Jeffrey L. Susman, MD

Antibiotics fail to head off sepsis

SHORTNESS OF BREATH AND RIGHT-SIDED CHEST PAIN prompted a 45-year-old woman to go to the emergency department (ED) early one morning. She had a history of chronic lung problems with multiple diagnoses of pneumonia, pneumothorax, blebs, and bronchiectasis. The ED doctor diagnosed community-acquired pneumonia and admitted her for intravenous antibiotic treatment.

Late that afternoon the patient’s condition deteriorated rapidly. She was transferred to the intensive care unit, where she died of septic shock caused by Pseudomonas aeruginosa 22 hours after she had arrived at the ED.

PLAINTIFF’S CLAIM The patient should have received broader-spectrum antibiotics.

THE DEFENSE The hospitalist who treated the woman as an inpatient claimed that the treatment she received was appropriate and that she probably would have died even if other antibiotics had been prescribed. The hospitalist also claimed that the nursing staff failed to notify her of the patient’s low blood pressure readings until 10 hours after the initial evaluation. A nurse denied this claim, asserting that the hospitalist had been paged several times during the day. The discharge summary and nursing notes on the patient were missing.

VERDICT $5.28 million arbitration award.

COMMENT It surprises me how often key portions of medical records go missing! Here, the absence of a discharge summary and nursing notes may well have contributed to a $5 million award.

Change, and not for the better

AN ATYPICAL MOLE ON THE LEFT CALF was brought to the attention of a primary care physician by a 36-year-old man during a full physical. The mole was 1 3 1 cm; the patient reported that it had been changing. The mole’s appearance didn’t worry the physician, who described it in his notes as either a hemangioma or dermatofibroma. The doctor advised the patient to return in 6 months if he wanted the mole removed for cosmetic reasons.

Over the next 5 months, the patient noticed further changes in the mole and called the doctor’s office. He was seen by a colleague of his physician, who immediately sent the patient for a biopsy and surgical consultation. The mole was removed and diagnosed as an ulcerating melanoma with downward growth.

Shortly thereafter, the patient underwent wide excision and lymph node dissection, which showed clear margins and no lymph node involvement. Twenty months later, a mass was found in the patient’s liver. Biopsy diagnosed metastatic spread of the melanoma. The patient died 2 months later.

PLAINTIFF’S CLAIM The patient should have had a biopsy and received a surgical referral at the time of the physical examination when he first reported the mole.

THE DEFENSE Waiting for 6 months was appropriate because the mole didn’t look like a melanoma when the patient first called it to the physician’s attention. The melanoma had already metastasized at the time of the physical examination and the diagnostic delay didn’t affect the outcome.

VERDICT $1 million Massachusetts settlement.

COMMENT A changing mole should always raise concern. Biopsy, excision, or a referral could have avoided a million-dollar settlement.

Failure to address persistent symptoms proves disastrous

PAIN IN THE BACK AND CHEST along with respiratory difficulty prompted a 49-year-old man to visit his physician. The physician told him to go to a hospital. The doctor who examined the patient at the hospital diagnosed muscle strain and prescribed muscle relaxants.

The following day, the patient returned to his physician complaining of continuing symptoms. The doctor sent him home. He died the next day of an aortic rupture caused by an undiagnosed dissection.

PLAINTIFF’S CLAIM The 2 physicians should have diagnosed the dissection, which would have permitted treatment and prevented death. The patient had been treated previously at the hospital, and his records should have raised suspicion of an aortic aneurysm. The hospital physician was a new hire and hadn’t received proper training in the hospital’s electronic records system. He should have ordered a computed tomography scan or cardiology consult. The patient’s physician failed to address the ongoing symptoms. He should have hospitalized the patient at the time of the second visit.

THE DEFENSE The hospital physician claimed he had intended to contact the cardiologist who had treated the patient, but the patient couldn’t remember the cardiologist’s name. The patient’s symptoms didn’t suggest an aortic dissection, and the dissection occurred after the patient was discharged from the hospital.

VERDICT $3.4 million New York verdict against the hospital physician only.

COMMENT Although the hoofbeats are usually horses, always remember the zebras (or should it be lions?), particularly when a patient returns repeatedly with ongoing symptoms.

Controlled substances out of control

A WOMAN WITH CHRONIC MIGRAINES, anxiety problems, and nausea also had cardiomyopathy and chronic atrial fibrillation, which could be triggered by pain from her other ailments. She came under the care of a physician who prescribed a number of drugs, including meperidine, hydrocodone, tizanidine, diazepam, promethazine, alprazolam, and oxcarbazepine. The doctor prescribed injectable forms of certain medications after the patient told him her next-door neighbor was a nurse and could help administer the drugs.

Four years after coming under the doctor’s care, the patient signed a Controlled Substance Agreement specifying that the physician would discontinue her as a patient if she got controlled substances from another doctor. (Evidence was later found that the patient was receiving prescriptions from other physicians.)

While under treatment by her doctor, the patient was hospitalized a number of times for medication overdoses. The record from one hospitalization reported that she had made angry, profanity-laced requests for meperidine and promethazine.

About 2 years after signing the Controlled Substance Agreement, the patient received prescriptions from her doctor for 210 doses of meperidine, 100 doses of promethazine, and 60 pills each of diazepam, alprazolam, and acetaminophen and hydrocodone. She filled the prescriptions at 2 pharmacies without objections from the pharmacists. She died of an accidental drug overdose the following month.

Postmortem blood testing showed high levels of meperidine and promethazine. The patient had apparently taken the equivalent of 11 “shots” of meperidine (5 times the maximum prescribed amount), probably by injecting herself through a peripherally inserted central catheter rather than by intramuscular injection, as prescribed.

PLAINTIFF’S CLAIM The patient’s doctor was negligent in prescribing large amounts of controlled substances when he should have known that she was a drug seeker with a drug abuse problem. The pharmacies were negligent for filling the prescriptions without question.

THE DEFENSE The patient was solely responsible for her own death because she gave herself a large overdose.

VERDICT $500,000 Alabama verdict. The case against the pharmacies was dismissed.

COMMENT Increasingly it is expected that physicians (and pharmacists) perform due diligence when prescribing opioids, including taking reasonable precautions against the drug-seeking patient.

Antibiotics fail to head off sepsis

SHORTNESS OF BREATH AND RIGHT-SIDED CHEST PAIN prompted a 45-year-old woman to go to the emergency department (ED) early one morning. She had a history of chronic lung problems with multiple diagnoses of pneumonia, pneumothorax, blebs, and bronchiectasis. The ED doctor diagnosed community-acquired pneumonia and admitted her for intravenous antibiotic treatment.

Late that afternoon the patient’s condition deteriorated rapidly. She was transferred to the intensive care unit, where she died of septic shock caused by Pseudomonas aeruginosa 22 hours after she had arrived at the ED.

PLAINTIFF’S CLAIM The patient should have received broader-spectrum antibiotics.

THE DEFENSE The hospitalist who treated the woman as an inpatient claimed that the treatment she received was appropriate and that she probably would have died even if other antibiotics had been prescribed. The hospitalist also claimed that the nursing staff failed to notify her of the patient’s low blood pressure readings until 10 hours after the initial evaluation. A nurse denied this claim, asserting that the hospitalist had been paged several times during the day. The discharge summary and nursing notes on the patient were missing.

VERDICT $5.28 million arbitration award.

COMMENT It surprises me how often key portions of medical records go missing! Here, the absence of a discharge summary and nursing notes may well have contributed to a $5 million award.

Change, and not for the better

AN ATYPICAL MOLE ON THE LEFT CALF was brought to the attention of a primary care physician by a 36-year-old man during a full physical. The mole was 1 3 1 cm; the patient reported that it had been changing. The mole’s appearance didn’t worry the physician, who described it in his notes as either a hemangioma or dermatofibroma. The doctor advised the patient to return in 6 months if he wanted the mole removed for cosmetic reasons.

Over the next 5 months, the patient noticed further changes in the mole and called the doctor’s office. He was seen by a colleague of his physician, who immediately sent the patient for a biopsy and surgical consultation. The mole was removed and diagnosed as an ulcerating melanoma with downward growth.

Shortly thereafter, the patient underwent wide excision and lymph node dissection, which showed clear margins and no lymph node involvement. Twenty months later, a mass was found in the patient’s liver. Biopsy diagnosed metastatic spread of the melanoma. The patient died 2 months later.

PLAINTIFF’S CLAIM The patient should have had a biopsy and received a surgical referral at the time of the physical examination when he first reported the mole.

THE DEFENSE Waiting for 6 months was appropriate because the mole didn’t look like a melanoma when the patient first called it to the physician’s attention. The melanoma had already metastasized at the time of the physical examination and the diagnostic delay didn’t affect the outcome.

VERDICT $1 million Massachusetts settlement.

COMMENT A changing mole should always raise concern. Biopsy, excision, or a referral could have avoided a million-dollar settlement.

Failure to address persistent symptoms proves disastrous

PAIN IN THE BACK AND CHEST along with respiratory difficulty prompted a 49-year-old man to visit his physician. The physician told him to go to a hospital. The doctor who examined the patient at the hospital diagnosed muscle strain and prescribed muscle relaxants.

The following day, the patient returned to his physician complaining of continuing symptoms. The doctor sent him home. He died the next day of an aortic rupture caused by an undiagnosed dissection.

PLAINTIFF’S CLAIM The 2 physicians should have diagnosed the dissection, which would have permitted treatment and prevented death. The patient had been treated previously at the hospital, and his records should have raised suspicion of an aortic aneurysm. The hospital physician was a new hire and hadn’t received proper training in the hospital’s electronic records system. He should have ordered a computed tomography scan or cardiology consult. The patient’s physician failed to address the ongoing symptoms. He should have hospitalized the patient at the time of the second visit.

THE DEFENSE The hospital physician claimed he had intended to contact the cardiologist who had treated the patient, but the patient couldn’t remember the cardiologist’s name. The patient’s symptoms didn’t suggest an aortic dissection, and the dissection occurred after the patient was discharged from the hospital.

VERDICT $3.4 million New York verdict against the hospital physician only.

COMMENT Although the hoofbeats are usually horses, always remember the zebras (or should it be lions?), particularly when a patient returns repeatedly with ongoing symptoms.

