Medical Verdicts

Disabling stroke follows failure to treat stenosis

NUMBNESS AND WEAKNESS IN HIS LEFT ARM brought a 52-year-old man to his internist. A magnetic resonance imaging scan revealed that the patient had suffered a minor, nondisabling stroke within the previous few weeks caused by an embolism arising from stenosis of the right internal carotid artery. The internist referred the patient to a neurologist but didn’t inform the neurologist that the man’s symptoms were becoming worse.

The neurologist saw the patient about a week later. She was unaware of the unstable symptoms and didn’t communicate with the internist, whose office was 1 floor below hers. The neurologist put the patient on low-dose aspirin and sent him for a nonurgent ultrasound to determine the extent of the stenosis.

The ultrasound report, which the neurologist read 8 days after the patient visit, indicated an 80% to 90% stenosis of the right internal carotid artery. The neurologist claimed she tried to reach the patient 4 times over 2 days. She left one message, but did not reach him.

Two days after the neurologist obtained the ultrasound report, the patient had a major stroke caused by a clot that had broken off from his right internal carotid artery. The stroke left him mostly paralyzed on his left side, confined to a wheelchair, and unable to work or drive.

PLAINTIFF’S CLAIM The internist failed to convey all medically significant information to the neurologist; he had a duty to intervene when he received worrisome clinical information. The neurologist should have ordered an urgent carotid endarterectomy, which would have prevented a major stroke. She also should have contacted the internist; communication would have brought to light the need for urgent treatment.

DOCTORS’ DEFENSE The internist claimed that the neurology referral was all that was required of him. The neurologist maintained that the risk of another embolic stroke within 90 days of the minor stroke was low and that nonurgent evaluation was appropriate. Both doctors claimed that the major stroke was an unfortunate and unpredictable occurrence and that, in any event, vascular surgery wouldn’t have been performed for at least 4 to 6 weeks after the small stroke because of concern over severe cerebral hemorrhage.

VERDICT $1.75 million Massachusetts settlement.

COMMENT Communicate, communicate, communicate. Without appropriate coordination of care, such unfortunate stories are likely to be repeated. Never assume that another colleague is going to follow up on that markedly abnormal finding—take matters into your own hands!

Child’s hearing loss blamed on missed meningitis Dx

A 1-YEAR-OLD GIRL WITH A PERSISTENT FEVER was seen by her pediatrician, who diagnosed tonsillitis. During the hours after her visit to the pediatrician, the child’s fever reached 104°F and she began to vomit. She was brought to an emergency room, where a radiograph revealed a potentially abnormal density of the lungs. Developing pneumonia was suspected, and she was admitted to the hospital. Doctors also suspected meningitis, but didn’t detect any abnormalities of the meninges. An antibiotic was given.

On the third day of hospitalization, a nurse observed nuchal rigidity. The child remained in the hospital for 2 weeks, during which time her body temperature remained at 100°F or higher. Two days after discharge, the girl experienced a total loss of hearing. A computed tomography scan revealed damage to the cochleae.

PLAINTIFF’S CLAIM The damage to the patient’s cochleae was caused by untreated meningitis. Nuchal rigidity should have prompted an immediate spinal tap or other test for meningitis.

DOCTOR’S DEFENSE Proper care was given; the child’s symptoms didn’t warrant additional treatment. The cochlear damage was congenital.

VERDICT $3 million New York settlement.

COMMENT Meningitis may occur less often nowadays, but it should never be forgotten. When in doubt, order (or perform) a lumbar puncture, which can lead to a life-saving diagnosis. Early initiation of presumptive antibiotic treatment is critical.

Untreated high blood sugar ends in coma and disability

A 65-YEAR-OLD MAN sought treatment from an endocrinologist for previously diagnosed diabetes. An in-office pin prick test showed a blood sugar level exceeding the instrument’s limit. The endocrinologist ordered blood work at an outside lab. The tests indicated dangerous blood sugar levels, which were reported to the endocrinologist and his staff. The doctor allegedly didn’t act on the results.

About a week after seeing the endocrinologist, the patient collapsed; he was rushed to a hospital and placed in a protective coma. He emerged from the coma with significant injuries, including blindness in 1 eye and bilateral foot drop.

PLAINTIFF’S CLAIM The in-office test results should have alerted the doctor to a serious problem. The doctor should have sent the patient to the hospital for an immediate blood test.

DOCTOR’S DEFENSE The doctor denied any negligence.

VERDICT $1.5 million Connecticut settlement.

COMMENT Delayed or inappropriate follow up of in-office lab work remains a preventable cause of liability. If you order a test, make sure you have a protocol in place to assure timely adjudication of test results.

Disabling stroke follows failure to treat stenosis

NUMBNESS AND WEAKNESS IN HIS LEFT ARM brought a 52-year-old man to his internist. A magnetic resonance imaging scan revealed that the patient had suffered a minor, nondisabling stroke within the previous few weeks caused by an embolism arising from stenosis of the right internal carotid artery. The internist referred the patient to a neurologist but didn’t inform the neurologist that the man’s symptoms were becoming worse.

The neurologist saw the patient about a week later. She was unaware of the unstable symptoms and didn’t communicate with the internist, whose office was 1 floor below hers. The neurologist put the patient on low-dose aspirin and sent him for a nonurgent ultrasound to determine the extent of the stenosis.

The ultrasound report, which the neurologist read 8 days after the patient visit, indicated an 80% to 90% stenosis of the right internal carotid artery. The neurologist claimed she tried to reach the patient 4 times over 2 days. She left one message, but did not reach him.

Two days after the neurologist obtained the ultrasound report, the patient had a major stroke caused by a clot that had broken off from his right internal carotid artery. The stroke left him mostly paralyzed on his left side, confined to a wheelchair, and unable to work or drive.

PLAINTIFF’S CLAIM The internist failed to convey all medically significant information to the neurologist; he had a duty to intervene when he received worrisome clinical information. The neurologist should have ordered an urgent carotid endarterectomy, which would have prevented a major stroke. She also should have contacted the internist; communication would have brought to light the need for urgent treatment.

DOCTORS’ DEFENSE The internist claimed that the neurology referral was all that was required of him. The neurologist maintained that the risk of another embolic stroke within 90 days of the minor stroke was low and that nonurgent evaluation was appropriate. Both doctors claimed that the major stroke was an unfortunate and unpredictable occurrence and that, in any event, vascular surgery wouldn’t have been performed for at least 4 to 6 weeks after the small stroke because of concern over severe cerebral hemorrhage.

VERDICT $1.75 million Massachusetts settlement.

COMMENT Communicate, communicate, communicate. Without appropriate coordination of care, such unfortunate stories are likely to be repeated. Never assume that another colleague is going to follow up on that markedly abnormal finding—take matters into your own hands!

Child’s hearing loss blamed on missed meningitis Dx

A 1-YEAR-OLD GIRL WITH A PERSISTENT FEVER was seen by her pediatrician, who diagnosed tonsillitis. During the hours after her visit to the pediatrician, the child’s fever reached 104°F and she began to vomit. She was brought to an emergency room, where a radiograph revealed a potentially abnormal density of the lungs. Developing pneumonia was suspected, and she was admitted to the hospital. Doctors also suspected meningitis, but didn’t detect any abnormalities of the meninges. An antibiotic was given.

On the third day of hospitalization, a nurse observed nuchal rigidity. The child remained in the hospital for 2 weeks, during which time her body temperature remained at 100°F or higher. Two days after discharge, the girl experienced a total loss of hearing. A computed tomography scan revealed damage to the cochleae.

PLAINTIFF’S CLAIM The damage to the patient’s cochleae was caused by untreated meningitis. Nuchal rigidity should have prompted an immediate spinal tap or other test for meningitis.

DOCTOR’S DEFENSE Proper care was given; the child’s symptoms didn’t warrant additional treatment. The cochlear damage was congenital.

VERDICT $3 million New York settlement.

COMMENT Meningitis may occur less often nowadays, but it should never be forgotten. When in doubt, order (or perform) a lumbar puncture, which can lead to a life-saving diagnosis. Early initiation of presumptive antibiotic treatment is critical.

Untreated high blood sugar ends in coma and disability

A 65-YEAR-OLD MAN sought treatment from an endocrinologist for previously diagnosed diabetes. An in-office pin prick test showed a blood sugar level exceeding the instrument’s limit. The endocrinologist ordered blood work at an outside lab. The tests indicated dangerous blood sugar levels, which were reported to the endocrinologist and his staff. The doctor allegedly didn’t act on the results.

About a week after seeing the endocrinologist, the patient collapsed; he was rushed to a hospital and placed in a protective coma. He emerged from the coma with significant injuries, including blindness in 1 eye and bilateral foot drop.

PLAINTIFF’S CLAIM The in-office test results should have alerted the doctor to a serious problem. The doctor should have sent the patient to the hospital for an immediate blood test.

DOCTOR’S DEFENSE The doctor denied any negligence.

VERDICT $1.5 million Connecticut settlement.

COMMENT Delayed or inappropriate follow up of in-office lab work remains a preventable cause of liability. If you order a test, make sure you have a protocol in place to assure timely adjudication of test results.

Disabling stroke follows failure to treat stenosis

NUMBNESS AND WEAKNESS IN HIS LEFT ARM brought a 52-year-old man to his internist. A magnetic resonance imaging scan revealed that the patient had suffered a minor, nondisabling stroke within the previous few weeks caused by an embolism arising from stenosis of the right internal carotid artery. The internist referred the patient to a neurologist but didn’t inform the neurologist that the man’s symptoms were becoming worse.

The neurologist saw the patient about a week later. She was unaware of the unstable symptoms and didn’t communicate with the internist, whose office was 1 floor below hers. The neurologist put the patient on low-dose aspirin and sent him for a nonurgent ultrasound to determine the extent of the stenosis.

The ultrasound report, which the neurologist read 8 days after the patient visit, indicated an 80% to 90% stenosis of the right internal carotid artery. The neurologist claimed she tried to reach the patient 4 times over 2 days. She left one message, but did not reach him.

Two days after the neurologist obtained the ultrasound report, the patient had a major stroke caused by a clot that had broken off from his right internal carotid artery. The stroke left him mostly paralyzed on his left side, confined to a wheelchair, and unable to work or drive.

PLAINTIFF’S CLAIM The internist failed to convey all medically significant information to the neurologist; he had a duty to intervene when he received worrisome clinical information. The neurologist should have ordered an urgent carotid endarterectomy, which would have prevented a major stroke. She also should have contacted the internist; communication would have brought to light the need for urgent treatment.

DOCTORS’ DEFENSE The internist claimed that the neurology referral was all that was required of him. The neurologist maintained that the risk of another embolic stroke within 90 days of the minor stroke was low and that nonurgent evaluation was appropriate. Both doctors claimed that the major stroke was an unfortunate and unpredictable occurrence and that, in any event, vascular surgery wouldn’t have been performed for at least 4 to 6 weeks after the small stroke because of concern over severe cerebral hemorrhage.

VERDICT $1.75 million Massachusetts settlement.

COMMENT Communicate, communicate, communicate. Without appropriate coordination of care, such unfortunate stories are likely to be repeated. Never assume that another colleague is going to follow up on that markedly abnormal finding—take matters into your own hands!

Child’s hearing loss blamed on missed meningitis Dx

A 1-YEAR-OLD GIRL WITH A PERSISTENT FEVER was seen by her pediatrician, who diagnosed tonsillitis. During the hours after her visit to the pediatrician, the child’s fever reached 104°F and she began to vomit. She was brought to an emergency room, where a radiograph revealed a potentially abnormal density of the lungs. Developing pneumonia was suspected, and she was admitted to the hospital. Doctors also suspected meningitis, but didn’t detect any abnormalities of the meninges. An antibiotic was given.

On the third day of hospitalization, a nurse observed nuchal rigidity. The child remained in the hospital for 2 weeks, during which time her body temperature remained at 100°F or higher. Two days after discharge, the girl experienced a total loss of hearing. A computed tomography scan revealed damage to the cochleae.

PLAINTIFF’S CLAIM The damage to the patient’s cochleae was caused by untreated meningitis. Nuchal rigidity should have prompted an immediate spinal tap or other test for meningitis.

DOCTOR’S DEFENSE Proper care was given; the child’s symptoms didn’t warrant additional treatment. The cochlear damage was congenital.

VERDICT $3 million New York settlement.

COMMENT Meningitis may occur less often nowadays, but it should never be forgotten. When in doubt, order (or perform) a lumbar puncture, which can lead to a life-saving diagnosis. Early initiation of presumptive antibiotic treatment is critical.

Untreated high blood sugar ends in coma and disability

A 65-YEAR-OLD MAN sought treatment from an endocrinologist for previously diagnosed diabetes. An in-office pin prick test showed a blood sugar level exceeding the instrument’s limit. The endocrinologist ordered blood work at an outside lab. The tests indicated dangerous blood sugar levels, which were reported to the endocrinologist and his staff. The doctor allegedly didn’t act on the results.

About a week after seeing the endocrinologist, the patient collapsed; he was rushed to a hospital and placed in a protective coma. He emerged from the coma with significant injuries, including blindness in 1 eye and bilateral foot drop.

PLAINTIFF’S CLAIM The in-office test results should have alerted the doctor to a serious problem. The doctor should have sent the patient to the hospital for an immediate blood test.

DOCTOR’S DEFENSE The doctor denied any negligence.

VERDICT $1.5 million Connecticut settlement.

COMMENT Delayed or inappropriate follow up of in-office lab work remains a preventable cause of liability. If you order a test, make sure you have a protocol in place to assure timely adjudication of test results.

Complaint of arm pain ends in death

TWO WEEKS OF SEVERE PAIN IN HER LEFT ARM, along with severe chest pain and a sensation of “elephants” on her chest, prompted a 49-year-old woman to visit her primary care physician. The patient had gone to the emergency room 3 months earlier with chest pain. A stress test done at that time was negative, and an electrocardiogram was normal. The woman had a history of hypercholesterolemia and a family history of heart disease. She had recently quit smoking after 25 years.

The physician’s nurse practitioner noted bilateral arm pain and diagnosed arthralgia. The doctor and nurse claimed that the doctor performed an impromptu physical examination as the patient was leaving the office (the patient claimed, in disallowed testimony, that she had seen the doctor only in the parking lot, and he didn’t examine her). The doctor said that the patient denied chest pain when he examined her and reported bilateral rather than left arm pain. He also said he found a neck spasm and prescribed Darvocet for the arm pain. The doctor didn’t record the findings of the exam.

The patient died in her bathroom 2 days later. The cause was an arrhythmia resulting from decreased blood flow to the heart from atherosclerotic disease.

PLAINTIFF’S CLAIM Cardiac ischemia should have been ruled out at the office visit.

DOCTOR’S DEFENSE An adequate examination was performed to rule out cardiac disease, and reliance on the previous stress test results was proper.

VERDICT $1.215 million Florida verdict.

COMMENT Appropriate documentation might have averted a $1.2 million plaintiff verdict!

Delayed diagnosis leads to quadriplegia

A 60-YEAR-OLD WOMAN WAS TREATED FOR NECK PAIN at a hospital and released. The next day, she went to a medical center because of pain running down her arm. Nine hours later, she lost sensation in her legs.

Magnetic resonance imaging performed the following day revealed an epidural abscess. The woman underwent surgery at another hospital that night.

PLAINTIFF’S CLAIM The delay in diagnosis and surgery caused the plaintiff to become quadriplegic.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $1.9 million New Jersey settlement.

