Everything Is Not As It Seems

It was a warm day on a long July 4^th holiday weekend when 39-year-old William[i], his wife, Carrie, and their two sons decided to go hiking on the family’s property where they intended to build a new home.  The site was undeveloped and mostly flat except for a steep ravine on the rear side of the parcel.  They began to walk the property around noon. As they gazed down into the ravine, William and one of his boys decided they would hike to the bottom and back up.  William, at 260 pounds, was technically obese, but he felt that he could make the trek up and down the ravine.  Carrie decided to wait at the top.  At approximately 2:00 p.m., as he was climbing back up the hill, William developed numbness and tingling in his legs and had pain in his back.  Carrie and one of her sons ran to a neighbor’s house to get help.  The neighbor helped Carrie get William into their truck, and Carrie rushed him to the hospital.

An Emergency Department nurse examined William at approximately 4:01 p.m.  William reported to the nurse that prior to arriving at the hospital the feeling had come back in his legs, and the tingling had gone away.  He described that there had been bilateral pain in his hips, but this had resolved by the time he reached the ED.  He stated he had experienced no nausea or vomiting.  Although not entirely clear from the hospital chart, he may have had some abdominal discomfort at the time he developed the other symptoms. William also reported to one of the ED nurses that he had a “weird feeling in the center of his back after the tingling resolved.”  It was unclear whether the complaint of abdominal pain had resolved itself before or after arrival at the ED; however, a nurse’s note at 4:01 p.m. stated that William was alert and oriented and denied any pain.

Dr. Kindly came in to examine William at 4:15 p.m., approximately one hour after his arrival at the ED. William told Dr. Kindly about having pain in his low back at the midline of the lumbar area, although it is not entirely clear whether that complaint had already resolved itself by the time she saw him.  Dr. Kindly does not believe she was told about the “weird feeling in his back” by the nurse and does not believe she saw the nurse’s note. 

Dr. Kindly noted that there was no significant past medical history other than a hernia repair.  She checked William’s general constitution, respiratory, cardiovascular and gastrointestinal systems, and performed a bilateral straight leg raising test because of the complaint of bilateral hip pain and low back pain.  The straight leg raising test was negative bilaterally, even though he had complained of some midline lumbar tenderness.  Dr. Kindly ordered a lumbosacral x-ray, which she read personally.  The x-ray revealed no fractures or destructive lesions; however, a first degree spondylolisthesis of L5 and S1, with bilateral spondylytic defects at L5, was detected and verified by a radiologist the next day.  William was discharged that evening with instructions to take a muscle relaxant three times a day and an over-the-counter anti-inflammatory medicine three times a day as needed.  He was instructed to follow-up with his regular physician if his symptoms persisted or return to the ED if the symptoms worsened.

After arriving home, William ate supper and went to bed early.  Carrie went to work the next day, and when she returned home, she said he appeared sleepy.  William took a short walk out in the yard but came back in complaining his legs were becoming numb and tingly again.  She had him sit until the symptoms cleared.  Later they went to bed; Carrie awoke at 3:00 a.m. and found William asleep on the couch.  She woke him and urged him to come back to bed.  He said he did not feel well and would sleep on their son’s bed.  She left for work at 6:15 a.m. and observed him sleeping on her son’s bed.  She spoke to her son around 1:30 p.m. and asked how his dad was doing.  The son reported that his dad had been sleeping all day.  She asked her son to check on him, and he reported that his dad looked blue and was not breathing.  She instructed her son to call 911; Carrie also called 911 and then immediately drove home.  When she arrived home the emergency team told her, “He’s gone, and there was nothing we could do.”

Carrie, who is a registered nurse, requested an autopsy several weeks after her husband’s death.  The autopsy report stated that the cause of death was aortic dissection.  Carrie filed suit against Dr. Kindly and the hospital.  She testified at trial that she told both the nurses and the ED physician that her husband normally had high blood pressure and that his blood pressure taken in the ED was very low for him (112/59).  She (and her expert) testified that based on the low blood pressure and the complete loss of use of his legs shortly before arrival at the ED, Dr. Kindly should have checked William’s pulses in both legs and obtained at least one more blood pressure reading.  Further, her position was that these findings dictated that Dr. Kindly should have called in a vascular surgery consult and ordered a CT or MRI which would have found the aortic dissection

Dr. Kindly and her experts testified that a person with a dissecting aorta would have severe pain in the chest or back area at the level of the dissection.  The pain would be so unrelenting and excruciating that it would require narcotics to dull it.  Our emergency medicine expert testified that he has dealt with dissections his entire career and has never known a case that did not cause severe pain.  William never complained of such pain while in the ED.  Our experts also testified that the history, taken by Dr. Kindly and the nurses, was thorough and proper.  Based on this, Dr. Kindly would not have been expected to order a CT or MRI or order a cardiovascular consult. 

After deliberation, the jury came back with a defense verdict for Dr. Kindly and the hospital.  The plaintiffs presented a highly sympathetic scenario, which included a young son discovering his deceased father in bed.  In spite of the sympathy, the jury was not convinced that our doctor was negligent when she failed to suspect a dissecting aortic aneurysm from symptoms that led her to a different conclusion.  The strength of Dr. Kindly’s testimony and documentation, coupled with solid expert support, led to the defense verdict.

[i] All names have been changed