Facts

On May 2, 2017, at around 10 a.m., the patient, Jane Doe, 37, presented to an internist. The internist noted that the patient had left arm and face numbness. The patient also complained of leg weakness and a headache that she described as 10/10 pain. She also had sensation of purple and white dots with loss of vision out of her left eye. The internist sent her to the emergency room.

The patient was admitted at defendant hospital around 11:46 a.m., where it was noted that she had crossed eyes and saw purple spots in both eyes. She also had the left facial tingling and weakness. She also complained of chest pain and shortness of breath. She was taking prednisone to treat lupus. The hospitalist obtained a neurologic consult and also ordered imaging studies.

A pulmonary CT Scan to rule out a pulmonary embolus revealed an incidental finding of an "aneurysmal dilation of the ascending aorta measuring 4.8 cm. Dissection involving the ascending aorta extending to involve the aortic arch." This was consistent with the wet read at 8:12 p.m., which reported an "ascending aortic aneurysm with dissection (type A)." An MRI of her head found a "small focus of restricted diffusion within the right temporal lobe [which was] consistent with acute ischemia/infarct."

The patient was transferred to one of defendant's other hospitals for a higher level of care. The cardiothoracic surgeon described the dissection as "subacute." The cardiothoracic surgeon noted that on examination, the patient's blood pressure in the right arm was 50 mmHg lower than the left arm. The right hand was also unilaterally "cool." On bedside echo, the cardiothoracic surgeon described the insufficiency as "only mild AI." The cardiothoracic surgeon decided that the patient had "passed the critical period" and decided against surgery. He decided to "let her heal and wait six weeks." At his deposition, the cardiothoracic surgeon explained that he was concerned about the patient's history of systemic lupus erythematosus, use of potent steroids, and the brain infarct that would make this patient an unacceptably high surgical risk.

Over a day after seeing the cardiothoracic surgeon, at approximately 1:11 p.m. on May 4, 2017, a Code Blue was called after patient's rhythm became asystole and non-responsive. Chest compressions were initiated by nursing staff and the patient was quickly and timely intubated by an anesthesiologist. An echocardiogram was performed and, according to the new cardiothoracic surgeon, "a new, large, pericardial effusion with evidence of cardiac tamponade physiology consistent with ruptured type A aortic dissection." In other words, the patient died from an aortic rupture secondary to the dissection. The patient remained pulseless and asystolic despite resuscitative medication and efforts and the time of death was recorded at 1:35 p.m.

She left behind two minor children, a 15-year old daughter and an 11-year old son at the time of her death.

PLAINTIFF'S CONTENTIONS: Plaintiffs claimed that the mortality rate in relation to Type A Aortic Dissections is extremely high and required an emergent surgery that could not wait. There is no such thing as "subacute."

If the patient presents with a Type A dissection, that patient requires emergent surgery unless the symptoms have persisted for two weeks or longer. Here, the decedent's symptoms had been presented for five days.

Plaintiffs contended the decision to hold off surgery due to decedent's steroid usage and extremely minor stroke ended in a fatal aortic rupture. Plaintiffs also contended that while any Type A Aortic Dissection is significant and needs surgery, this dissection in particular was devastating as it extended into the arch and into the innominate artery with complete thrombosis/blockage, causing no blood flow to the right carotid artery.

Plaintiffs further contended that the acute embolic stroke was extremely minor and was indeed caused by the dissection. This was not a legitimate reason to put off surgery.

DEFENDANT'S CONTENTIONS: Defendant argued that it was a judgment call to put off surgery. Decedent was a sick woman who had a serious and well-documented history of lupus. Use of steroids during and after surgery would have been an unacceptable risk. Moreover, decedent's brain infarct also made her an unacceptably high risk for surgery.

Defendant argued that even had decedent had surgery to repair the aortic dissection, more likely than not she would have passed away especially given her existing issues. Defendant also argued that the cardiothoracic surgeon was presented with a complicated patient with a difficult history and made a complex medical decision that was reasonable under the circumstances.

Damages

Plaintiffs damages were limited pursuant to Civil Code Section 3333.2 of the Medical Injury Compensation Reform Act of 1975. Plaintiffs contended lost past and future income in the amount of $280,000 as well as loss of household services. Defendant contended that there was evidence that decedent was disabled and could not return to work and would not be able to contribute much, if at all, to household services.

Result

The parties resolved the case for $320,000 after a mediation session.

Other Information

MEDIATOR: Hon. Steven Denton of Judicate West.