Medical Verdicts

Gallbladder surgery uncovers something more

ABDOMINAL PAIN prompted a 46-year-old woman to seek treatment at a local medical center, where she had minor therapy. She returned to the hospital repeatedly over the next 3 years and received various treatments for abdominal pain, culminating in the removal of her gallbladder.

During the procedure, the surgeon found an ovarian tumor that turned out to be stage III cancer. The patient underwent oophorectomy and several courses of chemotherapy.

PLAINTIFF’S CLAIM The cancer should have been diagnosed at any of the patient’s previous examinations.

THE DEFENSE The patient’s symptoms were vague; ovarian cancer is often diagnosed at a late stage.

VERDICT $160,000 New York settlement.

COMMENT It never ceases to amaze that we’re held to such high (irrational?) standards whenever cancer is diagnosed. Although pertinent details of this case—such as the size of the tumor and frequency of pelvic exams—aren’t provided, it goes to show you that lawyers will do what lawyers do.

Diagnosis minus treatment equals catastrophe

A SWOLLEN, PAINFUL LEFT KNEE led a 65-year-old man to go to the emergency department (ED). The physician who examined his knee prescribed acetaminophen and hydrocodone and naproxen and sent the patient home with instructions to apply ice and heat.

The patient went back to the ED 2 days later because the knee was still swollen and painful. He was told to keep taking the prescribed medications and to follow up with a doctor at a local practice, who examined the patient later that day. The doctor aspirated brown, pus-filled material from the knee and diagnosed sepsis in the knee joint. He told the patient to drive to his family physician’s office, about 70 miles away, for treatment. The patient was carried back to his car and made the drive slowly.

By the time he arrived at his doctor’s office, the patient was in shock and kidney failure and breathing with difficulty. He was put on a ventilator and given antibiotics. He died several days later from septic shock and multiple organ failure.

PLAINTIFF’S CLAIM If the patient had been given antibiotics during his first or second examination, he would have lived.

THE DEFENSE No information about the defense is available.

VERDICT $10.9 million South Carolina verdict.

COMMENT It’s horrible enough that this patient wasn’t diagnosed promptly, but unfathomable that he was sent on his way without treatment!

Circumcision proceeds without consent

AFTER THE BIRTH OF A HEALTHY BABY BOY, a nurse presented the baby’s mother with a consent form for circumcision, which she didn’t sign. Before the birth, the parents had told the child’s pediatrician—who had also been the pediatrician for the mother’s 2 brothers and her oldest son—that they didn’t want their baby circumcised if it was a boy. Despite a lack of consent, the pediatrician circumcised the infant, without incident, the day after his birth. The parents were outraged.

PLAINTIFF’S CLAIM Because the pediatrician had cared for other male members of the family, he should have been aware of the family’s wishes regarding circumcision. The Gomco clamp method used to circumcise the baby caused pain throughout the 25-minute procedure, and the child suffered pain for 2 weeks while his penis healed. The baby, who had been calm before the surgery, became fussy afterwards and remained so for a year. He has a greater risk of developing some health problems because of the circumcision.

THE DEFENSE The circumcision was performed because the hospital staff erred in not following the hospital’s protocol. The procedure was done properly and without complications; the baby suffered no injuries from it. Remaining uncircumcised has no benefit; because circumcision lowers the risk of urinary tract and foreskin infections, as well as other illnesses, the child would be healthier than uncircumcised boys.

VERDICT Indiana defense verdict for the pediatrician. (The hospital reached a confidential settlement with the parents before trial.)

COMMENT It still astounds when wrong side surgeries occur—and how about this example of a circumcision without consent?! This is why checklists are so important. Obviously, appropriate informed consent should precede any procedure.

A drug adverse effect—that wasn’t

A 68-YEAR-OLD WOMAN went to her physician complaining of gastrointestinal discomfort. The doctor surmised that medication prescribed for hypertension was causing the discomfort and changed the medication. He recommended a follow-up visit in 2 weeks.

Three days later, the patient returned to the clinic complaining of abdominal pain. A physician assistant made the same diagnosis as the physician.

The patient went to the hospital 4 days later because the pain had increased. She was found to have a ruptured appendix and underwent an appendectomy. After surgery, the patient experienced residual pain.

PLAINTIFF’S CLAIM The physician and physician assistant were negligent in failing to diagnose appendicitis promptly. The case proceeded to trial against the physician assistant and the clinic.

THE DEFENSE The patient was properly evaluated and didn’t have symptoms suggesting appendicitis. Diagnostic tests weren’t necessary because the second visit was a follow-up examination.

VERDICT $150,000 New York verdict.

COMMENT Thoroughly documenting the history and physical examination is key to avoiding malpractice claims.

Antibiotics prescribed by phone can’t substitute for office visit

THREE DAYS OF FATIGUE AND A 103°F FEVER in a 42-year-old man prompted his wife to call his primary care physician. She discussed the symptoms with a nurse, who told her the doctor didn’t have an opening to see her husband. Instead, the physician called in a prescription for antibiotics because the symptoms resembled ones the patient had had about 8 months earlier that cleared up with antibiotics.

The patient felt well enough to pick up the antibiotics and the couple’s 2 children from preschool. When he got home, he took the antibiotics and went to bed. His wife found him dead that evening. The cause was determined to be cardiac arrest from myocarditis.

PLAINTIFF’S CLAIM Based on the reported symptoms, the doctor should have seen the patient immediately and referred him to an emergency department, where myocarditis would have been diagnosed and lifesaving treatment could have been started.

THE DEFENSE The patient’s wife didn’t properly describe all the symptoms to the nurse when she called. If she had, the doctor’s office would have scheduled an immediate appointment. In any case, myocarditis is difficult to diagnose; a pathologist’s findings indicated that the patient had focal myocarditis only in the right ventricle, which would have caused no symptoms detectable by a physical examination or electrocardiogram.

VERDICT $220,255 New Jersey judgment. The jury returned a $1 million verdict on a finding that the doctor was 20% responsible for the damages and the patient’s pre-existing condition was 80% responsible.

COMMENT I’m increasingly alarmed by the trend to find clinicians partially responsible for damages. A 20% share of liability added up to more than $200,000 in this case.

Gallbladder surgery uncovers something more

ABDOMINAL PAIN prompted a 46-year-old woman to seek treatment at a local medical center, where she had minor therapy. She returned to the hospital repeatedly over the next 3 years and received various treatments for abdominal pain, culminating in the removal of her gallbladder.

During the procedure, the surgeon found an ovarian tumor that turned out to be stage III cancer. The patient underwent oophorectomy and several courses of chemotherapy.

PLAINTIFF’S CLAIM The cancer should have been diagnosed at any of the patient’s previous examinations.

THE DEFENSE The patient’s symptoms were vague; ovarian cancer is often diagnosed at a late stage.

VERDICT $160,000 New York settlement.

COMMENT It never ceases to amaze that we’re held to such high (irrational?) standards whenever cancer is diagnosed. Although pertinent details of this case—such as the size of the tumor and frequency of pelvic exams—aren’t provided, it goes to show you that lawyers will do what lawyers do.

Diagnosis minus treatment equals catastrophe

A SWOLLEN, PAINFUL LEFT KNEE led a 65-year-old man to go to the emergency department (ED). The physician who examined his knee prescribed acetaminophen and hydrocodone and naproxen and sent the patient home with instructions to apply ice and heat.

The patient went back to the ED 2 days later because the knee was still swollen and painful. He was told to keep taking the prescribed medications and to follow up with a doctor at a local practice, who examined the patient later that day. The doctor aspirated brown, pus-filled material from the knee and diagnosed sepsis in the knee joint. He told the patient to drive to his family physician’s office, about 70 miles away, for treatment. The patient was carried back to his car and made the drive slowly.

By the time he arrived at his doctor’s office, the patient was in shock and kidney failure and breathing with difficulty. He was put on a ventilator and given antibiotics. He died several days later from septic shock and multiple organ failure.

PLAINTIFF’S CLAIM If the patient had been given antibiotics during his first or second examination, he would have lived.

THE DEFENSE No information about the defense is available.

VERDICT $10.9 million South Carolina verdict.

COMMENT It’s horrible enough that this patient wasn’t diagnosed promptly, but unfathomable that he was sent on his way without treatment!

Circumcision proceeds without consent

AFTER THE BIRTH OF A HEALTHY BABY BOY, a nurse presented the baby’s mother with a consent form for circumcision, which she didn’t sign. Before the birth, the parents had told the child’s pediatrician—who had also been the pediatrician for the mother’s 2 brothers and her oldest son—that they didn’t want their baby circumcised if it was a boy. Despite a lack of consent, the pediatrician circumcised the infant, without incident, the day after his birth. The parents were outraged.

PLAINTIFF’S CLAIM Because the pediatrician had cared for other male members of the family, he should have been aware of the family’s wishes regarding circumcision. The Gomco clamp method used to circumcise the baby caused pain throughout the 25-minute procedure, and the child suffered pain for 2 weeks while his penis healed. The baby, who had been calm before the surgery, became fussy afterwards and remained so for a year. He has a greater risk of developing some health problems because of the circumcision.

THE DEFENSE The circumcision was performed because the hospital staff erred in not following the hospital’s protocol. The procedure was done properly and without complications; the baby suffered no injuries from it. Remaining uncircumcised has no benefit; because circumcision lowers the risk of urinary tract and foreskin infections, as well as other illnesses, the child would be healthier than uncircumcised boys.

VERDICT Indiana defense verdict for the pediatrician. (The hospital reached a confidential settlement with the parents before trial.)

COMMENT It still astounds when wrong side surgeries occur—and how about this example of a circumcision without consent?! This is why checklists are so important. Obviously, appropriate informed consent should precede any procedure.

A drug adverse effect—that wasn’t

A 68-YEAR-OLD WOMAN went to her physician complaining of gastrointestinal discomfort. The doctor surmised that medication prescribed for hypertension was causing the discomfort and changed the medication. He recommended a follow-up visit in 2 weeks.

Three days later, the patient returned to the clinic complaining of abdominal pain. A physician assistant made the same diagnosis as the physician.

The patient went to the hospital 4 days later because the pain had increased. She was found to have a ruptured appendix and underwent an appendectomy. After surgery, the patient experienced residual pain.

PLAINTIFF’S CLAIM The physician and physician assistant were negligent in failing to diagnose appendicitis promptly. The case proceeded to trial against the physician assistant and the clinic.

THE DEFENSE The patient was properly evaluated and didn’t have symptoms suggesting appendicitis. Diagnostic tests weren’t necessary because the second visit was a follow-up examination.

VERDICT $150,000 New York verdict.

COMMENT Thoroughly documenting the history and physical examination is key to avoiding malpractice claims.

Antibiotics prescribed by phone can’t substitute for office visit

THREE DAYS OF FATIGUE AND A 103°F FEVER in a 42-year-old man prompted his wife to call his primary care physician. She discussed the symptoms with a nurse, who told her the doctor didn’t have an opening to see her husband. Instead, the physician called in a prescription for antibiotics because the symptoms resembled ones the patient had had about 8 months earlier that cleared up with antibiotics.

The patient felt well enough to pick up the antibiotics and the couple’s 2 children from preschool. When he got home, he took the antibiotics and went to bed. His wife found him dead that evening. The cause was determined to be cardiac arrest from myocarditis.

PLAINTIFF’S CLAIM Based on the reported symptoms, the doctor should have seen the patient immediately and referred him to an emergency department, where myocarditis would have been diagnosed and lifesaving treatment could have been started.

