Monday, February 04, 2008

I’ll take $67 million to go with that, please!

To go with what? To go with the $14 million John Ritter’s family has already received in settlements following his death, according to the Los Angeles Times. In the upcoming malpractice suit, $67 million is the amount being sought from two doctors involved in Ritter’s care, one who read a CT scan in 2001 and another who treated Ritter the night of his death in 2003.

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.”


Anonymous said...

There is not enough information to judge whether errors were made and, if so, how substantial they were. Whether there was a quick palpation of carotid, radial, and femoral pulses is not noted. This takes seconds and should be done in virtually all patients with chest pain. Marked pulse deficits may provide a strong indication that dissection may exist. Was heparin begun before this simple procedure? The failure of ancillary hospital staff to promptly perform tests ordered by a physician is no surprise. However, make a stink about it and you may find yourself running afoul of some kind of Orwellian "disruptive physician" policy.

All the facts are needed. That said, aortic dissection is very difficult to diagnose and can be missed by competent physicians. I suspect that Ritter's physicians treated him appropriately.

MD in Texas

Dan Walter said...

I agree with you doc. Seems to me that the the physicians acted in good faith - unlike what happend to my wife at Johns Hopkins. Dr. Hugh Calkins told us HE was going to do a procedure. But he let a trainee perform the procedure without our knowledge or consent. My wife nearly died. We're not rich or famous, so we were not compensated for very real losses.

The Happy Hospitalist said...

What's happening here and thousands of times a year all throught out the country is lawyers and families are suing a differential diagnosis.

Aortic dissection is but one of many possible diagnosis that can present in very similar ways, both clinically and often times objectively.

It is not rare that treatment of one condition of high suspicion can cause harm if another condition turns out to be the diagnosis.

Classic example.

Medicine will never be a 100% infallable diagnostic tree. All diseases present in different degrees of severity and in different degrees of complaints. To fault a physician, in their best clinical judgement with the data they have and training and experience to act on objective data is a major driving point of unsustainable defensive medical practices today.

What if John had a brain tumor and his blood thinners used to treat suspected coronary disease caused him to have a massive stoke and die. Should a doctor be sued because he did not know the patient had a brain tumor?

What if John had pericarditis, and recieved blood thinners. What if he bleed into his pericardial sac and develped tamponade and died.

What if John recieved his blood thinners for suspected coronary disease and developed a massive gastrointenstinal hemorrhage from an unknown colon cancer and bleed out before any possible intervention could save his life.

What if John recieved his blood thinners for suspected coronary disease and developed HIT syndrome and developed massive pulmonary embolisms because of that and died.

What if

What if

What if

As long as as medical malpractice lawsuits are allowed to come to merit with a basis of failure to diagnose as the basis of the lawsuit, the over proceduralization, over imaging and over testing of our population will continue to bank rupt the nation.

It is not malpractice.

It is an acceptable margin of error in the practice of an art that has a field of greys and very few black and whites.

Clinical medicine affords probabilites. It is full of statistics. Normal lab values are based on standard deviations of the mean. Cancer outcomes are based on population statistics. All therapies, interventions, outcomes come with their own expectations, and outcomes data.

Evaluating a patient for the presence of disease is no different. There are probablities built into the most likely diagnosis and decision making, which often times must be made based on seconds and minutes. These decisions based on most likely probability and most likely explanation must be immune from hungry lawyers and families that don't get it.

They simple don't get it.

Its sad that John died. It's sad that the diagnosis was not first on the list. It's sad that two specialists who spent years in training, managing hundreds of cases just like this could be fooled into the wrong top differential on the diagnosis.

It is not the first time this will happen and it isn't the last. Medicine is not an exact science. Until physicians are afforded some protection from their ability to practice medicine, and not defensive medicine, threat of lawsuit will always be a main driving force for ALL evaluations, no matter how unlikely the diagnosis.

I suspect that ER doc and that cardiologist treated John exactly like they would have treated their own wife/husband/daughter/son/mother/father.

Dan Walter said...

Well put.

Anonymous said...

