Medical Verdicts

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, a prominent right hilar lymph node, and 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. He attributed the prominent lymph node to bronchitis and ordered surveillance at 3-month intervals.

A CT scan ordered by the pulmonary specialist 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 didn’t 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, a lymph node biopsy revealed that the patient had metastatic lung cancer. He died about a month later.

PLAINTIFF’S CLAIM Because the patient was a smoker and the CT scan showed a density, the suspicion for cancer should have been high. A specimen should have been obtained to rule out cancer.

DOCTORS’ 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?

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, a prominent right hilar lymph node, and 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. He attributed the prominent lymph node to bronchitis and ordered surveillance at 3-month intervals.

A CT scan ordered by the pulmonary specialist 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 didn’t 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, a lymph node biopsy revealed that the patient had metastatic lung cancer. He died about a month later.

PLAINTIFF’S CLAIM Because the patient was a smoker and the CT scan showed a density, the suspicion for cancer should have been high. A specimen should have been obtained to rule out cancer.

DOCTORS’ 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?

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, a prominent right hilar lymph node, and 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. He attributed the prominent lymph node to bronchitis and ordered surveillance at 3-month intervals.

A CT scan ordered by the pulmonary specialist 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 didn’t 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, a lymph node biopsy revealed that the patient had metastatic lung cancer. He died about a month later.

PLAINTIFF’S CLAIM Because the patient was a smoker and the CT scan showed a density, the suspicion for cancer should have been high. A specimen should have been obtained to rule out cancer.

DOCTORS’ 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?

Bleeding mother is transferred, but her baby is stillborn

A WOMAN 8 MONTHS PREGNANT called 911 when she experienced vaginal bleeding due to placental abruption. She was taken to the emergency room, where the ER physician evaluated her and judged her condition to be stable. He ordered transfer to another hospital. She continued to bleed during the transfer, and her child was delivered stillborn after arrival at the receiving hospital.

PATIENT’S CLAIM The ER physician was negligent for failing to recognize the need for an emergency cesarean delivery. Also, the hospital violated EMTALA—the Emergency Medical Treatment and Active Labor Act—because she was not stable.

PHYSICIAN’S DEFENSE The patient was properly assessed and was stable.

VERDICT $1,674,000 Iowa verdict. Fault was assessed 70% to the hospital and 30% to the physician.

Hysterectomy to blame for loss of second ovary?

A 41-YEAR-OLD PATIENT had previously undergone laparoscopy and endometrial ablation to treat her abnormal uterine bleeding and pelvic pain. She visited her ObGyn when the symptoms returned. Testing, including ultrasonography, was negative, but she continued to suffer occasional bleeding and pain for 20 months. At that time, the ObGyn performed a hysterectomy and removed the right ovary. Five months later, the left ovary was removed also.

PATIENT’S CLAIM The physician was negligent for performing an unnecessary hysterectomy. Also, if she had not had the hysterectomy, she would not have lost the left ovary. She denied that she agreed to have the hysterectomy.

PHYSICIAN’S DEFENSE He offered the patient multiple diagnostic and treatment options when ultrasonography detected an endometrial abnormality. The patient chose hysterectomy.

VERDICT Kansas defense verdict.

To learn more about chronic pelvic pain , read Dr. Fred Howard’s article

Misplaced sutures in hysterectomy lead to death

DURING A HYSTERECTOMY performed on a 51-year-old woman, sutures were allegedly inserted into the rectum and bladder. Within days of surgery, pelvic abscesses developed. Upon diagnosis, the patient was transferred to another hospital. A second surgery was unsuccessful, and the patient died 3 weeks after the original procedure.

PLAINTIFF’S CLAIM The postoperative complications should have been diagnosed days earlier.

PHYSICIAN’S DEFENSE The surgeon claimed that the attending physician was responsible for the delay in diagnosis. He also claimed that the patient’s family did not allow follow-up surgery to determine or treat the complications.

VERDICT Utah defense verdict for the surgeon. Confidential settlement with the attending physician and the hospital prior to trial.

Did amniotomy cause cord prolapse and infant’s problems?

A WOMAN IN LABOR AT FULL TERM presented at the hospital for delivery. Labor progressed normally, and the physicians performed an amniotomy. Prolapse of the umbilical cord occurred, and a cesarean delivery was performed about an hour later. The child suffered asphyxia, leading to brain damage with cognitive delays and mental retardation.

PATIENT’S CLAIM The physicians were negligent for (1) performing the amniotomy before determining that the fetal head was engaged in the bony pelvis; (2) failing to recognize cord prolapse in a timely manner; and (3) failing to perform a timely cesarean delivery.

PHYSICIAN’S DEFENSE The amniotomy was indicated because the fetal heart tones showed unexplained prolonged decelerations. Also, the child’s condition was unrelated to labor and delivery, because the child had no motor impairments.

VERDICT $500,000 Michigan settlement.

Bleeding mother is transferred, but her baby is stillborn

A WOMAN 8 MONTHS PREGNANT called 911 when she experienced vaginal bleeding due to placental abruption. She was taken to the emergency room, where the ER physician evaluated her and judged her condition to be stable. He ordered transfer to another hospital. She continued to bleed during the transfer, and her child was delivered stillborn after arrival at the receiving hospital.

PATIENT’S CLAIM The ER physician was negligent for failing to recognize the need for an emergency cesarean delivery. Also, the hospital violated EMTALA—the Emergency Medical Treatment and Active Labor Act—because she was not stable.

PHYSICIAN’S DEFENSE The patient was properly assessed and was stable.

VERDICT $1,674,000 Iowa verdict. Fault was assessed 70% to the hospital and 30% to the physician.

Hysterectomy to blame for loss of second ovary?

A 41-YEAR-OLD PATIENT had previously undergone laparoscopy and endometrial ablation to treat her abnormal uterine bleeding and pelvic pain. She visited her ObGyn when the symptoms returned. Testing, including ultrasonography, was negative, but she continued to suffer occasional bleeding and pain for 20 months. At that time, the ObGyn performed a hysterectomy and removed the right ovary. Five months later, the left ovary was removed also.

PATIENT’S CLAIM The physician was negligent for performing an unnecessary hysterectomy. Also, if she had not had the hysterectomy, she would not have lost the left ovary. She denied that she agreed to have the hysterectomy.

PHYSICIAN’S DEFENSE He offered the patient multiple diagnostic and treatment options when ultrasonography detected an endometrial abnormality. The patient chose hysterectomy.

VERDICT Kansas defense verdict.

To learn more about chronic pelvic pain , read Dr. Fred Howard’s article

Misplaced sutures in hysterectomy lead to death

DURING A HYSTERECTOMY performed on a 51-year-old woman, sutures were allegedly inserted into the rectum and bladder. Within days of surgery, pelvic abscesses developed. Upon diagnosis, the patient was transferred to another hospital. A second surgery was unsuccessful, and the patient died 3 weeks after the original procedure.

PLAINTIFF’S CLAIM The postoperative complications should have been diagnosed days earlier.

PHYSICIAN’S DEFENSE The surgeon claimed that the attending physician was responsible for the delay in diagnosis. He also claimed that the patient’s family did not allow follow-up surgery to determine or treat the complications.

VERDICT Utah defense verdict for the surgeon. Confidential settlement with the attending physician and the hospital prior to trial.

Did amniotomy cause cord prolapse and infant’s problems?

A WOMAN IN LABOR AT FULL TERM presented at the hospital for delivery. Labor progressed normally, and the physicians performed an amniotomy. Prolapse of the umbilical cord occurred, and a cesarean delivery was performed about an hour later. The child suffered asphyxia, leading to brain damage with cognitive delays and mental retardation.

PATIENT’S CLAIM The physicians were negligent for (1) performing the amniotomy before determining that the fetal head was engaged in the bony pelvis; (2) failing to recognize cord prolapse in a timely manner; and (3) failing to perform a timely cesarean delivery.

PHYSICIAN’S DEFENSE The amniotomy was indicated because the fetal heart tones showed unexplained prolonged decelerations. Also, the child’s condition was unrelated to labor and delivery, because the child had no motor impairments.

VERDICT $500,000 Michigan settlement.

Bleeding mother is transferred, but her baby is stillborn

A WOMAN 8 MONTHS PREGNANT called 911 when she experienced vaginal bleeding due to placental abruption. She was taken to the emergency room, where the ER physician evaluated her and judged her condition to be stable. He ordered transfer to another hospital. She continued to bleed during the transfer, and her child was delivered stillborn after arrival at the receiving hospital.

PATIENT’S CLAIM The ER physician was negligent for failing to recognize the need for an emergency cesarean delivery. Also, the hospital violated EMTALA—the Emergency Medical Treatment and Active Labor Act—because she was not stable.

PHYSICIAN’S DEFENSE The patient was properly assessed and was stable.

VERDICT $1,674,000 Iowa verdict. Fault was assessed 70% to the hospital and 30% to the physician.

Hysterectomy to blame for loss of second ovary?

A 41-YEAR-OLD PATIENT had previously undergone laparoscopy and endometrial ablation to treat her abnormal uterine bleeding and pelvic pain. She visited her ObGyn when the symptoms returned. Testing, including ultrasonography, was negative, but she continued to suffer occasional bleeding and pain for 20 months. At that time, the ObGyn performed a hysterectomy and removed the right ovary. Five months later, the left ovary was removed also.

PATIENT’S CLAIM The physician was negligent for performing an unnecessary hysterectomy. Also, if she had not had the hysterectomy, she would not have lost the left ovary. She denied that she agreed to have the hysterectomy.

PHYSICIAN’S DEFENSE He offered the patient multiple diagnostic and treatment options when ultrasonography detected an endometrial abnormality. The patient chose hysterectomy.

VERDICT Kansas defense verdict.

To learn more about chronic pelvic pain , read Dr. Fred Howard’s article

Misplaced sutures in hysterectomy lead to death

DURING A HYSTERECTOMY performed on a 51-year-old woman, sutures were allegedly inserted into the rectum and bladder. Within days of surgery, pelvic abscesses developed. Upon diagnosis, the patient was transferred to another hospital. A second surgery was unsuccessful, and the patient died 3 weeks after the original procedure.

PLAINTIFF’S CLAIM The postoperative complications should have been diagnosed days earlier.

PHYSICIAN’S DEFENSE The surgeon claimed that the attending physician was responsible for the delay in diagnosis. He also claimed that the patient’s family did not allow follow-up surgery to determine or treat the complications.

VERDICT Utah defense verdict for the surgeon. Confidential settlement with the attending physician and the hospital prior to trial.

Did amniotomy cause cord prolapse and infant’s problems?

A WOMAN IN LABOR AT FULL TERM presented at the hospital for delivery. Labor progressed normally, and the physicians performed an amniotomy. Prolapse of the umbilical cord occurred, and a cesarean delivery was performed about an hour later. The child suffered asphyxia, leading to brain damage with cognitive delays and mental retardation.