Controlled substances out of control

A WOMAN WITH CHRONIC MIGRAINES, anxiety problems, and nausea also had cardiomyopathy and chronic atrial fibrillation, which could be triggered by pain from her other ailments. She came under the care of a physician who prescribed a number of drugs, including meperidine, hydrocodone, tizanidine, diazepam, promethazine, alprazolam, and oxcarbazepine. The doctor prescribed injectable forms of certain medications after the patient told him her next-door neighbor was a nurse and could help administer the drugs.

Four years after coming under the doctor’s care, the patient signed a Controlled Substance Agreement specifying that the physician would discontinue her as a patient if she got controlled substances from another doctor. (Evidence was later found that the patient was receiving prescriptions from other physicians.)

While under treatment by her doctor, the patient was hospitalized a number of times for medication overdoses. The record from one hospitalization reported that she had made angry, profanity-laced requests for meperidine and promethazine.

About 2 years after signing the Controlled Substance Agreement, the patient received prescriptions from her doctor for 210 doses of meperidine, 100 doses of promethazine, and 60 pills each of diazepam, alprazolam, and acetaminophen and hydrocodone. She filled the prescriptions at 2 pharmacies without objections from the pharmacists. She died of an accidental drug overdose the following month.

Postmortem blood testing showed high levels of meperidine and promethazine. The patient had apparently taken the equivalent of 11 “shots” of meperidine (5 times the maximum prescribed amount), probably by injecting herself through a peripherally inserted central catheter rather than by intramuscular injection, as prescribed.

PLAINTIFF’S CLAIM The patient’s doctor was negligent in prescribing large amounts of controlled substances when he should have known that she was a drug seeker with a drug abuse problem. The pharmacies were negligent for filling the prescriptions without question.

THE DEFENSE The patient was solely responsible for her own death because she gave herself a large overdose.

VERDICT $500,000 Alabama verdict. The case against the pharmacies was dismissed.

COMMENT Increasingly it is expected that physicians (and pharmacists) perform due diligence when prescribing opioids, including taking reasonable precautions against the drug-seeking patient.

Antibiotics fail to head off sepsis

SHORTNESS OF BREATH AND RIGHT-SIDED CHEST PAIN prompted a 45-year-old woman to go to the emergency department (ED) early one morning. She had a history of chronic lung problems with multiple diagnoses of pneumonia, pneumothorax, blebs, and bronchiectasis. The ED doctor diagnosed community-acquired pneumonia and admitted her for intravenous antibiotic treatment.

Late that afternoon the patient’s condition deteriorated rapidly. She was transferred to the intensive care unit, where she died of septic shock caused by Pseudomonas aeruginosa 22 hours after she had arrived at the ED.

PLAINTIFF’S CLAIM The patient should have received broader-spectrum antibiotics.

THE DEFENSE The hospitalist who treated the woman as an inpatient claimed that the treatment she received was appropriate and that she probably would have died even if other antibiotics had been prescribed. The hospitalist also claimed that the nursing staff failed to notify her of the patient’s low blood pressure readings until 10 hours after the initial evaluation. A nurse denied this claim, asserting that the hospitalist had been paged several times during the day. The discharge summary and nursing notes on the patient were missing.

VERDICT $5.28 million arbitration award.

COMMENT It surprises me how often key portions of medical records go missing! Here, the absence of a discharge summary and nursing notes may well have contributed to a $5 million award.

Change, and not for the better

AN ATYPICAL MOLE ON THE LEFT CALF was brought to the attention of a primary care physician by a 36-year-old man during a full physical. The mole was 1 3 1 cm; the patient reported that it had been changing. The mole’s appearance didn’t worry the physician, who described it in his notes as either a hemangioma or dermatofibroma. The doctor advised the patient to return in 6 months if he wanted the mole removed for cosmetic reasons.

Over the next 5 months, the patient noticed further changes in the mole and called the doctor’s office. He was seen by a colleague of his physician, who immediately sent the patient for a biopsy and surgical consultation. The mole was removed and diagnosed as an ulcerating melanoma with downward growth.

Shortly thereafter, the patient underwent wide excision and lymph node dissection, which showed clear margins and no lymph node involvement. Twenty months later, a mass was found in the patient’s liver. Biopsy diagnosed metastatic spread of the melanoma. The patient died 2 months later.

PLAINTIFF’S CLAIM The patient should have had a biopsy and received a surgical referral at the time of the physical examination when he first reported the mole.

THE DEFENSE Waiting for 6 months was appropriate because the mole didn’t look like a melanoma when the patient first called it to the physician’s attention. The melanoma had already metastasized at the time of the physical examination and the diagnostic delay didn’t affect the outcome.

VERDICT $1 million Massachusetts settlement.

COMMENT A changing mole should always raise concern. Biopsy, excision, or a referral could have avoided a million-dollar settlement.

Failure to address persistent symptoms proves disastrous

PAIN IN THE BACK AND CHEST along with respiratory difficulty prompted a 49-year-old man to visit his physician. The physician told him to go to a hospital. The doctor who examined the patient at the hospital diagnosed muscle strain and prescribed muscle relaxants.

The following day, the patient returned to his physician complaining of continuing symptoms. The doctor sent him home. He died the next day of an aortic rupture caused by an undiagnosed dissection.

PLAINTIFF’S CLAIM The 2 physicians should have diagnosed the dissection, which would have permitted treatment and prevented death. The patient had been treated previously at the hospital, and his records should have raised suspicion of an aortic aneurysm. The hospital physician was a new hire and hadn’t received proper training in the hospital’s electronic records system. He should have ordered a computed tomography scan or cardiology consult. The patient’s physician failed to address the ongoing symptoms. He should have hospitalized the patient at the time of the second visit.

THE DEFENSE The hospital physician claimed he had intended to contact the cardiologist who had treated the patient, but the patient couldn’t remember the cardiologist’s name. The patient’s symptoms didn’t suggest an aortic dissection, and the dissection occurred after the patient was discharged from the hospital.

VERDICT $3.4 million New York verdict against the hospital physician only.

COMMENT Although the hoofbeats are usually horses, always remember the zebras (or should it be lions?), particularly when a patient returns repeatedly with ongoing symptoms.

Controlled substances out of control

A WOMAN WITH CHRONIC MIGRAINES, anxiety problems, and nausea also had cardiomyopathy and chronic atrial fibrillation, which could be triggered by pain from her other ailments. She came under the care of a physician who prescribed a number of drugs, including meperidine, hydrocodone, tizanidine, diazepam, promethazine, alprazolam, and oxcarbazepine. The doctor prescribed injectable forms of certain medications after the patient told him her next-door neighbor was a nurse and could help administer the drugs.

Four years after coming under the doctor’s care, the patient signed a Controlled Substance Agreement specifying that the physician would discontinue her as a patient if she got controlled substances from another doctor. (Evidence was later found that the patient was receiving prescriptions from other physicians.)

While under treatment by her doctor, the patient was hospitalized a number of times for medication overdoses. The record from one hospitalization reported that she had made angry, profanity-laced requests for meperidine and promethazine.

About 2 years after signing the Controlled Substance Agreement, the patient received prescriptions from her doctor for 210 doses of meperidine, 100 doses of promethazine, and 60 pills each of diazepam, alprazolam, and acetaminophen and hydrocodone. She filled the prescriptions at 2 pharmacies without objections from the pharmacists. She died of an accidental drug overdose the following month.

Postmortem blood testing showed high levels of meperidine and promethazine. The patient had apparently taken the equivalent of 11 “shots” of meperidine (5 times the maximum prescribed amount), probably by injecting herself through a peripherally inserted central catheter rather than by intramuscular injection, as prescribed.

PLAINTIFF’S CLAIM The patient’s doctor was negligent in prescribing large amounts of controlled substances when he should have known that she was a drug seeker with a drug abuse problem. The pharmacies were negligent for filling the prescriptions without question.

THE DEFENSE The patient was solely responsible for her own death because she gave herself a large overdose.

VERDICT $500,000 Alabama verdict. The case against the pharmacies was dismissed.

COMMENT Increasingly it is expected that physicians (and pharmacists) perform due diligence when prescribing opioids, including taking reasonable precautions against the drug-seeking patient.

When following CT guidelines isn’t enough

AN 86-YEAR-OLD MAN ON WARFARIN FAINTED AND FELL while baby-sitting his great-grandchildren. He had transient neurologic symptoms after collapsing but appeared normal by the time paramedics arrived. He was taken by private vehicle to the hospital, where an emergency department (ED) physician examined him. After tests for a myocardial infarction revealed normal enzymes, electrocardiogram, and chest radiograph, the patient was discharged home.

He returned to the hospital the following day and underwent a computed tomography (CT) scan, which showed a large cerebral hemorrhage. He died soon afterward.

PLAINTIFF’S CLAIM The patient should have had a CT scan during the first ED visit. A scan at that visit would have found the hemorrhage in time to save the patient’s life.

THE DEFENSE No discussion with family members about a blow to the head or head trauma occurred, and a CT scan wasn’t requested. The patient didn’t meet criteria for a head scan. Even if a scan had been done at the initial visit, it might not have revealed the bleed. Moreover, the patient’s age decreased the likelihood that earlier detection would have changed the outcome.

VERDICT Confidential Utah settlements. The hospital settled for a nominal sum early in the litigation process; the physician settled for a confidential amount immediately before trial.

COMMENT Even when clear guidelines for imaging exist, taking care to weigh extenuating circumstances—in this case, that the patient was on warfarin—is critical.

Failure to document treatment refusal proves costly

A 15-YEAR-OLD BOY lost consciousness at home on Halloween and needed cardiopulmonary resuscitation. When paramedics arrived on the scene, they found the boy conscious and breathing, so they left. The boy, who had a history of drug abuse, died 8 hours later of anoxic encephalopathy caused by cocaine and opiate intoxication.

PLAINTIFF’S CLAIM The paramedics were negligent in failing to evaluate the boy’s condition properly and transport him to a hospital.

THE DEFENSE The paramedics left without assessing the boy because he and his father said they didn’t want or need medical help. (The paramedics neglected to obtain signed refusal of treatment forms.)

VERDICT $5.1 million Illinois verdict.

COMMENT Here is a $5 million verdict that hinges on the completion of forms for refusal of treatment, a remarkable reminder of the importance of documentation.

Enlarging uterus goes uninvestigated

AT AN ANNUAL GYNECOLOGIC EXAMINATION, a woman’s physician noted that her uterus had enlarged since her last visit and described it as “top size” in the chart. At the patient’s next annual exam 21 months later, the uterus had grown to 14 weeks’ gestational size.

