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What Is Your Practice Worth?
At least once during your career, you will probably have to put a value on your practice. The need arises more often than you might think—if you sell it, of course; but also for estate planning, preparation of financial statements, and, unfortunately, during divorce negotiations; when an associate joins or leaves your office; or if you have occasion to combine or partner your practice with one or more others.
As you might guess, a medical practice is trickier to value than an ordinary business, and usually requires the services of an experienced professional appraiser. Entire books have been written on how to do it so I can't hope to cover the entire subject in 750 words, but there are three basic components to a practice appraisal:
▸ Tangible assets. Equipment, cash, accounts receivable, and other property owned by the practice.
▸ Liabilities. Accounts payable and outstanding loans.
▸ Intangible assets/“goodwill.” The reputation of the physicians, the location and name recognition of the practice, the loyalty and volume of patients, etc.
Using these components, there are three traditional approaches to determining value:
▸ Asset-based valuation. This approach uses a balance sheet to determine equity, the difference between what a practice owns (its assets) and what it owes (liabilities). (I covered balance sheets in the January 2006 column. If you missed it, you can go to www.skinandallergynews.com
▸ Income-based valuation. This looks at the source and strength of a practice's income stream as a creator of value, and whether that income stream under a different owner would mirror its present one. This, in turn, becomes the basis for an understanding of the fair market value of both tangible and intangible assets.
▸ Market valuation. This combines the previous two approaches and attempts to determine what the practice is worth in the local market by analyzing sales and mergers of comparable practices in the community.
Valuing tangible assets is comparatively straightforward, but there are several ways to do it, and when reviewing a practice appraisal you should ask which of them was used. Depreciated value is the book value of equipment and supplies as determined by their purchase price, less the amount their value has decreased since purchase. Remaining useful life value estimates how long the equipment can be expected to last. Market (or replacement) value is the amount it would cost on the open market to replace all equipment and supplies.
Intangible assets are more difficult to value. Many components are analyzed, including location, interior and exterior decor, accessibility to patients, age and functional status of equipment, systems in place to promote efficiency, reasons why patients come back (if in fact they do), and the overall reputation of the practice in the community. Other important factors include the payer mix (what percentage pays cash, how many third-party contracts are in place and how well they pay, etc.), and the extent and strength of the referral base.
It also is important to determine to what extent intangible assets can be transferred to another owner. Although such qualities as unique skill with a laser or filler substances and extraordinary personal charisma may increase your practice's value to you, they will be of little use to the next owner and he or she will be unwilling to pay for them.
Professional appraisers use a variety of techniques to estimate intangible asset value, and once again you should ask which were used. Cash flow analysis works on the assumption that cash flow is a measure of intangible value. Capitalization of earnings puts a value, or capitalization, on the practice's income streams using a variety of assumptions. Guideline comparison uses various publications, databases, and other records of transactions to compare your practice with other, similar ones that have changed hands in the past.
Two newer techniques that some believe provide a better estimate of intangible assets are the replacement method, which estimates the costs of starting the practice over again in the current market, and the excess earnings method, which determines the average earnings of a practice within your specialty and then measures how far above average your practice's earnings are. The theory behind the latter method is that a practice with above-average earnings is more valuable than an average one.
Whatever methods are used, it is important that the appraisal be done by an experienced financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation is supplied to support the conclusions reached. This is especially important if the appraisal will be relied upon in the sale of the practice. We'll talk about that next month.
At least once during your career, you will probably have to put a value on your practice. The need arises more often than you might think—if you sell it, of course; but also for estate planning, preparation of financial statements, and, unfortunately, during divorce negotiations; when an associate joins or leaves your office; or if you have occasion to combine or partner your practice with one or more others.
As you might guess, a medical practice is trickier to value than an ordinary business, and usually requires the services of an experienced professional appraiser. Entire books have been written on how to do it so I can't hope to cover the entire subject in 750 words, but there are three basic components to a practice appraisal:
▸ Tangible assets. Equipment, cash, accounts receivable, and other property owned by the practice.
▸ Liabilities. Accounts payable and outstanding loans.
▸ Intangible assets/“goodwill.” The reputation of the physicians, the location and name recognition of the practice, the loyalty and volume of patients, etc.
Using these components, there are three traditional approaches to determining value:
▸ Asset-based valuation. This approach uses a balance sheet to determine equity, the difference between what a practice owns (its assets) and what it owes (liabilities). (I covered balance sheets in the January 2006 column. If you missed it, you can go to www.skinandallergynews.com
▸ Income-based valuation. This looks at the source and strength of a practice's income stream as a creator of value, and whether that income stream under a different owner would mirror its present one. This, in turn, becomes the basis for an understanding of the fair market value of both tangible and intangible assets.
▸ Market valuation. This combines the previous two approaches and attempts to determine what the practice is worth in the local market by analyzing sales and mergers of comparable practices in the community.
Valuing tangible assets is comparatively straightforward, but there are several ways to do it, and when reviewing a practice appraisal you should ask which of them was used. Depreciated value is the book value of equipment and supplies as determined by their purchase price, less the amount their value has decreased since purchase. Remaining useful life value estimates how long the equipment can be expected to last. Market (or replacement) value is the amount it would cost on the open market to replace all equipment and supplies.
Intangible assets are more difficult to value. Many components are analyzed, including location, interior and exterior decor, accessibility to patients, age and functional status of equipment, systems in place to promote efficiency, reasons why patients come back (if in fact they do), and the overall reputation of the practice in the community. Other important factors include the payer mix (what percentage pays cash, how many third-party contracts are in place and how well they pay, etc.), and the extent and strength of the referral base.
It also is important to determine to what extent intangible assets can be transferred to another owner. Although such qualities as unique skill with a laser or filler substances and extraordinary personal charisma may increase your practice's value to you, they will be of little use to the next owner and he or she will be unwilling to pay for them.
Professional appraisers use a variety of techniques to estimate intangible asset value, and once again you should ask which were used. Cash flow analysis works on the assumption that cash flow is a measure of intangible value. Capitalization of earnings puts a value, or capitalization, on the practice's income streams using a variety of assumptions. Guideline comparison uses various publications, databases, and other records of transactions to compare your practice with other, similar ones that have changed hands in the past.
Two newer techniques that some believe provide a better estimate of intangible assets are the replacement method, which estimates the costs of starting the practice over again in the current market, and the excess earnings method, which determines the average earnings of a practice within your specialty and then measures how far above average your practice's earnings are. The theory behind the latter method is that a practice with above-average earnings is more valuable than an average one.
Whatever methods are used, it is important that the appraisal be done by an experienced financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation is supplied to support the conclusions reached. This is especially important if the appraisal will be relied upon in the sale of the practice. We'll talk about that next month.
At least once during your career, you will probably have to put a value on your practice. The need arises more often than you might think—if you sell it, of course; but also for estate planning, preparation of financial statements, and, unfortunately, during divorce negotiations; when an associate joins or leaves your office; or if you have occasion to combine or partner your practice with one or more others.
As you might guess, a medical practice is trickier to value than an ordinary business, and usually requires the services of an experienced professional appraiser. Entire books have been written on how to do it so I can't hope to cover the entire subject in 750 words, but there are three basic components to a practice appraisal:
▸ Tangible assets. Equipment, cash, accounts receivable, and other property owned by the practice.
▸ Liabilities. Accounts payable and outstanding loans.
▸ Intangible assets/“goodwill.” The reputation of the physicians, the location and name recognition of the practice, the loyalty and volume of patients, etc.
Using these components, there are three traditional approaches to determining value:
▸ Asset-based valuation. This approach uses a balance sheet to determine equity, the difference between what a practice owns (its assets) and what it owes (liabilities). (I covered balance sheets in the January 2006 column. If you missed it, you can go to www.skinandallergynews.com
▸ Income-based valuation. This looks at the source and strength of a practice's income stream as a creator of value, and whether that income stream under a different owner would mirror its present one. This, in turn, becomes the basis for an understanding of the fair market value of both tangible and intangible assets.
▸ Market valuation. This combines the previous two approaches and attempts to determine what the practice is worth in the local market by analyzing sales and mergers of comparable practices in the community.
Valuing tangible assets is comparatively straightforward, but there are several ways to do it, and when reviewing a practice appraisal you should ask which of them was used. Depreciated value is the book value of equipment and supplies as determined by their purchase price, less the amount their value has decreased since purchase. Remaining useful life value estimates how long the equipment can be expected to last. Market (or replacement) value is the amount it would cost on the open market to replace all equipment and supplies.
Intangible assets are more difficult to value. Many components are analyzed, including location, interior and exterior decor, accessibility to patients, age and functional status of equipment, systems in place to promote efficiency, reasons why patients come back (if in fact they do), and the overall reputation of the practice in the community. Other important factors include the payer mix (what percentage pays cash, how many third-party contracts are in place and how well they pay, etc.), and the extent and strength of the referral base.
It also is important to determine to what extent intangible assets can be transferred to another owner. Although such qualities as unique skill with a laser or filler substances and extraordinary personal charisma may increase your practice's value to you, they will be of little use to the next owner and he or she will be unwilling to pay for them.
Professional appraisers use a variety of techniques to estimate intangible asset value, and once again you should ask which were used. Cash flow analysis works on the assumption that cash flow is a measure of intangible value. Capitalization of earnings puts a value, or capitalization, on the practice's income streams using a variety of assumptions. Guideline comparison uses various publications, databases, and other records of transactions to compare your practice with other, similar ones that have changed hands in the past.
Two newer techniques that some believe provide a better estimate of intangible assets are the replacement method, which estimates the costs of starting the practice over again in the current market, and the excess earnings method, which determines the average earnings of a practice within your specialty and then measures how far above average your practice's earnings are. The theory behind the latter method is that a practice with above-average earnings is more valuable than an average one.
Whatever methods are used, it is important that the appraisal be done by an experienced financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation is supplied to support the conclusions reached. This is especially important if the appraisal will be relied upon in the sale of the practice. We'll talk about that next month.
OB blames disability on mother’s language ... Did doctors miss signs
of chorioamnionitis? ... “Postop gas, constipation led to divorce” ...
Missed tubo-ovarian abscess leads to death ...more
OB blames disability on mother’s language
A woman diagnosed with group B strep at 32 weeks’ gestation had spontaneous rupture of membranes at 36 to 37 weeks and developed a fever during labor and delivery. Several hours into labor, severe variable decelerations were noted and the infant was delivered by cesarean section. Within hours, the infant developed sepsis. The child survived, but suffers from learning disabilities.
PATIENT’S CLAIM The mother should have been given antibiotics before labor.
DOCTOR’S DEFENSE The physicians never received the lab report showing the test result. The child’s learning disability was not caused by any birth event, but by the mother’s use of her native Farsi at home.
VERDICT After mediation, the parties reached a $962,000 settlement.
Did doctors miss signs of chorioamnionitis?
A 30-year-old woman presented to the emergency room at 25 weeks’ gestation, complaining of abdominal pain. After examining her, doctors decided hospitalization was unnecessary. Nine days later, she returned to the hospital and reported vomiting and vaginal spotting. Immediate cesarean section was performed. The child was later diagnosed with mental and physical disabilities, including developmental delays and spastic quadriplegia.
PATIENT’S CLAIM The disabilities and premature birth were caused by an undiagnosed antepartum infection, and the chorioamnionitis should have been detected at the first emergency room visit. Prompt diagnosis and treatment would have prevented the adverse outcome.
DOCTOR’S DEFENSE The child’s injuries were unavoidable.
VERDICT $1.2 million settlement.
“Postop gas, constipation led to divorce”
A 34-year-old woman underwent laparoscopic tubal ligation. After the surgery, she developed a hernia, which was repaired via laparotomy.
PATIENT’S CLAIM The original surgery caused chronic constipation and gas and contributed to the patient’s divorce. The physician caused the hernia by failing to stitch the fascia closed.