PATIENT’S CLAIM The physicians were negligent for (1) performing the amniotomy before determining that the fetal head was engaged in the bony pelvis; (2) failing to recognize cord prolapse in a timely manner; and (3) failing to perform a timely cesarean delivery.

PHYSICIAN’S DEFENSE The amniotomy was indicated because the fetal heart tones showed unexplained prolonged decelerations. Also, the child’s condition was unrelated to labor and delivery, because the child had no motor impairments.

VERDICT $500,000 Michigan settlement.

Discontinued anticoagulant blamed for stroke

A MAN ON WARFARIN 3 YEARS AFTER A MASSIVE PULMONARY EMBOLISM visited a doctor, who reviewed the 37-year-old patient’s records and noted that test results showed he no longer had hypercoagulation. The doctor discontinued the warfarin.

About 5 months later, the patient suffered an embolic stroke that caused brain damage. He has impaired cognitive function and executive decision-making skills, as well as residual emotional and psychiatric problems.

PLAINTIFF’S CLAIM The patient had a hereditary disposition to clots and had suffered a previous embolism, necessitating lifelong use of warfarin.

DOCTOR’S DEFENSE Hypercoagulation is treated with 6 to 12 months of warfarin; the patient hadn’t showed a recurrence of hypercoagulation. The doctor denied conclusive evidence of a hereditary predisposition to developing clots.

VERDICT $3.1 million New York verdict.

COMMENT Whatever the underlying factors in this case, documenting a careful discussion of benefits and harms and consulting with experts can sometimes avoid a date in court.

Filing misstep leads to missed diagnosis

A 76-YEAR-OLD MAN HAD A CHEST RADIOGRAPH before undergoing cardiac catheterization. The radiograph showed a 4-cm mass in the left lung, which the radiologist reported as bronchogenic carcinoma. A staff member in the office of the physician who ordered the radiograph filed the radiologist’s report in the patient’s chart in the mistaken belief that the physician had seen it. No one saw the report again until 6 months later, after the patient had been diagnosed with lung cancer that had metastasized to the liver, pelvis, hip, femur, spine, and shoulder. The patient died 18 days after the diagnosis.

PLAINTIFF’S CLAIM If the cancer had been diagnosed earlier, the patient could have been made comfortable while undergoing treatment and would have survived longer.

DOCTORS’ DEFENSE The physician admitted liability, but claimed that the reduction in the patient’s life expectancy was minimal because his cancer was advanced at the time of the radiograph. The net increase in pain and suffering also was minimal because the patient would have undergone chemotherapy and radiation if the cancer had been diagnosed earlier.

VERDICT $1 million Illinois verdict.

COMMENT Coordination of care is key. Never assume that another clinician on the team has taken responsibility for a high-stakes finding such as a mass on a chest X-ray.

Too much amiodarone led to respiratory failure

AMIODARONE WAS PRESCRIBED TO REGULATE THE HEARTBEAT of a patient who underwent surgery at a Veteran’s Administration medical center to replace a defective heart defibrillator. The plan was to decrease the dosage gradually from 600 to 200 mg a day. A second doctor subsequently saw the patient and prescribed amiodarone but with no reduction in dosage. Each of the 7 authorized refills directed the patient to take 3 pills a day. The patient refilled the prescription 6 times at the VA hospital.

A year after the surgery, the patient was admitted to another hospital with respiratory problems, which were attributed to the amiodarone. The patient died a few weeks later after several relapses. The cause of death was listed as pulmonary fibrosis and respiratory failure caused by the medication.

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

DOCTOR’S DEFENSE No information about the doctor’s defense is available.

VERDICT $400,000 Utah settlement.

COMMENT Prescribing limited refills of medications that can cause substantial harm will help assure appropriate monitoring and evaluation for side effects.

Rising PSA, but no follow-up

CHEST PAIN PROMPTED A 48-YEAR-OLD MAN to visit his primary care physician. Blood work, including a prostate-specific antigen (PSA) test, revealed a slightly elevated PSA of 5.08. Five months later, the patient returned to the doctor complaining of a burning sensation on urination. Urinalysis and a digital rectal examination were normal. Laboratory test results included a PSA of 8.29. Nine months later the patient visited the physician for nonurologic complaints. Six months after that, when the patient had a complete physical because of a change in his insurance, his PSA was 17.11.

Subsequent testing revealed prostate cancer, and the patient underwent a non-nerve-sparing prostatectomy. A positron emission tomography scan done after the surgery showed an enlarged internal iliac lymph node, which indicated metastatic disease.

PLAINTIFF’S CLAIM The primary care physician was negligent in failing to follow up on the rising PSA values. The patient wasn’t informed of the PSA results.

THE DEFENSE The patient was informed of the abnormal test results (though it wasn’t charted). The patient would have had the same treatment, even with an earlier diagnosis, because he had a high Gleason score.

VERDICT $750,000 California settlement.

COMMENT Not charted = never happened. So many cases could be avoided if documentation was timely and complete!

Discontinued anticoagulant blamed for stroke

A MAN ON WARFARIN 3 YEARS AFTER A MASSIVE PULMONARY EMBOLISM visited a doctor, who reviewed the 37-year-old patient’s records and noted that test results showed he no longer had hypercoagulation. The doctor discontinued the warfarin.

About 5 months later, the patient suffered an embolic stroke that caused brain damage. He has impaired cognitive function and executive decision-making skills, as well as residual emotional and psychiatric problems.

PLAINTIFF’S CLAIM The patient had a hereditary disposition to clots and had suffered a previous embolism, necessitating lifelong use of warfarin.

DOCTOR’S DEFENSE Hypercoagulation is treated with 6 to 12 months of warfarin; the patient hadn’t showed a recurrence of hypercoagulation. The doctor denied conclusive evidence of a hereditary predisposition to developing clots.

VERDICT $3.1 million New York verdict.

COMMENT Whatever the underlying factors in this case, documenting a careful discussion of benefits and harms and consulting with experts can sometimes avoid a date in court.

Filing misstep leads to missed diagnosis

A 76-YEAR-OLD MAN HAD A CHEST RADIOGRAPH before undergoing cardiac catheterization. The radiograph showed a 4-cm mass in the left lung, which the radiologist reported as bronchogenic carcinoma. A staff member in the office of the physician who ordered the radiograph filed the radiologist’s report in the patient’s chart in the mistaken belief that the physician had seen it. No one saw the report again until 6 months later, after the patient had been diagnosed with lung cancer that had metastasized to the liver, pelvis, hip, femur, spine, and shoulder. The patient died 18 days after the diagnosis.

PLAINTIFF’S CLAIM If the cancer had been diagnosed earlier, the patient could have been made comfortable while undergoing treatment and would have survived longer.

DOCTORS’ DEFENSE The physician admitted liability, but claimed that the reduction in the patient’s life expectancy was minimal because his cancer was advanced at the time of the radiograph. The net increase in pain and suffering also was minimal because the patient would have undergone chemotherapy and radiation if the cancer had been diagnosed earlier.

VERDICT $1 million Illinois verdict.

COMMENT Coordination of care is key. Never assume that another clinician on the team has taken responsibility for a high-stakes finding such as a mass on a chest X-ray.

Too much amiodarone led to respiratory failure

AMIODARONE WAS PRESCRIBED TO REGULATE THE HEARTBEAT of a patient who underwent surgery at a Veteran’s Administration medical center to replace a defective heart defibrillator. The plan was to decrease the dosage gradually from 600 to 200 mg a day. A second doctor subsequently saw the patient and prescribed amiodarone but with no reduction in dosage. Each of the 7 authorized refills directed the patient to take 3 pills a day. The patient refilled the prescription 6 times at the VA hospital.

A year after the surgery, the patient was admitted to another hospital with respiratory problems, which were attributed to the amiodarone. The patient died a few weeks later after several relapses. The cause of death was listed as pulmonary fibrosis and respiratory failure caused by the medication.

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

DOCTOR’S DEFENSE No information about the doctor’s defense is available.

VERDICT $400,000 Utah settlement.

COMMENT Prescribing limited refills of medications that can cause substantial harm will help assure appropriate monitoring and evaluation for side effects.

Rising PSA, but no follow-up

CHEST PAIN PROMPTED A 48-YEAR-OLD MAN to visit his primary care physician. Blood work, including a prostate-specific antigen (PSA) test, revealed a slightly elevated PSA of 5.08. Five months later, the patient returned to the doctor complaining of a burning sensation on urination. Urinalysis and a digital rectal examination were normal. Laboratory test results included a PSA of 8.29. Nine months later the patient visited the physician for nonurologic complaints. Six months after that, when the patient had a complete physical because of a change in his insurance, his PSA was 17.11.

Subsequent testing revealed prostate cancer, and the patient underwent a non-nerve-sparing prostatectomy. A positron emission tomography scan done after the surgery showed an enlarged internal iliac lymph node, which indicated metastatic disease.

PLAINTIFF’S CLAIM The primary care physician was negligent in failing to follow up on the rising PSA values. The patient wasn’t informed of the PSA results.

THE DEFENSE The patient was informed of the abnormal test results (though it wasn’t charted). The patient would have had the same treatment, even with an earlier diagnosis, because he had a high Gleason score.

VERDICT $750,000 California settlement.

COMMENT Not charted = never happened. So many cases could be avoided if documentation was timely and complete!

Discontinued anticoagulant blamed for stroke

A MAN ON WARFARIN 3 YEARS AFTER A MASSIVE PULMONARY EMBOLISM visited a doctor, who reviewed the 37-year-old patient’s records and noted that test results showed he no longer had hypercoagulation. The doctor discontinued the warfarin.

About 5 months later, the patient suffered an embolic stroke that caused brain damage. He has impaired cognitive function and executive decision-making skills, as well as residual emotional and psychiatric problems.

PLAINTIFF’S CLAIM The patient had a hereditary disposition to clots and had suffered a previous embolism, necessitating lifelong use of warfarin.

DOCTOR’S DEFENSE Hypercoagulation is treated with 6 to 12 months of warfarin; the patient hadn’t showed a recurrence of hypercoagulation. The doctor denied conclusive evidence of a hereditary predisposition to developing clots.

VERDICT $3.1 million New York verdict.

COMMENT Whatever the underlying factors in this case, documenting a careful discussion of benefits and harms and consulting with experts can sometimes avoid a date in court.

Filing misstep leads to missed diagnosis

A 76-YEAR-OLD MAN HAD A CHEST RADIOGRAPH before undergoing cardiac catheterization. The radiograph showed a 4-cm mass in the left lung, which the radiologist reported as bronchogenic carcinoma. A staff member in the office of the physician who ordered the radiograph filed the radiologist’s report in the patient’s chart in the mistaken belief that the physician had seen it. No one saw the report again until 6 months later, after the patient had been diagnosed with lung cancer that had metastasized to the liver, pelvis, hip, femur, spine, and shoulder. The patient died 18 days after the diagnosis.

