Failure to Identify Blockage During Catheterization

In counterargument, it would be difficult to fault the NP for relying on the faulty catheterization report if he or she had no reason to suspect that it was erroneous. Unless the patient’s presentation on those four visits had been suggestive of CAD or discordant with pericarditis, it is not likely the NP breached the standard of care.

Always consider the possibility that a study could have been misinterpreted or that it could have mistakenly described the wrong patient. Additionally, even a reassuring cath report can’t account for all clinically important coronary events, such as vasospastic causes or plaque disruption. If the patient’s story is compelling, be willing to revisit the possibility of CAD.

Further, the plaintiff’s expert likely testified that the first cath report demonstrated a significant stenosis which required stenting and that the standard of care required aspirin, b-blockers, and lipid-lowering agents. Whether or not stent placement and medical optimization would have ultimately made a difference for this patient in the next three months, we don’t know. We do know the plaintiff’s attorney was able to persuade the jury that these efforts would have spared the patient and that the missed diagnosis was causally related to the plaintiff’s subsequent severe MI and unfortunate sequelae—justifying the monumental $25 million verdict.

Virginia state law places a $2 million cap on medical malpractice damages. However, as of the date of this writing, the plaintiff’s attorney is challenging the validity of Virginia’s cap.

The defendant’s theory brings up an important issue: the adherent plaque that does not by itself cause clinically important flow disruption—but causes mayhem if ruptured. The rupture of a “vulnerable plaque” was the unfortunate case with Tim Russert, the late, great host of Meet the Press. Mr. Russert was known to have CAD and by all accounts was well optimized, but suffered an unexpected and unpredictable rupture of a “vulnerable plaque,” which proved fatal.

Consider traditional fixed stenotic lesions that cause the usual flow limitations, but also remember that a modest lesion could represent a “vulnerable plaque” capable of rupture. —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.