THE DEFENSE The patient’s wife didn’t properly describe all the symptoms to the nurse when she called. If she had, the doctor’s office would have scheduled an immediate appointment. In any case, myocarditis is difficult to diagnose; a pathologist’s findings indicated that the patient had focal myocarditis only in the right ventricle, which would have caused no symptoms detectable by a physical examination or electrocardiogram.

VERDICT $220,255 New Jersey judgment. The jury returned a $1 million verdict on a finding that the doctor was 20% responsible for the damages and the patient’s pre-existing condition was 80% responsible.

COMMENT I’m increasingly alarmed by the trend to find clinicians partially responsible for damages. A 20% share of liability added up to more than $200,000 in this case.

Gallbladder surgery uncovers something more

ABDOMINAL PAIN prompted a 46-year-old woman to seek treatment at a local medical center, where she had minor therapy. She returned to the hospital repeatedly over the next 3 years and received various treatments for abdominal pain, culminating in the removal of her gallbladder.

During the procedure, the surgeon found an ovarian tumor that turned out to be stage III cancer. The patient underwent oophorectomy and several courses of chemotherapy.

PLAINTIFF’S CLAIM The cancer should have been diagnosed at any of the patient’s previous examinations.

THE DEFENSE The patient’s symptoms were vague; ovarian cancer is often diagnosed at a late stage.

VERDICT $160,000 New York settlement.

COMMENT It never ceases to amaze that we’re held to such high (irrational?) standards whenever cancer is diagnosed. Although pertinent details of this case—such as the size of the tumor and frequency of pelvic exams—aren’t provided, it goes to show you that lawyers will do what lawyers do.

Diagnosis minus treatment equals catastrophe

A SWOLLEN, PAINFUL LEFT KNEE led a 65-year-old man to go to the emergency department (ED). The physician who examined his knee prescribed acetaminophen and hydrocodone and naproxen and sent the patient home with instructions to apply ice and heat.

The patient went back to the ED 2 days later because the knee was still swollen and painful. He was told to keep taking the prescribed medications and to follow up with a doctor at a local practice, who examined the patient later that day. The doctor aspirated brown, pus-filled material from the knee and diagnosed sepsis in the knee joint. He told the patient to drive to his family physician’s office, about 70 miles away, for treatment. The patient was carried back to his car and made the drive slowly.

By the time he arrived at his doctor’s office, the patient was in shock and kidney failure and breathing with difficulty. He was put on a ventilator and given antibiotics. He died several days later from septic shock and multiple organ failure.

PLAINTIFF’S CLAIM If the patient had been given antibiotics during his first or second examination, he would have lived.

THE DEFENSE No information about the defense is available.

VERDICT $10.9 million South Carolina verdict.

COMMENT It’s horrible enough that this patient wasn’t diagnosed promptly, but unfathomable that he was sent on his way without treatment!

Circumcision proceeds without consent

AFTER THE BIRTH OF A HEALTHY BABY BOY, a nurse presented the baby’s mother with a consent form for circumcision, which she didn’t sign. Before the birth, the parents had told the child’s pediatrician—who had also been the pediatrician for the mother’s 2 brothers and her oldest son—that they didn’t want their baby circumcised if it was a boy. Despite a lack of consent, the pediatrician circumcised the infant, without incident, the day after his birth. The parents were outraged.

PLAINTIFF’S CLAIM Because the pediatrician had cared for other male members of the family, he should have been aware of the family’s wishes regarding circumcision. The Gomco clamp method used to circumcise the baby caused pain throughout the 25-minute procedure, and the child suffered pain for 2 weeks while his penis healed. The baby, who had been calm before the surgery, became fussy afterwards and remained so for a year. He has a greater risk of developing some health problems because of the circumcision.

THE DEFENSE The circumcision was performed because the hospital staff erred in not following the hospital’s protocol. The procedure was done properly and without complications; the baby suffered no injuries from it. Remaining uncircumcised has no benefit; because circumcision lowers the risk of urinary tract and foreskin infections, as well as other illnesses, the child would be healthier than uncircumcised boys.

VERDICT Indiana defense verdict for the pediatrician. (The hospital reached a confidential settlement with the parents before trial.)

COMMENT It still astounds when wrong side surgeries occur—and how about this example of a circumcision without consent?! This is why checklists are so important. Obviously, appropriate informed consent should precede any procedure.

A drug adverse effect—that wasn’t

A 68-YEAR-OLD WOMAN went to her physician complaining of gastrointestinal discomfort. The doctor surmised that medication prescribed for hypertension was causing the discomfort and changed the medication. He recommended a follow-up visit in 2 weeks.

Three days later, the patient returned to the clinic complaining of abdominal pain. A physician assistant made the same diagnosis as the physician.

The patient went to the hospital 4 days later because the pain had increased. She was found to have a ruptured appendix and underwent an appendectomy. After surgery, the patient experienced residual pain.

PLAINTIFF’S CLAIM The physician and physician assistant were negligent in failing to diagnose appendicitis promptly. The case proceeded to trial against the physician assistant and the clinic.

THE DEFENSE The patient was properly evaluated and didn’t have symptoms suggesting appendicitis. Diagnostic tests weren’t necessary because the second visit was a follow-up examination.

VERDICT $150,000 New York verdict.

COMMENT Thoroughly documenting the history and physical examination is key to avoiding malpractice claims.

Antibiotics prescribed by phone can’t substitute for office visit

THREE DAYS OF FATIGUE AND A 103°F FEVER in a 42-year-old man prompted his wife to call his primary care physician. She discussed the symptoms with a nurse, who told her the doctor didn’t have an opening to see her husband. Instead, the physician called in a prescription for antibiotics because the symptoms resembled ones the patient had had about 8 months earlier that cleared up with antibiotics.

The patient felt well enough to pick up the antibiotics and the couple’s 2 children from preschool. When he got home, he took the antibiotics and went to bed. His wife found him dead that evening. The cause was determined to be cardiac arrest from myocarditis.

PLAINTIFF’S CLAIM Based on the reported symptoms, the doctor should have seen the patient immediately and referred him to an emergency department, where myocarditis would have been diagnosed and lifesaving treatment could have been started.

THE DEFENSE The patient’s wife didn’t properly describe all the symptoms to the nurse when she called. If she had, the doctor’s office would have scheduled an immediate appointment. In any case, myocarditis is difficult to diagnose; a pathologist’s findings indicated that the patient had focal myocarditis only in the right ventricle, which would have caused no symptoms detectable by a physical examination or electrocardiogram.

VERDICT $220,255 New Jersey judgment. The jury returned a $1 million verdict on a finding that the doctor was 20% responsible for the damages and the patient’s pre-existing condition was 80% responsible.

COMMENT I’m increasingly alarmed by the trend to find clinicians partially responsible for damages. A 20% share of liability added up to more than $200,000 in this case.

Undiluted acid used for vulvar surgery

WIDE LOCAL EXCISION was performed on a 42-year-old woman with vulvar intraepithelial neoplasm, VIN II, with moderate dysplasia. Her ObGyn performed the surgery.

Instead of applying a diluted solution of acetic acid wash to delineate the borders of the dysplastic area, a highly concentrated acetic acid or trichloroacetic acid was used. The patient suffered severe chemical burns of the vulva that took several months to heal. She has permanent scarring of the vulvar area, severe tenderness, discoloration, and atrophy of the vaginal opening, with a band of thick scar tissue at the posterior fourchette. The perineum, extending to the anal area, is scarred, including a 2-mm plaque layer.

PATIENT’S CLAIM Sexual intercourse is extremely painful, and therefore impossible. She suffers discomfort at all times. Additional surgery has been recommended to alleviate her condition.

DEFENDANTS’ DEFENSE The case was settled before trial.

VERDICT A $600,000 Ohio settlement was reached.

Large baby with cervical spine injury

A WOMAN WAS IN LABOR with her third child. Her first baby was born by cesarean delivery. During the vaginal birth of her second child, shoulder dystocia was encountered; this child weighed 8 lb 4 oz at birth.

Using ultrasonography, the ObGyn determined vaginal birth was appropriate. Shoulder dystocia was encountered and the infant suffered injuries to the cervical spine and right arm. The newborn weighed 9 lb 13 oz.

PATIENT’S CLAIM The baby’s weight was grossly underestimated prior to delivery; ultrasonography was not properly performed or evaluated. The mother’s history, large fundal height, estimated fetal weight, and the mother’s request for a cesarean delivery should have resulted in the performance of a cesarean delivery.

PHYSICIAN’S DEFENSE Shoulder dystocia was not reasonably foreseeable. Injuries to the baby were due to the forces of labor.

VERDICT A confidential Texas settlement was reached.

Suture causes nerve damage

PELVIC PROLAPSE RECONSTRUCTION was performed; surgery included a pubovaginal sling procedure with graft, and repairs of Grade 2 cystocele and Grade 3 rectocele. The gynecologist used transvaginal sutures to attach the mesh to the sacrospinous ligament.

The patient immediately reported pain, tingling, and weakness in her buttocks and legs. The gynecologist diagnosed a hematoma and continued conservative treatment while waiting for the hematoma to resorb.

After 10 days, the patient terminated the gynecologist’s services and left the hospital. She saw a neurologist, who diagnosed proximal sciatic nerve irritation secondary to suturing. When a suture was removed from the sacral spinous ligament plexus, many of the patient’s neurologic symptoms immediately resolved. She still has pain and walks with a noticeable limp using a cane.

PATIENT’S CLAIM The gynecologist failed to determine that a suture was causing nerve damage. Removal of the suture within the first 3 days would have avoided neurologic injury.

PHYSICIAN’S DEFENSE Postsurgical care was proper. A neurologist was consulted, and a sonogram had ruled out deep vein thrombosis.

VERDICT A $1.58 million Illinois verdict was returned.

Colon damage after embolization

UTERINE FIBROID EMBOLIZATION was performed on a 51-year-old woman. The next day, she reported severe abdominal pain and was readmitted. A uterine infection was suspected, and she underwent a hysterectomy. Necrosis of the colon was found; a surgeon removed one-third of the colon and performed a colostomy. She underwent several operations, including rectal-vaginal fistula repair, before the colostomy was corrected.

PATIENT’S CLAIM Misdirected embolization injured an artery supplying the colon. She continues to suffer ongoing fecal urgency and frequency.

PHYSICIAN’S DEFENSE An anomalous connection between the patient’s uterine artery and mesenteric artery was impossible for the physician to have known prior to the embolization procedure.

VERDICT A California defense verdict was returned.

$1.18 M verdict set aside because of Facebook   postings

SEVERAL HOURS AFTER A WOMAN’S LABOR BEGAN, fetal bradycardia developed precipitously. The on-call ObGyn arrived after 10 minutes and ordered an immediate cesarean delivery, which occurred 22 minutes later. The child suffered a catastrophic, irreversible brain injury. He lived for 39 days before life support was removed and he died.

ESTATE’S CLAIM The nurses did not report decelerations to the ObGyn, and they were slow to notify him of the fetal bradycardia. The child would not have been injured if the nursing staff had reacted appropriately.

DEFENDANTS’ DEFENSE Isolated heart-rate decelerations during labor are not troubling. A cord accident occurred, which could not be predicted nor avoided. The ObGyn was called promptly; the emergency cesarean delivery was performed quickly. However, the injury already had occurred and was irreparable.

VERDICT A $1.18 million Kentucky verdict was returned. The hospital sought a mistrial because Facebook postings by a juror proved the case had been discussed and prejudged. The court found in favor of the hospital on its post-trial motion.