PLAINTIFF’S CLAIM If the cancer had been diagnosed earlier, the patient could have been made comfortable while undergoing treatment and would have survived longer.

DOCTORS’ DEFENSE The physician admitted liability, but claimed that the reduction in the patient’s life expectancy was minimal because his cancer was advanced at the time of the radiograph. The net increase in pain and suffering also was minimal because the patient would have undergone chemotherapy and radiation if the cancer had been diagnosed earlier.

VERDICT $1 million Illinois verdict.

COMMENT Coordination of care is key. Never assume that another clinician on the team has taken responsibility for a high-stakes finding such as a mass on a chest X-ray.

Too much amiodarone led to respiratory failure

AMIODARONE WAS PRESCRIBED TO REGULATE THE HEARTBEAT of a patient who underwent surgery at a Veteran’s Administration medical center to replace a defective heart defibrillator. The plan was to decrease the dosage gradually from 600 to 200 mg a day. A second doctor subsequently saw the patient and prescribed amiodarone but with no reduction in dosage. Each of the 7 authorized refills directed the patient to take 3 pills a day. The patient refilled the prescription 6 times at the VA hospital.

A year after the surgery, the patient was admitted to another hospital with respiratory problems, which were attributed to the amiodarone. The patient died a few weeks later after several relapses. The cause of death was listed as pulmonary fibrosis and respiratory failure caused by the medication.

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

DOCTOR’S DEFENSE No information about the doctor’s defense is available.

VERDICT $400,000 Utah settlement.

COMMENT Prescribing limited refills of medications that can cause substantial harm will help assure appropriate monitoring and evaluation for side effects.

Rising PSA, but no follow-up

CHEST PAIN PROMPTED A 48-YEAR-OLD MAN to visit his primary care physician. Blood work, including a prostate-specific antigen (PSA) test, revealed a slightly elevated PSA of 5.08. Five months later, the patient returned to the doctor complaining of a burning sensation on urination. Urinalysis and a digital rectal examination were normal. Laboratory test results included a PSA of 8.29. Nine months later the patient visited the physician for nonurologic complaints. Six months after that, when the patient had a complete physical because of a change in his insurance, his PSA was 17.11.

Subsequent testing revealed prostate cancer, and the patient underwent a non-nerve-sparing prostatectomy. A positron emission tomography scan done after the surgery showed an enlarged internal iliac lymph node, which indicated metastatic disease.

PLAINTIFF’S CLAIM The primary care physician was negligent in failing to follow up on the rising PSA values. The patient wasn’t informed of the PSA results.

THE DEFENSE The patient was informed of the abnormal test results (though it wasn’t charted). The patient would have had the same treatment, even with an earlier diagnosis, because he had a high Gleason score.

VERDICT $750,000 California settlement.

COMMENT Not charted = never happened. So many cases could be avoided if documentation was timely and complete!

Mother: 3 ObGyns, nursing staff are all liable for my stillbirth

EIGHT MONTHS INTO HER PREGNANCY, a morbidly obese 27-year-old woman experienced vaginal bleeding. She was examined by Dr. A, an ObGyn. After initial difficulty finding a fetal heart rate, he detected it after 1 hour and sent the woman home. At 42 weeks into her pregnancy, she returned for induction of labor. The nurses found the cervix to be thick and closed. The patient was discharged after Dr. B, another ObGyn, was consulted. She was seen by Dr. C, a third ObGyn, when she returned the next day. At first, the fetal heartbeat was detected, but within a few hours it could no longer be found. An emergency cesarean delivery was ordered, but the infant was stillborn.

PATIENT’S CLAIM Dr. A was negligent for not following the patient more closely after her visit at 8 months. Dr. B should have kept her overnight in the hospital for monitoring. Dr. C delayed ordering the cesarean delivery. And the nurses failed to assess, monitor, and communicate her condition.

PHYSICIANS’ DEFENSE Dr. B claimed (1) his assessment was reasonable based on the patient’s presentation, and (2) attempting a vaginal delivery was preferable because of the mother’s size, so there was no need to rush a cesarean delivery. Dr. C claimed he ordered the cesarean delivery in a timely manner. And the hospital claimed its nurses properly monitored the patient and informed Dr. C of her condition. Also, the fetus died of a thrombosis of the umbilical cord—which could not be detected or prevented—4 to 6 hours before the woman arrived at the hospital.

VERDICT Kentucky defense verdict.

Needle fragment left near uterus. Should the patient be told?

A WOMAN IN HER THIRTIES with uterine fibroids underwent a myomectomy performed by her gynecologist. The patient was not told that a small piece of the surgical needle broke off during the procedure and remained in the vicinity of her uterus. When she developed a bowel obstruction a few months later, she went to the emergency room, where the same gynecologist treated her and sent her home. Eventually, she was treated by another physician, who reviewed her medical records and informed her of the broken surgical needle mishap—which was not associated with the bowel obstruction.

PATIENT’S CLAIM The presence of the broken needle posed a threat to her health. She should have been told and given the option for its surgical removal.

PHYSICIAN’S DEFENSE The portion of the needle that had broken off was insignificant in size and was no medical threat. Breakage of a needle was a known risk of the procedure, and she was not informed because it had no medical significance.

VERDICT New Jersey defense verdict.

Aggressive D & C to blame for Asherman’s syndrome?

A 32-YEAR-OLD WOMAN who had recently given birth presented at the hospital with vaginal bleeding. Her ObGyn performed a dilation and curettage (D & C) procedure, with suction curettage followed by curettage with a sharp curette. This stopped the bleeding, and the patient was put on a 3-month birth-control regimen. When her menstruation did not resume after 3 months, the ObGyn diagnosed Asherman’s syndrome.

PATIENT’S CLAIM (1) The ObGyn should have checked her medical records more carefully, because the D & C was contraindicated. (2) She should have been treated with medical management rather than surgery. (3) The pathology report from the D & C indicated that the uterus and cervix were scraped overzealously during the sharp-curette phase.

PHYSICIAN’S DEFENSE The patient’s symptoms and a hematocrit of 28 showed she was hemodynamically unstable and—in the absence of surgery—at risk of rapid decompensation and death. Also, Asherman’s syndrome is a known risk of a D & C.

VERDICT A $700,000 New York verdict.

Woman learns too late her lump is not swollen milk gland

WHEN A 30-YEAR-OLD WOMAN went to Dr. K for prenatal care, she asked him to check a lump on her left breast. He diagnosed a milk gland that was swollen due to previous breastfeeding—but she had never breastfed. A sonogram was ordered and showed two masses that could be dermal or breast lesions; an excisional biopsy was ordered. Dr. K signed the report, but did not discuss it with the patient. For the remainder of her pregnancy, there was no follow-up examination of the lump. At her 6-month postdelivery checkup, the lump was not mentioned and a biopsy was not ordered. On her next visit, she was seen by Dr. L, whom she asked to examine the lump. No follow-up testing was performed when he concluded the lump was a swollen milk gland. When frequent stomach-related problems sent her to the emergency room, Dr. L prescribed pain medications and sent her home. Several months later, the patient underwent back surgery performed by Dr. M. The following day she learned that the breast lump was, in fact, cancer and that it had spread—and she now had two tumors on her spine and three on her brain. She had a mastectomy and underwent radiation treatment. Three years later, she died.

PLAINTIFF’S CLAIM Dr. K was negligent for failing to order the recommended biopsy

PHYSICIAN’S DEFENSE Dr. K admitted negligence, but argued causation. Death was caused by the cancer; nothing he did—or did not do—affected the outcome.

VERDICT $15,000 California verdict against Dr. K. Confidential settlement with Dr. L and his group.

Mother: 3 ObGyns, nursing staff are all liable for my stillbirth

EIGHT MONTHS INTO HER PREGNANCY, a morbidly obese 27-year-old woman experienced vaginal bleeding. She was examined by Dr. A, an ObGyn. After initial difficulty finding a fetal heart rate, he detected it after 1 hour and sent the woman home. At 42 weeks into her pregnancy, she returned for induction of labor. The nurses found the cervix to be thick and closed. The patient was discharged after Dr. B, another ObGyn, was consulted. She was seen by Dr. C, a third ObGyn, when she returned the next day. At first, the fetal heartbeat was detected, but within a few hours it could no longer be found. An emergency cesarean delivery was ordered, but the infant was stillborn.

PATIENT’S CLAIM Dr. A was negligent for not following the patient more closely after her visit at 8 months. Dr. B should have kept her overnight in the hospital for monitoring. Dr. C delayed ordering the cesarean delivery. And the nurses failed to assess, monitor, and communicate her condition.

PHYSICIANS’ DEFENSE Dr. B claimed (1) his assessment was reasonable based on the patient’s presentation, and (2) attempting a vaginal delivery was preferable because of the mother’s size, so there was no need to rush a cesarean delivery. Dr. C claimed he ordered the cesarean delivery in a timely manner. And the hospital claimed its nurses properly monitored the patient and informed Dr. C of her condition. Also, the fetus died of a thrombosis of the umbilical cord—which could not be detected or prevented—4 to 6 hours before the woman arrived at the hospital.

VERDICT Kentucky defense verdict.

Needle fragment left near uterus. Should the patient be told?

A WOMAN IN HER THIRTIES with uterine fibroids underwent a myomectomy performed by her gynecologist. The patient was not told that a small piece of the surgical needle broke off during the procedure and remained in the vicinity of her uterus. When she developed a bowel obstruction a few months later, she went to the emergency room, where the same gynecologist treated her and sent her home. Eventually, she was treated by another physician, who reviewed her medical records and informed her of the broken surgical needle mishap—which was not associated with the bowel obstruction.

PATIENT’S CLAIM The presence of the broken needle posed a threat to her health. She should have been told and given the option for its surgical removal.

PHYSICIAN’S DEFENSE The portion of the needle that had broken off was insignificant in size and was no medical threat. Breakage of a needle was a known risk of the procedure, and she was not informed because it had no medical significance.

VERDICT New Jersey defense verdict.

Aggressive D & C to blame for Asherman’s syndrome?

A 32-YEAR-OLD WOMAN who had recently given birth presented at the hospital with vaginal bleeding. Her ObGyn performed a dilation and curettage (D & C) procedure, with suction curettage followed by curettage with a sharp curette. This stopped the bleeding, and the patient was put on a 3-month birth-control regimen. When her menstruation did not resume after 3 months, the ObGyn diagnosed Asherman’s syndrome.

PATIENT’S CLAIM (1) The ObGyn should have checked her medical records more carefully, because the D & C was contraindicated. (2) She should have been treated with medical management rather than surgery. (3) The pathology report from the D & C indicated that the uterus and cervix were scraped overzealously during the sharp-curette phase.

