David M. Lang, JD, PA-C

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

In July 2007, a 54-year-old Texas man was seen at a family medical clinic, owned by Ms. A. and Mr. B., seeking pain medication for a chronic back injury. Earlier that year, Ms. A. and Mr. B. had retained Mr. C. to search for a medical director for the clinic, and Dr. D. was hired.

At the patient’s July 2007 visit, he was given prescriptions for acetaminophen with hydrocodone, alprazolam, and carisoprodol. He died two days later.

Plaintiff for the decedent alleged that Dr. D. provided inappropriate dosages and an inappropriate combination of drugs. According to the plaintiff, the decedent was not examined by Dr. D., and it was Dr. D.’s routine to sign preprinted prescriptions without examining patients or even being on the clinic premises.

The plaintiff also alleged negligence in the clinic’s hiring of Dr. D., maintaining that at the time he was hired, Dr. D. was under investigation by the state medical board regarding claims that he had been prescribing narcotics for cash payments; Dr. D.’s medical license had been suspended for a time in the 1990s. The plaintiff alleged gross negligence on the part of Ms. A., Mr. B., and Mr. C. in hiring Dr. D., claiming that they were all aware of Dr. D.’s history, the investigation, and his frequent failure to examine patients.

Ms. A. and Mr. B. claimed that they were unaware of Dr. D.’s background. Mr. C. argued that he had been unable to look into Dr. D.’s background on the medical board’s Web site because he did not know how to use a computer, and that checking Dr. D.’s background was the responsibility of Ms. A. and Mr. B.

Outcome
According to a published account, Mr. B. settled for an undisclosed amount prior to trial. A jury found Dr. D. 65% at fault, the clinic 30% at fault, and Mr. C. 5% at fault. The jury awarded $1.7 million in compensatory damages, $8 million in exemplary damages against Dr. D., and $1 million in exemplary damages against the clinic.

Comment
Prescribing narcotics with no exam, compounded by using preprinted narcotic prescriptions, is clearly egregious and was appropriately met with a substantial verdict. However, a version of this patient is seen in ambulatory settings every day: the patient with chronic pain, requesting (or commonly demanding) combinations of potent substances. It bears repeating that additive effects, such as central nervous system and respiratory depression, must be considered when prescribing or refilling medications.

Cases of “unintentional overdose” are a common source of malpractice litigation. A plaintiff’s lawyer will characterize a patient’s frequent and urgent demands for controlled substances as a “cry for help”—a cry that should have been recognized by the clinician.

While the result may depend on the jury pool, many jurors would have no trouble placing blame on a clinician now cast as “an enabler.” The patient’s friends and family, who may have formerly pressured clinicians to prescribe controlled substances for the patient, now may insist the clinician “kept him drugged up.”

Ideally, patients with heavy demands for controlled substances would be evaluated and managed in a chronic pain practice, or pursuant to a chronic pain policy. Both help minimize “doctor shopping,” improve patient care and adherence to accepted pain management strategies, provide a reasonable means to handle abusive or overly demanding patients, and provide a “unified front” for prescribing within a group. Clinicians should be prepared to meet high-pressure demands for narcotics with a frank response, saying that a clinician may be sanctioned for prescribing powerful substances that can have lethal effects.

Judge the need for narcotics independently, and conduct an appropriate examination—even in the patient of another clinician who insists he or she “just needs a refill.” Explain the inherent risks of polypharmacy, and document the discussion.

Conduct short, periodic staff meetings to discuss any patients with heavy or concerning controlled substance use. At the same time, treat all patients with concern and respect and compassion. —DML 

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

In July 2007, a 54-year-old Texas man was seen at a family medical clinic, owned by Ms. A. and Mr. B., seeking pain medication for a chronic back injury. Earlier that year, Ms. A. and Mr. B. had retained Mr. C. to search for a medical director for the clinic, and Dr. D. was hired.

At the patient’s July 2007 visit, he was given prescriptions for acetaminophen with hydrocodone, alprazolam, and carisoprodol. He died two days later.

Plaintiff for the decedent alleged that Dr. D. provided inappropriate dosages and an inappropriate combination of drugs. According to the plaintiff, the decedent was not examined by Dr. D., and it was Dr. D.’s routine to sign preprinted prescriptions without examining patients or even being on the clinic premises.

