Medicolegal Issues

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

In October 2007, a 72-year-old Pennsylvania woman underwent an elective cardiac catheterization in the right femoral artery at the recommendation of Dr. K. Shortly after the procedure, the patient had abdominal pain and back pain, with apparent bleeding in the abdominal cavity. She was kept at the hospital.

Almost two days later, the woman had persistent abdominal pain, a heart rate greater than 120 beats/min, and abdominal tenderness on palpation. Dr. L. was informed of this but did not examine the decedent; instead, he ordered abdominal x-rays, lab work, and administration of morphine.

Four hours later, the woman was found unresponsive. She had experienced cardiac arrest and was placed on a ventilator. In late November, she was transferred to another hospital, where she died about five weeks later. Her death was attributed to multiple organ failure and decreased intestinal blood flow.

The plaintiffs alleged negligence on the part of several defendants, including Dr. K., Dr. L., and the hospital. Dr. L. did not contest causal negligence but argued that other defendants were also at fault.

Outcome
According to a published account, a jury returned a $5.16 million verdict, including $4.13 million in wrongful death damages and $1.03 million in survival damages. The jury found Dr. L. 95% liable and Dr. K. 5% liable. Defense verdicts were entered for the other defendants.

Under the terms of an agreement into which the plaintiffs had previously entered with the defendants’ insurer, the plaintiffs recovered in the amount of $1.75 million.

Comment
This patient was hemodynamically unstable, with a pulse of 120, abdominal pain and tenderness, and an established intra-abdominal bleed. The standard of care required an effort to intervene immediately and stabilize her. Clearly, this did not occur.

Missed bleeding is hard to defend in court. Jurors understand bleeding and expect it to be identified, stopped, and remedied. As clinicians, we know that hemorrhage can be subtle, occult, and difficult to manage. In malpractice cases involving missed hemorrhage, however, plaintiff’s counsel will frequently argue that the clinician exhibited a brazen lack of concern for the patient and will seek a punitive component to damages. Allowing a patient to exsanguinate will inflame a jury, resulting in a heavy damage award—similar to the verdict returned in this case.

Undetected acute bleeding often stems from a misplaced reliance on hemoglobin and hematocrit (H&H) values. In short, H&H values cannot effectively detect acute hemorrhage. As an index of concentration, H&H values will decrease only after time or volume replacement. A skilled plaintiff’s lawyer can vividly demonstrate the fallibility of H&H to detect acute bleeding by emptying half the volume of a pitcher of red liquid in front of the defendant (and the jury) and asking if the concentration changes. As in an exsanguinated decedent’s H&H values in a malpractice case, it will not.

While the facts of this case are silent regarding the patient’s H&H values, it is of paramount importance to understand that the briskly bleeding patient will have a normal or near-normal H&H. During deposition in malpractice case after malpractice case, clinicians are pinned down as having failingly relied on a relatively normal H&H in the setting of rapid hemorrhage.

Hemorrhage must be considered in any patient with hemodynamically unstable vital signs in the setting of trauma, surgery, or coagulopathy—or in any patient with obvious volume loss or apparent unexplained internal fluid accumulation. —DML 

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

In October 2007, a 72-year-old Pennsylvania woman underwent an elective cardiac catheterization in the right femoral artery at the recommendation of Dr. K. Shortly after the procedure, the patient had abdominal pain and back pain, with apparent bleeding in the abdominal cavity. She was kept at the hospital.

Almost two days later, the woman had persistent abdominal pain, a heart rate greater than 120 beats/min, and abdominal tenderness on palpation. Dr. L. was informed of this but did not examine the decedent; instead, he ordered abdominal x-rays, lab work, and administration of morphine.

Four hours later, the woman was found unresponsive. She had experienced cardiac arrest and was placed on a ventilator. In late November, she was transferred to another hospital, where she died about five weeks later. Her death was attributed to multiple organ failure and decreased intestinal blood flow.

The plaintiffs alleged negligence on the part of several defendants, including Dr. K., Dr. L., and the hospital. Dr. L. did not contest causal negligence but argued that other defendants were also at fault.

Outcome
According to a published account, a jury returned a $5.16 million verdict, including $4.13 million in wrongful death damages and $1.03 million in survival damages. The jury found Dr. L. 95% liable and Dr. K. 5% liable. Defense verdicts were entered for the other defendants.

Under the terms of an agreement into which the plaintiffs had previously entered with the defendants’ insurer, the plaintiffs recovered in the amount of $1.75 million.

Comment
This patient was hemodynamically unstable, with a pulse of 120, abdominal pain and tenderness, and an established intra-abdominal bleed. The standard of care required an effort to intervene immediately and stabilize her. Clearly, this did not occur.

Missed bleeding is hard to defend in court. Jurors understand bleeding and expect it to be identified, stopped, and remedied. As clinicians, we know that hemorrhage can be subtle, occult, and difficult to manage. In malpractice cases involving missed hemorrhage, however, plaintiff’s counsel will frequently argue that the clinician exhibited a brazen lack of concern for the patient and will seek a punitive component to damages. Allowing a patient to exsanguinate will inflame a jury, resulting in a heavy damage award—similar to the verdict returned in this case.

Undetected acute bleeding often stems from a misplaced reliance on hemoglobin and hematocrit (H&H) values. In short, H&H values cannot effectively detect acute hemorrhage. As an index of concentration, H&H values will decrease only after time or volume replacement. A skilled plaintiff’s lawyer can vividly demonstrate the fallibility of H&H to detect acute bleeding by emptying half the volume of a pitcher of red liquid in front of the defendant (and the jury) and asking if the concentration changes. As in an exsanguinated decedent’s H&H values in a malpractice case, it will not.

While the facts of this case are silent regarding the patient’s H&H values, it is of paramount importance to understand that the briskly bleeding patient will have a normal or near-normal H&H. During deposition in malpractice case after malpractice case, clinicians are pinned down as having failingly relied on a relatively normal H&H in the setting of rapid hemorrhage.

Hemorrhage must be considered in any patient with hemodynamically unstable vital signs in the setting of trauma, surgery, or coagulopathy—or in any patient with obvious volume loss or apparent unexplained internal fluid accumulation. —DML 

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

In October 2007, a 72-year-old Pennsylvania woman underwent an elective cardiac catheterization in the right femoral artery at the recommendation of Dr. K. Shortly after the procedure, the patient had abdominal pain and back pain, with apparent bleeding in the abdominal cavity. She was kept at the hospital.

Almost two days later, the woman had persistent abdominal pain, a heart rate greater than 120 beats/min, and abdominal tenderness on palpation. Dr. L. was informed of this but did not examine the decedent; instead, he ordered abdominal x-rays, lab work, and administration of morphine.

Four hours later, the woman was found unresponsive. She had experienced cardiac arrest and was placed on a ventilator. In late November, she was transferred to another hospital, where she died about five weeks later. Her death was attributed to multiple organ failure and decreased intestinal blood flow.

The plaintiffs alleged negligence on the part of several defendants, including Dr. K., Dr. L., and the hospital. Dr. L. did not contest causal negligence but argued that other defendants were also at fault.

Outcome
According to a published account, a jury returned a $5.16 million verdict, including $4.13 million in wrongful death damages and $1.03 million in survival damages. The jury found Dr. L. 95% liable and Dr. K. 5% liable. Defense verdicts were entered for the other defendants.

Under the terms of an agreement into which the plaintiffs had previously entered with the defendants’ insurer, the plaintiffs recovered in the amount of $1.75 million.

Comment
This patient was hemodynamically unstable, with a pulse of 120, abdominal pain and tenderness, and an established intra-abdominal bleed. The standard of care required an effort to intervene immediately and stabilize her. Clearly, this did not occur.

Missed bleeding is hard to defend in court. Jurors understand bleeding and expect it to be identified, stopped, and remedied. As clinicians, we know that hemorrhage can be subtle, occult, and difficult to manage. In malpractice cases involving missed hemorrhage, however, plaintiff’s counsel will frequently argue that the clinician exhibited a brazen lack of concern for the patient and will seek a punitive component to damages. Allowing a patient to exsanguinate will inflame a jury, resulting in a heavy damage award—similar to the verdict returned in this case.

Undetected acute bleeding often stems from a misplaced reliance on hemoglobin and hematocrit (H&H) values. In short, H&H values cannot effectively detect acute hemorrhage. As an index of concentration, H&H values will decrease only after time or volume replacement. A skilled plaintiff’s lawyer can vividly demonstrate the fallibility of H&H to detect acute bleeding by emptying half the volume of a pitcher of red liquid in front of the defendant (and the jury) and asking if the concentration changes. As in an exsanguinated decedent’s H&H values in a malpractice case, it will not.

While the facts of this case are silent regarding the patient’s H&H values, it is of paramount importance to understand that the briskly bleeding patient will have a normal or near-normal H&H. During deposition in malpractice case after malpractice case, clinicians are pinned down as having failingly relied on a relatively normal H&H in the setting of rapid hemorrhage.

Hemorrhage must be considered in any patient with hemodynamically unstable vital signs in the setting of trauma, surgery, or coagulopathy—or in any patient with obvious volume loss or apparent unexplained internal fluid accumulation. —DML 

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A 64-year-old Alabama man, while dismounting from a dolly at work, lost his footing and fell back-first, landing on his shoulders but also striking the back of his neck and the back of his head. He later reported that he felt his neck pop before he lost consciousness. A coworker found the injured man, and he was quickly evaluated by a nurse in the employer’s medical office. No bumps or bruises were found, and the patient was given acetaminophen and instructed to rest on a heating pad for half an hour or so. He rested for some additional time before returning to work.

When the man arrived home that evening, he went to sleep. When he awoke, he was experiencing significant neck pain and he was taken to an emergency department (ED). He was treated in the ED by Dr. E. X-rays were taken, but they revealed nothing. The plaintiff was discharged after administration of pain medication, a muscle relaxer, and an anti-inflammatory agent.

The following day, the patient had trouble walking and using the bathroom. He was taken to Dr. J., who ordered an MRI that was performed three days after the patient’s accident. The day after the MRI, the patient was unable to get out of bed or move his legs, and his neck pain had worsened. He was taken by ambulance to a hospital, where additional x-rays were taken. Two fractures were found in his neck, which were exerting pressure against the spinal cord. The man was also diagnosed with a bruise on the spine on the back of the neck. He underwent surgery, but his disability persisted.

The plaintiff alleged negligence in the medical providers’ failure to make an earlier diagnosis of the spinal cord injury. The plaintiff claimed that a timely diagnosis and treatment with steroids would have changed his outcome.

The defendants claimed that no negligence was involved and that the plaintiff’s outcome would have been the same, even with earlier treatment. The only defendant at trial was Dr. E.

Outcome
The patient died in 2008, and his estate was substituted as plaintiff. According to a published report, a defense verdict was returned.

Comment
In this defense verdict, it appears that everyone did the right thing, but that technology failed to properly identify the real injury. On the day of the unwitnessed accident, the patient’s physical exam revealed no findings suggestive of spinal injury. Signs and symptoms that developed on the day after the accident were suggestive of spinal injury, but x-rays ordered by the defendant emergency physician failed to reveal any abnormality; the patient’s symptoms could easily have been explained by muscle pain and soreness attributable to his accident. Certainly, in retrospect, everyone wishes that an MRI had been performed on Day 1. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A 64-year-old Alabama man, while dismounting from a dolly at work, lost his footing and fell back-first, landing on his shoulders but also striking the back of his neck and the back of his head. He later reported that he felt his neck pop before he lost consciousness. A coworker found the injured man, and he was quickly evaluated by a nurse in the employer’s medical office. No bumps or bruises were found, and the patient was given acetaminophen and instructed to rest on a heating pad for half an hour or so. He rested for some additional time before returning to work.

When the man arrived home that evening, he went to sleep. When he awoke, he was experiencing significant neck pain and he was taken to an emergency department (ED). He was treated in the ED by Dr. E. X-rays were taken, but they revealed nothing. The plaintiff was discharged after administration of pain medication, a muscle relaxer, and an anti-inflammatory agent.

The following day, the patient had trouble walking and using the bathroom. He was taken to Dr. J., who ordered an MRI that was performed three days after the patient’s accident. The day after the MRI, the patient was unable to get out of bed or move his legs, and his neck pain had worsened. He was taken by ambulance to a hospital, where additional x-rays were taken. Two fractures were found in his neck, which were exerting pressure against the spinal cord. The man was also diagnosed with a bruise on the spine on the back of the neck. He underwent surgery, but his disability persisted.

The plaintiff alleged negligence in the medical providers’ failure to make an earlier diagnosis of the spinal cord injury. The plaintiff claimed that a timely diagnosis and treatment with steroids would have changed his outcome.

The defendants claimed that no negligence was involved and that the plaintiff’s outcome would have been the same, even with earlier treatment. The only defendant at trial was Dr. E.

Outcome
The patient died in 2008, and his estate was substituted as plaintiff. According to a published report, a defense verdict was returned.

Comment
In this defense verdict, it appears that everyone did the right thing, but that technology failed to properly identify the real injury. On the day of the unwitnessed accident, the patient’s physical exam revealed no findings suggestive of spinal injury. Signs and symptoms that developed on the day after the accident were suggestive of spinal injury, but x-rays ordered by the defendant emergency physician failed to reveal any abnormality; the patient’s symptoms could easily have been explained by muscle pain and soreness attributable to his accident. Certainly, in retrospect, everyone wishes that an MRI had been performed on Day 1. —JP

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A 64-year-old Alabama man, while dismounting from a dolly at work, lost his footing and fell back-first, landing on his shoulders but also striking the back of his neck and the back of his head. He later reported that he felt his neck pop before he lost consciousness. A coworker found the injured man, and he was quickly evaluated by a nurse in the employer’s medical office. No bumps or bruises were found, and the patient was given acetaminophen and instructed to rest on a heating pad for half an hour or so. He rested for some additional time before returning to work.