PHYSICIAN’S DEFENSE The patient’s symptoms and a hematocrit of 28 showed she was hemodynamically unstable and—in the absence of surgery—at risk of rapid decompensation and death. Also, Asherman’s syndrome is a known risk of a D & C.

VERDICT A $700,000 New York verdict.

Woman learns too late her lump is not swollen milk gland

WHEN A 30-YEAR-OLD WOMAN went to Dr. K for prenatal care, she asked him to check a lump on her left breast. He diagnosed a milk gland that was swollen due to previous breastfeeding—but she had never breastfed. A sonogram was ordered and showed two masses that could be dermal or breast lesions; an excisional biopsy was ordered. Dr. K signed the report, but did not discuss it with the patient. For the remainder of her pregnancy, there was no follow-up examination of the lump. At her 6-month postdelivery checkup, the lump was not mentioned and a biopsy was not ordered. On her next visit, she was seen by Dr. L, whom she asked to examine the lump. No follow-up testing was performed when he concluded the lump was a swollen milk gland. When frequent stomach-related problems sent her to the emergency room, Dr. L prescribed pain medications and sent her home. Several months later, the patient underwent back surgery performed by Dr. M. The following day she learned that the breast lump was, in fact, cancer and that it had spread—and she now had two tumors on her spine and three on her brain. She had a mastectomy and underwent radiation treatment. Three years later, she died.

PLAINTIFF’S CLAIM Dr. K was negligent for failing to order the recommended biopsy

PHYSICIAN’S DEFENSE Dr. K admitted negligence, but argued causation. Death was caused by the cancer; nothing he did—or did not do—affected the outcome.

VERDICT $15,000 California verdict against Dr. K. Confidential settlement with Dr. L and his group.

Mother: 3 ObGyns, nursing staff are all liable for my stillbirth

EIGHT MONTHS INTO HER PREGNANCY, a morbidly obese 27-year-old woman experienced vaginal bleeding. She was examined by Dr. A, an ObGyn. After initial difficulty finding a fetal heart rate, he detected it after 1 hour and sent the woman home. At 42 weeks into her pregnancy, she returned for induction of labor. The nurses found the cervix to be thick and closed. The patient was discharged after Dr. B, another ObGyn, was consulted. She was seen by Dr. C, a third ObGyn, when she returned the next day. At first, the fetal heartbeat was detected, but within a few hours it could no longer be found. An emergency cesarean delivery was ordered, but the infant was stillborn.

PATIENT’S CLAIM Dr. A was negligent for not following the patient more closely after her visit at 8 months. Dr. B should have kept her overnight in the hospital for monitoring. Dr. C delayed ordering the cesarean delivery. And the nurses failed to assess, monitor, and communicate her condition.

PHYSICIANS’ DEFENSE Dr. B claimed (1) his assessment was reasonable based on the patient’s presentation, and (2) attempting a vaginal delivery was preferable because of the mother’s size, so there was no need to rush a cesarean delivery. Dr. C claimed he ordered the cesarean delivery in a timely manner. And the hospital claimed its nurses properly monitored the patient and informed Dr. C of her condition. Also, the fetus died of a thrombosis of the umbilical cord—which could not be detected or prevented—4 to 6 hours before the woman arrived at the hospital.

VERDICT Kentucky defense verdict.

Needle fragment left near uterus. Should the patient be told?

A WOMAN IN HER THIRTIES with uterine fibroids underwent a myomectomy performed by her gynecologist. The patient was not told that a small piece of the surgical needle broke off during the procedure and remained in the vicinity of her uterus. When she developed a bowel obstruction a few months later, she went to the emergency room, where the same gynecologist treated her and sent her home. Eventually, she was treated by another physician, who reviewed her medical records and informed her of the broken surgical needle mishap—which was not associated with the bowel obstruction.

PATIENT’S CLAIM The presence of the broken needle posed a threat to her health. She should have been told and given the option for its surgical removal.

PHYSICIAN’S DEFENSE The portion of the needle that had broken off was insignificant in size and was no medical threat. Breakage of a needle was a known risk of the procedure, and she was not informed because it had no medical significance.

VERDICT New Jersey defense verdict.

Aggressive D & C to blame for Asherman’s syndrome?

A 32-YEAR-OLD WOMAN who had recently given birth presented at the hospital with vaginal bleeding. Her ObGyn performed a dilation and curettage (D & C) procedure, with suction curettage followed by curettage with a sharp curette. This stopped the bleeding, and the patient was put on a 3-month birth-control regimen. When her menstruation did not resume after 3 months, the ObGyn diagnosed Asherman’s syndrome.

PATIENT’S CLAIM (1) The ObGyn should have checked her medical records more carefully, because the D & C was contraindicated. (2) She should have been treated with medical management rather than surgery. (3) The pathology report from the D & C indicated that the uterus and cervix were scraped overzealously during the sharp-curette phase.

PHYSICIAN’S DEFENSE The patient’s symptoms and a hematocrit of 28 showed she was hemodynamically unstable and—in the absence of surgery—at risk of rapid decompensation and death. Also, Asherman’s syndrome is a known risk of a D & C.

VERDICT A $700,000 New York verdict.

Woman learns too late her lump is not swollen milk gland

WHEN A 30-YEAR-OLD WOMAN went to Dr. K for prenatal care, she asked him to check a lump on her left breast. He diagnosed a milk gland that was swollen due to previous breastfeeding—but she had never breastfed. A sonogram was ordered and showed two masses that could be dermal or breast lesions; an excisional biopsy was ordered. Dr. K signed the report, but did not discuss it with the patient. For the remainder of her pregnancy, there was no follow-up examination of the lump. At her 6-month postdelivery checkup, the lump was not mentioned and a biopsy was not ordered. On her next visit, she was seen by Dr. L, whom she asked to examine the lump. No follow-up testing was performed when he concluded the lump was a swollen milk gland. When frequent stomach-related problems sent her to the emergency room, Dr. L prescribed pain medications and sent her home. Several months later, the patient underwent back surgery performed by Dr. M. The following day she learned that the breast lump was, in fact, cancer and that it had spread—and she now had two tumors on her spine and three on her brain. She had a mastectomy and underwent radiation treatment. Three years later, she died.

PLAINTIFF’S CLAIM Dr. K was negligent for failing to order the recommended biopsy

PHYSICIAN’S DEFENSE Dr. K admitted negligence, but argued causation. Death was caused by the cancer; nothing he did—or did not do—affected the outcome.

VERDICT $15,000 California verdict against Dr. K. Confidential settlement with Dr. L and his group.

Baby harmed when couple, unaware of risk, elects induction

AFTER A NORMAL PREGNANCY, a woman opted for induction of labor because the baby’s father was scheduled to leave for a military weekend. When the fetal heart rate showed a concerning pattern, Dr. A, the delivering physician, applied vacuum five times, but failed to achieve delivery. As he lacked privileges to perform a cesarean delivery and a surgical team was unavailable, he sent for Dr. B, a senior partner with such privileges. Dr. B attempted delivery using forceps but failed, and then tried the vacuum extractor twice. The child was delivered—blue and flaccid, with slow irregular respirations. The Apgar score was 3 at 1 minute and 4 at 3 minutes. The infant was resuscitated with bag/mask ventilation for 90 seconds and taken to the nursery of the community hospital, where he was treated as a normal newborn. Although he was brought twice to his mother during the night, he did not feed. The next morning a nurse noticed that he was blue and not breathing. A code was called. The child then suffered seizures with apneic and bradycardic spells. A glucose draw 2.5 hours later showed significant hypoglycemia believed to exacerbate hypoxic injury. After transfer to a specialty-care hospital, a CT scan of the child at 17 hours of age showed brain swelling and subgaleal hemorrhage; the local radiologist, however, read it as normal. A diagnosis of significant brain damage has been given. Now 6.5 years old, the child cannot speak, drools constantly, suffers motor impairment on both sides, has difficulty eating, and is incontinent.

PATIENT’S CLAIM The parents were never told of the risks of induction and did not give informed consent regarding the use of misoprostol. An excessive dosage of the drug was administered, resulting in an abnormal uterine contraction that was not addressed by the nurses or delivering physician.

PHYSICIAN’S DEFENSE The injury was caused by some unknown event 4 to 6 days before delivery. Also, neither the hypoglycemic period nor the trauma contributed to the brain injury.

VERDICT $2 million Minnesota settlement. The case was tried first in the small community (pop. 2,000) where the hospital and clinic are located—despite efforts to have a change of venue—and supporters of the defendants filled the courtroom. A mistrial was declared after the jury deadlocked. Then a change of venue was granted, and the jury in a second trial returned a $9,566,500 verdict. Dr. A and the clinic had reached a high/low agreement of $2 million just before the second trial. Posttrial motions were pending.

In bicornuate uterus, abortion fails on two attempts

IN THE SIXTH WEEK OF PREGNANCY, a 33-year-old woman underwent an abortion. The procedure, performed by an ObGyn, was uneventful, but a later test showed that the abortion had failed. During a second attempt 1.5 weeks after that, the same ObGyn encountered difficulties, suggesting that the uterus had been perforated—and he stopped. Following transfer to a hospital, the patient was confirmed to have suffered perforation of the uterus—and also to have a bicornuate uterus. She was treated with antibiotics and decided to continue her pregnancy. Several weeks later, she miscarried.

PATIENT’S CLAIM The ObGyn was negligent for causing the perforation. She had informed him of her bicornuate uterus, and ultrasonography should have been used to allow proper completion of the abortion.

PHYSICIAN’S DEFENSE Perforation and retained pregnancy are complications of an abortion procedure. Such complications are more likely when the uterus is bicornuate.

VERDICT New York defense verdict.

Hemophilia carrier suffers massive bleed after surgery

A 33-YEAR-OLD WOMAN had a previous tubal ligation reversed by an ObGyn. Following the surgery, she suffered massive bleeding and deep-vein thrombosis, resulting in permanent postphlebitic syndrome in her left leg.

PATIENT’S CLAIM She had notified the anesthesiologist that her son had a history of being Factor IX-deficient, and she brought Factor IX with her for urgent matters.

PHYSICIAN’S DEFENSE The ObGyn claimed the patient never informed him that she was a hemophilia B carrier and Factor IX-deficient. Although the anesthesiologist recorded the information given to him by the patient, the ObGyn was never told about it.

VERDICT Illinois defense verdict.

