Facts

On April 30, 2006, the patient, a then 36-year-old married truck driver, was admitted to Huntington Memorial Hospital through the Emergency Department with congestive heart failure and shortness of breath. A CT angiogram performed in the ER to rule out pulmonary embolism revealed cardiomegaly and several enlarged mediastinal lymph nodes. The patient's prior medical history includes ongoing treatment for tuberculosis, diabetes mellitus and cigarette smoking. An echocardiogram performed soon after admission revealed diffuse hypokinesis consistent with a cardiomyopathy and an ejection fraction of approximately 30-35 percent.

On May 2, 2006, the internist, infectious disease specialist and pulmonologist opined that the differential diagnosis for the enlarged lymph nodes included disseminated tuberculosis, infection, including possible HIV, and neoplasm. Therefore, they recommended a lymph node biopsy by way of a mediastinoscopy.

On May 3, 2006, while still hospitalized, the patient was seen by a cardiothoracic surgeon who agreed with the assessment that the possible causes of the enlarged lymph nodes included infection and cancer. He too recommended a mediastinoscopy and in fact, consented the patient for the procedure on this date. His plan was to perform the biopsy the following day. Also, on May 3, 2006, a Adenosine Cardiolite stress test was performed, which was negative for ischemia and chest pain. However, the imaging portion of the study suggested that there were several areas of prior infarctions and an ejection fraction of 20 percent.

On May 4, 2006, defendant Dr. Vyshali Rao, M.D., a interventional cardiologist, was asked to see the patient. Her consultation took place about four to five hours prior to the mediastinoscopy. She added two cardiac medications to patient's medical regimen. In addition, Dr. Rao opined that the possible causes of patient's recently diagnosed cardiomyopathy was infectious, ischemic or idiopathic in nature. Finally, Dr. Rao's plan at this time was to await the results of the lymph node biopsy and to continue to follow the patient with the team.

Several hours later, the patient underwent the mediastinoscopy (lymph node biopsy). There were no complications during the procedure. However, immediately after the patient was extubated, he suffered a cardiopulmonary arrest. He was resuscitated but he did not regain consciousness. On May 6, 2006, the patient suffered another cardiopulmonary arrest, which was fatal.

An autopsy revealed triple vessel coronary artery disease and a hemorrhagic septal infarction. The coroner listed the causes of death as congestive heart failure, ischemia, and arteriosclerotic heart disease.

PLAINTIFF'S CONTENTIONS:
The plaintiffs contended that given the decedent's coronary artery risk factors, his presentation to the hospital with a primary cardiac problem and the evidence of prior infarctions on his stress test, the standard of care required that Dr. Rao not clear the patient for the mediastinoscopy until he underwent a coronary angiogram. In addition, they alleged that had an angiogram been performed, decedent would have undergone bypass surgery and the subject death would not have occurred.

DEFENDANT'S CONTENTIONS:
The defendant contended that her care and treatment of decedent under the circumstances was at all times within the applicable standard of care. In addition, defendant alleged that nothing she did or failed to do caused the subject death.

Settlement Discussions

No formal offer was made by plaintiffs on Dr. Rao prior to or during trial. A C.C.P. section 998 offer to waive costs in exchange for a dismissal was made by Dr. Rao approximately nine months prior to trial.

Damages

At trial, plaintiffs' put into evidence past loss of wages, household services and funeral and burial expenses totaling $104,495 and future loss of wages and household services totaling $800,730. In addition, plaintiffs claimed $250,000 in general damages.

Result

Defense verdict.

Other Information

Prior to trial, a number of named defendants were dismissed, including the treating cardiothoracic surgeon. EXPERT TESTIMONY: Stuart Fischer, M.D., testified that Dr. Rao negligently failed to recommend and perform a cardiac catheterization prior to the patient undergoing a mediastinoscopy (lymph node biopsy). The standard of care required that an angiogram be done prior to the biopsy because the decedent presented with a primary cardiac problem (congestive heart failure and cardiomyopathy of unknown origin, had several key risk factors for coronary artery disease including cigarette smoking and diabetes, and had a significantly abnormal Adenosine Cardiolite stress test. In addition, Dr. Rao negligently cleared the patient for the proposed surgery despite not establishing the underlying cause of decedent's cardiomyopathy. The standard of care, under the circumstances, was that the cardiologist should have presumed that decedent had coronary artery disease until proven otherwise. The other medical physicians involved with decedent's care and treatment prior to the mediastinoscopy were, in essence, relying on Dr. Rao's recommendation whether or not to proceed with the procedure. On the issue of causation, Dr. Fischer opined that had decedent undergone a coronary angiogram it would have revealed triple vessel coronary disease and the patient would have undergone bypass surgery prior to the mediastinoscopy thereby preventing the post procedure cardiopulmonary arrest and death. This opinion was based in part on the autopsy results, which revealed three-vessel coronary artery disease. Phillip H. Allman, Ph.D., testified that the present value of plaintiffs' past loss of earnings and household services was $90,495 based on the assumption that had decedent survived the hospitalization at issue, he would have returned to work as a truck driver by September 2006. Based on a 30-year life expectancy, plaintiffs' expert testified that the present value of the future loss of earnings and household services was $800,730. Michael Chaikin, M.D., testified that the standard of care did not require a pre-surgery cardiac catheterization under the circumstances. In addition, Dr. Rao was not consulted to clear the decedent for the pending mediastinoscopy. As to the issue of causation, Dr. Chaikin opined that the unexpected cardiopulmonary arrest immediately after the mediastinoscopy was due to decedent's adverse reaction to epinephrine and the administration of 1700 ccs of intravenous fluid.

Deliberation

55 minutes

Poll

9-3 (in favor of Rao)

Length

five days