Medical Verdicts

Delayed heart attack diagnosis ends in disability and a huge verdict

DESPITE FEELING ILL ON AWAKENING, a 50-year-old woman went to work, where she suffered crushing chest pain radiating down her left arm and up to her jaw. Her coworker (and husband at the time) recognized the symptoms of a heart attack and drove her to the emergency department (ED).

An electrocardiogram (EKG) performed more than 4 hours later was read as not indicating a heart attack. The patient was given pain medication and an antianxiety drug because she had a history of anxiety. She spent the night at the hospital, lying on a gurney in a hallway at times.

In the morning, her husband called his own cardiologist, whose office was across the street from the hospital. The cardiologist came to the ED and immediately arranged to have the patient transferred by ambulance to the intensive care unit at another hospital.

Upon arrival, the patient was immediately sent to the hospital’s cardiac catheterization lab, where a heart attack was diagnosed. She underwent immediate surgery, during which she suffered dissection of an artery. Because of damage to her heart, she couldn’t return to work.

PLAINTIFF’S CLAIM The patient lost 70% of her heart’s pumping capacity and would require a heart transplant eventually. A cardiologist should have evaluated the patient immediately upon her arrival at the first hospital; the EKG done at that hospital was misread. On the catheterization film taken before surgery at the second hospital, the front portion of the patient’s heart was motionless.

THE DEFENSE The dissection during surgery caused the patient’s injuries.

VERDICT $126.6 million New York verdict.

COMMENT I do some malpractice case review and have seen 2 cases just like this one. If it sounds like a horse (myocardial infarction), it is a horse until proven otherwise. I’ve heard of men in their 40s seeking urgent care, being diagnosed with dyspepsia, and dying within 2 days.

Inadequate INR monitoring implicated in woman's death

A 59-YEAR-OLD WOMAN was diagnosed with atrial fibrillation and heart failure by a cardiologist and put on warfarin, which the cardiologist discontinued after a few days. Warfarin was resumed when the patient underwent surgery to place a mechanical heart valve.

The patient’s international normalized ratio (INR) was tested daily while she was in the hospital, and warfarin was stopped several times. She was discharged with a prescription for 2 mg warfarin because her INR was 2.2, below the therapeutic range.

At a follow-up visit, the cardiologist checked the INR, which was 3.1. He saw the patient in the office again 8 days later, and 6 days after that a call was made to him, but no further blood tests were performed.

Eight days after the call, the patient was found unresponsive, with indications of gastrointestinal (GI) bleeding, and taken to the emergency department. Her INR level was at least 24.4, the highest the equipment could measure. In addition to GI bleeding, she had bleeding in her lungs. She died the next day.

PLAINTIFF’S CLAIM The defendants didn’t monitor INR properly; the doctor knew the importance of monitoring INR while the patient was taking warfarin.

THE DEFENSE The INR level was normal at the posthospital visit. That measurement, along with the monitoring done while the patient was hospitalized, was appropriate monitoring. The patient died of sepsis, not exsanguination.

VERDICT $386,648 net California verdict.

COMMENT This could have happened to any of us. If you monitor warfarin in your practice, make sure the follow-up system is water tight. Use a registry and double checking system. Be sure you know who is responsible during care transitions.

Delayed heart attack diagnosis ends in disability and a huge verdict

DESPITE FEELING ILL ON AWAKENING, a 50-year-old woman went to work, where she suffered crushing chest pain radiating down her left arm and up to her jaw. Her coworker (and husband at the time) recognized the symptoms of a heart attack and drove her to the emergency department (ED).

An electrocardiogram (EKG) performed more than 4 hours later was read as not indicating a heart attack. The patient was given pain medication and an antianxiety drug because she had a history of anxiety. She spent the night at the hospital, lying on a gurney in a hallway at times.

In the morning, her husband called his own cardiologist, whose office was across the street from the hospital. The cardiologist came to the ED and immediately arranged to have the patient transferred by ambulance to the intensive care unit at another hospital.

Upon arrival, the patient was immediately sent to the hospital’s cardiac catheterization lab, where a heart attack was diagnosed. She underwent immediate surgery, during which she suffered dissection of an artery. Because of damage to her heart, she couldn’t return to work.

PLAINTIFF’S CLAIM The patient lost 70% of her heart’s pumping capacity and would require a heart transplant eventually. A cardiologist should have evaluated the patient immediately upon her arrival at the first hospital; the EKG done at that hospital was misread. On the catheterization film taken before surgery at the second hospital, the front portion of the patient’s heart was motionless.

THE DEFENSE The dissection during surgery caused the patient’s injuries.

VERDICT $126.6 million New York verdict.

COMMENT I do some malpractice case review and have seen 2 cases just like this one. If it sounds like a horse (myocardial infarction), it is a horse until proven otherwise. I’ve heard of men in their 40s seeking urgent care, being diagnosed with dyspepsia, and dying within 2 days.

Inadequate INR monitoring implicated in woman's death

A 59-YEAR-OLD WOMAN was diagnosed with atrial fibrillation and heart failure by a cardiologist and put on warfarin, which the cardiologist discontinued after a few days. Warfarin was resumed when the patient underwent surgery to place a mechanical heart valve.

The patient’s international normalized ratio (INR) was tested daily while she was in the hospital, and warfarin was stopped several times. She was discharged with a prescription for 2 mg warfarin because her INR was 2.2, below the therapeutic range.

At a follow-up visit, the cardiologist checked the INR, which was 3.1. He saw the patient in the office again 8 days later, and 6 days after that a call was made to him, but no further blood tests were performed.

Eight days after the call, the patient was found unresponsive, with indications of gastrointestinal (GI) bleeding, and taken to the emergency department. Her INR level was at least 24.4, the highest the equipment could measure. In addition to GI bleeding, she had bleeding in her lungs. She died the next day.

PLAINTIFF’S CLAIM The defendants didn’t monitor INR properly; the doctor knew the importance of monitoring INR while the patient was taking warfarin.

THE DEFENSE The INR level was normal at the posthospital visit. That measurement, along with the monitoring done while the patient was hospitalized, was appropriate monitoring. The patient died of sepsis, not exsanguination.

VERDICT $386,648 net California verdict.

COMMENT This could have happened to any of us. If you monitor warfarin in your practice, make sure the follow-up system is water tight. Use a registry and double checking system. Be sure you know who is responsible during care transitions.

Delayed heart attack diagnosis ends in disability and a huge verdict

DESPITE FEELING ILL ON AWAKENING, a 50-year-old woman went to work, where she suffered crushing chest pain radiating down her left arm and up to her jaw. Her coworker (and husband at the time) recognized the symptoms of a heart attack and drove her to the emergency department (ED).

An electrocardiogram (EKG) performed more than 4 hours later was read as not indicating a heart attack. The patient was given pain medication and an antianxiety drug because she had a history of anxiety. She spent the night at the hospital, lying on a gurney in a hallway at times.

In the morning, her husband called his own cardiologist, whose office was across the street from the hospital. The cardiologist came to the ED and immediately arranged to have the patient transferred by ambulance to the intensive care unit at another hospital.

Upon arrival, the patient was immediately sent to the hospital’s cardiac catheterization lab, where a heart attack was diagnosed. She underwent immediate surgery, during which she suffered dissection of an artery. Because of damage to her heart, she couldn’t return to work.

PLAINTIFF’S CLAIM The patient lost 70% of her heart’s pumping capacity and would require a heart transplant eventually. A cardiologist should have evaluated the patient immediately upon her arrival at the first hospital; the EKG done at that hospital was misread. On the catheterization film taken before surgery at the second hospital, the front portion of the patient’s heart was motionless.

THE DEFENSE The dissection during surgery caused the patient’s injuries.

VERDICT $126.6 million New York verdict.

COMMENT I do some malpractice case review and have seen 2 cases just like this one. If it sounds like a horse (myocardial infarction), it is a horse until proven otherwise. I’ve heard of men in their 40s seeking urgent care, being diagnosed with dyspepsia, and dying within 2 days.

Inadequate INR monitoring implicated in woman's death

A 59-YEAR-OLD WOMAN was diagnosed with atrial fibrillation and heart failure by a cardiologist and put on warfarin, which the cardiologist discontinued after a few days. Warfarin was resumed when the patient underwent surgery to place a mechanical heart valve.

The patient’s international normalized ratio (INR) was tested daily while she was in the hospital, and warfarin was stopped several times. She was discharged with a prescription for 2 mg warfarin because her INR was 2.2, below the therapeutic range.

At a follow-up visit, the cardiologist checked the INR, which was 3.1. He saw the patient in the office again 8 days later, and 6 days after that a call was made to him, but no further blood tests were performed.

Eight days after the call, the patient was found unresponsive, with indications of gastrointestinal (GI) bleeding, and taken to the emergency department. Her INR level was at least 24.4, the highest the equipment could measure. In addition to GI bleeding, she had bleeding in her lungs. She died the next day.

PLAINTIFF’S CLAIM The defendants didn’t monitor INR properly; the doctor knew the importance of monitoring INR while the patient was taking warfarin.

THE DEFENSE The INR level was normal at the posthospital visit. That measurement, along with the monitoring done while the patient was hospitalized, was appropriate monitoring. The patient died of sepsis, not exsanguination.

VERDICT $386,648 net California verdict.

COMMENT This could have happened to any of us. If you monitor warfarin in your practice, make sure the follow-up system is water tight. Use a registry and double checking system. Be sure you know who is responsible during care transitions.

One twin has cerebral palsy; $103 million verdict

AFTER PREMATURE RUPTURE OF MEMBRANES at 25 weeks’ gestation, a woman went to the emergency department (ED) and was later released. Eight days later, she returned to the ED with abdominal pain; a soporific drug was administered. After several hours, it was determined that she was in labor. Twins were delivered vaginally. One child has cerebral palsy and requires assistance in daily activities, although her cognitive function is intact.

PARENTS’ CLAIM The mother should not have been released after premature rupture of her membranes. The nurses and ObGyns failed to timely recognize that the mother was in labor, and failed to prevent premature delivery. Proper recognition of contractions would have allowed for administration of a tocolytic to delay delivery. That drug had been effectively administered during the first two trimesters of the pregnancy. A cesarean delivery should have been performed.

DEFENDANTS’ DEFENSE There was no negligence. The hospital argued that fetal heart-rate monitors did not suggest contractions.

VERDICT A $103 million New York verdict was returned against the hospital; a defense verdict was returned for the physicians.

Perforated uterus and severed iliac artery after D&C

A GYNECOLOGIC SURGEON performed a dilation and curettage (D&C) on a 47-year-old woman. During surgery, the patient suffered a perforated uterus and a severed iliac artery, resulting in a myocardial infarction.

PATIENT’S CLAIM The surgeon failed to dilate the cervix appropriately to assess the cervical and endometrial cavity length, and then failed to use proper instrumentation in the uterus. He did not assess uterine shape before the D&C. The patient suffered cognitive and emotional injuries, and will require additional surgery.

PHYSICIAN’S DEFENSE The patient’s anatomy is abnormal. A perforation is a known complication of a D&C.

VERDICT A $350,000 Wisconsin settlement was reached.

Failure to monitor a high-risk patient

A WOMAN WITH A HEART CONDITION who routinely took a beta-blocker plus migraine medication also had lupus. Her pregnancy was therefore at high risk for developing intrauterine growth restriction. Her US Navy ObGyn was advised by a maternal-fetal medicine (MFM) specialist to monitor the pregnancy closely with frequent ultrasonography and other tests that were never performed.

The baby was born by emergency cesarean delivery at 36 weeks’ gestation. The child suffered severe hypoxia and a brain hemorrhage just before delivery, which caused serious, permanent physical and neurologic injuries. He needs 24-hour care, is confined to a wheelchair, and requires a feeding tube.

PATIENT’S CLAIM The ObGyn failed to monitor the mother for fetal growth restriction as recommended by the MFM specialist.

DEFENDANTS’ DEFENSE There was no negligence; the mother was treated properly.

VERDICT After a $28 million Virginia verdict was awarded, the parties continued to dispute whether the judgment would be paid under California law (where the child was born) or Virginia law (where the case was filed). Prior to a rehearing, a $25 million settlement was reached.

Uterine cancer went undiagnosed

A WOMAN IN HER 50s saw her gynecologist in March 2004 to report vaginal staining. She did not return to the physician’s office until January 2005, when she reported daily vaginal bleeding. Ultrasonography showed a 4-cm mass in the endometrial cavity, consistent with a large polyp. A hysteroscopy and biopsy revealed that the woman had uterine cancer. She underwent a hysterectomy and radiation therapy, but the cancer metastasized to her lungs and she died in October 2006.

ESTATE’S CLAIM The gynecologist failed to diagnose uterine cancer in a timely manner.

PHYSICIAN’S DEFENSE The patient’s cancer was aggressive; an earlier diagnosis would not have changed the outcome.

VERDICT A $820,000 Massachusetts settlement was reached.

Severe stenosis closes vaginal opening after TVT-O surgery

WHEN A 51-YEAR-OLD WOMAN NOTICED A BULGE in her vagina, she consulted her gynecologist. He determined the cause to be a cystocele and rectocele, and recommended a tension-free vaginal tape–obturator (TVT-O) procedure with anterior and posterior colporrhaphy.

The patient awoke from surgery in severe pain and was told that she had lost a lot of blood. Two weeks later, the physician explained that the stitches, not yet absorbed, were causing an abrasion, and that more vaginal tissue had been removed than planned.

Two more weeks passed, and the patient used a mirror to look at her vagina but could not see the opening. The TVT-O tape had created a ridge of tissue in the anterior vagina, causing severe stenosis. Vaginal dilators were required to expand the vagina. Entrapment of the dorsal clitoral nerve by the TVT-O tape was also discovered. The patient continues to experience dyspareunia and groin pain.

PATIENT’S CLAIM The gynecologist failed to tell her that, 2 months before surgery, the FDA had issued a public health warning about complications associated with transvaginal placement of surgical mesh during prolapse and urinary incontinence repair. Nor was she informed that the defendant had just completed training in TVT-O surgery, was not fully credentialed, and was proctored during the procedure.

PHYSICIAN’S DEFENSE The case was settled before the trial concluded.

VERDICT A $390,000 Virginia settlement was reached.

Lumpectomy, though no mass palpated

A 52-YEAR-OLD WOMAN FOUND A LUMP in her left breast. Her internist ordered mammography, which identified a 2-cm oval, asymmetrical density in the upper inner quadrant of the left breast. The radiologist recommended ultrasonography (US).

The patient consulted a surgical oncologist, who performed fine-needle aspiration. Pathology identified “clusters of malignant cells consistent with carcinoma,” and suggested a confirmatory biopsy. The oncologist recommended lumpectomy and sentinel node biopsy.

On the day of surgery, the patient could not locate the mass. The oncologist testified that he had palpated it. During surgery, gross examination did not show a mass or tumor. Frozen sections of sentinel nodes did not reveal evidence of cancer.

The patient suffered postsurgical seromas and lymphedema. The lymphedema has partially resolved, but causes pain in her left arm and breast.

PATIENT’S CLAIM The surgical oncologist should have performed US before surgery. It was negligent to continue with surgery when there were negative intraoperative findings for cancer or a mass.

PHYSICIAN’S DEFENSE Proper care was provided.

VERDICT A $950,000 Illinois verdict was returned.

Genetic testing fails to identify cystic fibrosis in one twin

AFTER HAVING ONE CHILD with cystic fibrosis (CF), parents underwent genetic testing. Embryos were prepared for in vitro fertilization (IVF) and sent to a genetic-testing laboratory. The lab reported that the embryos were negative for CF. Two embryos were implanted, and the mother gave birth to twins, one of which has CF.

PARENTS’ CLAIM Multiple errors by the genetic-testing laboratory led to an incorrect report on the embryos. The parents claimed wrongful birth.

DEFENDANTS’ DEFENSE The testing laboratory and physician owner argued that amniocentesis should have been performed during the pregnancy to rule out CF.

VERDICT The trial judge denied the use of the amniocentesis defense because an abortion would have been the only option available, and abortion is against the public policy of Tennessee. The court entered summary judgment on liability for the parents.

A $13 million verdict was returned, including $7 million to the parents for emotional distress.

One twin has cerebral palsy; $103 million verdict

AFTER PREMATURE RUPTURE OF MEMBRANES at 25 weeks’ gestation, a woman went to the emergency department (ED) and was later released. Eight days later, she returned to the ED with abdominal pain; a soporific drug was administered. After several hours, it was determined that she was in labor. Twins were delivered vaginally. One child has cerebral palsy and requires assistance in daily activities, although her cognitive function is intact.

PARENTS’ CLAIM The mother should not have been released after premature rupture of her membranes. The nurses and ObGyns failed to timely recognize that the mother was in labor, and failed to prevent premature delivery. Proper recognition of contractions would have allowed for administration of a tocolytic to delay delivery. That drug had been effectively administered during the first two trimesters of the pregnancy. A cesarean delivery should have been performed.

DEFENDANTS’ DEFENSE There was no negligence. The hospital argued that fetal heart-rate monitors did not suggest contractions.

VERDICT A $103 million New York verdict was returned against the hospital; a defense verdict was returned for the physicians.

Perforated uterus and severed iliac artery after D&C

A GYNECOLOGIC SURGEON performed a dilation and curettage (D&C) on a 47-year-old woman. During surgery, the patient suffered a perforated uterus and a severed iliac artery, resulting in a myocardial infarction.

PATIENT’S CLAIM The surgeon failed to dilate the cervix appropriately to assess the cervical and endometrial cavity length, and then failed to use proper instrumentation in the uterus. He did not assess uterine shape before the D&C. The patient suffered cognitive and emotional injuries, and will require additional surgery.

PHYSICIAN’S DEFENSE The patient’s anatomy is abnormal. A perforation is a known complication of a D&C.

VERDICT A $350,000 Wisconsin settlement was reached.

Failure to monitor a high-risk patient

A WOMAN WITH A HEART CONDITION who routinely took a beta-blocker plus migraine medication also had lupus. Her pregnancy was therefore at high risk for developing intrauterine growth restriction. Her US Navy ObGyn was advised by a maternal-fetal medicine (MFM) specialist to monitor the pregnancy closely with frequent ultrasonography and other tests that were never performed.

The baby was born by emergency cesarean delivery at 36 weeks’ gestation. The child suffered severe hypoxia and a brain hemorrhage just before delivery, which caused serious, permanent physical and neurologic injuries. He needs 24-hour care, is confined to a wheelchair, and requires a feeding tube.

PATIENT’S CLAIM The ObGyn failed to monitor the mother for fetal growth restriction as recommended by the MFM specialist.

DEFENDANTS’ DEFENSE There was no negligence; the mother was treated properly.

VERDICT After a $28 million Virginia verdict was awarded, the parties continued to dispute whether the judgment would be paid under California law (where the child was born) or Virginia law (where the case was filed). Prior to a rehearing, a $25 million settlement was reached.

Uterine cancer went undiagnosed

A WOMAN IN HER 50s saw her gynecologist in March 2004 to report vaginal staining. She did not return to the physician’s office until January 2005, when she reported daily vaginal bleeding. Ultrasonography showed a 4-cm mass in the endometrial cavity, consistent with a large polyp. A hysteroscopy and biopsy revealed that the woman had uterine cancer. She underwent a hysterectomy and radiation therapy, but the cancer metastasized to her lungs and she died in October 2006.

ESTATE’S CLAIM The gynecologist failed to diagnose uterine cancer in a timely manner.

PHYSICIAN’S DEFENSE The patient’s cancer was aggressive; an earlier diagnosis would not have changed the outcome.

VERDICT A $820,000 Massachusetts settlement was reached.

Severe stenosis closes vaginal opening after TVT-O surgery

WHEN A 51-YEAR-OLD WOMAN NOTICED A BULGE in her vagina, she consulted her gynecologist. He determined the cause to be a cystocele and rectocele, and recommended a tension-free vaginal tape–obturator (TVT-O) procedure with anterior and posterior colporrhaphy.

The patient awoke from surgery in severe pain and was told that she had lost a lot of blood. Two weeks later, the physician explained that the stitches, not yet absorbed, were causing an abrasion, and that more vaginal tissue had been removed than planned.

Two more weeks passed, and the patient used a mirror to look at her vagina but could not see the opening. The TVT-O tape had created a ridge of tissue in the anterior vagina, causing severe stenosis. Vaginal dilators were required to expand the vagina. Entrapment of the dorsal clitoral nerve by the TVT-O tape was also discovered. The patient continues to experience dyspareunia and groin pain.

PATIENT’S CLAIM The gynecologist failed to tell her that, 2 months before surgery, the FDA had issued a public health warning about complications associated with transvaginal placement of surgical mesh during prolapse and urinary incontinence repair. Nor was she informed that the defendant had just completed training in TVT-O surgery, was not fully credentialed, and was proctored during the procedure.

PHYSICIAN’S DEFENSE The case was settled before the trial concluded.

VERDICT A $390,000 Virginia settlement was reached.

Lumpectomy, though no mass palpated

A 52-YEAR-OLD WOMAN FOUND A LUMP in her left breast. Her internist ordered mammography, which identified a 2-cm oval, asymmetrical density in the upper inner quadrant of the left breast. The radiologist recommended ultrasonography (US).

The patient consulted a surgical oncologist, who performed fine-needle aspiration. Pathology identified “clusters of malignant cells consistent with carcinoma,” and suggested a confirmatory biopsy. The oncologist recommended lumpectomy and sentinel node biopsy.

On the day of surgery, the patient could not locate the mass. The oncologist testified that he had palpated it. During surgery, gross examination did not show a mass or tumor. Frozen sections of sentinel nodes did not reveal evidence of cancer.

The patient suffered postsurgical seromas and lymphedema. The lymphedema has partially resolved, but causes pain in her left arm and breast.

PATIENT’S CLAIM The surgical oncologist should have performed US before surgery. It was negligent to continue with surgery when there were negative intraoperative findings for cancer or a mass.

PHYSICIAN’S DEFENSE Proper care was provided.

VERDICT A $950,000 Illinois verdict was returned.

Genetic testing fails to identify cystic fibrosis in one twin

AFTER HAVING ONE CHILD with cystic fibrosis (CF), parents underwent genetic testing. Embryos were prepared for in vitro fertilization (IVF) and sent to a genetic-testing laboratory. The lab reported that the embryos were negative for CF. Two embryos were implanted, and the mother gave birth to twins, one of which has CF.

PARENTS’ CLAIM Multiple errors by the genetic-testing laboratory led to an incorrect report on the embryos. The parents claimed wrongful birth.

DEFENDANTS’ DEFENSE The testing laboratory and physician owner argued that amniocentesis should have been performed during the pregnancy to rule out CF.

VERDICT The trial judge denied the use of the amniocentesis defense because an abortion would have been the only option available, and abortion is against the public policy of Tennessee. The court entered summary judgment on liability for the parents.

A $13 million verdict was returned, including $7 million to the parents for emotional distress.

One twin has cerebral palsy; $103 million verdict

AFTER PREMATURE RUPTURE OF MEMBRANES at 25 weeks’ gestation, a woman went to the emergency department (ED) and was later released. Eight days later, she returned to the ED with abdominal pain; a soporific drug was administered. After several hours, it was determined that she was in labor. Twins were delivered vaginally. One child has cerebral palsy and requires assistance in daily activities, although her cognitive function is intact.

PARENTS’ CLAIM The mother should not have been released after premature rupture of her membranes. The nurses and ObGyns failed to timely recognize that the mother was in labor, and failed to prevent premature delivery. Proper recognition of contractions would have allowed for administration of a tocolytic to delay delivery. That drug had been effectively administered during the first two trimesters of the pregnancy. A cesarean delivery should have been performed.

DEFENDANTS’ DEFENSE There was no negligence. The hospital argued that fetal heart-rate monitors did not suggest contractions.

VERDICT A $103 million New York verdict was returned against the hospital; a defense verdict was returned for the physicians.

Perforated uterus and severed iliac artery after D&C

A GYNECOLOGIC SURGEON performed a dilation and curettage (D&C) on a 47-year-old woman. During surgery, the patient suffered a perforated uterus and a severed iliac artery, resulting in a myocardial infarction.

PATIENT’S CLAIM The surgeon failed to dilate the cervix appropriately to assess the cervical and endometrial cavity length, and then failed to use proper instrumentation in the uterus. He did not assess uterine shape before the D&C. The patient suffered cognitive and emotional injuries, and will require additional surgery.

PHYSICIAN’S DEFENSE The patient’s anatomy is abnormal. A perforation is a known complication of a D&C.

VERDICT A $350,000 Wisconsin settlement was reached.

Failure to monitor a high-risk patient

A WOMAN WITH A HEART CONDITION who routinely took a beta-blocker plus migraine medication also had lupus. Her pregnancy was therefore at high risk for developing intrauterine growth restriction. Her US Navy ObGyn was advised by a maternal-fetal medicine (MFM) specialist to monitor the pregnancy closely with frequent ultrasonography and other tests that were never performed.