The happy hospitalist is right on the money.A lot of doctors practice defensive medicine.Obtaining ct scans and MRI when the patients have no clinical findings.These tests lead to more tests and causes anxiety to the patient.It is time to fine the attorneys who bring lawsuits that are not justified.

Anonymous said...

" My wife nearly died. ... we were not compensated for very real losses."

I nearly died in a traffic accident some 20 years ago. I can't think of any real losses because the keyword is "nearly".

What losses does a person suffer when something almost happens.

I wonder not only because of your statement, but because of the mega-suit filed by the famous celerity couple whose child was given either the wrong dose or overdose of a drug. Apparently there were no lasting health effects on a child.

Should a person be compensated for worry and fear? (That would be great news for me; as a motorcycle I am "almost" killed and caused great fear several times a week)

Dan Walter said...

Well, "nearly killed" doesn't convey it all.

What happened was that the "attending physician" had let a trainee perform a pulmonary vein ablation procedure. The attending is on record as telling colleagues that at teaching hospitals such as Johns Hopkins, "the attending shows up to be there during the burn." (Which came as news to my wife and me).

So the trainee manipulates a Biosense Webster circular mapping catheter into the left ventricle of my wifes heart. (It says on the box to not do that).

The mapping catheter gets tangled in the mitral valve muscles of my wife's heart. This from the record:
“only the first 50% of the circular portion of the catheter tip could be withdrawn into the sheath and pulsatile motion could be appreciated.”

So they're trying to pull the catheter out, but it's tugging back like they've got a ten pound bass on the line. A nurse notes here that the "patient is waking and moving around, with chest pain @ 7/10."

They call in an expert who decides to roll the dice and just give the catheter a good hard yank. (It says on the box not to do that).

According to the record, the catheter is "suddenly free." This was accomplished by tearing two chordae tendinae and ripping a papillary muscle from its base.

So now she's in acute congestive heart failure with an oxygen mask and plummeting blood pressure. By this time the attending shows up and notes for the record that my wife's mitral valve was “flapping in the breeze,” and had “prolapsed into the atrium.” - and the docs decide to continue with the ablation procedure.

When they're done, they ship her to
ICU for observation, and it's not long before the folks there say we'de better do open-heart surgery to replace the valve or she's going to die soon.

So they do that. Then she is extubated too quickly, reintubated, suffers a stroke and goes into a coma.

She walked into Johns Hopkins under her own steam. She was a registered nurse and she owned her own business. Now she is permanently disabled.

Johns Hopkins says it was all just a complication. Not their fault.

Anonymous said...

Plaintiff's lawyer here (though I don't do med-mal-- because I don't want docs to hate me, and because I think so few of the claims are meritorious). I found the physician comments here very interesting and informative and stopped in to offer my $0.02.

I can't speak to the medical facts asserted but would like to add a bit of a lawyer's perspective without a dog in this fight.

First, if the plaintiffs settled with the hospital for $14 million, that is not a good reason for saying they should be barred from proceeding against the remaining defendants. Your post seems to mock them for this however; perhaps if they had a blog post entitled "I'd happily take another year to be alive and see my kids instead of my family getting all this money, please!" you'd see the other side of this. The income stream for someone pulling down several million a year is quite large; each side has economists, and if there is any question about whether the stakes are really that high that can be defended against in court.

Second, the lost-wage claim is not affected by the cap on non-economic damages, and is an elementary legal concept. It is not a novel invention of these plaintiffs and their lawyers, as you seem to suggest.

Third, I don't know what it proves to say the widow is "hoping for an emotional verdict;" I think it would be surprising if someone whose husband died was not emotional. The doctor defendants and their families are likely emotional about this case as well. Maybe they want an "emotional verdict" for themselves. Who cares? Court is about what you can prove. (Sort of you like in your field, I guess.)

Which ties in to my next point- the many medical unanswered questions, some of which were raised by commenters, may well be determinative. You can be certain that the doctors on trial, their highly competent lawyers, and the expert witnesses they retained, have explored each of them in great detail.

