Washington DC Metro Medical Malpractice Lawyer Blog

Stein, Mitchell, and Muse, LLP represented the family of a deceased sixteen-year-old eleventh-grader who developed acute abdominal pain associated with constipation and vomiting. This teenager was brought to a local emergency room by her mother in acute distress with abdominal pain, abdominal distension, and a three-week history of constipation. The young lady was seen by an emergency room physician who, within ninety minutes of her arrival, diagnosed her with acute abdominal pain, obstipation, and fecal impaction. Her symptoms included "nausea and vomiting" and "crying with pain." Her laboratory studies demonstrated a mildly elevated WBC and mildly abnormal liver enzymes.

An attempt at disimpaction was performed without success by the emergency room physician, who ordered two Fleets enemas which also failed to relieve the fecal impaction. In view of the patient's symptoms of abdominal pain, distention, and leukocytosis (elevated white blood cells and bands which are indicative of infection), the standard of care required that a surgical consultation be obtained STAT. Instead of a surgical consultation, the patient was evaluated by a pediatric team consisting of medical student and a resident who documented the presence of hypoactive bowel signs, severe distension, diffuse enlargement of the abdomen, guarding, tenderness to palpation, pain upon any movement of the torso, and stool in the right lower quadrant. The attending pediatrician wrongly concluded that the patient's abdominal condition was essentially unchanged from her initial presentation to the emergency room and that she did not need a surgical consultation. The patient's condition continued to worsen, and by 6:00 p.m. it was noted that her abdomen was "very distended up to the breasts." Her level of consciousness deteriorated and by 8:30 p.m. she was noted to be difficult to arouse. At 8:40 p.m., a code blue was called due to a cardiorespiratory arrest. Cardiopulmonary resuscitation with mask ventilation was initiated but not before the patient had gone into multi-organ system failure with metabolic and respiratory acidosis, kidney failure, and sepsis, with a principal diagnosis of bowel perforation and septic shock. An exploratory laparotomy was finally performed at 1:30 a.m. and she was found to have extensive fecal material in her colon. She was pronounced dead at 2:21 a.m. An autopsy disclosed that the cause of death was necrosis/autolysis consistent with toxic megacolon, with secondary cerebral and cerebellar edema.

No request was made for a surgical consultation. As a result, no surgeon saw the patient until after she went into a cardiorespiratory arrest secondary to fecal impaction and colon perforation. A timely exploratory laparotomy would have resulted in the removal of the fecal impaction and cured the gastrointestinal obstruction. Thus, a timely surgical consultation certainly would have saved the patient's life.

As technology keeps changing, with new features appearing almost constantly, more and more everyday written materials are becoming digitized, including records generated by hospitals, physicians, and other healthcare providers. The benefits of electronic medical records (EMRs) include:

• Readability - No more attempting to decipher doctors' handwriting, which is often notoriously illegible.
• Accessibility - Many EMR programs can be accessed from any computer. Thus, if a patient calls after hours, a doctor can easily access the patient's medical record. This can be pivotal when prescribing medications urgently, needing to review allergies or medical history, etc.
• Privacy - With paper charts, all records were frequently in one place, and anyone with access to your chart could view your complete medical history. EMRs can better protect such information. For example, a physical therapist writing progress notes into an old paper chart could see all its contents, but with EMR safeguards a patient can make available to that therapist only the records relating to physical therapy.
• Communication - While a nationwide medical record database has not yet been established, mainly due to privacy concerns, EMR systems used by most medical centers are integrated among specialties. So if a patient receives care at an emergency room, then later consults a neurologist at the same hospital, followed by an orthopedic surgeon, each successive provider in that system can access the patient's data as necessary. This obviously enhances effective treatment.
• Organization - Most EMRs are organized so that information is easier to find than in the older-style paper charts.

But EMRs are not flawless. Some EMR systems use templates intended to simplify data input, and a patient's physical-exam data entered on one visit can easily be transferred to subsequent visits which did not include a physical exam. Thus, EMRs may reflect outdated symptoms or treatment, creating an inaccurate record. This "check-box effect" can render a key evidence source factually incorrect, undermining a patient's claim for medical negligence.