DOCTOR’S DEFENSE It was not necessary to suture the fascia closed. The hernia occurred through an adhesion and below the fascia, so a stitch would not have prevented it. The patient’s marriage was in peril before the tubal ligation was performed.
VERDICT Defense verdict.
Missed tubo-ovarian abscess leads to death
A 42-year-old woman with anemia and complaints of generalized abdominal pain and heavy bleeding was referred to an ObGyn, who performed an endometrial biopsy and concluded that her pain and bleeding were caused by fibroids. A hysterectomy was scheduled, and pain medication was prescribed. When ultrasound imaging revealed a cyst, more pain medicine was prescribed, and the date for the hysterectomy was moved up. Blood tests showed extremely elevated white blood cell levels, indicative of infection, but the doctor did not receive results for several days.
The day after the patient visited the ObGyn, she collapsed at home and was taken to a hospital, where she died a few hours later. An autopsy revealed the death was due to sepsis from a right tubo-ovarian abscess. No fibroids were present.
PATIENT’S CLAIM The ObGyn was negligent in failing to examine the patient the day before her death, despite her report of severe pain. Furthermore, the physician caused the tubo-ovarian abscess at the time of the endometrial biopsy.
DOCTOR’S DEFENSE The diagnoses of uterine fibroids, possible ovarian cyst, and urinary tract infection explained all the patient’s symptoms, none of which were consistent with tubo-ovarian abscess.
VERDICT The jury ruled for the defense.
$12 million verdict despite counseling
A woman delivered an infant with spina bifida, who requires lifelong treatment.
PATIENT’S CLAIM The mother was not informed of the need for alpha-fetoprotein testing to detect neural tube defects and Down’s syndrome, and a nurse telephoned her to say the test was unnecessary because the woman was not at risk. As a result, the parents were denied the opportunity to have the pregnancy terminated.
DOCTOR’S DEFENSE The practice group’s records noted that test information was provided during a visit the previous year. The child’s problems were genetic and could not have been avoided.
VERDICT $12 million verdict.
5 operations needed after prolapse repair
A 51-year-old woman suffering from vaginal prolapse underwent pelvic reconstruction in January and continued under the surgeon’s care until May, when she was advised to return to the referring ObGyn. In June, she was found to have grossly distorted vaginal anatomy and infection, necessitating 5 additional operations.
PATIENT’S CLAIM The surgeon was negligent, failed to obtain informed consent, misrepresented the success rate of the procedure, and concealed the true condition of the vagina at the time of discharge. In addition, a mesh used to reinforce the anterior, apical, and posterior compartments of the vagina became infected, causing the distortion. The patient should have been treated with intravenous antibiotics and/or removal of the mesh.
DOCTOR’S DEFENSE Two prior reparative procedures had already been performed by the time he operated. The patient suffered not from infection, but from a reaction to the mesh, a foreign body.
VERDICT Defense verdict.
Did doctors treat UTI properly?
An 18-year-old woman in her 28th week of gestation presented to the hospital reporting decreased fetal movement. Urinary tract infection was diagnosed after leukocytes were detected in the woman’s urine. She was prescribed a 3-day regimen of antibiotics and discharged. Ten days later, she returned to report 2 episodes of vaginal bleeding. After reassuring fetal monitoring, the woman was again discharged.
About 5 days later, the woman returned and was diagnosed with prolonged preterm rupture of membranes, with contractions at 4- to 5-minute intervals. The woman was monitored over 17 hours, and her contractions lessened in frequency. When the fetus showed signs of bradycardia, cesarean section was performed. The child was diagnosed with severe mental retardation, cortical blindness, and spastic quadriplegia. The child is confined to a wheelchair and requires constant medical care and rehabilitation.
PATIENT’S CLAIM The urinary tract infection was not treated properly, and eventually led to ruptured membranes. A cesarean section should have been performed sooner.
DOCTOR’S DEFENSE The urinary tract infection caused the infant’s problems.
VERDICT $5 million settlement.
One twin dies, the other is severely handicapped
A woman pregnant with twins, who was using a fetal monitoring service at home, reported to the hospital at 29 weeks’ gestation because she was experiencing contractions. She was seen by a physician who reported she was less than 2-cm dilated. She was transferred to another facility; upon arrival, she was 4-cm dilated, and was given tocolytics to delay labor.
One child was delivered with respiratory distress syndrome, intracranial hemorrhage, and hydrocephalus, and the other infant died. The surviving twin, who is now 17 years of age, suffers from cerebral palsy, spastic quadriplegia, cortical blindness, and severe mental retardation. She is confined to a wheelchair, requires a feeding tube, and will need lifelong care.
PATIENT’S CLAIM The physician at the initial facility failed to administer tocolytics in time to prevent premature delivery.
DOCTOR’S DEFENSE There were no signs of labor, and administering tocolytics would not have prevented premature labor.
VERDICT $3 million settlement.
Patient delivers after D&C
A woman reported to the emergency room with severe abdominal pain, bleeding, and fever. Testing revealed she was 4 to 5 weeks pregnant. An OB performed a D&C. She gave birth to an unwanted child 7 months later.
PATIENT’S CLAIM The physician failed to tell her she was still pregnant after the D&C and did not provide her with follow-up instructions.
DOCTOR’S DEFENSE The physician performed the D&C not to terminate the pregnancy but to treat pelvic inflammatory disease and to remove remnants from a previous septic miscarriage. Subsequent testing confirmed that products of conception consistent with a nonviable pregnancy had been removed. The physician also claimed the patient was advised to report back to his office in 1 to 2 weeks to seek care for her pregnancy. Initially, the patient claimed she never received instructions to report back to the office for care; however, during testimony, she admitted to receiving instructions but could not recall them.
VERDICT Defense verdict.
Retained placenta leads to hysterectomy
A 40-year-old woman, acting as a surrogate for her brother and sister-in-law, gave birth to twins. Six weeks later, she underwent a hysterectomy.
PATIENT’S CLAIM The obstetrician failed to completely remove the placenta after the cesarean section, resulting in the hysterectomy 6 weeks later.
DOCTOR’S DEFENSE The failure to remove all of the placenta was not negligent, and the woman had placenta increta, which made it difficult to completely remove the placental tissue.
VERDICT The hospital settled for $125,000; the jury awarded the plaintiff $1.2 million against the physician.
The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, Nashville, Tenn (www.verdictslaska.com).The available information about the cases is sometimes incomplete; pertinent details may be unavailable. Moreover, the cases may or may not have merit. Still, these cases represent types of clinical situations that may result in litigation and are meant to illustrate variation in verdicts and awards. Any illustrations are generic and do not represent a specific legal case.
OB blames disability on mother’s language
A woman diagnosed with group B strep at 32 weeks’ gestation had spontaneous rupture of membranes at 36 to 37 weeks and developed a fever during labor and delivery. Several hours into labor, severe variable decelerations were noted and the infant was delivered by cesarean section. Within hours, the infant developed sepsis. The child survived, but suffers from learning disabilities.
PATIENT’S CLAIM The mother should have been given antibiotics before labor.
DOCTOR’S DEFENSE The physicians never received the lab report showing the test result. The child’s learning disability was not caused by any birth event, but by the mother’s use of her native Farsi at home.
VERDICT After mediation, the parties reached a $962,000 settlement.
Did doctors miss signs of chorioamnionitis?
A 30-year-old woman presented to the emergency room at 25 weeks’ gestation, complaining of abdominal pain. After examining her, doctors decided hospitalization was unnecessary. Nine days later, she returned to the hospital and reported vomiting and vaginal spotting. Immediate cesarean section was performed. The child was later diagnosed with mental and physical disabilities, including developmental delays and spastic quadriplegia.
PATIENT’S CLAIM The disabilities and premature birth were caused by an undiagnosed antepartum infection, and the chorioamnionitis should have been detected at the first emergency room visit. Prompt diagnosis and treatment would have prevented the adverse outcome.
DOCTOR’S DEFENSE The child’s injuries were unavoidable.
VERDICT $1.2 million settlement.
“Postop gas, constipation led to divorce”
A 34-year-old woman underwent laparoscopic tubal ligation. After the surgery, she developed a hernia, which was repaired via laparotomy.
PATIENT’S CLAIM The original surgery caused chronic constipation and gas and contributed to the patient’s divorce. The physician caused the hernia by failing to stitch the fascia closed.
DOCTOR’S DEFENSE It was not necessary to suture the fascia closed. The hernia occurred through an adhesion and below the fascia, so a stitch would not have prevented it. The patient’s marriage was in peril before the tubal ligation was performed.
VERDICT Defense verdict.
Missed tubo-ovarian abscess leads to death
A 42-year-old woman with anemia and complaints of generalized abdominal pain and heavy bleeding was referred to an ObGyn, who performed an endometrial biopsy and concluded that her pain and bleeding were caused by fibroids. A hysterectomy was scheduled, and pain medication was prescribed. When ultrasound imaging revealed a cyst, more pain medicine was prescribed, and the date for the hysterectomy was moved up. Blood tests showed extremely elevated white blood cell levels, indicative of infection, but the doctor did not receive results for several days.
The day after the patient visited the ObGyn, she collapsed at home and was taken to a hospital, where she died a few hours later. An autopsy revealed the death was due to sepsis from a right tubo-ovarian abscess. No fibroids were present.
PATIENT’S CLAIM The ObGyn was negligent in failing to examine the patient the day before her death, despite her report of severe pain. Furthermore, the physician caused the tubo-ovarian abscess at the time of the endometrial biopsy.
DOCTOR’S DEFENSE The diagnoses of uterine fibroids, possible ovarian cyst, and urinary tract infection explained all the patient’s symptoms, none of which were consistent with tubo-ovarian abscess.
VERDICT The jury ruled for the defense.
$12 million verdict despite counseling
A woman delivered an infant with spina bifida, who requires lifelong treatment.
PATIENT’S CLAIM The mother was not informed of the need for alpha-fetoprotein testing to detect neural tube defects and Down’s syndrome, and a nurse telephoned her to say the test was unnecessary because the woman was not at risk. As a result, the parents were denied the opportunity to have the pregnancy terminated.
DOCTOR’S DEFENSE The practice group’s records noted that test information was provided during a visit the previous year. The child’s problems were genetic and could not have been avoided.
VERDICT $12 million verdict.
5 operations needed after prolapse repair
A 51-year-old woman suffering from vaginal prolapse underwent pelvic reconstruction in January and continued under the surgeon’s care until May, when she was advised to return to the referring ObGyn. In June, she was found to have grossly distorted vaginal anatomy and infection, necessitating 5 additional operations.
PATIENT’S CLAIM The surgeon was negligent, failed to obtain informed consent, misrepresented the success rate of the procedure, and concealed the true condition of the vagina at the time of discharge. In addition, a mesh used to reinforce the anterior, apical, and posterior compartments of the vagina became infected, causing the distortion. The patient should have been treated with intravenous antibiotics and/or removal of the mesh.
DOCTOR’S DEFENSE Two prior reparative procedures had already been performed by the time he operated. The patient suffered not from infection, but from a reaction to the mesh, a foreign body.
VERDICT Defense verdict.
Did doctors treat UTI properly?
An 18-year-old woman in her 28th week of gestation presented to the hospital reporting decreased fetal movement. Urinary tract infection was diagnosed after leukocytes were detected in the woman’s urine. She was prescribed a 3-day regimen of antibiotics and discharged. Ten days later, she returned to report 2 episodes of vaginal bleeding. After reassuring fetal monitoring, the woman was again discharged.
About 5 days later, the woman returned and was diagnosed with prolonged preterm rupture of membranes, with contractions at 4- to 5-minute intervals. The woman was monitored over 17 hours, and her contractions lessened in frequency. When the fetus showed signs of bradycardia, cesarean section was performed. The child was diagnosed with severe mental retardation, cortical blindness, and spastic quadriplegia. The child is confined to a wheelchair and requires constant medical care and rehabilitation.