The baby was born by emergency cesarean delivery at 36 weeks’ gestation. The child suffered severe hypoxia and a brain hemorrhage just before delivery, which caused serious, permanent physical and neurologic injuries. He needs 24-hour care, is confined to a wheelchair, and requires a feeding tube.

PATIENT’S CLAIM The ObGyn failed to monitor the mother for fetal growth restriction as recommended by the MFM specialist.

DEFENDANTS’ DEFENSE There was no negligence; the mother was treated properly.

VERDICT After a $28 million Virginia verdict was awarded, the parties continued to dispute whether the judgment would be paid under California law (where the child was born) or Virginia law (where the case was filed). Prior to a rehearing, a $25 million settlement was reached.

Uterine cancer went undiagnosed

A WOMAN IN HER 50s saw her gynecologist in March 2004 to report vaginal staining. She did not return to the physician’s office until January 2005, when she reported daily vaginal bleeding. Ultrasonography showed a 4-cm mass in the endometrial cavity, consistent with a large polyp. A hysteroscopy and biopsy revealed that the woman had uterine cancer. She underwent a hysterectomy and radiation therapy, but the cancer metastasized to her lungs and she died in October 2006.

ESTATE’S CLAIM The gynecologist failed to diagnose uterine cancer in a timely manner.

PHYSICIAN’S DEFENSE The patient’s cancer was aggressive; an earlier diagnosis would not have changed the outcome.

VERDICT A $820,000 Massachusetts settlement was reached.

Severe stenosis closes vaginal opening after TVT-O surgery

WHEN A 51-YEAR-OLD WOMAN NOTICED A BULGE in her vagina, she consulted her gynecologist. He determined the cause to be a cystocele and rectocele, and recommended a tension-free vaginal tape–obturator (TVT-O) procedure with anterior and posterior colporrhaphy.

The patient awoke from surgery in severe pain and was told that she had lost a lot of blood. Two weeks later, the physician explained that the stitches, not yet absorbed, were causing an abrasion, and that more vaginal tissue had been removed than planned.

Two more weeks passed, and the patient used a mirror to look at her vagina but could not see the opening. The TVT-O tape had created a ridge of tissue in the anterior vagina, causing severe stenosis. Vaginal dilators were required to expand the vagina. Entrapment of the dorsal clitoral nerve by the TVT-O tape was also discovered. The patient continues to experience dyspareunia and groin pain.

PATIENT’S CLAIM The gynecologist failed to tell her that, 2 months before surgery, the FDA had issued a public health warning about complications associated with transvaginal placement of surgical mesh during prolapse and urinary incontinence repair. Nor was she informed that the defendant had just completed training in TVT-O surgery, was not fully credentialed, and was proctored during the procedure.

PHYSICIAN’S DEFENSE The case was settled before the trial concluded.

VERDICT A $390,000 Virginia settlement was reached.

Lumpectomy, though no mass palpated

A 52-YEAR-OLD WOMAN FOUND A LUMP in her left breast. Her internist ordered mammography, which identified a 2-cm oval, asymmetrical density in the upper inner quadrant of the left breast. The radiologist recommended ultrasonography (US).

The patient consulted a surgical oncologist, who performed fine-needle aspiration. Pathology identified “clusters of malignant cells consistent with carcinoma,” and suggested a confirmatory biopsy. The oncologist recommended lumpectomy and sentinel node biopsy.

On the day of surgery, the patient could not locate the mass. The oncologist testified that he had palpated it. During surgery, gross examination did not show a mass or tumor. Frozen sections of sentinel nodes did not reveal evidence of cancer.

The patient suffered postsurgical seromas and lymphedema. The lymphedema has partially resolved, but causes pain in her left arm and breast.

PATIENT’S CLAIM The surgical oncologist should have performed US before surgery. It was negligent to continue with surgery when there were negative intraoperative findings for cancer or a mass.

PHYSICIAN’S DEFENSE Proper care was provided.

VERDICT A $950,000 Illinois verdict was returned.

Genetic testing fails to identify cystic fibrosis in one twin

AFTER HAVING ONE CHILD with cystic fibrosis (CF), parents underwent genetic testing. Embryos were prepared for in vitro fertilization (IVF) and sent to a genetic-testing laboratory. The lab reported that the embryos were negative for CF. Two embryos were implanted, and the mother gave birth to twins, one of which has CF.

PARENTS’ CLAIM Multiple errors by the genetic-testing laboratory led to an incorrect report on the embryos. The parents claimed wrongful birth.

DEFENDANTS’ DEFENSE The testing laboratory and physician owner argued that amniocentesis should have been performed during the pregnancy to rule out CF.

VERDICT The trial judge denied the use of the amniocentesis defense because an abortion would have been the only option available, and abortion is against the public policy of Tennessee. The court entered summary judgment on liability for the parents.

A $13 million verdict was returned, including $7 million to the parents for emotional distress.

Death follows a normal EKG

MID-CHEST DISCOMFORT, A COUGH, AND SWEATING brought a 59-year-old man to his primary care physician. The patient had normal vital signs and reported that belching relieved the chest discomfort. He had a history of severe coronary artery disease and had undergone angioplasty and stenting several years earlier.

The primary care physician performed an electrocardiogram (EKG), which was normal and unchanged from one done the year before. The doctor suspected bronchitis, but prescribed omeprazole because the patient had previously been diagnosed with gastroesophageal reflux disease. He ordered a chemical stress test to be performed within a month and a chest radiograph to be done if the patient’s symptoms didn’t improve.

Two hours after returning home, the patient called an ambulance. He told paramedics that he’d been having chest pain for an hour. While they were putting the patient into the ambulance, he went into cardiac arrest. Four defibrillation attempts en route to the hospital and additional resuscitation attempts in the ED failed; he was pronounced dead 3½ hours after leaving his physician’s office.

No autopsy was performed. The patient’s widow found the omeprazole bottle, with one pill missing, and fast-food hamburger wrappers on the kitchen table.

PLAINTIFF’S CLAIM The primary care physician should have sent the patient to the ED to determine whether the chest pain had a cardiac cause; the patient was suffering from acute cardiac syndrome when the doctor saw him.

THE DEFENSE The patient’s normal EKG and vital signs and the fact that belching relieved his chest symptoms indicated that the complaints did not arise from cardiac causes or require emergency assessment. The patient didn’t report chest pain at the office visit; the later cardiac arrest probably resulted from a sudden plaque rupture unrelated to the earlier chest discomfort.

VERDICT $1.5 million Illinois verdict.

COMMENT I hope most doctors won’t have to learn this lesson from their own experience. A normal EKG does not rule out acute ischemia in a high-risk patient with chest pain and sweating. Admit such patients immediately to a cardiac observation unit.

Kidney failure after multiple meds

A MAN WAS TAKING MULTIPLE MEDICATIONS: 3 blood pressure drugs prescribed by his primary care physician, an NSAID prescribed by another doctor, and sizable doses of BC Powder, an over-the-counter analgesic containing aspirin, salicylamide, and caffeine. After 4 years on this medication regimen, the patient’s kidneys failed.

PLAINTIFF’S CLAIM The primary care physician failed to properly monitor kidney function with blood and urine tests while his patient was taking the medications. Proper testing would have resulted in a diagnosis of kidney disease before the patient’s kidneys failed completely. In addition, the primary care physician failed to explain the risks and side effects of the medications to the patient.

THE DEFENSE The patient refused kidney function testing and did not follow medical advice. He consumed excessive amounts of alcohol against medical advice, did not tell the primary care physician about other drugs he was taking, and had allowed his supply of blood pressure medication to run out.

VERDICT $2 million gross verdict in Georgia, with a finding of 47% comparative negligence.

COMMENT This case offers several lessons: First, each BC Powder packet contains the equivalent of 2 aspirin. Second, chronic, high-dose NSAIDs can cause renal failure, especially in patients whose renal function is compromised by hypertension. Third, all patients with hypertension should undergo periodic monitoring of renal function.

Death follows a normal EKG

MID-CHEST DISCOMFORT, A COUGH, AND SWEATING brought a 59-year-old man to his primary care physician. The patient had normal vital signs and reported that belching relieved the chest discomfort. He had a history of severe coronary artery disease and had undergone angioplasty and stenting several years earlier.

The primary care physician performed an electrocardiogram (EKG), which was normal and unchanged from one done the year before. The doctor suspected bronchitis, but prescribed omeprazole because the patient had previously been diagnosed with gastroesophageal reflux disease. He ordered a chemical stress test to be performed within a month and a chest radiograph to be done if the patient’s symptoms didn’t improve.

Two hours after returning home, the patient called an ambulance. He told paramedics that he’d been having chest pain for an hour. While they were putting the patient into the ambulance, he went into cardiac arrest. Four defibrillation attempts en route to the hospital and additional resuscitation attempts in the ED failed; he was pronounced dead 3½ hours after leaving his physician’s office.

No autopsy was performed. The patient’s widow found the omeprazole bottle, with one pill missing, and fast-food hamburger wrappers on the kitchen table.

PLAINTIFF’S CLAIM The primary care physician should have sent the patient to the ED to determine whether the chest pain had a cardiac cause; the patient was suffering from acute cardiac syndrome when the doctor saw him.

THE DEFENSE The patient’s normal EKG and vital signs and the fact that belching relieved his chest symptoms indicated that the complaints did not arise from cardiac causes or require emergency assessment. The patient didn’t report chest pain at the office visit; the later cardiac arrest probably resulted from a sudden plaque rupture unrelated to the earlier chest discomfort.

VERDICT $1.5 million Illinois verdict.

COMMENT I hope most doctors won’t have to learn this lesson from their own experience. A normal EKG does not rule out acute ischemia in a high-risk patient with chest pain and sweating. Admit such patients immediately to a cardiac observation unit.

Kidney failure after multiple meds

A MAN WAS TAKING MULTIPLE MEDICATIONS: 3 blood pressure drugs prescribed by his primary care physician, an NSAID prescribed by another doctor, and sizable doses of BC Powder, an over-the-counter analgesic containing aspirin, salicylamide, and caffeine. After 4 years on this medication regimen, the patient’s kidneys failed.

PLAINTIFF’S CLAIM The primary care physician failed to properly monitor kidney function with blood and urine tests while his patient was taking the medications. Proper testing would have resulted in a diagnosis of kidney disease before the patient’s kidneys failed completely. In addition, the primary care physician failed to explain the risks and side effects of the medications to the patient.

THE DEFENSE The patient refused kidney function testing and did not follow medical advice. He consumed excessive amounts of alcohol against medical advice, did not tell the primary care physician about other drugs he was taking, and had allowed his supply of blood pressure medication to run out.

VERDICT $2 million gross verdict in Georgia, with a finding of 47% comparative negligence.

COMMENT This case offers several lessons: First, each BC Powder packet contains the equivalent of 2 aspirin. Second, chronic, high-dose NSAIDs can cause renal failure, especially in patients whose renal function is compromised by hypertension. Third, all patients with hypertension should undergo periodic monitoring of renal function.

Death follows a normal EKG

MID-CHEST DISCOMFORT, A COUGH, AND SWEATING brought a 59-year-old man to his primary care physician. The patient had normal vital signs and reported that belching relieved the chest discomfort. He had a history of severe coronary artery disease and had undergone angioplasty and stenting several years earlier.

The primary care physician performed an electrocardiogram (EKG), which was normal and unchanged from one done the year before. The doctor suspected bronchitis, but prescribed omeprazole because the patient had previously been diagnosed with gastroesophageal reflux disease. He ordered a chemical stress test to be performed within a month and a chest radiograph to be done if the patient’s symptoms didn’t improve.

Two hours after returning home, the patient called an ambulance. He told paramedics that he’d been having chest pain for an hour. While they were putting the patient into the ambulance, he went into cardiac arrest. Four defibrillation attempts en route to the hospital and additional resuscitation attempts in the ED failed; he was pronounced dead 3½ hours after leaving his physician’s office.

No autopsy was performed. The patient’s widow found the omeprazole bottle, with one pill missing, and fast-food hamburger wrappers on the kitchen table.

PLAINTIFF’S CLAIM The primary care physician should have sent the patient to the ED to determine whether the chest pain had a cardiac cause; the patient was suffering from acute cardiac syndrome when the doctor saw him.

THE DEFENSE The patient’s normal EKG and vital signs and the fact that belching relieved his chest symptoms indicated that the complaints did not arise from cardiac causes or require emergency assessment. The patient didn’t report chest pain at the office visit; the later cardiac arrest probably resulted from a sudden plaque rupture unrelated to the earlier chest discomfort.

VERDICT $1.5 million Illinois verdict.

COMMENT I hope most doctors won’t have to learn this lesson from their own experience. A normal EKG does not rule out acute ischemia in a high-risk patient with chest pain and sweating. Admit such patients immediately to a cardiac observation unit.

Kidney failure after multiple meds

A MAN WAS TAKING MULTIPLE MEDICATIONS: 3 blood pressure drugs prescribed by his primary care physician, an NSAID prescribed by another doctor, and sizable doses of BC Powder, an over-the-counter analgesic containing aspirin, salicylamide, and caffeine. After 4 years on this medication regimen, the patient’s kidneys failed.

PLAINTIFF’S CLAIM The primary care physician failed to properly monitor kidney function with blood and urine tests while his patient was taking the medications. Proper testing would have resulted in a diagnosis of kidney disease before the patient’s kidneys failed completely. In addition, the primary care physician failed to explain the risks and side effects of the medications to the patient.

THE DEFENSE The patient refused kidney function testing and did not follow medical advice. He consumed excessive amounts of alcohol against medical advice, did not tell the primary care physician about other drugs he was taking, and had allowed his supply of blood pressure medication to run out.

VERDICT $2 million gross verdict in Georgia, with a finding of 47% comparative negligence.

COMMENT This case offers several lessons: First, each BC Powder packet contains the equivalent of 2 aspirin. Second, chronic, high-dose NSAIDs can cause renal failure, especially in patients whose renal function is compromised by hypertension. Third, all patients with hypertension should undergo periodic monitoring of renal function.

When an atypical presentation is missed

A 50-YEAR-OLD MORBIDLY OBESE MAN went to his family physician with complaints of back pain radiating to the chest, episodic shortness of breath, and diaphoresis. He had a history of uncontrolled high cholesterol. An electrocardiogram showed a Q wave in an inferior lead, which the physician attributed to an old infarct. The doctor didn’t order cardiac enzymes because his office couldn’t do the test.

The physician discharged the patient with a diagnosis of chest pain and a prescription for acetaminophen and hydrocodone. He was scheduled to see a cardiologist in 10 days, but no further cardiology workup was done.

The man died an hour later.

PLAINTIFF’S CLAIM The doctor was negligent in failing to recognize acute coronary syndrome resulting from obstructive coronary artery disease.

THE DEFENSE The patient was discharged in stable condition; cardiac arrest so soon after discharge increased the likelihood that the patient would have suffered sudden cardiac death even if he’d received emergency treatment.

VERDICT $825,000 Virginia settlement.

COMMENT Common, serious problems can present in atypical ways. A high index of suspicion for coronary artery disease in high-risk patients with thoracic pain and shortness of breath—as well as a rapid, thorough evaluation—should keep you out of court (and your patients alive).

Treatment delayed while infection spins out of control

VOMITING, DIARRHEA, AND PAIN AND SWELLING IN THE RIGHT HAND led to an ambulance trip to the emergency department (ED) for a 31-year-old woman. The ED physician diagnosed cellulitis and sepsis. Later that day, the patient was admitted to the intensive care unit, where the admitting physician noted lethargy and confusion, tachycardia, and blueness of the middle and ring fingers on the woman’s right hand. Her medical record suggested that she might have been bitten by a spider.

The patient spent the next 3 days in the ICU in deteriorating condition. She was then transferred to another hospital for treatment of necrotizing fasciitis. She underwent a number of surgeries, including amputation of her right middle and ring fingers, which resulted in significant scarring and deformity of her right hand and forearm.

PLAINTIFF’S CLAIM The defendants were negligent in failing to diagnose necrotizing fasciitis promptly.

THE DEFENSE The defendants who didn’t settle denied any negligence.

VERDICT $80,000 Indiana settlement with the defendant hospital and 1 physician; Indiana defense verdict for the other defendants.

COMMENT When serious infections don’t resolve in a timely manner, expert consultation is imperative.

Inattention to history dooms patient to repeat it

HEADACHES, FEVER, CHILLS, AND JOINT AND MUSCLE PAIN prompted a 42-year-old man to visit his medical group. He told the nurse practitioner (NP) who examined him that his mother had died of a ruptured cerebral aneurysm. The NP diagnosed a viral syndrome, ordered blood tests, and sent the patient home with prescriptions for antibiotics and pain medication. The patient didn’t undergo a neurologic examination.

About 2 weeks later, while continuing to suffer from headaches, the man collapsed and was found unresponsive. A computed tomography scan of his brain showed a subarachnoid hemorrhage and intercerebral hematoma. Further tests revealed a ruptured complex aneurysm, the cause of the hemorrhage. Despite aggressive treatment, the patient fell into a coma and died 3 months later.

PLAINTIFF’S CLAIM The NP should have realized that the patient was at high risk of an aneurysm.

THE DEFENSE No information about the defense is available.

VERDICT $1.5 million New Jersey settlement.

COMMENT I provided expert opinion in a similar case a couple of years ago. The lesson: Pay attention to the family history!

Persistent breast lumps, but no biopsy

ABOUT 3 YEARS AFTER GIVING BIRTH, a 38-year-old woman, who was still breastfeeding, went to her primary care physician complaining of pain, a dime-sized lump in her breast, and discharge from the nipple. The patient’s 2-year-old breast implants limited examination by the nurse practitioner (NP) who saw her. Galactorrhea was diagnosed and the woman was told to stop breastfeeding, apply ice packs, and come back in 2 weeks.

When the patient returned, her only remaining complaint was the lump, which the primary care physician attributed to mastitis. At a routine check-up 5 months later, the patient continued to complain of breast lumps. No breast exam was done, but the woman was referred to a gynecologist. An appointment for a breast ultrasound was scheduled for later in the month, but the patient said she didn’t receive notification of the date.

Metastatic breast cancer was subsequently diagnosed, and the woman died about 3 years later.

PLAINTIFF’S CLAIM The NP and primary care physician should have recommended a biopsy sooner.

THE DEFENSE The care given was proper; an earlier diagnosis wouldn’t have changed the outcome.

VERDICT $750,000 Massachusetts settlement.

COMMENT Failure to recommend biopsy of breast lumps is a leading cause of malpractice cases against family physicians. All persistent breast lumps require referral for biopsy— regardless of the patient’s age.

A red flag that was ignored for too long

A MAN IN HIS EARLY 30S consulted an orthopedist for mid-back pain. The doctor took radiographs of the man’s lower back and reported that he saw nothing amiss. When the man returned 3 months later complaining of the same kind of pain, the orthopedist examined him, prescribed a muscle relaxant, and sent him for physical therapy. The physician did not take any radiographs.

Four months later, the patient came back with pain in his mid-back and ribs. The orthopedist ordered radiographs of the ribs, which were read as normal.

After 18 months, the patient consulted another orthopedist, who ordered a magnetic resonance imaging scan and diagnosed a spinal plasmacytoma at levels T9 to T11. The tumor had destroyed some vertebrae and was compressing the spinal cord.

The patient underwent surgery to remove the tumor and insert screws from T6 to L2 to stabilize the spine. He wore a brace around his torso for months and had a bone marrow transplant. The patient couldn’t return to work.

PLAINTIFF’S CLAIM The tumor was clearly visible on the radiographs taken at the patient’s third visit to the first orthopedist; thoracic spine radiographs should have been taken at the previous 2 visits.

THE DEFENSE No information about the defense is available.

VERDICT $875,000 New Jersey settlement.

COMMENT Current guidelines recommend a red flags approach to imaging. This patient had a red flag—unremitting pain. When back pain persists unabated, it’s time for a thorough evaluation.

When an atypical presentation is missed

A 50-YEAR-OLD MORBIDLY OBESE MAN went to his family physician with complaints of back pain radiating to the chest, episodic shortness of breath, and diaphoresis. He had a history of uncontrolled high cholesterol. An electrocardiogram showed a Q wave in an inferior lead, which the physician attributed to an old infarct. The doctor didn’t order cardiac enzymes because his office couldn’t do the test.

The physician discharged the patient with a diagnosis of chest pain and a prescription for acetaminophen and hydrocodone. He was scheduled to see a cardiologist in 10 days, but no further cardiology workup was done.

The man died an hour later.

PLAINTIFF’S CLAIM The doctor was negligent in failing to recognize acute coronary syndrome resulting from obstructive coronary artery disease.

THE DEFENSE The patient was discharged in stable condition; cardiac arrest so soon after discharge increased the likelihood that the patient would have suffered sudden cardiac death even if he’d received emergency treatment.

VERDICT $825,000 Virginia settlement.

COMMENT Common, serious problems can present in atypical ways. A high index of suspicion for coronary artery disease in high-risk patients with thoracic pain and shortness of breath—as well as a rapid, thorough evaluation—should keep you out of court (and your patients alive).

Treatment delayed while infection spins out of control

VOMITING, DIARRHEA, AND PAIN AND SWELLING IN THE RIGHT HAND led to an ambulance trip to the emergency department (ED) for a 31-year-old woman. The ED physician diagnosed cellulitis and sepsis. Later that day, the patient was admitted to the intensive care unit, where the admitting physician noted lethargy and confusion, tachycardia, and blueness of the middle and ring fingers on the woman’s right hand. Her medical record suggested that she might have been bitten by a spider.

The patient spent the next 3 days in the ICU in deteriorating condition. She was then transferred to another hospital for treatment of necrotizing fasciitis. She underwent a number of surgeries, including amputation of her right middle and ring fingers, which resulted in significant scarring and deformity of her right hand and forearm.

PLAINTIFF’S CLAIM The defendants were negligent in failing to diagnose necrotizing fasciitis promptly.

THE DEFENSE The defendants who didn’t settle denied any negligence.

VERDICT $80,000 Indiana settlement with the defendant hospital and 1 physician; Indiana defense verdict for the other defendants.

COMMENT When serious infections don’t resolve in a timely manner, expert consultation is imperative.

Inattention to history dooms patient to repeat it

HEADACHES, FEVER, CHILLS, AND JOINT AND MUSCLE PAIN prompted a 42-year-old man to visit his medical group. He told the nurse practitioner (NP) who examined him that his mother had died of a ruptured cerebral aneurysm. The NP diagnosed a viral syndrome, ordered blood tests, and sent the patient home with prescriptions for antibiotics and pain medication. The patient didn’t undergo a neurologic examination.

About 2 weeks later, while continuing to suffer from headaches, the man collapsed and was found unresponsive. A computed tomography scan of his brain showed a subarachnoid hemorrhage and intercerebral hematoma. Further tests revealed a ruptured complex aneurysm, the cause of the hemorrhage. Despite aggressive treatment, the patient fell into a coma and died 3 months later.

PLAINTIFF’S CLAIM The NP should have realized that the patient was at high risk of an aneurysm.

THE DEFENSE No information about the defense is available.

VERDICT $1.5 million New Jersey settlement.

COMMENT I provided expert opinion in a similar case a couple of years ago. The lesson: Pay attention to the family history!

Persistent breast lumps, but no biopsy

ABOUT 3 YEARS AFTER GIVING BIRTH, a 38-year-old woman, who was still breastfeeding, went to her primary care physician complaining of pain, a dime-sized lump in her breast, and discharge from the nipple. The patient’s 2-year-old breast implants limited examination by the nurse practitioner (NP) who saw her. Galactorrhea was diagnosed and the woman was told to stop breastfeeding, apply ice packs, and come back in 2 weeks.

When the patient returned, her only remaining complaint was the lump, which the primary care physician attributed to mastitis. At a routine check-up 5 months later, the patient continued to complain of breast lumps. No breast exam was done, but the woman was referred to a gynecologist. An appointment for a breast ultrasound was scheduled for later in the month, but the patient said she didn’t receive notification of the date.

Metastatic breast cancer was subsequently diagnosed, and the woman died about 3 years later.

PLAINTIFF’S CLAIM The NP and primary care physician should have recommended a biopsy sooner.

THE DEFENSE The care given was proper; an earlier diagnosis wouldn’t have changed the outcome.

VERDICT $750,000 Massachusetts settlement.

COMMENT Failure to recommend biopsy of breast lumps is a leading cause of malpractice cases against family physicians. All persistent breast lumps require referral for biopsy— regardless of the patient’s age.