Ultimately, it is up to patients to ensure the accuracy of their medical records. You can and should request a copy of your medical records, review them carefully, and point out any mistakes to your healthcare provider. If you or a loved one may have suffered an injury due to improper medical care or inaccurate medical recordkeeping, contact an attorney at Stein, Mitchell, and Muse, LLP for a free consultation.

By Michael Cohen, M.D. and Gerard E. Mitchell, Esq

The most common symptoms presented to family physicians and other primary care practitioners are complaints of headaches. Who doesn't have an occasional headache? A general practitioner with 2,000 patients will probably have 300 patients present with complaints of headaches each year. What causes headaches, and what can be done about it?

Headaches can be caused by all anatomical sites, organs and tissues of the head. Headaches can also be located in different parts of the head -- in the forehead, the back of the head (deep or superficial), originating from the eyes, ears, emanating from the throat, or sinuses.

Headaches can last all day long. Or they might only occur in the evening. Sometimes they wake you up in the morning, or your headache begins right after you wake up. Some headaches appear only on weekends. Sitting in front of a computer or watching television brings on headaches in some people. Maybe your headaches begin only when the weather is very cold or hot. Loud noises might be the culprit. Or all of the above! Finally, headaches can be associated with additional symptoms like nausea, vomiting, light sensitivity, or noise intolerance (not necessarily loud noise), and can cause anxiety and depression. Headaches can interfere with work, recreation, the most basic maintenance of daily life, and one's basic duties and tasks.

Your physician will begin by taking a good history, and about 75% of headaches can be reliably diagnosed if the physician can elicit this information from the patient. Physicians are trained to assess the cause by the characteristics of the headache. In the majority of these headaches treatment is proposed by your physician, and it may result in excluding certain foods and drinks, beginning with common irritants like chocolate, coffee or cheese. Allergies causing headaches can also be narrowed down by certain relatively easy measures like avoiding some animal products or certain garments. In some patients medication can also help if carefully thought out and carefully used. In 25% of patients with headache complaints, the patient needs further studies and evaluations to arrive at the proper diagnosis before treatment can be instituted.

Headaches can emerge from serious diseases, such brain cancer or a severe brain infection, or even intracranial bleeding. Imaging with a CT scan or MRI can lead to findings of the cause of the headache when the headache is due to a process which changes brain and skull anatomical relations and appearances.

General hematological and biochemical studies are also important. Anemia can cause headaches in a young menstruating woman, resulting from excessive menstrual bleeding. Once corrected, the pain will resolve. Viral hepatitis can raise liver enzymes and this can lead to severe headaches as well. Allowing the disease process to go through its natural cycle, or obtaining treatment as with Hepatitis C, will typically lead to resolution of the headache. Headaches can be caused by tension at work, and reducing stress levels often results in significant gains and frequently in the resolution of the pain.

Treatment of headaches has to be prescribed with the utmost care and with a clear plan to comply with the Hippocratic oath of "First do no harm," because many of the anti-headache drugs are toxic and have serious side effects. For example, several migraine headaches are treated with drugs that may cause bone marrow suppression and even death. In cluster headaches patients are occasionally treated with steroids, frequently with poor indication and serious adverse events. Beta-blockers and anti-epileptics are also prescribed with poor indications. Also, in headache treatment more and more chronically afflicted patients are referred to interventional invasive therapies. These include the use of electrical stimulators and local nerve treatments. In some patients treatment is provided by surgeons, typically a neurosurgeon, or by an ENT specialist, an ophthalmologist, or a pain specialist.

All these treatments present opportunities but they all also carry significant risk of failure. When patients experience failures in treatment, the consequences can be severe for the patient. Inappropriate surgical procedures can result in paralysis of facial muscles or neuro-ophthalmic injuries to the eyes or sinuses. Strokes may also result from local injections of drugs that may be transported to the central nervous system.

If you have been injured in the course of headache treatments you may want to consult a lawyer who is experienced and knowledgeable in the evaluation of the applicable standards of care and consequences of failed headache therapies.