PATIENT’S CLAIM The urinary tract infection was not treated properly, and eventually led to ruptured membranes. A cesarean section should have been performed sooner.
DOCTOR’S DEFENSE The urinary tract infection caused the infant’s problems.
VERDICT $5 million settlement.
One twin dies, the other is severely handicapped
A woman pregnant with twins, who was using a fetal monitoring service at home, reported to the hospital at 29 weeks’ gestation because she was experiencing contractions. She was seen by a physician who reported she was less than 2-cm dilated. She was transferred to another facility; upon arrival, she was 4-cm dilated, and was given tocolytics to delay labor.
One child was delivered with respiratory distress syndrome, intracranial hemorrhage, and hydrocephalus, and the other infant died. The surviving twin, who is now 17 years of age, suffers from cerebral palsy, spastic quadriplegia, cortical blindness, and severe mental retardation. She is confined to a wheelchair, requires a feeding tube, and will need lifelong care.
PATIENT’S CLAIM The physician at the initial facility failed to administer tocolytics in time to prevent premature delivery.
DOCTOR’S DEFENSE There were no signs of labor, and administering tocolytics would not have prevented premature labor.
VERDICT $3 million settlement.
Patient delivers after D&C
A woman reported to the emergency room with severe abdominal pain, bleeding, and fever. Testing revealed she was 4 to 5 weeks pregnant. An OB performed a D&C. She gave birth to an unwanted child 7 months later.
PATIENT’S CLAIM The physician failed to tell her she was still pregnant after the D&C and did not provide her with follow-up instructions.
DOCTOR’S DEFENSE The physician performed the D&C not to terminate the pregnancy but to treat pelvic inflammatory disease and to remove remnants from a previous septic miscarriage. Subsequent testing confirmed that products of conception consistent with a nonviable pregnancy had been removed. The physician also claimed the patient was advised to report back to his office in 1 to 2 weeks to seek care for her pregnancy. Initially, the patient claimed she never received instructions to report back to the office for care; however, during testimony, she admitted to receiving instructions but could not recall them.
VERDICT Defense verdict.
Retained placenta leads to hysterectomy
A 40-year-old woman, acting as a surrogate for her brother and sister-in-law, gave birth to twins. Six weeks later, she underwent a hysterectomy.
PATIENT’S CLAIM The obstetrician failed to completely remove the placenta after the cesarean section, resulting in the hysterectomy 6 weeks later.
DOCTOR’S DEFENSE The failure to remove all of the placenta was not negligent, and the woman had placenta increta, which made it difficult to completely remove the placental tissue.
VERDICT The hospital settled for $125,000; the jury awarded the plaintiff $1.2 million against the physician.
The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, Nashville, Tenn (www.verdictslaska.com).The available information about the cases is sometimes incomplete; pertinent details may be unavailable. Moreover, the cases may or may not have merit. Still, these cases represent types of clinical situations that may result in litigation and are meant to illustrate variation in verdicts and awards. Any illustrations are generic and do not represent a specific legal case.
OB blames disability on mother’s language
A woman diagnosed with group B strep at 32 weeks’ gestation had spontaneous rupture of membranes at 36 to 37 weeks and developed a fever during labor and delivery. Several hours into labor, severe variable decelerations were noted and the infant was delivered by cesarean section. Within hours, the infant developed sepsis. The child survived, but suffers from learning disabilities.
PATIENT’S CLAIM The mother should have been given antibiotics before labor.
DOCTOR’S DEFENSE The physicians never received the lab report showing the test result. The child’s learning disability was not caused by any birth event, but by the mother’s use of her native Farsi at home.
VERDICT After mediation, the parties reached a $962,000 settlement.
Did doctors miss signs of chorioamnionitis?
A 30-year-old woman presented to the emergency room at 25 weeks’ gestation, complaining of abdominal pain. After examining her, doctors decided hospitalization was unnecessary. Nine days later, she returned to the hospital and reported vomiting and vaginal spotting. Immediate cesarean section was performed. The child was later diagnosed with mental and physical disabilities, including developmental delays and spastic quadriplegia.
PATIENT’S CLAIM The disabilities and premature birth were caused by an undiagnosed antepartum infection, and the chorioamnionitis should have been detected at the first emergency room visit. Prompt diagnosis and treatment would have prevented the adverse outcome.
DOCTOR’S DEFENSE The child’s injuries were unavoidable.
VERDICT $1.2 million settlement.
“Postop gas, constipation led to divorce”
A 34-year-old woman underwent laparoscopic tubal ligation. After the surgery, she developed a hernia, which was repaired via laparotomy.
PATIENT’S CLAIM The original surgery caused chronic constipation and gas and contributed to the patient’s divorce. The physician caused the hernia by failing to stitch the fascia closed.
DOCTOR’S DEFENSE It was not necessary to suture the fascia closed. The hernia occurred through an adhesion and below the fascia, so a stitch would not have prevented it. The patient’s marriage was in peril before the tubal ligation was performed.
VERDICT Defense verdict.
Missed tubo-ovarian abscess leads to death
A 42-year-old woman with anemia and complaints of generalized abdominal pain and heavy bleeding was referred to an ObGyn, who performed an endometrial biopsy and concluded that her pain and bleeding were caused by fibroids. A hysterectomy was scheduled, and pain medication was prescribed. When ultrasound imaging revealed a cyst, more pain medicine was prescribed, and the date for the hysterectomy was moved up. Blood tests showed extremely elevated white blood cell levels, indicative of infection, but the doctor did not receive results for several days.
The day after the patient visited the ObGyn, she collapsed at home and was taken to a hospital, where she died a few hours later. An autopsy revealed the death was due to sepsis from a right tubo-ovarian abscess. No fibroids were present.
PATIENT’S CLAIM The ObGyn was negligent in failing to examine the patient the day before her death, despite her report of severe pain. Furthermore, the physician caused the tubo-ovarian abscess at the time of the endometrial biopsy.
DOCTOR’S DEFENSE The diagnoses of uterine fibroids, possible ovarian cyst, and urinary tract infection explained all the patient’s symptoms, none of which were consistent with tubo-ovarian abscess.
VERDICT The jury ruled for the defense.
$12 million verdict despite counseling
A woman delivered an infant with spina bifida, who requires lifelong treatment.
PATIENT’S CLAIM The mother was not informed of the need for alpha-fetoprotein testing to detect neural tube defects and Down’s syndrome, and a nurse telephoned her to say the test was unnecessary because the woman was not at risk. As a result, the parents were denied the opportunity to have the pregnancy terminated.
DOCTOR’S DEFENSE The practice group’s records noted that test information was provided during a visit the previous year. The child’s problems were genetic and could not have been avoided.
VERDICT $12 million verdict.
5 operations needed after prolapse repair
A 51-year-old woman suffering from vaginal prolapse underwent pelvic reconstruction in January and continued under the surgeon’s care until May, when she was advised to return to the referring ObGyn. In June, she was found to have grossly distorted vaginal anatomy and infection, necessitating 5 additional operations.
PATIENT’S CLAIM The surgeon was negligent, failed to obtain informed consent, misrepresented the success rate of the procedure, and concealed the true condition of the vagina at the time of discharge. In addition, a mesh used to reinforce the anterior, apical, and posterior compartments of the vagina became infected, causing the distortion. The patient should have been treated with intravenous antibiotics and/or removal of the mesh.
DOCTOR’S DEFENSE Two prior reparative procedures had already been performed by the time he operated. The patient suffered not from infection, but from a reaction to the mesh, a foreign body.
VERDICT Defense verdict.
Did doctors treat UTI properly?
An 18-year-old woman in her 28th week of gestation presented to the hospital reporting decreased fetal movement. Urinary tract infection was diagnosed after leukocytes were detected in the woman’s urine. She was prescribed a 3-day regimen of antibiotics and discharged. Ten days later, she returned to report 2 episodes of vaginal bleeding. After reassuring fetal monitoring, the woman was again discharged.
About 5 days later, the woman returned and was diagnosed with prolonged preterm rupture of membranes, with contractions at 4- to 5-minute intervals. The woman was monitored over 17 hours, and her contractions lessened in frequency. When the fetus showed signs of bradycardia, cesarean section was performed. The child was diagnosed with severe mental retardation, cortical blindness, and spastic quadriplegia. The child is confined to a wheelchair and requires constant medical care and rehabilitation.
PATIENT’S CLAIM The urinary tract infection was not treated properly, and eventually led to ruptured membranes. A cesarean section should have been performed sooner.
DOCTOR’S DEFENSE The urinary tract infection caused the infant’s problems.
VERDICT $5 million settlement.
One twin dies, the other is severely handicapped
A woman pregnant with twins, who was using a fetal monitoring service at home, reported to the hospital at 29 weeks’ gestation because she was experiencing contractions. She was seen by a physician who reported she was less than 2-cm dilated. She was transferred to another facility; upon arrival, she was 4-cm dilated, and was given tocolytics to delay labor.
One child was delivered with respiratory distress syndrome, intracranial hemorrhage, and hydrocephalus, and the other infant died. The surviving twin, who is now 17 years of age, suffers from cerebral palsy, spastic quadriplegia, cortical blindness, and severe mental retardation. She is confined to a wheelchair, requires a feeding tube, and will need lifelong care.
PATIENT’S CLAIM The physician at the initial facility failed to administer tocolytics in time to prevent premature delivery.
DOCTOR’S DEFENSE There were no signs of labor, and administering tocolytics would not have prevented premature labor.
VERDICT $3 million settlement.
Patient delivers after D&C
A woman reported to the emergency room with severe abdominal pain, bleeding, and fever. Testing revealed she was 4 to 5 weeks pregnant. An OB performed a D&C. She gave birth to an unwanted child 7 months later.
PATIENT’S CLAIM The physician failed to tell her she was still pregnant after the D&C and did not provide her with follow-up instructions.
DOCTOR’S DEFENSE The physician performed the D&C not to terminate the pregnancy but to treat pelvic inflammatory disease and to remove remnants from a previous septic miscarriage. Subsequent testing confirmed that products of conception consistent with a nonviable pregnancy had been removed. The physician also claimed the patient was advised to report back to his office in 1 to 2 weeks to seek care for her pregnancy. Initially, the patient claimed she never received instructions to report back to the office for care; however, during testimony, she admitted to receiving instructions but could not recall them.
VERDICT Defense verdict.
Retained placenta leads to hysterectomy
A 40-year-old woman, acting as a surrogate for her brother and sister-in-law, gave birth to twins. Six weeks later, she underwent a hysterectomy.
PATIENT’S CLAIM The obstetrician failed to completely remove the placenta after the cesarean section, resulting in the hysterectomy 6 weeks later.
DOCTOR’S DEFENSE The failure to remove all of the placenta was not negligent, and the woman had placenta increta, which made it difficult to completely remove the placental tissue.
VERDICT The hospital settled for $125,000; the jury awarded the plaintiff $1.2 million against the physician.
The cases in this column are selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska, Nashville, Tenn (www.verdictslaska.com).The available information about the cases is sometimes incomplete; pertinent details may be unavailable. Moreover, the cases may or may not have merit. Still, these cases represent types of clinical situations that may result in litigation and are meant to illustrate variation in verdicts and awards. Any illustrations are generic and do not represent a specific legal case.
You must justify D&C with fibroid resection
HPV-positive test in a pregnant woman
More RVUs for 3 office hysteroscopy procedures
- Diagnostic hysteroscopy carries .65 more (RVUs) for the office setting.
- Endometrial ablation has 63.25 RVUs for the office setting, but only 9.66 for the hospital setting.
- Essure, a new hysteroscopic sterilization technology, carries 57.91 RVUs in the office setting.
The vastly increased RVU for the latter 2 procedures in the office setting covers the more expensive equipment needed.
