.

VERDICT Connecticut defense verdict.

Preeclampsia leads to infant’s death and 24/7 care for mother

A WOMAN AT 30 WEEKS’ GESTATION complained of headaches to her ObGyn during a routine examination. Her blood pressure, although within normal limits, was above her baseline level, and a dipstick urine demonstrated proteinuria. The next morning, she had a seizure and was taken to the hospital. Preeclampsia was diagnosed. An emergent cesarean delivery was performed. The infant, who suffered neurologic impairments, died at 18 months. The mother was hospitalized for 7 months due to hypoxia-induced neurologic injuries, sepsis, lung problems, a ministroke, and a second hypoxic episode. Wheelchair-bound, she is speech-impaired and requires 24-hour care.

PATIENT’S CLAIM The ObGyn’s failure to diagnose preeclampsia was negligent.

PHYSICIAN’S DEFENSE The patient showed no signs of preeclampsia. Despite protein in her urine and elevated blood pressure, the levels were not in a range indicating preeclampsia.

VERDICT South Carolina defense verdict.

Did emboli in utero from deceased twin cause other twin’s postnatal problems?

A WOMAN PREGNANT WITH TWINS was admitted to the hospital because of premature contractions. Tests performed 3 weeks later indicated the intrauterine demise of one twin. The other twin showed signs of distress 8 days later and was delivered by cesarean later that day. The infant experienced hypoxic-ischemic brain damage, which caused severe mental retardation, cerebral palsy, and spastic quadriparesis.

PATIENT’S CLAIM Prior to delivery, emboli of thromboplastin material from the deceased fetus traveled to the surviving fetus, contributing to that fetus’s injuries. The delivery should have been performed sooner.

PHYSICIAN’S DEFENSE The plaintiff’s proposed theory for the injuries was not supported scientifically.

VERDICT All defendants except the hospital settled for a total of $1.5 million prior to trial. A $4 million Florida verdict against the hospital for injuries to the surviving twin was reduced to $2.95 million.

Was excessive force applied in case of shoulder dystocia?

THE OBGYN WHO HAD PROVIDED ALL PRENATAL CARE encountered shoulder dystocia during the infant’s delivery. The problem was resolved with the McRoberts maneuver with suprapubic pressure, the Wood’s screw maneuver, and attempted delivery of the posterior arm. Born with a severe left brachial plexus injury, the child underwent surgery but still has limited use of his left arm and hand.

PATIENT’S CLAIM Among relatives present at the delivery were two nurses. They testified at the trial that the physician used excessive downward lateral traction and also allowed a nurse to apply fundal pressure.

PHYSICIAN’S DEFENSE Shoulder dystocia was unexpected, excessive traction was not used, and once dystocia was evident, fundal pressure was not used.

VERDICT $80,000 Illinois settlement with the hospital prior to trial. Although the jury delivered a defense verdict for the physician, a $1,000,000/$200,000 high/low agreement was in place.

Follow-up foul-up leads to metastatic disease

A PRECANCEROUS POLYP was found in the stomach of a 50-year-old man during diagnostic gastroscopy. The pathologist’s report noted that an adjacent or underlying malignant process could not be ruled out and recommended additional tissue sampling. Upon reading the report, the gastroenterologist who had performed the gastroscopy wrote that another biopsy should be done within a few months.

The patient was seen subsequently by his primary care physician, whose office note mentioned the precancerous biopsy findings and indicated that another biopsy was necessary; the physician also wrote that malignancy in the stomach would have to be ruled out eventually. The doctor’s plan called for a repeat gastroscopy to reevaluate the dysplastic polyp. However, neither the primary care physician nor the gastroenterologist took additional steps to order, perform, or refer the patient for a follow-up endoscopy and biopsy of the lesion.

Three years later, the patient developed difficulty swallowing and lost weight rapidly. Diagnostic testing revealed a malignant tumor, at the same location as the polyp, and malignant-appearing lymph nodes.

The patient received a feeding jejunostomy tube and underwent concomitant radiation and chemotherapy. Surgery was planned, but the disease metastasized and was deemed inoperable. Despite additional treatment, the patient died at age 54.