A red flag that was ignored for too long

A MAN IN HIS EARLY 30S consulted an orthopedist for mid-back pain. The doctor took radiographs of the man’s lower back and reported that he saw nothing amiss. When the man returned 3 months later complaining of the same kind of pain, the orthopedist examined him, prescribed a muscle relaxant, and sent him for physical therapy. The physician did not take any radiographs.

Four months later, the patient came back with pain in his mid-back and ribs. The orthopedist ordered radiographs of the ribs, which were read as normal.

After 18 months, the patient consulted another orthopedist, who ordered a magnetic resonance imaging scan and diagnosed a spinal plasmacytoma at levels T9 to T11. The tumor had destroyed some vertebrae and was compressing the spinal cord.

The patient underwent surgery to remove the tumor and insert screws from T6 to L2 to stabilize the spine. He wore a brace around his torso for months and had a bone marrow transplant. The patient couldn’t return to work.

PLAINTIFF’S CLAIM The tumor was clearly visible on the radiographs taken at the patient’s third visit to the first orthopedist; thoracic spine radiographs should have been taken at the previous 2 visits.

THE DEFENSE No information about the defense is available.

VERDICT $875,000 New Jersey settlement.

COMMENT Current guidelines recommend a red flags approach to imaging. This patient had a red flag—unremitting pain. When back pain persists unabated, it’s time for a thorough evaluation.

When an atypical presentation is missed

A 50-YEAR-OLD MORBIDLY OBESE MAN went to his family physician with complaints of back pain radiating to the chest, episodic shortness of breath, and diaphoresis. He had a history of uncontrolled high cholesterol. An electrocardiogram showed a Q wave in an inferior lead, which the physician attributed to an old infarct. The doctor didn’t order cardiac enzymes because his office couldn’t do the test.

The physician discharged the patient with a diagnosis of chest pain and a prescription for acetaminophen and hydrocodone. He was scheduled to see a cardiologist in 10 days, but no further cardiology workup was done.

The man died an hour later.

PLAINTIFF’S CLAIM The doctor was negligent in failing to recognize acute coronary syndrome resulting from obstructive coronary artery disease.

THE DEFENSE The patient was discharged in stable condition; cardiac arrest so soon after discharge increased the likelihood that the patient would have suffered sudden cardiac death even if he’d received emergency treatment.

VERDICT $825,000 Virginia settlement.

COMMENT Common, serious problems can present in atypical ways. A high index of suspicion for coronary artery disease in high-risk patients with thoracic pain and shortness of breath—as well as a rapid, thorough evaluation—should keep you out of court (and your patients alive).

Treatment delayed while infection spins out of control

VOMITING, DIARRHEA, AND PAIN AND SWELLING IN THE RIGHT HAND led to an ambulance trip to the emergency department (ED) for a 31-year-old woman. The ED physician diagnosed cellulitis and sepsis. Later that day, the patient was admitted to the intensive care unit, where the admitting physician noted lethargy and confusion, tachycardia, and blueness of the middle and ring fingers on the woman’s right hand. Her medical record suggested that she might have been bitten by a spider.

The patient spent the next 3 days in the ICU in deteriorating condition. She was then transferred to another hospital for treatment of necrotizing fasciitis. She underwent a number of surgeries, including amputation of her right middle and ring fingers, which resulted in significant scarring and deformity of her right hand and forearm.

PLAINTIFF’S CLAIM The defendants were negligent in failing to diagnose necrotizing fasciitis promptly.

THE DEFENSE The defendants who didn’t settle denied any negligence.

VERDICT $80,000 Indiana settlement with the defendant hospital and 1 physician; Indiana defense verdict for the other defendants.

COMMENT When serious infections don’t resolve in a timely manner, expert consultation is imperative.

Inattention to history dooms patient to repeat it

HEADACHES, FEVER, CHILLS, AND JOINT AND MUSCLE PAIN prompted a 42-year-old man to visit his medical group. He told the nurse practitioner (NP) who examined him that his mother had died of a ruptured cerebral aneurysm. The NP diagnosed a viral syndrome, ordered blood tests, and sent the patient home with prescriptions for antibiotics and pain medication. The patient didn’t undergo a neurologic examination.

About 2 weeks later, while continuing to suffer from headaches, the man collapsed and was found unresponsive. A computed tomography scan of his brain showed a subarachnoid hemorrhage and intercerebral hematoma. Further tests revealed a ruptured complex aneurysm, the cause of the hemorrhage. Despite aggressive treatment, the patient fell into a coma and died 3 months later.

PLAINTIFF’S CLAIM The NP should have realized that the patient was at high risk of an aneurysm.

THE DEFENSE No information about the defense is available.

VERDICT $1.5 million New Jersey settlement.

COMMENT I provided expert opinion in a similar case a couple of years ago. The lesson: Pay attention to the family history!

Persistent breast lumps, but no biopsy

ABOUT 3 YEARS AFTER GIVING BIRTH, a 38-year-old woman, who was still breastfeeding, went to her primary care physician complaining of pain, a dime-sized lump in her breast, and discharge from the nipple. The patient’s 2-year-old breast implants limited examination by the nurse practitioner (NP) who saw her. Galactorrhea was diagnosed and the woman was told to stop breastfeeding, apply ice packs, and come back in 2 weeks.

When the patient returned, her only remaining complaint was the lump, which the primary care physician attributed to mastitis. At a routine check-up 5 months later, the patient continued to complain of breast lumps. No breast exam was done, but the woman was referred to a gynecologist. An appointment for a breast ultrasound was scheduled for later in the month, but the patient said she didn’t receive notification of the date.

Metastatic breast cancer was subsequently diagnosed, and the woman died about 3 years later.

PLAINTIFF’S CLAIM The NP and primary care physician should have recommended a biopsy sooner.

THE DEFENSE The care given was proper; an earlier diagnosis wouldn’t have changed the outcome.

VERDICT $750,000 Massachusetts settlement.

COMMENT Failure to recommend biopsy of breast lumps is a leading cause of malpractice cases against family physicians. All persistent breast lumps require referral for biopsy— regardless of the patient’s age.

A red flag that was ignored for too long

A MAN IN HIS EARLY 30S consulted an orthopedist for mid-back pain. The doctor took radiographs of the man’s lower back and reported that he saw nothing amiss. When the man returned 3 months later complaining of the same kind of pain, the orthopedist examined him, prescribed a muscle relaxant, and sent him for physical therapy. The physician did not take any radiographs.

Four months later, the patient came back with pain in his mid-back and ribs. The orthopedist ordered radiographs of the ribs, which were read as normal.

After 18 months, the patient consulted another orthopedist, who ordered a magnetic resonance imaging scan and diagnosed a spinal plasmacytoma at levels T9 to T11. The tumor had destroyed some vertebrae and was compressing the spinal cord.

The patient underwent surgery to remove the tumor and insert screws from T6 to L2 to stabilize the spine. He wore a brace around his torso for months and had a bone marrow transplant. The patient couldn’t return to work.

PLAINTIFF’S CLAIM The tumor was clearly visible on the radiographs taken at the patient’s third visit to the first orthopedist; thoracic spine radiographs should have been taken at the previous 2 visits.

THE DEFENSE No information about the defense is available.

VERDICT $875,000 New Jersey settlement.

COMMENT Current guidelines recommend a red flags approach to imaging. This patient had a red flag—unremitting pain. When back pain persists unabated, it’s time for a thorough evaluation.

Infant’s brain damage blamed on delayed delivery

DURING DELIVERY, THE MOTHER’S PERINATOLOGIST recognized a severe shoulder dystocia. The perinatologist abandoned vaginal delivery and ordered an emergency cesarean delivery. The mother was transferred to an operating room (OR) with the baby’s head out between her legs. In the OR, the perinatologist pushed the baby’s head back into the uterus and performed a cesarean extraction. Nineteen minutes elapsed from when the vaginal delivery was abandoned and the baby was delivered.

The child was unresponsive at birth with no spontaneous movement or respiration. She was intubated and transferred to the NICU, where she was resuscitated. MRI confirmed that the child had hypoxic ischemia and severe, permanent brain damage from acute birth asphyxia. The child is blind, deaf, hypertensive, and has diffuse spasticity. She has a tracheostomy, a gastrostomy tube, and requires 24-hour care.

PARENTS’ CLAIM The perinatologist was negligent for abandoning vaginal delivery when delivery was progressing appropriately and there was no fetal distress. If the perinatologist had rotated the baby’s shoulder to the oblique position and/or used suprapubic pressure, the shoulder would have become disimpacted and the baby would have been safely delivered within seconds. Delay in delivery allowed for 19 minutes of umbilical cord compression, resulting in brain damage.

PHYSICIAN’S DEFENSE Cesarean delivery was appropriate; the baby did not suffer cord compression. Injury to the brain occurred days before delivery, based on prenatal ultrasonography.

VERDICT A $5.5 million California settlement was reached.

Failure to diagnose breast cancer: death

A 38-YEAR-OLD WOMAN went to her primary care physician (PCP) 3 years after giving birth. She reported breast pain, nipple discharge, and a dime-sized lump. The woman was still breastfeeding. An exam by the nurse practitioner (NP) was limited because the patient had breast implants. The NP suspected a galactocele and advised the patient to stop breastfeeding and apply ice packs. When the patient returned in 2 weeks, only the lump remained. The PCP determined that she had mastitis.

Five months later, she returned with additional lumps in both breasts, and was referred to a gynecologist. Ultrasonography (US) was ordered, but the patient never followed up. A year later, the patient was found to have metastatic breast cancer and died after 3 years of treatment.

ESTATE’S CLAIM The PCP and NP were negligent for not referring her for a breast biopsy when a lump was first detected.

DEFENDANTS’ DEFENSE Proper care was given. An earlier diagnosis would not have changed the outcome.

VERDICT A $750,000 Massachusetts settlement was reached.

What caused this child’s autism?

AFTER 33 HOURS OF LABOR, a baby was delivered vaginally by an ObGyn, nurse, and midwife. The child was diagnosed with autism several years later. His development is delayed, and he suffers cognitive impairment.

PARENTS’ CLAIM The child’s autism is due to a prolonged hypoxic event during labor. Fetal heart-rate monitoring demonstrated fetal distress, with a bradycardia. A cesarean delivery should have been performed.

PHYSICIAN’S DEFENSE The child has genetic autism unrelated to the birth process.

VERDICT A $1.35 million New York settlement was reached.

Was oxytocin the culprit?

DURING AN EXTENDED LABOR, the ObGyn continued to give the mother oxytocin, although there were signs of fetal distress. The child was born with brain damage, cannot walk, talk, or see, and requires 24-hour care.

PATIENT’S CLAIM The use of oxytocin was inappropriate given the signs of fetal distress. Oxytocin caused a lack of oxygen to the child, resulting in brain damage. A cesarean delivery should have been performed when fetal distress was identified.

DEFENDANTS’ DEFENSE The case was settled before trial.

VERDICT A $12 million Illinois settlement was reached: $11 million from the hospital and $1 million from the ObGyn.

Bowel perforation, sepsis after ovary removal

DURING LEFT OOPHORECTOMY, the ObGyn encountered adhesions. Five days later, the 41-year-old patient reported severe pain. A second procedure revealed sepsis and perforation of the large bowel. A colostomy was performed. The patient underwent additional corrective operations.

PATIENT’S CLAIM The ObGyn was negligent for causing tissue damage to the colon that perforated and escalated into sepsis. A surgeon should have been consulted when the ObGyn found the adhesions, so the bowel could be properly inspected before the abdomen was closed. The physician was also negligent for not recognizing symptoms of sepsis earlier.

PHYSICIAN’S DEFENSE Bowel injury is a known complication of oophorectomy. The patient appeared to be making a fairly good recovery until infection became evident; she was immediately treated.

VERDICT A $6.3 million New Jersey verdict was returned, including $300,000 for the husband’s loss of consortium.

Traumatic delivery causes seizures

DURING CESAREAN DELIVERY, the ObGyn rotated the baby from a transverse to a cephalic lie, and used a vacuum extractor to deliver the head through the hysterotomy incision.

When the child was 25 hours old, he suffered a seizure that lasted 6 minutes. Focal seizure activity involving the left side of his body and a skull fracture were identified. He was transferred to another hospital, where radiologic studies indicated a middle right cerebral artery infarct. The child developed an ongoing seizure disorder, speech and language delays, and mild, left-sided weakness.

PARENTS’ CLAIM The baby’s head was not properly delivered through the cesarean incision nor should the ObGyn have used vacuum extraction. The combination of the rotation and use of vacuum caused trauma to the infant’s head. In addition, the baby was placed in the well-baby nursery, which was inappropriate because he was born through thick meconium, resuscitated by a neonatal nurse, and had a depressed skull fracture.

PHYSICIAN’S DEFENSE Delivery was not traumatic; all treatment was appropriate.

VERDICT A $4.6 million New York settlement was reached with the hospital and ObGyn’s insurer.

Mother gets severe headache during birth

A 35-YEAR-OLD WOMAN began having a severe headache during delivery that continued after birth. She was discharged from the hospital and collapsed at home a day later. She was returned to the ED, where she was left in a hallway for 6 hours. She lost consciousness while in the hallway. Imaging and neurologic evaluation determined that she suffered a hypoxic brain injury from intracranial bleeding. She has slow response time, difficulty with all aspects of everyday life, and requires full-time attendant care.

PATIENT’S CLAIM Although she complained of a headache, no testing was done prior to her hospital discharge. Treatment was extremely delayed in the ED; an earlier diagnosis could have prevented brain damage.

PHYSICIAN’S DEFENSE Nothing could have prevented the brain damage.

VERDICT A $3.5 million California settlement was mediated.

Shoulder dystocia; brachial plexus injury

WHEN SHOULDER DYSTOCIA was encountered during delivery, the ObGyn applied gentle pressure to deliver the head. He was assisted by an ObGyn resident. The child was born with a brachial plexus injury, causing left-arm paralysis. She underwent surgery that increased her range of motion, but she will need years of physical therapy.

PATIENT’S CLAIM The ObGyn applied excessive traction and the resident improperly applied fundal pressure.

DEFENDANTS’ DEFENSE Only gentle traction was used. The resident did not apply fundal pressure.

VERDICT A New York jury found the ObGyn at fault and awarded the patient $3.5 million. The resident was vindicated.

Was premature baby viable?

AN EXPECTANT MOTHER MISCARRIED AT HOME at 6 months’ gestation, and an ambulance was called. After the EMTs helped the mother to the ambulance, they retrieved the fetus. When the baby was seen moving its head, the EMTs requested assistance from the advanced life support (ALS) team. ALS personnel visually assessed the fetus, determined it was nonviable, and placed the baby in a small container. The mother and baby arrived at the hospital 17 minutes after the ambulance was called.

At the hospital, a nurse noticed that the fetus was warm and had a heartbeat. The baby was taken to a special-care nursery for resuscitation and then transferred to another hospital’s NICU. The baby died after 46 days from severe brain damage due to lack of oxygen.

PARENTS’ CLAIM The EMTs and ALS team should have provided better evaluation and treatment for the infant; they were not trained to determine an infant’s viability. Placing the infant inside a plastic bag inside a box with a lid further deprived the baby of oxygen.

DEFENDANTS’ DEFENSE The case was settled before trial.

VERDICT A $1 million Massachusetts settlement was reached.

Were records altered because of a delayed diagnosis?

A WOMAN FOUND A LUMP in her left breast. A gynecologist ordered mammography. In January 2006, the radiologist requested ultrasonography (US), and reported that it conclusively indicated that the mass was a cyst. The gynecologist told the patient the tests were normal; further action was unnecessary. The patient saw the gynecologist four more times before being referred to a breast surgeon. In June 2006, she underwent surgical resection and chemotherapy for a malignant breast tumor.

PATIENT’S CLAIM The gynecologist was negligent for not referring the patient to a surgeon earlier. The gynecologist altered records: excerpts from the mammogram and US reports had been scanned in with a notation that the gynecologist had told the patient to follow up with a surgeon. When the gynecologist faxed the same reports to the surgeon, the annotations were absent. The gynecologist also changed the December 2005 chart, which referred to an US she never ordered.

PHYSICIAN’S DEFENSE The gynecologist stated that she regularly “merged” two reports into one document in her practice.

VERDICT A $700,000 Pennsylvania verdict was returned.

Excessive force or standard of care?

SHOULDER DYSTOCIA occurred during labor. The child sustained left brachial plexus palsy. At age 6, his left arm is paralyzed and smaller than the right arm. He has trouble performing normal daily tasks.

PATIENT’S CLAIM The ObGyn used excessive force by pulling on the baby’s head to complete the delivery. Standard of care required the ObGyn to take a more gentle approach to achieve delivery.

PHYSICIAN’S DEFENSE Delivery was performed appropriately, and did not deviate from standard of care.

VERDICT A $20.881 million Maryland verdict was returned, including $20 million for pain and suffering. The total award was reduced to $1,531,082 when the pain and suffering award was cut to $650,000 under the state’s statutory cap.

Preterm birth from an asymptomatic UTI?

A BABY WAS BORN AT 31 WEEKS’ gestation. The child has cerebral palsy, spastic quadriplegia, and requires assistance in all aspects of life.

PARENTS’ CLAIM Chorioamnionitis from a urinary tract infection (UTI) caused preterm birth. Urinalysis performed 7 weeks earlier indicated an infection, but the second-year resident caring for the mother failed to treat the UTI. The resident should have obtained a confirming urine culture, prescribed antibiotics, and monitored the mother more closely. The resident was poorly supervised.

DEFENDANTS’ DEFENSE Chorioamnionitis developed just before birth and could not be detected or prevented. A UTI cannot remain asymptomatic for 7 weeks and still cause premature birth. The mother was at increased risk of premature delivery because she had given birth to an anencephalic infant a year earlier. She began prenatal care in the middle of her pregnancy and ignored a referral to a high-risk maternal fetal specialist.

VERDICT A New York defense verdict was returned.

Infant’s brain damage blamed on delayed delivery

DURING DELIVERY, THE MOTHER’S PERINATOLOGIST recognized a severe shoulder dystocia. The perinatologist abandoned vaginal delivery and ordered an emergency cesarean delivery. The mother was transferred to an operating room (OR) with the baby’s head out between her legs. In the OR, the perinatologist pushed the baby’s head back into the uterus and performed a cesarean extraction. Nineteen minutes elapsed from when the vaginal delivery was abandoned and the baby was delivered.

The child was unresponsive at birth with no spontaneous movement or respiration. She was intubated and transferred to the NICU, where she was resuscitated. MRI confirmed that the child had hypoxic ischemia and severe, permanent brain damage from acute birth asphyxia. The child is blind, deaf, hypertensive, and has diffuse spasticity. She has a tracheostomy, a gastrostomy tube, and requires 24-hour care.

PARENTS’ CLAIM The perinatologist was negligent for abandoning vaginal delivery when delivery was progressing appropriately and there was no fetal distress. If the perinatologist had rotated the baby’s shoulder to the oblique position and/or used suprapubic pressure, the shoulder would have become disimpacted and the baby would have been safely delivered within seconds. Delay in delivery allowed for 19 minutes of umbilical cord compression, resulting in brain damage.

PHYSICIAN’S DEFENSE Cesarean delivery was appropriate; the baby did not suffer cord compression. Injury to the brain occurred days before delivery, based on prenatal ultrasonography.

VERDICT A $5.5 million California settlement was reached.

Failure to diagnose breast cancer: death

A 38-YEAR-OLD WOMAN went to her primary care physician (PCP) 3 years after giving birth. She reported breast pain, nipple discharge, and a dime-sized lump. The woman was still breastfeeding. An exam by the nurse practitioner (NP) was limited because the patient had breast implants. The NP suspected a galactocele and advised the patient to stop breastfeeding and apply ice packs. When the patient returned in 2 weeks, only the lump remained. The PCP determined that she had mastitis.

Five months later, she returned with additional lumps in both breasts, and was referred to a gynecologist. Ultrasonography (US) was ordered, but the patient never followed up. A year later, the patient was found to have metastatic breast cancer and died after 3 years of treatment.

ESTATE’S CLAIM The PCP and NP were negligent for not referring her for a breast biopsy when a lump was first detected.

DEFENDANTS’ DEFENSE Proper care was given. An earlier diagnosis would not have changed the outcome.

VERDICT A $750,000 Massachusetts settlement was reached.

What caused this child’s autism?

AFTER 33 HOURS OF LABOR, a baby was delivered vaginally by an ObGyn, nurse, and midwife. The child was diagnosed with autism several years later. His development is delayed, and he suffers cognitive impairment.

PARENTS’ CLAIM The child’s autism is due to a prolonged hypoxic event during labor. Fetal heart-rate monitoring demonstrated fetal distress, with a bradycardia. A cesarean delivery should have been performed.

PHYSICIAN’S DEFENSE The child has genetic autism unrelated to the birth process.

VERDICT A $1.35 million New York settlement was reached.

Was oxytocin the culprit?

DURING AN EXTENDED LABOR, the ObGyn continued to give the mother oxytocin, although there were signs of fetal distress. The child was born with brain damage, cannot walk, talk, or see, and requires 24-hour care.

PATIENT’S CLAIM The use of oxytocin was inappropriate given the signs of fetal distress. Oxytocin caused a lack of oxygen to the child, resulting in brain damage. A cesarean delivery should have been performed when fetal distress was identified.

DEFENDANTS’ DEFENSE The case was settled before trial.

VERDICT A $12 million Illinois settlement was reached: $11 million from the hospital and $1 million from the ObGyn.

Bowel perforation, sepsis after ovary removal

DURING LEFT OOPHORECTOMY, the ObGyn encountered adhesions. Five days later, the 41-year-old patient reported severe pain. A second procedure revealed sepsis and perforation of the large bowel. A colostomy was performed. The patient underwent additional corrective operations.

PATIENT’S CLAIM The ObGyn was negligent for causing tissue damage to the colon that perforated and escalated into sepsis. A surgeon should have been consulted when the ObGyn found the adhesions, so the bowel could be properly inspected before the abdomen was closed. The physician was also negligent for not recognizing symptoms of sepsis earlier.

PHYSICIAN’S DEFENSE Bowel injury is a known complication of oophorectomy. The patient appeared to be making a fairly good recovery until infection became evident; she was immediately treated.

VERDICT A $6.3 million New Jersey verdict was returned, including $300,000 for the husband’s loss of consortium.

Traumatic delivery causes seizures

DURING CESAREAN DELIVERY, the ObGyn rotated the baby from a transverse to a cephalic lie, and used a vacuum extractor to deliver the head through the hysterotomy incision.

When the child was 25 hours old, he suffered a seizure that lasted 6 minutes. Focal seizure activity involving the left side of his body and a skull fracture were identified. He was transferred to another hospital, where radiologic studies indicated a middle right cerebral artery infarct. The child developed an ongoing seizure disorder, speech and language delays, and mild, left-sided weakness.

PARENTS’ CLAIM The baby’s head was not properly delivered through the cesarean incision nor should the ObGyn have used vacuum extraction. The combination of the rotation and use of vacuum caused trauma to the infant’s head. In addition, the baby was placed in the well-baby nursery, which was inappropriate because he was born through thick meconium, resuscitated by a neonatal nurse, and had a depressed skull fracture.

PHYSICIAN’S DEFENSE Delivery was not traumatic; all treatment was appropriate.

VERDICT A $4.6 million New York settlement was reached with the hospital and ObGyn’s insurer.

Mother gets severe headache during birth

A 35-YEAR-OLD WOMAN began having a severe headache during delivery that continued after birth. She was discharged from the hospital and collapsed at home a day later. She was returned to the ED, where she was left in a hallway for 6 hours. She lost consciousness while in the hallway. Imaging and neurologic evaluation determined that she suffered a hypoxic brain injury from intracranial bleeding. She has slow response time, difficulty with all aspects of everyday life, and requires full-time attendant care.

PATIENT’S CLAIM Although she complained of a headache, no testing was done prior to her hospital discharge. Treatment was extremely delayed in the ED; an earlier diagnosis could have prevented brain damage.

PHYSICIAN’S DEFENSE Nothing could have prevented the brain damage.

VERDICT A $3.5 million California settlement was mediated.

Shoulder dystocia; brachial plexus injury

WHEN SHOULDER DYSTOCIA was encountered during delivery, the ObGyn applied gentle pressure to deliver the head. He was assisted by an ObGyn resident. The child was born with a brachial plexus injury, causing left-arm paralysis. She underwent surgery that increased her range of motion, but she will need years of physical therapy.

PATIENT’S CLAIM The ObGyn applied excessive traction and the resident improperly applied fundal pressure.

DEFENDANTS’ DEFENSE Only gentle traction was used. The resident did not apply fundal pressure.

VERDICT A New York jury found the ObGyn at fault and awarded the patient $3.5 million. The resident was vindicated.

Was premature baby viable?