When the man arrived home that evening, he went to sleep. When he awoke, he was experiencing significant neck pain and he was taken to an emergency department (ED). He was treated in the ED by Dr. E. X-rays were taken, but they revealed nothing. The plaintiff was discharged after administration of pain medication, a muscle relaxer, and an anti-inflammatory agent.

The following day, the patient had trouble walking and using the bathroom. He was taken to Dr. J., who ordered an MRI that was performed three days after the patient’s accident. The day after the MRI, the patient was unable to get out of bed or move his legs, and his neck pain had worsened. He was taken by ambulance to a hospital, where additional x-rays were taken. Two fractures were found in his neck, which were exerting pressure against the spinal cord. The man was also diagnosed with a bruise on the spine on the back of the neck. He underwent surgery, but his disability persisted.

The plaintiff alleged negligence in the medical providers’ failure to make an earlier diagnosis of the spinal cord injury. The plaintiff claimed that a timely diagnosis and treatment with steroids would have changed his outcome.

The defendants claimed that no negligence was involved and that the plaintiff’s outcome would have been the same, even with earlier treatment. The only defendant at trial was Dr. E.

Outcome
The patient died in 2008, and his estate was substituted as plaintiff. According to a published report, a defense verdict was returned.

Comment
In this defense verdict, it appears that everyone did the right thing, but that technology failed to properly identify the real injury. On the day of the unwitnessed accident, the patient’s physical exam revealed no findings suggestive of spinal injury. Signs and symptoms that developed on the day after the accident were suggestive of spinal injury, but x-rays ordered by the defendant emergency physician failed to reveal any abnormality; the patient’s symptoms could easily have been explained by muscle pain and soreness attributable to his accident. Certainly, in retrospect, everyone wishes that an MRI had been performed on Day 1. —JP

Errors in clinical judgment were cited in 77% of more than 800 clinically coded obstetric malpractice cases analyzed by CRICO Strategies, a division of CRICO. CRICO is the patient safety and medical malpractice insurance company owned by the Harvard medical community since 1976. The findings of the analysis were published in a 2010 report entitled Malpractice Risks in Obstetrics.¹ The cases on which the report is based were asserted from 2005 to 2009.

According to the report, other prevalent areas of causation were:

• miscommunication (36% of cases)
• technical error (26%)
• inadequate documentation (26%)
• administrative failures (23%)
• ineffective supervision (15%).

The report also reveals the top three most common OB risks or allegations:

• delay in treatment of fetal distress
• improper performance of vaginal delivery
• improper management of pregnancy.

In the CRICO analysis, OB malpractice issues were rarely the result of a single act or omission by a single clinician. Rather, cases typically involved a series of missteps and mishandled decisions by a team of physicians and nurses who converged too late to resolve a rapidly devolving crisis.

“Obstetrics has some unique vulnerabilities, most often involving situations in which a sequence of errors or oversights cascade into a crisis that can put mother and baby in jeopardy,” said Robert Hanscom, senior vice president of CRICO Strategies. “Because there is rarely that standout ‘single event,’ it is absolutely paramount that OB practices understand how these missteps unfold, and then focus on education and training initiatives designed specifically to help clinicians avert those mistakes.”

Although the rate of OB claims is relatively infrequent—less than one case for every 1,000 births—the average malpractice payment is approximately $947,000. That figure is more than twice that of other clinical areas, and second only to surgery in total indemnity payments.

We want to hear from you! Tell us what you think.

Errors in clinical judgment were cited in 77% of more than 800 clinically coded obstetric malpractice cases analyzed by CRICO Strategies, a division of CRICO. CRICO is the patient safety and medical malpractice insurance company owned by the Harvard medical community since 1976. The findings of the analysis were published in a 2010 report entitled Malpractice Risks in Obstetrics.¹ The cases on which the report is based were asserted from 2005 to 2009.

According to the report, other prevalent areas of causation were:

• miscommunication (36% of cases)
• technical error (26%)
• inadequate documentation (26%)
• administrative failures (23%)
• ineffective supervision (15%).

The report also reveals the top three most common OB risks or allegations:

• delay in treatment of fetal distress
• improper performance of vaginal delivery
• improper management of pregnancy.

In the CRICO analysis, OB malpractice issues were rarely the result of a single act or omission by a single clinician. Rather, cases typically involved a series of missteps and mishandled decisions by a team of physicians and nurses who converged too late to resolve a rapidly devolving crisis.

“Obstetrics has some unique vulnerabilities, most often involving situations in which a sequence of errors or oversights cascade into a crisis that can put mother and baby in jeopardy,” said Robert Hanscom, senior vice president of CRICO Strategies. “Because there is rarely that standout ‘single event,’ it is absolutely paramount that OB practices understand how these missteps unfold, and then focus on education and training initiatives designed specifically to help clinicians avert those mistakes.”

Although the rate of OB claims is relatively infrequent—less than one case for every 1,000 births—the average malpractice payment is approximately $947,000. That figure is more than twice that of other clinical areas, and second only to surgery in total indemnity payments.

We want to hear from you! Tell us what you think.

Errors in clinical judgment were cited in 77% of more than 800 clinically coded obstetric malpractice cases analyzed by CRICO Strategies, a division of CRICO. CRICO is the patient safety and medical malpractice insurance company owned by the Harvard medical community since 1976. The findings of the analysis were published in a 2010 report entitled Malpractice Risks in Obstetrics.¹ The cases on which the report is based were asserted from 2005 to 2009.

According to the report, other prevalent areas of causation were:

• miscommunication (36% of cases)
• technical error (26%)
• inadequate documentation (26%)
• administrative failures (23%)
• ineffective supervision (15%).

The report also reveals the top three most common OB risks or allegations:

• delay in treatment of fetal distress
• improper performance of vaginal delivery
• improper management of pregnancy.

In the CRICO analysis, OB malpractice issues were rarely the result of a single act or omission by a single clinician. Rather, cases typically involved a series of missteps and mishandled decisions by a team of physicians and nurses who converged too late to resolve a rapidly devolving crisis.

“Obstetrics has some unique vulnerabilities, most often involving situations in which a sequence of errors or oversights cascade into a crisis that can put mother and baby in jeopardy,” said Robert Hanscom, senior vice president of CRICO Strategies. “Because there is rarely that standout ‘single event,’ it is absolutely paramount that OB practices understand how these missteps unfold, and then focus on education and training initiatives designed specifically to help clinicians avert those mistakes.”

Although the rate of OB claims is relatively infrequent—less than one case for every 1,000 births—the average malpractice payment is approximately $947,000. That figure is more than twice that of other clinical areas, and second only to surgery in total indemnity payments.

We want to hear from you! Tell us what you think.

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Obesity Distracts from Pulmonary Embolism
A 32-year-old Maryland woman presented to her primary care physician in August 2005 with complaints of recent-­onset shortness of breath. Results from a cardiac workup were normal. The patient returned to the same doctor two more times with persistent symptoms. The doctor ordered CT in order to rule out the possibility of pulmonary embolism, but the test was not done. Instead, an echocardiogram was performed, resulting in a technically limited study with results indicating that the woman’s heart function was normal and showing no evidence of pulmonary hypertension.

The woman was then referred to the defendant pulmonologist, Dr. M. She first presented to the defendant in November 2005 and continued to receive treatment from him until the following May. The woman was originally prescribed prednisone for what the defendant diagnosed as sarcoidosis. When this was later discovered to be an incorrect diagnosis, Dr. M. prescribed furosemide to relieve excess fluid buildup. The patient was 5’2” tall and weighed approximately 350 lb. The defendant made a diagnosis of obesity-related hypoventilation/shortness of breath.

During this time, the patient was seen by a bariatric surgeon. Bariatric surgery was scheduled for May 2005. While in the bariatric surgeon’s office before the surgery, the woman began to experience labored breathing. The bariatric surgeon contacted Dr. M. by phone and recommended that he see the patient to investigate her breathing difficulties, which the surgeon had observed. The woman reportedly told the defendant that she was having trouble breathing, but that it was no different from any other day. Additionally, the patient had not yet taken her furosemide or used her oxygen that day.

The woman scheduled an appointment with the defendant for three days later, but she experienced a fatal pulmonary embolism one day before the scheduled visit.

Plaintiffs for the decedent alleged negligence in the defendant pulmonologist’s failure to make a diagnosis of pulmonary embolism and in failing to order CT angiography, which would have revealed evidence of the pulmonary emboli.

The defendant claimed that the diagnosis made was reasonable.

Outcome
According to a published report, an $800,000 verdict was returned.

Comment
The CT scan that the primary care provider ordered to rule out pulmonary embolism was never done. An echocardiogram was not only not the test ordered, but also the wrong test, and technically limited. Neither the physician who correctly ordered the test to rule out a life-threatening condition nor the defendant pulmonologist, who should have had pulmonary embolus on the list of diagnostic alternatives, ever tried again to get this important information. With the passage of time, the true diagnosis got lost in the shuffle, and the patient’s obesity allowed the diagnosis of a weight-based problem to distract.

When a patient’s symptoms are so concerning that they rate a personal call from the bariatric surgeon to the pulmonologist in the patient’s presence, the explanation of failure to have taken medications should not have prevailed. Three days was too long to postpone an evaluation, as the end result proved. —JP

Crohn’s Flair Misdiagnosed in Pregnant Woman
A woman from California was given a diagnosis of Crohn’s disease in 2003. In 2006, she became pregnant for the first time and began to receive prenatal treatment from Dr. D., an obstetrician. The pregnancy was considered high-risk due to the Crohn’s disease. The patient was referred to a gastrointestinal specialist for a baseline examination in November 2006, but in January 2007, Dr. D. took over her GI-related care as well.

Dr. D. referred the woman to Dr. W., a specialist in high-risk pregnancy. When Dr. W. first saw her in February 2007, he made the determination that her Crohn’s disease was inactive and that the fetus was fine. He advised her that if any symptoms flared, she should consult with her GI specialist. Dr. W. saw the patient for two additional visits and noted no problems with the exception of a bowel impaction.

In May and June, the woman went to the hospital on four occasions with complaints of severe abdominal pain. Each time, Dr. D. was called, and the patient was released in improved condition.

The patient claimed that she suffered from severe pain and nausea that caused her to be virtually bedbound beginning in May. Early in July, she called Dr. D. to report that she was still in pain, and she was instructed to go to the hospital for induction of labor and delivery, as her due date was only three days away. After 23 hours of labor, the woman delivered a healthy baby girl. The patient had anemia when she was discharged.

After a few days, she called Dr. D. and asked to come to the office for a complete blood count to check on her anemia. She also complained of minimal headaches and dizziness. She did not keep the appointment for her blood test. A little more than a week later, the plaintiff was taken to the hospital with a lump on her right abdomen. When CT revealed a mass, she was scheduled for surgery, which involved the removal of a 12-inch piece of bowel to treat a perforation of the bowel that was attributed to a Crohn’s flair.

The plaintiff claimed that the defendants had ignored her reported symptoms of a Crohn’s flair, which led to the perforation. The defendants claimed that the plaintiff had not had a Crohn’s flair during her pregnancy and that all of her complaints were attributable to the pregnancy.

Outcome
According to a published account, a defense verdict was returned.

Comment
Pain in a pregnant woman needs an explanation. The finding early in the patient’s pregnancy that there was no Crohn’s flare did not mean that a flare would not occur later. The defendants prevailed, but it appears that the obstetricians failed to determine a cause for the pain. If the obstetricians had kept the gastroenterologist in the loop, they might have been able to prevent the loss of bowel. —JP

Oral Neoplasm Goes Undiagnosed
An Ohio woman was under the care of Dr. V. from 1998 to 2006. She was being treated for fibrocystic breast disease, cysts, phyllodes tumor, and carcinoma. In 2006, the patient developed a malignant spindle-cell neoplasm in her mouth. The lesion metastasized to her lungs and brain, and she died in February 2007.

The plaintiff claimed that the defendant was negligent in her treatment of the decedent.

Outcome
According to a published account, a defense verdict was returned.

Comment
Failing to look into the oral cavity and then investigate any suspicious lesions—especially in a patient with a history of cancer—falls below the standard of care. Unfortunately, many clinicians have not had adequate education in oral health care and do not include an oral exam as a routine part of the physical examination. —RDD     

Delayed Referral Renders Tendon Injury Irreparable
At age 39, a Nevada man sustained a complete rupture of his left distal biceps tendon after experiencing a hyperextension injury that occurred when a ping-pong table he was unloading suddenly slipped off the truck. The plaintiff was a personal trainer and a champion bodybuilder.

The injury was initially diagnosed at a non-party medical center; there, the patient was referred to a non-party orthopedist who recommended surgical repair to correct the deformity while preserving the man’s strength. The orthopedist believed that the time in which surgical correction could be accomplished was limited.