Bilateral mastectomy: nipples not spared

A 46-YEAR-OLD WOMAN UNDERWENT prophylactic bilateral mastectomy. A plastic surgeon drew presurgical markings on the day of surgery; the breast surgeon removed the nipples.

PATIENT’S CLAIM All parties had agreed the nipples would be spared. The plastic surgeon drew improper markings and failed to remind the breast surgeon prior to surgery that the nipples would be preserved.

PHYSICIAN’S DEFENSE The breast surgeon was at fault for misinterpreting the markings.

VERDICT The patient reached a pretrial settlement with the breast surgeon. The case proceeded against the plastic surgeon. A Maryland defense verdict was returned for the plastic surgeon.

Signs of intrauterine growth restriction; stillborn child

AT 24 WEEKS’ GESTATION, a 17-year-old woman who smoked reported spotting. An ultrasound demonstrated significant fetal growth restriction. The mother was hospitalized to assess the spotting; no testing was ordered to assess fetal growth. When blood was not found in the birth canal, she was discharged. During the next month, she saw the ObGyn three times; testing indicated that the fetus was at least 3 weeks behind the stage of pregnancy. The ObGyn did not order additional testing nor consult a specialist. At 31 weeks’ gestation, ultrasonography found no fetal heart tones. The stillborn was delivered by cesarean section.

ESTATE’S CLAIM A wrongful death suit was filed by the parents, who also claimed lack of informed consent concerning the risk of stillbirth in the presence of intrauterine growth restriction.

PHYSICIANS’ DEFENSE The mother’s smoking was mentioned at trial as a possible explanation of why fetal development was delayed. The ObGyn denied negligence.

VERDICT A $800,000 Maryland verdict was awarded to the parents.

Three BrCa patients share $72.6 M

THREE MENOPAUSAL WOMEN took Premarin (conjugated estrogens) plus Provera (medroxyprogesterone), and/or Prempro (conjugated estrogens/medroxyprogesterone acetate). Each discontinued hormone therapy after being diagnosed with hormone-positive breast cancer.

PATIENTS’ CLAIM The only source of hormonal stimulation for their cancer was the use of estrogen plus progestin.

DEFENDANTS’ DEFENSE Science is currently unable to determine precisely what causes breast cancer. Each plaintiff had risk factors.

VERDICT The three cases were consolidated to a reverse-bifurcated trial, with causation and damages assessed first. The Pennsylvania jury found the Wyeth Pharmaceutical products to be factual causes of the patients’ cancer, and awarded a total of $72.6 million in compensatory damages. The parties settled for confidential amounts before the liability phase began.

Undiluted acid used for vulvar surgery

WIDE LOCAL EXCISION was performed on a 42-year-old woman with vulvar intraepithelial neoplasm, VIN II, with moderate dysplasia. Her ObGyn performed the surgery.

Instead of applying a diluted solution of acetic acid wash to delineate the borders of the dysplastic area, a highly concentrated acetic acid or trichloroacetic acid was used. The patient suffered severe chemical burns of the vulva that took several months to heal. She has permanent scarring of the vulvar area, severe tenderness, discoloration, and atrophy of the vaginal opening, with a band of thick scar tissue at the posterior fourchette. The perineum, extending to the anal area, is scarred, including a 2-mm plaque layer.

PATIENT’S CLAIM Sexual intercourse is extremely painful, and therefore impossible. She suffers discomfort at all times. Additional surgery has been recommended to alleviate her condition.

DEFENDANTS’ DEFENSE The case was settled before trial.

VERDICT A $600,000 Ohio settlement was reached.

Large baby with cervical spine injury

A WOMAN WAS IN LABOR with her third child. Her first baby was born by cesarean delivery. During the vaginal birth of her second child, shoulder dystocia was encountered; this child weighed 8 lb 4 oz at birth.

Using ultrasonography, the ObGyn determined vaginal birth was appropriate. Shoulder dystocia was encountered and the infant suffered injuries to the cervical spine and right arm. The newborn weighed 9 lb 13 oz.

PATIENT’S CLAIM The baby’s weight was grossly underestimated prior to delivery; ultrasonography was not properly performed or evaluated. The mother’s history, large fundal height, estimated fetal weight, and the mother’s request for a cesarean delivery should have resulted in the performance of a cesarean delivery.

PHYSICIAN’S DEFENSE Shoulder dystocia was not reasonably foreseeable. Injuries to the baby were due to the forces of labor.

VERDICT A confidential Texas settlement was reached.

Suture causes nerve damage

PELVIC PROLAPSE RECONSTRUCTION was performed; surgery included a pubovaginal sling procedure with graft, and repairs of Grade 2 cystocele and Grade 3 rectocele. The gynecologist used transvaginal sutures to attach the mesh to the sacrospinous ligament.

The patient immediately reported pain, tingling, and weakness in her buttocks and legs. The gynecologist diagnosed a hematoma and continued conservative treatment while waiting for the hematoma to resorb.

After 10 days, the patient terminated the gynecologist’s services and left the hospital. She saw a neurologist, who diagnosed proximal sciatic nerve irritation secondary to suturing. When a suture was removed from the sacral spinous ligament plexus, many of the patient’s neurologic symptoms immediately resolved. She still has pain and walks with a noticeable limp using a cane.

PATIENT’S CLAIM The gynecologist failed to determine that a suture was causing nerve damage. Removal of the suture within the first 3 days would have avoided neurologic injury.

PHYSICIAN’S DEFENSE Postsurgical care was proper. A neurologist was consulted, and a sonogram had ruled out deep vein thrombosis.

VERDICT A $1.58 million Illinois verdict was returned.

Colon damage after embolization

UTERINE FIBROID EMBOLIZATION was performed on a 51-year-old woman. The next day, she reported severe abdominal pain and was readmitted. A uterine infection was suspected, and she underwent a hysterectomy. Necrosis of the colon was found; a surgeon removed one-third of the colon and performed a colostomy. She underwent several operations, including rectal-vaginal fistula repair, before the colostomy was corrected.

PATIENT’S CLAIM Misdirected embolization injured an artery supplying the colon. She continues to suffer ongoing fecal urgency and frequency.

PHYSICIAN’S DEFENSE An anomalous connection between the patient’s uterine artery and mesenteric artery was impossible for the physician to have known prior to the embolization procedure.

VERDICT A California defense verdict was returned.

$1.18 M verdict set aside because of Facebook   postings

SEVERAL HOURS AFTER A WOMAN’S LABOR BEGAN, fetal bradycardia developed precipitously. The on-call ObGyn arrived after 10 minutes and ordered an immediate cesarean delivery, which occurred 22 minutes later. The child suffered a catastrophic, irreversible brain injury. He lived for 39 days before life support was removed and he died.

ESTATE’S CLAIM The nurses did not report decelerations to the ObGyn, and they were slow to notify him of the fetal bradycardia. The child would not have been injured if the nursing staff had reacted appropriately.

DEFENDANTS’ DEFENSE Isolated heart-rate decelerations during labor are not troubling. A cord accident occurred, which could not be predicted nor avoided. The ObGyn was called promptly; the emergency cesarean delivery was performed quickly. However, the injury already had occurred and was irreparable.

VERDICT A $1.18 million Kentucky verdict was returned. The hospital sought a mistrial because Facebook postings by a juror proved the case had been discussed and prejudged. The court found in favor of the hospital on its post-trial motion.

Bilateral mastectomy: nipples not spared

A 46-YEAR-OLD WOMAN UNDERWENT prophylactic bilateral mastectomy. A plastic surgeon drew presurgical markings on the day of surgery; the breast surgeon removed the nipples.

PATIENT’S CLAIM All parties had agreed the nipples would be spared. The plastic surgeon drew improper markings and failed to remind the breast surgeon prior to surgery that the nipples would be preserved.

PHYSICIAN’S DEFENSE The breast surgeon was at fault for misinterpreting the markings.

VERDICT The patient reached a pretrial settlement with the breast surgeon. The case proceeded against the plastic surgeon. A Maryland defense verdict was returned for the plastic surgeon.

Signs of intrauterine growth restriction; stillborn child

AT 24 WEEKS’ GESTATION, a 17-year-old woman who smoked reported spotting. An ultrasound demonstrated significant fetal growth restriction. The mother was hospitalized to assess the spotting; no testing was ordered to assess fetal growth. When blood was not found in the birth canal, she was discharged. During the next month, she saw the ObGyn three times; testing indicated that the fetus was at least 3 weeks behind the stage of pregnancy. The ObGyn did not order additional testing nor consult a specialist. At 31 weeks’ gestation, ultrasonography found no fetal heart tones. The stillborn was delivered by cesarean section.

ESTATE’S CLAIM A wrongful death suit was filed by the parents, who also claimed lack of informed consent concerning the risk of stillbirth in the presence of intrauterine growth restriction.

PHYSICIANS’ DEFENSE The mother’s smoking was mentioned at trial as a possible explanation of why fetal development was delayed. The ObGyn denied negligence.

VERDICT A $800,000 Maryland verdict was awarded to the parents.

Three BrCa patients share $72.6 M

THREE MENOPAUSAL WOMEN took Premarin (conjugated estrogens) plus Provera (medroxyprogesterone), and/or Prempro (conjugated estrogens/medroxyprogesterone acetate). Each discontinued hormone therapy after being diagnosed with hormone-positive breast cancer.

PATIENTS’ CLAIM The only source of hormonal stimulation for their cancer was the use of estrogen plus progestin.

DEFENDANTS’ DEFENSE Science is currently unable to determine precisely what causes breast cancer. Each plaintiff had risk factors.

VERDICT The three cases were consolidated to a reverse-bifurcated trial, with causation and damages assessed first. The Pennsylvania jury found the Wyeth Pharmaceutical products to be factual causes of the patients’ cancer, and awarded a total of $72.6 million in compensatory damages. The parties settled for confidential amounts before the liability phase began.

Undiluted acid used for vulvar surgery

WIDE LOCAL EXCISION was performed on a 42-year-old woman with vulvar intraepithelial neoplasm, VIN II, with moderate dysplasia. Her ObGyn performed the surgery.

Instead of applying a diluted solution of acetic acid wash to delineate the borders of the dysplastic area, a highly concentrated acetic acid or trichloroacetic acid was used. The patient suffered severe chemical burns of the vulva that took several months to heal. She has permanent scarring of the vulvar area, severe tenderness, discoloration, and atrophy of the vaginal opening, with a band of thick scar tissue at the posterior fourchette. The perineum, extending to the anal area, is scarred, including a 2-mm plaque layer.

PATIENT’S CLAIM Sexual intercourse is extremely painful, and therefore impossible. She suffers discomfort at all times. Additional surgery has been recommended to alleviate her condition.

DEFENDANTS’ DEFENSE The case was settled before trial.

VERDICT A $600,000 Ohio settlement was reached.

Large baby with cervical spine injury

A WOMAN WAS IN LABOR with her third child. Her first baby was born by cesarean delivery. During the vaginal birth of her second child, shoulder dystocia was encountered; this child weighed 8 lb 4 oz at birth.

Using ultrasonography, the ObGyn determined vaginal birth was appropriate. Shoulder dystocia was encountered and the infant suffered injuries to the cervical spine and right arm. The newborn weighed 9 lb 13 oz.

PATIENT’S CLAIM The baby’s weight was grossly underestimated prior to delivery; ultrasonography was not properly performed or evaluated. The mother’s history, large fundal height, estimated fetal weight, and the mother’s request for a cesarean delivery should have resulted in the performance of a cesarean delivery.