Hysteroscopic procedures do not have a professional and technical component in the typical sense. Although you may have additional practice costs such as a dedicated treatment room or special equipment, these may not be accurately reflected in the allowable for the hysteroscopic procedure you perform in the office setting. The current RVU system does not allow for separate payment of a “facility fee”; all practice costs associated with performing the procedure are added into the practice expense portion of the RVU for each procedure. Although all payers bundle the surgical tray into the reimbursement for the procedure, consider negotiating for a “facility fee” that adequately covers your additional expenses, by pointing out that money will be saved when the hysteroscopy is performed in the office.
- Diagnostic hysteroscopy carries .65 more (RVUs) for the office setting.
- Endometrial ablation has 63.25 RVUs for the office setting, but only 9.66 for the hospital setting.
- Essure, a new hysteroscopic sterilization technology, carries 57.91 RVUs in the office setting.
The vastly increased RVU for the latter 2 procedures in the office setting covers the more expensive equipment needed.
Hysteroscopic procedures do not have a professional and technical component in the typical sense. Although you may have additional practice costs such as a dedicated treatment room or special equipment, these may not be accurately reflected in the allowable for the hysteroscopic procedure you perform in the office setting. The current RVU system does not allow for separate payment of a “facility fee”; all practice costs associated with performing the procedure are added into the practice expense portion of the RVU for each procedure. Although all payers bundle the surgical tray into the reimbursement for the procedure, consider negotiating for a “facility fee” that adequately covers your additional expenses, by pointing out that money will be saved when the hysteroscopy is performed in the office.
- Diagnostic hysteroscopy carries .65 more (RVUs) for the office setting.
- Endometrial ablation has 63.25 RVUs for the office setting, but only 9.66 for the hospital setting.
- Essure, a new hysteroscopic sterilization technology, carries 57.91 RVUs in the office setting.
The vastly increased RVU for the latter 2 procedures in the office setting covers the more expensive equipment needed.
Hysteroscopic procedures do not have a professional and technical component in the typical sense. Although you may have additional practice costs such as a dedicated treatment room or special equipment, these may not be accurately reflected in the allowable for the hysteroscopic procedure you perform in the office setting. The current RVU system does not allow for separate payment of a “facility fee”; all practice costs associated with performing the procedure are added into the practice expense portion of the RVU for each procedure. Although all payers bundle the surgical tray into the reimbursement for the procedure, consider negotiating for a “facility fee” that adequately covers your additional expenses, by pointing out that money will be saved when the hysteroscopy is performed in the office.
ASP or Client-Server: Which Is Better for You?
Last year I discussed the basic rules to keep in mind when shopping for an electronic medical record system, and last month's column included a discussion of the advantages of adding Web-based messaging to your EMR system. (If you missed those columns, you can find them on the SKIN & ALLERGY NEWS Web site at www.skinandallergynews.com
First, the difference: You have a choice of where you want the software hosted. If it is to be run on hardware within your office, that is a server-based, or client-server, system. If you rely on a vendor to run the software on its hardware via the Internet, that is a Web-based system, or, in industry jargon, an application service provider (ASP) system. Both options provide distinct advantages and disadvantages.
Client-server systems run and store data on hardware you own and keep on your premises. You pay up front for hardware, software, and setup, and usually a monthly maintenance fee thereafter.
Such a system gives you greater control and fewer worries about interrupted access or breach of confidentiality, but up-front equipment costs are high and the responsibility of maintaining and securing your database is entirely yours. Obviously, regular backups are essential. You can either create backup tapes or disks yourself and physically store them elsewhere, or—a far better option, in my view—you can hire a service that regularly and automatically copies your data to off-site computers. A growing number of remote backup services are available at reasonable prices. (As always, I have no financial interest in any product or enterprise discussed in this column.)
In an ASP system, both the application and data reside on the vendor's servers, and your office accesses them through a Web browser or other specialized software. The up-front setup fee is comparatively small, and ongoing monthly payments are based on frequency of usage and the complexity of your data.
The main advantage of an ASP is that your data are maintained by computing professionals at the vendor's facility.
As one vendor explained, you would consider it foolish to keep your money under a mattress at home. Instead, you entrust it to a bank that is staffed by security professionals. So why not do the same with your medical records? You also typically get access to far more sophisticated hardware and software features than you could afford to buy yourself.
The glaring disadvantage of the ASP is the active Internet connection it requires. No Internet connection works 100% of the time; your Internet service provider or internal network may fail, or a virus, worm, Trojan horse, or hacker can wreak havoc with your records.
If you go this route, there are several essential features to ask about. These include multiple layers of security, uninterruptible power sources, instant switchover to backup hardware in case of a crash, and frequent, reliable backups. In short, you need reliable assurances that your records will always be secure and available.
So which is right for you? If you have a multiphysician practice and you are an expert with computers (or have ready access to one), client-server may be your best option. Smaller offices with little to no computer expertise are probably better off choosing an ASP, at least to start.
An ASP has more sophisticated equipment, additional layers of security, and larger, specialized staffs than your office does. In smaller practices, the ASP is often easier to customize than an internal system. In a large practice with numerous and diverse subspecializations, client-server systems often provide more flexibility. You will pay a premium for the extra customization work, however.
In the end, it may come down to which of the potential downsides you fear more: being unable to access your records while your Internet connection is down, or losing data and time (or worse) if your hardware crashes or gets damaged in a fire or other calamity. One option to consider is starting with a hosted ASP service, then moving in-house if that becomes necessary or advantageous.
Last year I discussed the basic rules to keep in mind when shopping for an electronic medical record system, and last month's column included a discussion of the advantages of adding Web-based messaging to your EMR system. (If you missed those columns, you can find them on the SKIN & ALLERGY NEWS Web site at www.skinandallergynews.com
First, the difference: You have a choice of where you want the software hosted. If it is to be run on hardware within your office, that is a server-based, or client-server, system. If you rely on a vendor to run the software on its hardware via the Internet, that is a Web-based system, or, in industry jargon, an application service provider (ASP) system. Both options provide distinct advantages and disadvantages.
Client-server systems run and store data on hardware you own and keep on your premises. You pay up front for hardware, software, and setup, and usually a monthly maintenance fee thereafter.
Such a system gives you greater control and fewer worries about interrupted access or breach of confidentiality, but up-front equipment costs are high and the responsibility of maintaining and securing your database is entirely yours. Obviously, regular backups are essential. You can either create backup tapes or disks yourself and physically store them elsewhere, or—a far better option, in my view—you can hire a service that regularly and automatically copies your data to off-site computers. A growing number of remote backup services are available at reasonable prices. (As always, I have no financial interest in any product or enterprise discussed in this column.)
In an ASP system, both the application and data reside on the vendor's servers, and your office accesses them through a Web browser or other specialized software. The up-front setup fee is comparatively small, and ongoing monthly payments are based on frequency of usage and the complexity of your data.
The main advantage of an ASP is that your data are maintained by computing professionals at the vendor's facility.
As one vendor explained, you would consider it foolish to keep your money under a mattress at home. Instead, you entrust it to a bank that is staffed by security professionals. So why not do the same with your medical records? You also typically get access to far more sophisticated hardware and software features than you could afford to buy yourself.
The glaring disadvantage of the ASP is the active Internet connection it requires. No Internet connection works 100% of the time; your Internet service provider or internal network may fail, or a virus, worm, Trojan horse, or hacker can wreak havoc with your records.
If you go this route, there are several essential features to ask about. These include multiple layers of security, uninterruptible power sources, instant switchover to backup hardware in case of a crash, and frequent, reliable backups. In short, you need reliable assurances that your records will always be secure and available.
So which is right for you? If you have a multiphysician practice and you are an expert with computers (or have ready access to one), client-server may be your best option. Smaller offices with little to no computer expertise are probably better off choosing an ASP, at least to start.
An ASP has more sophisticated equipment, additional layers of security, and larger, specialized staffs than your office does. In smaller practices, the ASP is often easier to customize than an internal system. In a large practice with numerous and diverse subspecializations, client-server systems often provide more flexibility. You will pay a premium for the extra customization work, however.
In the end, it may come down to which of the potential downsides you fear more: being unable to access your records while your Internet connection is down, or losing data and time (or worse) if your hardware crashes or gets damaged in a fire or other calamity. One option to consider is starting with a hosted ASP service, then moving in-house if that becomes necessary or advantageous.
Last year I discussed the basic rules to keep in mind when shopping for an electronic medical record system, and last month's column included a discussion of the advantages of adding Web-based messaging to your EMR system. (If you missed those columns, you can find them on the SKIN & ALLERGY NEWS Web site at www.skinandallergynews.com
First, the difference: You have a choice of where you want the software hosted. If it is to be run on hardware within your office, that is a server-based, or client-server, system. If you rely on a vendor to run the software on its hardware via the Internet, that is a Web-based system, or, in industry jargon, an application service provider (ASP) system. Both options provide distinct advantages and disadvantages.
Client-server systems run and store data on hardware you own and keep on your premises. You pay up front for hardware, software, and setup, and usually a monthly maintenance fee thereafter.
Such a system gives you greater control and fewer worries about interrupted access or breach of confidentiality, but up-front equipment costs are high and the responsibility of maintaining and securing your database is entirely yours. Obviously, regular backups are essential. You can either create backup tapes or disks yourself and physically store them elsewhere, or—a far better option, in my view—you can hire a service that regularly and automatically copies your data to off-site computers. A growing number of remote backup services are available at reasonable prices. (As always, I have no financial interest in any product or enterprise discussed in this column.)
In an ASP system, both the application and data reside on the vendor's servers, and your office accesses them through a Web browser or other specialized software. The up-front setup fee is comparatively small, and ongoing monthly payments are based on frequency of usage and the complexity of your data.
The main advantage of an ASP is that your data are maintained by computing professionals at the vendor's facility.
As one vendor explained, you would consider it foolish to keep your money under a mattress at home. Instead, you entrust it to a bank that is staffed by security professionals. So why not do the same with your medical records? You also typically get access to far more sophisticated hardware and software features than you could afford to buy yourself.
The glaring disadvantage of the ASP is the active Internet connection it requires. No Internet connection works 100% of the time; your Internet service provider or internal network may fail, or a virus, worm, Trojan horse, or hacker can wreak havoc with your records.
If you go this route, there are several essential features to ask about. These include multiple layers of security, uninterruptible power sources, instant switchover to backup hardware in case of a crash, and frequent, reliable backups. In short, you need reliable assurances that your records will always be secure and available.
So which is right for you? If you have a multiphysician practice and you are an expert with computers (or have ready access to one), client-server may be your best option. Smaller offices with little to no computer expertise are probably better off choosing an ASP, at least to start.
An ASP has more sophisticated equipment, additional layers of security, and larger, specialized staffs than your office does. In smaller practices, the ASP is often easier to customize than an internal system. In a large practice with numerous and diverse subspecializations, client-server systems often provide more flexibility. You will pay a premium for the extra customization work, however.
In the end, it may come down to which of the potential downsides you fear more: being unable to access your records while your Internet connection is down, or losing data and time (or worse) if your hardware crashes or gets damaged in a fire or other calamity. One option to consider is starting with a hosted ASP service, then moving in-house if that becomes necessary or advantageous.
Medical Verdicts
$24.1 million awarded in VBAC gone awry
A pregnant woman who desired vaginal delivery for her third child after experiencing 2 successful cesarean sections was induced for 3 days. When the fetus showed signs of distress, the OB used a vacuum extractor for 48 minutes to help deliver the child and ordered the nurses to apply fundal pressure. The woman’s uterus and bladder ruptured, causing oxygen deprivation to the fetus.
The child’s Apgar scores were 2 and 3. She has cerebral palsy, cannot speak, has little use of limbs, and is fed through a stomach tube. The mother required an emergency hysterectomy and surgery to repair her ruptured bladder. Her vocal cords were damaged during intubation, which required another operation.
The woman contended that the OB used the vacuum extractor for too long, failed to perform an emergency cesarean section, and should not have ordered fundal pressure.
- The hospital and senior physician settled for a confidential amount before trial. A $24.1 million verdict was returned against the OB.