Ten months after that, when the woman returned to her physician complaining of abdominal discomfort, her uterus was larger than at the previous examination. The physician advised her to consider a hysterectomy.

About 2 months later, the patient went to the doctor again because of increasing pelvic pressure. Her uterus was 18 to 20 weeks’ gestational size. The physician ordered an ultrasound, which showed a large mass on each ovary and no fibroids or masses within the uterus. Magnetic resonance imaging confirmed the ultrasound findings.

The doctor referred the woman to an oncological gynecologist. She subsequently underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy and bilateral periaortic lymph node dissection. The pathology report described ovarian cancer with an ominous prognosis.

PLAINTIFF’S CLAIM The plaintiff alleged that the physician was negligent for failing to order testing when he first noticed the abnormal size of the uterus and at the patient’s subsequent visits. Failure to do so at the first exam and subsequent visits was negligent and allowed the cancer to advance instead of allowing for surgery and cure at an early stage.

THE DEFENSE No information about the defense is available.

VERDICT $650,000 Maryland settlement.

COMMENT It’s never a good policy to ignore a changing physical exam without good documentation, including a clear discussion of medical decision making.

Third ED visit isn’t the charm

A 39-YEAR-OLD QUADRIPLEGIC MAN went to the emergency department (ED) complaining of abdominal pain. His history included involvement in a shooting when he was 16, drug abuse, homelessness, and frequent visits to the ED, where the staff knew him to be combative and ignore medical advice. The ED physician who saw the man ordered a radiograph and other testing, then released him without a conclusive diagnosis.

A month later, the man came back to the ED by ambulance, complaining of severe abdominal pain that he’d had for 4 days. Another ED physician saw him but didn’t make a diagnosis. After 4 hours, the hospital discharged the patient by ambulance to stay with family. When the family refused to accept him, the ambulance brought him back to the hospital.

With the involvement of social services, the patient was wheeled across the street to a motel. After about 5 hours, during which the motel staff said the patient was screaming in pain, the staff called an ambulance, which brought the man back to the ED covered with bloody vomit.

The same ED physician who had seen him earlier examined him, along with another ED physician. A fecal impaction was removed manually and a soap suds enema administered. The patient seemed to improve and, after about 7 hours, was released and rolled outside with a taxi voucher.

He said the hospital staff told him he was abusing the hospital’s services and the police would be called if he returned. He was taken to the house of a family member, where he was found dead 4 hours later from a ruptured duodenal ulcer.

PLAINTIFF’S CLAIM The physician who saw the patient at the first ED visit should have diagnosed peptic ulcer disease; the doctors who saw the man at the second and third visits should have diagnosed the ruptured ulcer. The hospital violated the federal Emergency Medical Treatment and Labor Act (EMTALA) by failing to stabilize the patient before discharging him.

THE DEFENSE The patient was stable and improving each time he was discharged. The hospital denied threatening to arrest the patient if he returned to the ED after the third visit.

VERDICT $1.4 million Kentucky verdict. The first trial ended in a mistrial. All defendants except the hospital settled for undisclosed amounts before a second trial, at which the hospital was found to be 15% at fault and a $1.5 million award for punitive damages was assessed against the hospital for violating EMTALA.

The hospital appealed and the matter was returned for trial after a ruling that affirmed everything except the punitive damages. At the third trial, a jury awarded $1.4 million in punitive damages.

COMMENT Most of us have a visceral reaction when faced with a drug abusing, noncompliant patient who frequently shows up at the ED. We must remember that such patients do get sick and that in this case, despite repeated visits to the ED, a tragedy occurred.

When following CT guidelines isn’t enough

AN 86-YEAR-OLD MAN ON WARFARIN FAINTED AND FELL while baby-sitting his great-grandchildren. He had transient neurologic symptoms after collapsing but appeared normal by the time paramedics arrived. He was taken by private vehicle to the hospital, where an emergency department (ED) physician examined him. After tests for a myocardial infarction revealed normal enzymes, electrocardiogram, and chest radiograph, the patient was discharged home.

He returned to the hospital the following day and underwent a computed tomography (CT) scan, which showed a large cerebral hemorrhage. He died soon afterward.

PLAINTIFF’S CLAIM The patient should have had a CT scan during the first ED visit. A scan at that visit would have found the hemorrhage in time to save the patient’s life.

THE DEFENSE No discussion with family members about a blow to the head or head trauma occurred, and a CT scan wasn’t requested. The patient didn’t meet criteria for a head scan. Even if a scan had been done at the initial visit, it might not have revealed the bleed. Moreover, the patient’s age decreased the likelihood that earlier detection would have changed the outcome.

VERDICT Confidential Utah settlements. The hospital settled for a nominal sum early in the litigation process; the physician settled for a confidential amount immediately before trial.

COMMENT Even when clear guidelines for imaging exist, taking care to weigh extenuating circumstances—in this case, that the patient was on warfarin—is critical.

Failure to document treatment refusal proves costly

A 15-YEAR-OLD BOY lost consciousness at home on Halloween and needed cardiopulmonary resuscitation. When paramedics arrived on the scene, they found the boy conscious and breathing, so they left. The boy, who had a history of drug abuse, died 8 hours later of anoxic encephalopathy caused by cocaine and opiate intoxication.

PLAINTIFF’S CLAIM The paramedics were negligent in failing to evaluate the boy’s condition properly and transport him to a hospital.

THE DEFENSE The paramedics left without assessing the boy because he and his father said they didn’t want or need medical help. (The paramedics neglected to obtain signed refusal of treatment forms.)

VERDICT $5.1 million Illinois verdict.

COMMENT Here is a $5 million verdict that hinges on the completion of forms for refusal of treatment, a remarkable reminder of the importance of documentation.

Enlarging uterus goes uninvestigated

AT AN ANNUAL GYNECOLOGIC EXAMINATION, a woman’s physician noted that her uterus had enlarged since her last visit and described it as “top size” in the chart. At the patient’s next annual exam 21 months later, the uterus had grown to 14 weeks’ gestational size.

Ten months after that, when the woman returned to her physician complaining of abdominal discomfort, her uterus was larger than at the previous examination. The physician advised her to consider a hysterectomy.

About 2 months later, the patient went to the doctor again because of increasing pelvic pressure. Her uterus was 18 to 20 weeks’ gestational size. The physician ordered an ultrasound, which showed a large mass on each ovary and no fibroids or masses within the uterus. Magnetic resonance imaging confirmed the ultrasound findings.

The doctor referred the woman to an oncological gynecologist. She subsequently underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy and bilateral periaortic lymph node dissection. The pathology report described ovarian cancer with an ominous prognosis.

PLAINTIFF’S CLAIM The plaintiff alleged that the physician was negligent for failing to order testing when he first noticed the abnormal size of the uterus and at the patient’s subsequent visits. Failure to do so at the first exam and subsequent visits was negligent and allowed the cancer to advance instead of allowing for surgery and cure at an early stage.

THE DEFENSE No information about the defense is available.

VERDICT $650,000 Maryland settlement.

COMMENT It’s never a good policy to ignore a changing physical exam without good documentation, including a clear discussion of medical decision making.

Third ED visit isn’t the charm

A 39-YEAR-OLD QUADRIPLEGIC MAN went to the emergency department (ED) complaining of abdominal pain. His history included involvement in a shooting when he was 16, drug abuse, homelessness, and frequent visits to the ED, where the staff knew him to be combative and ignore medical advice. The ED physician who saw the man ordered a radiograph and other testing, then released him without a conclusive diagnosis.

A month later, the man came back to the ED by ambulance, complaining of severe abdominal pain that he’d had for 4 days. Another ED physician saw him but didn’t make a diagnosis. After 4 hours, the hospital discharged the patient by ambulance to stay with family. When the family refused to accept him, the ambulance brought him back to the hospital.

With the involvement of social services, the patient was wheeled across the street to a motel. After about 5 hours, during which the motel staff said the patient was screaming in pain, the staff called an ambulance, which brought the man back to the ED covered with bloody vomit.

The same ED physician who had seen him earlier examined him, along with another ED physician. A fecal impaction was removed manually and a soap suds enema administered. The patient seemed to improve and, after about 7 hours, was released and rolled outside with a taxi voucher.

He said the hospital staff told him he was abusing the hospital’s services and the police would be called if he returned. He was taken to the house of a family member, where he was found dead 4 hours later from a ruptured duodenal ulcer.

PLAINTIFF’S CLAIM The physician who saw the patient at the first ED visit should have diagnosed peptic ulcer disease; the doctors who saw the man at the second and third visits should have diagnosed the ruptured ulcer. The hospital violated the federal Emergency Medical Treatment and Labor Act (EMTALA) by failing to stabilize the patient before discharging him.

THE DEFENSE The patient was stable and improving each time he was discharged. The hospital denied threatening to arrest the patient if he returned to the ED after the third visit.

VERDICT $1.4 million Kentucky verdict. The first trial ended in a mistrial. All defendants except the hospital settled for undisclosed amounts before a second trial, at which the hospital was found to be 15% at fault and a $1.5 million award for punitive damages was assessed against the hospital for violating EMTALA.

The hospital appealed and the matter was returned for trial after a ruling that affirmed everything except the punitive damages. At the third trial, a jury awarded $1.4 million in punitive damages.

COMMENT Most of us have a visceral reaction when faced with a drug abusing, noncompliant patient who frequently shows up at the ED. We must remember that such patients do get sick and that in this case, despite repeated visits to the ED, a tragedy occurred.

When following CT guidelines isn’t enough

AN 86-YEAR-OLD MAN ON WARFARIN FAINTED AND FELL while baby-sitting his great-grandchildren. He had transient neurologic symptoms after collapsing but appeared normal by the time paramedics arrived. He was taken by private vehicle to the hospital, where an emergency department (ED) physician examined him. After tests for a myocardial infarction revealed normal enzymes, electrocardiogram, and chest radiograph, the patient was discharged home.

He returned to the hospital the following day and underwent a computed tomography (CT) scan, which showed a large cerebral hemorrhage. He died soon afterward.

PLAINTIFF’S CLAIM The patient should have had a CT scan during the first ED visit. A scan at that visit would have found the hemorrhage in time to save the patient’s life.

THE DEFENSE No discussion with family members about a blow to the head or head trauma occurred, and a CT scan wasn’t requested. The patient didn’t meet criteria for a head scan. Even if a scan had been done at the initial visit, it might not have revealed the bleed. Moreover, the patient’s age decreased the likelihood that earlier detection would have changed the outcome.