PHYSICIAN’S DEFENSE Shoulder dystocia was not reasonably foreseeable. Injuries to the baby were due to the forces of labor.

VERDICT A confidential Texas settlement was reached.

Suture causes nerve damage

PELVIC PROLAPSE RECONSTRUCTION was performed; surgery included a pubovaginal sling procedure with graft, and repairs of Grade 2 cystocele and Grade 3 rectocele. The gynecologist used transvaginal sutures to attach the mesh to the sacrospinous ligament.

The patient immediately reported pain, tingling, and weakness in her buttocks and legs. The gynecologist diagnosed a hematoma and continued conservative treatment while waiting for the hematoma to resorb.

After 10 days, the patient terminated the gynecologist’s services and left the hospital. She saw a neurologist, who diagnosed proximal sciatic nerve irritation secondary to suturing. When a suture was removed from the sacral spinous ligament plexus, many of the patient’s neurologic symptoms immediately resolved. She still has pain and walks with a noticeable limp using a cane.

PATIENT’S CLAIM The gynecologist failed to determine that a suture was causing nerve damage. Removal of the suture within the first 3 days would have avoided neurologic injury.

PHYSICIAN’S DEFENSE Postsurgical care was proper. A neurologist was consulted, and a sonogram had ruled out deep vein thrombosis.

VERDICT A $1.58 million Illinois verdict was returned.

Colon damage after embolization

UTERINE FIBROID EMBOLIZATION was performed on a 51-year-old woman. The next day, she reported severe abdominal pain and was readmitted. A uterine infection was suspected, and she underwent a hysterectomy. Necrosis of the colon was found; a surgeon removed one-third of the colon and performed a colostomy. She underwent several operations, including rectal-vaginal fistula repair, before the colostomy was corrected.

PATIENT’S CLAIM Misdirected embolization injured an artery supplying the colon. She continues to suffer ongoing fecal urgency and frequency.

PHYSICIAN’S DEFENSE An anomalous connection between the patient’s uterine artery and mesenteric artery was impossible for the physician to have known prior to the embolization procedure.

VERDICT A California defense verdict was returned.

$1.18 M verdict set aside because of Facebook   postings

SEVERAL HOURS AFTER A WOMAN’S LABOR BEGAN, fetal bradycardia developed precipitously. The on-call ObGyn arrived after 10 minutes and ordered an immediate cesarean delivery, which occurred 22 minutes later. The child suffered a catastrophic, irreversible brain injury. He lived for 39 days before life support was removed and he died.

ESTATE’S CLAIM The nurses did not report decelerations to the ObGyn, and they were slow to notify him of the fetal bradycardia. The child would not have been injured if the nursing staff had reacted appropriately.

DEFENDANTS’ DEFENSE Isolated heart-rate decelerations during labor are not troubling. A cord accident occurred, which could not be predicted nor avoided. The ObGyn was called promptly; the emergency cesarean delivery was performed quickly. However, the injury already had occurred and was irreparable.

VERDICT A $1.18 million Kentucky verdict was returned. The hospital sought a mistrial because Facebook postings by a juror proved the case had been discussed and prejudged. The court found in favor of the hospital on its post-trial motion.

Bilateral mastectomy: nipples not spared

A 46-YEAR-OLD WOMAN UNDERWENT prophylactic bilateral mastectomy. A plastic surgeon drew presurgical markings on the day of surgery; the breast surgeon removed the nipples.

PATIENT’S CLAIM All parties had agreed the nipples would be spared. The plastic surgeon drew improper markings and failed to remind the breast surgeon prior to surgery that the nipples would be preserved.

PHYSICIAN’S DEFENSE The breast surgeon was at fault for misinterpreting the markings.

VERDICT The patient reached a pretrial settlement with the breast surgeon. The case proceeded against the plastic surgeon. A Maryland defense verdict was returned for the plastic surgeon.

Signs of intrauterine growth restriction; stillborn child

AT 24 WEEKS’ GESTATION, a 17-year-old woman who smoked reported spotting. An ultrasound demonstrated significant fetal growth restriction. The mother was hospitalized to assess the spotting; no testing was ordered to assess fetal growth. When blood was not found in the birth canal, she was discharged. During the next month, she saw the ObGyn three times; testing indicated that the fetus was at least 3 weeks behind the stage of pregnancy. The ObGyn did not order additional testing nor consult a specialist. At 31 weeks’ gestation, ultrasonography found no fetal heart tones. The stillborn was delivered by cesarean section.

ESTATE’S CLAIM A wrongful death suit was filed by the parents, who also claimed lack of informed consent concerning the risk of stillbirth in the presence of intrauterine growth restriction.

PHYSICIANS’ DEFENSE The mother’s smoking was mentioned at trial as a possible explanation of why fetal development was delayed. The ObGyn denied negligence.

VERDICT A $800,000 Maryland verdict was awarded to the parents.

Three BrCa patients share $72.6 M

THREE MENOPAUSAL WOMEN took Premarin (conjugated estrogens) plus Provera (medroxyprogesterone), and/or Prempro (conjugated estrogens/medroxyprogesterone acetate). Each discontinued hormone therapy after being diagnosed with hormone-positive breast cancer.

PATIENTS’ CLAIM The only source of hormonal stimulation for their cancer was the use of estrogen plus progestin.

DEFENDANTS’ DEFENSE Science is currently unable to determine precisely what causes breast cancer. Each plaintiff had risk factors.

VERDICT The three cases were consolidated to a reverse-bifurcated trial, with causation and damages assessed first. The Pennsylvania jury found the Wyeth Pharmaceutical products to be factual causes of the patients’ cancer, and awarded a total of $72.6 million in compensatory damages. The parties settled for confidential amounts before the liability phase began.

“Hemorrhoids” turn out to be cancer

A 49-YEAR-OLD WOMAN, whose husband was on active duty with the US Army, went to an army community hospital in March complaining of hemorrhoids, back pain, and itching, burning, and pain with bowel movements. A guaiac-based fecal occult blood test was positive; no further testing was done to rule out rectal cancer.

The woman was discharged with pain medication but returned the following day, reporting intense anal pain despite taking the medication and bright red blood in her stools. The symptoms were attributed to hemorrhoids, and the patient was given a toilet “donut” and topical medication. Although her records noted a referral to a general surgeon, the referral wasn’t arranged or scheduled.

The patient returned to the hospital in April, May, and June with continuing complaints that included unrelieved constipation. A laxative was prescribed, but no further testing was done, nor was the patient referred to a surgeon.

In August, she went to the emergency department because of rectal bleeding for the previous 2 weeks, abdominal pain, blood in her urine, and difficulty breathing. Once again the symptoms were blamed on hemorrhoids even though the patient questioned the diagnosis.

The patient continued to see various providers at the army community hospital for the rest of the year, during which time she turned 50. None of them recommended a colonoscopy despite standard recommendations to begin colorectal cancer screening at 50 years of age and the woman’s symptoms, which suggested colorectal cancer.

In March of the following year, the patient consulted a bariatric surgeon in private practice, who recommended evaluating the patient’s bloody stools and offered to perform a diagnostic colonoscopy if authorized. The army hospital didn’t immediately authorize the procedure, and it wasn’t performed.

In late September, the patient consulted a surgeon at the hospital, by which time bright red blood was squirting from her anal region and appeared in the toilet water after every bowel movement. She had never undergone a full colon evaluation.

Less than a week after the surgery consult, the patient’s husband was transferred to another military base. Her doctors said that a surgeon at the new base would be told about her medical condition, but that didn’t happen.

Five months later, a surgery consultation at the new military base found a rectal lesion extending 8 cm into the rectum from the anal verge. Pathology confirmed stage IIIC mucinous adenocarcinoma that had spread to the lymph nodes. Two years later, after several surgeries, chemotherapy, and radiation, the patient died at 53 years of age.

PLAINTIFF’S CLAIM If testing to rule out rectal cancer, such as a colonoscopy, had been performed earlier, the cancer would have been diagnosed at a curable stage.

THE DEFENSE No information about the defense is available.

VERDICT $2.15 million Tennessee settlement.

COMMENT Recurrent, unrelenting symptoms should prompt the alert clinician to explore alternative diagnoses.

For want of diagnosis and treatment, kidney function is lost

A FEBRILE ILLNESS prompted a patient to visit his primary care physician. After 3 months of treatment by the primary care doctor, the patient sought a second opinion and treatment from a federally funded community health clinic, where he was treated for 2 more months. During that time, the patient developed signs and symptoms of impaired kidney function, which laboratory results confirmed.

The clinic staff didn’t address the possible loss of kidney function. Three days after his last examination at the clinic, the patient went to a hospital emergency department, where he was promptly diagnosed with subacute bacterial endocarditis. His kidney function could not be restored.

PLAINTIFF’S CLAIM The primary care physician and the staff at the clinic were negligent in failing to diagnose and treat the kidney issues. Also, they didn’t recognize and treat the signs and symptoms of subacute bacterial endocarditis.

THE DEFENSE The primary care physician claimed that the patient’s injuries resulted solely from negligence on the part of the clinic staff. He maintained that the patient’s kidney function was normal when the man left his care. The federal government, on behalf of the clinic staff, claimed that the primary care physician was at least 50% responsible for the patient’s injuries.

VERDICT $1.45 million Texas settlement.

COMMENT Subacute bacterial endocarditis can be a challenging diagnosis because of the subtlety and variety of presentations. Remember the zebras when confronted with unexplained symptoms and signs.

Neuropathy blamed on belated diabetes diagnosis

A PATIENT IN A FAMILY PRACTICE was treated by several of the doctors and a physician assistant in the group over about a decade. After the patient developed neuropathy in his arms and legs, he was diagnosed with type 2 diabetes.

PLAINTIFF’S CLAIM Earlier diagnosis of the diabetes would have prevented development of neuropathy. High blood glucose levels identified on tests weren’t addressed.

THE DEFENSE Only 3 tests had shown excessive levels of glucose; the patient had many comorbidities that required attention. A special diet had been prescribed that would have helped control glucose levels. This was an appropriate initial step to address a diagnosis of type 2 diabetes.

VERDICT $285,000 New York settlement.

COMMENT It’s easy to overlook or postpone treatment of apparently less urgent issues such as glucose intolerance. Clear documentation and explicit discussion with patients might help mitigate the risk of adverse judgments.

Too many narcotic prescriptions

A WOMAN TREATED FOR CHRONIC SINUSITIS by an ear, nose, and throat physician received prescriptions for oxycodone, acetaminophen and oxycodone, and methadone for years to relieve headaches and facial pain. She died at 40 years of age from a methadone overdose. The physician admitted in a deposition that he’d kept on prescribing the medications even after the patient’s health insurer informed him that she was obtaining narcotics from multiple providers.

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

THE DEFENSE No information about the defense is available.

VERDICT $1.05 million New Jersey settlement.

COMMENT Strict tracking and oversight of opioid administration is essential. Clear documentation and regular follow-up remain very important.

Delayed Tx turns skin breakdown into a long-term problem

A NEARLY IMMOBILE WOMAN was discharged from a hospital—where she’d been treated for congestive heart failure, hypertension, diabetes, altered mental status, severe arthritis, and gout—and transported by ambulance to her home. Discharge diagnoses included possible obstructive sleep apnea and hypercapnia. Because the patient needed a great deal of help with activities of daily living, her physician ordered home health services.