The patient decided instead to go to a Veterans Administration facility for care; he was seen by the defendant internist in the VA triage department one week after the injury. According to the patient, the defendant told him that there was no urgency to schedule the surgery and gave him a nonurgent referral to a VA orthopedist. The man also reported that the defendant ordered a nonurgent magnetic resonance angiogram (MRA) of the arm, filled out the proper VA forms for an orthopedic referral, prescribed ibuprofen and hydrocodone with acetaminophen, and instructed the patient to use a sling.

It was not until about six weeks after his injury that the patient saw a VA orthopedist, who then referred him back to the non-party orthopedist for surgery. The surgery was performed about nine weeks after the injury. By that time, the proximal tendon was found to be scarred and could not be reattached.

The plaintiff alleged that the cosmetic deformity and loss of strength in the arm could not be corrected. He claimed that an MRI, not an MRA, should have been ordered by the defendant, and that the defendant failed to obtain for him a timely referral to an orthopedic surgeon.

The defendant claimed that he had taken all of the proper steps to comply with the VA’s referral procedure. The defendant charged the plaintiff with contributory negligence for not seeing an orthopedist sooner and for his history of using anabolic steroids.

Outcome
According to a published report, a defense verdict was returned.

Comment
As in most malpractice cases, the “blame” is rarely black and white. While this is true in this case, it brings an important issue to bear. Timely referrals are extremely important, especially in orthopedic injuries, such as the one in this case. Referral policies should be reexamined to avoid lengthy referral times—particularly when a large organization is involved. —RDD

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Obesity Distracts from Pulmonary Embolism
A 32-year-old Maryland woman presented to her primary care physician in August 2005 with complaints of recent-­onset shortness of breath. Results from a cardiac workup were normal. The patient returned to the same doctor two more times with persistent symptoms. The doctor ordered CT in order to rule out the possibility of pulmonary embolism, but the test was not done. Instead, an echocardiogram was performed, resulting in a technically limited study with results indicating that the woman’s heart function was normal and showing no evidence of pulmonary hypertension.

The woman was then referred to the defendant pulmonologist, Dr. M. She first presented to the defendant in November 2005 and continued to receive treatment from him until the following May. The woman was originally prescribed prednisone for what the defendant diagnosed as sarcoidosis. When this was later discovered to be an incorrect diagnosis, Dr. M. prescribed furosemide to relieve excess fluid buildup. The patient was 5’2” tall and weighed approximately 350 lb. The defendant made a diagnosis of obesity-related hypoventilation/shortness of breath.

During this time, the patient was seen by a bariatric surgeon. Bariatric surgery was scheduled for May 2005. While in the bariatric surgeon’s office before the surgery, the woman began to experience labored breathing. The bariatric surgeon contacted Dr. M. by phone and recommended that he see the patient to investigate her breathing difficulties, which the surgeon had observed. The woman reportedly told the defendant that she was having trouble breathing, but that it was no different from any other day. Additionally, the patient had not yet taken her furosemide or used her oxygen that day.

The woman scheduled an appointment with the defendant for three days later, but she experienced a fatal pulmonary embolism one day before the scheduled visit.

Plaintiffs for the decedent alleged negligence in the defendant pulmonologist’s failure to make a diagnosis of pulmonary embolism and in failing to order CT angiography, which would have revealed evidence of the pulmonary emboli.

The defendant claimed that the diagnosis made was reasonable.

Outcome
According to a published report, an $800,000 verdict was returned.

Comment
The CT scan that the primary care provider ordered to rule out pulmonary embolism was never done. An echocardiogram was not only not the test ordered, but also the wrong test, and technically limited. Neither the physician who correctly ordered the test to rule out a life-threatening condition nor the defendant pulmonologist, who should have had pulmonary embolus on the list of diagnostic alternatives, ever tried again to get this important information. With the passage of time, the true diagnosis got lost in the shuffle, and the patient’s obesity allowed the diagnosis of a weight-based problem to distract.

When a patient’s symptoms are so concerning that they rate a personal call from the bariatric surgeon to the pulmonologist in the patient’s presence, the explanation of failure to have taken medications should not have prevailed. Three days was too long to postpone an evaluation, as the end result proved. —JP

Crohn’s Flair Misdiagnosed in Pregnant Woman
A woman from California was given a diagnosis of Crohn’s disease in 2003. In 2006, she became pregnant for the first time and began to receive prenatal treatment from Dr. D., an obstetrician. The pregnancy was considered high-risk due to the Crohn’s disease. The patient was referred to a gastrointestinal specialist for a baseline examination in November 2006, but in January 2007, Dr. D. took over her GI-related care as well.

Dr. D. referred the woman to Dr. W., a specialist in high-risk pregnancy. When Dr. W. first saw her in February 2007, he made the determination that her Crohn’s disease was inactive and that the fetus was fine. He advised her that if any symptoms flared, she should consult with her GI specialist. Dr. W. saw the patient for two additional visits and noted no problems with the exception of a bowel impaction.

In May and June, the woman went to the hospital on four occasions with complaints of severe abdominal pain. Each time, Dr. D. was called, and the patient was released in improved condition.

The patient claimed that she suffered from severe pain and nausea that caused her to be virtually bedbound beginning in May. Early in July, she called Dr. D. to report that she was still in pain, and she was instructed to go to the hospital for induction of labor and delivery, as her due date was only three days away. After 23 hours of labor, the woman delivered a healthy baby girl. The patient had anemia when she was discharged.

After a few days, she called Dr. D. and asked to come to the office for a complete blood count to check on her anemia. She also complained of minimal headaches and dizziness. She did not keep the appointment for her blood test. A little more than a week later, the plaintiff was taken to the hospital with a lump on her right abdomen. When CT revealed a mass, she was scheduled for surgery, which involved the removal of a 12-inch piece of bowel to treat a perforation of the bowel that was attributed to a Crohn’s flair.

The plaintiff claimed that the defendants had ignored her reported symptoms of a Crohn’s flair, which led to the perforation. The defendants claimed that the plaintiff had not had a Crohn’s flair during her pregnancy and that all of her complaints were attributable to the pregnancy.

Outcome
According to a published account, a defense verdict was returned.

Comment
Pain in a pregnant woman needs an explanation. The finding early in the patient’s pregnancy that there was no Crohn’s flare did not mean that a flare would not occur later. The defendants prevailed, but it appears that the obstetricians failed to determine a cause for the pain. If the obstetricians had kept the gastroenterologist in the loop, they might have been able to prevent the loss of bowel. —JP

Oral Neoplasm Goes Undiagnosed
An Ohio woman was under the care of Dr. V. from 1998 to 2006. She was being treated for fibrocystic breast disease, cysts, phyllodes tumor, and carcinoma. In 2006, the patient developed a malignant spindle-cell neoplasm in her mouth. The lesion metastasized to her lungs and brain, and she died in February 2007.

The plaintiff claimed that the defendant was negligent in her treatment of the decedent.

Outcome
According to a published account, a defense verdict was returned.

Comment
Failing to look into the oral cavity and then investigate any suspicious lesions—especially in a patient with a history of cancer—falls below the standard of care. Unfortunately, many clinicians have not had adequate education in oral health care and do not include an oral exam as a routine part of the physical examination. —RDD     

Delayed Referral Renders Tendon Injury Irreparable
At age 39, a Nevada man sustained a complete rupture of his left distal biceps tendon after experiencing a hyperextension injury that occurred when a ping-pong table he was unloading suddenly slipped off the truck. The plaintiff was a personal trainer and a champion bodybuilder.

The injury was initially diagnosed at a non-party medical center; there, the patient was referred to a non-party orthopedist who recommended surgical repair to correct the deformity while preserving the man’s strength. The orthopedist believed that the time in which surgical correction could be accomplished was limited.

The patient decided instead to go to a Veterans Administration facility for care; he was seen by the defendant internist in the VA triage department one week after the injury. According to the patient, the defendant told him that there was no urgency to schedule the surgery and gave him a nonurgent referral to a VA orthopedist. The man also reported that the defendant ordered a nonurgent magnetic resonance angiogram (MRA) of the arm, filled out the proper VA forms for an orthopedic referral, prescribed ibuprofen and hydrocodone with acetaminophen, and instructed the patient to use a sling.

It was not until about six weeks after his injury that the patient saw a VA orthopedist, who then referred him back to the non-party orthopedist for surgery. The surgery was performed about nine weeks after the injury. By that time, the proximal tendon was found to be scarred and could not be reattached.

The plaintiff alleged that the cosmetic deformity and loss of strength in the arm could not be corrected. He claimed that an MRI, not an MRA, should have been ordered by the defendant, and that the defendant failed to obtain for him a timely referral to an orthopedic surgeon.

The defendant claimed that he had taken all of the proper steps to comply with the VA’s referral procedure. The defendant charged the plaintiff with contributory negligence for not seeing an orthopedist sooner and for his history of using anabolic steroids.

Outcome
According to a published report, a defense verdict was returned.

Comment
As in most malpractice cases, the “blame” is rarely black and white. While this is true in this case, it brings an important issue to bear. Timely referrals are extremely important, especially in orthopedic injuries, such as the one in this case. Referral policies should be reexamined to avoid lengthy referral times—particularly when a large organization is involved. —RDD

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Obesity Distracts from Pulmonary Embolism
A 32-year-old Maryland woman presented to her primary care physician in August 2005 with complaints of recent-­onset shortness of breath. Results from a cardiac workup were normal. The patient returned to the same doctor two more times with persistent symptoms. The doctor ordered CT in order to rule out the possibility of pulmonary embolism, but the test was not done. Instead, an echocardiogram was performed, resulting in a technically limited study with results indicating that the woman’s heart function was normal and showing no evidence of pulmonary hypertension.

The woman was then referred to the defendant pulmonologist, Dr. M. She first presented to the defendant in November 2005 and continued to receive treatment from him until the following May. The woman was originally prescribed prednisone for what the defendant diagnosed as sarcoidosis. When this was later discovered to be an incorrect diagnosis, Dr. M. prescribed furosemide to relieve excess fluid buildup. The patient was 5’2” tall and weighed approximately 350 lb. The defendant made a diagnosis of obesity-related hypoventilation/shortness of breath.

During this time, the patient was seen by a bariatric surgeon. Bariatric surgery was scheduled for May 2005. While in the bariatric surgeon’s office before the surgery, the woman began to experience labored breathing. The bariatric surgeon contacted Dr. M. by phone and recommended that he see the patient to investigate her breathing difficulties, which the surgeon had observed. The woman reportedly told the defendant that she was having trouble breathing, but that it was no different from any other day. Additionally, the patient had not yet taken her furosemide or used her oxygen that day.

The woman scheduled an appointment with the defendant for three days later, but she experienced a fatal pulmonary embolism one day before the scheduled visit.

Plaintiffs for the decedent alleged negligence in the defendant pulmonologist’s failure to make a diagnosis of pulmonary embolism and in failing to order CT angiography, which would have revealed evidence of the pulmonary emboli.

The defendant claimed that the diagnosis made was reasonable.

Outcome
According to a published report, an $800,000 verdict was returned.

Comment
The CT scan that the primary care provider ordered to rule out pulmonary embolism was never done. An echocardiogram was not only not the test ordered, but also the wrong test, and technically limited. Neither the physician who correctly ordered the test to rule out a life-threatening condition nor the defendant pulmonologist, who should have had pulmonary embolus on the list of diagnostic alternatives, ever tried again to get this important information. With the passage of time, the true diagnosis got lost in the shuffle, and the patient’s obesity allowed the diagnosis of a weight-based problem to distract.

When a patient’s symptoms are so concerning that they rate a personal call from the bariatric surgeon to the pulmonologist in the patient’s presence, the explanation of failure to have taken medications should not have prevailed. Three days was too long to postpone an evaluation, as the end result proved. —JP

Crohn’s Flair Misdiagnosed in Pregnant Woman
A woman from California was given a diagnosis of Crohn’s disease in 2003. In 2006, she became pregnant for the first time and began to receive prenatal treatment from Dr. D., an obstetrician. The pregnancy was considered high-risk due to the Crohn’s disease. The patient was referred to a gastrointestinal specialist for a baseline examination in November 2006, but in January 2007, Dr. D. took over her GI-related care as well.

Dr. D. referred the woman to Dr. W., a specialist in high-risk pregnancy. When Dr. W. first saw her in February 2007, he made the determination that her Crohn’s disease was inactive and that the fetus was fine. He advised her that if any symptoms flared, she should consult with her GI specialist. Dr. W. saw the patient for two additional visits and noted no problems with the exception of a bowel impaction.

In May and June, the woman went to the hospital on four occasions with complaints of severe abdominal pain. Each time, Dr. D. was called, and the patient was released in improved condition.

The patient claimed that she suffered from severe pain and nausea that caused her to be virtually bedbound beginning in May. Early in July, she called Dr. D. to report that she was still in pain, and she was instructed to go to the hospital for induction of labor and delivery, as her due date was only three days away. After 23 hours of labor, the woman delivered a healthy baby girl. The patient had anemia when she was discharged.

After a few days, she called Dr. D. and asked to come to the office for a complete blood count to check on her anemia. She also complained of minimal headaches and dizziness. She did not keep the appointment for her blood test. A little more than a week later, the plaintiff was taken to the hospital with a lump on her right abdomen. When CT revealed a mass, she was scheduled for surgery, which involved the removal of a 12-inch piece of bowel to treat a perforation of the bowel that was attributed to a Crohn’s flair.

The plaintiff claimed that the defendants had ignored her reported symptoms of a Crohn’s flair, which led to the perforation. The defendants claimed that the plaintiff had not had a Crohn’s flair during her pregnancy and that all of her complaints were attributable to the pregnancy.