VERDICT Confidential Utah settlements. The hospital settled for a nominal sum early in the litigation process; the physician settled for a confidential amount immediately before trial.

COMMENT Even when clear guidelines for imaging exist, taking care to weigh extenuating circumstances—in this case, that the patient was on warfarin—is critical.

Failure to document treatment refusal proves costly

A 15-YEAR-OLD BOY lost consciousness at home on Halloween and needed cardiopulmonary resuscitation. When paramedics arrived on the scene, they found the boy conscious and breathing, so they left. The boy, who had a history of drug abuse, died 8 hours later of anoxic encephalopathy caused by cocaine and opiate intoxication.

PLAINTIFF’S CLAIM The paramedics were negligent in failing to evaluate the boy’s condition properly and transport him to a hospital.

THE DEFENSE The paramedics left without assessing the boy because he and his father said they didn’t want or need medical help. (The paramedics neglected to obtain signed refusal of treatment forms.)

VERDICT $5.1 million Illinois verdict.

COMMENT Here is a $5 million verdict that hinges on the completion of forms for refusal of treatment, a remarkable reminder of the importance of documentation.

Enlarging uterus goes uninvestigated

AT AN ANNUAL GYNECOLOGIC EXAMINATION, a woman’s physician noted that her uterus had enlarged since her last visit and described it as “top size” in the chart. At the patient’s next annual exam 21 months later, the uterus had grown to 14 weeks’ gestational size.

Ten months after that, when the woman returned to her physician complaining of abdominal discomfort, her uterus was larger than at the previous examination. The physician advised her to consider a hysterectomy.

About 2 months later, the patient went to the doctor again because of increasing pelvic pressure. Her uterus was 18 to 20 weeks’ gestational size. The physician ordered an ultrasound, which showed a large mass on each ovary and no fibroids or masses within the uterus. Magnetic resonance imaging confirmed the ultrasound findings.

The doctor referred the woman to an oncological gynecologist. She subsequently underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy and bilateral periaortic lymph node dissection. The pathology report described ovarian cancer with an ominous prognosis.

PLAINTIFF’S CLAIM The plaintiff alleged that the physician was negligent for failing to order testing when he first noticed the abnormal size of the uterus and at the patient’s subsequent visits. Failure to do so at the first exam and subsequent visits was negligent and allowed the cancer to advance instead of allowing for surgery and cure at an early stage.

THE DEFENSE No information about the defense is available.

VERDICT $650,000 Maryland settlement.

COMMENT It’s never a good policy to ignore a changing physical exam without good documentation, including a clear discussion of medical decision making.

Third ED visit isn’t the charm

A 39-YEAR-OLD QUADRIPLEGIC MAN went to the emergency department (ED) complaining of abdominal pain. His history included involvement in a shooting when he was 16, drug abuse, homelessness, and frequent visits to the ED, where the staff knew him to be combative and ignore medical advice. The ED physician who saw the man ordered a radiograph and other testing, then released him without a conclusive diagnosis.

A month later, the man came back to the ED by ambulance, complaining of severe abdominal pain that he’d had for 4 days. Another ED physician saw him but didn’t make a diagnosis. After 4 hours, the hospital discharged the patient by ambulance to stay with family. When the family refused to accept him, the ambulance brought him back to the hospital.

With the involvement of social services, the patient was wheeled across the street to a motel. After about 5 hours, during which the motel staff said the patient was screaming in pain, the staff called an ambulance, which brought the man back to the ED covered with bloody vomit.

The same ED physician who had seen him earlier examined him, along with another ED physician. A fecal impaction was removed manually and a soap suds enema administered. The patient seemed to improve and, after about 7 hours, was released and rolled outside with a taxi voucher.

He said the hospital staff told him he was abusing the hospital’s services and the police would be called if he returned. He was taken to the house of a family member, where he was found dead 4 hours later from a ruptured duodenal ulcer.

PLAINTIFF’S CLAIM The physician who saw the patient at the first ED visit should have diagnosed peptic ulcer disease; the doctors who saw the man at the second and third visits should have diagnosed the ruptured ulcer. The hospital violated the federal Emergency Medical Treatment and Labor Act (EMTALA) by failing to stabilize the patient before discharging him.

THE DEFENSE The patient was stable and improving each time he was discharged. The hospital denied threatening to arrest the patient if he returned to the ED after the third visit.

VERDICT $1.4 million Kentucky verdict. The first trial ended in a mistrial. All defendants except the hospital settled for undisclosed amounts before a second trial, at which the hospital was found to be 15% at fault and a $1.5 million award for punitive damages was assessed against the hospital for violating EMTALA.

The hospital appealed and the matter was returned for trial after a ruling that affirmed everything except the punitive damages. At the third trial, a jury awarded $1.4 million in punitive damages.

COMMENT Most of us have a visceral reaction when faced with a drug abusing, noncompliant patient who frequently shows up at the ED. We must remember that such patients do get sick and that in this case, despite repeated visits to the ED, a tragedy occurred.

Gallbladder surgery uncovers something more

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

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

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

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

VERDICT $160,000 New York settlement.

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

Diagnosis minus treatment equals catastrophe

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

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

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

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

THE DEFENSE No information about the defense is available.

VERDICT $10.9 million South Carolina verdict.

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

Circumcision proceeds without consent

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

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

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

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

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

A drug adverse effect—that wasn’t

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

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

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

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

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

VERDICT $150,000 New York verdict.

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

Antibiotics prescribed by phone can’t substitute for office visit

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

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

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

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

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

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

Gallbladder surgery uncovers something more

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

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

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

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

VERDICT $160,000 New York settlement.

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

Diagnosis minus treatment equals catastrophe

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

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

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

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

THE DEFENSE No information about the defense is available.

VERDICT $10.9 million South Carolina verdict.

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

Circumcision proceeds without consent

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

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

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

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

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

A drug adverse effect—that wasn’t

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

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

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

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

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

VERDICT $150,000 New York verdict.

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

Antibiotics prescribed by phone can’t substitute for office visit

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

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

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

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

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

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

Gallbladder surgery uncovers something more

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

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

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

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

VERDICT $160,000 New York settlement.

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

Diagnosis minus treatment equals catastrophe

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

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

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

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

THE DEFENSE No information about the defense is available.

VERDICT $10.9 million South Carolina verdict.

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

Circumcision proceeds without consent

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

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

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

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

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

A drug adverse effect—that wasn’t

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

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

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

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

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

VERDICT $150,000 New York verdict.

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

Antibiotics prescribed by phone can’t substitute for office visit

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

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

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

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

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

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

“Hemorrhoids” turn out to be cancer

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

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

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

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

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

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

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

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

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

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

THE DEFENSE No information about the defense is available.

VERDICT $2.15 million Tennessee settlement.

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

For want of diagnosis and treatment, kidney function is lost

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

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

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

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

VERDICT $1.45 million Texas settlement.

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

Neuropathy blamed on belated diabetes diagnosis

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

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

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

VERDICT $285,000 New York settlement.

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

Too many narcotic prescriptions

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

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

THE DEFENSE No information about the defense is available.

VERDICT $1.05 million New Jersey settlement.

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

Delayed Tx turns skin breakdown into a long-term problem

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

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

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

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

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

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

THE DEFENSE The defendants denied any negligence.

VERDICT Alabama defense verdict.

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

“Hemorrhoids” turn out to be cancer

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

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

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

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

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

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

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

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

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

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

THE DEFENSE No information about the defense is available.

VERDICT $2.15 million Tennessee settlement.

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

For want of diagnosis and treatment, kidney function is lost

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

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

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

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

VERDICT $1.45 million Texas settlement.

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

Neuropathy blamed on belated diabetes diagnosis

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

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

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

VERDICT $285,000 New York settlement.

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

Too many narcotic prescriptions

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

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

THE DEFENSE No information about the defense is available.

VERDICT $1.05 million New Jersey settlement.

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

Delayed Tx turns skin breakdown into a long-term problem

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

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

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

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

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

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

THE DEFENSE The defendants denied any negligence.

VERDICT Alabama defense verdict.

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

“Hemorrhoids” turn out to be cancer

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

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

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

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

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

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

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

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

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

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

THE DEFENSE No information about the defense is available.

VERDICT $2.15 million Tennessee settlement.

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

For want of diagnosis and treatment, kidney function is lost

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

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

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

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

VERDICT $1.45 million Texas settlement.

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

Neuropathy blamed on belated diabetes diagnosis

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

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

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

VERDICT $285,000 New York settlement.

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

Too many narcotic prescriptions

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

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

THE DEFENSE No information about the defense is available.

VERDICT $1.05 million New Jersey settlement.

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

Delayed Tx turns skin breakdown into a long-term problem

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

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

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

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

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

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

THE DEFENSE The defendants denied any negligence.

VERDICT Alabama defense verdict.

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

Bedside visit comes too late

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

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

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

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

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

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

VERDICT $1,815,658 Texas verdict.

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

Failure to investigate suspicious symptoms ends badly

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

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

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

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

THE DEFENSE No information about the defense is available.

VERDICT $1 million Maryland settlement.

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

Unrecognized spinal infection leads to paralysis

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

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

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

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

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

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

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

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

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

Bedside visit comes too late

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

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

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

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

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

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

VERDICT $1,815,658 Texas verdict.

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

Failure to investigate suspicious symptoms ends badly

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

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

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

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

THE DEFENSE No information about the defense is available.

VERDICT $1 million Maryland settlement.

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

Unrecognized spinal infection leads to paralysis

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

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

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

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

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

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

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

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

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

Bedside visit comes too late

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

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

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

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

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

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

VERDICT $1,815,658 Texas verdict.

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

Failure to investigate suspicious symptoms ends badly

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

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

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

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

THE DEFENSE No information about the defense is available.

VERDICT $1 million Maryland settlement.

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

Unrecognized spinal infection leads to paralysis

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

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

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

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

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

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

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

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

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

Not your garden variety neck pain

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

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

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

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

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

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

VERDICT $3 million Massachusetts settlement.

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

Untimely death blamed on undiagnosed PE

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

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

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

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

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

VERDICT $6.1 million Maryland verdict.

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

Delayed herpes diagnosis leads to lifelong consequences

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

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

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

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

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

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

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

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

VERDICT Multiple New York settlements totaling $10.2 million.

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

Not your garden variety neck pain

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

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

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

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

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

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

VERDICT $3 million Massachusetts settlement.