The plaintiff also alleged negligence in the clinic’s hiring of Dr. D., maintaining that at the time he was hired, Dr. D. was under investigation by the state medical board regarding claims that he had been prescribing narcotics for cash payments; Dr. D.’s medical license had been suspended for a time in the 1990s. The plaintiff alleged gross negligence on the part of Ms. A., Mr. B., and Mr. C. in hiring Dr. D., claiming that they were all aware of Dr. D.’s history, the investigation, and his frequent failure to examine patients.

Ms. A. and Mr. B. claimed that they were unaware of Dr. D.’s background. Mr. C. argued that he had been unable to look into Dr. D.’s background on the medical board’s Web site because he did not know how to use a computer, and that checking Dr. D.’s background was the responsibility of Ms. A. and Mr. B.

Outcome
According to a published account, Mr. B. settled for an undisclosed amount prior to trial. A jury found Dr. D. 65% at fault, the clinic 30% at fault, and Mr. C. 5% at fault. The jury awarded $1.7 million in compensatory damages, $8 million in exemplary damages against Dr. D., and $1 million in exemplary damages against the clinic.

Comment
Prescribing narcotics with no exam, compounded by using preprinted narcotic prescriptions, is clearly egregious and was appropriately met with a substantial verdict. However, a version of this patient is seen in ambulatory settings every day: the patient with chronic pain, requesting (or commonly demanding) combinations of potent substances. It bears repeating that additive effects, such as central nervous system and respiratory depression, must be considered when prescribing or refilling medications.

Cases of “unintentional overdose” are a common source of malpractice litigation. A plaintiff’s lawyer will characterize a patient’s frequent and urgent demands for controlled substances as a “cry for help”—a cry that should have been recognized by the clinician.

While the result may depend on the jury pool, many jurors would have no trouble placing blame on a clinician now cast as “an enabler.” The patient’s friends and family, who may have formerly pressured clinicians to prescribe controlled substances for the patient, now may insist the clinician “kept him drugged up.”

Ideally, patients with heavy demands for controlled substances would be evaluated and managed in a chronic pain practice, or pursuant to a chronic pain policy. Both help minimize “doctor shopping,” improve patient care and adherence to accepted pain management strategies, provide a reasonable means to handle abusive or overly demanding patients, and provide a “unified front” for prescribing within a group. Clinicians should be prepared to meet high-pressure demands for narcotics with a frank response, saying that a clinician may be sanctioned for prescribing powerful substances that can have lethal effects.

Judge the need for narcotics independently, and conduct an appropriate examination—even in the patient of another clinician who insists he or she “just needs a refill.” Explain the inherent risks of polypharmacy, and document the discussion.

Conduct short, periodic staff meetings to discuss any patients with heavy or concerning controlled substance use. At the same time, treat all patients with concern and respect and compassion. —DML 

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

In July 2007, a 54-year-old Texas man was seen at a family medical clinic, owned by Ms. A. and Mr. B., seeking pain medication for a chronic back injury. Earlier that year, Ms. A. and Mr. B. had retained Mr. C. to search for a medical director for the clinic, and Dr. D. was hired.

At the patient’s July 2007 visit, he was given prescriptions for acetaminophen with hydrocodone, alprazolam, and carisoprodol. He died two days later.

Plaintiff for the decedent alleged that Dr. D. provided inappropriate dosages and an inappropriate combination of drugs. According to the plaintiff, the decedent was not examined by Dr. D., and it was Dr. D.’s routine to sign preprinted prescriptions without examining patients or even being on the clinic premises.

The plaintiff also alleged negligence in the clinic’s hiring of Dr. D., maintaining that at the time he was hired, Dr. D. was under investigation by the state medical board regarding claims that he had been prescribing narcotics for cash payments; Dr. D.’s medical license had been suspended for a time in the 1990s. The plaintiff alleged gross negligence on the part of Ms. A., Mr. B., and Mr. C. in hiring Dr. D., claiming that they were all aware of Dr. D.’s history, the investigation, and his frequent failure to examine patients.