AN EXPECTANT MOTHER MISCARRIED AT HOME at 6 months’ gestation, and an ambulance was called. After the EMTs helped the mother to the ambulance, they retrieved the fetus. When the baby was seen moving its head, the EMTs requested assistance from the advanced life support (ALS) team. ALS personnel visually assessed the fetus, determined it was nonviable, and placed the baby in a small container. The mother and baby arrived at the hospital 17 minutes after the ambulance was called.

At the hospital, a nurse noticed that the fetus was warm and had a heartbeat. The baby was taken to a special-care nursery for resuscitation and then transferred to another hospital’s NICU. The baby died after 46 days from severe brain damage due to lack of oxygen.

PARENTS’ CLAIM The EMTs and ALS team should have provided better evaluation and treatment for the infant; they were not trained to determine an infant’s viability. Placing the infant inside a plastic bag inside a box with a lid further deprived the baby of oxygen.

DEFENDANTS’ DEFENSE The case was settled before trial.

VERDICT A $1 million Massachusetts settlement was reached.

Were records altered because of a delayed diagnosis?

A WOMAN FOUND A LUMP in her left breast. A gynecologist ordered mammography. In January 2006, the radiologist requested ultrasonography (US), and reported that it conclusively indicated that the mass was a cyst. The gynecologist told the patient the tests were normal; further action was unnecessary. The patient saw the gynecologist four more times before being referred to a breast surgeon. In June 2006, she underwent surgical resection and chemotherapy for a malignant breast tumor.

PATIENT’S CLAIM The gynecologist was negligent for not referring the patient to a surgeon earlier. The gynecologist altered records: excerpts from the mammogram and US reports had been scanned in with a notation that the gynecologist had told the patient to follow up with a surgeon. When the gynecologist faxed the same reports to the surgeon, the annotations were absent. The gynecologist also changed the December 2005 chart, which referred to an US she never ordered.

PHYSICIAN’S DEFENSE The gynecologist stated that she regularly “merged” two reports into one document in her practice.

VERDICT A $700,000 Pennsylvania verdict was returned.

Excessive force or standard of care?

SHOULDER DYSTOCIA occurred during labor. The child sustained left brachial plexus palsy. At age 6, his left arm is paralyzed and smaller than the right arm. He has trouble performing normal daily tasks.

PATIENT’S CLAIM The ObGyn used excessive force by pulling on the baby’s head to complete the delivery. Standard of care required the ObGyn to take a more gentle approach to achieve delivery.

PHYSICIAN’S DEFENSE Delivery was performed appropriately, and did not deviate from standard of care.

VERDICT A $20.881 million Maryland verdict was returned, including $20 million for pain and suffering. The total award was reduced to $1,531,082 when the pain and suffering award was cut to $650,000 under the state’s statutory cap.

Preterm birth from an asymptomatic UTI?

A BABY WAS BORN AT 31 WEEKS’ gestation. The child has cerebral palsy, spastic quadriplegia, and requires assistance in all aspects of life.

PARENTS’ CLAIM Chorioamnionitis from a urinary tract infection (UTI) caused preterm birth. Urinalysis performed 7 weeks earlier indicated an infection, but the second-year resident caring for the mother failed to treat the UTI. The resident should have obtained a confirming urine culture, prescribed antibiotics, and monitored the mother more closely. The resident was poorly supervised.

DEFENDANTS’ DEFENSE Chorioamnionitis developed just before birth and could not be detected or prevented. A UTI cannot remain asymptomatic for 7 weeks and still cause premature birth. The mother was at increased risk of premature delivery because she had given birth to an anencephalic infant a year earlier. She began prenatal care in the middle of her pregnancy and ignored a referral to a high-risk maternal fetal specialist.

VERDICT A New York defense verdict was returned.

Infant’s brain damage blamed on delayed delivery

DURING DELIVERY, THE MOTHER’S PERINATOLOGIST recognized a severe shoulder dystocia. The perinatologist abandoned vaginal delivery and ordered an emergency cesarean delivery. The mother was transferred to an operating room (OR) with the baby’s head out between her legs. In the OR, the perinatologist pushed the baby’s head back into the uterus and performed a cesarean extraction. Nineteen minutes elapsed from when the vaginal delivery was abandoned and the baby was delivered.

The child was unresponsive at birth with no spontaneous movement or respiration. She was intubated and transferred to the NICU, where she was resuscitated. MRI confirmed that the child had hypoxic ischemia and severe, permanent brain damage from acute birth asphyxia. The child is blind, deaf, hypertensive, and has diffuse spasticity. She has a tracheostomy, a gastrostomy tube, and requires 24-hour care.

PARENTS’ CLAIM The perinatologist was negligent for abandoning vaginal delivery when delivery was progressing appropriately and there was no fetal distress. If the perinatologist had rotated the baby’s shoulder to the oblique position and/or used suprapubic pressure, the shoulder would have become disimpacted and the baby would have been safely delivered within seconds. Delay in delivery allowed for 19 minutes of umbilical cord compression, resulting in brain damage.

PHYSICIAN’S DEFENSE Cesarean delivery was appropriate; the baby did not suffer cord compression. Injury to the brain occurred days before delivery, based on prenatal ultrasonography.

VERDICT A $5.5 million California settlement was reached.

Failure to diagnose breast cancer: death

A 38-YEAR-OLD WOMAN went to her primary care physician (PCP) 3 years after giving birth. She reported breast pain, nipple discharge, and a dime-sized lump. The woman was still breastfeeding. An exam by the nurse practitioner (NP) was limited because the patient had breast implants. The NP suspected a galactocele and advised the patient to stop breastfeeding and apply ice packs. When the patient returned in 2 weeks, only the lump remained. The PCP determined that she had mastitis.

Five months later, she returned with additional lumps in both breasts, and was referred to a gynecologist. Ultrasonography (US) was ordered, but the patient never followed up. A year later, the patient was found to have metastatic breast cancer and died after 3 years of treatment.

ESTATE’S CLAIM The PCP and NP were negligent for not referring her for a breast biopsy when a lump was first detected.

DEFENDANTS’ DEFENSE Proper care was given. An earlier diagnosis would not have changed the outcome.

VERDICT A $750,000 Massachusetts settlement was reached.

What caused this child’s autism?

AFTER 33 HOURS OF LABOR, a baby was delivered vaginally by an ObGyn, nurse, and midwife. The child was diagnosed with autism several years later. His development is delayed, and he suffers cognitive impairment.

PARENTS’ CLAIM The child’s autism is due to a prolonged hypoxic event during labor. Fetal heart-rate monitoring demonstrated fetal distress, with a bradycardia. A cesarean delivery should have been performed.

PHYSICIAN’S DEFENSE The child has genetic autism unrelated to the birth process.

VERDICT A $1.35 million New York settlement was reached.

Was oxytocin the culprit?

DURING AN EXTENDED LABOR, the ObGyn continued to give the mother oxytocin, although there were signs of fetal distress. The child was born with brain damage, cannot walk, talk, or see, and requires 24-hour care.

PATIENT’S CLAIM The use of oxytocin was inappropriate given the signs of fetal distress. Oxytocin caused a lack of oxygen to the child, resulting in brain damage. A cesarean delivery should have been performed when fetal distress was identified.

DEFENDANTS’ DEFENSE The case was settled before trial.

VERDICT A $12 million Illinois settlement was reached: $11 million from the hospital and $1 million from the ObGyn.

Bowel perforation, sepsis after ovary removal

DURING LEFT OOPHORECTOMY, the ObGyn encountered adhesions. Five days later, the 41-year-old patient reported severe pain. A second procedure revealed sepsis and perforation of the large bowel. A colostomy was performed. The patient underwent additional corrective operations.

PATIENT’S CLAIM The ObGyn was negligent for causing tissue damage to the colon that perforated and escalated into sepsis. A surgeon should have been consulted when the ObGyn found the adhesions, so the bowel could be properly inspected before the abdomen was closed. The physician was also negligent for not recognizing symptoms of sepsis earlier.

PHYSICIAN’S DEFENSE Bowel injury is a known complication of oophorectomy. The patient appeared to be making a fairly good recovery until infection became evident; she was immediately treated.

VERDICT A $6.3 million New Jersey verdict was returned, including $300,000 for the husband’s loss of consortium.

Traumatic delivery causes seizures

DURING CESAREAN DELIVERY, the ObGyn rotated the baby from a transverse to a cephalic lie, and used a vacuum extractor to deliver the head through the hysterotomy incision.

When the child was 25 hours old, he suffered a seizure that lasted 6 minutes. Focal seizure activity involving the left side of his body and a skull fracture were identified. He was transferred to another hospital, where radiologic studies indicated a middle right cerebral artery infarct. The child developed an ongoing seizure disorder, speech and language delays, and mild, left-sided weakness.

PARENTS’ CLAIM The baby’s head was not properly delivered through the cesarean incision nor should the ObGyn have used vacuum extraction. The combination of the rotation and use of vacuum caused trauma to the infant’s head. In addition, the baby was placed in the well-baby nursery, which was inappropriate because he was born through thick meconium, resuscitated by a neonatal nurse, and had a depressed skull fracture.

PHYSICIAN’S DEFENSE Delivery was not traumatic; all treatment was appropriate.

VERDICT A $4.6 million New York settlement was reached with the hospital and ObGyn’s insurer.

Mother gets severe headache during birth

A 35-YEAR-OLD WOMAN began having a severe headache during delivery that continued after birth. She was discharged from the hospital and collapsed at home a day later. She was returned to the ED, where she was left in a hallway for 6 hours. She lost consciousness while in the hallway. Imaging and neurologic evaluation determined that she suffered a hypoxic brain injury from intracranial bleeding. She has slow response time, difficulty with all aspects of everyday life, and requires full-time attendant care.

PATIENT’S CLAIM Although she complained of a headache, no testing was done prior to her hospital discharge. Treatment was extremely delayed in the ED; an earlier diagnosis could have prevented brain damage.

PHYSICIAN’S DEFENSE Nothing could have prevented the brain damage.

VERDICT A $3.5 million California settlement was mediated.

Shoulder dystocia; brachial plexus injury

WHEN SHOULDER DYSTOCIA was encountered during delivery, the ObGyn applied gentle pressure to deliver the head. He was assisted by an ObGyn resident. The child was born with a brachial plexus injury, causing left-arm paralysis. She underwent surgery that increased her range of motion, but she will need years of physical therapy.

PATIENT’S CLAIM The ObGyn applied excessive traction and the resident improperly applied fundal pressure.

DEFENDANTS’ DEFENSE Only gentle traction was used. The resident did not apply fundal pressure.

VERDICT A New York jury found the ObGyn at fault and awarded the patient $3.5 million. The resident was vindicated.

Was premature baby viable?

AN EXPECTANT MOTHER MISCARRIED AT HOME at 6 months’ gestation, and an ambulance was called. After the EMTs helped the mother to the ambulance, they retrieved the fetus. When the baby was seen moving its head, the EMTs requested assistance from the advanced life support (ALS) team. ALS personnel visually assessed the fetus, determined it was nonviable, and placed the baby in a small container. The mother and baby arrived at the hospital 17 minutes after the ambulance was called.

At the hospital, a nurse noticed that the fetus was warm and had a heartbeat. The baby was taken to a special-care nursery for resuscitation and then transferred to another hospital’s NICU. The baby died after 46 days from severe brain damage due to lack of oxygen.

PARENTS’ CLAIM The EMTs and ALS team should have provided better evaluation and treatment for the infant; they were not trained to determine an infant’s viability. Placing the infant inside a plastic bag inside a box with a lid further deprived the baby of oxygen.

DEFENDANTS’ DEFENSE The case was settled before trial.

VERDICT A $1 million Massachusetts settlement was reached.

Were records altered because of a delayed diagnosis?

A WOMAN FOUND A LUMP in her left breast. A gynecologist ordered mammography. In January 2006, the radiologist requested ultrasonography (US), and reported that it conclusively indicated that the mass was a cyst. The gynecologist told the patient the tests were normal; further action was unnecessary. The patient saw the gynecologist four more times before being referred to a breast surgeon. In June 2006, she underwent surgical resection and chemotherapy for a malignant breast tumor.

PATIENT’S CLAIM The gynecologist was negligent for not referring the patient to a surgeon earlier. The gynecologist altered records: excerpts from the mammogram and US reports had been scanned in with a notation that the gynecologist had told the patient to follow up with a surgeon. When the gynecologist faxed the same reports to the surgeon, the annotations were absent. The gynecologist also changed the December 2005 chart, which referred to an US she never ordered.

PHYSICIAN’S DEFENSE The gynecologist stated that she regularly “merged” two reports into one document in her practice.

VERDICT A $700,000 Pennsylvania verdict was returned.

Excessive force or standard of care?

SHOULDER DYSTOCIA occurred during labor. The child sustained left brachial plexus palsy. At age 6, his left arm is paralyzed and smaller than the right arm. He has trouble performing normal daily tasks.

PATIENT’S CLAIM The ObGyn used excessive force by pulling on the baby’s head to complete the delivery. Standard of care required the ObGyn to take a more gentle approach to achieve delivery.

PHYSICIAN’S DEFENSE Delivery was performed appropriately, and did not deviate from standard of care.

VERDICT A $20.881 million Maryland verdict was returned, including $20 million for pain and suffering. The total award was reduced to $1,531,082 when the pain and suffering award was cut to $650,000 under the state’s statutory cap.

Preterm birth from an asymptomatic UTI?

A BABY WAS BORN AT 31 WEEKS’ gestation. The child has cerebral palsy, spastic quadriplegia, and requires assistance in all aspects of life.

PARENTS’ CLAIM Chorioamnionitis from a urinary tract infection (UTI) caused preterm birth. Urinalysis performed 7 weeks earlier indicated an infection, but the second-year resident caring for the mother failed to treat the UTI. The resident should have obtained a confirming urine culture, prescribed antibiotics, and monitored the mother more closely. The resident was poorly supervised.

DEFENDANTS’ DEFENSE Chorioamnionitis developed just before birth and could not be detected or prevented. A UTI cannot remain asymptomatic for 7 weeks and still cause premature birth. The mother was at increased risk of premature delivery because she had given birth to an anencephalic infant a year earlier. She began prenatal care in the middle of her pregnancy and ignored a referral to a high-risk maternal fetal specialist.

VERDICT A New York defense verdict was returned.

Antibiotics fail to head off sepsis

SHORTNESS OF BREATH AND RIGHT-SIDED CHEST PAIN prompted a 45-year-old woman to go to the emergency department (ED) early one morning. She had a history of chronic lung problems with multiple diagnoses of pneumonia, pneumothorax, blebs, and bronchiectasis. The ED doctor diagnosed community-acquired pneumonia and admitted her for intravenous antibiotic treatment.

Late that afternoon the patient’s condition deteriorated rapidly. She was transferred to the intensive care unit, where she died of septic shock caused by Pseudomonas aeruginosa 22 hours after she had arrived at the ED.

PLAINTIFF’S CLAIM The patient should have received broader-spectrum antibiotics.

THE DEFENSE The hospitalist who treated the woman as an inpatient claimed that the treatment she received was appropriate and that she probably would have died even if other antibiotics had been prescribed. The hospitalist also claimed that the nursing staff failed to notify her of the patient’s low blood pressure readings until 10 hours after the initial evaluation. A nurse denied this claim, asserting that the hospitalist had been paged several times during the day. The discharge summary and nursing notes on the patient were missing.

VERDICT $5.28 million arbitration award.

COMMENT It surprises me how often key portions of medical records go missing! Here, the absence of a discharge summary and nursing notes may well have contributed to a $5 million award.

Change, and not for the better

AN ATYPICAL MOLE ON THE LEFT CALF was brought to the attention of a primary care physician by a 36-year-old man during a full physical. The mole was 1 3 1 cm; the patient reported that it had been changing. The mole’s appearance didn’t worry the physician, who described it in his notes as either a hemangioma or dermatofibroma. The doctor advised the patient to return in 6 months if he wanted the mole removed for cosmetic reasons.

Over the next 5 months, the patient noticed further changes in the mole and called the doctor’s office. He was seen by a colleague of his physician, who immediately sent the patient for a biopsy and surgical consultation. The mole was removed and diagnosed as an ulcerating melanoma with downward growth.

Shortly thereafter, the patient underwent wide excision and lymph node dissection, which showed clear margins and no lymph node involvement. Twenty months later, a mass was found in the patient’s liver. Biopsy diagnosed metastatic spread of the melanoma. The patient died 2 months later.

PLAINTIFF’S CLAIM The patient should have had a biopsy and received a surgical referral at the time of the physical examination when he first reported the mole.

THE DEFENSE Waiting for 6 months was appropriate because the mole didn’t look like a melanoma when the patient first called it to the physician’s attention. The melanoma had already metastasized at the time of the physical examination and the diagnostic delay didn’t affect the outcome.

VERDICT $1 million Massachusetts settlement.

COMMENT A changing mole should always raise concern. Biopsy, excision, or a referral could have avoided a million-dollar settlement.

Failure to address persistent symptoms proves disastrous

PAIN IN THE BACK AND CHEST along with respiratory difficulty prompted a 49-year-old man to visit his physician. The physician told him to go to a hospital. The doctor who examined the patient at the hospital diagnosed muscle strain and prescribed muscle relaxants.

The following day, the patient returned to his physician complaining of continuing symptoms. The doctor sent him home. He died the next day of an aortic rupture caused by an undiagnosed dissection.

PLAINTIFF’S CLAIM The 2 physicians should have diagnosed the dissection, which would have permitted treatment and prevented death. The patient had been treated previously at the hospital, and his records should have raised suspicion of an aortic aneurysm. The hospital physician was a new hire and hadn’t received proper training in the hospital’s electronic records system. He should have ordered a computed tomography scan or cardiology consult. The patient’s physician failed to address the ongoing symptoms. He should have hospitalized the patient at the time of the second visit.

THE DEFENSE The hospital physician claimed he had intended to contact the cardiologist who had treated the patient, but the patient couldn’t remember the cardiologist’s name. The patient’s symptoms didn’t suggest an aortic dissection, and the dissection occurred after the patient was discharged from the hospital.

VERDICT $3.4 million New York verdict against the hospital physician only.

COMMENT Although the hoofbeats are usually horses, always remember the zebras (or should it be lions?), particularly when a patient returns repeatedly with ongoing symptoms.

Controlled substances out of control

A WOMAN WITH CHRONIC MIGRAINES, anxiety problems, and nausea also had cardiomyopathy and chronic atrial fibrillation, which could be triggered by pain from her other ailments. She came under the care of a physician who prescribed a number of drugs, including meperidine, hydrocodone, tizanidine, diazepam, promethazine, alprazolam, and oxcarbazepine. The doctor prescribed injectable forms of certain medications after the patient told him her next-door neighbor was a nurse and could help administer the drugs.

Four years after coming under the doctor’s care, the patient signed a Controlled Substance Agreement specifying that the physician would discontinue her as a patient if she got controlled substances from another doctor. (Evidence was later found that the patient was receiving prescriptions from other physicians.)

While under treatment by her doctor, the patient was hospitalized a number of times for medication overdoses. The record from one hospitalization reported that she had made angry, profanity-laced requests for meperidine and promethazine.

About 2 years after signing the Controlled Substance Agreement, the patient received prescriptions from her doctor for 210 doses of meperidine, 100 doses of promethazine, and 60 pills each of diazepam, alprazolam, and acetaminophen and hydrocodone. She filled the prescriptions at 2 pharmacies without objections from the pharmacists. She died of an accidental drug overdose the following month.

Postmortem blood testing showed high levels of meperidine and promethazine. The patient had apparently taken the equivalent of 11 “shots” of meperidine (5 times the maximum prescribed amount), probably by injecting herself through a peripherally inserted central catheter rather than by intramuscular injection, as prescribed.

PLAINTIFF’S CLAIM The patient’s doctor was negligent in prescribing large amounts of controlled substances when he should have known that she was a drug seeker with a drug abuse problem. The pharmacies were negligent for filling the prescriptions without question.

THE DEFENSE The patient was solely responsible for her own death because she gave herself a large overdose.

VERDICT $500,000 Alabama verdict. The case against the pharmacies was dismissed.

COMMENT Increasingly it is expected that physicians (and pharmacists) perform due diligence when prescribing opioids, including taking reasonable precautions against the drug-seeking patient.

Antibiotics fail to head off sepsis

SHORTNESS OF BREATH AND RIGHT-SIDED CHEST PAIN prompted a 45-year-old woman to go to the emergency department (ED) early one morning. She had a history of chronic lung problems with multiple diagnoses of pneumonia, pneumothorax, blebs, and bronchiectasis. The ED doctor diagnosed community-acquired pneumonia and admitted her for intravenous antibiotic treatment.

Late that afternoon the patient’s condition deteriorated rapidly. She was transferred to the intensive care unit, where she died of septic shock caused by Pseudomonas aeruginosa 22 hours after she had arrived at the ED.

PLAINTIFF’S CLAIM The patient should have received broader-spectrum antibiotics.

THE DEFENSE The hospitalist who treated the woman as an inpatient claimed that the treatment she received was appropriate and that she probably would have died even if other antibiotics had been prescribed. The hospitalist also claimed that the nursing staff failed to notify her of the patient’s low blood pressure readings until 10 hours after the initial evaluation. A nurse denied this claim, asserting that the hospitalist had been paged several times during the day. The discharge summary and nursing notes on the patient were missing.

VERDICT $5.28 million arbitration award.

COMMENT It surprises me how often key portions of medical records go missing! Here, the absence of a discharge summary and nursing notes may well have contributed to a $5 million award.

Change, and not for the better

AN ATYPICAL MOLE ON THE LEFT CALF was brought to the attention of a primary care physician by a 36-year-old man during a full physical. The mole was 1 3 1 cm; the patient reported that it had been changing. The mole’s appearance didn’t worry the physician, who described it in his notes as either a hemangioma or dermatofibroma. The doctor advised the patient to return in 6 months if he wanted the mole removed for cosmetic reasons.

Over the next 5 months, the patient noticed further changes in the mole and called the doctor’s office. He was seen by a colleague of his physician, who immediately sent the patient for a biopsy and surgical consultation. The mole was removed and diagnosed as an ulcerating melanoma with downward growth.

Shortly thereafter, the patient underwent wide excision and lymph node dissection, which showed clear margins and no lymph node involvement. Twenty months later, a mass was found in the patient’s liver. Biopsy diagnosed metastatic spread of the melanoma. The patient died 2 months later.

PLAINTIFF’S CLAIM The patient should have had a biopsy and received a surgical referral at the time of the physical examination when he first reported the mole.

THE DEFENSE Waiting for 6 months was appropriate because the mole didn’t look like a melanoma when the patient first called it to the physician’s attention. The melanoma had already metastasized at the time of the physical examination and the diagnostic delay didn’t affect the outcome.

VERDICT $1 million Massachusetts settlement.

COMMENT A changing mole should always raise concern. Biopsy, excision, or a referral could have avoided a million-dollar settlement.

Failure to address persistent symptoms proves disastrous

PAIN IN THE BACK AND CHEST along with respiratory difficulty prompted a 49-year-old man to visit his physician. The physician told him to go to a hospital. The doctor who examined the patient at the hospital diagnosed muscle strain and prescribed muscle relaxants.

The following day, the patient returned to his physician complaining of continuing symptoms. The doctor sent him home. He died the next day of an aortic rupture caused by an undiagnosed dissection.

PLAINTIFF’S CLAIM The 2 physicians should have diagnosed the dissection, which would have permitted treatment and prevented death. The patient had been treated previously at the hospital, and his records should have raised suspicion of an aortic aneurysm. The hospital physician was a new hire and hadn’t received proper training in the hospital’s electronic records system. He should have ordered a computed tomography scan or cardiology consult. The patient’s physician failed to address the ongoing symptoms. He should have hospitalized the patient at the time of the second visit.

THE DEFENSE The hospital physician claimed he had intended to contact the cardiologist who had treated the patient, but the patient couldn’t remember the cardiologist’s name. The patient’s symptoms didn’t suggest an aortic dissection, and the dissection occurred after the patient was discharged from the hospital.

VERDICT $3.4 million New York verdict against the hospital physician only.

COMMENT Although the hoofbeats are usually horses, always remember the zebras (or should it be lions?), particularly when a patient returns repeatedly with ongoing symptoms.

Controlled substances out of control

A WOMAN WITH CHRONIC MIGRAINES, anxiety problems, and nausea also had cardiomyopathy and chronic atrial fibrillation, which could be triggered by pain from her other ailments. She came under the care of a physician who prescribed a number of drugs, including meperidine, hydrocodone, tizanidine, diazepam, promethazine, alprazolam, and oxcarbazepine. The doctor prescribed injectable forms of certain medications after the patient told him her next-door neighbor was a nurse and could help administer the drugs.