COMMENT While most radiculopathy (whether cervical or lumbar) can be treated conservatively, cauda equina or symptoms of myelopathy indicate a neurosurgical emergency. A delay in definitive diagnosis and treatment will undoubtedly play out in court.

“Classic” endocarditis is missed again, and again

AFTER 5 OR 6 WEEKS OF SYMPTOMS, including fever, chills, myalgia, weight loss, fatigue, light-headedness, weakness, non-productive cough, and intermittent fever that peaked at 102.3°F, a 24-year-old woman sought treatment at her family physician’s office. She had a documented grade III heart murmur, interpreted by her physician as a long-standing benign systolic murmur.

Although she didn’t report dysuria, urgency, frequency, flank pain, or other urinary symptoms, the physician assistant who saw the patient at this visit diagnosed a urinary tract infection. The PA prescribed antibiotics and instructed the patient to follow up in several weeks.

The woman returned twice during the month after her initial visit; she was seen by a physician on both occasions. She reported a syncopal episode and was diagnosed with ongoing anemia attributable to normal iron deficiency. No diagnostic tests were ordered.

During follow-up visits over the next 2 months, the patient complained of increasing fatigue, shortness of breath, tremors, and loss of appetite. She was given a diagnosis of depression and a prescription for Zoloft. When she continued to deteriorate, she was given an additional diagnosis of possible bronchitis or pneumonia.

Early one evening 3 months after her initial visit, on a day when she had been seen at the practice, the patient collapsed at home. She was taken by ambulance to a hospital, where she died of cardiopulmonary arrest. An autopsy revealed bacterial endocarditis of the mitral valve.

PLAINTIFF’S CLAIM The patient had a classic presentation of endocarditis; a proper workup would have led to diagnosis and treatment.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $1.2 million Virginia settlement.

COMMENT Although horses are common, when a patient fails to improve, we need to think of zebras, too. In this case, the combination of fever, constitutional symptoms, and a heart murmur should have at least raised the suspicion of bacterial endocarditis.

Malignant mole never made it to pathology

A WOMAN NOTICED A NEW MOLE ON HER LEFT FOOT, which didn’t concern her until 4 years later, when it began to grow, itch, and turn red. She went to her family physician, who decided to remove the mole. After doing so, the doctor told the patient that he’d send it for pathologic inspection and handed it to the assisting nurse, expecting her to prepare it properly for the laboratory.

When the time came to remove the stitches, the patient asked her family physician if a doctor in the medical practice where she worked could take them out. The family physician agreed. The patient didn’t return to her family physician afterward; she transferred to a primary care physician in the office where she worked.

The mole then returned to the patient’s foot, and she requested transfer of her records to the new physician. When the records arrived, they didn’t include a pathology report; it appeared that the mole hadn’t been sent to the pathology lab.

The patient’s physician sent her to a podiatrist, who removed the recurrent mole a little over a year after she first consulted her family physician. The pathology report indicated it was a malignant melanoma.

PLAINTIFF’S CLAIM It was negligent to fail to send the mole to a pathology lab and to fail to notice that a pathology report had not come back. The delay in diagnosis and treatment of the cancer increased the risk of recurrence and other complications.

THE DEFENSE The family physician blamed the procedures of the group, and the group blamed the family doctor.

VERDICT $3.25 million Kentucky verdict.

COMMENT I recently participated as an expert witness (for the defense) in a similar malpractice case in which the defendant did send the mole to pathology. In today’s litigious society, how can we not send every “mole” for pathologic examination?

Complaint of arm pain ends in death

TWO WEEKS OF SEVERE PAIN IN HER LEFT ARM, along with severe chest pain and a sensation of “elephants” on her chest, prompted a 49-year-old woman to visit her primary care physician. The patient had gone to the emergency room 3 months earlier with chest pain. A stress test done at that time was negative, and an electrocardiogram was normal. The woman had a history of hypercholesterolemia and a family history of heart disease. She had recently quit smoking after 25 years.

The physician’s nurse practitioner noted bilateral arm pain and diagnosed arthralgia. The doctor and nurse claimed that the doctor performed an impromptu physical examination as the patient was leaving the office (the patient claimed, in disallowed testimony, that she had seen the doctor only in the parking lot, and he didn’t examine her). The doctor said that the patient denied chest pain when he examined her and reported bilateral rather than left arm pain. He also said he found a neck spasm and prescribed Darvocet for the arm pain. The doctor didn’t record the findings of the exam.

The patient died in her bathroom 2 days later. The cause was an arrhythmia resulting from decreased blood flow to the heart from atherosclerotic disease.

PLAINTIFF’S CLAIM Cardiac ischemia should have been ruled out at the office visit.

DOCTOR’S DEFENSE An adequate examination was performed to rule out cardiac disease, and reliance on the previous stress test results was proper.

VERDICT $1.215 million Florida verdict.

COMMENT Appropriate documentation might have averted a $1.2 million plaintiff verdict!

Delayed diagnosis leads to quadriplegia

A 60-YEAR-OLD WOMAN WAS TREATED FOR NECK PAIN at a hospital and released. The next day, she went to a medical center because of pain running down her arm. Nine hours later, she lost sensation in her legs.

Magnetic resonance imaging performed the following day revealed an epidural abscess. The woman underwent surgery at another hospital that night.

PLAINTIFF’S CLAIM The delay in diagnosis and surgery caused the plaintiff to become quadriplegic.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $1.9 million New Jersey settlement.

COMMENT While most radiculopathy (whether cervical or lumbar) can be treated conservatively, cauda equina or symptoms of myelopathy indicate a neurosurgical emergency. A delay in definitive diagnosis and treatment will undoubtedly play out in court.

“Classic” endocarditis is missed again, and again

AFTER 5 OR 6 WEEKS OF SYMPTOMS, including fever, chills, myalgia, weight loss, fatigue, light-headedness, weakness, non-productive cough, and intermittent fever that peaked at 102.3°F, a 24-year-old woman sought treatment at her family physician’s office. She had a documented grade III heart murmur, interpreted by her physician as a long-standing benign systolic murmur.

Although she didn’t report dysuria, urgency, frequency, flank pain, or other urinary symptoms, the physician assistant who saw the patient at this visit diagnosed a urinary tract infection. The PA prescribed antibiotics and instructed the patient to follow up in several weeks.

The woman returned twice during the month after her initial visit; she was seen by a physician on both occasions. She reported a syncopal episode and was diagnosed with ongoing anemia attributable to normal iron deficiency. No diagnostic tests were ordered.

During follow-up visits over the next 2 months, the patient complained of increasing fatigue, shortness of breath, tremors, and loss of appetite. She was given a diagnosis of depression and a prescription for Zoloft. When she continued to deteriorate, she was given an additional diagnosis of possible bronchitis or pneumonia.

Early one evening 3 months after her initial visit, on a day when she had been seen at the practice, the patient collapsed at home. She was taken by ambulance to a hospital, where she died of cardiopulmonary arrest. An autopsy revealed bacterial endocarditis of the mitral valve.

PLAINTIFF’S CLAIM The patient had a classic presentation of endocarditis; a proper workup would have led to diagnosis and treatment.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $1.2 million Virginia settlement.

COMMENT Although horses are common, when a patient fails to improve, we need to think of zebras, too. In this case, the combination of fever, constitutional symptoms, and a heart murmur should have at least raised the suspicion of bacterial endocarditis.

Malignant mole never made it to pathology

A WOMAN NOTICED A NEW MOLE ON HER LEFT FOOT, which didn’t concern her until 4 years later, when it began to grow, itch, and turn red. She went to her family physician, who decided to remove the mole. After doing so, the doctor told the patient that he’d send it for pathologic inspection and handed it to the assisting nurse, expecting her to prepare it properly for the laboratory.

When the time came to remove the stitches, the patient asked her family physician if a doctor in the medical practice where she worked could take them out. The family physician agreed. The patient didn’t return to her family physician afterward; she transferred to a primary care physician in the office where she worked.

The mole then returned to the patient’s foot, and she requested transfer of her records to the new physician. When the records arrived, they didn’t include a pathology report; it appeared that the mole hadn’t been sent to the pathology lab.

The patient’s physician sent her to a podiatrist, who removed the recurrent mole a little over a year after she first consulted her family physician. The pathology report indicated it was a malignant melanoma.

PLAINTIFF’S CLAIM It was negligent to fail to send the mole to a pathology lab and to fail to notice that a pathology report had not come back. The delay in diagnosis and treatment of the cancer increased the risk of recurrence and other complications.

THE DEFENSE The family physician blamed the procedures of the group, and the group blamed the family doctor.

VERDICT $3.25 million Kentucky verdict.

COMMENT I recently participated as an expert witness (for the defense) in a similar malpractice case in which the defendant did send the mole to pathology. In today’s litigious society, how can we not send every “mole” for pathologic examination?

Complaint of arm pain ends in death

TWO WEEKS OF SEVERE PAIN IN HER LEFT ARM, along with severe chest pain and a sensation of “elephants” on her chest, prompted a 49-year-old woman to visit her primary care physician. The patient had gone to the emergency room 3 months earlier with chest pain. A stress test done at that time was negative, and an electrocardiogram was normal. The woman had a history of hypercholesterolemia and a family history of heart disease. She had recently quit smoking after 25 years.

The physician’s nurse practitioner noted bilateral arm pain and diagnosed arthralgia. The doctor and nurse claimed that the doctor performed an impromptu physical examination as the patient was leaving the office (the patient claimed, in disallowed testimony, that she had seen the doctor only in the parking lot, and he didn’t examine her). The doctor said that the patient denied chest pain when he examined her and reported bilateral rather than left arm pain. He also said he found a neck spasm and prescribed Darvocet for the arm pain. The doctor didn’t record the findings of the exam.

The patient died in her bathroom 2 days later. The cause was an arrhythmia resulting from decreased blood flow to the heart from atherosclerotic disease.

PLAINTIFF’S CLAIM Cardiac ischemia should have been ruled out at the office visit.

DOCTOR’S DEFENSE An adequate examination was performed to rule out cardiac disease, and reliance on the previous stress test results was proper.

VERDICT $1.215 million Florida verdict.

COMMENT Appropriate documentation might have averted a $1.2 million plaintiff verdict!

Delayed diagnosis leads to quadriplegia

A 60-YEAR-OLD WOMAN WAS TREATED FOR NECK PAIN at a hospital and released. The next day, she went to a medical center because of pain running down her arm. Nine hours later, she lost sensation in her legs.

Magnetic resonance imaging performed the following day revealed an epidural abscess. The woman underwent surgery at another hospital that night.

PLAINTIFF’S CLAIM The delay in diagnosis and surgery caused the plaintiff to become quadriplegic.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $1.9 million New Jersey settlement.

COMMENT While most radiculopathy (whether cervical or lumbar) can be treated conservatively, cauda equina or symptoms of myelopathy indicate a neurosurgical emergency. A delay in definitive diagnosis and treatment will undoubtedly play out in court.

“Classic” endocarditis is missed again, and again

AFTER 5 OR 6 WEEKS OF SYMPTOMS, including fever, chills, myalgia, weight loss, fatigue, light-headedness, weakness, non-productive cough, and intermittent fever that peaked at 102.3°F, a 24-year-old woman sought treatment at her family physician’s office. She had a documented grade III heart murmur, interpreted by her physician as a long-standing benign systolic murmur.

Although she didn’t report dysuria, urgency, frequency, flank pain, or other urinary symptoms, the physician assistant who saw the patient at this visit diagnosed a urinary tract infection. The PA prescribed antibiotics and instructed the patient to follow up in several weeks.

The woman returned twice during the month after her initial visit; she was seen by a physician on both occasions. She reported a syncopal episode and was diagnosed with ongoing anemia attributable to normal iron deficiency. No diagnostic tests were ordered.

During follow-up visits over the next 2 months, the patient complained of increasing fatigue, shortness of breath, tremors, and loss of appetite. She was given a diagnosis of depression and a prescription for Zoloft. When she continued to deteriorate, she was given an additional diagnosis of possible bronchitis or pneumonia.

Early one evening 3 months after her initial visit, on a day when she had been seen at the practice, the patient collapsed at home. She was taken by ambulance to a hospital, where she died of cardiopulmonary arrest. An autopsy revealed bacterial endocarditis of the mitral valve.

PLAINTIFF’S CLAIM The patient had a classic presentation of endocarditis; a proper workup would have led to diagnosis and treatment.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $1.2 million Virginia settlement.

COMMENT Although horses are common, when a patient fails to improve, we need to think of zebras, too. In this case, the combination of fever, constitutional symptoms, and a heart murmur should have at least raised the suspicion of bacterial endocarditis.

Malignant mole never made it to pathology

A WOMAN NOTICED A NEW MOLE ON HER LEFT FOOT, which didn’t concern her until 4 years later, when it began to grow, itch, and turn red. She went to her family physician, who decided to remove the mole. After doing so, the doctor told the patient that he’d send it for pathologic inspection and handed it to the assisting nurse, expecting her to prepare it properly for the laboratory.

When the time came to remove the stitches, the patient asked her family physician if a doctor in the medical practice where she worked could take them out. The family physician agreed. The patient didn’t return to her family physician afterward; she transferred to a primary care physician in the office where she worked.

The mole then returned to the patient’s foot, and she requested transfer of her records to the new physician. When the records arrived, they didn’t include a pathology report; it appeared that the mole hadn’t been sent to the pathology lab.

The patient’s physician sent her to a podiatrist, who removed the recurrent mole a little over a year after she first consulted her family physician. The pathology report indicated it was a malignant melanoma.

PLAINTIFF’S CLAIM It was negligent to fail to send the mole to a pathology lab and to fail to notice that a pathology report had not come back. The delay in diagnosis and treatment of the cancer increased the risk of recurrence and other complications.

THE DEFENSE The family physician blamed the procedures of the group, and the group blamed the family doctor.

VERDICT $3.25 million Kentucky verdict.

COMMENT I recently participated as an expert witness (for the defense) in a similar malpractice case in which the defendant did send the mole to pathology. In today’s litigious society, how can we not send every “mole” for pathologic examination?

Was surgery telecast without consent, as patient claims?

A 48-YEAR-OLD WOMAN underwent a minimally invasive hysteroscopic myomectomy. The surgery was telecast live for Ethicon, which paid the surgeon an honorarium of $500. The patient subsequently developed metastatic ovarian cancer. She sued her gynecologist for failing to detect her ovarian cancer in a timely manner. At the time of trial she was in hospice care. During discovery, she asked that a copy of the telecast be produced. The day before trial, her counsel found the video on the Internet and obtained a copy. It did not reveal any identifying information about the patient.

• PATIENT’S CLAIM The defendant was negligent for failure to: (1) send her for genetic testing/counseling based on her family history; (2) recommend/perform a hysterectomy, as her family history required aggressive treatment; (3) obtain informed consent for the surgery; (4) disclose that the surgery was to be telecast live for ethicon; and (5) disclose that he received an honorarium. The patient also claimed she was given a diagnosis of ovarian cancer 11 months after the surgery.
  
• PHYSICIAN’S DEFENSE At her first visit, the patient indicated she had already been counseled and didn’t need more counseling. She also refused a hysterectomy, choosing instead a minimally invasive procedure. The standard of care at the time did not require referral for genetic counseling/testing. The patient was informed about the telecast, but disclosing the honorarium to her was not required.
  
• VERDICT Illinois defense verdict. Ethicon was granted summary judgment, and the plaintiff voluntarily dismissed the physician from the misappropriation of identity claim.
  