Home birth, unlicensed midwives, cord prolapse
A woman who wished to deliver at home, aided by midwives, underwent 2 sonograms during her pregnancy, which revealed multiple large fibroids blocking the birth canal. One of the midwives claimed that 2 consulting OBs were aware of the patient’s condition but claimed she could tolerate a trial of labor at home. One physician argued he never spoke with the midwife about the fibroids and that a consultation never occurred. The doctor also claimed that both midwives were unlicensed and should have referred the woman to an OB for a cesarean section.
After rupture of the membranes, the midwife performed a vaginal examination while the fetal head was not engaged in the pelvis. The midwife tugged on the umbilical cord, causing it to prolapse. The fetus was deprived of oxygen for 45 minutes. The woman was rushed to the hospital for an emergency cesarean section. The baby suffered birth asphyxia, hypoxic ischemic encephalopathy, spastic quadriplegia, and cerebral palsy. Five years later, the child has seizures and severe developmental disabilities, and requires tube feeding.
- The case settled for $3 million.
Experts comment on father’s video in shoulder dystocia case
After giving birth to a child with Erb palsy, the mother argued the OB applied excessive traction and angulation of the head-to-shoulder angle as she twisted and pulled on the infant for more than 50 seconds before shoulder dystocia was relieved. There were no signs of fetal distress.
Neither the physician nor the nursing staff remembered the delivery, but the child’s father made a videotape of the birth. In a pretrial ruling, the judge determined the videotape could not be viewed by the jury, but experts could comment on it. The birth record showed that neither the shoulder dystocia nor paralysis of the right arm was observed by the physician or the nursing staff.
The infant has full use of his hand but has a permanent deformity with inward rotation of the upper arm and elbow and winging of the shoulder blade. The child has had physical therapy, but surgery was considered inappropriate.
- Although judgment was not entered on the verdict, both parties agreed to a structured settlement of $650,000.
Oxytocin was increased despite ominous signs
A woman was admitted to the hospital for induction of labor. That morning, the fetal monitor tracing was reassuring and oxytocin was initiated. By early afternoon, contraction patterns demonstrated hyperstimulation, with prolonged decelerations. The nurses did not intervene or alert the physician. Oxytocin was continued and increased.
By 1 PM, the fetal monitoring strip showed late decelerations, rising baseline, diminished variability, and lack of accelerations. Oxytocin was continued even though the patient was experiencing extensive contractions. This deteriorating pattern continued until 11:17 PM when the doctor left the room to attend to 2 other deliveries.
At this point, the contraction patterns showed a marked decrease in baseline, severe late decelerations, and absent variability. The nurse continued the oxytocin at more than 24 mU. Upon her return to the delivery room shortly after midnight, the doctor noted a nonreassuring fetal tracing.
At delivery the infant’s Apgar scores were 2, 4, and 5. Initial cord blood gas was 6.98. She was diagnosed with hypoxic ischemic encephalopathy and remained in the NICU for 1 month. She is severely neurologically impaired and nonambulatory, and cannot communicate. She resides in a nursing home where she is fed through a stomach tube.
The mother contended that neither the physician nor the nurse provided adequate intervention. Denying negligence, the defendants argued there was no approximate cause for the infant’s condition and claimed the injury occurred during the last few minutes before delivery.
- The case settled for $21.5 million.
Death from ARDS after delivery of twins
A 22-year-old woman at 34 weeks’ gestation reported to the hospital complaining of intermittent headaches. Her blood pressure was elevated and she was admitted. Six days later, labor was induced and she gave birth to healthy twins. After 12 days in the hospital she was discharged. The following day she returned to the hospital in respiratory distress, and she lost consciousness. She was stabilized with a ventilator but developed adult respiratory distress syndrome and died 10 days later.
The patient’s representatives claimed the physicians failed to diagnose a viral infection, which led to the patient’s death. Claims against several individuals and facilities were discontinued with the exception of 2 hospitals. Representatives for the 2 facilities argued the infection could not have been prevented or treated with antibiotics or any other medication.
- The case settled for $1.4 million.
$24.1 million awarded in VBAC gone awry
A pregnant woman who desired vaginal delivery for her third child after experiencing 2 successful cesarean sections was induced for 3 days. When the fetus showed signs of distress, the OB used a vacuum extractor for 48 minutes to help deliver the child and ordered the nurses to apply fundal pressure. The woman’s uterus and bladder ruptured, causing oxygen deprivation to the fetus.
The child’s Apgar scores were 2 and 3. She has cerebral palsy, cannot speak, has little use of limbs, and is fed through a stomach tube. The mother required an emergency hysterectomy and surgery to repair her ruptured bladder. Her vocal cords were damaged during intubation, which required another operation.
The woman contended that the OB used the vacuum extractor for too long, failed to perform an emergency cesarean section, and should not have ordered fundal pressure.
- The hospital and senior physician settled for a confidential amount before trial. A $24.1 million verdict was returned against the OB.
Home birth, unlicensed midwives, cord prolapse
A woman who wished to deliver at home, aided by midwives, underwent 2 sonograms during her pregnancy, which revealed multiple large fibroids blocking the birth canal. One of the midwives claimed that 2 consulting OBs were aware of the patient’s condition but claimed she could tolerate a trial of labor at home. One physician argued he never spoke with the midwife about the fibroids and that a consultation never occurred. The doctor also claimed that both midwives were unlicensed and should have referred the woman to an OB for a cesarean section.
After rupture of the membranes, the midwife performed a vaginal examination while the fetal head was not engaged in the pelvis. The midwife tugged on the umbilical cord, causing it to prolapse. The fetus was deprived of oxygen for 45 minutes. The woman was rushed to the hospital for an emergency cesarean section. The baby suffered birth asphyxia, hypoxic ischemic encephalopathy, spastic quadriplegia, and cerebral palsy. Five years later, the child has seizures and severe developmental disabilities, and requires tube feeding.
- The case settled for $3 million.
Experts comment on father’s video in shoulder dystocia case
After giving birth to a child with Erb palsy, the mother argued the OB applied excessive traction and angulation of the head-to-shoulder angle as she twisted and pulled on the infant for more than 50 seconds before shoulder dystocia was relieved. There were no signs of fetal distress.
Neither the physician nor the nursing staff remembered the delivery, but the child’s father made a videotape of the birth. In a pretrial ruling, the judge determined the videotape could not be viewed by the jury, but experts could comment on it. The birth record showed that neither the shoulder dystocia nor paralysis of the right arm was observed by the physician or the nursing staff.
The infant has full use of his hand but has a permanent deformity with inward rotation of the upper arm and elbow and winging of the shoulder blade. The child has had physical therapy, but surgery was considered inappropriate.
- Although judgment was not entered on the verdict, both parties agreed to a structured settlement of $650,000.
Oxytocin was increased despite ominous signs
A woman was admitted to the hospital for induction of labor. That morning, the fetal monitor tracing was reassuring and oxytocin was initiated. By early afternoon, contraction patterns demonstrated hyperstimulation, with prolonged decelerations. The nurses did not intervene or alert the physician. Oxytocin was continued and increased.
By 1 PM, the fetal monitoring strip showed late decelerations, rising baseline, diminished variability, and lack of accelerations. Oxytocin was continued even though the patient was experiencing extensive contractions. This deteriorating pattern continued until 11:17 PM when the doctor left the room to attend to 2 other deliveries.
At this point, the contraction patterns showed a marked decrease in baseline, severe late decelerations, and absent variability. The nurse continued the oxytocin at more than 24 mU. Upon her return to the delivery room shortly after midnight, the doctor noted a nonreassuring fetal tracing.
At delivery the infant’s Apgar scores were 2, 4, and 5. Initial cord blood gas was 6.98. She was diagnosed with hypoxic ischemic encephalopathy and remained in the NICU for 1 month. She is severely neurologically impaired and nonambulatory, and cannot communicate. She resides in a nursing home where she is fed through a stomach tube.
The mother contended that neither the physician nor the nurse provided adequate intervention. Denying negligence, the defendants argued there was no approximate cause for the infant’s condition and claimed the injury occurred during the last few minutes before delivery.
- The case settled for $21.5 million.
Death from ARDS after delivery of twins
A 22-year-old woman at 34 weeks’ gestation reported to the hospital complaining of intermittent headaches. Her blood pressure was elevated and she was admitted. Six days later, labor was induced and she gave birth to healthy twins. After 12 days in the hospital she was discharged. The following day she returned to the hospital in respiratory distress, and she lost consciousness. She was stabilized with a ventilator but developed adult respiratory distress syndrome and died 10 days later.
The patient’s representatives claimed the physicians failed to diagnose a viral infection, which led to the patient’s death. Claims against several individuals and facilities were discontinued with the exception of 2 hospitals. Representatives for the 2 facilities argued the infection could not have been prevented or treated with antibiotics or any other medication.
- The case settled for $1.4 million.
$24.1 million awarded in VBAC gone awry
A pregnant woman who desired vaginal delivery for her third child after experiencing 2 successful cesarean sections was induced for 3 days. When the fetus showed signs of distress, the OB used a vacuum extractor for 48 minutes to help deliver the child and ordered the nurses to apply fundal pressure. The woman’s uterus and bladder ruptured, causing oxygen deprivation to the fetus.
The child’s Apgar scores were 2 and 3. She has cerebral palsy, cannot speak, has little use of limbs, and is fed through a stomach tube. The mother required an emergency hysterectomy and surgery to repair her ruptured bladder. Her vocal cords were damaged during intubation, which required another operation.
The woman contended that the OB used the vacuum extractor for too long, failed to perform an emergency cesarean section, and should not have ordered fundal pressure.
- The hospital and senior physician settled for a confidential amount before trial. A $24.1 million verdict was returned against the OB.
Home birth, unlicensed midwives, cord prolapse
A woman who wished to deliver at home, aided by midwives, underwent 2 sonograms during her pregnancy, which revealed multiple large fibroids blocking the birth canal. One of the midwives claimed that 2 consulting OBs were aware of the patient’s condition but claimed she could tolerate a trial of labor at home. One physician argued he never spoke with the midwife about the fibroids and that a consultation never occurred. The doctor also claimed that both midwives were unlicensed and should have referred the woman to an OB for a cesarean section.
After rupture of the membranes, the midwife performed a vaginal examination while the fetal head was not engaged in the pelvis. The midwife tugged on the umbilical cord, causing it to prolapse. The fetus was deprived of oxygen for 45 minutes. The woman was rushed to the hospital for an emergency cesarean section. The baby suffered birth asphyxia, hypoxic ischemic encephalopathy, spastic quadriplegia, and cerebral palsy. Five years later, the child has seizures and severe developmental disabilities, and requires tube feeding.
- The case settled for $3 million.
Experts comment on father’s video in shoulder dystocia case
After giving birth to a child with Erb palsy, the mother argued the OB applied excessive traction and angulation of the head-to-shoulder angle as she twisted and pulled on the infant for more than 50 seconds before shoulder dystocia was relieved. There were no signs of fetal distress.
Neither the physician nor the nursing staff remembered the delivery, but the child’s father made a videotape of the birth. In a pretrial ruling, the judge determined the videotape could not be viewed by the jury, but experts could comment on it. The birth record showed that neither the shoulder dystocia nor paralysis of the right arm was observed by the physician or the nursing staff.
The infant has full use of his hand but has a permanent deformity with inward rotation of the upper arm and elbow and winging of the shoulder blade. The child has had physical therapy, but surgery was considered inappropriate.
- Although judgment was not entered on the verdict, both parties agreed to a structured settlement of $650,000.
Oxytocin was increased despite ominous signs
A woman was admitted to the hospital for induction of labor. That morning, the fetal monitor tracing was reassuring and oxytocin was initiated. By early afternoon, contraction patterns demonstrated hyperstimulation, with prolonged decelerations. The nurses did not intervene or alert the physician. Oxytocin was continued and increased.