Four years after coming under the doctor’s care, the patient signed a Controlled Substance Agreement specifying that the physician would discontinue her as a patient if she got controlled substances from another doctor. (Evidence was later found that the patient was receiving prescriptions from other physicians.)

While under treatment by her doctor, the patient was hospitalized a number of times for medication overdoses. The record from one hospitalization reported that she had made angry, profanity-laced requests for meperidine and promethazine.

About 2 years after signing the Controlled Substance Agreement, the patient received prescriptions from her doctor for 210 doses of meperidine, 100 doses of promethazine, and 60 pills each of diazepam, alprazolam, and acetaminophen and hydrocodone. She filled the prescriptions at 2 pharmacies without objections from the pharmacists. She died of an accidental drug overdose the following month.

Postmortem blood testing showed high levels of meperidine and promethazine. The patient had apparently taken the equivalent of 11 “shots” of meperidine (5 times the maximum prescribed amount), probably by injecting herself through a peripherally inserted central catheter rather than by intramuscular injection, as prescribed.

PLAINTIFF’S CLAIM The patient’s doctor was negligent in prescribing large amounts of controlled substances when he should have known that she was a drug seeker with a drug abuse problem. The pharmacies were negligent for filling the prescriptions without question.

THE DEFENSE The patient was solely responsible for her own death because she gave herself a large overdose.

VERDICT $500,000 Alabama verdict. The case against the pharmacies was dismissed.

COMMENT Increasingly it is expected that physicians (and pharmacists) perform due diligence when prescribing opioids, including taking reasonable precautions against the drug-seeking patient.

Antibiotics fail to head off sepsis

SHORTNESS OF BREATH AND RIGHT-SIDED CHEST PAIN prompted a 45-year-old woman to go to the emergency department (ED) early one morning. She had a history of chronic lung problems with multiple diagnoses of pneumonia, pneumothorax, blebs, and bronchiectasis. The ED doctor diagnosed community-acquired pneumonia and admitted her for intravenous antibiotic treatment.

Late that afternoon the patient’s condition deteriorated rapidly. She was transferred to the intensive care unit, where she died of septic shock caused by Pseudomonas aeruginosa 22 hours after she had arrived at the ED.

PLAINTIFF’S CLAIM The patient should have received broader-spectrum antibiotics.

THE DEFENSE The hospitalist who treated the woman as an inpatient claimed that the treatment she received was appropriate and that she probably would have died even if other antibiotics had been prescribed. The hospitalist also claimed that the nursing staff failed to notify her of the patient’s low blood pressure readings until 10 hours after the initial evaluation. A nurse denied this claim, asserting that the hospitalist had been paged several times during the day. The discharge summary and nursing notes on the patient were missing.

VERDICT $5.28 million arbitration award.

COMMENT It surprises me how often key portions of medical records go missing! Here, the absence of a discharge summary and nursing notes may well have contributed to a $5 million award.

Change, and not for the better

AN ATYPICAL MOLE ON THE LEFT CALF was brought to the attention of a primary care physician by a 36-year-old man during a full physical. The mole was 1 3 1 cm; the patient reported that it had been changing. The mole’s appearance didn’t worry the physician, who described it in his notes as either a hemangioma or dermatofibroma. The doctor advised the patient to return in 6 months if he wanted the mole removed for cosmetic reasons.

Over the next 5 months, the patient noticed further changes in the mole and called the doctor’s office. He was seen by a colleague of his physician, who immediately sent the patient for a biopsy and surgical consultation. The mole was removed and diagnosed as an ulcerating melanoma with downward growth.

Shortly thereafter, the patient underwent wide excision and lymph node dissection, which showed clear margins and no lymph node involvement. Twenty months later, a mass was found in the patient’s liver. Biopsy diagnosed metastatic spread of the melanoma. The patient died 2 months later.

PLAINTIFF’S CLAIM The patient should have had a biopsy and received a surgical referral at the time of the physical examination when he first reported the mole.

THE DEFENSE Waiting for 6 months was appropriate because the mole didn’t look like a melanoma when the patient first called it to the physician’s attention. The melanoma had already metastasized at the time of the physical examination and the diagnostic delay didn’t affect the outcome.

VERDICT $1 million Massachusetts settlement.

COMMENT A changing mole should always raise concern. Biopsy, excision, or a referral could have avoided a million-dollar settlement.

Failure to address persistent symptoms proves disastrous

PAIN IN THE BACK AND CHEST along with respiratory difficulty prompted a 49-year-old man to visit his physician. The physician told him to go to a hospital. The doctor who examined the patient at the hospital diagnosed muscle strain and prescribed muscle relaxants.

The following day, the patient returned to his physician complaining of continuing symptoms. The doctor sent him home. He died the next day of an aortic rupture caused by an undiagnosed dissection.

PLAINTIFF’S CLAIM The 2 physicians should have diagnosed the dissection, which would have permitted treatment and prevented death. The patient had been treated previously at the hospital, and his records should have raised suspicion of an aortic aneurysm. The hospital physician was a new hire and hadn’t received proper training in the hospital’s electronic records system. He should have ordered a computed tomography scan or cardiology consult. The patient’s physician failed to address the ongoing symptoms. He should have hospitalized the patient at the time of the second visit.

THE DEFENSE The hospital physician claimed he had intended to contact the cardiologist who had treated the patient, but the patient couldn’t remember the cardiologist’s name. The patient’s symptoms didn’t suggest an aortic dissection, and the dissection occurred after the patient was discharged from the hospital.

VERDICT $3.4 million New York verdict against the hospital physician only.

COMMENT Although the hoofbeats are usually horses, always remember the zebras (or should it be lions?), particularly when a patient returns repeatedly with ongoing symptoms.

Controlled substances out of control

A WOMAN WITH CHRONIC MIGRAINES, anxiety problems, and nausea also had cardiomyopathy and chronic atrial fibrillation, which could be triggered by pain from her other ailments. She came under the care of a physician who prescribed a number of drugs, including meperidine, hydrocodone, tizanidine, diazepam, promethazine, alprazolam, and oxcarbazepine. The doctor prescribed injectable forms of certain medications after the patient told him her next-door neighbor was a nurse and could help administer the drugs.

Four years after coming under the doctor’s care, the patient signed a Controlled Substance Agreement specifying that the physician would discontinue her as a patient if she got controlled substances from another doctor. (Evidence was later found that the patient was receiving prescriptions from other physicians.)

While under treatment by her doctor, the patient was hospitalized a number of times for medication overdoses. The record from one hospitalization reported that she had made angry, profanity-laced requests for meperidine and promethazine.

About 2 years after signing the Controlled Substance Agreement, the patient received prescriptions from her doctor for 210 doses of meperidine, 100 doses of promethazine, and 60 pills each of diazepam, alprazolam, and acetaminophen and hydrocodone. She filled the prescriptions at 2 pharmacies without objections from the pharmacists. She died of an accidental drug overdose the following month.

Postmortem blood testing showed high levels of meperidine and promethazine. The patient had apparently taken the equivalent of 11 “shots” of meperidine (5 times the maximum prescribed amount), probably by injecting herself through a peripherally inserted central catheter rather than by intramuscular injection, as prescribed.

PLAINTIFF’S CLAIM The patient’s doctor was negligent in prescribing large amounts of controlled substances when he should have known that she was a drug seeker with a drug abuse problem. The pharmacies were negligent for filling the prescriptions without question.

THE DEFENSE The patient was solely responsible for her own death because she gave herself a large overdose.

VERDICT $500,000 Alabama verdict. The case against the pharmacies was dismissed.

COMMENT Increasingly it is expected that physicians (and pharmacists) perform due diligence when prescribing opioids, including taking reasonable precautions against the drug-seeking patient.

Faulty equipment blamed for improper diagnosis: $78M

AT 36 WEEKS’ GESTATION, a woman went to the emergency department (ED) with abdominal pain. After ultrasonography (US), a nurse told her the fetus had died in utero, but the mother continued to feel fetal movement. The ED physician requested a second US, but it took 75 minutes for a radiology technician to arrive. This US showed a beating fetal heart with placental abruption. After cesarean delivery, the child was found to have cerebral palsy.

PATIENT’S CLAIM The first US was performed by an inexperienced technician using outdated equipment and the wrong transducer. An experienced technician with newer equipment should have been immediately available. The ED physician did not react when fetal distress was first identified.

DEFENDANTS’ DEFENSE The ED physician was told that the baby had died. Perhaps the child’s heart had started again by the time the second US was performed and a heartbeat found. The hospital denied negligence.

VERDICT A Pennsylvania jury found the ED physician not negligent; the hospital was 100% at fault. A $78.5 million verdict included $1.5 million in emotional distress to the mother, $10 million in pain and suffering for the child, $2million in lost future earnings, and the rest in future medical expenses.

Ligated ureter found after hysterectomy

A 50-YEAR-OLD WOMAN underwent laparoscopically assisted vaginal hysterectomy. She went to the ED with pain 6 days later. Imaging studies indicated a ligated ureter; a nephrostomy tube was placed. She required a nephrostomy bag for 4 months and underwent two repair operations.

PATIENT’S CLAIM The patient’s ureter was ligated and/or constricted during surgery. The gynecologist was negligent in failing to recognize and repair the injury during surgery.

PHYSICIAN’S DEFENSE The ureter was not ligated during surgery; therefore it could not have been discovered. In addition, injury to a ureter is a known risk of the procedure.

VERDICT An Arizona defense verdict was returned.

Myomectomy after cesarean; mother dies

IMMEDIATELY AFTER A WOMAN with preeclampsia had a cesarean delivery, she underwent a myomectomy. The day before discharge, her abdominal incision opened and a clear liquid drained. The day after discharge, she went to the ED with intense abdominal pain. Necrotizing fasciitis was found and debridement surgery performed. She was transferred to another hospital but died of sepsis several days later.

ESTATE’S CLAIM The infection occurred because the myomectomy was performed immediately following cesarean delivery. Prophylactic antibiotics were not prescribed before surgery. The mother was not fully informed as to the risks of concurrent operations. The ObGyns failed to recognize the infection before discharging the patient.

PHYSICIANS’ DEFENSE The patient was fully informed of the risks of surgery; it was reasonable to perform myomectomy immediately following cesarean delivery. There were no signs or symptoms of infection before discharge. Cesarean incisions open about 30% of the time—not a cause for concern. Prophylactic antibiotics for cesarean procedures are not standard of care. The patient’s infection was caused by a rapidly spreading, rare bacterium.

VERDICT A Michigan defense verdict was returned.

TOLAC to cesarean: baby has cerebral palsy

A WOMAN WANTED A TRIAL OF LABOR after a previous cesarean delivery (TOLAC). During labor, fetal distress was noted, and a cesarean delivery was performed. Uterine rupture had occurred. The baby has spastic cerebral palsy with significantly impaired neuromotor and cognitive abilities.

PARENTS’ CLAIM The hospital staff and physicians overlooked earlier fetal distress. A timelier delivery would have prevented the child’s injuries.

DEFENDANTs’ DEFENSE The hospital reached a confidential settlement. The ObGyns claimed fetal tracings were not suggestive of uterine rupture; they met the standard of care.

VERDICT A Texas defense verdict was returned.

Problems escalate after amniocentesis

WHEN GESTATIONAL DIABETES WAS DIAGNOSED at 33 weeks’ gestation, a family practitioner (FP) referred the mother to an ObGyn practice. Two ObGyns performed amniocentesis to check fetal lung maturity. After the procedure, fetal distress was noted, and the ObGyns instructed the FP to induce labor.

The baby suffered brain damage, had seizures, and has cerebral palsy. She was born without kidney function. By age 10, she had 2 kidney transplant operations and functions at a pre-kindergarten level.

PATIENT’S CLAIM The mother was not fully informed of the risks of and alternatives to amniocentesis. Although complications arose before amniocentesis, the test proceeded. The ObGyns were negligent in not performing cesarean delivery when fetal distress was detected.

DEFENDANTS’ DEFENSE The FP and hospital settled prior to trial. The ObGyns claimed that their care was an appropriate alternative to the actions the patient claimed should have been taken.

VERDICT Costs for the child’s care had reached $1.4 million before trial. A $9 million Virginia verdict was returned that included $7 million for the child and $2 million for the mother, but the settlement was reduced by the state cap.

Did HT cause breast cancer?

A 52-YEAR-OLD WOMAN was prescribed conjugated estrogens/medroxyprogesterone acetate (Prempro, Wyeth, Inc.) for hormone therapy by her gynecologist.

After taking the drug for 5 years, the patient developed invasive breast cancer. She underwent a lumpectomy, chemotherapy, and three reconstructive surgeries.

PATIENT’S CLAIM The manufacturer failed to warn of a woman’s risk of developing breast cancer while taking the product.

DEFENDANT’S DEFENSE Prempro alone does not cause cancer. The drug is just one of many contributing factors that may or may not increase the risk of developing breast cancer.

VERDICT A $3.75 million Connecticut verdict was returned for the patient plus $250,000 to her husband for loss of consortium.

Failure to diagnose preeclampsia—twice

AT 28 WEEKS’ GESTATION, a woman with a history of hypertension went to an ED with headache, nausea, vomiting, cramping, and ringing in her ears. After waiting 4 hours before being seen, her BP was 150/108 mm Hg and normal fetal heart tones were heard. The ED physician diagnosed otitis media and discharged her.

Later that evening, the patient returned to the ED with similar symptoms. A urine specimen showed significant proteinuria and the fetal heart rate was 158 bpm. A second ED physician diagnosed a urinary tract infection, prescribed antibiotics and pain medication, and sent her home.

A few hours later, she returned to the ED by ambulance suffering from eclamptic seizures. Her BP was 174/121 mm Hg, and no fetal heart tones were heard. She delivered a stillborn child by cesarean delivery.

PATIENT’S CLAIM The ED physicians were negligent in failing to diagnose preeclampsia at the first two visits.

PHYSICIANS’ DEFENSE The first ED physician settled for $45,000 while serving a prison sentence after conviction on two sex-abuse felonies related to his treatment of female patients at the same ED. The second ED physician denied negligence.

VERDICT A $50,000 Alabama verdict was returned for compensatory damages for the mother and $600,000 punitive damages for the stillborn child.

Inflated Foley catheter injures mother

DURING A LONG AND DIFFICULT LABOR, an ObGyn used forceps to complete delivery of a 31-year-old woman’s first child. The baby was healthy, but the mother has suffered urinary incontinence since delivery. Despite several repair operations, the condition remains.

PATIENT’S CLAIM The ObGyn was negligent in failing to remove a fully inflated Foley catheter before beginning delivery, leading to a urethral sphincter injury.

PHYSICIAN’S DEFENSE The decision regarding removal of the catheter was a matter of hospital policy. The ObGyn blamed improper catheter placement on the nurses.

VERDICT A Kentucky defense verdict was returned.

Faulty equipment blamed for improper diagnosis: $78M

AT 36 WEEKS’ GESTATION, a woman went to the emergency department (ED) with abdominal pain. After ultrasonography (US), a nurse told her the fetus had died in utero, but the mother continued to feel fetal movement. The ED physician requested a second US, but it took 75 minutes for a radiology technician to arrive. This US showed a beating fetal heart with placental abruption. After cesarean delivery, the child was found to have cerebral palsy.

PATIENT’S CLAIM The first US was performed by an inexperienced technician using outdated equipment and the wrong transducer. An experienced technician with newer equipment should have been immediately available. The ED physician did not react when fetal distress was first identified.

DEFENDANTS’ DEFENSE The ED physician was told that the baby had died. Perhaps the child’s heart had started again by the time the second US was performed and a heartbeat found. The hospital denied negligence.

VERDICT A Pennsylvania jury found the ED physician not negligent; the hospital was 100% at fault. A $78.5 million verdict included $1.5 million in emotional distress to the mother, $10 million in pain and suffering for the child, $2million in lost future earnings, and the rest in future medical expenses.

Ligated ureter found after hysterectomy

A 50-YEAR-OLD WOMAN underwent laparoscopically assisted vaginal hysterectomy. She went to the ED with pain 6 days later. Imaging studies indicated a ligated ureter; a nephrostomy tube was placed. She required a nephrostomy bag for 4 months and underwent two repair operations.

PATIENT’S CLAIM The patient’s ureter was ligated and/or constricted during surgery. The gynecologist was negligent in failing to recognize and repair the injury during surgery.

PHYSICIAN’S DEFENSE The ureter was not ligated during surgery; therefore it could not have been discovered. In addition, injury to a ureter is a known risk of the procedure.

VERDICT An Arizona defense verdict was returned.

Myomectomy after cesarean; mother dies

IMMEDIATELY AFTER A WOMAN with preeclampsia had a cesarean delivery, she underwent a myomectomy. The day before discharge, her abdominal incision opened and a clear liquid drained. The day after discharge, she went to the ED with intense abdominal pain. Necrotizing fasciitis was found and debridement surgery performed. She was transferred to another hospital but died of sepsis several days later.

ESTATE’S CLAIM The infection occurred because the myomectomy was performed immediately following cesarean delivery. Prophylactic antibiotics were not prescribed before surgery. The mother was not fully informed as to the risks of concurrent operations. The ObGyns failed to recognize the infection before discharging the patient.

PHYSICIANS’ DEFENSE The patient was fully informed of the risks of surgery; it was reasonable to perform myomectomy immediately following cesarean delivery. There were no signs or symptoms of infection before discharge. Cesarean incisions open about 30% of the time—not a cause for concern. Prophylactic antibiotics for cesarean procedures are not standard of care. The patient’s infection was caused by a rapidly spreading, rare bacterium.

VERDICT A Michigan defense verdict was returned.

TOLAC to cesarean: baby has cerebral palsy

A WOMAN WANTED A TRIAL OF LABOR after a previous cesarean delivery (TOLAC). During labor, fetal distress was noted, and a cesarean delivery was performed. Uterine rupture had occurred. The baby has spastic cerebral palsy with significantly impaired neuromotor and cognitive abilities.

PARENTS’ CLAIM The hospital staff and physicians overlooked earlier fetal distress. A timelier delivery would have prevented the child’s injuries.

DEFENDANTs’ DEFENSE The hospital reached a confidential settlement. The ObGyns claimed fetal tracings were not suggestive of uterine rupture; they met the standard of care.

VERDICT A Texas defense verdict was returned.

Problems escalate after amniocentesis

WHEN GESTATIONAL DIABETES WAS DIAGNOSED at 33 weeks’ gestation, a family practitioner (FP) referred the mother to an ObGyn practice. Two ObGyns performed amniocentesis to check fetal lung maturity. After the procedure, fetal distress was noted, and the ObGyns instructed the FP to induce labor.

The baby suffered brain damage, had seizures, and has cerebral palsy. She was born without kidney function. By age 10, she had 2 kidney transplant operations and functions at a pre-kindergarten level.

PATIENT’S CLAIM The mother was not fully informed of the risks of and alternatives to amniocentesis. Although complications arose before amniocentesis, the test proceeded. The ObGyns were negligent in not performing cesarean delivery when fetal distress was detected.

DEFENDANTS’ DEFENSE The FP and hospital settled prior to trial. The ObGyns claimed that their care was an appropriate alternative to the actions the patient claimed should have been taken.

VERDICT Costs for the child’s care had reached $1.4 million before trial. A $9 million Virginia verdict was returned that included $7 million for the child and $2 million for the mother, but the settlement was reduced by the state cap.

Did HT cause breast cancer?

A 52-YEAR-OLD WOMAN was prescribed conjugated estrogens/medroxyprogesterone acetate (Prempro, Wyeth, Inc.) for hormone therapy by her gynecologist.

After taking the drug for 5 years, the patient developed invasive breast cancer. She underwent a lumpectomy, chemotherapy, and three reconstructive surgeries.

PATIENT’S CLAIM The manufacturer failed to warn of a woman’s risk of developing breast cancer while taking the product.

DEFENDANT’S DEFENSE Prempro alone does not cause cancer. The drug is just one of many contributing factors that may or may not increase the risk of developing breast cancer.

VERDICT A $3.75 million Connecticut verdict was returned for the patient plus $250,000 to her husband for loss of consortium.

Failure to diagnose preeclampsia—twice

AT 28 WEEKS’ GESTATION, a woman with a history of hypertension went to an ED with headache, nausea, vomiting, cramping, and ringing in her ears. After waiting 4 hours before being seen, her BP was 150/108 mm Hg and normal fetal heart tones were heard. The ED physician diagnosed otitis media and discharged her.

Later that evening, the patient returned to the ED with similar symptoms. A urine specimen showed significant proteinuria and the fetal heart rate was 158 bpm. A second ED physician diagnosed a urinary tract infection, prescribed antibiotics and pain medication, and sent her home.

A few hours later, she returned to the ED by ambulance suffering from eclamptic seizures. Her BP was 174/121 mm Hg, and no fetal heart tones were heard. She delivered a stillborn child by cesarean delivery.

PATIENT’S CLAIM The ED physicians were negligent in failing to diagnose preeclampsia at the first two visits.

PHYSICIANS’ DEFENSE The first ED physician settled for $45,000 while serving a prison sentence after conviction on two sex-abuse felonies related to his treatment of female patients at the same ED. The second ED physician denied negligence.

VERDICT A $50,000 Alabama verdict was returned for compensatory damages for the mother and $600,000 punitive damages for the stillborn child.

Inflated Foley catheter injures mother

DURING A LONG AND DIFFICULT LABOR, an ObGyn used forceps to complete delivery of a 31-year-old woman’s first child. The baby was healthy, but the mother has suffered urinary incontinence since delivery. Despite several repair operations, the condition remains.

PATIENT’S CLAIM The ObGyn was negligent in failing to remove a fully inflated Foley catheter before beginning delivery, leading to a urethral sphincter injury.

PHYSICIAN’S DEFENSE The decision regarding removal of the catheter was a matter of hospital policy. The ObGyn blamed improper catheter placement on the nurses.

VERDICT A Kentucky defense verdict was returned.

Faulty equipment blamed for improper diagnosis: $78M

AT 36 WEEKS’ GESTATION, a woman went to the emergency department (ED) with abdominal pain. After ultrasonography (US), a nurse told her the fetus had died in utero, but the mother continued to feel fetal movement. The ED physician requested a second US, but it took 75 minutes for a radiology technician to arrive. This US showed a beating fetal heart with placental abruption. After cesarean delivery, the child was found to have cerebral palsy.

PATIENT’S CLAIM The first US was performed by an inexperienced technician using outdated equipment and the wrong transducer. An experienced technician with newer equipment should have been immediately available. The ED physician did not react when fetal distress was first identified.

DEFENDANTS’ DEFENSE The ED physician was told that the baby had died. Perhaps the child’s heart had started again by the time the second US was performed and a heartbeat found. The hospital denied negligence.

VERDICT A Pennsylvania jury found the ED physician not negligent; the hospital was 100% at fault. A $78.5 million verdict included $1.5 million in emotional distress to the mother, $10 million in pain and suffering for the child, $2million in lost future earnings, and the rest in future medical expenses.

Ligated ureter found after hysterectomy

A 50-YEAR-OLD WOMAN underwent laparoscopically assisted vaginal hysterectomy. She went to the ED with pain 6 days later. Imaging studies indicated a ligated ureter; a nephrostomy tube was placed. She required a nephrostomy bag for 4 months and underwent two repair operations.

PATIENT’S CLAIM The patient’s ureter was ligated and/or constricted during surgery. The gynecologist was negligent in failing to recognize and repair the injury during surgery.

PHYSICIAN’S DEFENSE The ureter was not ligated during surgery; therefore it could not have been discovered. In addition, injury to a ureter is a known risk of the procedure.

VERDICT An Arizona defense verdict was returned.

Myomectomy after cesarean; mother dies

IMMEDIATELY AFTER A WOMAN with preeclampsia had a cesarean delivery, she underwent a myomectomy. The day before discharge, her abdominal incision opened and a clear liquid drained. The day after discharge, she went to the ED with intense abdominal pain. Necrotizing fasciitis was found and debridement surgery performed. She was transferred to another hospital but died of sepsis several days later.

ESTATE’S CLAIM The infection occurred because the myomectomy was performed immediately following cesarean delivery. Prophylactic antibiotics were not prescribed before surgery. The mother was not fully informed as to the risks of concurrent operations. The ObGyns failed to recognize the infection before discharging the patient.

PHYSICIANS’ DEFENSE The patient was fully informed of the risks of surgery; it was reasonable to perform myomectomy immediately following cesarean delivery. There were no signs or symptoms of infection before discharge. Cesarean incisions open about 30% of the time—not a cause for concern. Prophylactic antibiotics for cesarean procedures are not standard of care. The patient’s infection was caused by a rapidly spreading, rare bacterium.

VERDICT A Michigan defense verdict was returned.

TOLAC to cesarean: baby has cerebral palsy

A WOMAN WANTED A TRIAL OF LABOR after a previous cesarean delivery (TOLAC). During labor, fetal distress was noted, and a cesarean delivery was performed. Uterine rupture had occurred. The baby has spastic cerebral palsy with significantly impaired neuromotor and cognitive abilities.

