But, you ask, what about California’s $250,000 damage cap? That’s for damages related to pain and suffering. The $67 million, according to Ritter’s family and their lawyers, represents “actual” damages---money they say Ritter likely would have made over the next several years given the projected success of his acting career.
I blogged about this a couple of years ago. At that time I maintained (based on what I could glean from news reports) that Ritter’s presentation was more suggestive of myocardial ischemia or infarction than aortic dissection, that he did not exhibit risk factors for dissection and that his doctors acted appropriately on the clinical information they had. Although new reports from the past couple of weeks suggest some twists and turns in the story I still maintain (to the extent that one can believe newspaper reports) that Ritter’s doctors acted appropriately.
Let’s look at some of the clinical issues. According to the Los Angeles Times report the chest x-ray Ritter’s doctors ordered in the ER was not done in a timely manner (or not done at all). By the time the doctors realized this, apparently, Ritter had destabilized and they, acutely aware that time to reperfusion means less opportunity to salvage heart muscle and save the patient (one study suggests a mortality increase of 0.9% per minute of delay), were scrambling to get him off to the cardiac catheterization laboratory. That seems reasonable from where I sit, but important issues to be hammered out include the value of plain chest radiography (a portable chest x-ray done under less than optimal conditions, at that) in the initial evaluation of patients with aortic dissection. What are the positive and negative predictive values? Are they good enough to have averted Ritter’s trip to the cath lab? At the rate Ritter was deteriorating, would there have been time for a CT? Would the CT have diagnosed Ritter’s dissection any more rapidly than his doctors were able to do during cardiac catheterization? Aortic angiography, a part of cardiac catheterization, is a test used to diagnose acute aortic disease and, according to the LA Times report, revealed the dissection:
He also quickly planned a cardiac catheterization. During the procedure, Ritter's condition worsened and a large aortic dissection was found.
The article also notes:
Around 7:15 p.m., a test showed abnormalities that the doctor thought were consistent with a heart attack. Lee, who was on call, was at Ritter's bedside at 7:25 p.m.
What were those abnormalities? Were they biomarkers? Electrocardiographic signs? How specific were they? Did they suggest the “acute coronary syndrome” pathway (aspirin, anticoagulation, cath lab) as an appropriate course of action?
And what about the CT scan Ritter received 2 years earlier? The plaintiffs contend Ritter’s aorta was enlarged then; the defense experts say it wasn’t. What was the diameter of the aortic annulus? Did it exceed a threshold for follow up imaging or even elective surgery?
Do the answers to these difficult and complex questions satisfy the burden of proof that a different course of action, according to a reasonable standard of care, should have been taken and that such action would have saved Ritter’s life? It seems a real stretch to me provided the issues are given an objective analysis. But comments from Ritter’s widow suggests she’s hoping for an emotional verdict:
"You can't treat my kid's dad for something and kill him in the process," she said."I think the money will show how angry the jury will be about what happened to John and what could happen to them."
If anything near that amount of money is awarded it will send some not so healthy messages, one of which concerns how we should treat VIPs. As the LA Times article points out concerning the case:
It also will highlight how differently malpractice lawsuits play out when the alleged victim is wealthy. Ritter, best known for his starring role as Jack Tripper on "Three's Company," was an actor with tremendous earning potential, the plaintiffs' lawyers say. Because of his subsequent success on the series "8 Simple Rules for Dating My Teenage Daughter," his family is asking for more than $67 million in damages -- a stratospheric sum compared with most such claims.
Ritter’s wife goes on to suggest her motivation is to help others:
Yasbeck said she knows the trial will provide a public airing of Ritter's health and potential wealth and attract plenty of media attention. She said she hopes it also will bring awareness to aortic diseases."It's never comfortable, but the idea of the awareness that this brings to the issue trumps that," she said. "My discomfort is nothing compared to people who are losing their family to aortic dissection. I can be uncomfortable for however long the trial goes. I'm ready."
And if she should decide to donate the proceeds of this legal action to the American Heart Association it would trump a great deal of cynicism that’s bound to follow any claim that it’s “not about the money.”