By 1 PM, the fetal monitoring strip showed late decelerations, rising baseline, diminished variability, and lack of accelerations. Oxytocin was continued even though the patient was experiencing extensive contractions. This deteriorating pattern continued until 11:17 PM when the doctor left the room to attend to 2 other deliveries.
At this point, the contraction patterns showed a marked decrease in baseline, severe late decelerations, and absent variability. The nurse continued the oxytocin at more than 24 mU. Upon her return to the delivery room shortly after midnight, the doctor noted a nonreassuring fetal tracing.
At delivery the infant’s Apgar scores were 2, 4, and 5. Initial cord blood gas was 6.98. She was diagnosed with hypoxic ischemic encephalopathy and remained in the NICU for 1 month. She is severely neurologically impaired and nonambulatory, and cannot communicate. She resides in a nursing home where she is fed through a stomach tube.
The mother contended that neither the physician nor the nurse provided adequate intervention. Denying negligence, the defendants argued there was no approximate cause for the infant’s condition and claimed the injury occurred during the last few minutes before delivery.
- The case settled for $21.5 million.
Death from ARDS after delivery of twins
A 22-year-old woman at 34 weeks’ gestation reported to the hospital complaining of intermittent headaches. Her blood pressure was elevated and she was admitted. Six days later, labor was induced and she gave birth to healthy twins. After 12 days in the hospital she was discharged. The following day she returned to the hospital in respiratory distress, and she lost consciousness. She was stabilized with a ventilator but developed adult respiratory distress syndrome and died 10 days later.
The patient’s representatives claimed the physicians failed to diagnose a viral infection, which led to the patient’s death. Claims against several individuals and facilities were discontinued with the exception of 2 hospitals. Representatives for the 2 facilities argued the infection could not have been prevented or treated with antibiotics or any other medication.
- The case settled for $1.4 million.
E-Mail, Your Patients, and You
As more patients attempt to e-mail their physicians, I am increasingly asked if this is a good idea. The answer is, as with most things, it depends.
Although this is not a particularly new issue, and many patients are enthusiastic about the prospect of communicating with their physicians online, most physicians remain reluctant to do so. Aside from the obvious privacy issues, many balk at one more unreimbursed demand on their time. While I share those concerns, there also are real benefits to be gained from online communication, among them increased practice efficiency for you, and increased quality of care and satisfaction for your patients.
I started giving one of my e-mail addresses to selected patients several years ago as an experiment, hoping to take some pressure off of our overloaded telephone system. The patients were grateful for simplified and more direct access to me, and I appreciated the decline in phone messages and interruptions while I was seeing patients. I also noticed a welcome decrease in those frustrating, unnecessary follow-up visits—you know, “The rash is completely gone, but you told me to come back. …”
Of course, the experiment has yielded some problems. Privacy is always a concern, although no patients have yet raised the issue. Also, some patients don't always give me the information I need, and often include a lot of stuff I don't need. And occasionally, despite my best efforts to educate them on appropriate e-mail use, I receive requests for refills or treatment I cannot provide without an office visit.
In general, however, I have found that the advantages for everyone involved (not least my nurses and receptionists) far outweigh the problems. And now, newer technologies such as encrypted e-mail, Web-based messaging, and integrated online communication systems should go a long way toward assuaging privacy concerns.
Contrary to popular belief, ordinary unencrypted e-mail does not necessarily violate the Health Insurance Portability and Accountability Act (HIPAA). As I've noted many times, HIPAA allows you to handle medical information in just about any way you wish, as long as patients are informed of what you are doing and accept any risks of breach of privacy associated with it. As long as the Notice of Privacy Practices that you distribute to patients explains your e-mail policies, and each e-mail includes a standard confidentiality disclaimer, you will be HIPAA compliant.
Still, if the lack of encryption and other privacy safeguards makes you (or your patients) uncomfortable, encryption software can be added to your practice's e-mail system. Kryptiq (www.kryptiq.comwww.sigaba.comwww.tumbleweed.comwww.zixcorp.com
But rather than simply encrypting their e-mail, increasing numbers of physicians are opting for Web-based messaging. Patients enter your Web site and send a message using an electronic template that you design. You (or a designated staffer) will be notified by regular e-mail when messages are received, and you can post a reply on a page that can only be accessed by the patient. Besides enhanced privacy and security, the big advantage of Web messaging is the ability to use templates, which ensure that messages include the information you need and minimize extraneous chatter. And you can design separate templates for nurses and receptionists so every message need not go through you.
Web-based messaging services can be freestanding or incorporated into existing secure Web sites. Medem (www.medem.comwww.medfusion.netwww.relayhealth.com
To really do it right, though, you need to integrate your messaging service into your medical records. If you are looking to add an electronic medical record (EMR) system to your office, add Web messaging to your list of essential features.
Last year I discussed the basic rules to keep in mind when shopping for an EMR system. (If you missed that column, you can find it on the SKIN & ALLERGY NEWS Web site, www.skinandallergynews.com
Naturally, this is not only your best option over the long haul, but also the most expensive. However, all of us not planning to retire in the next decade will be looking into EMR whether we want to or not. So it behooves us to make sure efficient patient communication capabilities are an integral part of any system we choose.
As more patients attempt to e-mail their physicians, I am increasingly asked if this is a good idea. The answer is, as with most things, it depends.
Although this is not a particularly new issue, and many patients are enthusiastic about the prospect of communicating with their physicians online, most physicians remain reluctant to do so. Aside from the obvious privacy issues, many balk at one more unreimbursed demand on their time. While I share those concerns, there also are real benefits to be gained from online communication, among them increased practice efficiency for you, and increased quality of care and satisfaction for your patients.
I started giving one of my e-mail addresses to selected patients several years ago as an experiment, hoping to take some pressure off of our overloaded telephone system. The patients were grateful for simplified and more direct access to me, and I appreciated the decline in phone messages and interruptions while I was seeing patients. I also noticed a welcome decrease in those frustrating, unnecessary follow-up visits—you know, “The rash is completely gone, but you told me to come back. …”
Of course, the experiment has yielded some problems. Privacy is always a concern, although no patients have yet raised the issue. Also, some patients don't always give me the information I need, and often include a lot of stuff I don't need. And occasionally, despite my best efforts to educate them on appropriate e-mail use, I receive requests for refills or treatment I cannot provide without an office visit.
In general, however, I have found that the advantages for everyone involved (not least my nurses and receptionists) far outweigh the problems. And now, newer technologies such as encrypted e-mail, Web-based messaging, and integrated online communication systems should go a long way toward assuaging privacy concerns.
Contrary to popular belief, ordinary unencrypted e-mail does not necessarily violate the Health Insurance Portability and Accountability Act (HIPAA). As I've noted many times, HIPAA allows you to handle medical information in just about any way you wish, as long as patients are informed of what you are doing and accept any risks of breach of privacy associated with it. As long as the Notice of Privacy Practices that you distribute to patients explains your e-mail policies, and each e-mail includes a standard confidentiality disclaimer, you will be HIPAA compliant.
Still, if the lack of encryption and other privacy safeguards makes you (or your patients) uncomfortable, encryption software can be added to your practice's e-mail system. Kryptiq (www.kryptiq.comwww.sigaba.comwww.tumbleweed.comwww.zixcorp.com
But rather than simply encrypting their e-mail, increasing numbers of physicians are opting for Web-based messaging. Patients enter your Web site and send a message using an electronic template that you design. You (or a designated staffer) will be notified by regular e-mail when messages are received, and you can post a reply on a page that can only be accessed by the patient. Besides enhanced privacy and security, the big advantage of Web messaging is the ability to use templates, which ensure that messages include the information you need and minimize extraneous chatter. And you can design separate templates for nurses and receptionists so every message need not go through you.
Web-based messaging services can be freestanding or incorporated into existing secure Web sites. Medem (www.medem.comwww.medfusion.netwww.relayhealth.com
To really do it right, though, you need to integrate your messaging service into your medical records. If you are looking to add an electronic medical record (EMR) system to your office, add Web messaging to your list of essential features.
Last year I discussed the basic rules to keep in mind when shopping for an EMR system. (If you missed that column, you can find it on the SKIN & ALLERGY NEWS Web site, www.skinandallergynews.com
Naturally, this is not only your best option over the long haul, but also the most expensive. However, all of us not planning to retire in the next decade will be looking into EMR whether we want to or not. So it behooves us to make sure efficient patient communication capabilities are an integral part of any system we choose.
As more patients attempt to e-mail their physicians, I am increasingly asked if this is a good idea. The answer is, as with most things, it depends.
Although this is not a particularly new issue, and many patients are enthusiastic about the prospect of communicating with their physicians online, most physicians remain reluctant to do so. Aside from the obvious privacy issues, many balk at one more unreimbursed demand on their time. While I share those concerns, there also are real benefits to be gained from online communication, among them increased practice efficiency for you, and increased quality of care and satisfaction for your patients.
I started giving one of my e-mail addresses to selected patients several years ago as an experiment, hoping to take some pressure off of our overloaded telephone system. The patients were grateful for simplified and more direct access to me, and I appreciated the decline in phone messages and interruptions while I was seeing patients. I also noticed a welcome decrease in those frustrating, unnecessary follow-up visits—you know, “The rash is completely gone, but you told me to come back. …”
Of course, the experiment has yielded some problems. Privacy is always a concern, although no patients have yet raised the issue. Also, some patients don't always give me the information I need, and often include a lot of stuff I don't need. And occasionally, despite my best efforts to educate them on appropriate e-mail use, I receive requests for refills or treatment I cannot provide without an office visit.
In general, however, I have found that the advantages for everyone involved (not least my nurses and receptionists) far outweigh the problems. And now, newer technologies such as encrypted e-mail, Web-based messaging, and integrated online communication systems should go a long way toward assuaging privacy concerns.
Contrary to popular belief, ordinary unencrypted e-mail does not necessarily violate the Health Insurance Portability and Accountability Act (HIPAA). As I've noted many times, HIPAA allows you to handle medical information in just about any way you wish, as long as patients are informed of what you are doing and accept any risks of breach of privacy associated with it. As long as the Notice of Privacy Practices that you distribute to patients explains your e-mail policies, and each e-mail includes a standard confidentiality disclaimer, you will be HIPAA compliant.
Still, if the lack of encryption and other privacy safeguards makes you (or your patients) uncomfortable, encryption software can be added to your practice's e-mail system. Kryptiq (www.kryptiq.comwww.sigaba.comwww.tumbleweed.comwww.zixcorp.com
But rather than simply encrypting their e-mail, increasing numbers of physicians are opting for Web-based messaging. Patients enter your Web site and send a message using an electronic template that you design. You (or a designated staffer) will be notified by regular e-mail when messages are received, and you can post a reply on a page that can only be accessed by the patient. Besides enhanced privacy and security, the big advantage of Web messaging is the ability to use templates, which ensure that messages include the information you need and minimize extraneous chatter. And you can design separate templates for nurses and receptionists so every message need not go through you.
Web-based messaging services can be freestanding or incorporated into existing secure Web sites. Medem (www.medem.comwww.medfusion.netwww.relayhealth.com
To really do it right, though, you need to integrate your messaging service into your medical records. If you are looking to add an electronic medical record (EMR) system to your office, add Web messaging to your list of essential features.
Last year I discussed the basic rules to keep in mind when shopping for an EMR system. (If you missed that column, you can find it on the SKIN & ALLERGY NEWS Web site, www.skinandallergynews.com
Naturally, this is not only your best option over the long haul, but also the most expensive. However, all of us not planning to retire in the next decade will be looking into EMR whether we want to or not. So it behooves us to make sure efficient patient communication capabilities are an integral part of any system we choose.
Medical Verdicts
Vocal cord, carpal tunnel damage alleged after cystectomy complications
A 37-year-old woman underwent laparoscopic surgery for removal of an ovarian cyst. After the cyst was removed, the patient had hypotension and tachycardia. She received 12 blood transfusions but her condition did not improve.