PARENTS’ CLAIM The hospital staff and physicians overlooked earlier fetal distress. A timelier delivery would have prevented the child’s injuries.

DEFENDANTs’ DEFENSE The hospital reached a confidential settlement. The ObGyns claimed fetal tracings were not suggestive of uterine rupture; they met the standard of care.

VERDICT A Texas defense verdict was returned.

Problems escalate after amniocentesis

WHEN GESTATIONAL DIABETES WAS DIAGNOSED at 33 weeks’ gestation, a family practitioner (FP) referred the mother to an ObGyn practice. Two ObGyns performed amniocentesis to check fetal lung maturity. After the procedure, fetal distress was noted, and the ObGyns instructed the FP to induce labor.

The baby suffered brain damage, had seizures, and has cerebral palsy. She was born without kidney function. By age 10, she had 2 kidney transplant operations and functions at a pre-kindergarten level.

PATIENT’S CLAIM The mother was not fully informed of the risks of and alternatives to amniocentesis. Although complications arose before amniocentesis, the test proceeded. The ObGyns were negligent in not performing cesarean delivery when fetal distress was detected.

DEFENDANTS’ DEFENSE The FP and hospital settled prior to trial. The ObGyns claimed that their care was an appropriate alternative to the actions the patient claimed should have been taken.

VERDICT Costs for the child’s care had reached $1.4 million before trial. A $9 million Virginia verdict was returned that included $7 million for the child and $2 million for the mother, but the settlement was reduced by the state cap.

Did HT cause breast cancer?

A 52-YEAR-OLD WOMAN was prescribed conjugated estrogens/medroxyprogesterone acetate (Prempro, Wyeth, Inc.) for hormone therapy by her gynecologist.

After taking the drug for 5 years, the patient developed invasive breast cancer. She underwent a lumpectomy, chemotherapy, and three reconstructive surgeries.

PATIENT’S CLAIM The manufacturer failed to warn of a woman’s risk of developing breast cancer while taking the product.

DEFENDANT’S DEFENSE Prempro alone does not cause cancer. The drug is just one of many contributing factors that may or may not increase the risk of developing breast cancer.

VERDICT A $3.75 million Connecticut verdict was returned for the patient plus $250,000 to her husband for loss of consortium.

Failure to diagnose preeclampsia—twice

AT 28 WEEKS’ GESTATION, a woman with a history of hypertension went to an ED with headache, nausea, vomiting, cramping, and ringing in her ears. After waiting 4 hours before being seen, her BP was 150/108 mm Hg and normal fetal heart tones were heard. The ED physician diagnosed otitis media and discharged her.

Later that evening, the patient returned to the ED with similar symptoms. A urine specimen showed significant proteinuria and the fetal heart rate was 158 bpm. A second ED physician diagnosed a urinary tract infection, prescribed antibiotics and pain medication, and sent her home.

A few hours later, she returned to the ED by ambulance suffering from eclamptic seizures. Her BP was 174/121 mm Hg, and no fetal heart tones were heard. She delivered a stillborn child by cesarean delivery.

PATIENT’S CLAIM The ED physicians were negligent in failing to diagnose preeclampsia at the first two visits.

PHYSICIANS’ DEFENSE The first ED physician settled for $45,000 while serving a prison sentence after conviction on two sex-abuse felonies related to his treatment of female patients at the same ED. The second ED physician denied negligence.

VERDICT A $50,000 Alabama verdict was returned for compensatory damages for the mother and $600,000 punitive damages for the stillborn child.

Inflated Foley catheter injures mother

DURING A LONG AND DIFFICULT LABOR, an ObGyn used forceps to complete delivery of a 31-year-old woman’s first child. The baby was healthy, but the mother has suffered urinary incontinence since delivery. Despite several repair operations, the condition remains.

PATIENT’S CLAIM The ObGyn was negligent in failing to remove a fully inflated Foley catheter before beginning delivery, leading to a urethral sphincter injury.

PHYSICIAN’S DEFENSE The decision regarding removal of the catheter was a matter of hospital policy. The ObGyn blamed improper catheter placement on the nurses.

VERDICT A Kentucky defense verdict was returned.

Prolonged delivery: child with cerebral palsy   awarded $70M

AFTER MORE THAN 4 HOURS of second-stage labor followed by prolonged pushing and crowning, the baby was born depressed. Later, the child was found to have cerebral palsy.

PARENTS’ CLAIM The ObGyn was negligent in failing to perform an episiotomy, not attempting vacuum extraction, and not using forceps to assist delivery. Although fetal heart-rate monitoring results deteriorated, the ObGyn did not assess contractions for 30 minutes at one point. Hospital staff members were unable to adequately intubate or ventilate the newborn. The hospital staff disposed of the baby’s cord blood. Records were altered.

The parents’ counsel proposed that the defendants’ insurance company refused all settlement efforts prior to trial because the case venue was known to be conservative regarding jury verdicts.

DEFENDANTS’ DEFENSE The hospital and the ObGyn were not negligent; the mother and baby received proper care. Hospital staff acted appropriately.

VERDICT During the trial, the hospital settled for an undisclosed amount. An additional $2 million was offered on behalf of the ObGyn later in the trial, but the parents refused settlement at that time.

A California jury returned a $74.525 million verdict against the ObGyn. The child was awarded $70.725 million for medical expenses, lost earnings, and damages. The parents were awarded $3.8 million for emotional distress.

Was ectopic pregnancy missed?

A WOMAN IN SEVERE ABDOMINAL PAIN saw her internist. CT scans revealed a right ovarian cyst. When pain continued, she saw her ObGyn 3 weeks later, and her bowel was full of hard stool. Ultrasonography (US) showed a multicystic right ovary and a thin endometrial stripe. She was taking birth control pills and her husband had a vasectomy. She was told her abdominal pain was from constipation and ovarian cysts. A week later, she had laparoscopic surgery to remove an ectopic pregnancy.

PATIENT’S CLAIM The ObGyn did not perform a pregnancy test, and did not diagnose an ectopic pregnancy in a timely manner. An earlier diagnosis would have allowed medical rather than surgical resolution.

PHYSICIAN’S DEFENSE It was too early to determine if the pregnancy was intrauterine or ectopic. An earlier diagnosis would have resulted in laparoscopic surgery rather than medical treatment, as the medication (methotrexate) can cause increased pain.

VERDICT An Illinois defense verdict was returned.

Foreshortened vagina inhibits intercourse

A 65-YEAR-OLD WOMAN underwent anterior and posterior colphorrhaphy to repair a cystocele and rectocele, sacrospinous ligament fixation for vaginal prolapse, and a TVT mid-urethral suspension procedure to correct stress urinary incontinence. During two follow-up visits, the gynecologist determined that she was healing normally.

Within the next few weeks, the patient came to believe that her vagina had been sewn shut. She did not return to her gynecologist, but sought treatment with another physician 6 months later. It was determined that she had a stenotic and foreshortened vagina.

PATIENT’S CLAIM Too much vaginal tissue was removed during surgery.

PHYSICIAN’S DEFENSE The stenotic and foreshortened vagina was an unexpected result of the healing process after surgery.

VERDICT An Illinois defense verdict was returned.

Hydrocephalus in utero not seen until too late

A WOMAN HAD PRENATAL TREATMENT at a federally funded health clinic. A certified nurse midwife (CNM) ordered second-trimester US, with normal results. During the third trimester, the mother switched to a private ObGyn who ordered testing. US indicated the fetus was hydrocephalic. The child was born with cognitive disabilities and will need lifelong care.

PARENTS’ CLAIM The CNM ordered US too early in the pregnancy to be of diagnostic value; no further testing was undertaken. When hydrocephalus was seen, an abortion was not legally available because of fetal age.

DEFENDANT’S DEFENSE Even if US had been performed later in the second trimester, the defect would not have shown.

VERDICT A $4 million New Jersey settlement was reached.

Severe brachial plexus injury

WHEN SHOULDER DYSTOCIA WAS ENCOUNTERED, the ObGyn used standard maneuvers to deliver the child. The baby suffered a severe brachial plexus injury with rupture of C7 nerve and avulsions at C8 and T1.

Nerve-graft surgery at 6 months and tendon transfer surgery at 2 years resulted in recovery of good shoulder and elbow function, but the child has inadequate use of his wrist and hand. Additional surgeries are planned.

PARENTS’ CLAIM The ObGyn did not inform the mother that she was at risk for shoulder dystocia, nor did he discuss cesarean delivery. The mother’s risk factors included short stature, gestational diabetes, excessive weight gain during pregnancy, and two previous deliveries that involved vacuum assistance and a broken clavicle. The ObGyn applied excessive traction to the fetal head during delivery.

PHYSICIAN’S DEFENSE The mother’s risk factors were not severe enough to consider the chance of shoulder dystocia. The baby’s injuries were due to the normal forces of labor. Traction placed on the baby’s head during delivery was gentle and appropriate.

VERDICT A $5.5 million Iowa verdict was returned.

Faulty testing: baby has Down syndrome

AT 13 WEEKS’ GESTATION, a 34-year-old woman underwent chorionic villus sampling (CVS) at a maternal-fetal medicine center. Results showed a normal chromosomal profile. Later, two sonograms indicated possible Down syndrome. The parents were assured that the baby did not have a genetic disorder; amniocentesis was never suggested.

A week before the baby’s birth, the parents were told the child has Down syndrome.

PARENTS’ CLAIM Maternal tissue, not fetal tissue, had been removed and tested during CVS. The parents would have aborted the fetus had they known she had Down syndrome.

DEFENDANTS’ DEFENSE CVS was properly administered.

VERDICT A $3 million Missouri verdict was returned against the center where the testing was performed.

Why did the uterus seem to be growing?

A 52-YEAR-OLD WOMAN’S UTERUS was larger than normal in February 2007. By November 2008, her uterus was the size of a 14-week gestation. In September 2009, she complained of abdominal discomfort. Her uterus was larger than at the previous visit. The gynecologist suggested a hysterectomy, but nothing was scheduled.

In November 2009, she reported increasing pelvic pressure; her uterus was the size of an 18-week gestation. US and MRI showed large masses on both ovaries although the uterus had no masses or fibroids within it. A gynecologic oncologist performed abdominal hysterectomy with bilateral salpingo-oophorectomy and bilateral peri-aortic lymph node dissection. Pathology returned a diagnosis of ovarian cancer. The patient underwent chemotherapy.

PATIENT’S CLAIM The gynecologist was negligent in not ordering testing in 2007 when the larger-than-normal uterus was first detected, or in subsequent visits through September 2009. A more timely reaction would have given her an opportunity to treat the cancer at an earlier stage.

PHYSICIAN’S DEFENSE The case was settled before trial.

VERDICT A $650,000 Maryland settlement was reached.

Erb’s palsy after shoulder dystocia

DURING VAGINAL DELIVERY, the ObGyn encountered shoulder dystocia. The child suffered a brachial plexus injury and has Erb’s palsy. There was some improvement after two operations, but she still has muscle weakness, arm-length discrepancy, and limited range of motion.

PARENTS’ CLAIM The ObGyn applied excessive downward traction on the baby’s head when her left shoulder could not pass under the pubic bone.

PHYSICIAN’S DEFENSE The injury was caused by uterine contractions and maternal pushing. Proper maneuvers and gentle pressure were used.

VERDICT A $1.34 million New Jersey verdict was returned.

Prolonged delivery: child with cerebral palsy   awarded $70M

AFTER MORE THAN 4 HOURS of second-stage labor followed by prolonged pushing and crowning, the baby was born depressed. Later, the child was found to have cerebral palsy.

PARENTS’ CLAIM The ObGyn was negligent in failing to perform an episiotomy, not attempting vacuum extraction, and not using forceps to assist delivery. Although fetal heart-rate monitoring results deteriorated, the ObGyn did not assess contractions for 30 minutes at one point. Hospital staff members were unable to adequately intubate or ventilate the newborn. The hospital staff disposed of the baby’s cord blood. Records were altered.

The parents’ counsel proposed that the defendants’ insurance company refused all settlement efforts prior to trial because the case venue was known to be conservative regarding jury verdicts.

DEFENDANTS’ DEFENSE The hospital and the ObGyn were not negligent; the mother and baby received proper care. Hospital staff acted appropriately.

VERDICT During the trial, the hospital settled for an undisclosed amount. An additional $2 million was offered on behalf of the ObGyn later in the trial, but the parents refused settlement at that time.

A California jury returned a $74.525 million verdict against the ObGyn. The child was awarded $70.725 million for medical expenses, lost earnings, and damages. The parents were awarded $3.8 million for emotional distress.

Was ectopic pregnancy missed?

A WOMAN IN SEVERE ABDOMINAL PAIN saw her internist. CT scans revealed a right ovarian cyst. When pain continued, she saw her ObGyn 3 weeks later, and her bowel was full of hard stool. Ultrasonography (US) showed a multicystic right ovary and a thin endometrial stripe. She was taking birth control pills and her husband had a vasectomy. She was told her abdominal pain was from constipation and ovarian cysts. A week later, she had laparoscopic surgery to remove an ectopic pregnancy.

PATIENT’S CLAIM The ObGyn did not perform a pregnancy test, and did not diagnose an ectopic pregnancy in a timely manner. An earlier diagnosis would have allowed medical rather than surgical resolution.

PHYSICIAN’S DEFENSE It was too early to determine if the pregnancy was intrauterine or ectopic. An earlier diagnosis would have resulted in laparoscopic surgery rather than medical treatment, as the medication (methotrexate) can cause increased pain.

VERDICT An Illinois defense verdict was returned.

Foreshortened vagina inhibits intercourse

A 65-YEAR-OLD WOMAN underwent anterior and posterior colphorrhaphy to repair a cystocele and rectocele, sacrospinous ligament fixation for vaginal prolapse, and a TVT mid-urethral suspension procedure to correct stress urinary incontinence. During two follow-up visits, the gynecologist determined that she was healing normally.

Within the next few weeks, the patient came to believe that her vagina had been sewn shut. She did not return to her gynecologist, but sought treatment with another physician 6 months later. It was determined that she had a stenotic and foreshortened vagina.

PATIENT’S CLAIM Too much vaginal tissue was removed during surgery.

PHYSICIAN’S DEFENSE The stenotic and foreshortened vagina was an unexpected result of the healing process after surgery.

VERDICT An Illinois defense verdict was returned.

Hydrocephalus in utero not seen until too late

A WOMAN HAD PRENATAL TREATMENT at a federally funded health clinic. A certified nurse midwife (CNM) ordered second-trimester US, with normal results. During the third trimester, the mother switched to a private ObGyn who ordered testing. US indicated the fetus was hydrocephalic. The child was born with cognitive disabilities and will need lifelong care.

PARENTS’ CLAIM The CNM ordered US too early in the pregnancy to be of diagnostic value; no further testing was undertaken. When hydrocephalus was seen, an abortion was not legally available because of fetal age.

DEFENDANT’S DEFENSE Even if US had been performed later in the second trimester, the defect would not have shown.

VERDICT A $4 million New Jersey settlement was reached.

Severe brachial plexus injury

WHEN SHOULDER DYSTOCIA WAS ENCOUNTERED, the ObGyn used standard maneuvers to deliver the child. The baby suffered a severe brachial plexus injury with rupture of C7 nerve and avulsions at C8 and T1.

Nerve-graft surgery at 6 months and tendon transfer surgery at 2 years resulted in recovery of good shoulder and elbow function, but the child has inadequate use of his wrist and hand. Additional surgeries are planned.

PARENTS’ CLAIM The ObGyn did not inform the mother that she was at risk for shoulder dystocia, nor did he discuss cesarean delivery. The mother’s risk factors included short stature, gestational diabetes, excessive weight gain during pregnancy, and two previous deliveries that involved vacuum assistance and a broken clavicle. The ObGyn applied excessive traction to the fetal head during delivery.

PHYSICIAN’S DEFENSE The mother’s risk factors were not severe enough to consider the chance of shoulder dystocia. The baby’s injuries were due to the normal forces of labor. Traction placed on the baby’s head during delivery was gentle and appropriate.

VERDICT A $5.5 million Iowa verdict was returned.

Faulty testing: baby has Down syndrome

AT 13 WEEKS’ GESTATION, a 34-year-old woman underwent chorionic villus sampling (CVS) at a maternal-fetal medicine center. Results showed a normal chromosomal profile. Later, two sonograms indicated possible Down syndrome. The parents were assured that the baby did not have a genetic disorder; amniocentesis was never suggested.

A week before the baby’s birth, the parents were told the child has Down syndrome.

PARENTS’ CLAIM Maternal tissue, not fetal tissue, had been removed and tested during CVS. The parents would have aborted the fetus had they known she had Down syndrome.

DEFENDANTS’ DEFENSE CVS was properly administered.

VERDICT A $3 million Missouri verdict was returned against the center where the testing was performed.

Why did the uterus seem to be growing?

A 52-YEAR-OLD WOMAN’S UTERUS was larger than normal in February 2007. By November 2008, her uterus was the size of a 14-week gestation. In September 2009, she complained of abdominal discomfort. Her uterus was larger than at the previous visit. The gynecologist suggested a hysterectomy, but nothing was scheduled.

In November 2009, she reported increasing pelvic pressure; her uterus was the size of an 18-week gestation. US and MRI showed large masses on both ovaries although the uterus had no masses or fibroids within it. A gynecologic oncologist performed abdominal hysterectomy with bilateral salpingo-oophorectomy and bilateral peri-aortic lymph node dissection. Pathology returned a diagnosis of ovarian cancer. The patient underwent chemotherapy.

PATIENT’S CLAIM The gynecologist was negligent in not ordering testing in 2007 when the larger-than-normal uterus was first detected, or in subsequent visits through September 2009. A more timely reaction would have given her an opportunity to treat the cancer at an earlier stage.

PHYSICIAN’S DEFENSE The case was settled before trial.

VERDICT A $650,000 Maryland settlement was reached.

Erb’s palsy after shoulder dystocia

DURING VAGINAL DELIVERY, the ObGyn encountered shoulder dystocia. The child suffered a brachial plexus injury and has Erb’s palsy. There was some improvement after two operations, but she still has muscle weakness, arm-length discrepancy, and limited range of motion.

PARENTS’ CLAIM The ObGyn applied excessive downward traction on the baby’s head when her left shoulder could not pass under the pubic bone.

PHYSICIAN’S DEFENSE The injury was caused by uterine contractions and maternal pushing. Proper maneuvers and gentle pressure were used.

VERDICT A $1.34 million New Jersey verdict was returned.

Prolonged delivery: child with cerebral palsy   awarded $70M

AFTER MORE THAN 4 HOURS of second-stage labor followed by prolonged pushing and crowning, the baby was born depressed. Later, the child was found to have cerebral palsy.

PARENTS’ CLAIM The ObGyn was negligent in failing to perform an episiotomy, not attempting vacuum extraction, and not using forceps to assist delivery. Although fetal heart-rate monitoring results deteriorated, the ObGyn did not assess contractions for 30 minutes at one point. Hospital staff members were unable to adequately intubate or ventilate the newborn. The hospital staff disposed of the baby’s cord blood. Records were altered.

The parents’ counsel proposed that the defendants’ insurance company refused all settlement efforts prior to trial because the case venue was known to be conservative regarding jury verdicts.

DEFENDANTS’ DEFENSE The hospital and the ObGyn were not negligent; the mother and baby received proper care. Hospital staff acted appropriately.

VERDICT During the trial, the hospital settled for an undisclosed amount. An additional $2 million was offered on behalf of the ObGyn later in the trial, but the parents refused settlement at that time.

A California jury returned a $74.525 million verdict against the ObGyn. The child was awarded $70.725 million for medical expenses, lost earnings, and damages. The parents were awarded $3.8 million for emotional distress.

Was ectopic pregnancy missed?

A WOMAN IN SEVERE ABDOMINAL PAIN saw her internist. CT scans revealed a right ovarian cyst. When pain continued, she saw her ObGyn 3 weeks later, and her bowel was full of hard stool. Ultrasonography (US) showed a multicystic right ovary and a thin endometrial stripe. She was taking birth control pills and her husband had a vasectomy. She was told her abdominal pain was from constipation and ovarian cysts. A week later, she had laparoscopic surgery to remove an ectopic pregnancy.

PATIENT’S CLAIM The ObGyn did not perform a pregnancy test, and did not diagnose an ectopic pregnancy in a timely manner. An earlier diagnosis would have allowed medical rather than surgical resolution.

PHYSICIAN’S DEFENSE It was too early to determine if the pregnancy was intrauterine or ectopic. An earlier diagnosis would have resulted in laparoscopic surgery rather than medical treatment, as the medication (methotrexate) can cause increased pain.

VERDICT An Illinois defense verdict was returned.

Foreshortened vagina inhibits intercourse

A 65-YEAR-OLD WOMAN underwent anterior and posterior colphorrhaphy to repair a cystocele and rectocele, sacrospinous ligament fixation for vaginal prolapse, and a TVT mid-urethral suspension procedure to correct stress urinary incontinence. During two follow-up visits, the gynecologist determined that she was healing normally.

Within the next few weeks, the patient came to believe that her vagina had been sewn shut. She did not return to her gynecologist, but sought treatment with another physician 6 months later. It was determined that she had a stenotic and foreshortened vagina.

PATIENT’S CLAIM Too much vaginal tissue was removed during surgery.

PHYSICIAN’S DEFENSE The stenotic and foreshortened vagina was an unexpected result of the healing process after surgery.

VERDICT An Illinois defense verdict was returned.

Hydrocephalus in utero not seen until too late

A WOMAN HAD PRENATAL TREATMENT at a federally funded health clinic. A certified nurse midwife (CNM) ordered second-trimester US, with normal results. During the third trimester, the mother switched to a private ObGyn who ordered testing. US indicated the fetus was hydrocephalic. The child was born with cognitive disabilities and will need lifelong care.

PARENTS’ CLAIM The CNM ordered US too early in the pregnancy to be of diagnostic value; no further testing was undertaken. When hydrocephalus was seen, an abortion was not legally available because of fetal age.

DEFENDANT’S DEFENSE Even if US had been performed later in the second trimester, the defect would not have shown.

VERDICT A $4 million New Jersey settlement was reached.

Severe brachial plexus injury

WHEN SHOULDER DYSTOCIA WAS ENCOUNTERED, the ObGyn used standard maneuvers to deliver the child. The baby suffered a severe brachial plexus injury with rupture of C7 nerve and avulsions at C8 and T1.

Nerve-graft surgery at 6 months and tendon transfer surgery at 2 years resulted in recovery of good shoulder and elbow function, but the child has inadequate use of his wrist and hand. Additional surgeries are planned.

PARENTS’ CLAIM The ObGyn did not inform the mother that she was at risk for shoulder dystocia, nor did he discuss cesarean delivery. The mother’s risk factors included short stature, gestational diabetes, excessive weight gain during pregnancy, and two previous deliveries that involved vacuum assistance and a broken clavicle. The ObGyn applied excessive traction to the fetal head during delivery.

PHYSICIAN’S DEFENSE The mother’s risk factors were not severe enough to consider the chance of shoulder dystocia. The baby’s injuries were due to the normal forces of labor. Traction placed on the baby’s head during delivery was gentle and appropriate.

VERDICT A $5.5 million Iowa verdict was returned.

Faulty testing: baby has Down syndrome

AT 13 WEEKS’ GESTATION, a 34-year-old woman underwent chorionic villus sampling (CVS) at a maternal-fetal medicine center. Results showed a normal chromosomal profile. Later, two sonograms indicated possible Down syndrome. The parents were assured that the baby did not have a genetic disorder; amniocentesis was never suggested.

A week before the baby’s birth, the parents were told the child has Down syndrome.

PARENTS’ CLAIM Maternal tissue, not fetal tissue, had been removed and tested during CVS. The parents would have aborted the fetus had they known she had Down syndrome.

DEFENDANTS’ DEFENSE CVS was properly administered.

VERDICT A $3 million Missouri verdict was returned against the center where the testing was performed.

Why did the uterus seem to be growing?

A 52-YEAR-OLD WOMAN’S UTERUS was larger than normal in February 2007. By November 2008, her uterus was the size of a 14-week gestation. In September 2009, she complained of abdominal discomfort. Her uterus was larger than at the previous visit. The gynecologist suggested a hysterectomy, but nothing was scheduled.

In November 2009, she reported increasing pelvic pressure; her uterus was the size of an 18-week gestation. US and MRI showed large masses on both ovaries although the uterus had no masses or fibroids within it. A gynecologic oncologist performed abdominal hysterectomy with bilateral salpingo-oophorectomy and bilateral peri-aortic lymph node dissection. Pathology returned a diagnosis of ovarian cancer. The patient underwent chemotherapy.