Baby harmed when couple, unaware of risk, elects induction

AFTER A NORMAL PREGNANCY, a woman opted for induction of labor because the baby’s father was scheduled to leave for a military weekend. When the fetal heart rate showed a concerning pattern, Dr. A, the delivering physician, applied vacuum five times, but failed to achieve delivery. As he lacked privileges to perform a cesarean delivery and a surgical team was unavailable, he sent for Dr. B, a senior partner with such privileges. Dr. B attempted delivery using forceps but failed, and then tried the vacuum extractor twice. The child was delivered—blue and flaccid, with slow irregular respirations. The Apgar score was 3 at 1 minute and 4 at 3 minutes. The infant was resuscitated with bag/mask ventilation for 90 seconds and taken to the nursery of the community hospital, where he was treated as a normal newborn. Although he was brought twice to his mother during the night, he did not feed. The next morning a nurse noticed that he was blue and not breathing. A code was called. The child then suffered seizures with apneic and bradycardic spells. A glucose draw 2.5 hours later showed significant hypoglycemia believed to exacerbate hypoxic injury. After transfer to a specialty-care hospital, a CT scan of the child at 17 hours of age showed brain swelling and subgaleal hemorrhage; the local radiologist, however, read it as normal. A diagnosis of significant brain damage has been given. Now 6.5 years old, the child cannot speak, drools constantly, suffers motor impairment on both sides, has difficulty eating, and is incontinent.

PATIENT’S CLAIM The parents were never told of the risks of induction and did not give informed consent regarding the use of misoprostol. An excessive dosage of the drug was administered, resulting in an abnormal uterine contraction that was not addressed by the nurses or delivering physician.

PHYSICIAN’S DEFENSE The injury was caused by some unknown event 4 to 6 days before delivery. Also, neither the hypoglycemic period nor the trauma contributed to the brain injury.

VERDICT $2 million Minnesota settlement. The case was tried first in the small community (pop. 2,000) where the hospital and clinic are located—despite efforts to have a change of venue—and supporters of the defendants filled the courtroom. A mistrial was declared after the jury deadlocked. Then a change of venue was granted, and the jury in a second trial returned a $9,566,500 verdict. Dr. A and the clinic had reached a high/low agreement of $2 million just before the second trial. Posttrial motions were pending.

In bicornuate uterus, abortion fails on two attempts

IN THE SIXTH WEEK OF PREGNANCY, a 33-year-old woman underwent an abortion. The procedure, performed by an ObGyn, was uneventful, but a later test showed that the abortion had failed. During a second attempt 1.5 weeks after that, the same ObGyn encountered difficulties, suggesting that the uterus had been perforated—and he stopped. Following transfer to a hospital, the patient was confirmed to have suffered perforation of the uterus—and also to have a bicornuate uterus. She was treated with antibiotics and decided to continue her pregnancy. Several weeks later, she miscarried.

PATIENT’S CLAIM The ObGyn was negligent for causing the perforation. She had informed him of her bicornuate uterus, and ultrasonography should have been used to allow proper completion of the abortion.

PHYSICIAN’S DEFENSE Perforation and retained pregnancy are complications of an abortion procedure. Such complications are more likely when the uterus is bicornuate.

VERDICT New York defense verdict.

Hemophilia carrier suffers massive bleed after surgery

A 33-YEAR-OLD WOMAN had a previous tubal ligation reversed by an ObGyn. Following the surgery, she suffered massive bleeding and deep-vein thrombosis, resulting in permanent postphlebitic syndrome in her left leg.

PATIENT’S CLAIM She had notified the anesthesiologist that her son had a history of being Factor IX-deficient, and she brought Factor IX with her for urgent matters.

PHYSICIAN’S DEFENSE The ObGyn claimed the patient never informed him that she was a hemophilia B carrier and Factor IX-deficient. Although the anesthesiologist recorded the information given to him by the patient, the ObGyn was never told about it.

VERDICT Illinois defense verdict.

Baby harmed when couple, unaware of risk, elects induction

AFTER A NORMAL PREGNANCY, a woman opted for induction of labor because the baby’s father was scheduled to leave for a military weekend. When the fetal heart rate showed a concerning pattern, Dr. A, the delivering physician, applied vacuum five times, but failed to achieve delivery. As he lacked privileges to perform a cesarean delivery and a surgical team was unavailable, he sent for Dr. B, a senior partner with such privileges. Dr. B attempted delivery using forceps but failed, and then tried the vacuum extractor twice. The child was delivered—blue and flaccid, with slow irregular respirations. The Apgar score was 3 at 1 minute and 4 at 3 minutes. The infant was resuscitated with bag/mask ventilation for 90 seconds and taken to the nursery of the community hospital, where he was treated as a normal newborn. Although he was brought twice to his mother during the night, he did not feed. The next morning a nurse noticed that he was blue and not breathing. A code was called. The child then suffered seizures with apneic and bradycardic spells. A glucose draw 2.5 hours later showed significant hypoglycemia believed to exacerbate hypoxic injury. After transfer to a specialty-care hospital, a CT scan of the child at 17 hours of age showed brain swelling and subgaleal hemorrhage; the local radiologist, however, read it as normal. A diagnosis of significant brain damage has been given. Now 6.5 years old, the child cannot speak, drools constantly, suffers motor impairment on both sides, has difficulty eating, and is incontinent.

PATIENT’S CLAIM The parents were never told of the risks of induction and did not give informed consent regarding the use of misoprostol. An excessive dosage of the drug was administered, resulting in an abnormal uterine contraction that was not addressed by the nurses or delivering physician.

PHYSICIAN’S DEFENSE The injury was caused by some unknown event 4 to 6 days before delivery. Also, neither the hypoglycemic period nor the trauma contributed to the brain injury.

VERDICT $2 million Minnesota settlement. The case was tried first in the small community (pop. 2,000) where the hospital and clinic are located—despite efforts to have a change of venue—and supporters of the defendants filled the courtroom. A mistrial was declared after the jury deadlocked. Then a change of venue was granted, and the jury in a second trial returned a $9,566,500 verdict. Dr. A and the clinic had reached a high/low agreement of $2 million just before the second trial. Posttrial motions were pending.

In bicornuate uterus, abortion fails on two attempts

IN THE SIXTH WEEK OF PREGNANCY, a 33-year-old woman underwent an abortion. The procedure, performed by an ObGyn, was uneventful, but a later test showed that the abortion had failed. During a second attempt 1.5 weeks after that, the same ObGyn encountered difficulties, suggesting that the uterus had been perforated—and he stopped. Following transfer to a hospital, the patient was confirmed to have suffered perforation of the uterus—and also to have a bicornuate uterus. She was treated with antibiotics and decided to continue her pregnancy. Several weeks later, she miscarried.

PATIENT’S CLAIM The ObGyn was negligent for causing the perforation. She had informed him of her bicornuate uterus, and ultrasonography should have been used to allow proper completion of the abortion.

PHYSICIAN’S DEFENSE Perforation and retained pregnancy are complications of an abortion procedure. Such complications are more likely when the uterus is bicornuate.

VERDICT New York defense verdict.

Hemophilia carrier suffers massive bleed after surgery

A 33-YEAR-OLD WOMAN had a previous tubal ligation reversed by an ObGyn. Following the surgery, she suffered massive bleeding and deep-vein thrombosis, resulting in permanent postphlebitic syndrome in her left leg.

PATIENT’S CLAIM She had notified the anesthesiologist that her son had a history of being Factor IX-deficient, and she brought Factor IX with her for urgent matters.

PHYSICIAN’S DEFENSE The ObGyn claimed the patient never informed him that she was a hemophilia B carrier and Factor IX-deficient. Although the anesthesiologist recorded the information given to him by the patient, the ObGyn was never told about it.

VERDICT Illinois defense verdict.

Lack of CT follow-up delays cancer diagnosis

SEVERAL WEEKS OF ABDOMINAL PAIN in the lower left quadrant prompted a 58-year-old woman to visit her doctor in March. A colonoscopy performed in July showed 2 small polyps, which were removed. The woman returned in August complaining of feeling weak and again in early September with pain and rectal bleeding. An abdominal computed tomography (CT) scan performed 11 days later revealed a 4 × 3-inch left pelvic mass.

Believing that the CT results suggested an inflammatory process, the doctor prescribed antibiotics. The patient subsequently developed anemia, but didn’t undergo small bowel follow through and barium enema because of equipment failure and scheduling difficulties. She was told to diet and exercise and follow up in 3 months. She returned in a few days with the same complaints and was started on Levaquin and Flagyl.

The patient was seen again the following May, 8 months after the CT scan. A barium enema and small bowel follow through performed in July were negative.

In November, the patient went to a hospital complaining of abdominal pain. A CT scan showed a diffuse abdominal and pelvic mass; a needle biopsy diagnosed a gastrointestinal stromal tumor. Disease was widespread; the patient’s chance of survival was estimated at <50%.

PLAINTIFF’S CLAIM A diagnosis should have been made at the time of the first abdominal CT scan.

DOCTOR’S DEFENSE No information about the doctor’s defense is available.

VERDICT $700,000 Virginia settlement.

COMMENT Whenever a mass—potentially cancer—is involved, effective follow-up is key. Even when the risk is deemed small, repeat imaging is usually the prudent path.

PE recognized too late

TWO MONTHS AFTER UNDERGOING KNEE SURGERY, a 35-year-old man was hospitalized for diverticulitis. A week and a half later, he went to an emergency room complaining of chest pain, shortness of breath, and heart palpitations. The ER physician performed an electrocardiogram (EKG), which he read as normal. He diagnosed a panic attack, prescribed lorazepam, and discharged the patient.

Two days later, the patient visited a psychiatrist complaining of panic attacks. Believing that the man had a medical condition, the psychiatrist told him to see his personal doctor or go to an ER. The patient went to his primary care physician, who suspected angina and admitted him to a local medical center.

In the 12 hours before he was seen, the patient’s pain and breathing problems increased and his calf swelled. By the time his doctor and a cardiologist noted the swelling and diagnosed pulmonary embolism (PE), a clot had traveled to his heart. He was airlifted to another hospital, where he died within 8 hours.

PLAINTIFF’S CLAIM The doctors were negligent in failing to promptly diagnose and treat PE. The ER physician failed to read the EKG correctly and take a detailed history; he diagnosed a panic attack without ruling out PE. The patient’s increased heart rate, shortness of breath, and abnormal EKG should have raised suspicion of an embolism.

DOCTORS’ DEFENSE The diagnosis was reasonable.

VERDICT $1.26 million Pennsylvania verdict.

COMMENT PE should be in the differential diagnosis of any patient with chest pain or shortness of breath.

“GERD” turns out to be heart disease

INDIGESTION AND PAIN IN HIS ARMS FOR 2 MONTHS led a 38-year-old man to consult his primary care physician, who diagnosed gastroesophageal reflux disease (GERD) and prescribed medication. The patient called the doctor to express satisfaction with the reflux medication and symptom relief, but the doctor doubled the dosage and told the patient he would refer him to a gastroenterologist. (The plaintiff later claimed that the medication never worked, and other medical records appeared to support that claim.)

About 6 weeks after the initial visit, the primary care physician referred the patient to a gastroenterologist, who also diagnosed GERD and scheduled an endoscopy. The gastroenterologist noted that a cardiac stress test should be considered if the symptoms worsened or the endoscopy was negative.