One twin lives and other dies in delayed C-section

A WOMAN PREGNANT with twins presented at the hospital at 35.5 weeks’ gestation with spontaneous rupture of membranes. Dr. A, the ObGyn on call at the time, determined that both twins were in the breech position and the male twin had ruptured membranes. He ordered fetal heart monitoring. The following morning, Dr. B ordered an immediate cesarean delivery because of the possibility of a prolapsed cord. After a 2-hour delay, the twins were delivered—the female successfully, but the male twin was stillborn. The baby’s body was placed in the mother’s hospital room until it was removed for autopsy 2 days later.

• PATIENT’S CLAIM (1) Dr. A should have ordered an immediate cesarean delivery. (2) Dr. B should have made sure that the cesarean delivery he ordered was performed more timely. (3) Because of the patient’s large size, fetal heart rates could not be monitored properly. (4) The hospital should not have left the child’s body in the mother’s room for 2 days.
  
• PHYSICIAN’S DEFENSE Dr. A claimed an immediate cesarean delivery was not necessary.
  
• VERDICT Indiana defense verdict for Dr. A. Claims against Dr. B and the hospital were dismissed on summary judgment.
  

$19.6M for mother’s incontinence and child’s CP

A 37-YEAR-OLD WOMAN’S labor and delivery were managed by Dr. A, a resident, and Dr. B, an obstetrician. Following labor induction, the mother’s temperature rose and the heart rates of both mother and fetus increased. Believing the mother could have chorioamnionitis, Dr. A and Dr. B decided on a forceps delivery. During the delivery, the mother suffered a 4th degree laceration of the vagina. Dr. A repaired the laceration.

• PATIENT’S CLAIM Repair of the laceration was not effective, and she suffers permanent residual incontinence as a result. Also, the child suffered cerebral palsy resulting from injury during delivery.
  
• PHYSICIAN’S DEFENSE The mother made a good recovery. The child did not suffer a brain injury. Rather he has tibial torsion and is pigeon-toed—which caused problems with his gait.
  
• VERDICT $19.6 million New York verdict: $11,965,000 for the mother and $7,650,000 for the child.
  

Was surgery telecast without consent, as patient claims?

A 48-YEAR-OLD WOMAN underwent a minimally invasive hysteroscopic myomectomy. The surgery was telecast live for Ethicon, which paid the surgeon an honorarium of $500. The patient subsequently developed metastatic ovarian cancer. She sued her gynecologist for failing to detect her ovarian cancer in a timely manner. At the time of trial she was in hospice care. During discovery, she asked that a copy of the telecast be produced. The day before trial, her counsel found the video on the Internet and obtained a copy. It did not reveal any identifying information about the patient.

• PATIENT’S CLAIM The defendant was negligent for failure to: (1) send her for genetic testing/counseling based on her family history; (2) recommend/perform a hysterectomy, as her family history required aggressive treatment; (3) obtain informed consent for the surgery; (4) disclose that the surgery was to be telecast live for ethicon; and (5) disclose that he received an honorarium. The patient also claimed she was given a diagnosis of ovarian cancer 11 months after the surgery.
  
• PHYSICIAN’S DEFENSE At her first visit, the patient indicated she had already been counseled and didn’t need more counseling. She also refused a hysterectomy, choosing instead a minimally invasive procedure. The standard of care at the time did not require referral for genetic counseling/testing. The patient was informed about the telecast, but disclosing the honorarium to her was not required.
  
• VERDICT Illinois defense verdict. Ethicon was granted summary judgment, and the plaintiff voluntarily dismissed the physician from the misappropriation of identity claim.
  

One twin lives and other dies in delayed C-section

A WOMAN PREGNANT with twins presented at the hospital at 35.5 weeks’ gestation with spontaneous rupture of membranes. Dr. A, the ObGyn on call at the time, determined that both twins were in the breech position and the male twin had ruptured membranes. He ordered fetal heart monitoring. The following morning, Dr. B ordered an immediate cesarean delivery because of the possibility of a prolapsed cord. After a 2-hour delay, the twins were delivered—the female successfully, but the male twin was stillborn. The baby’s body was placed in the mother’s hospital room until it was removed for autopsy 2 days later.

• PATIENT’S CLAIM (1) Dr. A should have ordered an immediate cesarean delivery. (2) Dr. B should have made sure that the cesarean delivery he ordered was performed more timely. (3) Because of the patient’s large size, fetal heart rates could not be monitored properly. (4) The hospital should not have left the child’s body in the mother’s room for 2 days.
  
• PHYSICIAN’S DEFENSE Dr. A claimed an immediate cesarean delivery was not necessary.
  
• VERDICT Indiana defense verdict for Dr. A. Claims against Dr. B and the hospital were dismissed on summary judgment.
  

$19.6M for mother’s incontinence and child’s CP

A 37-YEAR-OLD WOMAN’S labor and delivery were managed by Dr. A, a resident, and Dr. B, an obstetrician. Following labor induction, the mother’s temperature rose and the heart rates of both mother and fetus increased. Believing the mother could have chorioamnionitis, Dr. A and Dr. B decided on a forceps delivery. During the delivery, the mother suffered a 4th degree laceration of the vagina. Dr. A repaired the laceration.

• PATIENT’S CLAIM Repair of the laceration was not effective, and she suffers permanent residual incontinence as a result. Also, the child suffered cerebral palsy resulting from injury during delivery.
  
• PHYSICIAN’S DEFENSE The mother made a good recovery. The child did not suffer a brain injury. Rather he has tibial torsion and is pigeon-toed—which caused problems with his gait.
  
• VERDICT $19.6 million New York verdict: $11,965,000 for the mother and $7,650,000 for the child.
  

Was surgery telecast without consent, as patient claims?

A 48-YEAR-OLD WOMAN underwent a minimally invasive hysteroscopic myomectomy. The surgery was telecast live for Ethicon, which paid the surgeon an honorarium of $500. The patient subsequently developed metastatic ovarian cancer. She sued her gynecologist for failing to detect her ovarian cancer in a timely manner. At the time of trial she was in hospice care. During discovery, she asked that a copy of the telecast be produced. The day before trial, her counsel found the video on the Internet and obtained a copy. It did not reveal any identifying information about the patient.

• PATIENT’S CLAIM The defendant was negligent for failure to: (1) send her for genetic testing/counseling based on her family history; (2) recommend/perform a hysterectomy, as her family history required aggressive treatment; (3) obtain informed consent for the surgery; (4) disclose that the surgery was to be telecast live for ethicon; and (5) disclose that he received an honorarium. The patient also claimed she was given a diagnosis of ovarian cancer 11 months after the surgery.
  
• PHYSICIAN’S DEFENSE At her first visit, the patient indicated she had already been counseled and didn’t need more counseling. She also refused a hysterectomy, choosing instead a minimally invasive procedure. The standard of care at the time did not require referral for genetic counseling/testing. The patient was informed about the telecast, but disclosing the honorarium to her was not required.
  
• VERDICT Illinois defense verdict. Ethicon was granted summary judgment, and the plaintiff voluntarily dismissed the physician from the misappropriation of identity claim.
  

One twin lives and other dies in delayed C-section

A WOMAN PREGNANT with twins presented at the hospital at 35.5 weeks’ gestation with spontaneous rupture of membranes. Dr. A, the ObGyn on call at the time, determined that both twins were in the breech position and the male twin had ruptured membranes. He ordered fetal heart monitoring. The following morning, Dr. B ordered an immediate cesarean delivery because of the possibility of a prolapsed cord. After a 2-hour delay, the twins were delivered—the female successfully, but the male twin was stillborn. The baby’s body was placed in the mother’s hospital room until it was removed for autopsy 2 days later.

• PATIENT’S CLAIM (1) Dr. A should have ordered an immediate cesarean delivery. (2) Dr. B should have made sure that the cesarean delivery he ordered was performed more timely. (3) Because of the patient’s large size, fetal heart rates could not be monitored properly. (4) The hospital should not have left the child’s body in the mother’s room for 2 days.
  
• PHYSICIAN’S DEFENSE Dr. A claimed an immediate cesarean delivery was not necessary.
  
• VERDICT Indiana defense verdict for Dr. A. Claims against Dr. B and the hospital were dismissed on summary judgment.
  

$19.6M for mother’s incontinence and child’s CP

A 37-YEAR-OLD WOMAN’S labor and delivery were managed by Dr. A, a resident, and Dr. B, an obstetrician. Following labor induction, the mother’s temperature rose and the heart rates of both mother and fetus increased. Believing the mother could have chorioamnionitis, Dr. A and Dr. B decided on a forceps delivery. During the delivery, the mother suffered a 4th degree laceration of the vagina. Dr. A repaired the laceration.

• PATIENT’S CLAIM Repair of the laceration was not effective, and she suffers permanent residual incontinence as a result. Also, the child suffered cerebral palsy resulting from injury during delivery.
  
• PHYSICIAN’S DEFENSE The mother made a good recovery. The child did not suffer a brain injury. Rather he has tibial torsion and is pigeon-toed—which caused problems with his gait.
  
• VERDICT $19.6 million New York verdict: $11,965,000 for the mother and $7,650,000 for the child.
  

MD: “She had no complaints because I have no notes”

FOLLOWING HYSTERECTOMY, a 49-year-old woman complained of abdominal pain, fever, chills, and nausea. She continued to complain of the same symptoms on multiple visits to her physician. She also called him to report that her abdomen was painful to the touch. After one such call, the physician prescribed an antibiotic.

A routine x-ray of the patient’s prosthetic hip 5 months after the hysterectomy showed a surgical sponge in her abdomen. She reported this finding to the defendant, who then left a voicemail that (1) he was away, (2) she could live to 100 years old with that sponge inside her, and (3) she should return for a consultation in a few weeks.

Instead she sought the care of another physician.

A month later, she developed a bowel obstruction. In emergency surgery, the sponge was removed as it had created an abscess and bowel obstruction. After the surgery, the patient recovered and had no further abdominal complaints.

PATIENT’S CLAIM The physician was negligent for leaving the sponge in the abdomen and for failing to follow up on her consistent complaints of abdominal pain.

PHYSICIAN’S DEFENSE The nurses were responsible for a proper sponge count. Also, the patient did not complain of pain after surgery—because he had no notes stating that she did.

VERDICT $4,904,886 Maryland verdict, which was reduced by caps to $1,329,886.

Incontinence is worse after TVT and takedown

A WOMAN WHO WAS SUFFERING from stress urinary incontinence underwent a tension-free vaginal tape procedure (TVT). Following surgery, she developed urinary retention. To address this, her physician performed a TVT “takedown” procedure—and accidentally injured her bladder and urethra. The injuries were recognized and repaired. Because of worsening incontinence, the patient transferred her care to a urologist. Following a transvaginal sling procedure, her incontinence improved.

Eventually, she underwent a total abdominal hysterectomy as well as a procedure to address a prolapse involving her bladder. At this point, the patient became severely incontinent. A revision of the transvaginal sling repair was then performed.

PATIENT’S CLAIM Despite all the procedures, she remains incontinent. She also developed disabling chronic pelvic pain due to the procedures.

PHYSICIAN’S DEFENSE He denied negligence and insisted that the patient’s chronic pelvic pain was due to interstitial cystitis. He admitted causing the bladder and urethra injuries during the TVT takedown, but he recognized and repaired them immediately.

VERDICT Colorado defense verdict.

Colon is injured in D & E following fetal death

A 23-YEAR-OLD WOMAN suffered a fetal demise at 15 to 17 weeks’ gestation. Dr. A, an ObGyn, decided to perform a dilation and evacuation (D & E) involving removal of fetal parts in a blind procedure. On the preceding day, he inserted a laminaria to enlarge the cervix for the evacuation.

During the D & E, he inadvertently punctured the uterine wall with ring forceps and then grasped part of the sigmoid colon, believing he was removing a bone embedded in the wall. This caused vascular disruption and ischemia to the colon, but did not lacerate it. Aware that a complication had occurred, Dr. A switched to laparoscopy and consulted Dr. B, a general surgeon. When the scope indicated a 1.5- to 2-cm perforation in the fundus of the uterus, as well as bluish discoloration in the mesentery, Dr. B decided to resect the colon and perform a temporary colostomy.

The colostomy was reversed 3 months later. The patient has since given birth to a child by cesarean delivery.

PATIENT’S CLAIM Dr. A was negligent for pulling the colon into the uterus and clamping it to the uterine wall.

PHYSICIAN’S DEFENSE Dr. A claimed the uterus was penetrated accidently during the blind procedure. When he grasped the colon’s mesentery, he then released it in under 1 minute.

VERDICT Illinois defense verdict.

MD: “She had no complaints because I have no notes”

FOLLOWING HYSTERECTOMY, a 49-year-old woman complained of abdominal pain, fever, chills, and nausea. She continued to complain of the same symptoms on multiple visits to her physician. She also called him to report that her abdomen was painful to the touch. After one such call, the physician prescribed an antibiotic.

A routine x-ray of the patient’s prosthetic hip 5 months after the hysterectomy showed a surgical sponge in her abdomen. She reported this finding to the defendant, who then left a voicemail that (1) he was away, (2) she could live to 100 years old with that sponge inside her, and (3) she should return for a consultation in a few weeks.

Instead she sought the care of another physician.

A month later, she developed a bowel obstruction. In emergency surgery, the sponge was removed as it had created an abscess and bowel obstruction. After the surgery, the patient recovered and had no further abdominal complaints.

PATIENT’S CLAIM The physician was negligent for leaving the sponge in the abdomen and for failing to follow up on her consistent complaints of abdominal pain.

PHYSICIAN’S DEFENSE The nurses were responsible for a proper sponge count. Also, the patient did not complain of pain after surgery—because he had no notes stating that she did.

VERDICT $4,904,886 Maryland verdict, which was reduced by caps to $1,329,886.

Incontinence is worse after TVT and takedown

A WOMAN WHO WAS SUFFERING from stress urinary incontinence underwent a tension-free vaginal tape procedure (TVT). Following surgery, she developed urinary retention. To address this, her physician performed a TVT “takedown” procedure—and accidentally injured her bladder and urethra. The injuries were recognized and repaired. Because of worsening incontinence, the patient transferred her care to a urologist. Following a transvaginal sling procedure, her incontinence improved.

Eventually, she underwent a total abdominal hysterectomy as well as a procedure to address a prolapse involving her bladder. At this point, the patient became severely incontinent. A revision of the transvaginal sling repair was then performed.

PATIENT’S CLAIM Despite all the procedures, she remains incontinent. She also developed disabling chronic pelvic pain due to the procedures.

PHYSICIAN’S DEFENSE He denied negligence and insisted that the patient’s chronic pelvic pain was due to interstitial cystitis. He admitted causing the bladder and urethra injuries during the TVT takedown, but he recognized and repaired them immediately.

VERDICT Colorado defense verdict.

Colon is injured in D & E following fetal death

A 23-YEAR-OLD WOMAN suffered a fetal demise at 15 to 17 weeks’ gestation. Dr. A, an ObGyn, decided to perform a dilation and evacuation (D & E) involving removal of fetal parts in a blind procedure. On the preceding day, he inserted a laminaria to enlarge the cervix for the evacuation.

