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Malpractice Chronicle

2011;21(5):4-8, 42

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

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

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

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

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

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

The defendant claimed that the diagnosis made was reasonable.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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