Sunday, February 15, 2009

JURY DEBRIEF: Just the facts

The following is an account of the civil case in which I was a juror:

In late May 2002 a 30 year old, 429 lbs. male PATIENT walked into HOSPITAL X complaining of breathing difficulties. According to the history taken on his admission forms, PATIENT has had a history of asthma, sleep apnea and cellulitis. Morbid Obesity, a term I previously thought was just a saying and not a technical medical condition/diagnosis, was also listed.

The cellulitis was reported, on the admission papers, to be located on his abdomen. Later it was described to be on his "pannus."

An ER Doctor moved PATIENT to the Intensive Care Unit after he was intubated. Soon he had gone into respiratory failure and was placed on a respirator. The ER Doctor ordered a central line. A surgeon, who was on call at the time, was unsuccessful administering a central line. DOCTOR A, a Pulmonologist, also made an attempt on PATIENT - specifially into the femoral vein. The attempt by the pulmonolgist was unsuccessful. Later a vascular surgeon successfully carried out the central line order through the subclaivian vein.

The failed attempt by DOCTOR A resulted in a hematoma along with ecchymosis in the right groin area of the PATIENT. Also a DVT: Deep Vein Thrombosis developed in the PATIENT's lower right leg. In order to avoid a typically fatal PE: Pulmonary Embolism (which may result from a DVT clot traveling through the circulatory system from an extremeity to the lungs), PATIENT was given various blood thinning medication: including Coumadin.

***Because my Juror's notes were destroyed, I am having a difficult time trying to reconstruct the various steroids and other respiratory antibiotics administered to the PATIENT due to his pneumonia (lung infection), which had also developed. There was quite a cocktail of pharmaceuticals in PATIENT, the only name I can remember is the aforementioned Coumadin. The point I want to state is that PATIENT'S blood at this time was relatively thin - causing the blood loss from the femoral vein central line attempt to be significant.***

DOCTOR B, an infectious disease specialist, was called in by DOCTOR A for a consult on PATIENT'S hematoma.

PATIENT'S health in the ICU improved to the point of extubation (a reversal of the intubation: "they took out the breathing tube"). By this time is was the middle of June 2002. The PATIENT'S sedentary lifestyle, indicative of prolonged medical stays, warranted a transfer to a subacute facility instead of a release home due to a need of physical therapy. Also, the PATIENT was in the middle of a multi-week Pneumonia antibotic course. PATIENT was transferred from to HOSPITAL Y (a subacute medical facility).

DOCTOR B, the infectious disease specialist, also saw PATIENT at HOSPITAL Y. The hematoma, by the accounts of various doctor's notes, was either improving or staying the same. An ultrasound had found the hematoma to be 3.0 x 1.5 centimeters in area. The ecchymosis was changing colors and also moving. At the time, it was explained as a healing process (typical of buises changing color) and the move to other parts of the thigh was caused by gravity (PATIENT lying down for most of the day).

The opinion of DOCTOR B was that no infection existed in the right groin area of the PATIENT. Although the hematoma remained, he decided against an I&D: Incision
and Drainage. It was in the judgment of DOCTOR B that an attempt to stick a needle through the patient's groin (a normally "dirty" area of the anatomy colonized by multiple strains of bacteria) into a collection of blood (the hematoma) would be an unnecessary risk without sufficient reward.

In late June 2002 the DOCTOR B "signed off" on the case, citing that his consultation was no longer necessary for it was clear that PATIENTs hematoma was not infected. It is important to note that White Blood Cell levels (a common indicator used to evaluate infections and possible infections) were detailed in the notes of DOCTOR B. Multiple reasons for an elevated White Blood Count were explained as a resulting factors attributed to PATIENT's:
-loss of blood from the central line attempt
-Deep Vein Thrombosis
-Prescribed Steroids related to Pulmonary care

While at HOSPITAL Y, PATIENT's doctor of record was DOCTOR C (An internist). DOCTOR B was responsible for the overall care of the PATIENT while at HOSPITAL Y. This is who had called in the Infectious Disease Specialist (the fact that it was the same DOCTOR B from HOSPITAL X is a coincidence, for DOCTOR B was on staff at both hospitals).

In early July 2002, while at HOSPITAL Y, the PATIENT's health decreased rapidly and aggressively. An apparent infection and resulted in the PATIENT going into Septic Shock. PATIENT was immediately transferred to HOSPITAL Z (an acute hospital facility).