PATIENT’S CLAIM The gynecologist was negligent in not ordering testing in 2007 when the larger-than-normal uterus was first detected, or in subsequent visits through September 2009. A more timely reaction would have given her an opportunity to treat the cancer at an earlier stage.

PHYSICIAN’S DEFENSE The case was settled before trial.

VERDICT A $650,000 Maryland settlement was reached.

Erb’s palsy after shoulder dystocia

DURING VAGINAL DELIVERY, the ObGyn encountered shoulder dystocia. The child suffered a brachial plexus injury and has Erb’s palsy. There was some improvement after two operations, but she still has muscle weakness, arm-length discrepancy, and limited range of motion.

PARENTS’ CLAIM The ObGyn applied excessive downward traction on the baby’s head when her left shoulder could not pass under the pubic bone.

PHYSICIAN’S DEFENSE The injury was caused by uterine contractions and maternal pushing. Proper maneuvers and gentle pressure were used.

VERDICT A $1.34 million New Jersey verdict was returned.

When following CT guidelines isn’t enough

AN 86-YEAR-OLD MAN ON WARFARIN FAINTED AND FELL while baby-sitting his great-grandchildren. He had transient neurologic symptoms after collapsing but appeared normal by the time paramedics arrived. He was taken by private vehicle to the hospital, where an emergency department (ED) physician examined him. After tests for a myocardial infarction revealed normal enzymes, electrocardiogram, and chest radiograph, the patient was discharged home.

He returned to the hospital the following day and underwent a computed tomography (CT) scan, which showed a large cerebral hemorrhage. He died soon afterward.

PLAINTIFF’S CLAIM The patient should have had a CT scan during the first ED visit. A scan at that visit would have found the hemorrhage in time to save the patient’s life.

THE DEFENSE No discussion with family members about a blow to the head or head trauma occurred, and a CT scan wasn’t requested. The patient didn’t meet criteria for a head scan. Even if a scan had been done at the initial visit, it might not have revealed the bleed. Moreover, the patient’s age decreased the likelihood that earlier detection would have changed the outcome.

VERDICT Confidential Utah settlements. The hospital settled for a nominal sum early in the litigation process; the physician settled for a confidential amount immediately before trial.

COMMENT Even when clear guidelines for imaging exist, taking care to weigh extenuating circumstances—in this case, that the patient was on warfarin—is critical.

Failure to document treatment refusal proves costly

A 15-YEAR-OLD BOY lost consciousness at home on Halloween and needed cardiopulmonary resuscitation. When paramedics arrived on the scene, they found the boy conscious and breathing, so they left. The boy, who had a history of drug abuse, died 8 hours later of anoxic encephalopathy caused by cocaine and opiate intoxication.

PLAINTIFF’S CLAIM The paramedics were negligent in failing to evaluate the boy’s condition properly and transport him to a hospital.

THE DEFENSE The paramedics left without assessing the boy because he and his father said they didn’t want or need medical help. (The paramedics neglected to obtain signed refusal of treatment forms.)

VERDICT $5.1 million Illinois verdict.

COMMENT Here is a $5 million verdict that hinges on the completion of forms for refusal of treatment, a remarkable reminder of the importance of documentation.

Enlarging uterus goes uninvestigated

AT AN ANNUAL GYNECOLOGIC EXAMINATION, a woman’s physician noted that her uterus had enlarged since her last visit and described it as “top size” in the chart. At the patient’s next annual exam 21 months later, the uterus had grown to 14 weeks’ gestational size.

Ten months after that, when the woman returned to her physician complaining of abdominal discomfort, her uterus was larger than at the previous examination. The physician advised her to consider a hysterectomy.

About 2 months later, the patient went to the doctor again because of increasing pelvic pressure. Her uterus was 18 to 20 weeks’ gestational size. The physician ordered an ultrasound, which showed a large mass on each ovary and no fibroids or masses within the uterus. Magnetic resonance imaging confirmed the ultrasound findings.

The doctor referred the woman to an oncological gynecologist. She subsequently underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy and bilateral periaortic lymph node dissection. The pathology report described ovarian cancer with an ominous prognosis.

PLAINTIFF’S CLAIM The plaintiff alleged that the physician was negligent for failing to order testing when he first noticed the abnormal size of the uterus and at the patient’s subsequent visits. Failure to do so at the first exam and subsequent visits was negligent and allowed the cancer to advance instead of allowing for surgery and cure at an early stage.

THE DEFENSE No information about the defense is available.

VERDICT $650,000 Maryland settlement.

COMMENT It’s never a good policy to ignore a changing physical exam without good documentation, including a clear discussion of medical decision making.

Third ED visit isn’t the charm

A 39-YEAR-OLD QUADRIPLEGIC MAN went to the emergency department (ED) complaining of abdominal pain. His history included involvement in a shooting when he was 16, drug abuse, homelessness, and frequent visits to the ED, where the staff knew him to be combative and ignore medical advice. The ED physician who saw the man ordered a radiograph and other testing, then released him without a conclusive diagnosis.

A month later, the man came back to the ED by ambulance, complaining of severe abdominal pain that he’d had for 4 days. Another ED physician saw him but didn’t make a diagnosis. After 4 hours, the hospital discharged the patient by ambulance to stay with family. When the family refused to accept him, the ambulance brought him back to the hospital.

With the involvement of social services, the patient was wheeled across the street to a motel. After about 5 hours, during which the motel staff said the patient was screaming in pain, the staff called an ambulance, which brought the man back to the ED covered with bloody vomit.

The same ED physician who had seen him earlier examined him, along with another ED physician. A fecal impaction was removed manually and a soap suds enema administered. The patient seemed to improve and, after about 7 hours, was released and rolled outside with a taxi voucher.

He said the hospital staff told him he was abusing the hospital’s services and the police would be called if he returned. He was taken to the house of a family member, where he was found dead 4 hours later from a ruptured duodenal ulcer.

PLAINTIFF’S CLAIM The physician who saw the patient at the first ED visit should have diagnosed peptic ulcer disease; the doctors who saw the man at the second and third visits should have diagnosed the ruptured ulcer. The hospital violated the federal Emergency Medical Treatment and Labor Act (EMTALA) by failing to stabilize the patient before discharging him.

THE DEFENSE The patient was stable and improving each time he was discharged. The hospital denied threatening to arrest the patient if he returned to the ED after the third visit.

VERDICT $1.4 million Kentucky verdict. The first trial ended in a mistrial. All defendants except the hospital settled for undisclosed amounts before a second trial, at which the hospital was found to be 15% at fault and a $1.5 million award for punitive damages was assessed against the hospital for violating EMTALA.

The hospital appealed and the matter was returned for trial after a ruling that affirmed everything except the punitive damages. At the third trial, a jury awarded $1.4 million in punitive damages.

COMMENT Most of us have a visceral reaction when faced with a drug abusing, noncompliant patient who frequently shows up at the ED. We must remember that such patients do get sick and that in this case, despite repeated visits to the ED, a tragedy occurred.

When following CT guidelines isn’t enough

AN 86-YEAR-OLD MAN ON WARFARIN FAINTED AND FELL while baby-sitting his great-grandchildren. He had transient neurologic symptoms after collapsing but appeared normal by the time paramedics arrived. He was taken by private vehicle to the hospital, where an emergency department (ED) physician examined him. After tests for a myocardial infarction revealed normal enzymes, electrocardiogram, and chest radiograph, the patient was discharged home.

He returned to the hospital the following day and underwent a computed tomography (CT) scan, which showed a large cerebral hemorrhage. He died soon afterward.

PLAINTIFF’S CLAIM The patient should have had a CT scan during the first ED visit. A scan at that visit would have found the hemorrhage in time to save the patient’s life.

THE DEFENSE No discussion with family members about a blow to the head or head trauma occurred, and a CT scan wasn’t requested. The patient didn’t meet criteria for a head scan. Even if a scan had been done at the initial visit, it might not have revealed the bleed. Moreover, the patient’s age decreased the likelihood that earlier detection would have changed the outcome.

VERDICT Confidential Utah settlements. The hospital settled for a nominal sum early in the litigation process; the physician settled for a confidential amount immediately before trial.

COMMENT Even when clear guidelines for imaging exist, taking care to weigh extenuating circumstances—in this case, that the patient was on warfarin—is critical.

Failure to document treatment refusal proves costly

A 15-YEAR-OLD BOY lost consciousness at home on Halloween and needed cardiopulmonary resuscitation. When paramedics arrived on the scene, they found the boy conscious and breathing, so they left. The boy, who had a history of drug abuse, died 8 hours later of anoxic encephalopathy caused by cocaine and opiate intoxication.

PLAINTIFF’S CLAIM The paramedics were negligent in failing to evaluate the boy’s condition properly and transport him to a hospital.

THE DEFENSE The paramedics left without assessing the boy because he and his father said they didn’t want or need medical help. (The paramedics neglected to obtain signed refusal of treatment forms.)

VERDICT $5.1 million Illinois verdict.

COMMENT Here is a $5 million verdict that hinges on the completion of forms for refusal of treatment, a remarkable reminder of the importance of documentation.

Enlarging uterus goes uninvestigated

AT AN ANNUAL GYNECOLOGIC EXAMINATION, a woman’s physician noted that her uterus had enlarged since her last visit and described it as “top size” in the chart. At the patient’s next annual exam 21 months later, the uterus had grown to 14 weeks’ gestational size.

Ten months after that, when the woman returned to her physician complaining of abdominal discomfort, her uterus was larger than at the previous examination. The physician advised her to consider a hysterectomy.

About 2 months later, the patient went to the doctor again because of increasing pelvic pressure. Her uterus was 18 to 20 weeks’ gestational size. The physician ordered an ultrasound, which showed a large mass on each ovary and no fibroids or masses within the uterus. Magnetic resonance imaging confirmed the ultrasound findings.

The doctor referred the woman to an oncological gynecologist. She subsequently underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy and bilateral periaortic lymph node dissection. The pathology report described ovarian cancer with an ominous prognosis.

PLAINTIFF’S CLAIM The plaintiff alleged that the physician was negligent for failing to order testing when he first noticed the abnormal size of the uterus and at the patient’s subsequent visits. Failure to do so at the first exam and subsequent visits was negligent and allowed the cancer to advance instead of allowing for surgery and cure at an early stage.

THE DEFENSE No information about the defense is available.

VERDICT $650,000 Maryland settlement.

COMMENT It’s never a good policy to ignore a changing physical exam without good documentation, including a clear discussion of medical decision making.

Third ED visit isn’t the charm

A 39-YEAR-OLD QUADRIPLEGIC MAN went to the emergency department (ED) complaining of abdominal pain. His history included involvement in a shooting when he was 16, drug abuse, homelessness, and frequent visits to the ED, where the staff knew him to be combative and ignore medical advice. The ED physician who saw the man ordered a radiograph and other testing, then released him without a conclusive diagnosis.

A month later, the man came back to the ED by ambulance, complaining of severe abdominal pain that he’d had for 4 days. Another ED physician saw him but didn’t make a diagnosis. After 4 hours, the hospital discharged the patient by ambulance to stay with family. When the family refused to accept him, the ambulance brought him back to the hospital.

With the involvement of social services, the patient was wheeled across the street to a motel. After about 5 hours, during which the motel staff said the patient was screaming in pain, the staff called an ambulance, which brought the man back to the ED covered with bloody vomit.

The same ED physician who had seen him earlier examined him, along with another ED physician. A fecal impaction was removed manually and a soap suds enema administered. The patient seemed to improve and, after about 7 hours, was released and rolled outside with a taxi voucher.

He said the hospital staff told him he was abusing the hospital’s services and the police would be called if he returned. He was taken to the house of a family member, where he was found dead 4 hours later from a ruptured duodenal ulcer.

PLAINTIFF’S CLAIM The physician who saw the patient at the first ED visit should have diagnosed peptic ulcer disease; the doctors who saw the man at the second and third visits should have diagnosed the ruptured ulcer. The hospital violated the federal Emergency Medical Treatment and Labor Act (EMTALA) by failing to stabilize the patient before discharging him.

THE DEFENSE The patient was stable and improving each time he was discharged. The hospital denied threatening to arrest the patient if he returned to the ED after the third visit.

VERDICT $1.4 million Kentucky verdict. The first trial ended in a mistrial. All defendants except the hospital settled for undisclosed amounts before a second trial, at which the hospital was found to be 15% at fault and a $1.5 million award for punitive damages was assessed against the hospital for violating EMTALA.

The hospital appealed and the matter was returned for trial after a ruling that affirmed everything except the punitive damages. At the third trial, a jury awarded $1.4 million in punitive damages.

COMMENT Most of us have a visceral reaction when faced with a drug abusing, noncompliant patient who frequently shows up at the ED. We must remember that such patients do get sick and that in this case, despite repeated visits to the ED, a tragedy occurred.

When following CT guidelines isn’t enough

AN 86-YEAR-OLD MAN ON WARFARIN FAINTED AND FELL while baby-sitting his great-grandchildren. He had transient neurologic symptoms after collapsing but appeared normal by the time paramedics arrived. He was taken by private vehicle to the hospital, where an emergency department (ED) physician examined him. After tests for a myocardial infarction revealed normal enzymes, electrocardiogram, and chest radiograph, the patient was discharged home.

He returned to the hospital the following day and underwent a computed tomography (CT) scan, which showed a large cerebral hemorrhage. He died soon afterward.

PLAINTIFF’S CLAIM The patient should have had a CT scan during the first ED visit. A scan at that visit would have found the hemorrhage in time to save the patient’s life.

THE DEFENSE No discussion with family members about a blow to the head or head trauma occurred, and a CT scan wasn’t requested. The patient didn’t meet criteria for a head scan. Even if a scan had been done at the initial visit, it might not have revealed the bleed. Moreover, the patient’s age decreased the likelihood that earlier detection would have changed the outcome.

VERDICT Confidential Utah settlements. The hospital settled for a nominal sum early in the litigation process; the physician settled for a confidential amount immediately before trial.

COMMENT Even when clear guidelines for imaging exist, taking care to weigh extenuating circumstances—in this case, that the patient was on warfarin—is critical.

Failure to document treatment refusal proves costly

A 15-YEAR-OLD BOY lost consciousness at home on Halloween and needed cardiopulmonary resuscitation. When paramedics arrived on the scene, they found the boy conscious and breathing, so they left. The boy, who had a history of drug abuse, died 8 hours later of anoxic encephalopathy caused by cocaine and opiate intoxication.

PLAINTIFF’S CLAIM The paramedics were negligent in failing to evaluate the boy’s condition properly and transport him to a hospital.

THE DEFENSE The paramedics left without assessing the boy because he and his father said they didn’t want or need medical help. (The paramedics neglected to obtain signed refusal of treatment forms.)

VERDICT $5.1 million Illinois verdict.

COMMENT Here is a $5 million verdict that hinges on the completion of forms for refusal of treatment, a remarkable reminder of the importance of documentation.

Enlarging uterus goes uninvestigated

AT AN ANNUAL GYNECOLOGIC EXAMINATION, a woman’s physician noted that her uterus had enlarged since her last visit and described it as “top size” in the chart. At the patient’s next annual exam 21 months later, the uterus had grown to 14 weeks’ gestational size.

Ten months after that, when the woman returned to her physician complaining of abdominal discomfort, her uterus was larger than at the previous examination. The physician advised her to consider a hysterectomy.

About 2 months later, the patient went to the doctor again because of increasing pelvic pressure. Her uterus was 18 to 20 weeks’ gestational size. The physician ordered an ultrasound, which showed a large mass on each ovary and no fibroids or masses within the uterus. Magnetic resonance imaging confirmed the ultrasound findings.

The doctor referred the woman to an oncological gynecologist. She subsequently underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy and bilateral periaortic lymph node dissection. The pathology report described ovarian cancer with an ominous prognosis.

PLAINTIFF’S CLAIM The plaintiff alleged that the physician was negligent for failing to order testing when he first noticed the abnormal size of the uterus and at the patient’s subsequent visits. Failure to do so at the first exam and subsequent visits was negligent and allowed the cancer to advance instead of allowing for surgery and cure at an early stage.

THE DEFENSE No information about the defense is available.

VERDICT $650,000 Maryland settlement.

COMMENT It’s never a good policy to ignore a changing physical exam without good documentation, including a clear discussion of medical decision making.

Third ED visit isn’t the charm

A 39-YEAR-OLD QUADRIPLEGIC MAN went to the emergency department (ED) complaining of abdominal pain. His history included involvement in a shooting when he was 16, drug abuse, homelessness, and frequent visits to the ED, where the staff knew him to be combative and ignore medical advice. The ED physician who saw the man ordered a radiograph and other testing, then released him without a conclusive diagnosis.

A month later, the man came back to the ED by ambulance, complaining of severe abdominal pain that he’d had for 4 days. Another ED physician saw him but didn’t make a diagnosis. After 4 hours, the hospital discharged the patient by ambulance to stay with family. When the family refused to accept him, the ambulance brought him back to the hospital.

With the involvement of social services, the patient was wheeled across the street to a motel. After about 5 hours, during which the motel staff said the patient was screaming in pain, the staff called an ambulance, which brought the man back to the ED covered with bloody vomit.

The same ED physician who had seen him earlier examined him, along with another ED physician. A fecal impaction was removed manually and a soap suds enema administered. The patient seemed to improve and, after about 7 hours, was released and rolled outside with a taxi voucher.

He said the hospital staff told him he was abusing the hospital’s services and the police would be called if he returned. He was taken to the house of a family member, where he was found dead 4 hours later from a ruptured duodenal ulcer.

PLAINTIFF’S CLAIM The physician who saw the patient at the first ED visit should have diagnosed peptic ulcer disease; the doctors who saw the man at the second and third visits should have diagnosed the ruptured ulcer. The hospital violated the federal Emergency Medical Treatment and Labor Act (EMTALA) by failing to stabilize the patient before discharging him.

THE DEFENSE The patient was stable and improving each time he was discharged. The hospital denied threatening to arrest the patient if he returned to the ED after the third visit.

VERDICT $1.4 million Kentucky verdict. The first trial ended in a mistrial. All defendants except the hospital settled for undisclosed amounts before a second trial, at which the hospital was found to be 15% at fault and a $1.5 million award for punitive damages was assessed against the hospital for violating EMTALA.

The hospital appealed and the matter was returned for trial after a ruling that affirmed everything except the punitive damages. At the third trial, a jury awarded $1.4 million in punitive damages.

COMMENT Most of us have a visceral reaction when faced with a drug abusing, noncompliant patient who frequently shows up at the ED. We must remember that such patients do get sick and that in this case, despite repeated visits to the ED, a tragedy occurred.

New mother dies from pulmonary embolism

A 39-YEAR-OLD WOMAN’S SECOND CHILD WAS BORN by cesarean delivery. The mother died the next day from a pulmonary embolism.

ESTATE’S CLAIM Physicians and nurses at the hospital were negligent in failing to recognize the mother’s risk factors for pulmonary embolism, including obesity, being over age 35, and hypertension. They failed to ensure that compression boots were in place and working prior to delivery. Although orders had been given for the woman to walk within 8 hours of delivery, she did not get out of bed and walk for 24 hours after delivery.

DEFENDANTS’ DEFENSE The case was settled before trial.

VERDICT A $3.5 million Illinois settlement was reached.

Woman told “Biopsy isn’t urgent”

TWO MONTHS AFTER HER INITIAL VISIT, a 58-year-old woman returned to the gynecologist with vaginal bleeding. In March 2004, ultrasonography (US) showed slight thickening of the endometrial lining and a “pin dot” described as being a prepolyp. Vaginal bleeding was determined to be due to thinning of the vaginal wall with menopause.

The patient reported daily vaginal bleeding when she saw the gynecologist in January 2005. A new, large, rounded, solid mass within the endometrial cavity consistent with a large endometrial polyp was seen on US. The radiologist recommended hysteroscopic biopsy with excision, but the gynecologist told the patient it was not urgent.

In March 2005, hysteroscopy confirmed carcinosarcoma of the uterus. The patient underwent a hysterectomy followed by pelvic radiation and brachytherapy.

Eight months later, metastasis was found in the lungs; she died in October 2006.

ESTATE’S CLAIM The gynecologist failed to react when the patient first reported vaginal bleeding. An earlier diagnosis could have prevented her death.

PHYSICIAN’S DEFENSE The case was settled before trial.

VERDICT An $820,000 Massachusetts settlement was reached.

US report misses fetal abnormalities

A PREGNANT WOMAN UNDERWENT US. The preliminary report indicated echogenic cardiac focus and unilateral pyelectasis. Twenty-five days later, the mother underwent a level II US. A radiologist wrote that fetal anatomy was normal in both reports. The mother had two additional sonograms, with no reported abnormality.

The baby was born with aplasia and hypoplasia with both arms absent below a short humerus, an absent left leg, and a shortened right leg with a remnant foot and three small toes.

PARENTS’ CLAIM The radiologist’s US reports failed to accurately describe the fetal anatomy, depriving the parents of the chance to terminate the pregnancy.

DEFENDANTS’ DEFENSE Proper treatment was given.

VERDICT A $4.5 million Florida verdict was returned. Fault was assigned to the radiologist (85%) and the level II technologist (15%).

Forceps delivery injures mother’s pelvic floor

DURING A TRIAL OF LABOR, a 34-year-old woman experienced deep transverse arrest and lack of progress due to pelvic restriction. The ObGyn proceeded to deliver the baby vaginally using forceps, which caused pelvic floor injuries to the mother.

Several months later, she underwent corrective repair surgery for pelvic floor prolapse. She has continuing vaginal and rectal pain and dysfunction.

PATIENT’S CLAIM A cesarean delivery should have been performed as soon as pelvic restriction was found. The injuries reduce the woman’s chances of having another child.

PHYSICIAN’S DEFENSE A trial of labor was proper. The patient’s continuing fertility problems are related to chronic yeast infections and prescription birth control.

VERDICT A $1,716,469 Illinois verdict was returned, which included $484,000 to the patient’s husband for loss of consortium.

7 CASES OF INJURED BOWEL

1 Woman dies from bowel injury

DURING A SLING PROCEDURE for vaginal prolapse, a 50-year-old woman required a transfusion. The next day, she was nauseated and constipated. A day later, she went to the ED with shortness of breath and chest and abdominal pain. Her symptoms persisted for 8 days before an injury to her transverse colon was found during exploratory surgery. She suffered massive organ failure caused by sepsis and died 3 weeks after the initial surgery.

ESTATE’S CLAIM The gynecologist should have investigated why she needed a transfusion during surgery. He should have reacted earlier to her postsurgical complaints.

PHYSICIAN’S DEFENSE Bowel injury is a known risk of the procedure. The patient suffered multiple strokes after being readmitted to the hospital.

VERDICT A $2.4 million South Carolina verdict was returned.

2 Colostomy, coma after hysterectomy

DUE TO FIBROID TUMORS and pelvic pain, a 39-year-old woman’s ObGyn suggested laparoscopic-assisted vaginal hysterectomy. A third-year resident performed most of the procedure. The ObGyn’s associate covered postsurgical care.

When the patient reported increasing pain and rectal bleeding, an exploratory laparotomy was performed 3 days after surgery. Bowel and ureter injuries were repaired and a permanent colostomy was created. The patient developed septic shock with multiple organ failure, and was placed in a chemically induced coma for 3 weeks, after which she had to relearn to walk, talk, and care for herself.

PATIENT’S CLAIM The ObGyn was negligent in performing the surgery. He failed to obtain consent for the resident’s participation. The associate failed to respond to her declining postoperative condition in a timely manner.

DEFENDANTS’ DEFENSE Surgery was properly performed and postoperative care was appropriate. The bowel injury was a thermal or pressure necrosis that occurred 3 days after surgery. Two different consent forms signed by the patient included notification that a resident might assist; the resident was introduced to the patient prior to surgery. The patient’s injury claims were exaggerated; her future medical bills would be limited to colostomy supplies.

VERDICT A $1,926,069 Texas verdict was returned.

3 Were physicians qualified on robot?

A 48-YEAR-OLD WOMAN UNDERWENT robotic-assisted total hysterectomy and oophorectomy for uterine fibroids and cysts. During surgery, the physicians realized that the sigmoid colon had been perforated. A general surgeon repaired the injury with a loop ileostomy, which was successfully reversed 3 months later. The patient continues to have constipation, with occasional bleeding, pain, and burning.

PATIENT’S CLAIM The risks of robotic surgery were never fully explained to her. Failure to properly visualize her internal organs led to the injury; the extent of damage exceeded what is considered “acceptable risk” of the procedure. The physicians had little experience and training in robotic surgery.

PHYSICIANS’ DEFENSE The case was settled before trial.

VERDICT A $350,000 Massachusetts settlement was reached.