Six days later, before the endoscopy, the patient died after complaining of chest pain and temporary loss of vision. An autopsy attributed death to a fatal arrhythmia caused by idiopathic cardiomyopathy. The pathologist who performed the autopsy testified that the patient had dilated cardiomyopathy with a noncontributing component of ischemic change.

PLAINTIFF’S CLAIM The doctors failed to diagnose and treat the patient’s cardiac condition. The patient should have been referred for an EKG or other cardiac evaluation when he was first seen; doing so would have revealed the cardiomyopathy, which could then have been treated.

DOCTORS’ DEFENSE The patient’s symptoms were consistent with GERD and didn’t require cardiac testing. The autopsy report and evidence from the tissue slides were inconsistent with heart disease.

Additionally, the gastroenterologist claimed that cardiac disease could not have been diagnosed and treated in 6 days even if he’d referred the patient for evaluation. He also claimed that the patient died of a stroke.

VERDICT $2.3 million Virginia verdict against the primary care physician only.

COMMENT The misdiagnosis of cardiac disease is common; remember coronary artery disease when confronted with unresponsive GERD.

Lack of CT follow-up delays cancer diagnosis

SEVERAL WEEKS OF ABDOMINAL PAIN in the lower left quadrant prompted a 58-year-old woman to visit her doctor in March. A colonoscopy performed in July showed 2 small polyps, which were removed. The woman returned in August complaining of feeling weak and again in early September with pain and rectal bleeding. An abdominal computed tomography (CT) scan performed 11 days later revealed a 4 × 3-inch left pelvic mass.

Believing that the CT results suggested an inflammatory process, the doctor prescribed antibiotics. The patient subsequently developed anemia, but didn’t undergo small bowel follow through and barium enema because of equipment failure and scheduling difficulties. She was told to diet and exercise and follow up in 3 months. She returned in a few days with the same complaints and was started on Levaquin and Flagyl.

The patient was seen again the following May, 8 months after the CT scan. A barium enema and small bowel follow through performed in July were negative.

In November, the patient went to a hospital complaining of abdominal pain. A CT scan showed a diffuse abdominal and pelvic mass; a needle biopsy diagnosed a gastrointestinal stromal tumor. Disease was widespread; the patient’s chance of survival was estimated at <50%.

PLAINTIFF’S CLAIM A diagnosis should have been made at the time of the first abdominal CT scan.

DOCTOR’S DEFENSE No information about the doctor’s defense is available.

VERDICT $700,000 Virginia settlement.

COMMENT Whenever a mass—potentially cancer—is involved, effective follow-up is key. Even when the risk is deemed small, repeat imaging is usually the prudent path.

PE recognized too late

TWO MONTHS AFTER UNDERGOING KNEE SURGERY, a 35-year-old man was hospitalized for diverticulitis. A week and a half later, he went to an emergency room complaining of chest pain, shortness of breath, and heart palpitations. The ER physician performed an electrocardiogram (EKG), which he read as normal. He diagnosed a panic attack, prescribed lorazepam, and discharged the patient.

Two days later, the patient visited a psychiatrist complaining of panic attacks. Believing that the man had a medical condition, the psychiatrist told him to see his personal doctor or go to an ER. The patient went to his primary care physician, who suspected angina and admitted him to a local medical center.

In the 12 hours before he was seen, the patient’s pain and breathing problems increased and his calf swelled. By the time his doctor and a cardiologist noted the swelling and diagnosed pulmonary embolism (PE), a clot had traveled to his heart. He was airlifted to another hospital, where he died within 8 hours.

PLAINTIFF’S CLAIM The doctors were negligent in failing to promptly diagnose and treat PE. The ER physician failed to read the EKG correctly and take a detailed history; he diagnosed a panic attack without ruling out PE. The patient’s increased heart rate, shortness of breath, and abnormal EKG should have raised suspicion of an embolism.

DOCTORS’ DEFENSE The diagnosis was reasonable.

VERDICT $1.26 million Pennsylvania verdict.

COMMENT PE should be in the differential diagnosis of any patient with chest pain or shortness of breath.

“GERD” turns out to be heart disease

INDIGESTION AND PAIN IN HIS ARMS FOR 2 MONTHS led a 38-year-old man to consult his primary care physician, who diagnosed gastroesophageal reflux disease (GERD) and prescribed medication. The patient called the doctor to express satisfaction with the reflux medication and symptom relief, but the doctor doubled the dosage and told the patient he would refer him to a gastroenterologist. (The plaintiff later claimed that the medication never worked, and other medical records appeared to support that claim.)

About 6 weeks after the initial visit, the primary care physician referred the patient to a gastroenterologist, who also diagnosed GERD and scheduled an endoscopy. The gastroenterologist noted that a cardiac stress test should be considered if the symptoms worsened or the endoscopy was negative.

Six days later, before the endoscopy, the patient died after complaining of chest pain and temporary loss of vision. An autopsy attributed death to a fatal arrhythmia caused by idiopathic cardiomyopathy. The pathologist who performed the autopsy testified that the patient had dilated cardiomyopathy with a noncontributing component of ischemic change.

PLAINTIFF’S CLAIM The doctors failed to diagnose and treat the patient’s cardiac condition. The patient should have been referred for an EKG or other cardiac evaluation when he was first seen; doing so would have revealed the cardiomyopathy, which could then have been treated.

DOCTORS’ DEFENSE The patient’s symptoms were consistent with GERD and didn’t require cardiac testing. The autopsy report and evidence from the tissue slides were inconsistent with heart disease.

Additionally, the gastroenterologist claimed that cardiac disease could not have been diagnosed and treated in 6 days even if he’d referred the patient for evaluation. He also claimed that the patient died of a stroke.

VERDICT $2.3 million Virginia verdict against the primary care physician only.

COMMENT The misdiagnosis of cardiac disease is common; remember coronary artery disease when confronted with unresponsive GERD.

Lack of CT follow-up delays cancer diagnosis

SEVERAL WEEKS OF ABDOMINAL PAIN in the lower left quadrant prompted a 58-year-old woman to visit her doctor in March. A colonoscopy performed in July showed 2 small polyps, which were removed. The woman returned in August complaining of feeling weak and again in early September with pain and rectal bleeding. An abdominal computed tomography (CT) scan performed 11 days later revealed a 4 × 3-inch left pelvic mass.

Believing that the CT results suggested an inflammatory process, the doctor prescribed antibiotics. The patient subsequently developed anemia, but didn’t undergo small bowel follow through and barium enema because of equipment failure and scheduling difficulties. She was told to diet and exercise and follow up in 3 months. She returned in a few days with the same complaints and was started on Levaquin and Flagyl.

The patient was seen again the following May, 8 months after the CT scan. A barium enema and small bowel follow through performed in July were negative.

In November, the patient went to a hospital complaining of abdominal pain. A CT scan showed a diffuse abdominal and pelvic mass; a needle biopsy diagnosed a gastrointestinal stromal tumor. Disease was widespread; the patient’s chance of survival was estimated at <50%.

PLAINTIFF’S CLAIM A diagnosis should have been made at the time of the first abdominal CT scan.

DOCTOR’S DEFENSE No information about the doctor’s defense is available.

VERDICT $700,000 Virginia settlement.

COMMENT Whenever a mass—potentially cancer—is involved, effective follow-up is key. Even when the risk is deemed small, repeat imaging is usually the prudent path.

PE recognized too late

TWO MONTHS AFTER UNDERGOING KNEE SURGERY, a 35-year-old man was hospitalized for diverticulitis. A week and a half later, he went to an emergency room complaining of chest pain, shortness of breath, and heart palpitations. The ER physician performed an electrocardiogram (EKG), which he read as normal. He diagnosed a panic attack, prescribed lorazepam, and discharged the patient.

Two days later, the patient visited a psychiatrist complaining of panic attacks. Believing that the man had a medical condition, the psychiatrist told him to see his personal doctor or go to an ER. The patient went to his primary care physician, who suspected angina and admitted him to a local medical center.

In the 12 hours before he was seen, the patient’s pain and breathing problems increased and his calf swelled. By the time his doctor and a cardiologist noted the swelling and diagnosed pulmonary embolism (PE), a clot had traveled to his heart. He was airlifted to another hospital, where he died within 8 hours.

PLAINTIFF’S CLAIM The doctors were negligent in failing to promptly diagnose and treat PE. The ER physician failed to read the EKG correctly and take a detailed history; he diagnosed a panic attack without ruling out PE. The patient’s increased heart rate, shortness of breath, and abnormal EKG should have raised suspicion of an embolism.

DOCTORS’ DEFENSE The diagnosis was reasonable.

VERDICT $1.26 million Pennsylvania verdict.

COMMENT PE should be in the differential diagnosis of any patient with chest pain or shortness of breath.

“GERD” turns out to be heart disease

INDIGESTION AND PAIN IN HIS ARMS FOR 2 MONTHS led a 38-year-old man to consult his primary care physician, who diagnosed gastroesophageal reflux disease (GERD) and prescribed medication. The patient called the doctor to express satisfaction with the reflux medication and symptom relief, but the doctor doubled the dosage and told the patient he would refer him to a gastroenterologist. (The plaintiff later claimed that the medication never worked, and other medical records appeared to support that claim.)

About 6 weeks after the initial visit, the primary care physician referred the patient to a gastroenterologist, who also diagnosed GERD and scheduled an endoscopy. The gastroenterologist noted that a cardiac stress test should be considered if the symptoms worsened or the endoscopy was negative.

Six days later, before the endoscopy, the patient died after complaining of chest pain and temporary loss of vision. An autopsy attributed death to a fatal arrhythmia caused by idiopathic cardiomyopathy. The pathologist who performed the autopsy testified that the patient had dilated cardiomyopathy with a noncontributing component of ischemic change.

PLAINTIFF’S CLAIM The doctors failed to diagnose and treat the patient’s cardiac condition. The patient should have been referred for an EKG or other cardiac evaluation when he was first seen; doing so would have revealed the cardiomyopathy, which could then have been treated.

DOCTORS’ DEFENSE The patient’s symptoms were consistent with GERD and didn’t require cardiac testing. The autopsy report and evidence from the tissue slides were inconsistent with heart disease.

Additionally, the gastroenterologist claimed that cardiac disease could not have been diagnosed and treated in 6 days even if he’d referred the patient for evaluation. He also claimed that the patient died of a stroke.

VERDICT $2.3 million Virginia verdict against the primary care physician only.

COMMENT The misdiagnosis of cardiac disease is common; remember coronary artery disease when confronted with unresponsive GERD.

Would you recognize appendicitis here?

A 20-YEAR-OLD WOMAN in the third trimester of pregnancy went to Dr. A, her ObGyn, complaining of abdominal pain. On each of the next 3 days, she presented at the emergency room with the same complaint. She was discharged twice, but was admitted on the third day. Dr. B provided care that day, and Dr. A took over on the following day. The patient was prescribed antibiotics after an infection was diagnosed. Then, after giving birth on that same day, her condition worsened. A ruptured appendix was discovered during exploratory laparotomy. The patient continued to decline and then died 3 weeks later.

