Medical Practice Case Study

Running head: MEDICAL MALPRACTICE 1

Medical Malpractice: Analysis of a Case Study

Name:

Institution:

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Presence of Elements of Medical Malpractice Case

The patient-physician relationship assumes the form of a contractual obligation (right in

personam) of the physician to provide medical attention whenever the patient requires relief.

This obligation is summarized in the form of the following tasks: (a) a legal duty of care in

determining whether to provide medical care, (b) duty of care in determining the nature of

treatment to provide and (c) duty of care in the provision of medical care. This obligation is a

legal duty that, if breached (right in rem), incurs judicial intervention (Pandit & Pandit, 2009).

Negligence assumes different forms such as active negligence, gross negligence, willful

neglect, or negligence per se. The latter can be defined as follows: “conduct…in violation of

statute…because it is so palpably opposed to the dictates of common prudence that it can be said

without hesitation or doubt that no careful person would have been guilty of it…a violation of a

public duty, enjoined by law for the protection of person or property…” (Pandit & Pandit, 2009).

A breach of any of the above three duties and the applicable standard of care constitutes medical

negligence. Negligence is deemed actionable if it was the direct and proximate cause of the

patient’s injury, meaning that an adverse outcome would not have occurred sans the sequence of

events (Gittler & Goldstein. 1996).

In proving causation of the patient’s injury, it is critical to assess whether the medical

practitioner deviated from the applicable standard of care. “Standard of care” refers to the bare

minimum of care that is generally acceptable by the physician’s peers under similar

circumstances. Failure to meet this standard must be demonstrated to have been the proximate

cause of the injury regardless of the practitioner’s geographical and specialist distinctions, in

which case expert opinion is required (Gittler & Goldstein. 1996). This rule is applicable for

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medical care procedures such as the rationale behind ordering and interpreting diagnostic tests

and the provision or withholding of care.

In this scenario, the health care provider failed to conform to the applicable standard of

care directly leading to injury (death) of the patient. In this scenario, the physician’s negligence

led to a number of violations, namely: mis-administration of methadone; failure to ascertain drug

abuse hx with the methadone treatment program; failure to institute blood transfusion to a minor;

failure to conduct toxicology and alcohol screening; and failure to monitor the patient for

neurological sequela and medication-related serum concentration.

Standard of Care: Death from Methadone Overdose

In this case, death from methadone toxicity is due to the following reasons. Firstly, the

physician failed to obtain a definitive and pertinent drug history before administering an opioid.

This failure in medical clearance is effectively mitigated by referring to electronic prescription-

drug program that the patient alleged he was in, the patient’s insurance provider or the detention

center from which he escaped from (Boyer, 2012). In addition to deferring to medical clearance,

an additional standard of care would be urine toxicology screening and serum alcohol testing.

Both serum alcohol and chlordiazepoxide (Librium) potentiate the CNS-depressant action of

methadone. The physician is also required to inform the patient of the possible risks of using

methadone, especially its prominent role in opioid overdose-related deaths due to respiratory

depression (Boyer, 2012). Once administered, the medical practitioner is required to ensure close

monitoring of both serum methadone concentration and respiratory function. Regular assessment

of respiratory effort should include oxygen saturation assessment and palpation and auscultation

to investigate the presence of pulmonary edema and strenuous respiratory effort.

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Standard of Care: Failure to Administer Blood

The physician failed, firstly, to administer blood to a patient that needed it and, once the

pt refused blood transfusion, the physician is not on record as having provided blood substitutes.

The minimum standard of care for patients that refuse blood transfusion would be as follows:

despite the legal implications of administering blood to a patient that refuses it, in this instance, it

was the practitioner’s duty to proceed in a fashion that would still deliver the very best care for

the pt especially since his injuries seemed survivable; and ensure close monitoring of the

isovolumic status, hemoglobin level and oxygen saturation (Chand, Subramanya & Rao, 2014).