Outcome
According to a published account, a defense verdict was returned.

Comment
Pain in a pregnant woman needs an explanation. The finding early in the patient’s pregnancy that there was no Crohn’s flare did not mean that a flare would not occur later. The defendants prevailed, but it appears that the obstetricians failed to determine a cause for the pain. If the obstetricians had kept the gastroenterologist in the loop, they might have been able to prevent the loss of bowel. —JP

Oral Neoplasm Goes Undiagnosed
An Ohio woman was under the care of Dr. V. from 1998 to 2006. She was being treated for fibrocystic breast disease, cysts, phyllodes tumor, and carcinoma. In 2006, the patient developed a malignant spindle-cell neoplasm in her mouth. The lesion metastasized to her lungs and brain, and she died in February 2007.

The plaintiff claimed that the defendant was negligent in her treatment of the decedent.

Outcome
According to a published account, a defense verdict was returned.

Comment
Failing to look into the oral cavity and then investigate any suspicious lesions—especially in a patient with a history of cancer—falls below the standard of care. Unfortunately, many clinicians have not had adequate education in oral health care and do not include an oral exam as a routine part of the physical examination. —RDD     

Delayed Referral Renders Tendon Injury Irreparable
At age 39, a Nevada man sustained a complete rupture of his left distal biceps tendon after experiencing a hyperextension injury that occurred when a ping-pong table he was unloading suddenly slipped off the truck. The plaintiff was a personal trainer and a champion bodybuilder.

The injury was initially diagnosed at a non-party medical center; there, the patient was referred to a non-party orthopedist who recommended surgical repair to correct the deformity while preserving the man’s strength. The orthopedist believed that the time in which surgical correction could be accomplished was limited.

The patient decided instead to go to a Veterans Administration facility for care; he was seen by the defendant internist in the VA triage department one week after the injury. According to the patient, the defendant told him that there was no urgency to schedule the surgery and gave him a nonurgent referral to a VA orthopedist. The man also reported that the defendant ordered a nonurgent magnetic resonance angiogram (MRA) of the arm, filled out the proper VA forms for an orthopedic referral, prescribed ibuprofen and hydrocodone with acetaminophen, and instructed the patient to use a sling.

It was not until about six weeks after his injury that the patient saw a VA orthopedist, who then referred him back to the non-party orthopedist for surgery. The surgery was performed about nine weeks after the injury. By that time, the proximal tendon was found to be scarred and could not be reattached.

The plaintiff alleged that the cosmetic deformity and loss of strength in the arm could not be corrected. He claimed that an MRI, not an MRA, should have been ordered by the defendant, and that the defendant failed to obtain for him a timely referral to an orthopedic surgeon.

The defendant claimed that he had taken all of the proper steps to comply with the VA’s referral procedure. The defendant charged the plaintiff with contributory negligence for not seeing an orthopedist sooner and for his history of using anabolic steroids.

Outcome
According to a published report, a defense verdict was returned.

Comment
As in most malpractice cases, the “blame” is rarely black and white. While this is true in this case, it brings an important issue to bear. Timely referrals are extremely important, especially in orthopedic injuries, such as the one in this case. Referral policies should be reexamined to avoid lengthy referral times—particularly when a large organization is involved. —RDD

Blocked intestine after cesarean—
a nonsurgical cause?

A 34-YEAR-OLD WOMAN GAVE BIRTH to a healthy baby by cesarean delivery. Several weeks later, the mother reported abdominal pain, distention, and nausea. Her ObGyn suspected it was related to a somatic disorder.

Two months after delivery, the mother came to the emergency department with increasingly severe symptoms. One month later, at another hospital, physicians diagnosed a bowel obstruction. During emergency surgery, a lap sponge was found within the lumen of the patient’s small intestine.

PATIENT’S CLAIM The ObGyn left the lap sponge in her abdomen during cesarean delivery.

PHYSICIAN’S DEFENSE The sponge count from the cesarean delivery was correct. The ObGyn suggested that the patient had swallowed the sponge, because it was found within the lumen of the intestine, not in free space. The surgeon who removed the sponge agreed with the ObGyn, and recommended a psychiatric consult.

VERDICT A Louisiana defense verdict was returned.

Did vacuum extraction cause developmental delays?

SUCCESSFUL DELIVERY was performed using vacuum extraction. Later, mild balance and coordination issues, cognitive deficits, and speech delay were diagnosed in the child.

PATIENT’S CLAIM Use of the vacuum extractor was unnecessary; the instrument caused a subdural bleed that resulted in the child’s developmental delays.

PHYSICIAN’S DEFENSE Vacuum extraction was necessary because the baby was not progressing down the birth canal and was beginning to show signs of distress. Vacuum extraction did not cause the child’s injuries.

VERDICT A confidential South Carolina settlement was reached during jury deliberations.

Suture fails to dissolve; fistula develops

A WOMAN UNDERWENT SURGERY for uterine fibroids, during which injury to the bladder was repaired with a single suture.

A few weeks later, she developed abdominal pain, blood in her urine, and urinary incontinence. It was determined that the suture had not dissolved, and caused obstruction of the right ureter and kidney. A vesicovaginal fistula developed when the stitch migrated through the anterior wall of the vagina.

PATIENT’S CLAIM The gynecologist was at fault for injuring the bladder during surgery, and repairing it with a nondissolving suture.

PHYSICIAN’S DEFENSE Injury to the bladder and ureters is a known risk of the procedure. The correct type of suture was used; it was supposed to dissolve. The gynecologist tested the bladder and ureters using Indigo carmine-based dye before closing.

Over time, as the suture failed to dissolve, scar tissue occluded the ureter. Subsequent surgery returned the patient to baseline health.

VERDICT A Pennsylvania defense verdict was returned.

Baby stillborn. Vasa previa missed?

ULTRASONOGRAPHY REVEALED that the patient probably had a vasa previa. Her ObGyn referred her to an OB specialist, who ordered a second scan, which ruled out vasa previa. A month later, the patient was taken to the hospital with vaginal bleeding. It was determined that she was in labor, and her ObGyn performed a cesarean delivery. The baby was stillborn.

PATIENT’S CLAIM Both ObGyns failed to diagnose a vasa previa, which caused the stillbirth. Proper diagnosis would have allowed for cesarean delivery before labor began, resulting in a successful birth.

PHYSICIANS’ DEFENSE The pregnancy was properly managed. Vasa previa had been ruled out by ultrasonography. Placental abruption or a fetal-maternal hemorrhage was responsible for the stillbirth.

VERDICT A Kentucky defense verdict was returned.

Delay in delivery, then uterine infection, then hysterectomy

A 29-YEAR-OLD WOMAN was 34 weeks’ pregnant with her third child when she suspected that her water broke, and went to the hospital. Testing revealed the membranes had ruptured, but the ObGyn elected to delay delivery.

Amniotic fluid continued to leak for 5 days when suddenly the woman’s temperature spiked. A healthy baby was delivered by cesarean section 24 hours later.

After delivery, an intrauterine infection was diagnosed in the mother. She was transferred to another hospital, where she underwent a hysterectomy.

PATIENT’S CLAIM The ObGyn was negligent in failing to deliver the child when membranes initially broke. Leaking amniotic fluid contributed to the uterine infection.

PHYSICIAN’S DEFENSE It was appropriate to allow the pregnancy to continue because the fetus was premature. Infection could have occurred regardless of when delivery was performed.

VERDICT A $25,000 Mississippi verdict was returned.

What caused this child’s brain damage?

DURING PROLONGED DELIVERY, the physician assistant and residents in charge of labor and delivery noted meconiumstained amniotic fluid discharge. When advised, the mother’s ObGyn directed the hospital staff to perform amnioinfusion. The child was born vaginally several hours later and determined to have suffered brain damage.

The child cannot swallow and receives nutrition through a feeding tube. She cannot speak, is confined to a wheelchair, and has the cognitive function of an 18-month old.

PATIENT’S CLAIM The child suffered a hypoxic event caused by meconium aspiration, resulting in encephalopathy and cerebral palsy. The finding of stained amniotic fluid should have prompted the ObGyn to perform an emergency cesarean delivery.

PHYSICIAN’S DEFENSE Electronic fetal monitoring never indicated fetal distress. Amnioinfusion cleared the amniotic fluid, making a cesarean delivery unnecessary. The child’s condition resulted from preexisting neurological problems and/or a genetic condition that also caused microcephaly, a heart defect, and polydactylism.

VERDICT A New York defense verdict was returned.

Bowel is perforated: “Now I can’t conceive”

A WOMAN WAS GIVEN A DIAGNOSIS of endometriosis. During laparoscopic surgery to treat the condition, the gynecologist used a unipolar laparoscopic coagulator wand.

Eighteen days later, the patient went to the emergency department with severe lower abdominal pain. Peritonitis, caused by bowel perforation, was diagnosed, and she underwent surgery. A portion of bowel was removed. A colostomy was created, which was later reversed.

She developed adhesions from the peritonitis and required additional surgeries that, she alleged, caused subsequent fertility treatments to be unsuccessful.

PATIENT’S CLAIM The coagulator wand perforated the bowel. The gynecologist was negligent in his use of the wand; the wand manufacturer and the electrosurgical generator manufacturer were negligent in the equipment’s design; and the hospital was negligent in its maintenance of the equipment.

DEFENDANTS’ DEFENSE The instrument manufacturer denied any design defect and argued that the injury was not a burn but was caused by the coagulator wand making contact with another surgical instrument. The physician, generator manufacturer, and hospital denied negligence.

VERDICT The claim against the gynecologist was dismissed by summary judgment. The hospital and the generator manufacturer settled for an undisclosed amount. A $2.2 million California verdict was reached against the wand manufacturer.

Child has spina bifida despite evaluation

ULTRASONOGRAPHY RESULTS indicated normal fetal growth during a woman’s pregnancy. However, the child was born with spina bifida and required back and brain surgery shortly after birth. She wears ankle and foot orthotics and is incontinent.

PATIENT’S CLAIM The ObGyn failed to perform a prenatal alpha-fetoprotein test. The radiologist misinterpreted the sonogram.

PHYSICIANS’ DEFENSE The ObGyn believes that most spina bifida conditions are detectable by ultrasonography, and the radiologist’s report did not indicate spina bifida.

VERDICT The radiologist settled for $1 million before the trial. A $2.5 million New Jersey verdict was returned against the ObGyn.

Blocked intestine after cesarean—
a nonsurgical cause?

A 34-YEAR-OLD WOMAN GAVE BIRTH to a healthy baby by cesarean delivery. Several weeks later, the mother reported abdominal pain, distention, and nausea. Her ObGyn suspected it was related to a somatic disorder.

Two months after delivery, the mother came to the emergency department with increasingly severe symptoms. One month later, at another hospital, physicians diagnosed a bowel obstruction. During emergency surgery, a lap sponge was found within the lumen of the patient’s small intestine.

PATIENT’S CLAIM The ObGyn left the lap sponge in her abdomen during cesarean delivery.

PHYSICIAN’S DEFENSE The sponge count from the cesarean delivery was correct. The ObGyn suggested that the patient had swallowed the sponge, because it was found within the lumen of the intestine, not in free space. The surgeon who removed the sponge agreed with the ObGyn, and recommended a psychiatric consult.

VERDICT A Louisiana defense verdict was returned.

Did vacuum extraction cause developmental delays?

SUCCESSFUL DELIVERY was performed using vacuum extraction. Later, mild balance and coordination issues, cognitive deficits, and speech delay were diagnosed in the child.

PATIENT’S CLAIM Use of the vacuum extractor was unnecessary; the instrument caused a subdural bleed that resulted in the child’s developmental delays.

PHYSICIAN’S DEFENSE Vacuum extraction was necessary because the baby was not progressing down the birth canal and was beginning to show signs of distress. Vacuum extraction did not cause the child’s injuries.

VERDICT A confidential South Carolina settlement was reached during jury deliberations.

Suture fails to dissolve; fistula develops

A WOMAN UNDERWENT SURGERY for uterine fibroids, during which injury to the bladder was repaired with a single suture.

A few weeks later, she developed abdominal pain, blood in her urine, and urinary incontinence. It was determined that the suture had not dissolved, and caused obstruction of the right ureter and kidney. A vesicovaginal fistula developed when the stitch migrated through the anterior wall of the vagina.

PATIENT’S CLAIM The gynecologist was at fault for injuring the bladder during surgery, and repairing it with a nondissolving suture.

PHYSICIAN’S DEFENSE Injury to the bladder and ureters is a known risk of the procedure. The correct type of suture was used; it was supposed to dissolve. The gynecologist tested the bladder and ureters using Indigo carmine-based dye before closing.

Over time, as the suture failed to dissolve, scar tissue occluded the ureter. Subsequent surgery returned the patient to baseline health.

VERDICT A Pennsylvania defense verdict was returned.

Baby stillborn. Vasa previa missed?

ULTRASONOGRAPHY REVEALED that the patient probably had a vasa previa. Her ObGyn referred her to an OB specialist, who ordered a second scan, which ruled out vasa previa. A month later, the patient was taken to the hospital with vaginal bleeding. It was determined that she was in labor, and her ObGyn performed a cesarean delivery. The baby was stillborn.

PATIENT’S CLAIM Both ObGyns failed to diagnose a vasa previa, which caused the stillbirth. Proper diagnosis would have allowed for cesarean delivery before labor began, resulting in a successful birth.