Ms. A. and Mr. B. claimed that they were unaware of Dr. D.’s background. Mr. C. argued that he had been unable to look into Dr. D.’s background on the medical board’s Web site because he did not know how to use a computer, and that checking Dr. D.’s background was the responsibility of Ms. A. and Mr. B.

Outcome
According to a published account, Mr. B. settled for an undisclosed amount prior to trial. A jury found Dr. D. 65% at fault, the clinic 30% at fault, and Mr. C. 5% at fault. The jury awarded $1.7 million in compensatory damages, $8 million in exemplary damages against Dr. D., and $1 million in exemplary damages against the clinic.

Comment
Prescribing narcotics with no exam, compounded by using preprinted narcotic prescriptions, is clearly egregious and was appropriately met with a substantial verdict. However, a version of this patient is seen in ambulatory settings every day: the patient with chronic pain, requesting (or commonly demanding) combinations of potent substances. It bears repeating that additive effects, such as central nervous system and respiratory depression, must be considered when prescribing or refilling medications.

Cases of “unintentional overdose” are a common source of malpractice litigation. A plaintiff’s lawyer will characterize a patient’s frequent and urgent demands for controlled substances as a “cry for help”—a cry that should have been recognized by the clinician.

While the result may depend on the jury pool, many jurors would have no trouble placing blame on a clinician now cast as “an enabler.” The patient’s friends and family, who may have formerly pressured clinicians to prescribe controlled substances for the patient, now may insist the clinician “kept him drugged up.”

Ideally, patients with heavy demands for controlled substances would be evaluated and managed in a chronic pain practice, or pursuant to a chronic pain policy. Both help minimize “doctor shopping,” improve patient care and adherence to accepted pain management strategies, provide a reasonable means to handle abusive or overly demanding patients, and provide a “unified front” for prescribing within a group. Clinicians should be prepared to meet high-pressure demands for narcotics with a frank response, saying that a clinician may be sanctioned for prescribing powerful substances that can have lethal effects.

Judge the need for narcotics independently, and conduct an appropriate examination—even in the patient of another clinician who insists he or she “just needs a refill.” Explain the inherent risks of polypharmacy, and document the discussion.

Conduct short, periodic staff meetings to discuss any patients with heavy or concerning controlled substance use. At the same time, treat all patients with concern and respect and compassion. —DML 

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

A Kansas woman, age 41, presented to an ED on Christmas Day with cough, congestion, difficulty breathing, and a two-week history of flu-like symptoms (chest tightness and body aches); this, she had attributed to previously diagnosed fibromyalgia.

In the ED, the patient was seen by the defendant physician assistant, who made a diagnosis of sinusitis with a flare-up of her fibromyalgia. Medication was prescribed, and she was discharged after about two hours.

On the way home, the woman experienced cardiac arrest. She was returned to the hospital and pronounced dead less than two hours after discharge.

The plaintiff alleged negligence in the PA’s failure to order an ECG. The defendant denied that an ECG was indicated and claimed that the treatment provided was reasonable.

Outcome
Plaintiff settled with the hospital for an undisclosed amount prior to trial. A defense verdict was returned.

Comment
In this case, we don’t know the reproducibility or magnitude of the patient’s chest pain. Her history of fibromyalgia and flu-like symptoms may have blurred the presentation, which included “chest tightness”—especially considering that fibromyalgia can cause tender points over the anterior chest wall. Further, because 6% to 15% of patients with acute MI will exhibit some degree of reproducible chest tenderness, tenderness on exam can be misleading. Additionally, women with acute coronary syndrome (ACS) commonly present with subtle and nonspecific findings, including dyspnea, fatigue, and weakness. Frank chest pain is often absent.

During litigation, a plaintiff’s attorney will commonly argue that a “five-minute” test (such as an ECG) would have saved a patient. Here, the attorney likely offered expert testimony that ACS presentation can be subtle and atypical and that reasonably prudent clinicians should know this. Jurors familiar with ECGs as quick and noninvasive could reach the conclusion that a complaint of chest tightness in a 41-year-old woman requires that ACS be considered, regardless of her own opinion of the cause. It is important to have an index of suspicion for ACS, even without classic symptoms. It is also important to voice respect for the patient’s self-diagnosis, yet resist our temptation to hastily agree with any patient’s diagnostic assessment. —DML

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

A Kansas woman, age 41, presented to an ED on Christmas Day with cough, congestion, difficulty breathing, and a two-week history of flu-like symptoms (chest tightness and body aches); this, she had attributed to previously diagnosed fibromyalgia.