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

DOCTORS’ DEFENSE The primary care physician argued that both he and the gastroenterologist were responsible for making sure the follow-up was done; the gastroenterologist claimed that the primary care physician was solely responsible for follow-up testing.

VERDICT $1.5 million Massachusetts settlement.

COMMENT Poor coordination of care and follow-up of results is a common source of malpractice actions. Keep a paper or electronic “tickler file” for important follow-up issues.

Unaddressed cardiovascular risks prove fatal

A 46-YEAR-OLD MAN went to the hospital, where he was seen by a family practitioner. The physician noted that the patient had a history of smoking, high cholesterol, and thyroid problems.

Early the following month, the patient died of cardiopulmonary arrest. Autopsy results showed arteriosclerotic disease, acute dissection of the coronary plaques, and left ventricular hypertrophy.

PLAINTIFF’S CLAIM The family practitioner failed to take a careful history and prescribe aspirin therapy and cholesterol-lowering medication. The patient should have been referred for a cardiac work-up.

DOCTOR’S DEFENSE The patient was advised of the importance of treatment to correct his condition.

VERDICT $575,000 Michigan settlement.

COMMENT I’m seeing a great increase in cases involving failure to address cardiovascular risk factors. Be sure to thoroughly document refusal of interventions or nonadherence.

Lack of surveillance delays lung cancer diagnosis

A 64-YEAR-OLD MAN was referred to a pulmonary specialist in January by his primary care physician after a computed tomography (CT) scan showed a spiculated density adjacent to the right main-stem bronchus and a prominent right hilar lymph node. The CT scan also revealed a noncalcified nodule in the right middle lobe.

Before examining the patient, the pulmonary specialist ordered a positron emission tomography (PET) scan, which he interpreted as showing no significant uptake and considered negative. He attributed the prominent lymph node to bronchitis and ordered surveillance at 3-month intervals.

A CT scan in May showed no change, but the radiologist noted that “the possibility of malignancy cannot be excluded.” When the patient saw the specialist in early June, the doctor recommended another CT scan in 3 months.

The patient did not return to the specialist until September of the following year. By that time, a CT scan taken a couple of months before (June) as part of preoperative clearance for knee surgery showed that the irregular mass had grown significantly since the CT scan in May of the previous year. A bronchoscopy done in September to evaluate the mass was negative. In November, however, a lymph node biopsy revealed that the patient had metastatic lung cancer. He died about a month later.

PLAINTIFF’S CLAIM Because the patient had a history of smoking and the CT scan revealed a density, the suspicion for cancer should have been high despite a negative PET scan. A specimen should have been obtained by thoracoscopy or thoracotomy to rule out cancer.

THE DEFENSE The pulmonary specialist followed the correct protocol; failure to diagnose cancer at the September visit didn’t affect the outcome because the cancer was already metastatic and incurable. The patient didn’t quit smoking or follow up regularly with his primary care physician. Moreover, the cancer was at least stage IIA when the primary care physician referred the patient to the specialist.

VERDICT Pennsylvania defense verdict.

COMMENT Although a defense verdict was ultimately returned, wouldn’t a “tickler file” or a reminder to the patient (and documentation if the patient failed to follow up as recommended) have been easier?

Follow-up foul-up leads to metastatic disease

A PRECANCEROUS POLYP was found in the stomach of a 50-year-old man during diagnostic gastroscopy. The pathologist’s report noted that an adjacent or underlying malignant process could not be ruled out and recommended additional tissue sampling. Upon reading the report, the gastroenterologist who had performed the gastroscopy wrote that another biopsy should be done within a few months.

The patient was seen subsequently by his primary care physician, whose office note mentioned the precancerous biopsy findings and indicated that another biopsy was necessary; the physician also wrote that malignancy in the stomach would have to be ruled out eventually. The doctor’s plan called for a repeat gastroscopy to reevaluate the dysplastic polyp. However, neither the primary care physician nor the gastroenterologist took additional steps to order, perform, or refer the patient for a follow-up endoscopy and biopsy of the lesion.