PHYSICIANS’ DEFENSE The pregnancy was properly managed. Vasa previa had been ruled out by ultrasonography. Placental abruption or a fetal-maternal hemorrhage was responsible for the stillbirth.

VERDICT A Kentucky defense verdict was returned.

Delay in delivery, then uterine infection, then hysterectomy

A 29-YEAR-OLD WOMAN was 34 weeks’ pregnant with her third child when she suspected that her water broke, and went to the hospital. Testing revealed the membranes had ruptured, but the ObGyn elected to delay delivery.

Amniotic fluid continued to leak for 5 days when suddenly the woman’s temperature spiked. A healthy baby was delivered by cesarean section 24 hours later.

After delivery, an intrauterine infection was diagnosed in the mother. She was transferred to another hospital, where she underwent a hysterectomy.

PATIENT’S CLAIM The ObGyn was negligent in failing to deliver the child when membranes initially broke. Leaking amniotic fluid contributed to the uterine infection.

PHYSICIAN’S DEFENSE It was appropriate to allow the pregnancy to continue because the fetus was premature. Infection could have occurred regardless of when delivery was performed.

VERDICT A $25,000 Mississippi verdict was returned.

What caused this child’s brain damage?

DURING PROLONGED DELIVERY, the physician assistant and residents in charge of labor and delivery noted meconiumstained amniotic fluid discharge. When advised, the mother’s ObGyn directed the hospital staff to perform amnioinfusion. The child was born vaginally several hours later and determined to have suffered brain damage.

The child cannot swallow and receives nutrition through a feeding tube. She cannot speak, is confined to a wheelchair, and has the cognitive function of an 18-month old.

PATIENT’S CLAIM The child suffered a hypoxic event caused by meconium aspiration, resulting in encephalopathy and cerebral palsy. The finding of stained amniotic fluid should have prompted the ObGyn to perform an emergency cesarean delivery.

PHYSICIAN’S DEFENSE Electronic fetal monitoring never indicated fetal distress. Amnioinfusion cleared the amniotic fluid, making a cesarean delivery unnecessary. The child’s condition resulted from preexisting neurological problems and/or a genetic condition that also caused microcephaly, a heart defect, and polydactylism.

VERDICT A New York defense verdict was returned.

Bowel is perforated: “Now I can’t conceive”

A WOMAN WAS GIVEN A DIAGNOSIS of endometriosis. During laparoscopic surgery to treat the condition, the gynecologist used a unipolar laparoscopic coagulator wand.

Eighteen days later, the patient went to the emergency department with severe lower abdominal pain. Peritonitis, caused by bowel perforation, was diagnosed, and she underwent surgery. A portion of bowel was removed. A colostomy was created, which was later reversed.

She developed adhesions from the peritonitis and required additional surgeries that, she alleged, caused subsequent fertility treatments to be unsuccessful.

PATIENT’S CLAIM The coagulator wand perforated the bowel. The gynecologist was negligent in his use of the wand; the wand manufacturer and the electrosurgical generator manufacturer were negligent in the equipment’s design; and the hospital was negligent in its maintenance of the equipment.

DEFENDANTS’ DEFENSE The instrument manufacturer denied any design defect and argued that the injury was not a burn but was caused by the coagulator wand making contact with another surgical instrument. The physician, generator manufacturer, and hospital denied negligence.

VERDICT The claim against the gynecologist was dismissed by summary judgment. The hospital and the generator manufacturer settled for an undisclosed amount. A $2.2 million California verdict was reached against the wand manufacturer.

Child has spina bifida despite evaluation

ULTRASONOGRAPHY RESULTS indicated normal fetal growth during a woman’s pregnancy. However, the child was born with spina bifida and required back and brain surgery shortly after birth. She wears ankle and foot orthotics and is incontinent.

PATIENT’S CLAIM The ObGyn failed to perform a prenatal alpha-fetoprotein test. The radiologist misinterpreted the sonogram.

PHYSICIANS’ DEFENSE The ObGyn believes that most spina bifida conditions are detectable by ultrasonography, and the radiologist’s report did not indicate spina bifida.

VERDICT The radiologist settled for $1 million before the trial. A $2.5 million New Jersey verdict was returned against the ObGyn.

Blocked intestine after cesarean—
a nonsurgical cause?

A 34-YEAR-OLD WOMAN GAVE BIRTH to a healthy baby by cesarean delivery. Several weeks later, the mother reported abdominal pain, distention, and nausea. Her ObGyn suspected it was related to a somatic disorder.

Two months after delivery, the mother came to the emergency department with increasingly severe symptoms. One month later, at another hospital, physicians diagnosed a bowel obstruction. During emergency surgery, a lap sponge was found within the lumen of the patient’s small intestine.

PATIENT’S CLAIM The ObGyn left the lap sponge in her abdomen during cesarean delivery.

PHYSICIAN’S DEFENSE The sponge count from the cesarean delivery was correct. The ObGyn suggested that the patient had swallowed the sponge, because it was found within the lumen of the intestine, not in free space. The surgeon who removed the sponge agreed with the ObGyn, and recommended a psychiatric consult.

VERDICT A Louisiana defense verdict was returned.

Did vacuum extraction cause developmental delays?

SUCCESSFUL DELIVERY was performed using vacuum extraction. Later, mild balance and coordination issues, cognitive deficits, and speech delay were diagnosed in the child.

PATIENT’S CLAIM Use of the vacuum extractor was unnecessary; the instrument caused a subdural bleed that resulted in the child’s developmental delays.

PHYSICIAN’S DEFENSE Vacuum extraction was necessary because the baby was not progressing down the birth canal and was beginning to show signs of distress. Vacuum extraction did not cause the child’s injuries.

VERDICT A confidential South Carolina settlement was reached during jury deliberations.

Suture fails to dissolve; fistula develops

A WOMAN UNDERWENT SURGERY for uterine fibroids, during which injury to the bladder was repaired with a single suture.

A few weeks later, she developed abdominal pain, blood in her urine, and urinary incontinence. It was determined that the suture had not dissolved, and caused obstruction of the right ureter and kidney. A vesicovaginal fistula developed when the stitch migrated through the anterior wall of the vagina.

PATIENT’S CLAIM The gynecologist was at fault for injuring the bladder during surgery, and repairing it with a nondissolving suture.

PHYSICIAN’S DEFENSE Injury to the bladder and ureters is a known risk of the procedure. The correct type of suture was used; it was supposed to dissolve. The gynecologist tested the bladder and ureters using Indigo carmine-based dye before closing.

Over time, as the suture failed to dissolve, scar tissue occluded the ureter. Subsequent surgery returned the patient to baseline health.

VERDICT A Pennsylvania defense verdict was returned.

Baby stillborn. Vasa previa missed?

ULTRASONOGRAPHY REVEALED that the patient probably had a vasa previa. Her ObGyn referred her to an OB specialist, who ordered a second scan, which ruled out vasa previa. A month later, the patient was taken to the hospital with vaginal bleeding. It was determined that she was in labor, and her ObGyn performed a cesarean delivery. The baby was stillborn.

PATIENT’S CLAIM Both ObGyns failed to diagnose a vasa previa, which caused the stillbirth. Proper diagnosis would have allowed for cesarean delivery before labor began, resulting in a successful birth.

PHYSICIANS’ DEFENSE The pregnancy was properly managed. Vasa previa had been ruled out by ultrasonography. Placental abruption or a fetal-maternal hemorrhage was responsible for the stillbirth.

VERDICT A Kentucky defense verdict was returned.

Delay in delivery, then uterine infection, then hysterectomy

A 29-YEAR-OLD WOMAN was 34 weeks’ pregnant with her third child when she suspected that her water broke, and went to the hospital. Testing revealed the membranes had ruptured, but the ObGyn elected to delay delivery.

Amniotic fluid continued to leak for 5 days when suddenly the woman’s temperature spiked. A healthy baby was delivered by cesarean section 24 hours later.

After delivery, an intrauterine infection was diagnosed in the mother. She was transferred to another hospital, where she underwent a hysterectomy.

PATIENT’S CLAIM The ObGyn was negligent in failing to deliver the child when membranes initially broke. Leaking amniotic fluid contributed to the uterine infection.

PHYSICIAN’S DEFENSE It was appropriate to allow the pregnancy to continue because the fetus was premature. Infection could have occurred regardless of when delivery was performed.

VERDICT A $25,000 Mississippi verdict was returned.

What caused this child’s brain damage?

DURING PROLONGED DELIVERY, the physician assistant and residents in charge of labor and delivery noted meconiumstained amniotic fluid discharge. When advised, the mother’s ObGyn directed the hospital staff to perform amnioinfusion. The child was born vaginally several hours later and determined to have suffered brain damage.

The child cannot swallow and receives nutrition through a feeding tube. She cannot speak, is confined to a wheelchair, and has the cognitive function of an 18-month old.

PATIENT’S CLAIM The child suffered a hypoxic event caused by meconium aspiration, resulting in encephalopathy and cerebral palsy. The finding of stained amniotic fluid should have prompted the ObGyn to perform an emergency cesarean delivery.

PHYSICIAN’S DEFENSE Electronic fetal monitoring never indicated fetal distress. Amnioinfusion cleared the amniotic fluid, making a cesarean delivery unnecessary. The child’s condition resulted from preexisting neurological problems and/or a genetic condition that also caused microcephaly, a heart defect, and polydactylism.

VERDICT A New York defense verdict was returned.

Bowel is perforated: “Now I can’t conceive”

A WOMAN WAS GIVEN A DIAGNOSIS of endometriosis. During laparoscopic surgery to treat the condition, the gynecologist used a unipolar laparoscopic coagulator wand.

Eighteen days later, the patient went to the emergency department with severe lower abdominal pain. Peritonitis, caused by bowel perforation, was diagnosed, and she underwent surgery. A portion of bowel was removed. A colostomy was created, which was later reversed.

She developed adhesions from the peritonitis and required additional surgeries that, she alleged, caused subsequent fertility treatments to be unsuccessful.

PATIENT’S CLAIM The coagulator wand perforated the bowel. The gynecologist was negligent in his use of the wand; the wand manufacturer and the electrosurgical generator manufacturer were negligent in the equipment’s design; and the hospital was negligent in its maintenance of the equipment.

DEFENDANTS’ DEFENSE The instrument manufacturer denied any design defect and argued that the injury was not a burn but was caused by the coagulator wand making contact with another surgical instrument. The physician, generator manufacturer, and hospital denied negligence.

VERDICT The claim against the gynecologist was dismissed by summary judgment. The hospital and the generator manufacturer settled for an undisclosed amount. A $2.2 million California verdict was reached against the wand manufacturer.

Child has spina bifida despite evaluation

ULTRASONOGRAPHY RESULTS indicated normal fetal growth during a woman’s pregnancy. However, the child was born with spina bifida and required back and brain surgery shortly after birth. She wears ankle and foot orthotics and is incontinent.

PATIENT’S CLAIM The ObGyn failed to perform a prenatal alpha-fetoprotein test. The radiologist misinterpreted the sonogram.

PHYSICIANS’ DEFENSE The ObGyn believes that most spina bifida conditions are detectable by ultrasonography, and the radiologist’s report did not indicate spina bifida.

VERDICT The radiologist settled for $1 million before the trial. A $2.5 million New Jersey verdict was returned against the ObGyn.

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Delays, Missteps in Care of Child
The parents of a developmentally disabled 4-year-old boy took him to a Pennsylvania emergency department (ED) because he was vomiting and running a fever. The child had a heart rate of 180 beats/min and a respiratory rate of 40 breaths/min, but the triage nurse returned the child to the waiting room. Two hours later, another nurse recorded the child’s temperature, which revealed a fever. About 20 minutes later, a doctor saw the child and ordered acetaminophen and IV fluids, “stat.” A nurse requested an IV team, but it was not until an hour later that the fluids were finally administered. A few minutes after the line was placed, the child experienced a seizure and cardiac arrest. He died within the next hour.

The child’s adoptive mothers claimed that the hospital staff did not properly monitor the child’s vital signs, particularly in light of the child’s fever. The plaintiffs also claimed that the staff was negligent in waiting an hour to begin IV fluids when the order was “stat.” The plaintiffs also maintained that acetaminophen was never administered, despite the “stat” order.

Outcome
A $1 million settlement was reached.

Comment
“Stat” means “stat,” and not an hour later. But the failures here are more than just delay. A child with these vital signs was improperly triaged back to the waiting room when he needed constant vital sign monitoring at the least. Under these circumstances, checking vital signs two hours later was negligent. The jury came to a proper decision. —JP

Sponge Found Four Years After Laparotomy
A pregnant woman in her 30s went to a Michigan ED because she was bleeding and had abdominal pain. An ob/gyn performed emergency surgery to rule out an ectopic pregnancy. During the procedure, he found an ectopic pregnancy and performed a left salpingectomy.  The patient was discharged the next day but continued to have abdominal pain.

Four years later, at another hospital, the woman underwent CT because of an injury. The imaging revealed an object in her abdomen. She underwent an exploratory laparotomy; the object was removed and identified as a surgical sponge. After this surgery, the plaintiff developed an umbilical hernia and an infection.

The plaintiff claimed that the surgical sponge was left during the surgery that was performed four years earlier. She denied having undergone any other procedures between the salpingectomy and the surgery in which the sponge was removed.

The defendants claimed that the sponge that was removed was not the type that would have been used in the original procedure. The defendants also argued that the sponge counts were correct and that a retained sponge was a risk associated with the procedure.