The best med-mal lawyers- and in a case of this size, you are looking at the cream of the crop on both sides- know a hell of a lot of medicine, some of them have MD degrees. The doctors are not lying down here in court.

Jurors are a good bit more sympathetic to doctors than some doctors fear. My wild guess about this case-- the hospital had some serious culpability, his -real- income expectation was 30 to 40 million, and both sides of this lawsuit -think- they have at least a 50-50 shot of prevailing. (As opposed to cases where one side says 'holy crap; I am screwed if I face a jury.') One side is right; one is wrong; we have no idea which one it is, because we have so few facts.

I wish the court transcripts were posted online.

Anonymous said...

Bravo to the docs and happy hospitalist's comments. You clearly know what you are talking about.

I suspect that the actual facts of the case will be posted.

What we do know from the AP, is that the Defense attorneys will provide evidence that Ritter had failed an insurance exam 3 years prior to the incident for "incredibly abnormal" blood levels. Triglycerides were 7 times normal. He had evidence of plaque build-up. He was advised to see a cardiologist. He never did.

For three years, Ritter repeatedly missed follow-up visits, did not get a cardiologist, worked long hours on the set and was decidedly overweight. When he became ill, he went to the ER.

When the Cardiologist arrived at the ER, a code AMI (acute myocardial infarction) had been called. "In that situation, you don't wait around for an x-ray," stated the defense attorney.

In court yesterday, according to ABC news, the plaintiff's Cardiac Surgeon (supposed unbiased expert) repeatedly stated he was testifying with a "heavy heart" against the Cardiologist. Yet, he said that the Cardiologist had provided substandard care by treating for a heart attack.

Upon cross examination, things became heated when it was revealed that the Expert had a conflict of interest. In fact, Ritter's wife, Amy Yasbeck, had spent time speaking at the Expert's symposium recently.

The Cardiologist's Defense Attorney also quoted from this Expert's OWN book that stated, finding an aortic dissection was like looking for a "needle in a haystack" and that (essentially) in malpractice situations, physicians should be given the benefit of the doubt because they are so difficult to find and so easily mistaken for a heart attack.

The bottom line is, the plaintiffs want money. Ritter's actress wife could not get life insurance before her husband died and now she is afraid that she will not be able to live "the lifestyle to which she had become accustomed."

Yasbeck keeps claiming the Cardiologist could have performed a simple x-ray to save her husband's life. The Cardiologist had arrived when the situation had deteriorated into an emergency. Long before this happened, an x-ray could have easily been done by Ritter's Cardiologist had Ritter not been negligent with his own life and bothered to see one.

To the attorney who posted earlier: sometimes doctors don't want to settle because they don't want to be blackmailed by frivolous lawsuits. Settling would imply that they had some culpability and also drive up their premiums. Instead of both sides thinking they had strong cases, maybe the doctors just wanted to clear their names and WOULD not settle.

Anonymous said...

John Ritter initially presented with nausea/vomiting and a normal ECG, then developed chest pain after arrival in the ER and after the initial examination. A second ECG showed evolving ischemia and that's when the cardiologist Dr. Lee was immediately called and arrived 10 minutes later. A CT chest angiogram, if ordered, would have taken at least 60 or more minutes to obtain. A portable chest xray was ordered by the ER physician, but because Ritter's condition was deteriorating, it was decided to expedite directly to the cath lab. The goal at Providence is door to cath lab within 30 minutes for suspected coronary syndromes. The AHA protocol is to immediately give integrilin/plavix as soon as coronary syndrome is SUSPECTED.

Ritter's presentation was not typical of dissection in that "tearing back pain" was not a component.

The fact is that with today's public expectation that physicians can save everyone no matter what circumstance, you're dammed if you do and dammed if you don't. If a CT were ordered, he would have died on the table with his dissection; if he had gone to CT and had an MI, his heart would have been damaged. Ritter's condition deteriorated so quickly, as many unsuspecting dissections do, that he had a record time transfer to the cath lab, at which time the aorta had dissected into the pericardium causing tampanade then catastrophic rupture of the aorta. Even if the dissection were known, he would have ruptured by the time the cardiothoracic team would have been ready to go in the OR (they're not in the hospital 24 hrs/day).