These standards invariably mean that the practitioner should have considered administering

blood in that “golden hour” by obtaining the approval of the teenage boy’s parents or legal

guardians or by obtaining a court order that gave him/her the freedom to transfuse. Indeed, if the

patient refused consent for religious reasons, it may have been possible to explore the possibility

of acute hypervolemic hemodilution (Chand, Subramanya & Rao, 2014). However, due to the

exigent circumstances of this case, it was within the doctor’s ethical and legal duties to

administer the blood regardless, failure to which may expose him/her to criminal prosecution.

Secondly, the doctor should have expressly required regular monitoring and documentation of

vital signs at the observation department and medical-surgical unit.

Standard of Care: Subdural hematoma

It should have been evident to the physician that a single incident of blunt force trauma

such as the rapid deceleration of automobile accidents is sufficient to cause subdural hematoma

(SDH) (Logan, Bell & Leonard, 2001). The fact that the patient was intoxicated should have

hinted to even worse injury.

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The physician should have expressly required closer monitoring of vital signs, presence

of ocular palsy and papilloedema, serum oxygen saturation, urinary output, and level of

consciousness (LOC) and neurological status (q. 2 hours). The latter includes assessment of

reflexive patency, miosis, vertigo, confusion, slurred speech and Cushing’s triad, all of which are

proxies of intracranial pressure (ICP) (Logan, Bell & Leonard, 2001; Czosnyka & Pickard,

2004). Furthermore, the ED physician should have administered 80 g. Mannitol to protect against

an ICP surge, performed radiographic tests and referred the patient to a supervising neurologist

for specialist evaluation.

The Case for the Plaintiff: Arguments and Evidence

In arguing the case for the plaintiff’s family, I would posit that the care provided to him

was substandard and was the proximate cause of his death. Although the patient was alert at the

time of presentation, he was intoxicated and had just been rescued from a traumatic car accident.

If the physician had cared to perform toxicology screening (urine and serum tests), s/he would

have established that the patient had also ingested chlordiazepoxide (Librium) and would have

been more cautious in the administration of methadone, despite the intoxicated patient’s

protestations. Indeed, while it can be argued that the patient misled the physician regarding his

drug withdrawal treatment program, the physician is legally required to confirm drug history

from program records. Besides, as the patient was both a delinquent and engaged in underage

alcohol drinking, the practitioner should have practiced extra caution in taking the teenage

patient’s word as truth.

As the plaintiff’s legal representative, I would call on experts and respected practicing

physicians to demonstrate the typically accepted standard of care in this scenario. Depositions

would include how a pertinent history would have influenced medication, the legal obligation of

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a physician to provide homeostatic rescue of a trauma patient through blood transfusion and how

monitoring is a crucial part of the medical team’s responsibility. I would demonstrate that if there

were no negligence in history taking, negligence in diagnosis and treatment planning, and

negligence in monitoring, there would be no death from methadone overdose, failure to give

blood or blood substitutes and subdural hematoma respectively.

The Case for the Defendant: Arguments and Defense Options

In arguing the case for the defendant, I would posit that the standard of care provided was in line

with professional expectations and that comparative fault for the death rested entirely on the

patient. My strategy would be three-pronged: provide a character defense; demonstrate the

uncertainty of treatment protocols to guarantee relief; establish that the patient was to blame for

his death. I would call upon fellow treating physicians and nurses and past patients to testify as to

the bearing and credibility of my character. In cross-examining the defendant’s expert

testimonies, I would establish that there was no guarantee that a blood transfusion would have

saved the teenage boy’s life. Besides, since the boy was alert, seemed stable and denied

administration of blood, it can be argued that, firstly, it was impossible to anticipate such a rapid

deterioration in condition and, secondly, the patient had refused medical treatment (blood

transfusion). Lastly, I would argue that it was impossible to anticipate the teenager’s substance

abuse disorder which, firstly, provided no clinical rationale to conduct toxicology screening and,

secondly, was why it was not immediately evident that he had ingested the benzodiazepine

chlordiazepoxide.