Twelve days after discharge, a representative from the home health agency performed an initial assessment in the patient’s home, at which time the patient’s daughter reported that her mother had developed some skin breakdown on her buttocks that required care. The home health nurse allegedly told the daughter that the agency would need an order from her mother’s physician before starting home treatment for the skin breakdown.

The daughter phoned the physician every day for the next few days to get treatment authorization, but the doctor didn’t return her calls. The home health agency didn’t seek authorization from the doctor.

When the home health nurse returned to the patient’s home a week later to begin care, the daughter again mentioned the areas of skin breakdown, which by that time had become pressure sores. The nurse didn’t treat the pressure sores. The home health agency tried to contact the patient’s physician, who didn’t return their calls.

The agency finally received an order to treat the pressure sores 6 days after the home health nurse had begun caring for the patient, by which time the sores were infected and considerably larger. Healing required more than a year of treatment.

PLAINTIFF’S CLAIM As a result of the delay in treating the pressure sores, the patient’s condition was worse that it otherwise would have been.

THE DEFENSE The defendants denied any negligence.

VERDICT Alabama defense verdict.

COMMENT Better communication and coordination of care between home health providers and a patient’s medical home are important to provide optimal care—and avoid lawsuits.

“Hemorrhoids” turn out to be cancer

A 49-YEAR-OLD WOMAN, whose husband was on active duty with the US Army, went to an army community hospital in March complaining of hemorrhoids, back pain, and itching, burning, and pain with bowel movements. A guaiac-based fecal occult blood test was positive; no further testing was done to rule out rectal cancer.

The woman was discharged with pain medication but returned the following day, reporting intense anal pain despite taking the medication and bright red blood in her stools. The symptoms were attributed to hemorrhoids, and the patient was given a toilet “donut” and topical medication. Although her records noted a referral to a general surgeon, the referral wasn’t arranged or scheduled.

The patient returned to the hospital in April, May, and June with continuing complaints that included unrelieved constipation. A laxative was prescribed, but no further testing was done, nor was the patient referred to a surgeon.

In August, she went to the emergency department because of rectal bleeding for the previous 2 weeks, abdominal pain, blood in her urine, and difficulty breathing. Once again the symptoms were blamed on hemorrhoids even though the patient questioned the diagnosis.

The patient continued to see various providers at the army community hospital for the rest of the year, during which time she turned 50. None of them recommended a colonoscopy despite standard recommendations to begin colorectal cancer screening at 50 years of age and the woman’s symptoms, which suggested colorectal cancer.

In March of the following year, the patient consulted a bariatric surgeon in private practice, who recommended evaluating the patient’s bloody stools and offered to perform a diagnostic colonoscopy if authorized. The army hospital didn’t immediately authorize the procedure, and it wasn’t performed.

In late September, the patient consulted a surgeon at the hospital, by which time bright red blood was squirting from her anal region and appeared in the toilet water after every bowel movement. She had never undergone a full colon evaluation.

Less than a week after the surgery consult, the patient’s husband was transferred to another military base. Her doctors said that a surgeon at the new base would be told about her medical condition, but that didn’t happen.

Five months later, a surgery consultation at the new military base found a rectal lesion extending 8 cm into the rectum from the anal verge. Pathology confirmed stage IIIC mucinous adenocarcinoma that had spread to the lymph nodes. Two years later, after several surgeries, chemotherapy, and radiation, the patient died at 53 years of age.

PLAINTIFF’S CLAIM If testing to rule out rectal cancer, such as a colonoscopy, had been performed earlier, the cancer would have been diagnosed at a curable stage.

THE DEFENSE No information about the defense is available.

VERDICT $2.15 million Tennessee settlement.

COMMENT Recurrent, unrelenting symptoms should prompt the alert clinician to explore alternative diagnoses.

For want of diagnosis and treatment, kidney function is lost

A FEBRILE ILLNESS prompted a patient to visit his primary care physician. After 3 months of treatment by the primary care doctor, the patient sought a second opinion and treatment from a federally funded community health clinic, where he was treated for 2 more months. During that time, the patient developed signs and symptoms of impaired kidney function, which laboratory results confirmed.

The clinic staff didn’t address the possible loss of kidney function. Three days after his last examination at the clinic, the patient went to a hospital emergency department, where he was promptly diagnosed with subacute bacterial endocarditis. His kidney function could not be restored.

PLAINTIFF’S CLAIM The primary care physician and the staff at the clinic were negligent in failing to diagnose and treat the kidney issues. Also, they didn’t recognize and treat the signs and symptoms of subacute bacterial endocarditis.

THE DEFENSE The primary care physician claimed that the patient’s injuries resulted solely from negligence on the part of the clinic staff. He maintained that the patient’s kidney function was normal when the man left his care. The federal government, on behalf of the clinic staff, claimed that the primary care physician was at least 50% responsible for the patient’s injuries.

VERDICT $1.45 million Texas settlement.

COMMENT Subacute bacterial endocarditis can be a challenging diagnosis because of the subtlety and variety of presentations. Remember the zebras when confronted with unexplained symptoms and signs.

Neuropathy blamed on belated diabetes diagnosis

A PATIENT IN A FAMILY PRACTICE was treated by several of the doctors and a physician assistant in the group over about a decade. After the patient developed neuropathy in his arms and legs, he was diagnosed with type 2 diabetes.

PLAINTIFF’S CLAIM Earlier diagnosis of the diabetes would have prevented development of neuropathy. High blood glucose levels identified on tests weren’t addressed.

THE DEFENSE Only 3 tests had shown excessive levels of glucose; the patient had many comorbidities that required attention. A special diet had been prescribed that would have helped control glucose levels. This was an appropriate initial step to address a diagnosis of type 2 diabetes.

VERDICT $285,000 New York settlement.

COMMENT It’s easy to overlook or postpone treatment of apparently less urgent issues such as glucose intolerance. Clear documentation and explicit discussion with patients might help mitigate the risk of adverse judgments.

Too many narcotic prescriptions

A WOMAN TREATED FOR CHRONIC SINUSITIS by an ear, nose, and throat physician received prescriptions for oxycodone, acetaminophen and oxycodone, and methadone for years to relieve headaches and facial pain. She died at 40 years of age from a methadone overdose. The physician admitted in a deposition that he’d kept on prescribing the medications even after the patient’s health insurer informed him that she was obtaining narcotics from multiple providers.

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

THE DEFENSE No information about the defense is available.

VERDICT $1.05 million New Jersey settlement.

COMMENT Strict tracking and oversight of opioid administration is essential. Clear documentation and regular follow-up remain very important.

Delayed Tx turns skin breakdown into a long-term problem

A NEARLY IMMOBILE WOMAN was discharged from a hospital—where she’d been treated for congestive heart failure, hypertension, diabetes, altered mental status, severe arthritis, and gout—and transported by ambulance to her home. Discharge diagnoses included possible obstructive sleep apnea and hypercapnia. Because the patient needed a great deal of help with activities of daily living, her physician ordered home health services.

Twelve days after discharge, a representative from the home health agency performed an initial assessment in the patient’s home, at which time the patient’s daughter reported that her mother had developed some skin breakdown on her buttocks that required care. The home health nurse allegedly told the daughter that the agency would need an order from her mother’s physician before starting home treatment for the skin breakdown.

The daughter phoned the physician every day for the next few days to get treatment authorization, but the doctor didn’t return her calls. The home health agency didn’t seek authorization from the doctor.

When the home health nurse returned to the patient’s home a week later to begin care, the daughter again mentioned the areas of skin breakdown, which by that time had become pressure sores. The nurse didn’t treat the pressure sores. The home health agency tried to contact the patient’s physician, who didn’t return their calls.

The agency finally received an order to treat the pressure sores 6 days after the home health nurse had begun caring for the patient, by which time the sores were infected and considerably larger. Healing required more than a year of treatment.

PLAINTIFF’S CLAIM As a result of the delay in treating the pressure sores, the patient’s condition was worse that it otherwise would have been.

THE DEFENSE The defendants denied any negligence.

VERDICT Alabama defense verdict.

COMMENT Better communication and coordination of care between home health providers and a patient’s medical home are important to provide optimal care—and avoid lawsuits.

“Hemorrhoids” turn out to be cancer

A 49-YEAR-OLD WOMAN, whose husband was on active duty with the US Army, went to an army community hospital in March complaining of hemorrhoids, back pain, and itching, burning, and pain with bowel movements. A guaiac-based fecal occult blood test was positive; no further testing was done to rule out rectal cancer.

The woman was discharged with pain medication but returned the following day, reporting intense anal pain despite taking the medication and bright red blood in her stools. The symptoms were attributed to hemorrhoids, and the patient was given a toilet “donut” and topical medication. Although her records noted a referral to a general surgeon, the referral wasn’t arranged or scheduled.

The patient returned to the hospital in April, May, and June with continuing complaints that included unrelieved constipation. A laxative was prescribed, but no further testing was done, nor was the patient referred to a surgeon.

In August, she went to the emergency department because of rectal bleeding for the previous 2 weeks, abdominal pain, blood in her urine, and difficulty breathing. Once again the symptoms were blamed on hemorrhoids even though the patient questioned the diagnosis.

The patient continued to see various providers at the army community hospital for the rest of the year, during which time she turned 50. None of them recommended a colonoscopy despite standard recommendations to begin colorectal cancer screening at 50 years of age and the woman’s symptoms, which suggested colorectal cancer.

In March of the following year, the patient consulted a bariatric surgeon in private practice, who recommended evaluating the patient’s bloody stools and offered to perform a diagnostic colonoscopy if authorized. The army hospital didn’t immediately authorize the procedure, and it wasn’t performed.

In late September, the patient consulted a surgeon at the hospital, by which time bright red blood was squirting from her anal region and appeared in the toilet water after every bowel movement. She had never undergone a full colon evaluation.

Less than a week after the surgery consult, the patient’s husband was transferred to another military base. Her doctors said that a surgeon at the new base would be told about her medical condition, but that didn’t happen.

Five months later, a surgery consultation at the new military base found a rectal lesion extending 8 cm into the rectum from the anal verge. Pathology confirmed stage IIIC mucinous adenocarcinoma that had spread to the lymph nodes. Two years later, after several surgeries, chemotherapy, and radiation, the patient died at 53 years of age.

PLAINTIFF’S CLAIM If testing to rule out rectal cancer, such as a colonoscopy, had been performed earlier, the cancer would have been diagnosed at a curable stage.

THE DEFENSE No information about the defense is available.

VERDICT $2.15 million Tennessee settlement.

COMMENT Recurrent, unrelenting symptoms should prompt the alert clinician to explore alternative diagnoses.

For want of diagnosis and treatment, kidney function is lost

A FEBRILE ILLNESS prompted a patient to visit his primary care physician. After 3 months of treatment by the primary care doctor, the patient sought a second opinion and treatment from a federally funded community health clinic, where he was treated for 2 more months. During that time, the patient developed signs and symptoms of impaired kidney function, which laboratory results confirmed.

The clinic staff didn’t address the possible loss of kidney function. Three days after his last examination at the clinic, the patient went to a hospital emergency department, where he was promptly diagnosed with subacute bacterial endocarditis. His kidney function could not be restored.

PLAINTIFF’S CLAIM The primary care physician and the staff at the clinic were negligent in failing to diagnose and treat the kidney issues. Also, they didn’t recognize and treat the signs and symptoms of subacute bacterial endocarditis.

THE DEFENSE The primary care physician claimed that the patient’s injuries resulted solely from negligence on the part of the clinic staff. He maintained that the patient’s kidney function was normal when the man left his care. The federal government, on behalf of the clinic staff, claimed that the primary care physician was at least 50% responsible for the patient’s injuries.