PLAINTIFF’S CLAIM Failing to diagnose the appendicitis was negligent. On the 4 days the patient complained of pain, there was neither hands-on examination of her abdomen nor CT scans ordered. The nurses failed to recognize her condition and to see that she was properly evaluated.

PHYSICIANS’ DEFENSE Dr. A claimed his evaluation was performed properly. Dr. B claimed that, on the day the patient was admitted, he made a proper evaluation based on phone triage. The hospital claimed that the nurses performed proper triage and monitored her properly. And all claimed that a laparotomy required waiting until after delivery to be performed.

VERDICT Kentucky defense verdict. Posttrial motions were pending.

When findings are benign, should you refer, just to be safe?

A 36-YEAR-OLD PATIENT with presumptive fibroid tumors underwent a hysterectomy in which the ovaries and fallopian tubes were not removed. The pathologist initially reported that one tumor was benign, but that he was performing further tests. His second report confirmed the benign diagnosis and included mitotic count and spindle cells in the description of the microscopic exam. A year later, the patient developed abdominal pain, and the physician removed the fallopian tubes and ovaries. This time the same pathologist reported malignant uterine sarcoma in the ovaries. Upon reexamination of the previous year’s tissue, he believed the first tumor to be similar. A diagnosis of metastasis was given almost 2 years later.

PATIENT’S CLAIM She should have been referred to a gynecologic oncologist when the tumors were removed. This would have allowed her to be treated earlier and more effectively.

PHYSICIAN’S DEFENSE The initial diagnosis was benign and thus did not require a referral. Also, no adjuvant therapy would have improved the patient’s prognosis with this rare cancer.

VERDICT $2 million Illinois verdict.

Dystocia case is heard in bench trial

SHOULDER DYSTOCIA was encountered during delivery of the plaintiff child at a federally funded clinic. The OB used traction to complete the delivery, and the child suffered right brachial plexus injury, resulting in Erb’s palsy. No surgery was performed. The clinic was covered by the Federal Tort Claims Act, and the case was tried in a bench trial.

PATIENT’S CLAIM The treating OB used excessive traction, causing injury to the right brachial plexus.

PHYSICIAN’S DEFENSE Only moderate traction was used.

VERDICT $2,525,584 Illinois bench verdict. The court found the following: (1) negligence by the physician for repeatedly applying moderate traction to the point of excessive traction and rotating the infant’s head while the shoulder was trapped; (2) inappropriate grasping of the head while applying excessive traction; (3) failure to cut a generous episiotomy after shoulder dystocia was recognized; (4) failure to try other noninvasive measures before using excessive force; and (5) failure to recognize the likelihood of a macrosomic fetus.

No OB is available; complications ensue

SHORTLY AFTER a woman was admitted to the hospital for the birth of her child, complications occurred. The infant was delivered but suffered hypoxia and brain damage.

PATIENT’S CLAIM No OB was readily available to assist with the delivery. The nurses acted to delay the birth despite evidence that a hypoxic event was in progress and immediate delivery—even by a nurse—was essential. Fetal bradycardia continued for 5 to 6 minutes, resulting in hypoxia and brain damage in the infant.

PHYSICIAN’S DEFENSE Not reported.

VERDICT Confidential Utah settlement with the hospital. The physicians had been dismissed in summary judgment rulings.

Would you recognize appendicitis here?

A 20-YEAR-OLD WOMAN in the third trimester of pregnancy went to Dr. A, her ObGyn, complaining of abdominal pain. On each of the next 3 days, she presented at the emergency room with the same complaint. She was discharged twice, but was admitted on the third day. Dr. B provided care that day, and Dr. A took over on the following day. The patient was prescribed antibiotics after an infection was diagnosed. Then, after giving birth on that same day, her condition worsened. A ruptured appendix was discovered during exploratory laparotomy. The patient continued to decline and then died 3 weeks later.

PLAINTIFF’S CLAIM Failing to diagnose the appendicitis was negligent. On the 4 days the patient complained of pain, there was neither hands-on examination of her abdomen nor CT scans ordered. The nurses failed to recognize her condition and to see that she was properly evaluated.

PHYSICIANS’ DEFENSE Dr. A claimed his evaluation was performed properly. Dr. B claimed that, on the day the patient was admitted, he made a proper evaluation based on phone triage. The hospital claimed that the nurses performed proper triage and monitored her properly. And all claimed that a laparotomy required waiting until after delivery to be performed.

VERDICT Kentucky defense verdict. Posttrial motions were pending.

When findings are benign, should you refer, just to be safe?

A 36-YEAR-OLD PATIENT with presumptive fibroid tumors underwent a hysterectomy in which the ovaries and fallopian tubes were not removed. The pathologist initially reported that one tumor was benign, but that he was performing further tests. His second report confirmed the benign diagnosis and included mitotic count and spindle cells in the description of the microscopic exam. A year later, the patient developed abdominal pain, and the physician removed the fallopian tubes and ovaries. This time the same pathologist reported malignant uterine sarcoma in the ovaries. Upon reexamination of the previous year’s tissue, he believed the first tumor to be similar. A diagnosis of metastasis was given almost 2 years later.

PATIENT’S CLAIM She should have been referred to a gynecologic oncologist when the tumors were removed. This would have allowed her to be treated earlier and more effectively.

PHYSICIAN’S DEFENSE The initial diagnosis was benign and thus did not require a referral. Also, no adjuvant therapy would have improved the patient’s prognosis with this rare cancer.

VERDICT $2 million Illinois verdict.

Dystocia case is heard in bench trial

SHOULDER DYSTOCIA was encountered during delivery of the plaintiff child at a federally funded clinic. The OB used traction to complete the delivery, and the child suffered right brachial plexus injury, resulting in Erb’s palsy. No surgery was performed. The clinic was covered by the Federal Tort Claims Act, and the case was tried in a bench trial.

PATIENT’S CLAIM The treating OB used excessive traction, causing injury to the right brachial plexus.

PHYSICIAN’S DEFENSE Only moderate traction was used.

VERDICT $2,525,584 Illinois bench verdict. The court found the following: (1) negligence by the physician for repeatedly applying moderate traction to the point of excessive traction and rotating the infant’s head while the shoulder was trapped; (2) inappropriate grasping of the head while applying excessive traction; (3) failure to cut a generous episiotomy after shoulder dystocia was recognized; (4) failure to try other noninvasive measures before using excessive force; and (5) failure to recognize the likelihood of a macrosomic fetus.

No OB is available; complications ensue

SHORTLY AFTER a woman was admitted to the hospital for the birth of her child, complications occurred. The infant was delivered but suffered hypoxia and brain damage.

PATIENT’S CLAIM No OB was readily available to assist with the delivery. The nurses acted to delay the birth despite evidence that a hypoxic event was in progress and immediate delivery—even by a nurse—was essential. Fetal bradycardia continued for 5 to 6 minutes, resulting in hypoxia and brain damage in the infant.

PHYSICIAN’S DEFENSE Not reported.

VERDICT Confidential Utah settlement with the hospital. The physicians had been dismissed in summary judgment rulings.

Would you recognize appendicitis here?

A 20-YEAR-OLD WOMAN in the third trimester of pregnancy went to Dr. A, her ObGyn, complaining of abdominal pain. On each of the next 3 days, she presented at the emergency room with the same complaint. She was discharged twice, but was admitted on the third day. Dr. B provided care that day, and Dr. A took over on the following day. The patient was prescribed antibiotics after an infection was diagnosed. Then, after giving birth on that same day, her condition worsened. A ruptured appendix was discovered during exploratory laparotomy. The patient continued to decline and then died 3 weeks later.

PLAINTIFF’S CLAIM Failing to diagnose the appendicitis was negligent. On the 4 days the patient complained of pain, there was neither hands-on examination of her abdomen nor CT scans ordered. The nurses failed to recognize her condition and to see that she was properly evaluated.

PHYSICIANS’ DEFENSE Dr. A claimed his evaluation was performed properly. Dr. B claimed that, on the day the patient was admitted, he made a proper evaluation based on phone triage. The hospital claimed that the nurses performed proper triage and monitored her properly. And all claimed that a laparotomy required waiting until after delivery to be performed.

VERDICT Kentucky defense verdict. Posttrial motions were pending.

When findings are benign, should you refer, just to be safe?

A 36-YEAR-OLD PATIENT with presumptive fibroid tumors underwent a hysterectomy in which the ovaries and fallopian tubes were not removed. The pathologist initially reported that one tumor was benign, but that he was performing further tests. His second report confirmed the benign diagnosis and included mitotic count and spindle cells in the description of the microscopic exam. A year later, the patient developed abdominal pain, and the physician removed the fallopian tubes and ovaries. This time the same pathologist reported malignant uterine sarcoma in the ovaries. Upon reexamination of the previous year’s tissue, he believed the first tumor to be similar. A diagnosis of metastasis was given almost 2 years later.

PATIENT’S CLAIM She should have been referred to a gynecologic oncologist when the tumors were removed. This would have allowed her to be treated earlier and more effectively.

PHYSICIAN’S DEFENSE The initial diagnosis was benign and thus did not require a referral. Also, no adjuvant therapy would have improved the patient’s prognosis with this rare cancer.

VERDICT $2 million Illinois verdict.

Dystocia case is heard in bench trial

SHOULDER DYSTOCIA was encountered during delivery of the plaintiff child at a federally funded clinic. The OB used traction to complete the delivery, and the child suffered right brachial plexus injury, resulting in Erb’s palsy. No surgery was performed. The clinic was covered by the Federal Tort Claims Act, and the case was tried in a bench trial.

PATIENT’S CLAIM The treating OB used excessive traction, causing injury to the right brachial plexus.

PHYSICIAN’S DEFENSE Only moderate traction was used.

VERDICT $2,525,584 Illinois bench verdict. The court found the following: (1) negligence by the physician for repeatedly applying moderate traction to the point of excessive traction and rotating the infant’s head while the shoulder was trapped; (2) inappropriate grasping of the head while applying excessive traction; (3) failure to cut a generous episiotomy after shoulder dystocia was recognized; (4) failure to try other noninvasive measures before using excessive force; and (5) failure to recognize the likelihood of a macrosomic fetus.

No OB is available; complications ensue

SHORTLY AFTER a woman was admitted to the hospital for the birth of her child, complications occurred. The infant was delivered but suffered hypoxia and brain damage.

PATIENT’S CLAIM No OB was readily available to assist with the delivery. The nurses acted to delay the birth despite evidence that a hypoxic event was in progress and immediate delivery—even by a nurse—was essential. Fetal bradycardia continued for 5 to 6 minutes, resulting in hypoxia and brain damage in the infant.

