Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
Failure to Follow Up on Breast Mass
In Massachusetts in December 2002, a 42-year-old woman presented to the defendant primary care physician and reported that she had been in a motor vehicle accident almost a month earlier while wearing a seat belt. The patient said she had noticed some redness in her left breast, then discovered a mass in the upper left breast. The physician confirmed the presence of a mass in the patient’s left breast, noting that the location did not correspond to the expected location for breast trauma sustained in an automobile accident.
Mammography was performed the following day. A visible 4-cm mass, which corresponded to the palpable finding in the left breast, was noted. Ultrasound showed a corresponding area of abnormality. The radiologist recommended follow-up in one month. According to the radiologist’s notes, mammography had been performed, but the films were not available. He also noted that if the films became available, he would issue an addendum.
A follow-up ultrasound performed in January 2003 indicated that the lesion had increased in size. The radiologist noted that the lesion could represent a hematoma but recommended aspiration or biopsy. He noted that if no further action was taken for diagnosis, a follow-up ultrasound should be performed in one month; he also recommended careful clinical correlation and close follow-up.
An addendum to the mammogram report was issued four days after the follow-up ultrasound. That report noted a review of studies performed two years earlier along with the studies from December 2002 and January 2003. The radiologist wrote, “Aside from the previously described mass, a probable hematoma, there is no significant change.”
At the defendant primary care physician’s request, the patient was seen by the defendant surgeon. The surgeon felt that the affected area might have been injured by the seat belt shoulder strap during the accident and concluded that the mammogram and follow-up studies suggested a hematoma. The surgeon attempted to aspirate the mass without success. The patient was advised to apply moist heat three times a day and to undergo a repeat mammogram in six months, which the surgeon scheduled.
The surgeon wrote a letter to the primary care physician, in which he failed to mention the radiologist’s impression that the mass was enlarging; neither did he include the radiologist’s recommendations for aspiration or biopsy or repeat ultrasound in one month. The surgeon made no further recommendations to the patient.
In late July 2003, the patient was scheduled for repeat imaging studies, which showed that the mass had continued to enlarge. Biopsy revealed poorly differentiated invasive ductal carcinoma, and metastatic disease was also found. The patient underwent preoperative radiotherapy, mastectomy, and chemotherapy. She died two years later at age 46.
A $4.75 million settlement was reached.
Of the many dangers confronting diagnosticians, few are as problematic as an incidental fact that drives the workup in the wrong direction. Here, the presentation could be “breast mass and redness post–motor vehicle accident” (MVA) or simply a “breast mass.” The diagnosis may differ dramatically based on how much weight is accorded to certain facts—in this case, the patient’s nearly one-month-old car accident.
Here, we are not told the specifics of the imaging or whether the patient’s breast was tender. The primary care physician may have believed that the redness and mass were caused by the seat belt, but he was sufficiently concerned to order a mammogram, breast ultrasound, and surgical consultation.
By contrast, the surgeon accorded significant weight to the MVA in making his diagnosis. At first, a hematoma seemed plausible; however, there were clues that the mass might not be trauma-related: the initial near-month delay between trauma and presentation, the unexpected disconnect between the location of the mass and the erythema, and arguably, the negative aspiration. The primary care physician picked up on some of these clues and initially responded fairly aggressively, seeking two studies and a surgical consultation. Unfortunately, the consulting surgeon conclusively believed the mass to be a hematoma, and the referring physician, after receiving the surgeon’s comforting report, did not order the second follow-up ultrasound recommended by the radiologist.
Absent the history of the patient’s MVA, the surgeon likely would have insisted on a biopsy or fine-needle aspiration, and the outcome might have been different. We have all heard (and perhaps handed down to students) rules of diagnostic roundsmanship, including “Common things happen commonly,” and have been admonished, “Correlation is not causation.” Keep these admonitions in mind, and don’t be thrown off by what may be an incidental fact in the presentation. Don’t let the next cardiac ischemia masquerade as “pulled muscle from painting yesterday”; don’t let your next ectopic pregnancy slip by as a “bad burrito.” Give antecedent facts their due, but no more.
In sum: First, be prepared to discount what could be an incidental fact; it may save a patient’s life. Second, even after consultation, don’t jettison your initial clinical impression if you remain justifiably concerned. —DML
Should Pregnancy Have Been Considered High Risk?
A pregnant woman received prenatal care from nurse-midwives and family practice physicians at a federally funded community health center in Wisconsin. On the day of delivery, according to the patient, the nurse-midwives covering deliveries failed to come to the hospital to evaluate her.
A nurse-midwife arrived about 40 minutes before the woman’s delivery and had difficulty delivering the infant because of shoulder dystocia. A second nurse-midwife arrived and performed maneuvers to facilitate delivery. The infant sustained severe brain damage.
At a trial conducted on the issue of damages only, the plaintiff claimed her pregnancy was high risk due to her previous history of delivering two large infants, her advanced age, and symptoms of gestational diabetes. The plaintiff maintained that she should have been given a referral to an obstetrician/gynecologist and/or a perinatologist.
The judge awarded about $20 million to the plaintiff. According to a published report, a posttrial settlement of $18.2 million was reached.
We are not told any specifics regarding the patient’s age or prior deliveries or her specific prenatal screening to determine whether the fetus was large for gestational age—and if so, to what degree; or the birth weight, or maternal factors that may have been suggestive of cephalopelvic disproportion. We are also not told about the fetal presentation or given results of fetal heart monitoring.
Fetal macrosomia (an estimated fetal weight of ≥ 4,500 g) has been correlated with shoulder dystocia, as has gestational diabetes. If there was evidence of malpresentation combined with macrosomia and/or small pelvic outlet, it is likely that the standard of care would have required a cesarean delivery to avoid an unreasonable risk to the mother and fetus.
While shoulder dystocia can be unexpected and unavoidable, the clinician must have a plan to address it—and be well versed in the plan. This should include immediately recognizing the condition as an emergency, summoning help, and initiating appropriate maneuvers. Practice drills can help clinicians rehearse the plan before an emergency arises.
In this case, liability was not contested—which is tantamount to an admission of liability. The plaintiff likely had overwhelming evidence that the history of gestational diabetes and maternal screening made vaginal delivery unreasonably risky in this specific case. In short, obstetrical/midwifery practice carries an inherent high risk for litigation: Screen adequately for likely complications, consider the appropriate use of cesarean delivery for high-risk patients, know your positions and maneuvers, and maintain a plan for performing them. —DML