VERDICT $1.45 million Texas settlement.

COMMENT Subacute bacterial endocarditis can be a challenging diagnosis because of the subtlety and variety of presentations. Remember the zebras when confronted with unexplained symptoms and signs.

Neuropathy blamed on belated diabetes diagnosis

A PATIENT IN A FAMILY PRACTICE was treated by several of the doctors and a physician assistant in the group over about a decade. After the patient developed neuropathy in his arms and legs, he was diagnosed with type 2 diabetes.

PLAINTIFF’S CLAIM Earlier diagnosis of the diabetes would have prevented development of neuropathy. High blood glucose levels identified on tests weren’t addressed.

THE DEFENSE Only 3 tests had shown excessive levels of glucose; the patient had many comorbidities that required attention. A special diet had been prescribed that would have helped control glucose levels. This was an appropriate initial step to address a diagnosis of type 2 diabetes.

VERDICT $285,000 New York settlement.

COMMENT It’s easy to overlook or postpone treatment of apparently less urgent issues such as glucose intolerance. Clear documentation and explicit discussion with patients might help mitigate the risk of adverse judgments.

Too many narcotic prescriptions

A WOMAN TREATED FOR CHRONIC SINUSITIS by an ear, nose, and throat physician received prescriptions for oxycodone, acetaminophen and oxycodone, and methadone for years to relieve headaches and facial pain. She died at 40 years of age from a methadone overdose. The physician admitted in a deposition that he’d kept on prescribing the medications even after the patient’s health insurer informed him that she was obtaining narcotics from multiple providers.

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

THE DEFENSE No information about the defense is available.

VERDICT $1.05 million New Jersey settlement.

COMMENT Strict tracking and oversight of opioid administration is essential. Clear documentation and regular follow-up remain very important.

Delayed Tx turns skin breakdown into a long-term problem

A NEARLY IMMOBILE WOMAN was discharged from a hospital—where she’d been treated for congestive heart failure, hypertension, diabetes, altered mental status, severe arthritis, and gout—and transported by ambulance to her home. Discharge diagnoses included possible obstructive sleep apnea and hypercapnia. Because the patient needed a great deal of help with activities of daily living, her physician ordered home health services.

Twelve days after discharge, a representative from the home health agency performed an initial assessment in the patient’s home, at which time the patient’s daughter reported that her mother had developed some skin breakdown on her buttocks that required care. The home health nurse allegedly told the daughter that the agency would need an order from her mother’s physician before starting home treatment for the skin breakdown.

The daughter phoned the physician every day for the next few days to get treatment authorization, but the doctor didn’t return her calls. The home health agency didn’t seek authorization from the doctor.

When the home health nurse returned to the patient’s home a week later to begin care, the daughter again mentioned the areas of skin breakdown, which by that time had become pressure sores. The nurse didn’t treat the pressure sores. The home health agency tried to contact the patient’s physician, who didn’t return their calls.

The agency finally received an order to treat the pressure sores 6 days after the home health nurse had begun caring for the patient, by which time the sores were infected and considerably larger. Healing required more than a year of treatment.

PLAINTIFF’S CLAIM As a result of the delay in treating the pressure sores, the patient’s condition was worse that it otherwise would have been.

THE DEFENSE The defendants denied any negligence.

VERDICT Alabama defense verdict.

COMMENT Better communication and coordination of care between home health providers and a patient’s medical home are important to provide optimal care—and avoid lawsuits.

Bedside visit comes too late

A 22-YEAR-OLD MAN underwent a liver biopsy after being admitted to the hospital a week earlier with fever, chills, diarrhea, and general malaise. A number of specialists had seen him in the hospital because of abnormal laboratory studies, increasing fever, and a maculopapular rash over his trunk and face.

After the biopsy, the patient was dizzy and diaphoretic. His attending physician ordered hemoglobin and hematocrit levels, which were lower than earlier that day. Repeat testing showed a further decrease, prompting the physician to order 2 units of red blood cells.

Typing and cross-matching delayed the transfusion for several hours. Before it could be started, the patient was found unresponsive. When the attending physician came to the bedside, the patient had no palpable pulse. A code was called, but resuscitation efforts failed.

An autopsy found a small hole in the liver and 3500 mL of blood in the peritoneal cavity, as well as hepatitis with zonal and submassive necrosis, hemoperitoneum, and hypertrophy of the heart. An HIV test performed before the biopsy eventually came back positive.

PLAINTIFF’S CLAIM The attending physician and nurses were negligent in failing to respond to signs and symptoms of internal bleeding, including falling hematocrit and hemoglobin levels. The attending physician, who was at the hospital when the patient’s condition deteriorated, should have gone to the bedside and taken steps to prevent his death.

THE DEFENSE The patient had been stable overnight; a bedside exam was unnecessary.

VERDICT $1,815,658 Texas verdict.

COMMENT Considering the many demands on clinicians’ time, it’s easy to postpone a face-to-face evaluation of a patient after a procedure. In this case, such a delay cost more than $1.8 million. A laboratory test or nurses’ notes are sometimes inadequate substitutes for a physician’s evaluation.

Failure to investigate suspicious symptoms ends badly

A MAN WITH SIGNS AND SYMPTOMS SUGGESTIVE OF AORTIC ANEURYSM/DISSECTION—including chest pain, pericardial effusion, aortic regurgitation, and aortic dilatation—saw his physician, but the doctor didn’t order any tests, such as computed tomography (CT) with contrast, magnetic resonance imaging (MRI), or transesophageal echocardiogram (TEE).

Two weeks later, the 43-year-old patient returned to the physician, who noted left ventricular hypertrophy with pericardial effusion and mild aortic loop dilatation. Once again, the doctor didn’t order tests to rule out aneurysm/dissection.

Three weeks after the second office visit, the patient collapsed and was taken by ambulance to a hospital, where he was pronounced dead. An autopsy indicated that the cause of death was cardiac tamponade resulting from an undiagnosed aortic dissection.

PLAINTIFF’S CLAIM The physician should have ordered a CT scan with contrast, an MRI, or a TEE, any of which would have confirmed an aortic aneurysm/dissection, mandating immediate admission to a hospital for surgery.

THE DEFENSE No information about the defense is available.

VERDICT $1 million Maryland settlement.

COMMENT Although many common conditions will resolve spontaneously, it’s hard to imagine temporizing in a patient with chest pain and presumed aortic dissection.

Unrecognized spinal infection leads to paralysis

A 355-LB MAN WITH DIABETES AND SPINAL DISC DISEASE experienced a sharp pain between his shoulder blades after playing golf, followed by constant back pain radiating to his chest. He went to the emergency department (ED) the next day and was admitted to the hospital to rule out a heart attack.

During a week in the hospital, the patient was seen by several doctors and diagnosed with pneumonia and excessive myoglobin levels. A computed tomography (CT) scan of the thorax and abdomen showing fluid buildup in the lining around the lungs led to the pneumonia diagnosis. No definitive spinal view was available, however, because of a mixup between a secretary and a radiology technician.

When the patient saw the hospital attending physician (at the family practice group where she was a partner) after discharge from the hospital, he complained of shooting pain down his spine. The doctor prescribed muscle relaxants. Soon afterward, the patient developed difficulty walking and reported no bowel movements for 13 days.

Almost 2 weeks after discharge from the hospital, the patient broke his ankle. He told the paramedics who responded that he felt numb from his nipples to his feet. He was taken to a community hospital, where a doctor ordered another CT scan. The radiologist who read the scan failed to identify the serious spinal infection it indicated.

The patient was transferred back to the original hospital. No doctor saw him for 8 hours after transfer, by which time he was paralyzed from the chest down.

PLAINTIFF’S CLAIM The fluid buildup on the first CT scan was caused not by pneumonia but by an infection in the spinal discs that had spread to the vertebrae and surrounding tissue.

THE DEFENSE The attending physician denied at trial that the patient had told her about the shooting pains down his spine during the posthospitalization visit.

VERDICT $4.75 million Illinois verdict, preceded by more than $2.7 million in settlements with some of the doctors involved and the community hospital.

COMMENT Careful follow-up of ED visits and coordinated care are essential to avoid large verdicts such as this one.

Bedside visit comes too late

A 22-YEAR-OLD MAN underwent a liver biopsy after being admitted to the hospital a week earlier with fever, chills, diarrhea, and general malaise. A number of specialists had seen him in the hospital because of abnormal laboratory studies, increasing fever, and a maculopapular rash over his trunk and face.

After the biopsy, the patient was dizzy and diaphoretic. His attending physician ordered hemoglobin and hematocrit levels, which were lower than earlier that day. Repeat testing showed a further decrease, prompting the physician to order 2 units of red blood cells.

Typing and cross-matching delayed the transfusion for several hours. Before it could be started, the patient was found unresponsive. When the attending physician came to the bedside, the patient had no palpable pulse. A code was called, but resuscitation efforts failed.

An autopsy found a small hole in the liver and 3500 mL of blood in the peritoneal cavity, as well as hepatitis with zonal and submassive necrosis, hemoperitoneum, and hypertrophy of the heart. An HIV test performed before the biopsy eventually came back positive.

PLAINTIFF’S CLAIM The attending physician and nurses were negligent in failing to respond to signs and symptoms of internal bleeding, including falling hematocrit and hemoglobin levels. The attending physician, who was at the hospital when the patient’s condition deteriorated, should have gone to the bedside and taken steps to prevent his death.

THE DEFENSE The patient had been stable overnight; a bedside exam was unnecessary.

VERDICT $1,815,658 Texas verdict.

COMMENT Considering the many demands on clinicians’ time, it’s easy to postpone a face-to-face evaluation of a patient after a procedure. In this case, such a delay cost more than $1.8 million. A laboratory test or nurses’ notes are sometimes inadequate substitutes for a physician’s evaluation.

Failure to investigate suspicious symptoms ends badly

A MAN WITH SIGNS AND SYMPTOMS SUGGESTIVE OF AORTIC ANEURYSM/DISSECTION—including chest pain, pericardial effusion, aortic regurgitation, and aortic dilatation—saw his physician, but the doctor didn’t order any tests, such as computed tomography (CT) with contrast, magnetic resonance imaging (MRI), or transesophageal echocardiogram (TEE).

Two weeks later, the 43-year-old patient returned to the physician, who noted left ventricular hypertrophy with pericardial effusion and mild aortic loop dilatation. Once again, the doctor didn’t order tests to rule out aneurysm/dissection.

Three weeks after the second office visit, the patient collapsed and was taken by ambulance to a hospital, where he was pronounced dead. An autopsy indicated that the cause of death was cardiac tamponade resulting from an undiagnosed aortic dissection.

PLAINTIFF’S CLAIM The physician should have ordered a CT scan with contrast, an MRI, or a TEE, any of which would have confirmed an aortic aneurysm/dissection, mandating immediate admission to a hospital for surgery.

THE DEFENSE No information about the defense is available.

VERDICT $1 million Maryland settlement.

COMMENT Although many common conditions will resolve spontaneously, it’s hard to imagine temporizing in a patient with chest pain and presumed aortic dissection.

Unrecognized spinal infection leads to paralysis

A 355-LB MAN WITH DIABETES AND SPINAL DISC DISEASE experienced a sharp pain between his shoulder blades after playing golf, followed by constant back pain radiating to his chest. He went to the emergency department (ED) the next day and was admitted to the hospital to rule out a heart attack.