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

Untimely death blamed on undiagnosed PE

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

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

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

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

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

VERDICT $6.1 million Maryland verdict.

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

Delayed herpes diagnosis leads to lifelong consequences

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

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

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

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

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

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

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

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

VERDICT Multiple New York settlements totaling $10.2 million.

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

Not your garden variety neck pain

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

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

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

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

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

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

VERDICT $3 million Massachusetts settlement.

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

Untimely death blamed on undiagnosed PE

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

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

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

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

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

VERDICT $6.1 million Maryland verdict.

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

Delayed herpes diagnosis leads to lifelong consequences

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

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

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

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

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

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

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

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

VERDICT Multiple New York settlements totaling $10.2 million.

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

Culture results go undiscussed, man suffers stroke

TWO WEEKS AFTER PROSTATE SURGERY, a 76-year-old man went to the ED because he was having trouble urinating. The ED physician catheterized the patient, ordered a urine culture, and discharged him.

The culture results, showing methicillin-resistant Staphylococcus aureus, were sent to a printer in the ED twice, as was the usual practice, but evidently no one saw them.

The patient returned to the ED 2 weeks after his initial visit with the same complaint of difficult urination and was seen by the same physician. The physician again discharged him with a catheter but without mentioning the culture results. Two days later, the patient suffered a stroke, which paralyzed his left side.

PLAINTIFF’S CLAIM The bacteria had spread from the patient’s urine to his bloodstream, sparking a cascade of events that led to the stroke.

THE DEFENSE No information about the defense is available.

VERDICT $2.25 million New Jersey settlement.

COMMENT The repeated missed opportunities to diagnose and treat this patient’s infection were regrettable—and costly.

Inadequate differential proves fatal

SHORTNESS OF BREATH led a 52-year-old woman to visit her medical group, where she was a long-time patient. The family practitioner who saw her noted tachycardia and ordered an electrocardiogram, which was abnormal. The physician also ordered a chest x-ray and, because the woman had a history of anemia, a complete blood count and a number of other blood tests. He subsequently called the patient at home to tell her that the blood tests were normal and she didn’t have anemia.

Three days later, the patient went to an urgent care center complaining of shortness of breath and tightness in her chest. A pulmonary embolism was diagnosed, and she was transferred to a hospital ED. Later that evening, a code blue was called and the patient was resuscitated. She died the following day.

PLAINTIFF’S CLAIM The doctor assumed that the patient had anemia and failed to develop a differential diagnosis. The patient had risk factors for pulmonary embolism—obesity and the use of an ethinyl estradiol-etonogestrel vaginal contraceptive ring—which should have prompted the doctor to consider that possibility. If he had done so, the pulmonary embolism would have been diagnosed and the patient’s death prevented.

THE DEFENSE The patient’s presentation wasn’t typical for pulmonary embolism, and there wasn’t any way to know whether an earlier diagnosis would have resulted in survival.

VERDICT $1.9 million California verdict.

COMMENT Although pulmonary embolism can be a challenging diagnosis to make, it needs to be considered carefully in all patients with shortness of breath, chest pain, or poorly defined pulmonary or cardiac symptoms.

The correct diagnosis comes too late

FLU-LIKE SYMPTOMS AND AN IRREGULAR HEART RATE prompted a man to go to the ED, where the physician diagnosed a viral infection, prescribed pain medication, and discharged him. The following day, a laboratory report indicating a staph infection was sent to an ED secretary, but the patient wasn’t told the results.

The patient returned to the hospital 2 days later in a confused state. Tests revealed a staph infection and meningitis, for which the patient received antibiotics. A week later, the patient suffered a stroke, resulting in diminished cognitive ability, impaired vision, and right-sided motor deficits.

PLAINTIFF’S CLAIM The white blood cell count and C-reactive protein level measured at the patient’s first visit to the ED would have led to a diagnosis of bacterial infection. The patient should have been admitted to the hospital and given antibiotics at that time.

THE DEFENSE The original diagnosis was reasonable.

VERDICT Confidential settlement with the hospital. $900,000 net verdict against the physician in New Jersey.

COMMENT Lab reports gone awry and the lack of a fail-safe for abnormal tests result in a $900,000 judgment. Do you have adequate systems in place to avoid a communication failure like this one?

Slow response turns a bad situation into a disaster

A 66-YEAR-OLD MAN on warfarin therapy for chronic atrial fibrillation and a transient ischemic attack underwent lithotripsy for kidney stones. Three days after the lithotripsy, he went to the ED complaining of severe flank pain. A computed tomography (CT) scan of the abdomen showed a large retroperitoneal hematoma and prominent perinephric and pararenal hemorrhages.

The patient remained on a gurney in the hallway of the ED in deteriorating condition until he was admitted to the intensive care unit, by which time his condition was critical. He died the next day.

PLAINTIFF’S CLAIM The ED physician and admitting urologists failed to monitor and treat the patient’s active hemorrhage for 9 hours. They didn’t order coagulation studies or respond to signs of escalating hemorrhagic shock. They failed to seek timely consults from surgery and interventional radiology.

THE DEFENSE No information about the defense is available.

VERDICT $825,000 Virginia settlement.

COMMENT Preventing complications of anticoagulation is hard enough; the lack of a timely response in this case made a bad outcome disastrous.

Were steps taken quickly enough?

SEVERE LOWER ABDOMINAL PAIN prompted a 52-year-old woman to go to the ED. She said she hadn’t had a bowel movement in almost a week. The ED physician, in consultation with the attending physician, admitted her to the hospital and ordered intravenous fluids and a soap suds enema, which didn’t relieve the constipation. The patient’s vital signs deteriorated, and she was crying and restless.

When the attending physician saw the patient almost 3 hours after admission, she had a fever of 101.4°F. He ordered additional tests, a computed tomography (CT) scan, and antibiotics, but didn’t order them STAT.

About 1½ hours later, a house physician examined the patient, and, after speaking with the attending physician, transferred her to a step-down telemetry unit. About 1½ hours after the transfer, a nurse called the house physician to report that the patient’s condition was worsening. The house physician ordered pain relievers and a second enema but didn’t come to the hospital.

Because the patient wasn’t in the intensive care unit, no one checked on her again for 3½ hours. When the nurse did check, she found the patient pale, cold, and turning blue. The nurse called the house physician, who came to the hospital. The patient had a fever of 102.4°F and her blood pressure couldn’t be measured.

After speaking with the attending physician, the house physician had the patient admitted to the ICU and also ordered a STAT surgical consultation and CT scan. In the meantime, the patient went into cardiac arrest and couldn’t be revived. Death was caused by peritonitis with sepsis resulting from a large intestinal obstruction.

PLAINTIFF’S CLAIM The patient showed early signs of sepsis. She should have undergone testing sooner and been transferred to the ICU earlier.

THE DEFENSE The doctors claimed that all their actions were appropriate and that the actions suggested by the plaintiff wouldn’t have resulted in the patient’s survival.

VERDICT $3.8 million Pennsylvania verdict.

COMMENT Prompt evaluation and monitoring of this patient might have prevented death and a substantial verdict.

2 analgesic calamities: Death by fentanyl patch …

AFTER A WEEK OF INCREASING BACK PAIN, which had begun to shoot down his right leg, a 37-year-old man went to the ED. He was examined and given prescriptions for pain killers, including acetaminophen and hydrocodone, and muscle relaxants and discharged with instructions to return in 3 days for magnetic resonance imaging (MRI).

While he was at the hospital for the MRI, the patient returned to the ED because he was still in pain and his acetaminophen-hydrocodone prescription was running out. The ED physician prescribed a 0.75-mg fentanyl transdermal patch and instructed the patient to put it on his chest.

Three days later, the patient filled the prescription and applied the patch. The following day, his girlfriend found him dead in bed. Postmortem toxicology results showed a blood fentanyl level of 9.85 ng/mL, markedly higher than the therapeutic level. Respiratory failure caused by fentanyl toxicity was cited as the cause of death.

PLAINTIFF’S CLAIM The ED physician prescribed an excessive dose of fentanyl.

THE DEFENSE A defective patch or misuse of the patch caused the patient’s death.

VERDICT $1.2 million Indiana verdict.

… and methadone

A 36-YEAR-OLD MAN started treatment with a pain specialist for pain arising from a back problem, for which he had taken pain medication previously. The pain specialist prescribed methadone, 360 10-mg tablets. The prescription limited the patient to 2 tablets every 4 hours for a maximum dosage of 12 tablets (120 mg) per day.

Three days after the patient filled the prescription, he was found dead. An autopsy determined the cause of death to be drug toxicity from methadone. At the time the patient died, the bottle of methadone tablets contained 342 tablets, indicating that he had taken only 18 tablets, well within the maximum dosage authorized by the prescription.

PLAINTIFF’S CLAIM The prescribed methadone dosage was excessive for a patient just beginning to use the drug. A proper initial dosage is between 2.5 and 10 mg every 8 to 12 hours for a maximum of 30 mg per day.

THE DEFENSE No information about the defense is available.

VERDICT Confidential Utah settlement.

COMMENT These 2 cases have a common thread. The effects of opioids are often idiosyncratic. A plan for careful monitoring and follow-up should be prepared at initiation of treatment and when escalating the dosage.

Culture results go undiscussed, man suffers stroke

TWO WEEKS AFTER PROSTATE SURGERY, a 76-year-old man went to the ED because he was having trouble urinating. The ED physician catheterized the patient, ordered a urine culture, and discharged him.

The culture results, showing methicillin-resistant Staphylococcus aureus, were sent to a printer in the ED twice, as was the usual practice, but evidently no one saw them.

The patient returned to the ED 2 weeks after his initial visit with the same complaint of difficult urination and was seen by the same physician. The physician again discharged him with a catheter but without mentioning the culture results. Two days later, the patient suffered a stroke, which paralyzed his left side.

PLAINTIFF’S CLAIM The bacteria had spread from the patient’s urine to his bloodstream, sparking a cascade of events that led to the stroke.

THE DEFENSE No information about the defense is available.

VERDICT $2.25 million New Jersey settlement.

COMMENT The repeated missed opportunities to diagnose and treat this patient’s infection were regrettable—and costly.

Inadequate differential proves fatal

SHORTNESS OF BREATH led a 52-year-old woman to visit her medical group, where she was a long-time patient. The family practitioner who saw her noted tachycardia and ordered an electrocardiogram, which was abnormal. The physician also ordered a chest x-ray and, because the woman had a history of anemia, a complete blood count and a number of other blood tests. He subsequently called the patient at home to tell her that the blood tests were normal and she didn’t have anemia.