Jury Findings

If I were a juror, I would have the following findings. Firstly, that if the proximate cause

of death were methadone toxicity/overdose, the physician was responsible for failing to ascertain

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the teenager’s drug history and failing to conduct a toxicology screening and that the patient was

partly to blame because he misled the treating practitioner. Secondly, that if the proximate cause

of death was the failure to administer blood, the teenager was to blame because he refused to

undergo blood transfusion, but the doctor was at fault for failing to provide blood substitutes and

failing to obtain overruling parental/guardian consent. Thirdly, that if the proximate cause of

death was subdural hematoma, the medical team was entirely to blame for failing to monitor the

patient closely.

Awards

If I were part of a jury that found the defendant guilty of negligent care, I would award

damages in the following manner:

1. Plaintiff’s legal costs to be covered by the defendant

2. Total settlement payment for death occasioned by negligent methadone overdose:

US$278,000.00

I would reduce the verdict amount because the patient/plaintiff had a 30% responsibility

for the overdose since he did not act reasonably in alleging that he was under treatment

for drug withdrawal. This deduction would reduce the plaintiff’s award to

US$194,600.00

3. Total settlement payment for death due to failure to administer blood and negligent

failure to administer blood substitutes: US$210,000.00

Although the patient refused medical treatment (blood transfusion), the physician erred

by failing to provide blood substitutes as he attempted to contact a parent or legal

guardian to approve the intervention.

4. Total settlement payment for negligent death due to subdural hematoma: US$310,000.00

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The medical team failed to provide close monitoring, despite the team’s failure to provide

blood substitutes to a trauma patient. This failure was the proximate cause of death and

the team’s fault (i.e. 100% comparative fault).

Scenario Overview if the Patient was an Adult

If the patient in this scenario was an adult, it seems plausible that a drug check would be

performed prior to administering methadone. Additionally, toxicology screening would likely

have been performed to ascertain the absence of drug abuse somatization. Furthermore, it is

possible that a consult would have been requested early in the admission process.

Nonetheless, if I were a juror, I would have still found the medical team liable for

negligence for the methadone overdose with a reduction in settlement fees of 30% as in the case

above. Also, I would have found the physician liable for failure to administer red blood cell

substitutes and, since he did not inform the patient about the risk of imminent harm that he faced

if he refused blood transfusion, entirely culpable for the client’s death without exception. I would

also have held that the medical team was solely responsible for death due to SDH.

Summary

In this scenario, a teenage trauma patient presented with no signs of acute symptoms of

injury and was admitted for observation. Although the patient was intoxicated, the ED doctor did

not order toxicology tests. Furthermore, despite the implied risk of death, the physician does not

provide homeostatic therapy and, remarkably, does not request a consult nor order radiographic

analysis. While in observation, there is no record of close monitoring. This death is a case of

negligent care with the exception that the teenage pt acted unreasonably by misleading his health

care provider.

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References

Boyer, E.W. (2012). Management of Opioid Analgesic Overdose. N Engl J Med, 367(2): 146–

155. doi: 10.1056/NEJMra1202561

Czosnyka, M., & Pickard, J. (2004). Monitoring and Interpretation of Intracranial Pressure. J

Neurol Neurosurg Psychiatry, 75, 813-821. Doi: 10.1136/jnnp.2003.033126

Chand, K., Subramanya, H., & Rao, V. (2014). Management of Patients who Refuse Blood

Transfusion. Indian J Anaesth, 58(5), 658-664. doi: 4103/0019-5049.144680

Gittler, G., & Goldstein, E. (1996). The Elements of Medical Malpractice: An Overview.

Clinical Infectious Diseases, 23:1152-5

Logan, S., Bell, G., & Leonard, J. (2001). Acute Subdural Hematoma in a High School Football

Player After 2 Unreported Episodes of Head Trauma: A Case Report. J Athl Train, 36(4):

433–436. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC155441/

Pandit, M., & Pandit, S. (2009). Medical negligence: Coverage of the profession, duties, ethics,

case law, and enlightened defense - A legal perspective. Indian J Urol, 25(3): 372–378.

doi: 10.4103/0970-1591.56206

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