Three years later, the patient developed difficulty swallowing and lost weight rapidly. Diagnostic testing revealed a malignant tumor, at the same location as the polyp, and malignant-appearing lymph nodes.

The patient received a feeding jejunostomy tube and underwent concomitant radiation and chemotherapy. Surgery was planned, but the disease metastasized and was deemed inoperable. Despite additional treatment, the patient died at age 54.

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

DOCTORS’ DEFENSE The primary care physician argued that both he and the gastroenterologist were responsible for making sure the follow-up was done; the gastroenterologist claimed that the primary care physician was solely responsible for follow-up testing.

VERDICT $1.5 million Massachusetts settlement.

COMMENT Poor coordination of care and follow-up of results is a common source of malpractice actions. Keep a paper or electronic “tickler file” for important follow-up issues.

Unaddressed cardiovascular risks prove fatal

A 46-YEAR-OLD MAN went to the hospital, where he was seen by a family practitioner. The physician noted that the patient had a history of smoking, high cholesterol, and thyroid problems.

Early the following month, the patient died of cardiopulmonary arrest. Autopsy results showed arteriosclerotic disease, acute dissection of the coronary plaques, and left ventricular hypertrophy.

PLAINTIFF’S CLAIM The family practitioner failed to take a careful history and prescribe aspirin therapy and cholesterol-lowering medication. The patient should have been referred for a cardiac work-up.

DOCTOR’S DEFENSE The patient was advised of the importance of treatment to correct his condition.

VERDICT $575,000 Michigan settlement.

COMMENT I’m seeing a great increase in cases involving failure to address cardiovascular risk factors. Be sure to thoroughly document refusal of interventions or nonadherence.

Lack of surveillance delays lung cancer diagnosis

A 64-YEAR-OLD MAN was referred to a pulmonary specialist in January by his primary care physician after a computed tomography (CT) scan showed a spiculated density adjacent to the right main-stem bronchus and a prominent right hilar lymph node. The CT scan also revealed a noncalcified nodule in the right middle lobe.

Before examining the patient, the pulmonary specialist ordered a positron emission tomography (PET) scan, which he interpreted as showing no significant uptake and considered negative. He attributed the prominent lymph node to bronchitis and ordered surveillance at 3-month intervals.

A CT scan in May showed no change, but the radiologist noted that “the possibility of malignancy cannot be excluded.” When the patient saw the specialist in early June, the doctor recommended another CT scan in 3 months.

The patient did not return to the specialist until September of the following year. By that time, a CT scan taken a couple of months before (June) as part of preoperative clearance for knee surgery showed that the irregular mass had grown significantly since the CT scan in May of the previous year. A bronchoscopy done in September to evaluate the mass was negative. In November, however, a lymph node biopsy revealed that the patient had metastatic lung cancer. He died about a month later.

PLAINTIFF’S CLAIM Because the patient had a history of smoking and the CT scan revealed a density, the suspicion for cancer should have been high despite a negative PET scan. A specimen should have been obtained by thoracoscopy or thoracotomy to rule out cancer.

THE DEFENSE The pulmonary specialist followed the correct protocol; failure to diagnose cancer at the September visit didn’t affect the outcome because the cancer was already metastatic and incurable. The patient didn’t quit smoking or follow up regularly with his primary care physician. Moreover, the cancer was at least stage IIA when the primary care physician referred the patient to the specialist.

VERDICT Pennsylvania defense verdict.

COMMENT Although a defense verdict was ultimately returned, wouldn’t a “tickler file” or a reminder to the patient (and documentation if the patient failed to follow up as recommended) have been easier?

Follow-up foul-up leads to metastatic disease

A PRECANCEROUS POLYP was found in the stomach of a 50-year-old man during diagnostic gastroscopy. The pathologist’s report noted that an adjacent or underlying malignant process could not be ruled out and recommended additional tissue sampling. Upon reading the report, the gastroenterologist who had performed the gastroscopy wrote that another biopsy should be done within a few months.