Three days later, the patient went to an urgent care center complaining of shortness of breath and tightness in her chest. A pulmonary embolism was diagnosed, and she was transferred to a hospital ED. Later that evening, a code blue was called and the patient was resuscitated. She died the following day.

PLAINTIFF’S CLAIM The doctor assumed that the patient had anemia and failed to develop a differential diagnosis. The patient had risk factors for pulmonary embolism—obesity and the use of an ethinyl estradiol-etonogestrel vaginal contraceptive ring—which should have prompted the doctor to consider that possibility. If he had done so, the pulmonary embolism would have been diagnosed and the patient’s death prevented.

THE DEFENSE The patient’s presentation wasn’t typical for pulmonary embolism, and there wasn’t any way to know whether an earlier diagnosis would have resulted in survival.

VERDICT $1.9 million California verdict.

COMMENT Although pulmonary embolism can be a challenging diagnosis to make, it needs to be considered carefully in all patients with shortness of breath, chest pain, or poorly defined pulmonary or cardiac symptoms.

The correct diagnosis comes too late

FLU-LIKE SYMPTOMS AND AN IRREGULAR HEART RATE prompted a man to go to the ED, where the physician diagnosed a viral infection, prescribed pain medication, and discharged him. The following day, a laboratory report indicating a staph infection was sent to an ED secretary, but the patient wasn’t told the results.

The patient returned to the hospital 2 days later in a confused state. Tests revealed a staph infection and meningitis, for which the patient received antibiotics. A week later, the patient suffered a stroke, resulting in diminished cognitive ability, impaired vision, and right-sided motor deficits.

PLAINTIFF’S CLAIM The white blood cell count and C-reactive protein level measured at the patient’s first visit to the ED would have led to a diagnosis of bacterial infection. The patient should have been admitted to the hospital and given antibiotics at that time.

THE DEFENSE The original diagnosis was reasonable.

VERDICT Confidential settlement with the hospital. $900,000 net verdict against the physician in New Jersey.

COMMENT Lab reports gone awry and the lack of a fail-safe for abnormal tests result in a $900,000 judgment. Do you have adequate systems in place to avoid a communication failure like this one?

Slow response turns a bad situation into a disaster

A 66-YEAR-OLD MAN on warfarin therapy for chronic atrial fibrillation and a transient ischemic attack underwent lithotripsy for kidney stones. Three days after the lithotripsy, he went to the ED complaining of severe flank pain. A computed tomography (CT) scan of the abdomen showed a large retroperitoneal hematoma and prominent perinephric and pararenal hemorrhages.

The patient remained on a gurney in the hallway of the ED in deteriorating condition until he was admitted to the intensive care unit, by which time his condition was critical. He died the next day.

PLAINTIFF’S CLAIM The ED physician and admitting urologists failed to monitor and treat the patient’s active hemorrhage for 9 hours. They didn’t order coagulation studies or respond to signs of escalating hemorrhagic shock. They failed to seek timely consults from surgery and interventional radiology.

THE DEFENSE No information about the defense is available.

VERDICT $825,000 Virginia settlement.

COMMENT Preventing complications of anticoagulation is hard enough; the lack of a timely response in this case made a bad outcome disastrous.

Were steps taken quickly enough?

SEVERE LOWER ABDOMINAL PAIN prompted a 52-year-old woman to go to the ED. She said she hadn’t had a bowel movement in almost a week. The ED physician, in consultation with the attending physician, admitted her to the hospital and ordered intravenous fluids and a soap suds enema, which didn’t relieve the constipation. The patient’s vital signs deteriorated, and she was crying and restless.

When the attending physician saw the patient almost 3 hours after admission, she had a fever of 101.4°F. He ordered additional tests, a computed tomography (CT) scan, and antibiotics, but didn’t order them STAT.

About 1½ hours later, a house physician examined the patient, and, after speaking with the attending physician, transferred her to a step-down telemetry unit. About 1½ hours after the transfer, a nurse called the house physician to report that the patient’s condition was worsening. The house physician ordered pain relievers and a second enema but didn’t come to the hospital.

Because the patient wasn’t in the intensive care unit, no one checked on her again for 3½ hours. When the nurse did check, she found the patient pale, cold, and turning blue. The nurse called the house physician, who came to the hospital. The patient had a fever of 102.4°F and her blood pressure couldn’t be measured.

After speaking with the attending physician, the house physician had the patient admitted to the ICU and also ordered a STAT surgical consultation and CT scan. In the meantime, the patient went into cardiac arrest and couldn’t be revived. Death was caused by peritonitis with sepsis resulting from a large intestinal obstruction.

PLAINTIFF’S CLAIM The patient showed early signs of sepsis. She should have undergone testing sooner and been transferred to the ICU earlier.

THE DEFENSE The doctors claimed that all their actions were appropriate and that the actions suggested by the plaintiff wouldn’t have resulted in the patient’s survival.

VERDICT $3.8 million Pennsylvania verdict.

COMMENT Prompt evaluation and monitoring of this patient might have prevented death and a substantial verdict.

2 analgesic calamities: Death by fentanyl patch …

AFTER A WEEK OF INCREASING BACK PAIN, which had begun to shoot down his right leg, a 37-year-old man went to the ED. He was examined and given prescriptions for pain killers, including acetaminophen and hydrocodone, and muscle relaxants and discharged with instructions to return in 3 days for magnetic resonance imaging (MRI).

While he was at the hospital for the MRI, the patient returned to the ED because he was still in pain and his acetaminophen-hydrocodone prescription was running out. The ED physician prescribed a 0.75-mg fentanyl transdermal patch and instructed the patient to put it on his chest.

Three days later, the patient filled the prescription and applied the patch. The following day, his girlfriend found him dead in bed. Postmortem toxicology results showed a blood fentanyl level of 9.85 ng/mL, markedly higher than the therapeutic level. Respiratory failure caused by fentanyl toxicity was cited as the cause of death.

PLAINTIFF’S CLAIM The ED physician prescribed an excessive dose of fentanyl.

THE DEFENSE A defective patch or misuse of the patch caused the patient’s death.

VERDICT $1.2 million Indiana verdict.

… and methadone

A 36-YEAR-OLD MAN started treatment with a pain specialist for pain arising from a back problem, for which he had taken pain medication previously. The pain specialist prescribed methadone, 360 10-mg tablets. The prescription limited the patient to 2 tablets every 4 hours for a maximum dosage of 12 tablets (120 mg) per day.

Three days after the patient filled the prescription, he was found dead. An autopsy determined the cause of death to be drug toxicity from methadone. At the time the patient died, the bottle of methadone tablets contained 342 tablets, indicating that he had taken only 18 tablets, well within the maximum dosage authorized by the prescription.

PLAINTIFF’S CLAIM The prescribed methadone dosage was excessive for a patient just beginning to use the drug. A proper initial dosage is between 2.5 and 10 mg every 8 to 12 hours for a maximum of 30 mg per day.

THE DEFENSE No information about the defense is available.

VERDICT Confidential Utah settlement.

COMMENT These 2 cases have a common thread. The effects of opioids are often idiosyncratic. A plan for careful monitoring and follow-up should be prepared at initiation of treatment and when escalating the dosage.

Culture results go undiscussed, man suffers stroke

TWO WEEKS AFTER PROSTATE SURGERY, a 76-year-old man went to the ED because he was having trouble urinating. The ED physician catheterized the patient, ordered a urine culture, and discharged him.

The culture results, showing methicillin-resistant Staphylococcus aureus, were sent to a printer in the ED twice, as was the usual practice, but evidently no one saw them.

The patient returned to the ED 2 weeks after his initial visit with the same complaint of difficult urination and was seen by the same physician. The physician again discharged him with a catheter but without mentioning the culture results. Two days later, the patient suffered a stroke, which paralyzed his left side.

PLAINTIFF’S CLAIM The bacteria had spread from the patient’s urine to his bloodstream, sparking a cascade of events that led to the stroke.

THE DEFENSE No information about the defense is available.

VERDICT $2.25 million New Jersey settlement.

COMMENT The repeated missed opportunities to diagnose and treat this patient’s infection were regrettable—and costly.

Inadequate differential proves fatal

SHORTNESS OF BREATH led a 52-year-old woman to visit her medical group, where she was a long-time patient. The family practitioner who saw her noted tachycardia and ordered an electrocardiogram, which was abnormal. The physician also ordered a chest x-ray and, because the woman had a history of anemia, a complete blood count and a number of other blood tests. He subsequently called the patient at home to tell her that the blood tests were normal and she didn’t have anemia.

Three days later, the patient went to an urgent care center complaining of shortness of breath and tightness in her chest. A pulmonary embolism was diagnosed, and she was transferred to a hospital ED. Later that evening, a code blue was called and the patient was resuscitated. She died the following day.

PLAINTIFF’S CLAIM The doctor assumed that the patient had anemia and failed to develop a differential diagnosis. The patient had risk factors for pulmonary embolism—obesity and the use of an ethinyl estradiol-etonogestrel vaginal contraceptive ring—which should have prompted the doctor to consider that possibility. If he had done so, the pulmonary embolism would have been diagnosed and the patient’s death prevented.

THE DEFENSE The patient’s presentation wasn’t typical for pulmonary embolism, and there wasn’t any way to know whether an earlier diagnosis would have resulted in survival.

VERDICT $1.9 million California verdict.

COMMENT Although pulmonary embolism can be a challenging diagnosis to make, it needs to be considered carefully in all patients with shortness of breath, chest pain, or poorly defined pulmonary or cardiac symptoms.

The correct diagnosis comes too late

FLU-LIKE SYMPTOMS AND AN IRREGULAR HEART RATE prompted a man to go to the ED, where the physician diagnosed a viral infection, prescribed pain medication, and discharged him. The following day, a laboratory report indicating a staph infection was sent to an ED secretary, but the patient wasn’t told the results.

The patient returned to the hospital 2 days later in a confused state. Tests revealed a staph infection and meningitis, for which the patient received antibiotics. A week later, the patient suffered a stroke, resulting in diminished cognitive ability, impaired vision, and right-sided motor deficits.

PLAINTIFF’S CLAIM The white blood cell count and C-reactive protein level measured at the patient’s first visit to the ED would have led to a diagnosis of bacterial infection. The patient should have been admitted to the hospital and given antibiotics at that time.