During the D & E, he inadvertently punctured the uterine wall with ring forceps and then grasped part of the sigmoid colon, believing he was removing a bone embedded in the wall. This caused vascular disruption and ischemia to the colon, but did not lacerate it. Aware that a complication had occurred, Dr. A switched to laparoscopy and consulted Dr. B, a general surgeon. When the scope indicated a 1.5- to 2-cm perforation in the fundus of the uterus, as well as bluish discoloration in the mesentery, Dr. B decided to resect the colon and perform a temporary colostomy.

The colostomy was reversed 3 months later. The patient has since given birth to a child by cesarean delivery.

PATIENT’S CLAIM Dr. A was negligent for pulling the colon into the uterus and clamping it to the uterine wall.

PHYSICIAN’S DEFENSE Dr. A claimed the uterus was penetrated accidently during the blind procedure. When he grasped the colon’s mesentery, he then released it in under 1 minute.

VERDICT Illinois defense verdict.

MD: “She had no complaints because I have no notes”

FOLLOWING HYSTERECTOMY, a 49-year-old woman complained of abdominal pain, fever, chills, and nausea. She continued to complain of the same symptoms on multiple visits to her physician. She also called him to report that her abdomen was painful to the touch. After one such call, the physician prescribed an antibiotic.

A routine x-ray of the patient’s prosthetic hip 5 months after the hysterectomy showed a surgical sponge in her abdomen. She reported this finding to the defendant, who then left a voicemail that (1) he was away, (2) she could live to 100 years old with that sponge inside her, and (3) she should return for a consultation in a few weeks.

Instead she sought the care of another physician.

A month later, she developed a bowel obstruction. In emergency surgery, the sponge was removed as it had created an abscess and bowel obstruction. After the surgery, the patient recovered and had no further abdominal complaints.

PATIENT’S CLAIM The physician was negligent for leaving the sponge in the abdomen and for failing to follow up on her consistent complaints of abdominal pain.

PHYSICIAN’S DEFENSE The nurses were responsible for a proper sponge count. Also, the patient did not complain of pain after surgery—because he had no notes stating that she did.

VERDICT $4,904,886 Maryland verdict, which was reduced by caps to $1,329,886.

Incontinence is worse after TVT and takedown

A WOMAN WHO WAS SUFFERING from stress urinary incontinence underwent a tension-free vaginal tape procedure (TVT). Following surgery, she developed urinary retention. To address this, her physician performed a TVT “takedown” procedure—and accidentally injured her bladder and urethra. The injuries were recognized and repaired. Because of worsening incontinence, the patient transferred her care to a urologist. Following a transvaginal sling procedure, her incontinence improved.

Eventually, she underwent a total abdominal hysterectomy as well as a procedure to address a prolapse involving her bladder. At this point, the patient became severely incontinent. A revision of the transvaginal sling repair was then performed.

PATIENT’S CLAIM Despite all the procedures, she remains incontinent. She also developed disabling chronic pelvic pain due to the procedures.

PHYSICIAN’S DEFENSE He denied negligence and insisted that the patient’s chronic pelvic pain was due to interstitial cystitis. He admitted causing the bladder and urethra injuries during the TVT takedown, but he recognized and repaired them immediately.

VERDICT Colorado defense verdict.

Colon is injured in D & E following fetal death

A 23-YEAR-OLD WOMAN suffered a fetal demise at 15 to 17 weeks’ gestation. Dr. A, an ObGyn, decided to perform a dilation and evacuation (D & E) involving removal of fetal parts in a blind procedure. On the preceding day, he inserted a laminaria to enlarge the cervix for the evacuation.

During the D & E, he inadvertently punctured the uterine wall with ring forceps and then grasped part of the sigmoid colon, believing he was removing a bone embedded in the wall. This caused vascular disruption and ischemia to the colon, but did not lacerate it. Aware that a complication had occurred, Dr. A switched to laparoscopy and consulted Dr. B, a general surgeon. When the scope indicated a 1.5- to 2-cm perforation in the fundus of the uterus, as well as bluish discoloration in the mesentery, Dr. B decided to resect the colon and perform a temporary colostomy.

The colostomy was reversed 3 months later. The patient has since given birth to a child by cesarean delivery.

PATIENT’S CLAIM Dr. A was negligent for pulling the colon into the uterus and clamping it to the uterine wall.

PHYSICIAN’S DEFENSE Dr. A claimed the uterus was penetrated accidently during the blind procedure. When he grasped the colon’s mesentery, he then released it in under 1 minute.

VERDICT Illinois defense verdict.

Birth control change proves fatal

THE WORST HEADACHE SHE EVER HAD brought a 21-year-old woman to the emergency room. She had suffered severe headaches the previous month after switching from Depo-Provera shots to Nordette 28 birth control pills; the headaches went away, then returned.

A month after the ER visit, she visited a family medicine clinic, complaining of headaches, nausea, diarrhea, possible fever, and slight dizziness. A physician assistant prescribed Bactrim DS, Phenergan for the nausea, and Phrenilin for the headache.

Two days later, the patient was taken by ambulance to an ER because of numbness all over, nausea, vomiting, and dizziness. She was discharged, but brought back 4 hours later somnolent, difficult to arouse, and unable to obey commands. A computed tomography (CT) scan and magnetic resonance imaging performed the next morning showed blood clots in the brain, with complete occlusion of the superior sagittal sinus vein, and cerebral herniation.

A few days later, the patient was removed from life support. An autopsy indicated that the cause of death was a recent thrombus of the superior sagittal sinus with bilateral acute cerebral infarcts associated with secondary thrombi of tributary veins.

PLAINTIFF’S CLAIM The defendants were negligent in failing to pay attention to the change in the patient’s birth control regimen and test for cerebral thrombosis, a recognized adverse reaction when switching from shots to pills for birth control.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $7 million North Carolina verdict.

COMMENT If you want to avoid malpractice, make sure you obtain urgent imaging for the patient with the worst headache of his or her life.

“Bronchitis” turns out to be lung cancer

UPPER RESPIRATORY TRACT SYMPTOMS prompted the patient to visit his primary care physician, who diagnosed asthma. Six months later, the patient returned with difficulty breathing and discolored mucus. The doctor diagnosed acute bronchitis and ordered a chest radiograph, which showed a growth in the lung. A subsequent CT scan confirmed the finding and identified a swollen right paratracheal lymph node. The radiologist’s report noted that “neoplasm cannot be entirely excluded.”

A series of radiographs and CT scans over the next several months continued to show the growth, which appeared unchanged. Radiologists’ reports advised that cancer couldn’t be ruled out and recommended further evaluation.

More than a year after the initial radiograph, the patient began to complain of persistent back pain along with the respiratory problems. A pain specialist ordered magnetic resonance imaging of the thoracic spine, which showed that the growth had enlarged. The report noted that the mass “must be considered highly worrisome for metastatic or other tumor unless proven otherwise.” A subsequent biopsy revealed stage IV lung cancer.

PLAINTIFF’S CLAIM If the defendant had investigated the growth at the time of the first radiograph, the cancer might have been curable.

DOCTOR’S DEFENSE The lung cancer was caused by the patient’s smoking, and the physician had tried unsuccessfully to get the patient to quit. The doctor did what the radiologists recommended after each CT scan and radiograph. The cancer wasn’t diagnosed earlier because a second scan failed to note that the right lymph node was still enlarged.

VERDICT $3 million Pennsylvania verdict.

COMMENT Failure to aggressively follow up—and diagnose—lung masses is a common malpractice pitfall.

Undiagnosed diabetes leads to death

A 27-YEAR-OLD MAN went to his primary care physician complaining of dry mouth unrelieved by increased fluid intake and occasional soreness while swallowing. He’d lost 11 pounds in the last 5 months. Although the patient had a family history of diabetes and symptoms consistent with diabetes, the physician didn’t check his glucose levels.

Almost a month later, the young man returned with blurred vision and severe headaches. He also complained of bilateral calf cramps at night and had lost another 13 pounds. The physician referred him for an eye exam, but didn’t test for diabetes.

A few weeks later, the patient went to the hospital with the “worst headache ever.” He also reported blurred vision and seeing white dots. Immediately after giving the history, he suffered 2 generalized seizures. A brain scan showed edema; initial urine testing revealed a glucose level of 500, proteinuria 2+, blood, and positive ketones.

The patient was intubated and transferred to another hospital, where he was diagnosed with diabetic ketoacidosis and an elevated intracranial pressure of 57. He didn’t respond to treatment and was pronounced dead 3 days later. An autopsy revealed cerebral edema with herniation of the cerebellar tonsils and brain stem compression and hypoxic encephalopathy associated with diabetic ketoacidosis.

PLAINTIFF’S CLAIM The patient had diabetes when he first saw the doctor; the doctor was negligent in failing to perform a diabetes workup.

DOCTOR’S DEFENSE The patient had a virus when he was first seen, and the headaches were caused by eye strain. The patient died not from undiagnosed diabetes, but from an underlying virus, which couldn’t have been detected until an autopsy was performed.

VERDICT $1 million Massachusetts settlement.

COMMENT Be alert for common but potentially serious medical problems, such as diabetes, when faced with a patient with multiple nonspecific symptoms.

Birth control change proves fatal

THE WORST HEADACHE SHE EVER HAD brought a 21-year-old woman to the emergency room. She had suffered severe headaches the previous month after switching from Depo-Provera shots to Nordette 28 birth control pills; the headaches went away, then returned.

A month after the ER visit, she visited a family medicine clinic, complaining of headaches, nausea, diarrhea, possible fever, and slight dizziness. A physician assistant prescribed Bactrim DS, Phenergan for the nausea, and Phrenilin for the headache.

Two days later, the patient was taken by ambulance to an ER because of numbness all over, nausea, vomiting, and dizziness. She was discharged, but brought back 4 hours later somnolent, difficult to arouse, and unable to obey commands. A computed tomography (CT) scan and magnetic resonance imaging performed the next morning showed blood clots in the brain, with complete occlusion of the superior sagittal sinus vein, and cerebral herniation.

A few days later, the patient was removed from life support. An autopsy indicated that the cause of death was a recent thrombus of the superior sagittal sinus with bilateral acute cerebral infarcts associated with secondary thrombi of tributary veins.

PLAINTIFF’S CLAIM The defendants were negligent in failing to pay attention to the change in the patient’s birth control regimen and test for cerebral thrombosis, a recognized adverse reaction when switching from shots to pills for birth control.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $7 million North Carolina verdict.

COMMENT If you want to avoid malpractice, make sure you obtain urgent imaging for the patient with the worst headache of his or her life.

“Bronchitis” turns out to be lung cancer

UPPER RESPIRATORY TRACT SYMPTOMS prompted the patient to visit his primary care physician, who diagnosed asthma. Six months later, the patient returned with difficulty breathing and discolored mucus. The doctor diagnosed acute bronchitis and ordered a chest radiograph, which showed a growth in the lung. A subsequent CT scan confirmed the finding and identified a swollen right paratracheal lymph node. The radiologist’s report noted that “neoplasm cannot be entirely excluded.”

A series of radiographs and CT scans over the next several months continued to show the growth, which appeared unchanged. Radiologists’ reports advised that cancer couldn’t be ruled out and recommended further evaluation.

More than a year after the initial radiograph, the patient began to complain of persistent back pain along with the respiratory problems. A pain specialist ordered magnetic resonance imaging of the thoracic spine, which showed that the growth had enlarged. The report noted that the mass “must be considered highly worrisome for metastatic or other tumor unless proven otherwise.” A subsequent biopsy revealed stage IV lung cancer.

PLAINTIFF’S CLAIM If the defendant had investigated the growth at the time of the first radiograph, the cancer might have been curable.

DOCTOR’S DEFENSE The lung cancer was caused by the patient’s smoking, and the physician had tried unsuccessfully to get the patient to quit. The doctor did what the radiologists recommended after each CT scan and radiograph. The cancer wasn’t diagnosed earlier because a second scan failed to note that the right lymph node was still enlarged.

VERDICT $3 million Pennsylvania verdict.

COMMENT Failure to aggressively follow up—and diagnose—lung masses is a common malpractice pitfall.

Undiagnosed diabetes leads to death

A 27-YEAR-OLD MAN went to his primary care physician complaining of dry mouth unrelieved by increased fluid intake and occasional soreness while swallowing. He’d lost 11 pounds in the last 5 months. Although the patient had a family history of diabetes and symptoms consistent with diabetes, the physician didn’t check his glucose levels.

Almost a month later, the young man returned with blurred vision and severe headaches. He also complained of bilateral calf cramps at night and had lost another 13 pounds. The physician referred him for an eye exam, but didn’t test for diabetes.

A few weeks later, the patient went to the hospital with the “worst headache ever.” He also reported blurred vision and seeing white dots. Immediately after giving the history, he suffered 2 generalized seizures. A brain scan showed edema; initial urine testing revealed a glucose level of 500, proteinuria 2+, blood, and positive ketones.

The patient was intubated and transferred to another hospital, where he was diagnosed with diabetic ketoacidosis and an elevated intracranial pressure of 57. He didn’t respond to treatment and was pronounced dead 3 days later. An autopsy revealed cerebral edema with herniation of the cerebellar tonsils and brain stem compression and hypoxic encephalopathy associated with diabetic ketoacidosis.

PLAINTIFF’S CLAIM The patient had diabetes when he first saw the doctor; the doctor was negligent in failing to perform a diabetes workup.

DOCTOR’S DEFENSE The patient had a virus when he was first seen, and the headaches were caused by eye strain. The patient died not from undiagnosed diabetes, but from an underlying virus, which couldn’t have been detected until an autopsy was performed.

VERDICT $1 million Massachusetts settlement.

COMMENT Be alert for common but potentially serious medical problems, such as diabetes, when faced with a patient with multiple nonspecific symptoms.

Birth control change proves fatal

THE WORST HEADACHE SHE EVER HAD brought a 21-year-old woman to the emergency room. She had suffered severe headaches the previous month after switching from Depo-Provera shots to Nordette 28 birth control pills; the headaches went away, then returned.

A month after the ER visit, she visited a family medicine clinic, complaining of headaches, nausea, diarrhea, possible fever, and slight dizziness. A physician assistant prescribed Bactrim DS, Phenergan for the nausea, and Phrenilin for the headache.

Two days later, the patient was taken by ambulance to an ER because of numbness all over, nausea, vomiting, and dizziness. She was discharged, but brought back 4 hours later somnolent, difficult to arouse, and unable to obey commands. A computed tomography (CT) scan and magnetic resonance imaging performed the next morning showed blood clots in the brain, with complete occlusion of the superior sagittal sinus vein, and cerebral herniation.

A few days later, the patient was removed from life support. An autopsy indicated that the cause of death was a recent thrombus of the superior sagittal sinus with bilateral acute cerebral infarcts associated with secondary thrombi of tributary veins.

PLAINTIFF’S CLAIM The defendants were negligent in failing to pay attention to the change in the patient’s birth control regimen and test for cerebral thrombosis, a recognized adverse reaction when switching from shots to pills for birth control.

THE DEFENSE No information about the nature of the defense is available.

VERDICT $7 million North Carolina verdict.

COMMENT If you want to avoid malpractice, make sure you obtain urgent imaging for the patient with the worst headache of his or her life.

“Bronchitis” turns out to be lung cancer

UPPER RESPIRATORY TRACT SYMPTOMS prompted the patient to visit his primary care physician, who diagnosed asthma. Six months later, the patient returned with difficulty breathing and discolored mucus. The doctor diagnosed acute bronchitis and ordered a chest radiograph, which showed a growth in the lung. A subsequent CT scan confirmed the finding and identified a swollen right paratracheal lymph node. The radiologist’s report noted that “neoplasm cannot be entirely excluded.”