Exploratory surgery after internal bleeding was diagnosed revealed a lacerated abdominal artery. After the artery was repaired, the patient’s condition still did not improve. A dye-injection procedure showed another arterial laceration, which was repaired during a third surgery.
Plaintiff claims. In suing, the woman claimed the lacerations were caused by improper insertion of the trocar. In addition she claimed she had an allergic reaction to the blood transfusions, which caused respiratory distress and the need to be intubated.
According to the patient, the intubation caused permanent paralysis of her vocal cords. Additionally, she contended she developed carpal tunnel syndrome as a result of prolonged bed rest.
The patient maintained that her condition warranted emergency exploratory surgery and that the physician should have repaired both lacerations during the initial surgery.
Defense. The physician argued that arterial lacerations are a well-known risk factor of laparoscopic surgery and that he treated both lacerations appropriately.
He also contended that the patient’s vocal cords were not paralyzed and that she did not have carpal tunnel syndrome.
- The jury returned a defense verdict.
Did delayed c-section damage twins’ kidneys?
A 27-year-old woman at 28 weeks’ gestation with a twin pregnancy presented to the hospital complaining of painful vaginal bleeding. Fetal heart monitor tracings revealed a sinusoidal pattern. Fifty minutes later, twin girls were delivered by cesarean section. Both girls were born with kidney problems. One twin died from renal failure 6 weeks later. The other twin survived but suffers from chronic kidney problems.
The mother claimed the girls’ kidney problems were caused by the obstetrician’s delay in performing the cesarean section. The physicians acknowledged that a sinusoidal pattern is an emergency, but contended that the kidney problems were caused by a congenital defect that caused prenatal complications, which resulted in the sinusoidal pattern. The obstetrician claimed the 50-minute delay was caused by the anesthesiologist’s need to perform necessary setup procedures.
- The case settled for $1.5 million, including $250,000 for the wrongful death of the other twin.
$3 million in punitive damages follows fatal hysterectomy
A 36-year-old woman with a history of pain and endometriosis underwent laparoscopic hysterectomy. After she was transferred from recovery to the hospital floor, a decrease in her urinary output was noted. A fluid challenge test, hemoglobin, and hematocrit levels were ordered. The patient’s hemoglobin level was 9.8 g/dL, and she remained oliguric after the fluid challenge test. Because the physician was in surgery, the patient’s status was reported to him via his voice mail, which he did not check. When the patient’s blood pressure decreased, the physician was called again.
The patient vomited and aspirated and suffered hypoxic brain injury and organ damage. She was removed from life support a few days later.
In suing, the plaintiff’s representatives claimed the physician did not monitor the tests that were ordered and failed to check the patient after finishing his other surgery. They also claimed that the communication between the physician and hospital staff was deficient and that the nurses had difficulty reaching the doctor.
The physician countered that the nurses failed to properly monitor the patient and report changes in her status.
- The jury awarded the plaintiff $14 million (the physician paid 75% of this amount, which included $3 million in punitive damages; the hospital was responsible for 25%).
Trocar angle blamed for perforated bladder
Two days after undergoing laparoscopic tubal ligation, a woman had blood in her urine, abdominal pain, and vomiting. She was admitted to the hospital and diagnosed with a perforated bladder.
Although the patient’s condition seemed to improve after 2 days, she suffered severe respiratory distress and was moved to the ICU. Exploratory laparotomy revealed necrotizing tissue surrounding the perforated bladder. A severe infection ensued and the patient remained unconscious in the ICU for 2 weeks. She eventually recovered and was discharged.
In suing, the woman asserted that the surgeon improperly inserted a second trocar at a downward angle toward the bladder rather than at an upward angle to reach the fallopian tubes.
The physician contended that bladder perforation can occur during tubal ligation and that he had informed the woman of this risk before the operation.
- The jury awarded the plaintiff $5 million.
Jury finds oophorectomy was appropriate
A 33-year-old mother of 3 who did not want more children underwent laparoscopic vaginal hysterectomy for heavy menstrual cycles and pelvic pain. Both ovaries were removed and the patient was placed on long-term hormone therapy.
After surgery the woman claimed she did not consent to have her ovaries removed. The patient contended (although the physician denied) that when she confronted the physician about the ovary removal he responded, “I must be senile.”
The physician asserted that he told the patient he would visualize the entire area and repair whatever was necessary. During the procedure, the physician found that both ovaries were severely adherent to the uterus and that one had a cyst. The physician claimed that the decision to remove the ovaries was the appropriate treatment.
- The jury returned a defense verdict.
Ureter injury during hysterectomy leads to nephrectomy
Despite several adjustments in hormone replacement therapy, a 66-year-old woman had vaginal bleeding lasting longer than 1 year. Distressed by the bleeding, she said she would consider hysterectomy.
The physician to whom she was referred discussed a dilatation and curettage (D&C) and a hysterectomy, gave her literature on both procedures, and arranged for her to see an interactive video about the 2 procedures. The woman opted for a hysterectomy. After a history and physical examination the next month, both options were again discussed, and again she chose a hysterectomy.
During laparoscopic vaginal hysterectomy several months later, an inadvertent cystotomy was performed and both ureters avulsed. Another surgeon reimplanted the ureters and placed stents, which were removed after 6 weeks. Three months later the right kidney showed signs of reduced function. The woman declined reimplantation of the right ureter. Thereafter, she had abdominal, flank, low back, and leg pain. Nearly 7 years later, her right kidney was removed.
In suing, the woman claimed the hysterectomy was unnecessary and argued that she should have undergone either a D&C or endometrial ablation. She also asserted the physician performed the operation in the wrong plane, thereby damaging the ureters and bladder.
The physician contended that the surgery was within the standard of care for the woman’s condition and that the injury was a known potential complication that was discovered intraoperatively and repaired. He contended that the injury was caused by a Deaver retractor used during the repair surgery.
- The jury returned a defense verdict.
Patient’s request for fetal reduction too late?
At 10 weeks’ gestation, a woman pregnant with quadruplets discussed fetal reduction with her obstetrician to increase her chances of giving birth to a healthy infant(s). Her next appointment was 5 weeks later.
When she returned to the clinic, she was told it was too late to perform selective termination. About 12 weeks later the woman gave birth to quadruplets. One died within 24 hours from hyaline membrane disease and 2 have cerebral palsy. The fourth child is healthy.
In suing, the woman claimed the obstetrician did not inform her that his practice had a policy prohibiting fetal reduction after 14 weeks’ gestation and failed to refer her to a perinatologist who could have performed the procedure.
The health maintenance organization claimed they told the woman about their policy against performing selective termination after 14 weeks and that she had declined to have the procedure before that time.
- The case settled for $2.6 million.
Improper diagnosis leads to premature birth
A woman reported to the hospital at 25 weeks’ gestation complaining of abdominal pressure and contractions. The physician diagnosed a shortened cervix and discharged her.
Before the woman left the hospital she began to bleed, and an emergency cesarean section was performed.
In suing, the woman charged that the physician failed to properly treat the signs of premature labor. The child, who is now 3 years old, is blind, has cerebral palsy, is unable to communicate, and has limited mental status. The defendants argued that the treatment given was appropriate.
- The jury awarded the plaintiff $6.9 million.
Vocal cord, carpal tunnel damage alleged after cystectomy complications
A 37-year-old woman underwent laparoscopic surgery for removal of an ovarian cyst. After the cyst was removed, the patient had hypotension and tachycardia. She received 12 blood transfusions but her condition did not improve.
Exploratory surgery after internal bleeding was diagnosed revealed a lacerated abdominal artery. After the artery was repaired, the patient’s condition still did not improve. A dye-injection procedure showed another arterial laceration, which was repaired during a third surgery.
Plaintiff claims. In suing, the woman claimed the lacerations were caused by improper insertion of the trocar. In addition she claimed she had an allergic reaction to the blood transfusions, which caused respiratory distress and the need to be intubated.
According to the patient, the intubation caused permanent paralysis of her vocal cords. Additionally, she contended she developed carpal tunnel syndrome as a result of prolonged bed rest.
The patient maintained that her condition warranted emergency exploratory surgery and that the physician should have repaired both lacerations during the initial surgery.
Defense. The physician argued that arterial lacerations are a well-known risk factor of laparoscopic surgery and that he treated both lacerations appropriately.
He also contended that the patient’s vocal cords were not paralyzed and that she did not have carpal tunnel syndrome.
- The jury returned a defense verdict.
Did delayed c-section damage twins’ kidneys?
A 27-year-old woman at 28 weeks’ gestation with a twin pregnancy presented to the hospital complaining of painful vaginal bleeding. Fetal heart monitor tracings revealed a sinusoidal pattern. Fifty minutes later, twin girls were delivered by cesarean section. Both girls were born with kidney problems. One twin died from renal failure 6 weeks later. The other twin survived but suffers from chronic kidney problems.
The mother claimed the girls’ kidney problems were caused by the obstetrician’s delay in performing the cesarean section. The physicians acknowledged that a sinusoidal pattern is an emergency, but contended that the kidney problems were caused by a congenital defect that caused prenatal complications, which resulted in the sinusoidal pattern. The obstetrician claimed the 50-minute delay was caused by the anesthesiologist’s need to perform necessary setup procedures.
- The case settled for $1.5 million, including $250,000 for the wrongful death of the other twin.
$3 million in punitive damages follows fatal hysterectomy
A 36-year-old woman with a history of pain and endometriosis underwent laparoscopic hysterectomy. After she was transferred from recovery to the hospital floor, a decrease in her urinary output was noted. A fluid challenge test, hemoglobin, and hematocrit levels were ordered. The patient’s hemoglobin level was 9.8 g/dL, and she remained oliguric after the fluid challenge test. Because the physician was in surgery, the patient’s status was reported to him via his voice mail, which he did not check. When the patient’s blood pressure decreased, the physician was called again.
The patient vomited and aspirated and suffered hypoxic brain injury and organ damage. She was removed from life support a few days later.
In suing, the plaintiff’s representatives claimed the physician did not monitor the tests that were ordered and failed to check the patient after finishing his other surgery. They also claimed that the communication between the physician and hospital staff was deficient and that the nurses had difficulty reaching the doctor.
The physician countered that the nurses failed to properly monitor the patient and report changes in her status.
- The jury awarded the plaintiff $14 million (the physician paid 75% of this amount, which included $3 million in punitive damages; the hospital was responsible for 25%).
Trocar angle blamed for perforated bladder
Two days after undergoing laparoscopic tubal ligation, a woman had blood in her urine, abdominal pain, and vomiting. She was admitted to the hospital and diagnosed with a perforated bladder.
Although the patient’s condition seemed to improve after 2 days, she suffered severe respiratory distress and was moved to the ICU. Exploratory laparotomy revealed necrotizing tissue surrounding the perforated bladder. A severe infection ensued and the patient remained unconscious in the ICU for 2 weeks. She eventually recovered and was discharged.
In suing, the woman asserted that the surgeon improperly inserted a second trocar at a downward angle toward the bladder rather than at an upward angle to reach the fallopian tubes.
The physician contended that bladder perforation can occur during tubal ligation and that he had informed the woman of this risk before the operation.
- The jury awarded the plaintiff $5 million.
Jury finds oophorectomy was appropriate
A 33-year-old mother of 3 who did not want more children underwent laparoscopic vaginal hysterectomy for heavy menstrual cycles and pelvic pain. Both ovaries were removed and the patient was placed on long-term hormone therapy.
After surgery the woman claimed she did not consent to have her ovaries removed. The patient contended (although the physician denied) that when she confronted the physician about the ovary removal he responded, “I must be senile.”
The physician asserted that he told the patient he would visualize the entire area and repair whatever was necessary. During the procedure, the physician found that both ovaries were severely adherent to the uterus and that one had a cyst. The physician claimed that the decision to remove the ovaries was the appropriate treatment.
- The jury returned a defense verdict.
