Pa Editor-In-chief

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

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