A series of radiographs and CT scans over the next several months continued to show the growth, which appeared unchanged. Radiologists’ reports advised that cancer couldn’t be ruled out and recommended further evaluation.

More than a year after the initial radiograph, the patient began to complain of persistent back pain along with the respiratory problems. A pain specialist ordered magnetic resonance imaging of the thoracic spine, which showed that the growth had enlarged. The report noted that the mass “must be considered highly worrisome for metastatic or other tumor unless proven otherwise.” A subsequent biopsy revealed stage IV lung cancer.

PLAINTIFF’S CLAIM If the defendant had investigated the growth at the time of the first radiograph, the cancer might have been curable.

DOCTOR’S DEFENSE The lung cancer was caused by the patient’s smoking, and the physician had tried unsuccessfully to get the patient to quit. The doctor did what the radiologists recommended after each CT scan and radiograph. The cancer wasn’t diagnosed earlier because a second scan failed to note that the right lymph node was still enlarged.

VERDICT $3 million Pennsylvania verdict.

COMMENT Failure to aggressively follow up—and diagnose—lung masses is a common malpractice pitfall.

Undiagnosed diabetes leads to death

A 27-YEAR-OLD MAN went to his primary care physician complaining of dry mouth unrelieved by increased fluid intake and occasional soreness while swallowing. He’d lost 11 pounds in the last 5 months. Although the patient had a family history of diabetes and symptoms consistent with diabetes, the physician didn’t check his glucose levels.

Almost a month later, the young man returned with blurred vision and severe headaches. He also complained of bilateral calf cramps at night and had lost another 13 pounds. The physician referred him for an eye exam, but didn’t test for diabetes.

A few weeks later, the patient went to the hospital with the “worst headache ever.” He also reported blurred vision and seeing white dots. Immediately after giving the history, he suffered 2 generalized seizures. A brain scan showed edema; initial urine testing revealed a glucose level of 500, proteinuria 2+, blood, and positive ketones.

The patient was intubated and transferred to another hospital, where he was diagnosed with diabetic ketoacidosis and an elevated intracranial pressure of 57. He didn’t respond to treatment and was pronounced dead 3 days later. An autopsy revealed cerebral edema with herniation of the cerebellar tonsils and brain stem compression and hypoxic encephalopathy associated with diabetic ketoacidosis.

PLAINTIFF’S CLAIM The patient had diabetes when he first saw the doctor; the doctor was negligent in failing to perform a diabetes workup.

DOCTOR’S DEFENSE The patient had a virus when he was first seen, and the headaches were caused by eye strain. The patient died not from undiagnosed diabetes, but from an underlying virus, which couldn’t have been detected until an autopsy was performed.

VERDICT $1 million Massachusetts settlement.

COMMENT Be alert for common but potentially serious medical problems, such as diabetes, when faced with a patient with multiple nonspecific symptoms.

Emergent hysterectomy after abortion complications

A 40-YEAR-OLD WOMAN had a pregnancy termination at 8 weeks’ gestation. During the procedure, her uterus was perforated, resulting in excruciating pain. In a subsequent emergency hysterectomy, she lost 4 L of blood.

PATIENT’S CLAIM Even though she complained of pain during the abortion, the physician refused to stop, and clinic employees held her down until the procedure was completed.

PHYSICIAN’S DEFENSE The patient had been informed of the risks of the procedure, including a perforated uterus, and stopping in the middle was medically inappropriate. Also, the patient had been told it was important to remain still during the procedure, but she was unwilling or unable to do so.

VERDICT Confidential Nebraska settlement.

Extensive surgery precedes final report of “no ovarian Ca”

A 52-YEAR-OLD WOMAN underwent an exploratory laparotomy performed by Dr. A, a gynecologist. Tissues from her ovaries, peritoneal implant, and omentum were sent for testing. Preliminary findings indicated well-differentiated papillary serous cystadenocarcinoma, and were submitted for further consultation and definitive final diagnosis. The patient then met with Dr. B, a gynecological oncologist, who informed her that she had ovarian cancer with metastasis. She underwent extensive surgery: total abdominal hysterectomy, appendectomy, omentectomy, staging laparotomy, lymph-node dissection, and resection of pelvic implants. Following surgery, she was informed that she did not have ovarian cancer, and the final lab report indicated a borderline serous tumor.

PATIENT’S CLAIM The second surgery, 24 days following the initial surgery, was performed before a definitive diagnosis was received from the lab—and it was unnecessary.

PHYSICIAN’S DEFENSE Not reported.

VERDICT Florida defense verdict. An appeal was pending.

Patient takes drug while pregnant; her infant dies

AFTER THE BIRTH of her first child, a woman developed symptoms of hypertension. Dr. A, an internist, prescribed valsartan (Diovan, an angiotensin II receptor blocker manufactured by Novartis). Seven years later, the patient went to Dr. B when Dr. A was out of town. Dr. B wrote a prescription for valsartan and instructed her to return in 1 month to check her blood pressure and again in 1 year. She did not return for that check. Eight months after that, she was pregnant. Dr. C, her ObGyn, knew she was taking valsartan, but did not tell her to discontinue its use. For the first 6 months of her pregnancy, she continued taking valsartan. She later returned to Dr. B, who told her she could double her daily dosage of valsartan. She gave birth to a baby who lived only a few days.

PATIENT’S CLAIM Valsartan’s packaging and the PDR indicate that it is inappropriate to take valsartan during pregnancy. As a result of its ingestion, the infant died. Initially, the lawsuit included a products-related claim against Novartis, as well as a claim against the pharmacy that filled the prescription.

PHYSICIAN’S DEFENSE Dr. B assumed that Dr. C was managing the patient’s pregnancy and hypertension concerns. Dr. C admitted he did not know of the risks of valsartan to a fetus.

VERDICT Alabama defense verdict for Dr. B; $700,000 settlement with Dr. C; and $60,000 settlement with the pharmacy. Novartis was granted a summary judgment.

$2.5 million award when child has lethal heritable disease

A PATIENT GAVE BIRTH to a child who had Canavan disease, a neurologic disorder characterized by spongy degeneration of the central nervous system, with death often occurring by 4 years. The disease is found especially in Eastern European Jews.

PATIENT’S CLAIM The intake nurse at the health center failed to ask proper questions that would have suggested the need for genetic testing. The nurse and three midwives should have performed genetic testing once they learned the patient was Jewish to determine if she was a carrier of Canavan disease.

PHYSICIAN’S DEFENSE The patient failed to fill out the intake form properly, because she neglected to indicate whether her parents had the Jewish background that could be a carrier for Canavan disease.

VERDICT $2.5 million New Jersey settlement.

Blood loss addressed too late, mother dies after childbirth

A 35-YEAR-OLD WOMAN went to her ObGyn for a routine prenatal visit. As she was 6 to 7 cm dilated, she was sent to the hospital for evaluation. Her baby was delivered by C-section very early the following morning, and the patient was moved to the recovery room. Her blood pressure was low and continued to drop. A second physician examined her 1.5 hours later and removed a 250-mL clot from her vagina—at which time her blood pressure was 71/32. She was administered crystalloid fluids, but no blood or blood products. Within half an hour, diastolic pressure could not be obtained. It was decided to perform an ileac artery embolization. However, the patient became bradycardic and went into ventricular fibrillation. She was resuscitated and taken for an emergency hysterectomy, during which blood and a clot were found in her abdominal cavity. Again she arrested and was resuscitated, and then continued to decline and died.

PLAINTIFF’S CLAIM The patient first showed signs of serious postsurgical bleeding while in the recovery room, but the blood loss was not addressed. The hysterectomy was not performed in a timely manner to address the uterine atony, which caused the bleeding.

PHYSICIAN’S DEFENSE Not reported.

VERDICT $1 million Maryland settlement.

Surgery, inadequate Paps—then stage IV endocervical Ca

FOLLOWING A DIAGNOSIS of cancer in her endocervix, a woman had the cancer removed surgically. Her physician scheduled her for semiannual Pap smears to monitor the endocervix for recurrence of the cancer, but he ordered no other testing. He performed the Pap smears; however, as the surgery had closed off the endocervix, the spatula could reach only the ectocervix and not the endocervix, which needed to be sampled. When the lab reported back that there were no endocervical cells on the smears, the patient was just told that the results were normal. She also was not informed that the endocervix could not be reached. Eventually, the patient received a diagnosis of stage IV endocervical cancer.

PLAINTIFF’S CLAIM Follow-up Pap smears to obtain adequate samples including endocervical cells were to have been performed. Her physician concealed the fact that he was unable to obtain an adequate sample from the previously cancerous area, and he failed to monitor her for recurrence of that cancer.

PHYSICIAN’S DEFENSE The claims for all but one of the Pap smears was time-barred, and the concealment argument did not apply.

VERDICT Confidential Florida settlement after a defense motion for summary judgment was denied.

Emergent hysterectomy after abortion complications

A 40-YEAR-OLD WOMAN had a pregnancy termination at 8 weeks’ gestation. During the procedure, her uterus was perforated, resulting in excruciating pain. In a subsequent emergency hysterectomy, she lost 4 L of blood.

PATIENT’S CLAIM Even though she complained of pain during the abortion, the physician refused to stop, and clinic employees held her down until the procedure was completed.

PHYSICIAN’S DEFENSE The patient had been informed of the risks of the procedure, including a perforated uterus, and stopping in the middle was medically inappropriate. Also, the patient had been told it was important to remain still during the procedure, but she was unwilling or unable to do so.

VERDICT Confidential Nebraska settlement.

Extensive surgery precedes final report of “no ovarian Ca”

A 52-YEAR-OLD WOMAN underwent an exploratory laparotomy performed by Dr. A, a gynecologist. Tissues from her ovaries, peritoneal implant, and omentum were sent for testing. Preliminary findings indicated well-differentiated papillary serous cystadenocarcinoma, and were submitted for further consultation and definitive final diagnosis. The patient then met with Dr. B, a gynecological oncologist, who informed her that she had ovarian cancer with metastasis. She underwent extensive surgery: total abdominal hysterectomy, appendectomy, omentectomy, staging laparotomy, lymph-node dissection, and resection of pelvic implants. Following surgery, she was informed that she did not have ovarian cancer, and the final lab report indicated a borderline serous tumor.

PATIENT’S CLAIM The second surgery, 24 days following the initial surgery, was performed before a definitive diagnosis was received from the lab—and it was unnecessary.

PHYSICIAN’S DEFENSE Not reported.

VERDICT Florida defense verdict. An appeal was pending.

Patient takes drug while pregnant; her infant dies

AFTER THE BIRTH of her first child, a woman developed symptoms of hypertension. Dr. A, an internist, prescribed valsartan (Diovan, an angiotensin II receptor blocker manufactured by Novartis). Seven years later, the patient went to Dr. B when Dr. A was out of town. Dr. B wrote a prescription for valsartan and instructed her to return in 1 month to check her blood pressure and again in 1 year. She did not return for that check. Eight months after that, she was pregnant. Dr. C, her ObGyn, knew she was taking valsartan, but did not tell her to discontinue its use. For the first 6 months of her pregnancy, she continued taking valsartan. She later returned to Dr. B, who told her she could double her daily dosage of valsartan. She gave birth to a baby who lived only a few days.

PATIENT’S CLAIM Valsartan’s packaging and the PDR indicate that it is inappropriate to take valsartan during pregnancy. As a result of its ingestion, the infant died. Initially, the lawsuit included a products-related claim against Novartis, as well as a claim against the pharmacy that filled the prescription.

PHYSICIAN’S DEFENSE Dr. B assumed that Dr. C was managing the patient’s pregnancy and hypertension concerns. Dr. C admitted he did not know of the risks of valsartan to a fetus.

VERDICT Alabama defense verdict for Dr. B; $700,000 settlement with Dr. C; and $60,000 settlement with the pharmacy. Novartis was granted a summary judgment.

$2.5 million award when child has lethal heritable disease

A PATIENT GAVE BIRTH to a child who had Canavan disease, a neurologic disorder characterized by spongy degeneration of the central nervous system, with death often occurring by 4 years. The disease is found especially in Eastern European Jews.

PATIENT’S CLAIM The intake nurse at the health center failed to ask proper questions that would have suggested the need for genetic testing. The nurse and three midwives should have performed genetic testing once they learned the patient was Jewish to determine if she was a carrier of Canavan disease.

PHYSICIAN’S DEFENSE The patient failed to fill out the intake form properly, because she neglected to indicate whether her parents had the Jewish background that could be a carrier for Canavan disease.

VERDICT $2.5 million New Jersey settlement.

Blood loss addressed too late, mother dies after childbirth

A 35-YEAR-OLD WOMAN went to her ObGyn for a routine prenatal visit. As she was 6 to 7 cm dilated, she was sent to the hospital for evaluation. Her baby was delivered by C-section very early the following morning, and the patient was moved to the recovery room. Her blood pressure was low and continued to drop. A second physician examined her 1.5 hours later and removed a 250-mL clot from her vagina—at which time her blood pressure was 71/32. She was administered crystalloid fluids, but no blood or blood products. Within half an hour, diastolic pressure could not be obtained. It was decided to perform an ileac artery embolization. However, the patient became bradycardic and went into ventricular fibrillation. She was resuscitated and taken for an emergency hysterectomy, during which blood and a clot were found in her abdominal cavity. Again she arrested and was resuscitated, and then continued to decline and died.

PLAINTIFF’S CLAIM The patient first showed signs of serious postsurgical bleeding while in the recovery room, but the blood loss was not addressed. The hysterectomy was not performed in a timely manner to address the uterine atony, which caused the bleeding.

PHYSICIAN’S DEFENSE Not reported.

VERDICT $1 million Maryland settlement.

Surgery, inadequate Paps—then stage IV endocervical Ca

FOLLOWING A DIAGNOSIS of cancer in her endocervix, a woman had the cancer removed surgically. Her physician scheduled her for semiannual Pap smears to monitor the endocervix for recurrence of the cancer, but he ordered no other testing. He performed the Pap smears; however, as the surgery had closed off the endocervix, the spatula could reach only the ectocervix and not the endocervix, which needed to be sampled. When the lab reported back that there were no endocervical cells on the smears, the patient was just told that the results were normal. She also was not informed that the endocervix could not be reached. Eventually, the patient received a diagnosis of stage IV endocervical cancer.

PLAINTIFF’S CLAIM Follow-up Pap smears to obtain adequate samples including endocervical cells were to have been performed. Her physician concealed the fact that he was unable to obtain an adequate sample from the previously cancerous area, and he failed to monitor her for recurrence of that cancer.

PHYSICIAN’S DEFENSE The claims for all but one of the Pap smears was time-barred, and the concealment argument did not apply.

VERDICT Confidential Florida settlement after a defense motion for summary judgment was denied.

Emergent hysterectomy after abortion complications

A 40-YEAR-OLD WOMAN had a pregnancy termination at 8 weeks’ gestation. During the procedure, her uterus was perforated, resulting in excruciating pain. In a subsequent emergency hysterectomy, she lost 4 L of blood.

PATIENT’S CLAIM Even though she complained of pain during the abortion, the physician refused to stop, and clinic employees held her down until the procedure was completed.

PHYSICIAN’S DEFENSE The patient had been informed of the risks of the procedure, including a perforated uterus, and stopping in the middle was medically inappropriate. Also, the patient had been told it was important to remain still during the procedure, but she was unwilling or unable to do so.