Outcome
A defense verdict was returned.

Comment
How the defendants prevailed in this case is a mystery to me. In the absence of another explanation, a sponge found in the abdomen after a surgery is malpractice. Res ipsa loquitur, a Latin phrase meaning “the thing speaks for itself,” is the appropriate legal term to describe this situation. In cases like these, the plaintiffs don’t even need an expert to prove malpractice. Sponge counts always seem to be right, even when they are wrong; otherwise, the surgeon would not have closed the abdomen. I wish someone could tell me where that sponge came from. —JP

Heart Murmur Overlooked in College Athlete
A 19-year-old man who received a college basketball scholarship needed a physical examination for medical clearance to play. The physician who conducted the exam noted a “slight systolic heart murmur” and documented it on the college’s physical exam form. This finding may be consistent with hypertrophic cardiomyopathy, a congenital heart defect associated with a transient systolic murmur and known to cause sudden death in athletes. The physician ordered an echocardiogram and signed the college medical clearance form, stating that the young man was in excellent health and did not require any physical ­restrictions.

Three and a half years later, while playing in a college basketball game, the young man suddenly collapsed to the floor and became unresponsive. Emergency medical personnel arrived and attempted to revive him. The young man was taken to a hospital, where further attempts to revive him proved unsuccessful. He died at age 22, four months shy of being awarded his college degree.

The plaintiffs claimed that the examining physician was negligent in signing the medical clearance form before establishing whether the student’s heart murmur indicated a life-threatening cardiac condition and for failing to note that an echocardiogram was pending. The plaintiffs also claimed that the defendant had failed to follow up on the results of the echocardiogram and that an ECG should have been performed to evaluate the murmur. The plaintiffs claimed that the student would have had a normal life span if he had been diagnosed and treated properly.

The defendant claimed that there was no negligence involved, that the decedent had not kept the appointment for an echocardiogram, and that no physician who evaluated the decedent in the intervening years had ever detected a murmur.

Outcome
According to a published account, a $1.6 million verdict was returned.

Comment
A newly found murmur, whether loud or soft, deserves a complete work-up. This is particularly true when an athlete is involved. Even though an echocardiogram was ordered in this case, standard of care requires the clinician to follow up with the patient or to refer the patient to ensure adequate follow-up. —RDD

Failure to Make a Diagnosis of Colon Cancer
In October 2001, a 31-year-old man from Massachusetts went to his primary care physician’s office and was seen by a nurse practitioner. He complained of burning, cramping abdominal pain and inability to eat, which had resolved by the time of his appointment. The NP prescribed ranitidine and scheduled an appointment for a complete physical exam the following month.

During the subsequent physical exam, the patient complained of occasional abdominal pain and increased defecation. His family history included his mother’s diagnosis with colon cancer at age 54. The man also mentioned a history of chewing tobacco use and heavy coffee intake. No rectal exam was performed during this visit, nor was the patient provided with a fecal occult blood test. A colonoscopy was not ordered.

The NP changed his prescription to pantoprazole and ordered an upper GI series with contrast to rule out gastritis or ulcer; test results were negative for either. The patient’s primary care physician was given the test results, and neither the NP nor the physician initiated any discussion regarding what should be done next. The primary care physician never saw the man, nor did he review his chart at the time of this appointment.

In early December 2001, the man was seen again by the NP. He reported that his symptoms had improved on pantoprazole, but he continued to have eating problems. The NP maintained the original diagnosis of gastritis and discharged the man with instructions to call with any concerns and to return in six months. The NP did not include colon cancer in the differential diagnosis because of the patient’s age.

The man returned to the primary care physician’s office in April 2002 and was seen by the same NP. At this time, he reported worsening stomach cramps and a burning stomach. The NP switched his medication to lansoprazole while maintaining a diagnosis of gastritis. The NP made arrangements for the man to see a gastroenterologist for a possible esophagogastroduodenoscopy. The gastroenterology consult was not scheduled to take place until July.

The patient returned in May complaining of increased pain and loose stools whenever he ate cereal with milk. The NP’s revised diagnosis was gastritis and ulcer with lactose intolerance or nicotine addiction from chewing tobacco.

The gastroenterology consult was moved up, but the patient went to an ED before the scheduled visit. A work-up at the hospital, which included abdominal CT and a colonoscopy, resulted in a diagnosis of near obstruction of the right side of the colon by a stage IV tumor and metastasis to the peritoneum and lymph nodes. Immediate surgery was performed, followed by several rounds of chemotherapy, further abdominal surgery, and a cingulotomy for pain relief. The man died in December 2004.

The plaintiff claimed that the NP was negligent in failing to perform a rectal exam, conduct a fecal occult blood test, or order a colonoscopy. The plaintiff also claimed that after results from the upper GI were negative, a colonoscopy was required. The plaintiff claimed that in the fall of 2001, the colon cancer had probably been at stage IIIA with a 65% chance of survival, or stage IIIB with a 45% chance of survival, and that there was no chance of survival by the time the correct diagnosis was made.

The defendants claimed that a colonoscopy was not required because “burning” pain is more consistent with an upper GI process, and that the decedent’s history of chewing tobacco and excessive coffee consumption accounted for his eating difficulties. The primary care physician also claimed that a random review of patient files constituted adequate supervision and that there was no independent duty to review individual patient charts and sign off on them on a regular basis.

The defendants claimed that the decedent’s cancer was already at stage IV in the fall of 2001 and that nothing they could have done at that time would have changed the outcome. In addition, the defendants claimed that the decedent’s cancer was signet ring cell cancer, a very aggressive form of cancer that is nearly always fatal.

Outcome
The jury found both defendants negligent. They determined that the decedent had a 45% chance of survival at the time of his first visit, and that his chance of survival was reduced to zero. The jury calculated wrongful death damages at $5,210,000, and later reduced that figure, multiplying it by 45% for a loss-of-chance award. The plaintiff contacted an economist, who estimated the loss of net income and household services at $2 million. The jury also awarded pain and suffering damages, including those associated with “dying of colon cancer.” The total verdict was $4,694,500, and the total judgment was $7,549,142.

Comment
While the initial evaluation seemed reasonable, the patient’s family history of colon cancer, added to the fact that his condition was not significantly improving, should have indicated the need for further testing. It would have been prudent to order CT and an abdominal ultrasound to get a better look at the biliary tree. The rectal exam and fecal occult blood test are mandatory, particularly when ulcer is being considered. Even in a relatively young patient with gastric symptoms, use of chewing tobacco and coffee consumption should not preclude consideration of colon cancer. —RDD

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Delays, Missteps in Care of Child
The parents of a developmentally disabled 4-year-old boy took him to a Pennsylvania emergency department (ED) because he was vomiting and running a fever. The child had a heart rate of 180 beats/min and a respiratory rate of 40 breaths/min, but the triage nurse returned the child to the waiting room. Two hours later, another nurse recorded the child’s temperature, which revealed a fever. About 20 minutes later, a doctor saw the child and ordered acetaminophen and IV fluids, “stat.” A nurse requested an IV team, but it was not until an hour later that the fluids were finally administered. A few minutes after the line was placed, the child experienced a seizure and cardiac arrest. He died within the next hour.

The child’s adoptive mothers claimed that the hospital staff did not properly monitor the child’s vital signs, particularly in light of the child’s fever. The plaintiffs also claimed that the staff was negligent in waiting an hour to begin IV fluids when the order was “stat.” The plaintiffs also maintained that acetaminophen was never administered, despite the “stat” order.

Outcome
A $1 million settlement was reached.

Comment
“Stat” means “stat,” and not an hour later. But the failures here are more than just delay. A child with these vital signs was improperly triaged back to the waiting room when he needed constant vital sign monitoring at the least. Under these circumstances, checking vital signs two hours later was negligent. The jury came to a proper decision. —JP

Sponge Found Four Years After Laparotomy
A pregnant woman in her 30s went to a Michigan ED because she was bleeding and had abdominal pain. An ob/gyn performed emergency surgery to rule out an ectopic pregnancy. During the procedure, he found an ectopic pregnancy and performed a left salpingectomy.  The patient was discharged the next day but continued to have abdominal pain.

Four years later, at another hospital, the woman underwent CT because of an injury. The imaging revealed an object in her abdomen. She underwent an exploratory laparotomy; the object was removed and identified as a surgical sponge. After this surgery, the plaintiff developed an umbilical hernia and an infection.

The plaintiff claimed that the surgical sponge was left during the surgery that was performed four years earlier. She denied having undergone any other procedures between the salpingectomy and the surgery in which the sponge was removed.

The defendants claimed that the sponge that was removed was not the type that would have been used in the original procedure. The defendants also argued that the sponge counts were correct and that a retained sponge was a risk associated with the procedure.

Outcome
A defense verdict was returned.

Comment
How the defendants prevailed in this case is a mystery to me. In the absence of another explanation, a sponge found in the abdomen after a surgery is malpractice. Res ipsa loquitur, a Latin phrase meaning “the thing speaks for itself,” is the appropriate legal term to describe this situation. In cases like these, the plaintiffs don’t even need an expert to prove malpractice. Sponge counts always seem to be right, even when they are wrong; otherwise, the surgeon would not have closed the abdomen. I wish someone could tell me where that sponge came from. —JP

Heart Murmur Overlooked in College Athlete
A 19-year-old man who received a college basketball scholarship needed a physical examination for medical clearance to play. The physician who conducted the exam noted a “slight systolic heart murmur” and documented it on the college’s physical exam form. This finding may be consistent with hypertrophic cardiomyopathy, a congenital heart defect associated with a transient systolic murmur and known to cause sudden death in athletes. The physician ordered an echocardiogram and signed the college medical clearance form, stating that the young man was in excellent health and did not require any physical ­restrictions.

Three and a half years later, while playing in a college basketball game, the young man suddenly collapsed to the floor and became unresponsive. Emergency medical personnel arrived and attempted to revive him. The young man was taken to a hospital, where further attempts to revive him proved unsuccessful. He died at age 22, four months shy of being awarded his college degree.

The plaintiffs claimed that the examining physician was negligent in signing the medical clearance form before establishing whether the student’s heart murmur indicated a life-threatening cardiac condition and for failing to note that an echocardiogram was pending. The plaintiffs also claimed that the defendant had failed to follow up on the results of the echocardiogram and that an ECG should have been performed to evaluate the murmur. The plaintiffs claimed that the student would have had a normal life span if he had been diagnosed and treated properly.

The defendant claimed that there was no negligence involved, that the decedent had not kept the appointment for an echocardiogram, and that no physician who evaluated the decedent in the intervening years had ever detected a murmur.

Outcome
According to a published account, a $1.6 million verdict was returned.

Comment
A newly found murmur, whether loud or soft, deserves a complete work-up. This is particularly true when an athlete is involved. Even though an echocardiogram was ordered in this case, standard of care requires the clinician to follow up with the patient or to refer the patient to ensure adequate follow-up. —RDD

Failure to Make a Diagnosis of Colon Cancer
In October 2001, a 31-year-old man from Massachusetts went to his primary care physician’s office and was seen by a nurse practitioner. He complained of burning, cramping abdominal pain and inability to eat, which had resolved by the time of his appointment. The NP prescribed ranitidine and scheduled an appointment for a complete physical exam the following month.

During the subsequent physical exam, the patient complained of occasional abdominal pain and increased defecation. His family history included his mother’s diagnosis with colon cancer at age 54. The man also mentioned a history of chewing tobacco use and heavy coffee intake. No rectal exam was performed during this visit, nor was the patient provided with a fecal occult blood test. A colonoscopy was not ordered.

The NP changed his prescription to pantoprazole and ordered an upper GI series with contrast to rule out gastritis or ulcer; test results were negative for either. The patient’s primary care physician was given the test results, and neither the NP nor the physician initiated any discussion regarding what should be done next. The primary care physician never saw the man, nor did he review his chart at the time of this appointment.

In early December 2001, the man was seen again by the NP. He reported that his symptoms had improved on pantoprazole, but he continued to have eating problems. The NP maintained the original diagnosis of gastritis and discharged the man with instructions to call with any concerns and to return in six months. The NP did not include colon cancer in the differential diagnosis because of the patient’s age.

The man returned to the primary care physician’s office in April 2002 and was seen by the same NP. At this time, he reported worsening stomach cramps and a burning stomach. The NP switched his medication to lansoprazole while maintaining a diagnosis of gastritis. The NP made arrangements for the man to see a gastroenterologist for a possible esophagogastroduodenoscopy. The gastroenterology consult was not scheduled to take place until July.

The patient returned in May complaining of increased pain and loose stools whenever he ate cereal with milk. The NP’s revised diagnosis was gastritis and ulcer with lactose intolerance or nicotine addiction from chewing tobacco.

The gastroenterology consult was moved up, but the patient went to an ED before the scheduled visit. A work-up at the hospital, which included abdominal CT and a colonoscopy, resulted in a diagnosis of near obstruction of the right side of the colon by a stage IV tumor and metastasis to the peritoneum and lymph nodes. Immediate surgery was performed, followed by several rounds of chemotherapy, further abdominal surgery, and a cingulotomy for pain relief. The man died in December 2004.

The plaintiff claimed that the NP was negligent in failing to perform a rectal exam, conduct a fecal occult blood test, or order a colonoscopy. The plaintiff also claimed that after results from the upper GI were negative, a colonoscopy was required. The plaintiff claimed that in the fall of 2001, the colon cancer had probably been at stage IIIA with a 65% chance of survival, or stage IIIB with a 45% chance of survival, and that there was no chance of survival by the time the correct diagnosis was made.