PHYSICIAN’S DEFENSE Not reported.

VERDICT Confidential Utah settlement with the hospital. The physicians had been dismissed in summary judgment rulings.

Long after surgery, clips continue to migrate to bladder

A 34-YEAR-OLD WOMAN underwent a total vaginal hysterectomy with a laparoscopic Burch procedure. Following surgery, she developed a fever and tenderness in her lower left quadrant. Cystoscopy indicated multiple areas of petechial hemorrhages when her bladder was filled. A week after the surgery, she was discharged but continued treatment for ongoing pelvic pain. Two years later, exploratory surgery showed that two clips from the hysterectomy procedure had migrated into her bladder. These were removed. A third clip was removed a year later. Eight years after the original surgery, Prolene mesh and more clips were discovered embedded in her bladder. The following year, to correct the migrating clips and help with pain, she underwent a vaginal sling procedure, bilateral ureteral catheterization, and right inguinal hernia repair.

PATIENT’S CLAIM The physician was negligent in placing the mesh and clips during the hysterectomy, and as a result additional procedures were required.

PHYSICIAN’S DEFENSE There was no negligence. Also, erosion of a tack is a known complication of the surgery.

VERDICT Massachusetts defense verdict.

Defense reneges on settlement, so patient fights back

FOLLOWING SURGERY to excise a Bartholin’s cyst from her labium, a patient developed first one hematoma and then a second, each of which was excised in turn. Then tissue became necrotic and was also excised.

PATIENT’S CLAIM The procedures caused disfigurement and subsequent embarrassment. One labium was removed entirely, and nerve damage resulted in loss of sensation and painful intercourse. She also claimed lack of consent because she was advised of neither the risks of nor alternatives to surgery. Although married at the time of the procedures, she is now divorced.

PHYSICIAN’S DEFENSE Many of the patient’s problems resulted from her mental health issues.

VERDICT Confidential Utah settlement. The patient had originally accepted the defense attorney’s offer of an $85,000 settlement. This was never paid, as the adjustor would allow only up to $72,500. When the patient filed a motion to enforce the $85,000 settlement, the matter was settled for an undisclosed amount.

Removed ovaries weren’t diseased, but defense wins at trial

A 31-YEAR-OLD WOMAN with persistent abdominal pain and heavy, painful periods underwent a hysterectomy as recommended by her ObGyn. Believing the ovaries were diseased, he removed them during the procedure—but a pathology report indicated no disease. He also branded the patient’s uterus with a “UK” symbol. Although this branding received attention from the national media, the trial dealt with removal of the ovaries.

PATIENT’S CLAIM (1) She had told her ObGyn that she wanted to keep her ovaries, so she was unhappy they had been removed. (2) She experienced insomnia, depression, and decreased libido. (3) The surgery was not necessary; she should have been treated conservatively at first. (4) She did not give informed consent. (5) And the ObGyn performed 120 hysterectomies in the year of her surgery, eight times the national average of only 15.

PHYSICIAN’S DEFENSE The frequency of the procedures he performed was based on his expertise in laparoscopic hysterectomy. Removal of the ovaries was necessary and within the patient’s consent.

VERDICT Kentucky defense verdict.

MD claims cervix was removed, but it was there 3 years later

A 48-YEAR-OLD WOMAN underwent a total abdominal hysterectomy because of bleeding and cancer concerns. Three years later, she underwent further gynecologic surgery to remove her cervix.

PATIENT’S CLAIM The defendant had not removed her cervix during the hysterectomy, as she learned 3 years after the procedure. She suffered abdominal pain and the fear of cancer, and she required additional surgery to remove the cervix.

PHYSICIAN’S DEFENSE The cervix was removed during the hysterectomy, but if a small portion had been left, it was not negligent to leave it behind.

VERDICT Illinois defense verdict.

Long after surgery, clips continue to migrate to bladder

A 34-YEAR-OLD WOMAN underwent a total vaginal hysterectomy with a laparoscopic Burch procedure. Following surgery, she developed a fever and tenderness in her lower left quadrant. Cystoscopy indicated multiple areas of petechial hemorrhages when her bladder was filled. A week after the surgery, she was discharged but continued treatment for ongoing pelvic pain. Two years later, exploratory surgery showed that two clips from the hysterectomy procedure had migrated into her bladder. These were removed. A third clip was removed a year later. Eight years after the original surgery, Prolene mesh and more clips were discovered embedded in her bladder. The following year, to correct the migrating clips and help with pain, she underwent a vaginal sling procedure, bilateral ureteral catheterization, and right inguinal hernia repair.

PATIENT’S CLAIM The physician was negligent in placing the mesh and clips during the hysterectomy, and as a result additional procedures were required.

PHYSICIAN’S DEFENSE There was no negligence. Also, erosion of a tack is a known complication of the surgery.

VERDICT Massachusetts defense verdict.

Defense reneges on settlement, so patient fights back

FOLLOWING SURGERY to excise a Bartholin’s cyst from her labium, a patient developed first one hematoma and then a second, each of which was excised in turn. Then tissue became necrotic and was also excised.

PATIENT’S CLAIM The procedures caused disfigurement and subsequent embarrassment. One labium was removed entirely, and nerve damage resulted in loss of sensation and painful intercourse. She also claimed lack of consent because she was advised of neither the risks of nor alternatives to surgery. Although married at the time of the procedures, she is now divorced.

PHYSICIAN’S DEFENSE Many of the patient’s problems resulted from her mental health issues.

VERDICT Confidential Utah settlement. The patient had originally accepted the defense attorney’s offer of an $85,000 settlement. This was never paid, as the adjustor would allow only up to $72,500. When the patient filed a motion to enforce the $85,000 settlement, the matter was settled for an undisclosed amount.

Removed ovaries weren’t diseased, but defense wins at trial

A 31-YEAR-OLD WOMAN with persistent abdominal pain and heavy, painful periods underwent a hysterectomy as recommended by her ObGyn. Believing the ovaries were diseased, he removed them during the procedure—but a pathology report indicated no disease. He also branded the patient’s uterus with a “UK” symbol. Although this branding received attention from the national media, the trial dealt with removal of the ovaries.

PATIENT’S CLAIM (1) She had told her ObGyn that she wanted to keep her ovaries, so she was unhappy they had been removed. (2) She experienced insomnia, depression, and decreased libido. (3) The surgery was not necessary; she should have been treated conservatively at first. (4) She did not give informed consent. (5) And the ObGyn performed 120 hysterectomies in the year of her surgery, eight times the national average of only 15.

PHYSICIAN’S DEFENSE The frequency of the procedures he performed was based on his expertise in laparoscopic hysterectomy. Removal of the ovaries was necessary and within the patient’s consent.

VERDICT Kentucky defense verdict.

MD claims cervix was removed, but it was there 3 years later

A 48-YEAR-OLD WOMAN underwent a total abdominal hysterectomy because of bleeding and cancer concerns. Three years later, she underwent further gynecologic surgery to remove her cervix.

PATIENT’S CLAIM The defendant had not removed her cervix during the hysterectomy, as she learned 3 years after the procedure. She suffered abdominal pain and the fear of cancer, and she required additional surgery to remove the cervix.

PHYSICIAN’S DEFENSE The cervix was removed during the hysterectomy, but if a small portion had been left, it was not negligent to leave it behind.

VERDICT Illinois defense verdict.

Long after surgery, clips continue to migrate to bladder

A 34-YEAR-OLD WOMAN underwent a total vaginal hysterectomy with a laparoscopic Burch procedure. Following surgery, she developed a fever and tenderness in her lower left quadrant. Cystoscopy indicated multiple areas of petechial hemorrhages when her bladder was filled. A week after the surgery, she was discharged but continued treatment for ongoing pelvic pain. Two years later, exploratory surgery showed that two clips from the hysterectomy procedure had migrated into her bladder. These were removed. A third clip was removed a year later. Eight years after the original surgery, Prolene mesh and more clips were discovered embedded in her bladder. The following year, to correct the migrating clips and help with pain, she underwent a vaginal sling procedure, bilateral ureteral catheterization, and right inguinal hernia repair.

PATIENT’S CLAIM The physician was negligent in placing the mesh and clips during the hysterectomy, and as a result additional procedures were required.

PHYSICIAN’S DEFENSE There was no negligence. Also, erosion of a tack is a known complication of the surgery.

VERDICT Massachusetts defense verdict.

Defense reneges on settlement, so patient fights back

FOLLOWING SURGERY to excise a Bartholin’s cyst from her labium, a patient developed first one hematoma and then a second, each of which was excised in turn. Then tissue became necrotic and was also excised.

PATIENT’S CLAIM The procedures caused disfigurement and subsequent embarrassment. One labium was removed entirely, and nerve damage resulted in loss of sensation and painful intercourse. She also claimed lack of consent because she was advised of neither the risks of nor alternatives to surgery. Although married at the time of the procedures, she is now divorced.

PHYSICIAN’S DEFENSE Many of the patient’s problems resulted from her mental health issues.

VERDICT Confidential Utah settlement. The patient had originally accepted the defense attorney’s offer of an $85,000 settlement. This was never paid, as the adjustor would allow only up to $72,500. When the patient filed a motion to enforce the $85,000 settlement, the matter was settled for an undisclosed amount.

Removed ovaries weren’t diseased, but defense wins at trial

A 31-YEAR-OLD WOMAN with persistent abdominal pain and heavy, painful periods underwent a hysterectomy as recommended by her ObGyn. Believing the ovaries were diseased, he removed them during the procedure—but a pathology report indicated no disease. He also branded the patient’s uterus with a “UK” symbol. Although this branding received attention from the national media, the trial dealt with removal of the ovaries.

PATIENT’S CLAIM (1) She had told her ObGyn that she wanted to keep her ovaries, so she was unhappy they had been removed. (2) She experienced insomnia, depression, and decreased libido. (3) The surgery was not necessary; she should have been treated conservatively at first. (4) She did not give informed consent. (5) And the ObGyn performed 120 hysterectomies in the year of her surgery, eight times the national average of only 15.

PHYSICIAN’S DEFENSE The frequency of the procedures he performed was based on his expertise in laparoscopic hysterectomy. Removal of the ovaries was necessary and within the patient’s consent.

VERDICT Kentucky defense verdict.

MD claims cervix was removed, but it was there 3 years later

A 48-YEAR-OLD WOMAN underwent a total abdominal hysterectomy because of bleeding and cancer concerns. Three years later, she underwent further gynecologic surgery to remove her cervix.

PATIENT’S CLAIM The defendant had not removed her cervix during the hysterectomy, as she learned 3 years after the procedure. She suffered abdominal pain and the fear of cancer, and she required additional surgery to remove the cervix.

PHYSICIAN’S DEFENSE The cervix was removed during the hysterectomy, but if a small portion had been left, it was not negligent to leave it behind.

VERDICT Illinois defense verdict.