THE DEFENSE The original diagnosis was reasonable.

VERDICT Confidential settlement with the hospital. $900,000 net verdict against the physician in New Jersey.

COMMENT Lab reports gone awry and the lack of a fail-safe for abnormal tests result in a $900,000 judgment. Do you have adequate systems in place to avoid a communication failure like this one?

Slow response turns a bad situation into a disaster

A 66-YEAR-OLD MAN on warfarin therapy for chronic atrial fibrillation and a transient ischemic attack underwent lithotripsy for kidney stones. Three days after the lithotripsy, he went to the ED complaining of severe flank pain. A computed tomography (CT) scan of the abdomen showed a large retroperitoneal hematoma and prominent perinephric and pararenal hemorrhages.

The patient remained on a gurney in the hallway of the ED in deteriorating condition until he was admitted to the intensive care unit, by which time his condition was critical. He died the next day.

PLAINTIFF’S CLAIM The ED physician and admitting urologists failed to monitor and treat the patient’s active hemorrhage for 9 hours. They didn’t order coagulation studies or respond to signs of escalating hemorrhagic shock. They failed to seek timely consults from surgery and interventional radiology.

THE DEFENSE No information about the defense is available.

VERDICT $825,000 Virginia settlement.

COMMENT Preventing complications of anticoagulation is hard enough; the lack of a timely response in this case made a bad outcome disastrous.

Were steps taken quickly enough?

SEVERE LOWER ABDOMINAL PAIN prompted a 52-year-old woman to go to the ED. She said she hadn’t had a bowel movement in almost a week. The ED physician, in consultation with the attending physician, admitted her to the hospital and ordered intravenous fluids and a soap suds enema, which didn’t relieve the constipation. The patient’s vital signs deteriorated, and she was crying and restless.

When the attending physician saw the patient almost 3 hours after admission, she had a fever of 101.4°F. He ordered additional tests, a computed tomography (CT) scan, and antibiotics, but didn’t order them STAT.

About 1½ hours later, a house physician examined the patient, and, after speaking with the attending physician, transferred her to a step-down telemetry unit. About 1½ hours after the transfer, a nurse called the house physician to report that the patient’s condition was worsening. The house physician ordered pain relievers and a second enema but didn’t come to the hospital.

Because the patient wasn’t in the intensive care unit, no one checked on her again for 3½ hours. When the nurse did check, she found the patient pale, cold, and turning blue. The nurse called the house physician, who came to the hospital. The patient had a fever of 102.4°F and her blood pressure couldn’t be measured.

After speaking with the attending physician, the house physician had the patient admitted to the ICU and also ordered a STAT surgical consultation and CT scan. In the meantime, the patient went into cardiac arrest and couldn’t be revived. Death was caused by peritonitis with sepsis resulting from a large intestinal obstruction.

PLAINTIFF’S CLAIM The patient showed early signs of sepsis. She should have undergone testing sooner and been transferred to the ICU earlier.

THE DEFENSE The doctors claimed that all their actions were appropriate and that the actions suggested by the plaintiff wouldn’t have resulted in the patient’s survival.

VERDICT $3.8 million Pennsylvania verdict.

COMMENT Prompt evaluation and monitoring of this patient might have prevented death and a substantial verdict.

2 analgesic calamities: Death by fentanyl patch …

AFTER A WEEK OF INCREASING BACK PAIN, which had begun to shoot down his right leg, a 37-year-old man went to the ED. He was examined and given prescriptions for pain killers, including acetaminophen and hydrocodone, and muscle relaxants and discharged with instructions to return in 3 days for magnetic resonance imaging (MRI).

While he was at the hospital for the MRI, the patient returned to the ED because he was still in pain and his acetaminophen-hydrocodone prescription was running out. The ED physician prescribed a 0.75-mg fentanyl transdermal patch and instructed the patient to put it on his chest.

Three days later, the patient filled the prescription and applied the patch. The following day, his girlfriend found him dead in bed. Postmortem toxicology results showed a blood fentanyl level of 9.85 ng/mL, markedly higher than the therapeutic level. Respiratory failure caused by fentanyl toxicity was cited as the cause of death.

PLAINTIFF’S CLAIM The ED physician prescribed an excessive dose of fentanyl.

THE DEFENSE A defective patch or misuse of the patch caused the patient’s death.

VERDICT $1.2 million Indiana verdict.

… and methadone

A 36-YEAR-OLD MAN started treatment with a pain specialist for pain arising from a back problem, for which he had taken pain medication previously. The pain specialist prescribed methadone, 360 10-mg tablets. The prescription limited the patient to 2 tablets every 4 hours for a maximum dosage of 12 tablets (120 mg) per day.

Three days after the patient filled the prescription, he was found dead. An autopsy determined the cause of death to be drug toxicity from methadone. At the time the patient died, the bottle of methadone tablets contained 342 tablets, indicating that he had taken only 18 tablets, well within the maximum dosage authorized by the prescription.

PLAINTIFF’S CLAIM The prescribed methadone dosage was excessive for a patient just beginning to use the drug. A proper initial dosage is between 2.5 and 10 mg every 8 to 12 hours for a maximum of 30 mg per day.

THE DEFENSE No information about the defense is available.

VERDICT Confidential Utah settlement.

COMMENT These 2 cases have a common thread. The effects of opioids are often idiosyncratic. A plan for careful monitoring and follow-up should be prepared at initiation of treatment and when escalating the dosage.

“All in his head” Dx leaves boy limping for more than a year

A 9-YEAR-OLD BOY developed pain in his ankle and a resulting limp. Despite several visits to his pediatrician at a local clinic and consultations with specialists, the limp became worse. A work-up in the emergency department (ED) led to a diagnosis of dystonia and a follow-up visit with a specialist.

The specialist, whose area of expertise wasn’t dystonia, concluded that the symptoms were “in the boy’s head” and changed the diagnosis to conversion disorder without consulting the ED records or the physician who diagnosed dystonia. The boy was admitted to a rehabilitation hospital, where, according to his parents, he underwent a bizarre and punitive behavior regimen. The physician in charge at the hospital ordered removal of the crutches the patient needed to walk and directed that the boy do sit-ups and push-ups whenever he fell or lost his balance.

When the boy hadn’t improved after 30 days in the rehabilitation hospital, the treatment team ordered that he return to school on the condition that the school be informed that the child had a psychiatric condition and could walk normally if he wanted to. The school staff was instructed to forbid the boy to use crutches and not to help him up if he fell.

The situation continued for a year despite repeated questions from the boy’s parents and visits to the clinic. The family was dissuaded from seeking additional testing on the grounds that it would further “medicalize” his condition. A blood test done more than a year after the limp started confirmed the original diagnosis of dystonia.

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

THE DEFENSE No information about the defense is available.

VERDICT $890,000 Ohio verdict

COMMENT Although many unusual symptoms do have a psychiatric basis, in this case, poor communication and follow-up resulted in an almost $900,000 verdict.

When a migraine isn’t a migraine

WEAKNESS, LOSS OF BALANCE, AND HEARING LOSS prompted a 45-year-old woman to visit the emergency department (ED). An ED physician diagnosed a migraine headache and discharged her.

Five days later the woman returned to the ED with similar complaints, including imbalance, facial droop, dizziness, and weakness in the left arm. She was admitted to the hospital, where she had a stroke and died 5 days later.

PLAINTIFF’S CLAIM The ED doctor diagnosed a migraine headache and discharged the patient from the hospital when she really had a transient ischemic attack. The patient should have been referred for a neurologic evaluation, which would have revealed cardiomyopathy, which often shows no symptoms before precipitating a massive stroke.

THE DEFENSE No information about the defense is available.

VERDICT $3 million Illinois settlement.

COMMENT Faced with the hectic pace of practice, we need to carefully evaluate even the most routine complaints such as headache and perform a careful general physical, which in this case might have disclosed a murmur and raised the index of suspicion.

Confusion over warfarin Rx ends badly

A 48-YEAR-OLD MAN who had suffered a patellar tendon rupture to the left knee underwent bilateral patellar tendon repair by an orthopedic surgeon; long leg cylinder casts were applied to both legs. The patient started taking 5 mg warfarin the following day.

Two days later he was transferred to a skilled nursing facility for physical therapy and warfarin adjustment and assigned a primary care physician. During his stay in the nursing facility, the patient’s blood tests never showed a therapeutic warfarin level. He saw the orthopedist, who prescribed 4 to 6 more weeks of warfarin therapy and scheduled a return appointment for 2 weeks later.

The day after the patient saw the orthopedist, his primary care physician increased the warfarin dose to 6 mg. When a blood test 3 days later showed a nontherapeutic level, she increased the dose to 7 mg.

Twelve days later, the leg casts were removed and knee immobilizers applied. The doctor who removed the casts recommended that the patient keep taking warfarin for at least 6 more weeks until removal of the knee immobilizers and the start of range of motion exercises. The patient was given a prescription to take to the skilled nursing facility to continue warfarin at the discretion of the primary care physician. That same day, the primary care doctor ordered by telephone that the patient continue to receive the same dose of warfarin.

The patient was discharged home 2 days later with orders for physical therapy and a blood draw for prothrombin time/international normalized ratio (INR). Physical therapy began 3 days before the blood draw was to be performed. The blood draw was actually done a day later than ordered and one day after the patient had taken his last dose of warfarin.

The home health nurse notified the orthopedist that the patient had taken his last dose of warfarin and faxed him the results of the blood test, showing an INR of 1.3. Six days later, the nurse contacted the orthopedist again about the exhausted warfarin supply. The orthopedist told the nurse to get in touch with the primary care physician who had followed the patient during his stay at the skilled nursing facility. The nurse left a voice-mail message on the phone of the primary care physician’s nurse. Twenty-five days later, the patient suffered an embolism in his main pulmonary artery and died.

PLAINTIFF’S CLAIM The home health agency and physicians were negligent in failing to properly monitor the patient’s warfarin therapy.

THE DEFENSE The home health nurse acted properly in contacting the doctor. The orthopedist claimed that he had no duty to monitor the patient’s warfarin therapy because that was the responsibility of an internist. The primary care physician claimed that she wasn’t responsible for monitoring the warfarin after the patient was discharged from the skilled nursing facility.

VERDICT $76,760.12 net California verdict against the primary care physician with confidential post-trial settlement. The orthopedist received a defense verdict.