The patient was seen subsequently by his primary care physician, whose office note mentioned the precancerous biopsy findings and indicated that another biopsy was necessary; the physician also wrote that malignancy in the stomach would have to be ruled out eventually. The doctor’s plan called for a repeat gastroscopy to reevaluate the dysplastic polyp. However, neither the primary care physician nor the gastroenterologist took additional steps to order, perform, or refer the patient for a follow-up endoscopy and biopsy of the lesion.

Three years later, the patient developed difficulty swallowing and lost weight rapidly. Diagnostic testing revealed a malignant tumor, at the same location as the polyp, and malignant-appearing lymph nodes.

The patient received a feeding jejunostomy tube and underwent concomitant radiation and chemotherapy. Surgery was planned, but the disease metastasized and was deemed inoperable. Despite additional treatment, the patient died at age 54.

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

DOCTORS’ DEFENSE The primary care physician argued that both he and the gastroenterologist were responsible for making sure the follow-up was done; the gastroenterologist claimed that the primary care physician was solely responsible for follow-up testing.

VERDICT $1.5 million Massachusetts settlement.

COMMENT Poor coordination of care and follow-up of results is a common source of malpractice actions. Keep a paper or electronic “tickler file” for important follow-up issues.

Unaddressed cardiovascular risks prove fatal

A 46-YEAR-OLD MAN went to the hospital, where he was seen by a family practitioner. The physician noted that the patient had a history of smoking, high cholesterol, and thyroid problems.

Early the following month, the patient died of cardiopulmonary arrest. Autopsy results showed arteriosclerotic disease, acute dissection of the coronary plaques, and left ventricular hypertrophy.

PLAINTIFF’S CLAIM The family practitioner failed to take a careful history and prescribe aspirin therapy and cholesterol-lowering medication. The patient should have been referred for a cardiac work-up.

DOCTOR’S DEFENSE The patient was advised of the importance of treatment to correct his condition.

VERDICT $575,000 Michigan settlement.

COMMENT I’m seeing a great increase in cases involving failure to address cardiovascular risk factors. Be sure to thoroughly document refusal of interventions or nonadherence.

Lack of surveillance delays lung cancer diagnosis

A 64-YEAR-OLD MAN was referred to a pulmonary specialist in January by his primary care physician after a computed tomography (CT) scan showed a spiculated density adjacent to the right main-stem bronchus and a prominent right hilar lymph node. The CT scan also revealed a noncalcified nodule in the right middle lobe.

Before examining the patient, the pulmonary specialist ordered a positron emission tomography (PET) scan, which he interpreted as showing no significant uptake and considered negative. He attributed the prominent lymph node to bronchitis and ordered surveillance at 3-month intervals.

A CT scan in May showed no change, but the radiologist noted that “the possibility of malignancy cannot be excluded.” When the patient saw the specialist in early June, the doctor recommended another CT scan in 3 months.

The patient did not return to the specialist until September of the following year. By that time, a CT scan taken a couple of months before (June) as part of preoperative clearance for knee surgery showed that the irregular mass had grown significantly since the CT scan in May of the previous year. A bronchoscopy done in September to evaluate the mass was negative. In November, however, a lymph node biopsy revealed that the patient had metastatic lung cancer. He died about a month later.

PLAINTIFF’S CLAIM Because the patient had a history of smoking and the CT scan revealed a density, the suspicion for cancer should have been high despite a negative PET scan. A specimen should have been obtained by thoracoscopy or thoracotomy to rule out cancer.

THE DEFENSE The pulmonary specialist followed the correct protocol; failure to diagnose cancer at the September visit didn’t affect the outcome because the cancer was already metastatic and incurable. The patient didn’t quit smoking or follow up regularly with his primary care physician. Moreover, the cancer was at least stage IIA when the primary care physician referred the patient to the specialist.

VERDICT Pennsylvania defense verdict.

COMMENT Although a defense verdict was ultimately returned, wouldn’t a “tickler file” or a reminder to the patient (and documentation if the patient failed to follow up as recommended) have been easier?