During a week in the hospital, the patient was seen by several doctors and diagnosed with pneumonia and excessive myoglobin levels. A computed tomography (CT) scan of the thorax and abdomen showing fluid buildup in the lining around the lungs led to the pneumonia diagnosis. No definitive spinal view was available, however, because of a mixup between a secretary and a radiology technician.

When the patient saw the hospital attending physician (at the family practice group where she was a partner) after discharge from the hospital, he complained of shooting pain down his spine. The doctor prescribed muscle relaxants. Soon afterward, the patient developed difficulty walking and reported no bowel movements for 13 days.

Almost 2 weeks after discharge from the hospital, the patient broke his ankle. He told the paramedics who responded that he felt numb from his nipples to his feet. He was taken to a community hospital, where a doctor ordered another CT scan. The radiologist who read the scan failed to identify the serious spinal infection it indicated.

The patient was transferred back to the original hospital. No doctor saw him for 8 hours after transfer, by which time he was paralyzed from the chest down.

PLAINTIFF’S CLAIM The fluid buildup on the first CT scan was caused not by pneumonia but by an infection in the spinal discs that had spread to the vertebrae and surrounding tissue.

THE DEFENSE The attending physician denied at trial that the patient had told her about the shooting pains down his spine during the posthospitalization visit.

VERDICT $4.75 million Illinois verdict, preceded by more than $2.7 million in settlements with some of the doctors involved and the community hospital.

COMMENT Careful follow-up of ED visits and coordinated care are essential to avoid large verdicts such as this one.

Bedside visit comes too late

A 22-YEAR-OLD MAN underwent a liver biopsy after being admitted to the hospital a week earlier with fever, chills, diarrhea, and general malaise. A number of specialists had seen him in the hospital because of abnormal laboratory studies, increasing fever, and a maculopapular rash over his trunk and face.

After the biopsy, the patient was dizzy and diaphoretic. His attending physician ordered hemoglobin and hematocrit levels, which were lower than earlier that day. Repeat testing showed a further decrease, prompting the physician to order 2 units of red blood cells.

Typing and cross-matching delayed the transfusion for several hours. Before it could be started, the patient was found unresponsive. When the attending physician came to the bedside, the patient had no palpable pulse. A code was called, but resuscitation efforts failed.

An autopsy found a small hole in the liver and 3500 mL of blood in the peritoneal cavity, as well as hepatitis with zonal and submassive necrosis, hemoperitoneum, and hypertrophy of the heart. An HIV test performed before the biopsy eventually came back positive.

PLAINTIFF’S CLAIM The attending physician and nurses were negligent in failing to respond to signs and symptoms of internal bleeding, including falling hematocrit and hemoglobin levels. The attending physician, who was at the hospital when the patient’s condition deteriorated, should have gone to the bedside and taken steps to prevent his death.

THE DEFENSE The patient had been stable overnight; a bedside exam was unnecessary.

VERDICT $1,815,658 Texas verdict.

COMMENT Considering the many demands on clinicians’ time, it’s easy to postpone a face-to-face evaluation of a patient after a procedure. In this case, such a delay cost more than $1.8 million. A laboratory test or nurses’ notes are sometimes inadequate substitutes for a physician’s evaluation.

Failure to investigate suspicious symptoms ends badly

A MAN WITH SIGNS AND SYMPTOMS SUGGESTIVE OF AORTIC ANEURYSM/DISSECTION—including chest pain, pericardial effusion, aortic regurgitation, and aortic dilatation—saw his physician, but the doctor didn’t order any tests, such as computed tomography (CT) with contrast, magnetic resonance imaging (MRI), or transesophageal echocardiogram (TEE).

Two weeks later, the 43-year-old patient returned to the physician, who noted left ventricular hypertrophy with pericardial effusion and mild aortic loop dilatation. Once again, the doctor didn’t order tests to rule out aneurysm/dissection.

Three weeks after the second office visit, the patient collapsed and was taken by ambulance to a hospital, where he was pronounced dead. An autopsy indicated that the cause of death was cardiac tamponade resulting from an undiagnosed aortic dissection.

PLAINTIFF’S CLAIM The physician should have ordered a CT scan with contrast, an MRI, or a TEE, any of which would have confirmed an aortic aneurysm/dissection, mandating immediate admission to a hospital for surgery.

THE DEFENSE No information about the defense is available.

VERDICT $1 million Maryland settlement.

COMMENT Although many common conditions will resolve spontaneously, it’s hard to imagine temporizing in a patient with chest pain and presumed aortic dissection.

Unrecognized spinal infection leads to paralysis

A 355-LB MAN WITH DIABETES AND SPINAL DISC DISEASE experienced a sharp pain between his shoulder blades after playing golf, followed by constant back pain radiating to his chest. He went to the emergency department (ED) the next day and was admitted to the hospital to rule out a heart attack.

During a week in the hospital, the patient was seen by several doctors and diagnosed with pneumonia and excessive myoglobin levels. A computed tomography (CT) scan of the thorax and abdomen showing fluid buildup in the lining around the lungs led to the pneumonia diagnosis. No definitive spinal view was available, however, because of a mixup between a secretary and a radiology technician.

When the patient saw the hospital attending physician (at the family practice group where she was a partner) after discharge from the hospital, he complained of shooting pain down his spine. The doctor prescribed muscle relaxants. Soon afterward, the patient developed difficulty walking and reported no bowel movements for 13 days.

Almost 2 weeks after discharge from the hospital, the patient broke his ankle. He told the paramedics who responded that he felt numb from his nipples to his feet. He was taken to a community hospital, where a doctor ordered another CT scan. The radiologist who read the scan failed to identify the serious spinal infection it indicated.

The patient was transferred back to the original hospital. No doctor saw him for 8 hours after transfer, by which time he was paralyzed from the chest down.

PLAINTIFF’S CLAIM The fluid buildup on the first CT scan was caused not by pneumonia but by an infection in the spinal discs that had spread to the vertebrae and surrounding tissue.

THE DEFENSE The attending physician denied at trial that the patient had told her about the shooting pains down his spine during the posthospitalization visit.

VERDICT $4.75 million Illinois verdict, preceded by more than $2.7 million in settlements with some of the doctors involved and the community hospital.

COMMENT Careful follow-up of ED visits and coordinated care are essential to avoid large verdicts such as this one.

Not your garden variety neck pain

PERSISTENT BILATERAL NECK PAIN so severe that he couldn’t sit down brought a man to the emergency department (ED), where he was given ketorolac and diazepam. About an hour later, he said that the pain was better and was discharged with a diagnosis of neck strain and spasm and instructions to see his primary care physician if the pain persisted or worsened.

Four days later, the patient went to his primary care physician complaining of neck pain radiating down both arms, numbness in the right thumb, fever, chills, dysuria, and myalgia in his legs. The doctor observed decreased range of motion of the neck in all directions and diagnosed likely prostatitis. He ordered co-trimoxazole (trimethoprim and sulfamethoxazole), a nonemergent magnetic resonance imaging (MRI) scan, and physical therapy.

Fourteen hours after the doctor visit, the patient went back to the ED in a wheelchair. An emergency MRI showed epidural disease up and down the cervical spine and extending into the thoracic spine. An epidural abscess with spinal cord compression was diagnosed and decompression and evacuation surgery with spinal fusion was performed.

After several weeks in the hospital, the patient was referred to rehabilitation for partial quadriplegia. He has no use of his legs and very limited use of his hands and fingers. He’s confined to a wheelchair and needs help with most activities of daily living.

PLAINTIFF’S CLAIM When the patient visited his primary care physician, he had a classic presentation of a spinal abscess and should have undergone an emergent MRI, which would have revealed the abscess and allowed treatment with antibiotics and surgery before permanent damage occurred.

THE DEFENSE The patient’s symptoms weren’t a typical presentation of spinal abscess. There was no way the physician could have known what would happen the next day.

VERDICT $3 million Massachusetts settlement.

COMMENT Yes, there are zebras among the horses. We have to be vigilant to diagnose the rare serious cause of common problems such as neck pain. The combination of neck pain, patchy neurologic findings, signs of infection, and bladder symptoms should have raised red flags.

Untimely death blamed on undiagnosed PE

A 28-YEAR-OLD MAN went to the emergency department (ED) complaining of low-grade fever, nonproductive cough, and dizziness for 2 days. He also had tachycardia and significant hypoxia. An ED physician who saw the patient an hour after his arrival noted that he complained of weakness, shortness of breath, and light-headedness. The differential diagnosis included pneumonia, congestive heart failure, and pulmonary embolism.

After reviewing an electrocardiogram, chest radiograph, and laboratory studies, the ED doctor diagnosed pneumonia and renal insufficiency. The patient was admitted to the hospital, then transferred to another hospital about 8 hours later. He wasn’t evaluated by a physician when he was admitted to the second hospital.

About 5 hours after admission, the patient got out of bed and collapsed in the presence of his wife. A code was called, but the patient never regained consciousness and died about an hour and a half later. An autopsy established a pulmonary embolism as the cause of death.

PLAINTIFF’S CLAIM The doctors were negligent in failing to diagnose and treat the pulmonary embolism. Proper treatment would have allowed the patient to survive.

THE DEFENSE There was no negligence; heparin therapy wouldn’t have prevented the patient’s death.

VERDICT $6.1 million Maryland verdict.

COMMENT It isn’t enough to think of pulmonary embolism; a prompt definitive diagnostic work-up and timely treatment are key to preventing such a catastrophic outcome.

Delayed herpes diagnosis leads to lifelong consequences

A 10-DAY-OLD INFANT was examined by a pediatrician, who noted vesicles dotting the baby’s tongue, a possible manifestation of herpes, and observed herpes labialis on the mother’s lips. The pediatrician concluded that the vesicles didn’t indicate herpes and discharged the baby, instructing the parents to have him reexamined if he developed a fever, irritability, or lethargy. The next day the pediatrician consulted a neonatologist, who advised immediate reexamination. The baby was taken to a hospital, but then was immediately transported to another hospital.

At the second hospital, a physician examined the baby and consulted an oral surgeon. The surgeon believed that the vesicles were caused by burns from a hot baby bottle. The baby was discharged.

Six days later, the mother brought the baby to his regular pediatrician. She reported that the infant had been feverish and lethargic. The pediatrician didn’t find vesicles or other abnormalities. She ordered a complete blood count and blood culture, gave antibiotics, and told the parents to bring the baby back to see her the next day.

Very early the next day, the parents brought the baby to a hospital with a temperature of 101.2°F. The examining physician contacted the child’s pediatrician, who said she wanted to see the baby at 8:00 AM. When the pediatrician examined him, the infant’s temperature was 100.5°F. She gave antibiotics and instructed the parents to bring the baby back the next day, when his test results would be available.

The next day, the parents told the pediatrician’s assistant who examined the baby that his arms and legs had been twitching the previous evening. The infant received antibiotics but began to exhibit jerky movements. The parents were told to take him to a hospital, where he was diagnosed with herpes simplex and residual brain damage.

The child has quadriparesis and can’t talk, walk, or feed himself. He can eat only pureed food.

PLAINTIFF’S CLAIM The herpes simplex infection should have been diagnosed earlier. The pediatrician who examined the infant initially should have cultured the vesicles (and made sure that acyclovir was given) or consulted with, or referred the child to, a specialist. The physician who saw the child at the second hospital should have consulted a specialist, which would have led to the administration of acyclovir.

THE DEFENSE Hospitalization wasn’t necessary and a culture wasn’t appropriate. The appearance of the vesicles when the baby was examined at the second hospital didn’t suggest herpes.