VERDICT Confidential Nebraska settlement.

Extensive surgery precedes final report of “no ovarian Ca”

A 52-YEAR-OLD WOMAN underwent an exploratory laparotomy performed by Dr. A, a gynecologist. Tissues from her ovaries, peritoneal implant, and omentum were sent for testing. Preliminary findings indicated well-differentiated papillary serous cystadenocarcinoma, and were submitted for further consultation and definitive final diagnosis. The patient then met with Dr. B, a gynecological oncologist, who informed her that she had ovarian cancer with metastasis. She underwent extensive surgery: total abdominal hysterectomy, appendectomy, omentectomy, staging laparotomy, lymph-node dissection, and resection of pelvic implants. Following surgery, she was informed that she did not have ovarian cancer, and the final lab report indicated a borderline serous tumor.

PATIENT’S CLAIM The second surgery, 24 days following the initial surgery, was performed before a definitive diagnosis was received from the lab—and it was unnecessary.

PHYSICIAN’S DEFENSE Not reported.

VERDICT Florida defense verdict. An appeal was pending.

Patient takes drug while pregnant; her infant dies

AFTER THE BIRTH of her first child, a woman developed symptoms of hypertension. Dr. A, an internist, prescribed valsartan (Diovan, an angiotensin II receptor blocker manufactured by Novartis). Seven years later, the patient went to Dr. B when Dr. A was out of town. Dr. B wrote a prescription for valsartan and instructed her to return in 1 month to check her blood pressure and again in 1 year. She did not return for that check. Eight months after that, she was pregnant. Dr. C, her ObGyn, knew she was taking valsartan, but did not tell her to discontinue its use. For the first 6 months of her pregnancy, she continued taking valsartan. She later returned to Dr. B, who told her she could double her daily dosage of valsartan. She gave birth to a baby who lived only a few days.

PATIENT’S CLAIM Valsartan’s packaging and the PDR indicate that it is inappropriate to take valsartan during pregnancy. As a result of its ingestion, the infant died. Initially, the lawsuit included a products-related claim against Novartis, as well as a claim against the pharmacy that filled the prescription.

PHYSICIAN’S DEFENSE Dr. B assumed that Dr. C was managing the patient’s pregnancy and hypertension concerns. Dr. C admitted he did not know of the risks of valsartan to a fetus.

VERDICT Alabama defense verdict for Dr. B; $700,000 settlement with Dr. C; and $60,000 settlement with the pharmacy. Novartis was granted a summary judgment.

$2.5 million award when child has lethal heritable disease

A PATIENT GAVE BIRTH to a child who had Canavan disease, a neurologic disorder characterized by spongy degeneration of the central nervous system, with death often occurring by 4 years. The disease is found especially in Eastern European Jews.

PATIENT’S CLAIM The intake nurse at the health center failed to ask proper questions that would have suggested the need for genetic testing. The nurse and three midwives should have performed genetic testing once they learned the patient was Jewish to determine if she was a carrier of Canavan disease.

PHYSICIAN’S DEFENSE The patient failed to fill out the intake form properly, because she neglected to indicate whether her parents had the Jewish background that could be a carrier for Canavan disease.

VERDICT $2.5 million New Jersey settlement.

Blood loss addressed too late, mother dies after childbirth

A 35-YEAR-OLD WOMAN went to her ObGyn for a routine prenatal visit. As she was 6 to 7 cm dilated, she was sent to the hospital for evaluation. Her baby was delivered by C-section very early the following morning, and the patient was moved to the recovery room. Her blood pressure was low and continued to drop. A second physician examined her 1.5 hours later and removed a 250-mL clot from her vagina—at which time her blood pressure was 71/32. She was administered crystalloid fluids, but no blood or blood products. Within half an hour, diastolic pressure could not be obtained. It was decided to perform an ileac artery embolization. However, the patient became bradycardic and went into ventricular fibrillation. She was resuscitated and taken for an emergency hysterectomy, during which blood and a clot were found in her abdominal cavity. Again she arrested and was resuscitated, and then continued to decline and died.

PLAINTIFF’S CLAIM The patient first showed signs of serious postsurgical bleeding while in the recovery room, but the blood loss was not addressed. The hysterectomy was not performed in a timely manner to address the uterine atony, which caused the bleeding.

PHYSICIAN’S DEFENSE Not reported.

VERDICT $1 million Maryland settlement.

Surgery, inadequate Paps—then stage IV endocervical Ca

FOLLOWING A DIAGNOSIS of cancer in her endocervix, a woman had the cancer removed surgically. Her physician scheduled her for semiannual Pap smears to monitor the endocervix for recurrence of the cancer, but he ordered no other testing. He performed the Pap smears; however, as the surgery had closed off the endocervix, the spatula could reach only the ectocervix and not the endocervix, which needed to be sampled. When the lab reported back that there were no endocervical cells on the smears, the patient was just told that the results were normal. She also was not informed that the endocervix could not be reached. Eventually, the patient received a diagnosis of stage IV endocervical cancer.

PLAINTIFF’S CLAIM Follow-up Pap smears to obtain adequate samples including endocervical cells were to have been performed. Her physician concealed the fact that he was unable to obtain an adequate sample from the previously cancerous area, and he failed to monitor her for recurrence of that cancer.

PHYSICIAN’S DEFENSE The claims for all but one of the Pap smears was time-barred, and the concealment argument did not apply.

VERDICT Confidential Florida settlement after a defense motion for summary judgment was denied.

Sutures in sciatic nerve cause multiple problems

A GYNECOLOGIC ONCOLOGIST recommended and repaired a cystocele that was causing urinary incontinence in a patient. Immediately following the surgery, the patient experienced severe pain radiating from her right buttock to her right knee and developed numbness in her right toes. Two days later, after consultation with a neurologist, she underwent further surgery. After it was found that the first physician had placed sutures in the right sciatic nerve, they were removed. The nerve sustained permanent injury, and the patient continues to have chronic pain, paresthesia, weakness, fatigue, and an altered gait.

PATIENT’S CLAIM The physician was negligent for placing the sutures in the sciatic nerve.

PHYSICIAN’S DEFENSE The physician denied any negligence.

VERDICT $700,000 Indiana verdict, which included $25,000 for loss of consortium for the patient’s husband.

Was retained sponge from C-section—or later surgery?

A 16-YEAR-OLD PATIENT delivered a baby by C-section, which proceeded uneventfully. Eight months later, because of abdominal pain, the patient underwent an exploratory laparotomy performed by Dr. A, a surgeon. She continued to experience abdominal pain, the origin of which could not be found. After another 8 months, in exploratory surgery performed by Dr. B, a retained lap sponge was found and removed. At this time, the patient was 5 months pregnant. Two months later, the baby was delivered prematurely and lived for 12 days.

PATIENT’S CLAIM The retained lap sponge was left there during the laparotomy surgery performed by Dr. A, and it should have been found sooner.

PHYSICIAN’S DEFENSE The retained sponge was left during the C-section. Also, the death of the second child was unrelated to the retained sponge.

VERDICT Kentucky defense verdict. An appeal was pending.

$22 million award follows preeclamptic mother’s death

A 29-YEAR-OLD WOMAN who was 9 months pregnant presented at the hospital with a severe headache. She was admitted to labor and delivery, where she was examined by an experienced nurse and a 2nd year resident. A diagnosis of preeclampsia and HELLP syndrome, as indicated by lab tests, was given. The patient was administered three 10-mg doses of labetalol—despite hospital policy of administering the drug every 10 minutes in increasing doses until the blood pressure returns to a safe level. When labor was induced, her blood pressure rose dangerously and she became unresponsive. The baby was delivered successfully by emergency C-section. A CT scan indicated that the mother had suffered a massive brain hemorrhage. She was placed on a ventilator for 4 days, and died when it was disconnected.

PLAINTIFF’S CLAIM Labetalol was not administered properly and according to hospital policy.

PHYSICIAN’S DEFENSE The patient would likely not have survived because the preeclampsia and HELLP syndrome were so severe.

VERDICT $22 million Illinois verdict.

Woman conceives after undergoing tubal ligation

A 29-YEAR-OLD WOMAN underwent a tubal ligation. But 9 to 10 months later, she became pregnant. A subsequent ligation indicated a “normal appearing” right fallopian tube.

PATIENT’S CLAIM The physician failed to ligate the proper structure.

PHYSICIAN’S DEFENSE The right fallopian tube had recanalized and appeared normal. However, there was no negligence in performing the tubal ligation.

VERDICT District of Columbia defense verdict.

Placental fragment, aggressive D&C—failed pregnancy

A WEEK AFTER DELIVERING a healthy baby, a woman underwent an emergency dilation and curettage (D&C) because of severe, life-threatening bleeding. Two years later, she suffered a miscarriage, and 7 months after that an ectopic pregnancy.

PATIENT’S CLAIM The obstetrician negligent for failing to examine the placenta after the birth, leading to a retained placental fragment that caused the bleeding. An aggressively performed D&C resulted in Asherman’s syndrome, which caused the miscarriage and ectopic pregnancy.

PHYSICIAN’S DEFENSE At the time of delivery, the placenta was inspected properly. There was nothing to indicate a retained placental fragment, which is a recognized complication of delivery. The D&C was performed properly; uterine scarring is a recognized complication of the procedure.

VERDICT Illinois defense verdict.

Gallbladder disease during pregnancy is not properly treated

FOR A MONTH BEFORE DELIVERY of her child, a woman suffered severe abdominal pain and vomiting, for which she took over-the-counter calcium carbonate antacids. Two days before giving birth, she was admitted to the hospital dehydrated and with life-threatening elevated calcium in her blood. She was transferred to another hospital, where she gave birth to a child with cerebral palsy at 28 weeks’ gestation. She then underwent removal of her gallbladder.

PATIENT’S CLAIM The plaintiff child claimed the treating ObGyn failed to properly treat the mother’s gallbladder disease and pancreatitis.

PHYSICIAN’S DEFENSE The mother’s problems were mainly due to ingestion of an off-label dosage of over-the-counter calcium carbonate antacids.

VERDICT Nebraska defense verdict. The plaintiff appealed the case on the basis of exclusion of some expert testimony. The case was affirmed on appeal.

Sutures in sciatic nerve cause multiple problems

A GYNECOLOGIC ONCOLOGIST recommended and repaired a cystocele that was causing urinary incontinence in a patient. Immediately following the surgery, the patient experienced severe pain radiating from her right buttock to her right knee and developed numbness in her right toes. Two days later, after consultation with a neurologist, she underwent further surgery. After it was found that the first physician had placed sutures in the right sciatic nerve, they were removed. The nerve sustained permanent injury, and the patient continues to have chronic pain, paresthesia, weakness, fatigue, and an altered gait.

PATIENT’S CLAIM The physician was negligent for placing the sutures in the sciatic nerve.

PHYSICIAN’S DEFENSE The physician denied any negligence.

VERDICT $700,000 Indiana verdict, which included $25,000 for loss of consortium for the patient’s husband.

Was retained sponge from C-section—or later surgery?

A 16-YEAR-OLD PATIENT delivered a baby by C-section, which proceeded uneventfully. Eight months later, because of abdominal pain, the patient underwent an exploratory laparotomy performed by Dr. A, a surgeon. She continued to experience abdominal pain, the origin of which could not be found. After another 8 months, in exploratory surgery performed by Dr. B, a retained lap sponge was found and removed. At this time, the patient was 5 months pregnant. Two months later, the baby was delivered prematurely and lived for 12 days.

PATIENT’S CLAIM The retained lap sponge was left there during the laparotomy surgery performed by Dr. A, and it should have been found sooner.

PHYSICIAN’S DEFENSE The retained sponge was left during the C-section. Also, the death of the second child was unrelated to the retained sponge.

VERDICT Kentucky defense verdict. An appeal was pending.

$22 million award follows preeclamptic mother’s death

A 29-YEAR-OLD WOMAN who was 9 months pregnant presented at the hospital with a severe headache. She was admitted to labor and delivery, where she was examined by an experienced nurse and a 2nd year resident. A diagnosis of preeclampsia and HELLP syndrome, as indicated by lab tests, was given. The patient was administered three 10-mg doses of labetalol—despite hospital policy of administering the drug every 10 minutes in increasing doses until the blood pressure returns to a safe level. When labor was induced, her blood pressure rose dangerously and she became unresponsive. The baby was delivered successfully by emergency C-section. A CT scan indicated that the mother had suffered a massive brain hemorrhage. She was placed on a ventilator for 4 days, and died when it was disconnected.

PLAINTIFF’S CLAIM Labetalol was not administered properly and according to hospital policy.

PHYSICIAN’S DEFENSE The patient would likely not have survived because the preeclampsia and HELLP syndrome were so severe.

VERDICT $22 million Illinois verdict.

Woman conceives after undergoing tubal ligation

A 29-YEAR-OLD WOMAN underwent a tubal ligation. But 9 to 10 months later, she became pregnant. A subsequent ligation indicated a “normal appearing” right fallopian tube.

PATIENT’S CLAIM The physician failed to ligate the proper structure.

PHYSICIAN’S DEFENSE The right fallopian tube had recanalized and appeared normal. However, there was no negligence in performing the tubal ligation.

VERDICT District of Columbia defense verdict.

Placental fragment, aggressive D&C—failed pregnancy

A WEEK AFTER DELIVERING a healthy baby, a woman underwent an emergency dilation and curettage (D&C) because of severe, life-threatening bleeding. Two years later, she suffered a miscarriage, and 7 months after that an ectopic pregnancy.

PATIENT’S CLAIM The obstetrician negligent for failing to examine the placenta after the birth, leading to a retained placental fragment that caused the bleeding. An aggressively performed D&C resulted in Asherman’s syndrome, which caused the miscarriage and ectopic pregnancy.

PHYSICIAN’S DEFENSE At the time of delivery, the placenta was inspected properly. There was nothing to indicate a retained placental fragment, which is a recognized complication of delivery. The D&C was performed properly; uterine scarring is a recognized complication of the procedure.

VERDICT Illinois defense verdict.

Gallbladder disease during pregnancy is not properly treated

FOR A MONTH BEFORE DELIVERY of her child, a woman suffered severe abdominal pain and vomiting, for which she took over-the-counter calcium carbonate antacids. Two days before giving birth, she was admitted to the hospital dehydrated and with life-threatening elevated calcium in her blood. She was transferred to another hospital, where she gave birth to a child with cerebral palsy at 28 weeks’ gestation. She then underwent removal of her gallbladder.

PATIENT’S CLAIM The plaintiff child claimed the treating ObGyn failed to properly treat the mother’s gallbladder disease and pancreatitis.

PHYSICIAN’S DEFENSE The mother’s problems were mainly due to ingestion of an off-label dosage of over-the-counter calcium carbonate antacids.

VERDICT Nebraska defense verdict. The plaintiff appealed the case on the basis of exclusion of some expert testimony. The case was affirmed on appeal.

Sutures in sciatic nerve cause multiple problems

A GYNECOLOGIC ONCOLOGIST recommended and repaired a cystocele that was causing urinary incontinence in a patient. Immediately following the surgery, the patient experienced severe pain radiating from her right buttock to her right knee and developed numbness in her right toes. Two days later, after consultation with a neurologist, she underwent further surgery. After it was found that the first physician had placed sutures in the right sciatic nerve, they were removed. The nerve sustained permanent injury, and the patient continues to have chronic pain, paresthesia, weakness, fatigue, and an altered gait.

PATIENT’S CLAIM The physician was negligent for placing the sutures in the sciatic nerve.