The defendants claimed that a colonoscopy was not required because “burning” pain is more consistent with an upper GI process, and that the decedent’s history of chewing tobacco and excessive coffee consumption accounted for his eating difficulties. The primary care physician also claimed that a random review of patient files constituted adequate supervision and that there was no independent duty to review individual patient charts and sign off on them on a regular basis.

The defendants claimed that the decedent’s cancer was already at stage IV in the fall of 2001 and that nothing they could have done at that time would have changed the outcome. In addition, the defendants claimed that the decedent’s cancer was signet ring cell cancer, a very aggressive form of cancer that is nearly always fatal.

Outcome
The jury found both defendants negligent. They determined that the decedent had a 45% chance of survival at the time of his first visit, and that his chance of survival was reduced to zero. The jury calculated wrongful death damages at $5,210,000, and later reduced that figure, multiplying it by 45% for a loss-of-chance award. The plaintiff contacted an economist, who estimated the loss of net income and household services at $2 million. The jury also awarded pain and suffering damages, including those associated with “dying of colon cancer.” The total verdict was $4,694,500, and the total judgment was $7,549,142.

Comment
While the initial evaluation seemed reasonable, the patient’s family history of colon cancer, added to the fact that his condition was not significantly improving, should have indicated the need for further testing. It would have been prudent to order CT and an abdominal ultrasound to get a better look at the biliary tree. The rectal exam and fecal occult blood test are mandatory, particularly when ulcer is being considered. Even in a relatively young patient with gastric symptoms, use of chewing tobacco and coffee consumption should not preclude consideration of colon cancer. —RDD

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Delays, Missteps in Care of Child
The parents of a developmentally disabled 4-year-old boy took him to a Pennsylvania emergency department (ED) because he was vomiting and running a fever. The child had a heart rate of 180 beats/min and a respiratory rate of 40 breaths/min, but the triage nurse returned the child to the waiting room. Two hours later, another nurse recorded the child’s temperature, which revealed a fever. About 20 minutes later, a doctor saw the child and ordered acetaminophen and IV fluids, “stat.” A nurse requested an IV team, but it was not until an hour later that the fluids were finally administered. A few minutes after the line was placed, the child experienced a seizure and cardiac arrest. He died within the next hour.

The child’s adoptive mothers claimed that the hospital staff did not properly monitor the child’s vital signs, particularly in light of the child’s fever. The plaintiffs also claimed that the staff was negligent in waiting an hour to begin IV fluids when the order was “stat.” The plaintiffs also maintained that acetaminophen was never administered, despite the “stat” order.

Outcome
A $1 million settlement was reached.

Comment
“Stat” means “stat,” and not an hour later. But the failures here are more than just delay. A child with these vital signs was improperly triaged back to the waiting room when he needed constant vital sign monitoring at the least. Under these circumstances, checking vital signs two hours later was negligent. The jury came to a proper decision. —JP

Sponge Found Four Years After Laparotomy
A pregnant woman in her 30s went to a Michigan ED because she was bleeding and had abdominal pain. An ob/gyn performed emergency surgery to rule out an ectopic pregnancy. During the procedure, he found an ectopic pregnancy and performed a left salpingectomy.  The patient was discharged the next day but continued to have abdominal pain.

Four years later, at another hospital, the woman underwent CT because of an injury. The imaging revealed an object in her abdomen. She underwent an exploratory laparotomy; the object was removed and identified as a surgical sponge. After this surgery, the plaintiff developed an umbilical hernia and an infection.

The plaintiff claimed that the surgical sponge was left during the surgery that was performed four years earlier. She denied having undergone any other procedures between the salpingectomy and the surgery in which the sponge was removed.

The defendants claimed that the sponge that was removed was not the type that would have been used in the original procedure. The defendants also argued that the sponge counts were correct and that a retained sponge was a risk associated with the procedure.

Outcome
A defense verdict was returned.

Comment
How the defendants prevailed in this case is a mystery to me. In the absence of another explanation, a sponge found in the abdomen after a surgery is malpractice. Res ipsa loquitur, a Latin phrase meaning “the thing speaks for itself,” is the appropriate legal term to describe this situation. In cases like these, the plaintiffs don’t even need an expert to prove malpractice. Sponge counts always seem to be right, even when they are wrong; otherwise, the surgeon would not have closed the abdomen. I wish someone could tell me where that sponge came from. —JP

Heart Murmur Overlooked in College Athlete
A 19-year-old man who received a college basketball scholarship needed a physical examination for medical clearance to play. The physician who conducted the exam noted a “slight systolic heart murmur” and documented it on the college’s physical exam form. This finding may be consistent with hypertrophic cardiomyopathy, a congenital heart defect associated with a transient systolic murmur and known to cause sudden death in athletes. The physician ordered an echocardiogram and signed the college medical clearance form, stating that the young man was in excellent health and did not require any physical ­restrictions.

Three and a half years later, while playing in a college basketball game, the young man suddenly collapsed to the floor and became unresponsive. Emergency medical personnel arrived and attempted to revive him. The young man was taken to a hospital, where further attempts to revive him proved unsuccessful. He died at age 22, four months shy of being awarded his college degree.

The plaintiffs claimed that the examining physician was negligent in signing the medical clearance form before establishing whether the student’s heart murmur indicated a life-threatening cardiac condition and for failing to note that an echocardiogram was pending. The plaintiffs also claimed that the defendant had failed to follow up on the results of the echocardiogram and that an ECG should have been performed to evaluate the murmur. The plaintiffs claimed that the student would have had a normal life span if he had been diagnosed and treated properly.

The defendant claimed that there was no negligence involved, that the decedent had not kept the appointment for an echocardiogram, and that no physician who evaluated the decedent in the intervening years had ever detected a murmur.

Outcome
According to a published account, a $1.6 million verdict was returned.

Comment
A newly found murmur, whether loud or soft, deserves a complete work-up. This is particularly true when an athlete is involved. Even though an echocardiogram was ordered in this case, standard of care requires the clinician to follow up with the patient or to refer the patient to ensure adequate follow-up. —RDD

Failure to Make a Diagnosis of Colon Cancer
In October 2001, a 31-year-old man from Massachusetts went to his primary care physician’s office and was seen by a nurse practitioner. He complained of burning, cramping abdominal pain and inability to eat, which had resolved by the time of his appointment. The NP prescribed ranitidine and scheduled an appointment for a complete physical exam the following month.

During the subsequent physical exam, the patient complained of occasional abdominal pain and increased defecation. His family history included his mother’s diagnosis with colon cancer at age 54. The man also mentioned a history of chewing tobacco use and heavy coffee intake. No rectal exam was performed during this visit, nor was the patient provided with a fecal occult blood test. A colonoscopy was not ordered.

The NP changed his prescription to pantoprazole and ordered an upper GI series with contrast to rule out gastritis or ulcer; test results were negative for either. The patient’s primary care physician was given the test results, and neither the NP nor the physician initiated any discussion regarding what should be done next. The primary care physician never saw the man, nor did he review his chart at the time of this appointment.

In early December 2001, the man was seen again by the NP. He reported that his symptoms had improved on pantoprazole, but he continued to have eating problems. The NP maintained the original diagnosis of gastritis and discharged the man with instructions to call with any concerns and to return in six months. The NP did not include colon cancer in the differential diagnosis because of the patient’s age.

The man returned to the primary care physician’s office in April 2002 and was seen by the same NP. At this time, he reported worsening stomach cramps and a burning stomach. The NP switched his medication to lansoprazole while maintaining a diagnosis of gastritis. The NP made arrangements for the man to see a gastroenterologist for a possible esophagogastroduodenoscopy. The gastroenterology consult was not scheduled to take place until July.

The patient returned in May complaining of increased pain and loose stools whenever he ate cereal with milk. The NP’s revised diagnosis was gastritis and ulcer with lactose intolerance or nicotine addiction from chewing tobacco.

The gastroenterology consult was moved up, but the patient went to an ED before the scheduled visit. A work-up at the hospital, which included abdominal CT and a colonoscopy, resulted in a diagnosis of near obstruction of the right side of the colon by a stage IV tumor and metastasis to the peritoneum and lymph nodes. Immediate surgery was performed, followed by several rounds of chemotherapy, further abdominal surgery, and a cingulotomy for pain relief. The man died in December 2004.

The plaintiff claimed that the NP was negligent in failing to perform a rectal exam, conduct a fecal occult blood test, or order a colonoscopy. The plaintiff also claimed that after results from the upper GI were negative, a colonoscopy was required. The plaintiff claimed that in the fall of 2001, the colon cancer had probably been at stage IIIA with a 65% chance of survival, or stage IIIB with a 45% chance of survival, and that there was no chance of survival by the time the correct diagnosis was made.

The defendants claimed that a colonoscopy was not required because “burning” pain is more consistent with an upper GI process, and that the decedent’s history of chewing tobacco and excessive coffee consumption accounted for his eating difficulties. The primary care physician also claimed that a random review of patient files constituted adequate supervision and that there was no independent duty to review individual patient charts and sign off on them on a regular basis.

The defendants claimed that the decedent’s cancer was already at stage IV in the fall of 2001 and that nothing they could have done at that time would have changed the outcome. In addition, the defendants claimed that the decedent’s cancer was signet ring cell cancer, a very aggressive form of cancer that is nearly always fatal.

Outcome
The jury found both defendants negligent. They determined that the decedent had a 45% chance of survival at the time of his first visit, and that his chance of survival was reduced to zero. The jury calculated wrongful death damages at $5,210,000, and later reduced that figure, multiplying it by 45% for a loss-of-chance award. The plaintiff contacted an economist, who estimated the loss of net income and household services at $2 million. The jury also awarded pain and suffering damages, including those associated with “dying of colon cancer.” The total verdict was $4,694,500, and the total judgment was $7,549,142.

Comment
While the initial evaluation seemed reasonable, the patient’s family history of colon cancer, added to the fact that his condition was not significantly improving, should have indicated the need for further testing. It would have been prudent to order CT and an abdominal ultrasound to get a better look at the biliary tree. The rectal exam and fecal occult blood test are mandatory, particularly when ulcer is being considered. Even in a relatively young patient with gastric symptoms, use of chewing tobacco and coffee consumption should not preclude consideration of colon cancer. —RDD

PATIENT’S CLAIM The ED physician should have remained with the patient until she was in the ICU; promethazine was contraindicated and led to cardiopulmonary arrest; the ED physician failed to intubate the patient in a timely manner.

DEFENDANTS’ DEFENSE The physician’s return to the ED was proper because he handed over care to the critical care physician; promethazine was not contraindicated; appropriate care was provided, including attempts at resuscitation. The nursing staff never informed the ED physician of the patient’s history of congestive heart failure with a previous pregnancy.

VERDICT A Florida defense verdict was returned.

Heated solution burns genital area

A WOMAN UNDERWENT endometrial ablation for menorrhagia. A few days later, she discovered infected and painful blisters in her genital area.

PATIENT’S CLAIM The gynecologist was negligent in how he performed endometrial ablation. He ignored several warning beeps from the machine while the wand was filling the woman’s uterus with heated solution, and he removed the wand while it was still releasing hot liquid. The heated solution leaked from the uterus and damaged the vagina, rectal area, and other genital areas. The patient was not informed that the liquid had escaped, nor did she receive treatment for her second- and third-degree burns before she was discharged.

DEFENDANTS’ DEFENSE The gynecologist admitted that he never reviewed the operator’s manual for the procedure but denied negligence. He claimed two nurses assisting him failed to respond to his instructions to turn off the machine in time to avoid the incident. The nurses denied hearing any such instructions.

VERDICT The hospital was given a directed verdict and dismissed from the case. A $32,000 verdict was returned against the gynecologist.

READ Update on MIGS

Surgical towel found 6 years later

AFTER SUFFERING ABDOMINAL PAIN, a woman underwent a hysterectomy. She continued to report abdominal pain to her gynecologist for several years. Six years after the initial surgery, she sought care from another physician. During an exploratory laparotomy, a blue surgical towel was found adhered to the patient’s abdominal wall and bowel.

PATIENT’S CLAIM The gynecologist was negligent in leaving the surgical towel in the abdomen, and in failing to appropriately respond to her complaints of postoperative pain.

DEFENDANTS’ DEFENSE The hospital provides white radiopaque sponges for internal use during surgery, and those sponges were carefully counted. The blue towels were not counted because they are not intended for internal use; they are provided for medical personnel to wipe hands and medical equipment. The gynecologist claimed the hospital had not informed him that it was not counting blue towels, and that it was reasonable to expect that the blue towels had been counted.

VERDICT A $564,000 Indiana verdict was reached against the gynecologist; the hospital was vindicated.

Biopsy showed dysplasia; woman dies

AFTER AN ABNORMAL PAP SMEAR, a 27-year-old woman underwent colposcopy and cervical biopsy. When he received the test results, the gynecologist told her to return in 6 months. Three months later, she began having suspicious symptoms. When further testing yielded abnormal findings, she was referred to a gynecologic oncologist, who diagnosed cervical cancer. The woman underwent radical hysterectomy, radiotherapy, and chemotherapy, but the cancer had metastasized, and she died.

ESTATE’S CLAIM The gynecologist should have ordered additional testing when the original biopsy report was inconclusive. Advising 6-month follow-up was negligent.