What's horrifying and the real story the public doesn't know is the ER physician group settled for $1,000,000 (policy limit)-not because they didn't think they could properly defense this case-which was completely defensible, but because the insurance company said if they lost to a sympathetic jury (and what gets more sympathy that a widow and 2 small children), the docs would be personally liable for the difference, perhaps tens of millions. The disgusting decision was obvious. Cut and minimize your potential losses. Even though the malpractice rate will increase by $250,000/yr for the next 4 years.

The hospital PR and lawyer recommended settlement to avoid the bad publicity from a protracted public trial but failed to include a gag on Mrs. Ritter who goes about touting she wants "justice". What would be justice is if she realized the tireless hours doctors spend trying to fix the broken bodies of patient's who have abused their bodies for years, or come to the ER with fatal illness. There are some people and conditions even the best of doctors can't save.

Fellow ER doctor

Dan Walter said...

This from Dr. Lisa Sanders, NYT

Anonymous said...

It is interesting. A family seeks $67 million for lost future earnings. What if Ritters life was saved? Should the docs involved be compensated in kind for preserving such a valuable life? Why is a leg lost to negligence worth millions when a leg preserved due to medical skill be worth a few thousand or less?

Anonymous said...

If celebrities expect perfection and universal good outcomes, then threaten our very livelihood with huge lawsuits that go beyond our malpractice coverage when they don't get it, why should we want to take care of them at all? How about this line: "I'm sorry Mr. Celebrity, I can't be your doctor. I am not adequately insured in the event you have an adverse outcome." The reward isn't any greater when we deliver the optimal outcome, but the liability apparently is magnified when we don't or can't. Even when they receive VIP treatment and expeditious care as it sounds like Ritter did, if that care goes down the wrong path, even for justifiable reasons, they behave as though we were egregiously negligent and need to be punished. No doubt the trial lawyers are fanning the flames of passion with the family because they see big dollar signs. I suspect they are the true villains here, and they are manipulating the wife.

Anonymous said...

I have read a number of medical issue blogs, and I must compliment those that wrote before me. Rather than the usual hysteria that I have seen (such as a year and a half ago when drug eluting stents seemed to be causing problems, and the number of patients and their relatives were screaming that the docs were just there to make money and if anything happened, their estates would sue everybody), I see reasoned and thoughtful entries.
To be upfront, I am a cardiologist, and have been in the doctor's position a few times. It is a very difficult diagnosis to make when the symptoms are atypical. When faced with an animal that looks like a duck and sounds like a duck, it is usually a duck...but not always. In medicine, we play the odds If someone has pneumonia, we think that penicillin is more likely to save the patient than kill him with an allergic reaction. To continue the animal analogy, we look for horses rather than zebras. The public should also know that the correct treatment for a heart attack is immediate transfer to the cath lab (if the hospital has one); if we had to rule out an aortic dissection with each patient, many of our heart attack patients would die or have much greater heart damage and disability due to the delay in bringing the patient to the cath lab. Hospital programs are judged and rated at how quickly the patient can have the artery opened; this alone should show the public how fast we must move. In cardiolgy, we have a saying: Time is Muscle. I believe the cardiologist should be applauded for having gotten to the hospital within 10 minutes of being called.
It was unfortunate that John Ritter had a dissection and not a heart attack. But just because he had a maloccurence does not in anyway suggest there was malpractice.
Finally, all of the news reports state how his wife cries and loses herself with grief each time his death is discussed in court. I would like the lawyer who blogged earlier to explain why that has any relevance to the case. A friend of mine recently died skiing and his wife was devastated, and had the same tears as Mrs. Ritter - but that in no way means she should sue the mountain to teach it a lesson. It appears to me that emotional outbursts should have no place in a court since the judgment should be made by reason and not because we feel sad for the plaintiff.

Dan Walter said...

speaking of cardiology:

bruce said...

Found this page via Google. I am looking for advice on finding good clinical negligence solicitors in the UK. I don't want to go with just the first one I find, ideally I want some reviews.