PHYSICIAN’S DEFENSE The physician denied any negligence.

VERDICT $700,000 Indiana verdict, which included $25,000 for loss of consortium for the patient’s husband.

Was retained sponge from C-section—or later surgery?

A 16-YEAR-OLD PATIENT delivered a baby by C-section, which proceeded uneventfully. Eight months later, because of abdominal pain, the patient underwent an exploratory laparotomy performed by Dr. A, a surgeon. She continued to experience abdominal pain, the origin of which could not be found. After another 8 months, in exploratory surgery performed by Dr. B, a retained lap sponge was found and removed. At this time, the patient was 5 months pregnant. Two months later, the baby was delivered prematurely and lived for 12 days.

PATIENT’S CLAIM The retained lap sponge was left there during the laparotomy surgery performed by Dr. A, and it should have been found sooner.

PHYSICIAN’S DEFENSE The retained sponge was left during the C-section. Also, the death of the second child was unrelated to the retained sponge.

VERDICT Kentucky defense verdict. An appeal was pending.

$22 million award follows preeclamptic mother’s death

A 29-YEAR-OLD WOMAN who was 9 months pregnant presented at the hospital with a severe headache. She was admitted to labor and delivery, where she was examined by an experienced nurse and a 2nd year resident. A diagnosis of preeclampsia and HELLP syndrome, as indicated by lab tests, was given. The patient was administered three 10-mg doses of labetalol—despite hospital policy of administering the drug every 10 minutes in increasing doses until the blood pressure returns to a safe level. When labor was induced, her blood pressure rose dangerously and she became unresponsive. The baby was delivered successfully by emergency C-section. A CT scan indicated that the mother had suffered a massive brain hemorrhage. She was placed on a ventilator for 4 days, and died when it was disconnected.

PLAINTIFF’S CLAIM Labetalol was not administered properly and according to hospital policy.

PHYSICIAN’S DEFENSE The patient would likely not have survived because the preeclampsia and HELLP syndrome were so severe.

VERDICT $22 million Illinois verdict.

Woman conceives after undergoing tubal ligation

A 29-YEAR-OLD WOMAN underwent a tubal ligation. But 9 to 10 months later, she became pregnant. A subsequent ligation indicated a “normal appearing” right fallopian tube.

PATIENT’S CLAIM The physician failed to ligate the proper structure.

PHYSICIAN’S DEFENSE The right fallopian tube had recanalized and appeared normal. However, there was no negligence in performing the tubal ligation.

VERDICT District of Columbia defense verdict.

Placental fragment, aggressive D&C—failed pregnancy

A WEEK AFTER DELIVERING a healthy baby, a woman underwent an emergency dilation and curettage (D&C) because of severe, life-threatening bleeding. Two years later, she suffered a miscarriage, and 7 months after that an ectopic pregnancy.

PATIENT’S CLAIM The obstetrician negligent for failing to examine the placenta after the birth, leading to a retained placental fragment that caused the bleeding. An aggressively performed D&C resulted in Asherman’s syndrome, which caused the miscarriage and ectopic pregnancy.

PHYSICIAN’S DEFENSE At the time of delivery, the placenta was inspected properly. There was nothing to indicate a retained placental fragment, which is a recognized complication of delivery. The D&C was performed properly; uterine scarring is a recognized complication of the procedure.

VERDICT Illinois defense verdict.

Gallbladder disease during pregnancy is not properly treated

FOR A MONTH BEFORE DELIVERY of her child, a woman suffered severe abdominal pain and vomiting, for which she took over-the-counter calcium carbonate antacids. Two days before giving birth, she was admitted to the hospital dehydrated and with life-threatening elevated calcium in her blood. She was transferred to another hospital, where she gave birth to a child with cerebral palsy at 28 weeks’ gestation. She then underwent removal of her gallbladder.

PATIENT’S CLAIM The plaintiff child claimed the treating ObGyn failed to properly treat the mother’s gallbladder disease and pancreatitis.

PHYSICIAN’S DEFENSE The mother’s problems were mainly due to ingestion of an off-label dosage of over-the-counter calcium carbonate antacids.

VERDICT Nebraska defense verdict. The plaintiff appealed the case on the basis of exclusion of some expert testimony. The case was affirmed on appeal.

Testing confusion delays breast cancer Dx

A WOMAN NOTICED A HARD SPOT IN HER LEFT BREAST in April and reported it to her physician in June. The doctor referred the 47-year-old patient to another physician, who performed a mammogram in early August. Four days later, the woman received a call directing her to return for imaging of her right breast. The patient claimed that when she told a radiology technician that she was concerned about her left breast, the technician replied that the order called for a right breast exam. Shortly thereafter, the patient received a letter informing her that everything was fine and instructing her to come back in a year.

She was still feeling the mass in her left breast when she returned for her annual exam the following August. A few weeks later, she was diagnosed with breast cancer. When the case went to trial, the patient had been told she had 2 years to live.

PLAINTIFF’S CLAIM: The plaintiff’s claim centered on the delay in her diagnosis, though the specifics were not detailed in the case summary.

DOCTORS’ DEFENSE: The defendants blamed each other for the delay; they also claimed that the patient should have kept complaining if she felt a mass. They further maintained that the required treatment would have been the same if the cancer had been diagnosed the previous year.

VERDICT: $4.5 million Missouri verdict (second physician, 85% at fault; radiology technician, 15% at fault).

COMMENT: What can go wrong does go wrong: A slip in communication and follow-up led to this $4.5 million verdict. Failure to make a timely diagnosis of breast cancer remains one of the most litigious areas in medicine.

Pulmonary disease masks lung cancer

A WOMAN WITH IDIOPATHIC PULMONARY FIBROSIS had been monitored by her physician for 7 years with physical exams, pulmonary function tests, and radiographic studies, including CT scans of the chest. During an office visit in October, the 57-year-old patient complained of increased difficulty breathing. A pulmonary function test and CT scan showed progression of the pulmonary fibrosis.

The following July, a pulmonary function test showed further deterioration of the patient’s condition, and the physician quadrupled her corticosteroid dosage. When the patient reported breathing problems again in December, a pulmonary function test showed continued decrease in breathing function.

Five months after that, the patient developed a malignant thigh lesion. A chest CT scan later that month revealed a lobular mass in the lower right lung, which had not appeared on the scan done a year and a half before. A biopsy revealed stage 4 adenocarcinoma. The woman died less than a month later of metastatic lung cancer.

PLAINTIFF’S CLAIM: The physician failed to follow up properly on the worsening fibrosis, allowing the cancer to grow un-detected. The physician should have ordered a CT scan in July or December.

DOCTOR’S DEFENSE: No negligence occurred; the patient didn’t complain much about her symptoms, and no signs or symptoms during her visits suggested that more tests should have been ordered. An earlier diagnosis wouldn’t have made a difference because the patient would not have been a candidate for surgery.

VERDICT: New York defense verdict.

COMMENT: Although a defense verdict was returned, we have to be careful not to overlook a serious new problem in the midst of a chronic disease—in this case, lung cancer against a background of pulmonary fibrosis.

Undiagnosed infection has disastrous results

WHILE HOSPITALIZED FOR ROUTINE POST-PARTUM CARE after the uneventful birth of her second child, a 37-year-old woman developed tachycardia and hypotension along with an expanding, excoriating wound on her labia. She claimed that the wound was treated only by applying ice and monitoring blood counts. The patient’s condition deteriorated until, on the third postpartum day, her blood pressure dropped and she coded. She was revived, and necrotizing fasciitis was diagnosed.

The woman spent 4 months in the ICU, during which time she underwent many surgeries to debride the wound as well as a nephrectomy and a permanent colostomy. The surgeries caused extensive scarring in the groin area. For 6 months after discharge from the ICU, the patient couldn’t walk without a cane or walker.

PLAINTIFF’S CLAIM: The specifics of the claim—which likely focused on the wound care she received and the delay in her diagnosis—were not detailed in the case summary.

DOCTOR’S DEFENSE: No negligence occurred. Necrotizing fasciitis is rare, and none of the health care providers should have been expected to diagnose it.

VERDICT: Confidential Nebraska settlement.

COMMENT: This case serves as a potent reminder of the serious nature of this dreaded infection.

Misdiagnosed chest pain leads to fatal MI

A 43-YEAR-OLD MAN, who smoked cigarettes and had a strong family history of coronary artery disease, had been under the care of a primary care physician for 3 years. The patient’s history also included at least 1 episode of chest pain.

The patient visited his physician complaining of intermittent chest pain for several days. He described 2 episodes of nausea, vomiting, and pain in his back teeth, followed by pain radiating down his right chest to the right costal margin. He had no symptoms during the office visit. The physician ordered an in-office EKG, which he interpreted as normal.

The physician diagnosed the chest pain as gastrointestinal in origin and prescribed an antacid. Because of the patient’s cardiac risk factors, the doctor scheduled a stress test and EKG for 2 days later.

On the morning of the stress test, the patient’s wife found him unresponsive. Resuscitation failed, and he was pronounced dead. An autopsy revealed severe proximal coronary artery disease of the left main coronary artery, left anterior descending coronary artery, and right coronary artery, as well as evidence of “remote and recent myocardial infarction.”

PLAINTIFF’S CLAIM: The EKG demonstrated significant changes compared with an EKG performed 3 years earlier and indicated that the patient was suffering an acute coronary episode. The doctor was negligent in failing to diagnose the episode and transfer the patient for proper cardiac care.

DOCTOR’S DEFENSE: The patient’s presentation indicated gastrointestinal distress; the EKG was normal.

VERDICT: $1.5 million Massachusetts settlement.

COMMENT: It’s imperative to compare EKGs, chest radiographs, and other tests with baseline results. How many times do you see an EKG that shows subtle but important changes that influence management?

Testing confusion delays breast cancer Dx

A WOMAN NOTICED A HARD SPOT IN HER LEFT BREAST in April and reported it to her physician in June. The doctor referred the 47-year-old patient to another physician, who performed a mammogram in early August. Four days later, the woman received a call directing her to return for imaging of her right breast. The patient claimed that when she told a radiology technician that she was concerned about her left breast, the technician replied that the order called for a right breast exam. Shortly thereafter, the patient received a letter informing her that everything was fine and instructing her to come back in a year.

She was still feeling the mass in her left breast when she returned for her annual exam the following August. A few weeks later, she was diagnosed with breast cancer. When the case went to trial, the patient had been told she had 2 years to live.

PLAINTIFF’S CLAIM: The plaintiff’s claim centered on the delay in her diagnosis, though the specifics were not detailed in the case summary.

DOCTORS’ DEFENSE: The defendants blamed each other for the delay; they also claimed that the patient should have kept complaining if she felt a mass. They further maintained that the required treatment would have been the same if the cancer had been diagnosed the previous year.

VERDICT: $4.5 million Missouri verdict (second physician, 85% at fault; radiology technician, 15% at fault).

COMMENT: What can go wrong does go wrong: A slip in communication and follow-up led to this $4.5 million verdict. Failure to make a timely diagnosis of breast cancer remains one of the most litigious areas in medicine.

Pulmonary disease masks lung cancer

A WOMAN WITH IDIOPATHIC PULMONARY FIBROSIS had been monitored by her physician for 7 years with physical exams, pulmonary function tests, and radiographic studies, including CT scans of the chest. During an office visit in October, the 57-year-old patient complained of increased difficulty breathing. A pulmonary function test and CT scan showed progression of the pulmonary fibrosis.

The following July, a pulmonary function test showed further deterioration of the patient’s condition, and the physician quadrupled her corticosteroid dosage. When the patient reported breathing problems again in December, a pulmonary function test showed continued decrease in breathing function.

Five months after that, the patient developed a malignant thigh lesion. A chest CT scan later that month revealed a lobular mass in the lower right lung, which had not appeared on the scan done a year and a half before. A biopsy revealed stage 4 adenocarcinoma. The woman died less than a month later of metastatic lung cancer.

PLAINTIFF’S CLAIM: The physician failed to follow up properly on the worsening fibrosis, allowing the cancer to grow un-detected. The physician should have ordered a CT scan in July or December.

DOCTOR’S DEFENSE: No negligence occurred; the patient didn’t complain much about her symptoms, and no signs or symptoms during her visits suggested that more tests should have been ordered. An earlier diagnosis wouldn’t have made a difference because the patient would not have been a candidate for surgery.

VERDICT: New York defense verdict.

COMMENT: Although a defense verdict was returned, we have to be careful not to overlook a serious new problem in the midst of a chronic disease—in this case, lung cancer against a background of pulmonary fibrosis.

Undiagnosed infection has disastrous results

WHILE HOSPITALIZED FOR ROUTINE POST-PARTUM CARE after the uneventful birth of her second child, a 37-year-old woman developed tachycardia and hypotension along with an expanding, excoriating wound on her labia. She claimed that the wound was treated only by applying ice and monitoring blood counts. The patient’s condition deteriorated until, on the third postpartum day, her blood pressure dropped and she coded. She was revived, and necrotizing fasciitis was diagnosed.

The woman spent 4 months in the ICU, during which time she underwent many surgeries to debride the wound as well as a nephrectomy and a permanent colostomy. The surgeries caused extensive scarring in the groin area. For 6 months after discharge from the ICU, the patient couldn’t walk without a cane or walker.

PLAINTIFF’S CLAIM: The specifics of the claim—which likely focused on the wound care she received and the delay in her diagnosis—were not detailed in the case summary.

DOCTOR’S DEFENSE: No negligence occurred. Necrotizing fasciitis is rare, and none of the health care providers should have been expected to diagnose it.

VERDICT: Confidential Nebraska settlement.

COMMENT: This case serves as a potent reminder of the serious nature of this dreaded infection.

Misdiagnosed chest pain leads to fatal MI

A 43-YEAR-OLD MAN, who smoked cigarettes and had a strong family history of coronary artery disease, had been under the care of a primary care physician for 3 years. The patient’s history also included at least 1 episode of chest pain.

The patient visited his physician complaining of intermittent chest pain for several days. He described 2 episodes of nausea, vomiting, and pain in his back teeth, followed by pain radiating down his right chest to the right costal margin. He had no symptoms during the office visit. The physician ordered an in-office EKG, which he interpreted as normal.

The physician diagnosed the chest pain as gastrointestinal in origin and prescribed an antacid. Because of the patient’s cardiac risk factors, the doctor scheduled a stress test and EKG for 2 days later.

On the morning of the stress test, the patient’s wife found him unresponsive. Resuscitation failed, and he was pronounced dead. An autopsy revealed severe proximal coronary artery disease of the left main coronary artery, left anterior descending coronary artery, and right coronary artery, as well as evidence of “remote and recent myocardial infarction.”

PLAINTIFF’S CLAIM: The EKG demonstrated significant changes compared with an EKG performed 3 years earlier and indicated that the patient was suffering an acute coronary episode. The doctor was negligent in failing to diagnose the episode and transfer the patient for proper cardiac care.

DOCTOR’S DEFENSE: The patient’s presentation indicated gastrointestinal distress; the EKG was normal.

VERDICT: $1.5 million Massachusetts settlement.

COMMENT: It’s imperative to compare EKGs, chest radiographs, and other tests with baseline results. How many times do you see an EKG that shows subtle but important changes that influence management?