4 Adhesions limit view of bowel

A 76-YEAR-OLD WOMAN UNDERWENT surgical removal of an ovarian cyst. The ObGyn attempted a laparoscopic procedure but converted to laparotomy when extensive adhesions were encountered. The next morning, the patient discovered that her navel was discharging fecal matter. Exploratory surgery determined that the bowel had been perforated. She required additional surgery and had a long recovery.

PATIENT’S CLAIM The ObGyn was negligent in failing to diagnose and treat bowel perforation in a timely manner. An intraoperative bowel inspection should have occurred due to the likelihood of a bowel injury related to the adhesions.

PHYSICIAN’S DEFENSE Adhesions restricted inspection of every area.

VERDICT A $225,000 New York settlement was reached.

5 Skydiver’s ongoing postop pain

AFTER REPORTING DYSMENORRHEA and menometrorrhagia, a 34-year-old woman underwent dilatation and curettage, thermal endometrial ablation, and diagnostic laparoscopy. A day later, she reported increasing pain. The ObGyn’s examination revealed minimal abdominal distension, sluggish bowel sounds, and some guarding, with no rebound tenderness or acute distress. US showed a 3-cm pocket of fluid in the abdomen. Two hours later, an exam revealed a soft abdomen and normal bowel sounds. She was sent home with instructions to return the next day or, if her condition worsened, to go to the ED.

Her husband called the next day to report she was feeling better. The patient woke the following morning with massive distension, worse pain, and severe shortness of breath. At the ED, a CT scan revealed a large amount of abdominal fluid. During emergency laparotomy, an injury was found in the jejunum, necessitating a 3-inch resection.

PATIENT’S CLAIM The ObGyn was negligent in not treating her postoperative symptoms in a more proactive manner. Adhesions developed from peritonitis, leading to chronic abdominal pain. Several operations were required.

PHYSICIAN’S DEFENSE Bowel injury is a known complication of the procedure. There was no indication during surgery or at the office visit that the jejunum was injured. Adhesions were not the cause of the patient’s ongoing pain; very few adhesions were found during subsequent operations. The woman was an avid skydiver who had completed 200 jumps since her initial surgery.

VERDICT An Illinois defense verdict was returned.

6 Bowel injury at laparoscopy

WHEN THE GYNECOLOGIST recognized a bowel injury during laparoscopic salpingectomy, he called a general surgeon, who repaired three areas of bowel. The patient was released 2 days after surgery. She called the gynecologist 2 days later to report fever and vaginal bleeding. She was told to come to the office, but she cancelled when the fever subsided. The next day, she went to the ED, where sepsis was diagnosed. She was flown to another hospital for surgery. A 1-cm small-bowel perforation was found in an area of earlier repair because a suture had been disrupted. A temporary colostomy was reversed 3 months later.

PATIENT’S CLAIM The gynecologist was negligent in performing laparoscopic salpingectomy. The patient should not have been discharged because her white blood cell count and heart rate were elevated.

DEFENDANTS’ DEFENSE Performance of a laparoscopic procedure was proper. Discharge was reasonable, as there was only a potential for complications with no evident problems.

VERDICT An Missouri defense verdict was returned.

7 Was treatment of abscess delayed?

A 49-YEAR-OLD WOMAN with menorrhagia underwent cryoablation. Two weeks later, she went to the ED with pain and constipation. Following CT scans and US, she was found to have a tubo-ovarian abscess. After an enema and subsequent bowel movement, her pain improved. She was discharged with instructions to follow-up with her gynecologist. Six days later, the gynecologist prescribed triple antibiotics, analgesics, and weekly visits for the abscess. Two weeks later, she reported unbearable pain and was sent to the ED. She was found to have a microperforation of the sigmoid colon and multiple gynecologic pathologies, including myomata, right serous cystadenoma, and left tubo-ovarian complex suggestive of endometriosis. Hysterectomy and colostomy were performed; the colostomy was reversed several months later.

PATIENT’S CLAIM She should have been hospitalized when the abscess was found so that the infection could be treated properly. She alleged lack of informed consent for the cryoablation.

PHYSICIAN’S DEFENSE Hospitalization was unnecessary; the patient had initially improved, and the outcome would not have changed with intravenous antibiotics. The patient was fully informed of the risks of the procedure.

VERDICT A Pennsylvania defense verdict was returned.

New mother dies from pulmonary embolism

A 39-YEAR-OLD WOMAN’S SECOND CHILD WAS BORN by cesarean delivery. The mother died the next day from a pulmonary embolism.

ESTATE’S CLAIM Physicians and nurses at the hospital were negligent in failing to recognize the mother’s risk factors for pulmonary embolism, including obesity, being over age 35, and hypertension. They failed to ensure that compression boots were in place and working prior to delivery. Although orders had been given for the woman to walk within 8 hours of delivery, she did not get out of bed and walk for 24 hours after delivery.

DEFENDANTS’ DEFENSE The case was settled before trial.

VERDICT A $3.5 million Illinois settlement was reached.

Woman told “Biopsy isn’t urgent”

TWO MONTHS AFTER HER INITIAL VISIT, a 58-year-old woman returned to the gynecologist with vaginal bleeding. In March 2004, ultrasonography (US) showed slight thickening of the endometrial lining and a “pin dot” described as being a prepolyp. Vaginal bleeding was determined to be due to thinning of the vaginal wall with menopause.

The patient reported daily vaginal bleeding when she saw the gynecologist in January 2005. A new, large, rounded, solid mass within the endometrial cavity consistent with a large endometrial polyp was seen on US. The radiologist recommended hysteroscopic biopsy with excision, but the gynecologist told the patient it was not urgent.

In March 2005, hysteroscopy confirmed carcinosarcoma of the uterus. The patient underwent a hysterectomy followed by pelvic radiation and brachytherapy.

Eight months later, metastasis was found in the lungs; she died in October 2006.

ESTATE’S CLAIM The gynecologist failed to react when the patient first reported vaginal bleeding. An earlier diagnosis could have prevented her death.

PHYSICIAN’S DEFENSE The case was settled before trial.

VERDICT An $820,000 Massachusetts settlement was reached.

US report misses fetal abnormalities

A PREGNANT WOMAN UNDERWENT US. The preliminary report indicated echogenic cardiac focus and unilateral pyelectasis. Twenty-five days later, the mother underwent a level II US. A radiologist wrote that fetal anatomy was normal in both reports. The mother had two additional sonograms, with no reported abnormality.

The baby was born with aplasia and hypoplasia with both arms absent below a short humerus, an absent left leg, and a shortened right leg with a remnant foot and three small toes.

PARENTS’ CLAIM The radiologist’s US reports failed to accurately describe the fetal anatomy, depriving the parents of the chance to terminate the pregnancy.

DEFENDANTS’ DEFENSE Proper treatment was given.

VERDICT A $4.5 million Florida verdict was returned. Fault was assigned to the radiologist (85%) and the level II technologist (15%).

Forceps delivery injures mother’s pelvic floor

DURING A TRIAL OF LABOR, a 34-year-old woman experienced deep transverse arrest and lack of progress due to pelvic restriction. The ObGyn proceeded to deliver the baby vaginally using forceps, which caused pelvic floor injuries to the mother.

Several months later, she underwent corrective repair surgery for pelvic floor prolapse. She has continuing vaginal and rectal pain and dysfunction.

PATIENT’S CLAIM A cesarean delivery should have been performed as soon as pelvic restriction was found. The injuries reduce the woman’s chances of having another child.

PHYSICIAN’S DEFENSE A trial of labor was proper. The patient’s continuing fertility problems are related to chronic yeast infections and prescription birth control.

VERDICT A $1,716,469 Illinois verdict was returned, which included $484,000 to the patient’s husband for loss of consortium.

7 CASES OF INJURED BOWEL

1 Woman dies from bowel injury

DURING A SLING PROCEDURE for vaginal prolapse, a 50-year-old woman required a transfusion. The next day, she was nauseated and constipated. A day later, she went to the ED with shortness of breath and chest and abdominal pain. Her symptoms persisted for 8 days before an injury to her transverse colon was found during exploratory surgery. She suffered massive organ failure caused by sepsis and died 3 weeks after the initial surgery.

ESTATE’S CLAIM The gynecologist should have investigated why she needed a transfusion during surgery. He should have reacted earlier to her postsurgical complaints.

PHYSICIAN’S DEFENSE Bowel injury is a known risk of the procedure. The patient suffered multiple strokes after being readmitted to the hospital.

VERDICT A $2.4 million South Carolina verdict was returned.

2 Colostomy, coma after hysterectomy

DUE TO FIBROID TUMORS and pelvic pain, a 39-year-old woman’s ObGyn suggested laparoscopic-assisted vaginal hysterectomy. A third-year resident performed most of the procedure. The ObGyn’s associate covered postsurgical care.

When the patient reported increasing pain and rectal bleeding, an exploratory laparotomy was performed 3 days after surgery. Bowel and ureter injuries were repaired and a permanent colostomy was created. The patient developed septic shock with multiple organ failure, and was placed in a chemically induced coma for 3 weeks, after which she had to relearn to walk, talk, and care for herself.

PATIENT’S CLAIM The ObGyn was negligent in performing the surgery. He failed to obtain consent for the resident’s participation. The associate failed to respond to her declining postoperative condition in a timely manner.

DEFENDANTS’ DEFENSE Surgery was properly performed and postoperative care was appropriate. The bowel injury was a thermal or pressure necrosis that occurred 3 days after surgery. Two different consent forms signed by the patient included notification that a resident might assist; the resident was introduced to the patient prior to surgery. The patient’s injury claims were exaggerated; her future medical bills would be limited to colostomy supplies.

VERDICT A $1,926,069 Texas verdict was returned.

3 Were physicians qualified on robot?

A 48-YEAR-OLD WOMAN UNDERWENT robotic-assisted total hysterectomy and oophorectomy for uterine fibroids and cysts. During surgery, the physicians realized that the sigmoid colon had been perforated. A general surgeon repaired the injury with a loop ileostomy, which was successfully reversed 3 months later. The patient continues to have constipation, with occasional bleeding, pain, and burning.

PATIENT’S CLAIM The risks of robotic surgery were never fully explained to her. Failure to properly visualize her internal organs led to the injury; the extent of damage exceeded what is considered “acceptable risk” of the procedure. The physicians had little experience and training in robotic surgery.

PHYSICIANS’ DEFENSE The case was settled before trial.

VERDICT A $350,000 Massachusetts settlement was reached.

4 Adhesions limit view of bowel

A 76-YEAR-OLD WOMAN UNDERWENT surgical removal of an ovarian cyst. The ObGyn attempted a laparoscopic procedure but converted to laparotomy when extensive adhesions were encountered. The next morning, the patient discovered that her navel was discharging fecal matter. Exploratory surgery determined that the bowel had been perforated. She required additional surgery and had a long recovery.

PATIENT’S CLAIM The ObGyn was negligent in failing to diagnose and treat bowel perforation in a timely manner. An intraoperative bowel inspection should have occurred due to the likelihood of a bowel injury related to the adhesions.

PHYSICIAN’S DEFENSE Adhesions restricted inspection of every area.

VERDICT A $225,000 New York settlement was reached.

5 Skydiver’s ongoing postop pain

AFTER REPORTING DYSMENORRHEA and menometrorrhagia, a 34-year-old woman underwent dilatation and curettage, thermal endometrial ablation, and diagnostic laparoscopy. A day later, she reported increasing pain. The ObGyn’s examination revealed minimal abdominal distension, sluggish bowel sounds, and some guarding, with no rebound tenderness or acute distress. US showed a 3-cm pocket of fluid in the abdomen. Two hours later, an exam revealed a soft abdomen and normal bowel sounds. She was sent home with instructions to return the next day or, if her condition worsened, to go to the ED.

Her husband called the next day to report she was feeling better. The patient woke the following morning with massive distension, worse pain, and severe shortness of breath. At the ED, a CT scan revealed a large amount of abdominal fluid. During emergency laparotomy, an injury was found in the jejunum, necessitating a 3-inch resection.

PATIENT’S CLAIM The ObGyn was negligent in not treating her postoperative symptoms in a more proactive manner. Adhesions developed from peritonitis, leading to chronic abdominal pain. Several operations were required.

PHYSICIAN’S DEFENSE Bowel injury is a known complication of the procedure. There was no indication during surgery or at the office visit that the jejunum was injured. Adhesions were not the cause of the patient’s ongoing pain; very few adhesions were found during subsequent operations. The woman was an avid skydiver who had completed 200 jumps since her initial surgery.

VERDICT An Illinois defense verdict was returned.

6 Bowel injury at laparoscopy

WHEN THE GYNECOLOGIST recognized a bowel injury during laparoscopic salpingectomy, he called a general surgeon, who repaired three areas of bowel. The patient was released 2 days after surgery. She called the gynecologist 2 days later to report fever and vaginal bleeding. She was told to come to the office, but she cancelled when the fever subsided. The next day, she went to the ED, where sepsis was diagnosed. She was flown to another hospital for surgery. A 1-cm small-bowel perforation was found in an area of earlier repair because a suture had been disrupted. A temporary colostomy was reversed 3 months later.

PATIENT’S CLAIM The gynecologist was negligent in performing laparoscopic salpingectomy. The patient should not have been discharged because her white blood cell count and heart rate were elevated.

DEFENDANTS’ DEFENSE Performance of a laparoscopic procedure was proper. Discharge was reasonable, as there was only a potential for complications with no evident problems.

VERDICT An Missouri defense verdict was returned.

7 Was treatment of abscess delayed?

A 49-YEAR-OLD WOMAN with menorrhagia underwent cryoablation. Two weeks later, she went to the ED with pain and constipation. Following CT scans and US, she was found to have a tubo-ovarian abscess. After an enema and subsequent bowel movement, her pain improved. She was discharged with instructions to follow-up with her gynecologist. Six days later, the gynecologist prescribed triple antibiotics, analgesics, and weekly visits for the abscess. Two weeks later, she reported unbearable pain and was sent to the ED. She was found to have a microperforation of the sigmoid colon and multiple gynecologic pathologies, including myomata, right serous cystadenoma, and left tubo-ovarian complex suggestive of endometriosis. Hysterectomy and colostomy were performed; the colostomy was reversed several months later.

PATIENT’S CLAIM She should have been hospitalized when the abscess was found so that the infection could be treated properly. She alleged lack of informed consent for the cryoablation.

PHYSICIAN’S DEFENSE Hospitalization was unnecessary; the patient had initially improved, and the outcome would not have changed with intravenous antibiotics. The patient was fully informed of the risks of the procedure.

VERDICT A Pennsylvania defense verdict was returned.

New mother dies from pulmonary embolism

A 39-YEAR-OLD WOMAN’S SECOND CHILD WAS BORN by cesarean delivery. The mother died the next day from a pulmonary embolism.

ESTATE’S CLAIM Physicians and nurses at the hospital were negligent in failing to recognize the mother’s risk factors for pulmonary embolism, including obesity, being over age 35, and hypertension. They failed to ensure that compression boots were in place and working prior to delivery. Although orders had been given for the woman to walk within 8 hours of delivery, she did not get out of bed and walk for 24 hours after delivery.

DEFENDANTS’ DEFENSE The case was settled before trial.

VERDICT A $3.5 million Illinois settlement was reached.

Woman told “Biopsy isn’t urgent”

TWO MONTHS AFTER HER INITIAL VISIT, a 58-year-old woman returned to the gynecologist with vaginal bleeding. In March 2004, ultrasonography (US) showed slight thickening of the endometrial lining and a “pin dot” described as being a prepolyp. Vaginal bleeding was determined to be due to thinning of the vaginal wall with menopause.

The patient reported daily vaginal bleeding when she saw the gynecologist in January 2005. A new, large, rounded, solid mass within the endometrial cavity consistent with a large endometrial polyp was seen on US. The radiologist recommended hysteroscopic biopsy with excision, but the gynecologist told the patient it was not urgent.

In March 2005, hysteroscopy confirmed carcinosarcoma of the uterus. The patient underwent a hysterectomy followed by pelvic radiation and brachytherapy.

Eight months later, metastasis was found in the lungs; she died in October 2006.

ESTATE’S CLAIM The gynecologist failed to react when the patient first reported vaginal bleeding. An earlier diagnosis could have prevented her death.

PHYSICIAN’S DEFENSE The case was settled before trial.

VERDICT An $820,000 Massachusetts settlement was reached.

US report misses fetal abnormalities

A PREGNANT WOMAN UNDERWENT US. The preliminary report indicated echogenic cardiac focus and unilateral pyelectasis. Twenty-five days later, the mother underwent a level II US. A radiologist wrote that fetal anatomy was normal in both reports. The mother had two additional sonograms, with no reported abnormality.

The baby was born with aplasia and hypoplasia with both arms absent below a short humerus, an absent left leg, and a shortened right leg with a remnant foot and three small toes.

PARENTS’ CLAIM The radiologist’s US reports failed to accurately describe the fetal anatomy, depriving the parents of the chance to terminate the pregnancy.

DEFENDANTS’ DEFENSE Proper treatment was given.

VERDICT A $4.5 million Florida verdict was returned. Fault was assigned to the radiologist (85%) and the level II technologist (15%).

Forceps delivery injures mother’s pelvic floor

DURING A TRIAL OF LABOR, a 34-year-old woman experienced deep transverse arrest and lack of progress due to pelvic restriction. The ObGyn proceeded to deliver the baby vaginally using forceps, which caused pelvic floor injuries to the mother.

Several months later, she underwent corrective repair surgery for pelvic floor prolapse. She has continuing vaginal and rectal pain and dysfunction.

PATIENT’S CLAIM A cesarean delivery should have been performed as soon as pelvic restriction was found. The injuries reduce the woman’s chances of having another child.

PHYSICIAN’S DEFENSE A trial of labor was proper. The patient’s continuing fertility problems are related to chronic yeast infections and prescription birth control.

VERDICT A $1,716,469 Illinois verdict was returned, which included $484,000 to the patient’s husband for loss of consortium.

7 CASES OF INJURED BOWEL

1 Woman dies from bowel injury

DURING A SLING PROCEDURE for vaginal prolapse, a 50-year-old woman required a transfusion. The next day, she was nauseated and constipated. A day later, she went to the ED with shortness of breath and chest and abdominal pain. Her symptoms persisted for 8 days before an injury to her transverse colon was found during exploratory surgery. She suffered massive organ failure caused by sepsis and died 3 weeks after the initial surgery.

ESTATE’S CLAIM The gynecologist should have investigated why she needed a transfusion during surgery. He should have reacted earlier to her postsurgical complaints.

PHYSICIAN’S DEFENSE Bowel injury is a known risk of the procedure. The patient suffered multiple strokes after being readmitted to the hospital.

VERDICT A $2.4 million South Carolina verdict was returned.

2 Colostomy, coma after hysterectomy

DUE TO FIBROID TUMORS and pelvic pain, a 39-year-old woman’s ObGyn suggested laparoscopic-assisted vaginal hysterectomy. A third-year resident performed most of the procedure. The ObGyn’s associate covered postsurgical care.

When the patient reported increasing pain and rectal bleeding, an exploratory laparotomy was performed 3 days after surgery. Bowel and ureter injuries were repaired and a permanent colostomy was created. The patient developed septic shock with multiple organ failure, and was placed in a chemically induced coma for 3 weeks, after which she had to relearn to walk, talk, and care for herself.

PATIENT’S CLAIM The ObGyn was negligent in performing the surgery. He failed to obtain consent for the resident’s participation. The associate failed to respond to her declining postoperative condition in a timely manner.

DEFENDANTS’ DEFENSE Surgery was properly performed and postoperative care was appropriate. The bowel injury was a thermal or pressure necrosis that occurred 3 days after surgery. Two different consent forms signed by the patient included notification that a resident might assist; the resident was introduced to the patient prior to surgery. The patient’s injury claims were exaggerated; her future medical bills would be limited to colostomy supplies.

VERDICT A $1,926,069 Texas verdict was returned.

3 Were physicians qualified on robot?

A 48-YEAR-OLD WOMAN UNDERWENT robotic-assisted total hysterectomy and oophorectomy for uterine fibroids and cysts. During surgery, the physicians realized that the sigmoid colon had been perforated. A general surgeon repaired the injury with a loop ileostomy, which was successfully reversed 3 months later. The patient continues to have constipation, with occasional bleeding, pain, and burning.

PATIENT’S CLAIM The risks of robotic surgery were never fully explained to her. Failure to properly visualize her internal organs led to the injury; the extent of damage exceeded what is considered “acceptable risk” of the procedure. The physicians had little experience and training in robotic surgery.

PHYSICIANS’ DEFENSE The case was settled before trial.

VERDICT A $350,000 Massachusetts settlement was reached.

4 Adhesions limit view of bowel

A 76-YEAR-OLD WOMAN UNDERWENT surgical removal of an ovarian cyst. The ObGyn attempted a laparoscopic procedure but converted to laparotomy when extensive adhesions were encountered. The next morning, the patient discovered that her navel was discharging fecal matter. Exploratory surgery determined that the bowel had been perforated. She required additional surgery and had a long recovery.

PATIENT’S CLAIM The ObGyn was negligent in failing to diagnose and treat bowel perforation in a timely manner. An intraoperative bowel inspection should have occurred due to the likelihood of a bowel injury related to the adhesions.

PHYSICIAN’S DEFENSE Adhesions restricted inspection of every area.

VERDICT A $225,000 New York settlement was reached.

5 Skydiver’s ongoing postop pain

AFTER REPORTING DYSMENORRHEA and menometrorrhagia, a 34-year-old woman underwent dilatation and curettage, thermal endometrial ablation, and diagnostic laparoscopy. A day later, she reported increasing pain. The ObGyn’s examination revealed minimal abdominal distension, sluggish bowel sounds, and some guarding, with no rebound tenderness or acute distress. US showed a 3-cm pocket of fluid in the abdomen. Two hours later, an exam revealed a soft abdomen and normal bowel sounds. She was sent home with instructions to return the next day or, if her condition worsened, to go to the ED.

Her husband called the next day to report she was feeling better. The patient woke the following morning with massive distension, worse pain, and severe shortness of breath. At the ED, a CT scan revealed a large amount of abdominal fluid. During emergency laparotomy, an injury was found in the jejunum, necessitating a 3-inch resection.

PATIENT’S CLAIM The ObGyn was negligent in not treating her postoperative symptoms in a more proactive manner. Adhesions developed from peritonitis, leading to chronic abdominal pain. Several operations were required.

PHYSICIAN’S DEFENSE Bowel injury is a known complication of the procedure. There was no indication during surgery or at the office visit that the jejunum was injured. Adhesions were not the cause of the patient’s ongoing pain; very few adhesions were found during subsequent operations. The woman was an avid skydiver who had completed 200 jumps since her initial surgery.

VERDICT An Illinois defense verdict was returned.

6 Bowel injury at laparoscopy

WHEN THE GYNECOLOGIST recognized a bowel injury during laparoscopic salpingectomy, he called a general surgeon, who repaired three areas of bowel. The patient was released 2 days after surgery. She called the gynecologist 2 days later to report fever and vaginal bleeding. She was told to come to the office, but she cancelled when the fever subsided. The next day, she went to the ED, where sepsis was diagnosed. She was flown to another hospital for surgery. A 1-cm small-bowel perforation was found in an area of earlier repair because a suture had been disrupted. A temporary colostomy was reversed 3 months later.

PATIENT’S CLAIM The gynecologist was negligent in performing laparoscopic salpingectomy. The patient should not have been discharged because her white blood cell count and heart rate were elevated.

DEFENDANTS’ DEFENSE Performance of a laparoscopic procedure was proper. Discharge was reasonable, as there was only a potential for complications with no evident problems.

VERDICT An Missouri defense verdict was returned.

7 Was treatment of abscess delayed?

A 49-YEAR-OLD WOMAN with menorrhagia underwent cryoablation. Two weeks later, she went to the ED with pain and constipation. Following CT scans and US, she was found to have a tubo-ovarian abscess. After an enema and subsequent bowel movement, her pain improved. She was discharged with instructions to follow-up with her gynecologist. Six days later, the gynecologist prescribed triple antibiotics, analgesics, and weekly visits for the abscess. Two weeks later, she reported unbearable pain and was sent to the ED. She was found to have a microperforation of the sigmoid colon and multiple gynecologic pathologies, including myomata, right serous cystadenoma, and left tubo-ovarian complex suggestive of endometriosis. Hysterectomy and colostomy were performed; the colostomy was reversed several months later.

PATIENT’S CLAIM She should have been hospitalized when the abscess was found so that the infection could be treated properly. She alleged lack of informed consent for the cryoablation.

PHYSICIAN’S DEFENSE Hospitalization was unnecessary; the patient had initially improved, and the outcome would not have changed with intravenous antibiotics. The patient was fully informed of the risks of the procedure.

VERDICT A Pennsylvania defense verdict was returned.