Part 1

Despite recently-implemented policies and procedures to prevent it, reports of wrong-site surgery (e.g., amputating a right leg when a left leg should have been removed) still occur. The Joint Commission (JC) - a not-for-profit group that accredits the nation's hospitals - estimates that wrong-site surgeries occur around 40 times per week. The number of cases reported to the JC nearly doubled from 2004 to 2010. Please note that this number includes only reported cases, since approximately half of the states in the U.S. do not require hospitals to report cases of wrong-site surgery. Therefore, it is difficult to pin down the real number of cases.

A study noted that only one in three of these reported cases resulted in a medical malpractice case. There are a multitude of reasons for this, but - for starters - tort reform and damage caps make it difficult if not impossible to pursue cases where injuries are not severe enough to warrant the time and expense of litigation. It is often said that these reforms and caps are in place to drive down costs and help consumers, yet healthcare costs have continued to rise, as have reports of medical mishaps.

The Joint Commission approved a Universal Protocol for Preventing Wrong-Site, Wrong-Procedure, and Wrong-Person Surgery in July 2003, which became effective and mandatory for all accredited hospitals, ambulatory care centers, and office-based surgery facilities on July 1, 2004. The three principal components of the Universal Protocol are a pre-procedure verification, site marking, and a pre-incision "time-out."

Despite the implementation of the Universal Protocol, wrong-site, wrong-procedure, and wrong-person surgeries continue to occur in U.S. hospitals at alarming rates. Some reasons for this may include the increased time pressure put on physicians, as well as their lack of willingness to adhere to "protocols" and their underestimation of their fallibility. In addition, many of these errors are the result of simple oversights - failing to double-check imaging reports, not displaying imaging in the operating room, ensuring that x-rays are not flipped backwards, failing to double-check that the correct patient is on the operating table, or failing to take the required "time-out" or doing it halfheartedly or lackadaisically.

Email is used by nearly everyone in the United States -- from you to your family, friends, coworkers, and perhaps even your physician. Many physicians now send your prescriptions electronically to your pharmacy so when you arrive, you are spared the 20-30 minutes of waiting for the pharmacist to fill your script. Do you feel that your physician would pay more or less attention to you if you communicated with your doctor electronically, as a follow-up to a recent office visit?

Your physician is the same healthcare provider who cared for your now deceased father, so you feel comfortable and fortunate being his patient. Some of your health issues include hypertension, obesity, cardiomegaly, gastroesophageal reflux, asthma, chronic bronchitis, and high cholesterol. Your healthcare provider runs annual laboratory tests and orders radiological studies. You, and certainly your doctor, know you are at high risk for cardiovascular disease, however, you are not referred for a comprehensive cardiac workup. Your physician referred your father to a specialist, who received appropriate cardiology management, and he lived to his mid-eighties. However, you are not prescribed an appropriate medication regimen despite persistent laboratory abnormalities and serious cardiac signs and symptoms that worsened over time.

You and your physician exchange multiple emails. You state your concerns about new onset symptoms over the past few weeks of chest pain and pressure, fatigue, clamminess, diaphoresis (perfuse sweating), and elevated blood pressure readings. The doctor replies by email that everything is fine and no treatment or evaluation is necessary. Shortly thereafter, you suffer a fatal cardiac arrhythmia and myocardial infarction and are pronounced dead.

Given this man's serious family history, is trusting examination by email the best way to practice medicine? He placed his trust in the physician, having been reassured several times that there was nothing to worry about. Had he not been reassured, it was highly likely that he would have made an appointment, seen his doctor face-to-face, and hopefully the doctor would have examined him and referred him to a specialist.

As far as we know, email and texting haven't yet taken the place of a personal in-office visit, and hopefully it never will.

Laurie A. Amell, Esq. is a partner with the law firm of Stein, Mitchell, and Muse, LLPShe is also a nurse, and is listed in Best Lawyers of America, Super Lawyers, and is the Past President of the D.C. Trial Lawyers Association.