In the ED, the patient was seen by the defendant physician assistant, who made a diagnosis of sinusitis with a flare-up of her fibromyalgia. Medication was prescribed, and she was discharged after about two hours.

On the way home, the woman experienced cardiac arrest. She was returned to the hospital and pronounced dead less than two hours after discharge.

The plaintiff alleged negligence in the PA’s failure to order an ECG. The defendant denied that an ECG was indicated and claimed that the treatment provided was reasonable.

Outcome
Plaintiff settled with the hospital for an undisclosed amount prior to trial. A defense verdict was returned.

Comment
In this case, we don’t know the reproducibility or magnitude of the patient’s chest pain. Her history of fibromyalgia and flu-like symptoms may have blurred the presentation, which included “chest tightness”—especially considering that fibromyalgia can cause tender points over the anterior chest wall. Further, because 6% to 15% of patients with acute MI will exhibit some degree of reproducible chest tenderness, tenderness on exam can be misleading. Additionally, women with acute coronary syndrome (ACS) commonly present with subtle and nonspecific findings, including dyspnea, fatigue, and weakness. Frank chest pain is often absent.

During litigation, a plaintiff’s attorney will commonly argue that a “five-minute” test (such as an ECG) would have saved a patient. Here, the attorney likely offered expert testimony that ACS presentation can be subtle and atypical and that reasonably prudent clinicians should know this. Jurors familiar with ECGs as quick and noninvasive could reach the conclusion that a complaint of chest tightness in a 41-year-old woman requires that ACS be considered, regardless of her own opinion of the cause. It is important to have an index of suspicion for ACS, even without classic symptoms. It is also important to voice respect for the patient’s self-diagnosis, yet resist our temptation to hastily agree with any patient’s diagnostic assessment. —DML

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

A Kansas woman, age 41, presented to an ED on Christmas Day with cough, congestion, difficulty breathing, and a two-week history of flu-like symptoms (chest tightness and body aches); this, she had attributed to previously diagnosed fibromyalgia.

In the ED, the patient was seen by the defendant physician assistant, who made a diagnosis of sinusitis with a flare-up of her fibromyalgia. Medication was prescribed, and she was discharged after about two hours.

On the way home, the woman experienced cardiac arrest. She was returned to the hospital and pronounced dead less than two hours after discharge.

The plaintiff alleged negligence in the PA’s failure to order an ECG. The defendant denied that an ECG was indicated and claimed that the treatment provided was reasonable.

Outcome
Plaintiff settled with the hospital for an undisclosed amount prior to trial. A defense verdict was returned.

Comment
In this case, we don’t know the reproducibility or magnitude of the patient’s chest pain. Her history of fibromyalgia and flu-like symptoms may have blurred the presentation, which included “chest tightness”—especially considering that fibromyalgia can cause tender points over the anterior chest wall. Further, because 6% to 15% of patients with acute MI will exhibit some degree of reproducible chest tenderness, tenderness on exam can be misleading. Additionally, women with acute coronary syndrome (ACS) commonly present with subtle and nonspecific findings, including dyspnea, fatigue, and weakness. Frank chest pain is often absent.

During litigation, a plaintiff’s attorney will commonly argue that a “five-minute” test (such as an ECG) would have saved a patient. Here, the attorney likely offered expert testimony that ACS presentation can be subtle and atypical and that reasonably prudent clinicians should know this. Jurors familiar with ECGs as quick and noninvasive could reach the conclusion that a complaint of chest tightness in a 41-year-old woman requires that ACS be considered, regardless of her own opinion of the cause. It is important to have an index of suspicion for ACS, even without classic symptoms. It is also important to voice respect for the patient’s self-diagnosis, yet resist our temptation to hastily agree with any patient’s diagnostic assessment. —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.

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