VERDICT Multiple New York settlements totaling $10.2 million.

COMMENT As with many malpractice cases, there were many opportunities to prevent an egregious outcome. I wonder whether anyone involved stopped to entertain a differential diagnosis and note the urgent conditions the presentation clearly suggested.

Not your garden variety neck pain

PERSISTENT BILATERAL NECK PAIN so severe that he couldn’t sit down brought a man to the emergency department (ED), where he was given ketorolac and diazepam. About an hour later, he said that the pain was better and was discharged with a diagnosis of neck strain and spasm and instructions to see his primary care physician if the pain persisted or worsened.

Four days later, the patient went to his primary care physician complaining of neck pain radiating down both arms, numbness in the right thumb, fever, chills, dysuria, and myalgia in his legs. The doctor observed decreased range of motion of the neck in all directions and diagnosed likely prostatitis. He ordered co-trimoxazole (trimethoprim and sulfamethoxazole), a nonemergent magnetic resonance imaging (MRI) scan, and physical therapy.

Fourteen hours after the doctor visit, the patient went back to the ED in a wheelchair. An emergency MRI showed epidural disease up and down the cervical spine and extending into the thoracic spine. An epidural abscess with spinal cord compression was diagnosed and decompression and evacuation surgery with spinal fusion was performed.

After several weeks in the hospital, the patient was referred to rehabilitation for partial quadriplegia. He has no use of his legs and very limited use of his hands and fingers. He’s confined to a wheelchair and needs help with most activities of daily living.

PLAINTIFF’S CLAIM When the patient visited his primary care physician, he had a classic presentation of a spinal abscess and should have undergone an emergent MRI, which would have revealed the abscess and allowed treatment with antibiotics and surgery before permanent damage occurred.

THE DEFENSE The patient’s symptoms weren’t a typical presentation of spinal abscess. There was no way the physician could have known what would happen the next day.

VERDICT $3 million Massachusetts settlement.

COMMENT Yes, there are zebras among the horses. We have to be vigilant to diagnose the rare serious cause of common problems such as neck pain. The combination of neck pain, patchy neurologic findings, signs of infection, and bladder symptoms should have raised red flags.

Untimely death blamed on undiagnosed PE

A 28-YEAR-OLD MAN went to the emergency department (ED) complaining of low-grade fever, nonproductive cough, and dizziness for 2 days. He also had tachycardia and significant hypoxia. An ED physician who saw the patient an hour after his arrival noted that he complained of weakness, shortness of breath, and light-headedness. The differential diagnosis included pneumonia, congestive heart failure, and pulmonary embolism.

After reviewing an electrocardiogram, chest radiograph, and laboratory studies, the ED doctor diagnosed pneumonia and renal insufficiency. The patient was admitted to the hospital, then transferred to another hospital about 8 hours later. He wasn’t evaluated by a physician when he was admitted to the second hospital.

About 5 hours after admission, the patient got out of bed and collapsed in the presence of his wife. A code was called, but the patient never regained consciousness and died about an hour and a half later. An autopsy established a pulmonary embolism as the cause of death.

PLAINTIFF’S CLAIM The doctors were negligent in failing to diagnose and treat the pulmonary embolism. Proper treatment would have allowed the patient to survive.

THE DEFENSE There was no negligence; heparin therapy wouldn’t have prevented the patient’s death.

VERDICT $6.1 million Maryland verdict.

COMMENT It isn’t enough to think of pulmonary embolism; a prompt definitive diagnostic work-up and timely treatment are key to preventing such a catastrophic outcome.

Delayed herpes diagnosis leads to lifelong consequences

A 10-DAY-OLD INFANT was examined by a pediatrician, who noted vesicles dotting the baby’s tongue, a possible manifestation of herpes, and observed herpes labialis on the mother’s lips. The pediatrician concluded that the vesicles didn’t indicate herpes and discharged the baby, instructing the parents to have him reexamined if he developed a fever, irritability, or lethargy. The next day the pediatrician consulted a neonatologist, who advised immediate reexamination. The baby was taken to a hospital, but then was immediately transported to another hospital.

At the second hospital, a physician examined the baby and consulted an oral surgeon. The surgeon believed that the vesicles were caused by burns from a hot baby bottle. The baby was discharged.

Six days later, the mother brought the baby to his regular pediatrician. She reported that the infant had been feverish and lethargic. The pediatrician didn’t find vesicles or other abnormalities. She ordered a complete blood count and blood culture, gave antibiotics, and told the parents to bring the baby back to see her the next day.

Very early the next day, the parents brought the baby to a hospital with a temperature of 101.2°F. The examining physician contacted the child’s pediatrician, who said she wanted to see the baby at 8:00 AM. When the pediatrician examined him, the infant’s temperature was 100.5°F. She gave antibiotics and instructed the parents to bring the baby back the next day, when his test results would be available.

The next day, the parents told the pediatrician’s assistant who examined the baby that his arms and legs had been twitching the previous evening. The infant received antibiotics but began to exhibit jerky movements. The parents were told to take him to a hospital, where he was diagnosed with herpes simplex and residual brain damage.

The child has quadriparesis and can’t talk, walk, or feed himself. He can eat only pureed food.

PLAINTIFF’S CLAIM The herpes simplex infection should have been diagnosed earlier. The pediatrician who examined the infant initially should have cultured the vesicles (and made sure that acyclovir was given) or consulted with, or referred the child to, a specialist. The physician who saw the child at the second hospital should have consulted a specialist, which would have led to the administration of acyclovir.

THE DEFENSE Hospitalization wasn’t necessary and a culture wasn’t appropriate. The appearance of the vesicles when the baby was examined at the second hospital didn’t suggest herpes.

VERDICT Multiple New York settlements totaling $10.2 million.

COMMENT As with many malpractice cases, there were many opportunities to prevent an egregious outcome. I wonder whether anyone involved stopped to entertain a differential diagnosis and note the urgent conditions the presentation clearly suggested.

Not your garden variety neck pain

PERSISTENT BILATERAL NECK PAIN so severe that he couldn’t sit down brought a man to the emergency department (ED), where he was given ketorolac and diazepam. About an hour later, he said that the pain was better and was discharged with a diagnosis of neck strain and spasm and instructions to see his primary care physician if the pain persisted or worsened.

Four days later, the patient went to his primary care physician complaining of neck pain radiating down both arms, numbness in the right thumb, fever, chills, dysuria, and myalgia in his legs. The doctor observed decreased range of motion of the neck in all directions and diagnosed likely prostatitis. He ordered co-trimoxazole (trimethoprim and sulfamethoxazole), a nonemergent magnetic resonance imaging (MRI) scan, and physical therapy.

Fourteen hours after the doctor visit, the patient went back to the ED in a wheelchair. An emergency MRI showed epidural disease up and down the cervical spine and extending into the thoracic spine. An epidural abscess with spinal cord compression was diagnosed and decompression and evacuation surgery with spinal fusion was performed.

After several weeks in the hospital, the patient was referred to rehabilitation for partial quadriplegia. He has no use of his legs and very limited use of his hands and fingers. He’s confined to a wheelchair and needs help with most activities of daily living.

PLAINTIFF’S CLAIM When the patient visited his primary care physician, he had a classic presentation of a spinal abscess and should have undergone an emergent MRI, which would have revealed the abscess and allowed treatment with antibiotics and surgery before permanent damage occurred.

THE DEFENSE The patient’s symptoms weren’t a typical presentation of spinal abscess. There was no way the physician could have known what would happen the next day.

VERDICT $3 million Massachusetts settlement.

COMMENT Yes, there are zebras among the horses. We have to be vigilant to diagnose the rare serious cause of common problems such as neck pain. The combination of neck pain, patchy neurologic findings, signs of infection, and bladder symptoms should have raised red flags.

Untimely death blamed on undiagnosed PE

A 28-YEAR-OLD MAN went to the emergency department (ED) complaining of low-grade fever, nonproductive cough, and dizziness for 2 days. He also had tachycardia and significant hypoxia. An ED physician who saw the patient an hour after his arrival noted that he complained of weakness, shortness of breath, and light-headedness. The differential diagnosis included pneumonia, congestive heart failure, and pulmonary embolism.

After reviewing an electrocardiogram, chest radiograph, and laboratory studies, the ED doctor diagnosed pneumonia and renal insufficiency. The patient was admitted to the hospital, then transferred to another hospital about 8 hours later. He wasn’t evaluated by a physician when he was admitted to the second hospital.

About 5 hours after admission, the patient got out of bed and collapsed in the presence of his wife. A code was called, but the patient never regained consciousness and died about an hour and a half later. An autopsy established a pulmonary embolism as the cause of death.

PLAINTIFF’S CLAIM The doctors were negligent in failing to diagnose and treat the pulmonary embolism. Proper treatment would have allowed the patient to survive.

THE DEFENSE There was no negligence; heparin therapy wouldn’t have prevented the patient’s death.

VERDICT $6.1 million Maryland verdict.

COMMENT It isn’t enough to think of pulmonary embolism; a prompt definitive diagnostic work-up and timely treatment are key to preventing such a catastrophic outcome.

Delayed herpes diagnosis leads to lifelong consequences

A 10-DAY-OLD INFANT was examined by a pediatrician, who noted vesicles dotting the baby’s tongue, a possible manifestation of herpes, and observed herpes labialis on the mother’s lips. The pediatrician concluded that the vesicles didn’t indicate herpes and discharged the baby, instructing the parents to have him reexamined if he developed a fever, irritability, or lethargy. The next day the pediatrician consulted a neonatologist, who advised immediate reexamination. The baby was taken to a hospital, but then was immediately transported to another hospital.

At the second hospital, a physician examined the baby and consulted an oral surgeon. The surgeon believed that the vesicles were caused by burns from a hot baby bottle. The baby was discharged.

Six days later, the mother brought the baby to his regular pediatrician. She reported that the infant had been feverish and lethargic. The pediatrician didn’t find vesicles or other abnormalities. She ordered a complete blood count and blood culture, gave antibiotics, and told the parents to bring the baby back to see her the next day.

Very early the next day, the parents brought the baby to a hospital with a temperature of 101.2°F. The examining physician contacted the child’s pediatrician, who said she wanted to see the baby at 8:00 AM. When the pediatrician examined him, the infant’s temperature was 100.5°F. She gave antibiotics and instructed the parents to bring the baby back the next day, when his test results would be available.

The next day, the parents told the pediatrician’s assistant who examined the baby that his arms and legs had been twitching the previous evening. The infant received antibiotics but began to exhibit jerky movements. The parents were told to take him to a hospital, where he was diagnosed with herpes simplex and residual brain damage.

The child has quadriparesis and can’t talk, walk, or feed himself. He can eat only pureed food.

PLAINTIFF’S CLAIM The herpes simplex infection should have been diagnosed earlier. The pediatrician who examined the infant initially should have cultured the vesicles (and made sure that acyclovir was given) or consulted with, or referred the child to, a specialist. The physician who saw the child at the second hospital should have consulted a specialist, which would have led to the administration of acyclovir.

THE DEFENSE Hospitalization wasn’t necessary and a culture wasn’t appropriate. The appearance of the vesicles when the baby was examined at the second hospital didn’t suggest herpes.

VERDICT Multiple New York settlements totaling $10.2 million.

COMMENT As with many malpractice cases, there were many opportunities to prevent an egregious outcome. I wonder whether anyone involved stopped to entertain a differential diagnosis and note the urgent conditions the presentation clearly suggested.