PHYSICIAN’S DEFENSE The report indicated cervical dysplasia, making the 6-month time-frame proper.

VERDICT A South Carolina defense verdict was returned.

Premature baby succumbs

A PREGNANT WOMAN WAS REFERRED to a perinatal evaluation center for a full cervical examination because prior pregnancies had required cerclage. She was treated by Dr. A, a first-year intern, under the supervision of Dr. B, a fourth-year resident, and Dr. C, the attending ObGyn. Cerclage was not performed. Ten days later, the child was born at 19 weeks’ gestation, and died shortly after birth.

PATIENT’S CLAIM The hospital should have had a policy mandating that an attending physician evaluate obstetric patients whose cervical exam is abnormal. Cerclage should have been performed; cervical weakness had been treated in her second and third pregnancies, resulting in successful deliveries at 29 weeks and 34 weeks, respectively. The attending ObGyn never examined the patient.

DEFENDANTS’ DEFENSE The hospital claimed that a cervical examination showed that cerclage was unnecessary. Dr. C indicated that the correct decision and treatment were rendered; the intern and resident had reported their findings to him.

VERDICT A $3 million Pennsylvania verdict was returned.

Breast discharge during pregnancy

AT 7 MONTHS’ GESTATION, a 29-year-old woman reported burning pain and clear discharge from her right breast. The ObGyn told her he believed the complaints were related to her pregnancy; he did not examine her breasts.

The ObGyn’s partner palpated a lump in the woman’s right breast at her 6-week postpartum visit. Triple negative breast cancer was diagnosed. She underwent chemotherapy, mastectomy, and radiotherapy, but died of metastatic breast cancer.

ESTATE’S CLAIM The ObGyn failed to conduct a breast examination when the woman first complained of symptoms. This caused a delay in diagnosis, which reduced her chance of survival.

PHYSICIAN’S DEFENSE The ObGyn first denied the patient reported breast symptoms at her 7-month visit, as his records did not indicate a complaint. However, in a documented telephone call 4 days before the visit, the patient complained of burning pain and clear fluid leaking from her right breast. The ObGyn admitted that he would have followed up on the phone call, and that she must have told him complaints had subsided, or he would have noted continuing symptoms and performed a breast exam. He claimed a 3-month delay in diagnosis did not change the outcome because hers was a highly aggressive type of tumor that 1) is unresponsive to treatment and 2) carries an extremely poor survival rate compared with other types of breast cancer.

VERDICT A $1.5 million Illinois verdict was reached.

PATIENT’S CLAIM The ED physician should have remained with the patient until she was in the ICU; promethazine was contraindicated and led to cardiopulmonary arrest; the ED physician failed to intubate the patient in a timely manner.

DEFENDANTS’ DEFENSE The physician’s return to the ED was proper because he handed over care to the critical care physician; promethazine was not contraindicated; appropriate care was provided, including attempts at resuscitation. The nursing staff never informed the ED physician of the patient’s history of congestive heart failure with a previous pregnancy.

VERDICT A Florida defense verdict was returned.

Heated solution burns genital area

A WOMAN UNDERWENT endometrial ablation for menorrhagia. A few days later, she discovered infected and painful blisters in her genital area.

PATIENT’S CLAIM The gynecologist was negligent in how he performed endometrial ablation. He ignored several warning beeps from the machine while the wand was filling the woman’s uterus with heated solution, and he removed the wand while it was still releasing hot liquid. The heated solution leaked from the uterus and damaged the vagina, rectal area, and other genital areas. The patient was not informed that the liquid had escaped, nor did she receive treatment for her second- and third-degree burns before she was discharged.

DEFENDANTS’ DEFENSE The gynecologist admitted that he never reviewed the operator’s manual for the procedure but denied negligence. He claimed two nurses assisting him failed to respond to his instructions to turn off the machine in time to avoid the incident. The nurses denied hearing any such instructions.

VERDICT The hospital was given a directed verdict and dismissed from the case. A $32,000 verdict was returned against the gynecologist.

READ Update on MIGS

Surgical towel found 6 years later

AFTER SUFFERING ABDOMINAL PAIN, a woman underwent a hysterectomy. She continued to report abdominal pain to her gynecologist for several years. Six years after the initial surgery, she sought care from another physician. During an exploratory laparotomy, a blue surgical towel was found adhered to the patient’s abdominal wall and bowel.

PATIENT’S CLAIM The gynecologist was negligent in leaving the surgical towel in the abdomen, and in failing to appropriately respond to her complaints of postoperative pain.

DEFENDANTS’ DEFENSE The hospital provides white radiopaque sponges for internal use during surgery, and those sponges were carefully counted. The blue towels were not counted because they are not intended for internal use; they are provided for medical personnel to wipe hands and medical equipment. The gynecologist claimed the hospital had not informed him that it was not counting blue towels, and that it was reasonable to expect that the blue towels had been counted.

VERDICT A $564,000 Indiana verdict was reached against the gynecologist; the hospital was vindicated.

Biopsy showed dysplasia; woman dies

AFTER AN ABNORMAL PAP SMEAR, a 27-year-old woman underwent colposcopy and cervical biopsy. When he received the test results, the gynecologist told her to return in 6 months. Three months later, she began having suspicious symptoms. When further testing yielded abnormal findings, she was referred to a gynecologic oncologist, who diagnosed cervical cancer. The woman underwent radical hysterectomy, radiotherapy, and chemotherapy, but the cancer had metastasized, and she died.

ESTATE’S CLAIM The gynecologist should have ordered additional testing when the original biopsy report was inconclusive. Advising 6-month follow-up was negligent.

PHYSICIAN’S DEFENSE The report indicated cervical dysplasia, making the 6-month time-frame proper.

VERDICT A South Carolina defense verdict was returned.

Premature baby succumbs

A PREGNANT WOMAN WAS REFERRED to a perinatal evaluation center for a full cervical examination because prior pregnancies had required cerclage. She was treated by Dr. A, a first-year intern, under the supervision of Dr. B, a fourth-year resident, and Dr. C, the attending ObGyn. Cerclage was not performed. Ten days later, the child was born at 19 weeks’ gestation, and died shortly after birth.

PATIENT’S CLAIM The hospital should have had a policy mandating that an attending physician evaluate obstetric patients whose cervical exam is abnormal. Cerclage should have been performed; cervical weakness had been treated in her second and third pregnancies, resulting in successful deliveries at 29 weeks and 34 weeks, respectively. The attending ObGyn never examined the patient.

DEFENDANTS’ DEFENSE The hospital claimed that a cervical examination showed that cerclage was unnecessary. Dr. C indicated that the correct decision and treatment were rendered; the intern and resident had reported their findings to him.

VERDICT A $3 million Pennsylvania verdict was returned.

Breast discharge during pregnancy

AT 7 MONTHS’ GESTATION, a 29-year-old woman reported burning pain and clear discharge from her right breast. The ObGyn told her he believed the complaints were related to her pregnancy; he did not examine her breasts.

The ObGyn’s partner palpated a lump in the woman’s right breast at her 6-week postpartum visit. Triple negative breast cancer was diagnosed. She underwent chemotherapy, mastectomy, and radiotherapy, but died of metastatic breast cancer.

ESTATE’S CLAIM The ObGyn failed to conduct a breast examination when the woman first complained of symptoms. This caused a delay in diagnosis, which reduced her chance of survival.

PHYSICIAN’S DEFENSE The ObGyn first denied the patient reported breast symptoms at her 7-month visit, as his records did not indicate a complaint. However, in a documented telephone call 4 days before the visit, the patient complained of burning pain and clear fluid leaking from her right breast. The ObGyn admitted that he would have followed up on the phone call, and that she must have told him complaints had subsided, or he would have noted continuing symptoms and performed a breast exam. He claimed a 3-month delay in diagnosis did not change the outcome because hers was a highly aggressive type of tumor that 1) is unresponsive to treatment and 2) carries an extremely poor survival rate compared with other types of breast cancer.

VERDICT A $1.5 million Illinois verdict was reached.

PATIENT’S CLAIM The ED physician should have remained with the patient until she was in the ICU; promethazine was contraindicated and led to cardiopulmonary arrest; the ED physician failed to intubate the patient in a timely manner.

DEFENDANTS’ DEFENSE The physician’s return to the ED was proper because he handed over care to the critical care physician; promethazine was not contraindicated; appropriate care was provided, including attempts at resuscitation. The nursing staff never informed the ED physician of the patient’s history of congestive heart failure with a previous pregnancy.

VERDICT A Florida defense verdict was returned.

Heated solution burns genital area

A WOMAN UNDERWENT endometrial ablation for menorrhagia. A few days later, she discovered infected and painful blisters in her genital area.

PATIENT’S CLAIM The gynecologist was negligent in how he performed endometrial ablation. He ignored several warning beeps from the machine while the wand was filling the woman’s uterus with heated solution, and he removed the wand while it was still releasing hot liquid. The heated solution leaked from the uterus and damaged the vagina, rectal area, and other genital areas. The patient was not informed that the liquid had escaped, nor did she receive treatment for her second- and third-degree burns before she was discharged.

DEFENDANTS’ DEFENSE The gynecologist admitted that he never reviewed the operator’s manual for the procedure but denied negligence. He claimed two nurses assisting him failed to respond to his instructions to turn off the machine in time to avoid the incident. The nurses denied hearing any such instructions.

VERDICT The hospital was given a directed verdict and dismissed from the case. A $32,000 verdict was returned against the gynecologist.

READ Update on MIGS

Surgical towel found 6 years later

AFTER SUFFERING ABDOMINAL PAIN, a woman underwent a hysterectomy. She continued to report abdominal pain to her gynecologist for several years. Six years after the initial surgery, she sought care from another physician. During an exploratory laparotomy, a blue surgical towel was found adhered to the patient’s abdominal wall and bowel.

PATIENT’S CLAIM The gynecologist was negligent in leaving the surgical towel in the abdomen, and in failing to appropriately respond to her complaints of postoperative pain.

DEFENDANTS’ DEFENSE The hospital provides white radiopaque sponges for internal use during surgery, and those sponges were carefully counted. The blue towels were not counted because they are not intended for internal use; they are provided for medical personnel to wipe hands and medical equipment. The gynecologist claimed the hospital had not informed him that it was not counting blue towels, and that it was reasonable to expect that the blue towels had been counted.

VERDICT A $564,000 Indiana verdict was reached against the gynecologist; the hospital was vindicated.

Biopsy showed dysplasia; woman dies

AFTER AN ABNORMAL PAP SMEAR, a 27-year-old woman underwent colposcopy and cervical biopsy. When he received the test results, the gynecologist told her to return in 6 months. Three months later, she began having suspicious symptoms. When further testing yielded abnormal findings, she was referred to a gynecologic oncologist, who diagnosed cervical cancer. The woman underwent radical hysterectomy, radiotherapy, and chemotherapy, but the cancer had metastasized, and she died.

ESTATE’S CLAIM The gynecologist should have ordered additional testing when the original biopsy report was inconclusive. Advising 6-month follow-up was negligent.

PHYSICIAN’S DEFENSE The report indicated cervical dysplasia, making the 6-month time-frame proper.

VERDICT A South Carolina defense verdict was returned.

Premature baby succumbs

A PREGNANT WOMAN WAS REFERRED to a perinatal evaluation center for a full cervical examination because prior pregnancies had required cerclage. She was treated by Dr. A, a first-year intern, under the supervision of Dr. B, a fourth-year resident, and Dr. C, the attending ObGyn. Cerclage was not performed. Ten days later, the child was born at 19 weeks’ gestation, and died shortly after birth.

PATIENT’S CLAIM The hospital should have had a policy mandating that an attending physician evaluate obstetric patients whose cervical exam is abnormal. Cerclage should have been performed; cervical weakness had been treated in her second and third pregnancies, resulting in successful deliveries at 29 weeks and 34 weeks, respectively. The attending ObGyn never examined the patient.

DEFENDANTS’ DEFENSE The hospital claimed that a cervical examination showed that cerclage was unnecessary. Dr. C indicated that the correct decision and treatment were rendered; the intern and resident had reported their findings to him.

VERDICT A $3 million Pennsylvania verdict was returned.

Breast discharge during pregnancy

AT 7 MONTHS’ GESTATION, a 29-year-old woman reported burning pain and clear discharge from her right breast. The ObGyn told her he believed the complaints were related to her pregnancy; he did not examine her breasts.

The ObGyn’s partner palpated a lump in the woman’s right breast at her 6-week postpartum visit. Triple negative breast cancer was diagnosed. She underwent chemotherapy, mastectomy, and radiotherapy, but died of metastatic breast cancer.

ESTATE’S CLAIM The ObGyn failed to conduct a breast examination when the woman first complained of symptoms. This caused a delay in diagnosis, which reduced her chance of survival.

PHYSICIAN’S DEFENSE The ObGyn first denied the patient reported breast symptoms at her 7-month visit, as his records did not indicate a complaint. However, in a documented telephone call 4 days before the visit, the patient complained of burning pain and clear fluid leaking from her right breast. The ObGyn admitted that he would have followed up on the phone call, and that she must have told him complaints had subsided, or he would have noted continuing symptoms and performed a breast exam. He claimed a 3-month delay in diagnosis did not change the outcome because hers was a highly aggressive type of tumor that 1) is unresponsive to treatment and 2) carries an extremely poor survival rate compared with other types of breast cancer.

VERDICT A $1.5 million Illinois verdict was reached.