Ureter injury during hysterectomy leads to nephrectomy
Despite several adjustments in hormone replacement therapy, a 66-year-old woman had vaginal bleeding lasting longer than 1 year. Distressed by the bleeding, she said she would consider hysterectomy.
The physician to whom she was referred discussed a dilatation and curettage (D&C) and a hysterectomy, gave her literature on both procedures, and arranged for her to see an interactive video about the 2 procedures. The woman opted for a hysterectomy. After a history and physical examination the next month, both options were again discussed, and again she chose a hysterectomy.
During laparoscopic vaginal hysterectomy several months later, an inadvertent cystotomy was performed and both ureters avulsed. Another surgeon reimplanted the ureters and placed stents, which were removed after 6 weeks. Three months later the right kidney showed signs of reduced function. The woman declined reimplantation of the right ureter. Thereafter, she had abdominal, flank, low back, and leg pain. Nearly 7 years later, her right kidney was removed.
In suing, the woman claimed the hysterectomy was unnecessary and argued that she should have undergone either a D&C or endometrial ablation. She also asserted the physician performed the operation in the wrong plane, thereby damaging the ureters and bladder.
The physician contended that the surgery was within the standard of care for the woman’s condition and that the injury was a known potential complication that was discovered intraoperatively and repaired. He contended that the injury was caused by a Deaver retractor used during the repair surgery.
- The jury returned a defense verdict.
Patient’s request for fetal reduction too late?
At 10 weeks’ gestation, a woman pregnant with quadruplets discussed fetal reduction with her obstetrician to increase her chances of giving birth to a healthy infant(s). Her next appointment was 5 weeks later.
When she returned to the clinic, she was told it was too late to perform selective termination. About 12 weeks later the woman gave birth to quadruplets. One died within 24 hours from hyaline membrane disease and 2 have cerebral palsy. The fourth child is healthy.
In suing, the woman claimed the obstetrician did not inform her that his practice had a policy prohibiting fetal reduction after 14 weeks’ gestation and failed to refer her to a perinatologist who could have performed the procedure.
The health maintenance organization claimed they told the woman about their policy against performing selective termination after 14 weeks and that she had declined to have the procedure before that time.
- The case settled for $2.6 million.
Improper diagnosis leads to premature birth
A woman reported to the hospital at 25 weeks’ gestation complaining of abdominal pressure and contractions. The physician diagnosed a shortened cervix and discharged her.
Before the woman left the hospital she began to bleed, and an emergency cesarean section was performed.
In suing, the woman charged that the physician failed to properly treat the signs of premature labor. The child, who is now 3 years old, is blind, has cerebral palsy, is unable to communicate, and has limited mental status. The defendants argued that the treatment given was appropriate.
- The jury awarded the plaintiff $6.9 million.
Vocal cord, carpal tunnel damage alleged after cystectomy complications
A 37-year-old woman underwent laparoscopic surgery for removal of an ovarian cyst. After the cyst was removed, the patient had hypotension and tachycardia. She received 12 blood transfusions but her condition did not improve.
Exploratory surgery after internal bleeding was diagnosed revealed a lacerated abdominal artery. After the artery was repaired, the patient’s condition still did not improve. A dye-injection procedure showed another arterial laceration, which was repaired during a third surgery.
Plaintiff claims. In suing, the woman claimed the lacerations were caused by improper insertion of the trocar. In addition she claimed she had an allergic reaction to the blood transfusions, which caused respiratory distress and the need to be intubated.
According to the patient, the intubation caused permanent paralysis of her vocal cords. Additionally, she contended she developed carpal tunnel syndrome as a result of prolonged bed rest.
The patient maintained that her condition warranted emergency exploratory surgery and that the physician should have repaired both lacerations during the initial surgery.
Defense. The physician argued that arterial lacerations are a well-known risk factor of laparoscopic surgery and that he treated both lacerations appropriately.
He also contended that the patient’s vocal cords were not paralyzed and that she did not have carpal tunnel syndrome.
- The jury returned a defense verdict.
Did delayed c-section damage twins’ kidneys?
A 27-year-old woman at 28 weeks’ gestation with a twin pregnancy presented to the hospital complaining of painful vaginal bleeding. Fetal heart monitor tracings revealed a sinusoidal pattern. Fifty minutes later, twin girls were delivered by cesarean section. Both girls were born with kidney problems. One twin died from renal failure 6 weeks later. The other twin survived but suffers from chronic kidney problems.
The mother claimed the girls’ kidney problems were caused by the obstetrician’s delay in performing the cesarean section. The physicians acknowledged that a sinusoidal pattern is an emergency, but contended that the kidney problems were caused by a congenital defect that caused prenatal complications, which resulted in the sinusoidal pattern. The obstetrician claimed the 50-minute delay was caused by the anesthesiologist’s need to perform necessary setup procedures.
- The case settled for $1.5 million, including $250,000 for the wrongful death of the other twin.
$3 million in punitive damages follows fatal hysterectomy
A 36-year-old woman with a history of pain and endometriosis underwent laparoscopic hysterectomy. After she was transferred from recovery to the hospital floor, a decrease in her urinary output was noted. A fluid challenge test, hemoglobin, and hematocrit levels were ordered. The patient’s hemoglobin level was 9.8 g/dL, and she remained oliguric after the fluid challenge test. Because the physician was in surgery, the patient’s status was reported to him via his voice mail, which he did not check. When the patient’s blood pressure decreased, the physician was called again.
The patient vomited and aspirated and suffered hypoxic brain injury and organ damage. She was removed from life support a few days later.
In suing, the plaintiff’s representatives claimed the physician did not monitor the tests that were ordered and failed to check the patient after finishing his other surgery. They also claimed that the communication between the physician and hospital staff was deficient and that the nurses had difficulty reaching the doctor.
The physician countered that the nurses failed to properly monitor the patient and report changes in her status.
- The jury awarded the plaintiff $14 million (the physician paid 75% of this amount, which included $3 million in punitive damages; the hospital was responsible for 25%).
Trocar angle blamed for perforated bladder
Two days after undergoing laparoscopic tubal ligation, a woman had blood in her urine, abdominal pain, and vomiting. She was admitted to the hospital and diagnosed with a perforated bladder.
Although the patient’s condition seemed to improve after 2 days, she suffered severe respiratory distress and was moved to the ICU. Exploratory laparotomy revealed necrotizing tissue surrounding the perforated bladder. A severe infection ensued and the patient remained unconscious in the ICU for 2 weeks. She eventually recovered and was discharged.
In suing, the woman asserted that the surgeon improperly inserted a second trocar at a downward angle toward the bladder rather than at an upward angle to reach the fallopian tubes.
The physician contended that bladder perforation can occur during tubal ligation and that he had informed the woman of this risk before the operation.
- The jury awarded the plaintiff $5 million.
Jury finds oophorectomy was appropriate
A 33-year-old mother of 3 who did not want more children underwent laparoscopic vaginal hysterectomy for heavy menstrual cycles and pelvic pain. Both ovaries were removed and the patient was placed on long-term hormone therapy.
After surgery the woman claimed she did not consent to have her ovaries removed. The patient contended (although the physician denied) that when she confronted the physician about the ovary removal he responded, “I must be senile.”
The physician asserted that he told the patient he would visualize the entire area and repair whatever was necessary. During the procedure, the physician found that both ovaries were severely adherent to the uterus and that one had a cyst. The physician claimed that the decision to remove the ovaries was the appropriate treatment.
- The jury returned a defense verdict.
Ureter injury during hysterectomy leads to nephrectomy
Despite several adjustments in hormone replacement therapy, a 66-year-old woman had vaginal bleeding lasting longer than 1 year. Distressed by the bleeding, she said she would consider hysterectomy.
The physician to whom she was referred discussed a dilatation and curettage (D&C) and a hysterectomy, gave her literature on both procedures, and arranged for her to see an interactive video about the 2 procedures. The woman opted for a hysterectomy. After a history and physical examination the next month, both options were again discussed, and again she chose a hysterectomy.
During laparoscopic vaginal hysterectomy several months later, an inadvertent cystotomy was performed and both ureters avulsed. Another surgeon reimplanted the ureters and placed stents, which were removed after 6 weeks. Three months later the right kidney showed signs of reduced function. The woman declined reimplantation of the right ureter. Thereafter, she had abdominal, flank, low back, and leg pain. Nearly 7 years later, her right kidney was removed.
In suing, the woman claimed the hysterectomy was unnecessary and argued that she should have undergone either a D&C or endometrial ablation. She also asserted the physician performed the operation in the wrong plane, thereby damaging the ureters and bladder.
The physician contended that the surgery was within the standard of care for the woman’s condition and that the injury was a known potential complication that was discovered intraoperatively and repaired. He contended that the injury was caused by a Deaver retractor used during the repair surgery.
- The jury returned a defense verdict.
Patient’s request for fetal reduction too late?
At 10 weeks’ gestation, a woman pregnant with quadruplets discussed fetal reduction with her obstetrician to increase her chances of giving birth to a healthy infant(s). Her next appointment was 5 weeks later.
When she returned to the clinic, she was told it was too late to perform selective termination. About 12 weeks later the woman gave birth to quadruplets. One died within 24 hours from hyaline membrane disease and 2 have cerebral palsy. The fourth child is healthy.
In suing, the woman claimed the obstetrician did not inform her that his practice had a policy prohibiting fetal reduction after 14 weeks’ gestation and failed to refer her to a perinatologist who could have performed the procedure.
The health maintenance organization claimed they told the woman about their policy against performing selective termination after 14 weeks and that she had declined to have the procedure before that time.
- The case settled for $2.6 million.
Improper diagnosis leads to premature birth
A woman reported to the hospital at 25 weeks’ gestation complaining of abdominal pressure and contractions. The physician diagnosed a shortened cervix and discharged her.
Before the woman left the hospital she began to bleed, and an emergency cesarean section was performed.
In suing, the woman charged that the physician failed to properly treat the signs of premature labor. The child, who is now 3 years old, is blind, has cerebral palsy, is unable to communicate, and has limited mental status. The defendants argued that the treatment given was appropriate.
- The jury awarded the plaintiff $6.9 million.
Which code for Gartner’s duct cyst procedure?
But if it was a marsupialization procedure in which the cyst was drained first and then the walls of the cyst were sewn in place to form a pouch, then the procedure should be coded using the unlisted code, 58999 (unlisted procedure, female genital system [nonobstetrical]).
The Gartner’s duct is usually located in the lateral wall of the vagina, so the code to report marsupialization of a Bartholin gland cyst, 56440, would not apply.
Be sure to let the payer know that the procedure is very similar to the 2 codes 56440 (Bartholin’s) and 57135 (excision). Code 56440 has 4.89 RVUs, while 57135 has 5.25 RVUs.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
But if it was a marsupialization procedure in which the cyst was drained first and then the walls of the cyst were sewn in place to form a pouch, then the procedure should be coded using the unlisted code, 58999 (unlisted procedure, female genital system [nonobstetrical]).
The Gartner’s duct is usually located in the lateral wall of the vagina, so the code to report marsupialization of a Bartholin gland cyst, 56440, would not apply.
Be sure to let the payer know that the procedure is very similar to the 2 codes 56440 (Bartholin’s) and 57135 (excision). Code 56440 has 4.89 RVUs, while 57135 has 5.25 RVUs.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
But if it was a marsupialization procedure in which the cyst was drained first and then the walls of the cyst were sewn in place to form a pouch, then the procedure should be coded using the unlisted code, 58999 (unlisted procedure, female genital system [nonobstetrical]).
The Gartner’s duct is usually located in the lateral wall of the vagina, so the code to report marsupialization of a Bartholin gland cyst, 56440, would not apply.
Be sure to let the payer know that the procedure is very similar to the 2 codes 56440 (Bartholin’s) and 57135 (excision). Code 56440 has 4.89 RVUs, while 57135 has 5.25 RVUs.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.