Testing confusion delays breast cancer Dx

A WOMAN NOTICED A HARD SPOT IN HER LEFT BREAST in April and reported it to her physician in June. The doctor referred the 47-year-old patient to another physician, who performed a mammogram in early August. Four days later, the woman received a call directing her to return for imaging of her right breast. The patient claimed that when she told a radiology technician that she was concerned about her left breast, the technician replied that the order called for a right breast exam. Shortly thereafter, the patient received a letter informing her that everything was fine and instructing her to come back in a year.

She was still feeling the mass in her left breast when she returned for her annual exam the following August. A few weeks later, she was diagnosed with breast cancer. When the case went to trial, the patient had been told she had 2 years to live.

PLAINTIFF’S CLAIM: The plaintiff’s claim centered on the delay in her diagnosis, though the specifics were not detailed in the case summary.

DOCTORS’ DEFENSE: The defendants blamed each other for the delay; they also claimed that the patient should have kept complaining if she felt a mass. They further maintained that the required treatment would have been the same if the cancer had been diagnosed the previous year.

VERDICT: $4.5 million Missouri verdict (second physician, 85% at fault; radiology technician, 15% at fault).

COMMENT: What can go wrong does go wrong: A slip in communication and follow-up led to this $4.5 million verdict. Failure to make a timely diagnosis of breast cancer remains one of the most litigious areas in medicine.

Pulmonary disease masks lung cancer

A WOMAN WITH IDIOPATHIC PULMONARY FIBROSIS had been monitored by her physician for 7 years with physical exams, pulmonary function tests, and radiographic studies, including CT scans of the chest. During an office visit in October, the 57-year-old patient complained of increased difficulty breathing. A pulmonary function test and CT scan showed progression of the pulmonary fibrosis.

The following July, a pulmonary function test showed further deterioration of the patient’s condition, and the physician quadrupled her corticosteroid dosage. When the patient reported breathing problems again in December, a pulmonary function test showed continued decrease in breathing function.

Five months after that, the patient developed a malignant thigh lesion. A chest CT scan later that month revealed a lobular mass in the lower right lung, which had not appeared on the scan done a year and a half before. A biopsy revealed stage 4 adenocarcinoma. The woman died less than a month later of metastatic lung cancer.

PLAINTIFF’S CLAIM: The physician failed to follow up properly on the worsening fibrosis, allowing the cancer to grow un-detected. The physician should have ordered a CT scan in July or December.

DOCTOR’S DEFENSE: No negligence occurred; the patient didn’t complain much about her symptoms, and no signs or symptoms during her visits suggested that more tests should have been ordered. An earlier diagnosis wouldn’t have made a difference because the patient would not have been a candidate for surgery.

VERDICT: New York defense verdict.

COMMENT: Although a defense verdict was returned, we have to be careful not to overlook a serious new problem in the midst of a chronic disease—in this case, lung cancer against a background of pulmonary fibrosis.

Undiagnosed infection has disastrous results

WHILE HOSPITALIZED FOR ROUTINE POST-PARTUM CARE after the uneventful birth of her second child, a 37-year-old woman developed tachycardia and hypotension along with an expanding, excoriating wound on her labia. She claimed that the wound was treated only by applying ice and monitoring blood counts. The patient’s condition deteriorated until, on the third postpartum day, her blood pressure dropped and she coded. She was revived, and necrotizing fasciitis was diagnosed.

The woman spent 4 months in the ICU, during which time she underwent many surgeries to debride the wound as well as a nephrectomy and a permanent colostomy. The surgeries caused extensive scarring in the groin area. For 6 months after discharge from the ICU, the patient couldn’t walk without a cane or walker.

PLAINTIFF’S CLAIM: The specifics of the claim—which likely focused on the wound care she received and the delay in her diagnosis—were not detailed in the case summary.

DOCTOR’S DEFENSE: No negligence occurred. Necrotizing fasciitis is rare, and none of the health care providers should have been expected to diagnose it.

VERDICT: Confidential Nebraska settlement.

COMMENT: This case serves as a potent reminder of the serious nature of this dreaded infection.

Misdiagnosed chest pain leads to fatal MI

A 43-YEAR-OLD MAN, who smoked cigarettes and had a strong family history of coronary artery disease, had been under the care of a primary care physician for 3 years. The patient’s history also included at least 1 episode of chest pain.

The patient visited his physician complaining of intermittent chest pain for several days. He described 2 episodes of nausea, vomiting, and pain in his back teeth, followed by pain radiating down his right chest to the right costal margin. He had no symptoms during the office visit. The physician ordered an in-office EKG, which he interpreted as normal.

The physician diagnosed the chest pain as gastrointestinal in origin and prescribed an antacid. Because of the patient’s cardiac risk factors, the doctor scheduled a stress test and EKG for 2 days later.

On the morning of the stress test, the patient’s wife found him unresponsive. Resuscitation failed, and he was pronounced dead. An autopsy revealed severe proximal coronary artery disease of the left main coronary artery, left anterior descending coronary artery, and right coronary artery, as well as evidence of “remote and recent myocardial infarction.”

PLAINTIFF’S CLAIM: The EKG demonstrated significant changes compared with an EKG performed 3 years earlier and indicated that the patient was suffering an acute coronary episode. The doctor was negligent in failing to diagnose the episode and transfer the patient for proper cardiac care.

DOCTOR’S DEFENSE: The patient’s presentation indicated gastrointestinal distress; the EKG was normal.

VERDICT: $1.5 million Massachusetts settlement.

COMMENT: It’s imperative to compare EKGs, chest radiographs, and other tests with baseline results. How many times do you see an EKG that shows subtle but important changes that influence management?

Parents claim fetal body was mistreated

A WOMAN presented at the hospital with excessive vaginal bleeding at 18 to 20 weeks’ gestation. A sonogram indicated the absence of amniotic fluid and a fetal heart rate of 86 to 102 bpm. The patient was admitted to labor and delivery. A nurse found no fetal heart tones, and the attending OB, Dr. A, used ultrasonography to confirm fetal death. Labor induction to deliver the fetus was begun. When a breech position was found, Dr. A, who was now unavailable, had the nurse contact Dr. B. The fetal body was delivered without the head—but Dr. B completed no delivery note and the medical records did not mention decapitation. After the body was placed in a sterile basin, the head was delivered using a ring forceps. Nurses removed the body parts and swaddled them in a baby blanket. The parents, who had not seen the decapitation, refused to hold the wrapped fetus, fearing the head would fall off. The remains were put in a closed casket for the viewing and funeral.

• PLAINTIFFS’ CLAIM The plaintiff mother claimed medical malpractice. Both parents said the fetus should have been left to deliver spontaneously without intervention. There was negligence in the mistreatment of the fetal body and also in the application of excessive force or traction to the body, which caused the decapitation.
  
• PHYSICIAN’S DEFENSE The delivery was carried out correctly. Delivery of a stillborn fetus requires guidance, as the cervix cannot fully dilate. Also, an 18- to 20-week fetus is friable and delicate; thus, contractions created a sheering force on the fetal body and caused the decapitation. The latter was not caused by traction.
  
• VERDICT Missouri defense verdict. A posttrial motion was pending.
  

Myomectomy causes uterine and bowel injuries

A 47-YEAR-OLD WOMAN suffered from heavy menstrual bleeding caused by submucosal uterine fibroids. Her gynecologist tried to resect the largest fibroid using a resectoscope, but the fibroid did not free itself from the uterine wall when he applied electrical current. He continued the procedure until it was apparent he had perforated the uterus. He stopped and sent the patient home with pain medications and antibiotics. Because of a bowel injury, she developed peritonitis and sepsis and eventually required surgical repair of the bowel. Her recovery was good, but it required her to miss work for 1 month and aggravated an existing anxiety disorder.

• PATIENT’S CLAIM Because of the high risk of uterine and bowel injury, the procedure should have been terminated when the application of electrical current did not free the fibroid from the uterine wall.
  
• PHYSICIAN’S DEFENSE Not reported.
  
• VERDICT $500,000 Minnesota settlement.
  

Patient attempts suicide after Lupron injection

A 27-YEAR-OLD WOMAN suffering from depression was given a diagnosis of endometriosis. Her ObGyn injected her with leuprolide (Lupron), which can decrease the production of some hormones and influence moods, and has an effect that lasts for about 3 months. Five days later the patient reported depression, and then returned to the facility the next day. Eleven days after that, she attempted suicide. A diagnosis of bipolar disorder was made following 3 days of inpatient psychiatric evaluation. She was treated for 1 month as an outpatient.

• PATIENT’S CLAIM Lupron should not have been administered. The ObGyn was negligent for treating her with the drug and for not disclosing that it can cause depression. She was unable to handle the presence of other people, and thus did not return to work.
  
• PHYSICIAN’S DEFENSE First, because depression is a rare side effect of Lupron, it was unnecessary to disclose the risk. Second, given that the depression did not subside until 3 years after leuprolide injection, the drug had not caused the depression.
  
• VERDICT New York defense verdict.
  

Parents claim fetal body was mistreated

A WOMAN presented at the hospital with excessive vaginal bleeding at 18 to 20 weeks’ gestation. A sonogram indicated the absence of amniotic fluid and a fetal heart rate of 86 to 102 bpm. The patient was admitted to labor and delivery. A nurse found no fetal heart tones, and the attending OB, Dr. A, used ultrasonography to confirm fetal death. Labor induction to deliver the fetus was begun. When a breech position was found, Dr. A, who was now unavailable, had the nurse contact Dr. B. The fetal body was delivered without the head—but Dr. B completed no delivery note and the medical records did not mention decapitation. After the body was placed in a sterile basin, the head was delivered using a ring forceps. Nurses removed the body parts and swaddled them in a baby blanket. The parents, who had not seen the decapitation, refused to hold the wrapped fetus, fearing the head would fall off. The remains were put in a closed casket for the viewing and funeral.

• PLAINTIFFS’ CLAIM The plaintiff mother claimed medical malpractice. Both parents said the fetus should have been left to deliver spontaneously without intervention. There was negligence in the mistreatment of the fetal body and also in the application of excessive force or traction to the body, which caused the decapitation.
  
• PHYSICIAN’S DEFENSE The delivery was carried out correctly. Delivery of a stillborn fetus requires guidance, as the cervix cannot fully dilate. Also, an 18- to 20-week fetus is friable and delicate; thus, contractions created a sheering force on the fetal body and caused the decapitation. The latter was not caused by traction.
  
• VERDICT Missouri defense verdict. A posttrial motion was pending.
  

Myomectomy causes uterine and bowel injuries

A 47-YEAR-OLD WOMAN suffered from heavy menstrual bleeding caused by submucosal uterine fibroids. Her gynecologist tried to resect the largest fibroid using a resectoscope, but the fibroid did not free itself from the uterine wall when he applied electrical current. He continued the procedure until it was apparent he had perforated the uterus. He stopped and sent the patient home with pain medications and antibiotics. Because of a bowel injury, she developed peritonitis and sepsis and eventually required surgical repair of the bowel. Her recovery was good, but it required her to miss work for 1 month and aggravated an existing anxiety disorder.

• PATIENT’S CLAIM Because of the high risk of uterine and bowel injury, the procedure should have been terminated when the application of electrical current did not free the fibroid from the uterine wall.
  
• PHYSICIAN’S DEFENSE Not reported.
  
• VERDICT $500,000 Minnesota settlement.
  

Patient attempts suicide after Lupron injection

A 27-YEAR-OLD WOMAN suffering from depression was given a diagnosis of endometriosis. Her ObGyn injected her with leuprolide (Lupron), which can decrease the production of some hormones and influence moods, and has an effect that lasts for about 3 months. Five days later the patient reported depression, and then returned to the facility the next day. Eleven days after that, she attempted suicide. A diagnosis of bipolar disorder was made following 3 days of inpatient psychiatric evaluation. She was treated for 1 month as an outpatient.

• PATIENT’S CLAIM Lupron should not have been administered. The ObGyn was negligent for treating her with the drug and for not disclosing that it can cause depression. She was unable to handle the presence of other people, and thus did not return to work.
  
• PHYSICIAN’S DEFENSE First, because depression is a rare side effect of Lupron, it was unnecessary to disclose the risk. Second, given that the depression did not subside until 3 years after leuprolide injection, the drug had not caused the depression.
  
• VERDICT New York defense verdict.
  

Parents claim fetal body was mistreated

A WOMAN presented at the hospital with excessive vaginal bleeding at 18 to 20 weeks’ gestation. A sonogram indicated the absence of amniotic fluid and a fetal heart rate of 86 to 102 bpm. The patient was admitted to labor and delivery. A nurse found no fetal heart tones, and the attending OB, Dr. A, used ultrasonography to confirm fetal death. Labor induction to deliver the fetus was begun. When a breech position was found, Dr. A, who was now unavailable, had the nurse contact Dr. B. The fetal body was delivered without the head—but Dr. B completed no delivery note and the medical records did not mention decapitation. After the body was placed in a sterile basin, the head was delivered using a ring forceps. Nurses removed the body parts and swaddled them in a baby blanket. The parents, who had not seen the decapitation, refused to hold the wrapped fetus, fearing the head would fall off. The remains were put in a closed casket for the viewing and funeral.

• PLAINTIFFS’ CLAIM The plaintiff mother claimed medical malpractice. Both parents said the fetus should have been left to deliver spontaneously without intervention. There was negligence in the mistreatment of the fetal body and also in the application of excessive force or traction to the body, which caused the decapitation.
  
• PHYSICIAN’S DEFENSE The delivery was carried out correctly. Delivery of a stillborn fetus requires guidance, as the cervix cannot fully dilate. Also, an 18- to 20-week fetus is friable and delicate; thus, contractions created a sheering force on the fetal body and caused the decapitation. The latter was not caused by traction.
  
• VERDICT Missouri defense verdict. A posttrial motion was pending.
  

Myomectomy causes uterine and bowel injuries

A 47-YEAR-OLD WOMAN suffered from heavy menstrual bleeding caused by submucosal uterine fibroids. Her gynecologist tried to resect the largest fibroid using a resectoscope, but the fibroid did not free itself from the uterine wall when he applied electrical current. He continued the procedure until it was apparent he had perforated the uterus. He stopped and sent the patient home with pain medications and antibiotics. Because of a bowel injury, she developed peritonitis and sepsis and eventually required surgical repair of the bowel. Her recovery was good, but it required her to miss work for 1 month and aggravated an existing anxiety disorder.

• PATIENT’S CLAIM Because of the high risk of uterine and bowel injury, the procedure should have been terminated when the application of electrical current did not free the fibroid from the uterine wall.
  
• PHYSICIAN’S DEFENSE Not reported.
  
• VERDICT $500,000 Minnesota settlement.
  

Patient attempts suicide after Lupron injection

A 27-YEAR-OLD WOMAN suffering from depression was given a diagnosis of endometriosis. Her ObGyn injected her with leuprolide (Lupron), which can decrease the production of some hormones and influence moods, and has an effect that lasts for about 3 months. Five days later the patient reported depression, and then returned to the facility the next day. Eleven days after that, she attempted suicide. A diagnosis of bipolar disorder was made following 3 days of inpatient psychiatric evaluation. She was treated for 1 month as an outpatient.

• PATIENT’S CLAIM Lupron should not have been administered. The ObGyn was negligent for treating her with the drug and for not disclosing that it can cause depression. She was unable to handle the presence of other people, and thus did not return to work.
  
• PHYSICIAN’S DEFENSE First, because depression is a rare side effect of Lupron, it was unnecessary to disclose the risk. Second, given that the depression did not subside until 3 years after leuprolide injection, the drug had not caused the depression.
  
• VERDICT New York defense verdict.