COMMENT Another example of lack of coordination of care, noncompliance, and inadequate follow-up. Although we can only partially improve adherence, we should shoulder responsibility for coordinated care!

“All in his head” Dx leaves boy limping for more than a year

A 9-YEAR-OLD BOY developed pain in his ankle and a resulting limp. Despite several visits to his pediatrician at a local clinic and consultations with specialists, the limp became worse. A work-up in the emergency department (ED) led to a diagnosis of dystonia and a follow-up visit with a specialist.

The specialist, whose area of expertise wasn’t dystonia, concluded that the symptoms were “in the boy’s head” and changed the diagnosis to conversion disorder without consulting the ED records or the physician who diagnosed dystonia. The boy was admitted to a rehabilitation hospital, where, according to his parents, he underwent a bizarre and punitive behavior regimen. The physician in charge at the hospital ordered removal of the crutches the patient needed to walk and directed that the boy do sit-ups and push-ups whenever he fell or lost his balance.

When the boy hadn’t improved after 30 days in the rehabilitation hospital, the treatment team ordered that he return to school on the condition that the school be informed that the child had a psychiatric condition and could walk normally if he wanted to. The school staff was instructed to forbid the boy to use crutches and not to help him up if he fell.

The situation continued for a year despite repeated questions from the boy’s parents and visits to the clinic. The family was dissuaded from seeking additional testing on the grounds that it would further “medicalize” his condition. A blood test done more than a year after the limp started confirmed the original diagnosis of dystonia.

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

THE DEFENSE No information about the defense is available.

VERDICT $890,000 Ohio verdict

COMMENT Although many unusual symptoms do have a psychiatric basis, in this case, poor communication and follow-up resulted in an almost $900,000 verdict.

When a migraine isn’t a migraine

WEAKNESS, LOSS OF BALANCE, AND HEARING LOSS prompted a 45-year-old woman to visit the emergency department (ED). An ED physician diagnosed a migraine headache and discharged her.

Five days later the woman returned to the ED with similar complaints, including imbalance, facial droop, dizziness, and weakness in the left arm. She was admitted to the hospital, where she had a stroke and died 5 days later.

PLAINTIFF’S CLAIM The ED doctor diagnosed a migraine headache and discharged the patient from the hospital when she really had a transient ischemic attack. The patient should have been referred for a neurologic evaluation, which would have revealed cardiomyopathy, which often shows no symptoms before precipitating a massive stroke.

THE DEFENSE No information about the defense is available.

VERDICT $3 million Illinois settlement.

COMMENT Faced with the hectic pace of practice, we need to carefully evaluate even the most routine complaints such as headache and perform a careful general physical, which in this case might have disclosed a murmur and raised the index of suspicion.

Confusion over warfarin Rx ends badly

A 48-YEAR-OLD MAN who had suffered a patellar tendon rupture to the left knee underwent bilateral patellar tendon repair by an orthopedic surgeon; long leg cylinder casts were applied to both legs. The patient started taking 5 mg warfarin the following day.

Two days later he was transferred to a skilled nursing facility for physical therapy and warfarin adjustment and assigned a primary care physician. During his stay in the nursing facility, the patient’s blood tests never showed a therapeutic warfarin level. He saw the orthopedist, who prescribed 4 to 6 more weeks of warfarin therapy and scheduled a return appointment for 2 weeks later.

The day after the patient saw the orthopedist, his primary care physician increased the warfarin dose to 6 mg. When a blood test 3 days later showed a nontherapeutic level, she increased the dose to 7 mg.

Twelve days later, the leg casts were removed and knee immobilizers applied. The doctor who removed the casts recommended that the patient keep taking warfarin for at least 6 more weeks until removal of the knee immobilizers and the start of range of motion exercises. The patient was given a prescription to take to the skilled nursing facility to continue warfarin at the discretion of the primary care physician. That same day, the primary care doctor ordered by telephone that the patient continue to receive the same dose of warfarin.

The patient was discharged home 2 days later with orders for physical therapy and a blood draw for prothrombin time/international normalized ratio (INR). Physical therapy began 3 days before the blood draw was to be performed. The blood draw was actually done a day later than ordered and one day after the patient had taken his last dose of warfarin.

The home health nurse notified the orthopedist that the patient had taken his last dose of warfarin and faxed him the results of the blood test, showing an INR of 1.3. Six days later, the nurse contacted the orthopedist again about the exhausted warfarin supply. The orthopedist told the nurse to get in touch with the primary care physician who had followed the patient during his stay at the skilled nursing facility. The nurse left a voice-mail message on the phone of the primary care physician’s nurse. Twenty-five days later, the patient suffered an embolism in his main pulmonary artery and died.

PLAINTIFF’S CLAIM The home health agency and physicians were negligent in failing to properly monitor the patient’s warfarin therapy.

THE DEFENSE The home health nurse acted properly in contacting the doctor. The orthopedist claimed that he had no duty to monitor the patient’s warfarin therapy because that was the responsibility of an internist. The primary care physician claimed that she wasn’t responsible for monitoring the warfarin after the patient was discharged from the skilled nursing facility.

VERDICT $76,760.12 net California verdict against the primary care physician with confidential post-trial settlement. The orthopedist received a defense verdict.

COMMENT Another example of lack of coordination of care, noncompliance, and inadequate follow-up. Although we can only partially improve adherence, we should shoulder responsibility for coordinated care!

“All in his head” Dx leaves boy limping for more than a year

A 9-YEAR-OLD BOY developed pain in his ankle and a resulting limp. Despite several visits to his pediatrician at a local clinic and consultations with specialists, the limp became worse. A work-up in the emergency department (ED) led to a diagnosis of dystonia and a follow-up visit with a specialist.

The specialist, whose area of expertise wasn’t dystonia, concluded that the symptoms were “in the boy’s head” and changed the diagnosis to conversion disorder without consulting the ED records or the physician who diagnosed dystonia. The boy was admitted to a rehabilitation hospital, where, according to his parents, he underwent a bizarre and punitive behavior regimen. The physician in charge at the hospital ordered removal of the crutches the patient needed to walk and directed that the boy do sit-ups and push-ups whenever he fell or lost his balance.

When the boy hadn’t improved after 30 days in the rehabilitation hospital, the treatment team ordered that he return to school on the condition that the school be informed that the child had a psychiatric condition and could walk normally if he wanted to. The school staff was instructed to forbid the boy to use crutches and not to help him up if he fell.

The situation continued for a year despite repeated questions from the boy’s parents and visits to the clinic. The family was dissuaded from seeking additional testing on the grounds that it would further “medicalize” his condition. A blood test done more than a year after the limp started confirmed the original diagnosis of dystonia.

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

THE DEFENSE No information about the defense is available.

VERDICT $890,000 Ohio verdict

COMMENT Although many unusual symptoms do have a psychiatric basis, in this case, poor communication and follow-up resulted in an almost $900,000 verdict.

When a migraine isn’t a migraine

WEAKNESS, LOSS OF BALANCE, AND HEARING LOSS prompted a 45-year-old woman to visit the emergency department (ED). An ED physician diagnosed a migraine headache and discharged her.

Five days later the woman returned to the ED with similar complaints, including imbalance, facial droop, dizziness, and weakness in the left arm. She was admitted to the hospital, where she had a stroke and died 5 days later.

PLAINTIFF’S CLAIM The ED doctor diagnosed a migraine headache and discharged the patient from the hospital when she really had a transient ischemic attack. The patient should have been referred for a neurologic evaluation, which would have revealed cardiomyopathy, which often shows no symptoms before precipitating a massive stroke.

THE DEFENSE No information about the defense is available.

VERDICT $3 million Illinois settlement.

COMMENT Faced with the hectic pace of practice, we need to carefully evaluate even the most routine complaints such as headache and perform a careful general physical, which in this case might have disclosed a murmur and raised the index of suspicion.

Confusion over warfarin Rx ends badly

A 48-YEAR-OLD MAN who had suffered a patellar tendon rupture to the left knee underwent bilateral patellar tendon repair by an orthopedic surgeon; long leg cylinder casts were applied to both legs. The patient started taking 5 mg warfarin the following day.

Two days later he was transferred to a skilled nursing facility for physical therapy and warfarin adjustment and assigned a primary care physician. During his stay in the nursing facility, the patient’s blood tests never showed a therapeutic warfarin level. He saw the orthopedist, who prescribed 4 to 6 more weeks of warfarin therapy and scheduled a return appointment for 2 weeks later.

The day after the patient saw the orthopedist, his primary care physician increased the warfarin dose to 6 mg. When a blood test 3 days later showed a nontherapeutic level, she increased the dose to 7 mg.

Twelve days later, the leg casts were removed and knee immobilizers applied. The doctor who removed the casts recommended that the patient keep taking warfarin for at least 6 more weeks until removal of the knee immobilizers and the start of range of motion exercises. The patient was given a prescription to take to the skilled nursing facility to continue warfarin at the discretion of the primary care physician. That same day, the primary care doctor ordered by telephone that the patient continue to receive the same dose of warfarin.

The patient was discharged home 2 days later with orders for physical therapy and a blood draw for prothrombin time/international normalized ratio (INR). Physical therapy began 3 days before the blood draw was to be performed. The blood draw was actually done a day later than ordered and one day after the patient had taken his last dose of warfarin.

The home health nurse notified the orthopedist that the patient had taken his last dose of warfarin and faxed him the results of the blood test, showing an INR of 1.3. Six days later, the nurse contacted the orthopedist again about the exhausted warfarin supply. The orthopedist told the nurse to get in touch with the primary care physician who had followed the patient during his stay at the skilled nursing facility. The nurse left a voice-mail message on the phone of the primary care physician’s nurse. Twenty-five days later, the patient suffered an embolism in his main pulmonary artery and died.

PLAINTIFF’S CLAIM The home health agency and physicians were negligent in failing to properly monitor the patient’s warfarin therapy.

THE DEFENSE The home health nurse acted properly in contacting the doctor. The orthopedist claimed that he had no duty to monitor the patient’s warfarin therapy because that was the responsibility of an internist. The primary care physician claimed that she wasn’t responsible for monitoring the warfarin after the patient was discharged from the skilled nursing facility.

VERDICT $76,760.12 net California verdict against the primary care physician with confidential post-trial settlement. The orthopedist received a defense verdict.

COMMENT Another example of lack of coordination of care, noncompliance, and inadequate follow-up. Although we can only partially improve adherence, we should shoulder responsibility for coordinated care!