The source of the infection was PATIENT's right groin. As much as one liter of blood and pus were removed from the area. An I&D was preformed. The notes described "handfulls" of diseased tissue were removed. The subsequent tests on the tissue found positive traces of a highly resistant strain of E. Coli.

In mid-July 2002 PATIENT died at HOSPITAL Z. The autoposy listed Acute Bilateral Pneumia with Multi System Organ Failure as the causes of death.
This was a medical malpractice case.
The deceased's mother and two sisters were suing DOCTORS A, B & C on behalf of the PATIENT.

(IMPORTANT NOTE: There was a fourth Defendant involved in the case: a pulmonologist from HOSPITAL Y. However, this fourth Defendant was dismissed from the case shortly after their defense case was rested and before the closing arguments. The lawyer for the plaintiff had allowed for the dismissal. Also, there was a fifth Defendant: the vascular surgeon from HOSPITAL X. However, this fifth Defendant had died during the time period of PATIENT's death and the start of the trial.)

The attorney for the Plaintiff's case was built on the following:
-That DOCTOR A should have waited for a vascular surgeon before attempting the central line (and that DOCTOR A introduced an infection to the groin area from an existing nearby cellulitus, which resulted in an infected hematoma leading to the eventual death of the PATIENT)
-That DOCTOR B failed to correctly diagnose an infected hematoma (that further questioning and evaluating not performed would have discovered the infection and prevented the eventual death of the PATIENT)
-That DOCTOR C failed to call in more opinions to evaluate the potential infected groin and that DOCTOR C's overall care led to the deterioration of the PATIENT'S Health (causing the immediate transfer to HOSPITAL Z and to his eventual death)

The attorneys for the Defense built their cases on the following:
-That DOCTOR A is a well trained and qualified physician acting within the standard of care (and that pre-existing conditions like Morbid Obesity and other factors were causes of death)
-That DOCTOR B is a well trained and qualified physician acting within the standard of care (and that no infection existed or developed under his care)
-That DOCTOR C is a well trained and qualified physician acting within the standard of care (and that the eventual death of multi-organ failure at HOSPITAL Z were caused by pneumonia and factors successfully managed under the care of DOCTOR C while at HOSPITAL Y)

We, the Jury, had to rule on the three Defendants on an individual basis.
For each doctor: we had to either rule in favor of the Plaintiff (against the defense) or rule in favor of the defense (against the Plaintiff).
In order for a ruling in the Plaintiff's favor, all three statements had to be true for a specific doctor
1. The doctor was professionally negligent (defined as a deviation from the standard of care a reasonably well qualified physician would provide).
2. The doctor's care was harmful to the patient.
3. The doctor caused injury (in this case death - in any way) to the patient.

We, the Jury, instantly and unanimously agreed that DOCTOR A was not negligent. Therefore we did not discuss the merits of asking questions 2 & 3 because as soon as #1 was agreed to be false, we had to rule in favor of the Defendant.

DOCTOR B was evaluated in nearly the exact same fashion. None of us believed there was a deviation from the standard of care and thus ruled in favor of the Defendant.

The majority of our deliberation in the Jury Room was in reference to DOCTOR C. Some of us believed that DOCTOR C may have caused harm to the PATIENT, however we all agreed that the alleged harm did not lead - in any way - to the eventual death of the PATIENT. By rule, this lead us to file in favor of the Defendant.

Punitive damages were only to be discussed in the instance if we filed in the Plaintiff's favor for any of the three cases. (Point of curiosity: the Plaintiff's attorney asked us for $1 to $5 million dollars)

Hopefully I have provided more than ample material. If you want any more details from this case, let me know.

My next post will be more entertaining, for I will try to paint you all a picture of the characters involved in this case (both inside and outside of the Jury Room).

1 comment:

  1. Law and Order has nothing on this. Nice recall--especially impressive since your notes were destroyed and a lot of medical jargon was involved. I can't imagine administering a central line on a 450 pounder. That can't be very easy to do. I think weight played a heavy role in this man's death, pun partially intended, but no offense meant to the deceased. It's scary what happens to people over time, isn't it? Anyway, congrats on reaching a verdict and fulfilling your civic duty. It sounded laborious but rewarding at the same time.