Case Study: Doctor Drops the Ball in Identifying Coronary Symptoms
In this case, derived from the NCMIC claims files, the doctor faced a patient with numerous health issues who experienced a cardiac emergency.
Posted in Risk Management on Monday, July 29, 2019
Forty-year-old production worker John Deshazo was working at a printing company when he sustained a low-back injury in July 2017 while working on the assembly line. Because Calvin Preen, DC, was authorized by the printing company to treat employees who suffered work-related injuries, Mr. Deshazo made an appointment with him.
Upon his arrival at Dr. Preen’s office, Mr. Deshazo filled out a form detailing his current health condition and his health history, which did not include anything unusual. Dr. Preen reviewed this form prior to meeting with Mr. Deshazo for the first time, and he asked Mr. Deshazo about his interests and family. Dr. Preen recognized that they had quite a bit in common, and a nice rapport developed between them. For instance, they both enjoyed flying drones, had three children in middle school and high school, and enjoyed skiing and hiking.
After obtaining a history, Dr. Preen examined Mr. Deshazo and identified misalignments in Mr. Deshazo’s lumbar spine. Dr. Preen was able to effectively treat and improve the patient’s pain with chiropractic care. After five weeks of treatment, Mr. Deshazo was free of low-back complaints and left the care of Dr. Preen.
Approximately one year later, Mr. Deshazo awoke at 3 a.m., complaining to his wife about back pain and shortness of breath. Mrs. Deshazo suggested that he seek medical help, but he refused and went back to sleep. When he awoke, he still had the same complaints and he told his wife that he was going to see Dr. Preen because of his previous positive experience.
Dr. Preen’s schedule allowed him to see Mr. Deshazo at 10 a.m. that day. Mr. Deshazo filled out an updated history form and noted the following complaints: “Pain between shoulder blades and at breast bone, left arm at shoulder and also neck pain increases while lying down or bending forward. Breathing is difficult.” Dr. Preen documented in his records that Mr. Deshazo informed him that he had awakened at 3 a.m. with these same symptoms, and that thinking back, his symptoms had begun the previous day at work when he heard a “pop” in his upper back while working on a printing press.
Dr. Preen found Mr. Deshazo’s breathing difficulties occurred only when he took a deep breath. When Dr. Preen held Mr. Deshazo’s rib cage, the difficulty seemed to disappear. Dr. Preen then turned to Mr. Deshazo’s musculoskeletal complaints. His spine was painful from T3–T8, sharp in some areas and achy in others. There was radiating pain from Mr. Deshazo’s left medial elbow to his two little fingers. He had equal strength in both hands, and Dr. Preen noticed no difference in temperature between his two hands.
Upon palpation, Dr. Preen found fixations at C5–7. When checking Mr. Deshazo’s cervical ROM, Dr. Preen found muscle spasms in the patient’s left rhomboid major and minor, as well as left levator scapulae erector spinae and intercostal muscles from T3–T8.
Treatment that morning consisted of muscle work on the rhomboids, levator scapulae and intercostal muscles using active resistive technique. This provided some relief to Mr. Deshazo, but he still had pain in the mid-upper back. Dr. Preen adjusted the upper thoracic region with a thoracic lift maneuver while Mr. Deshazo was lying down, but Mr. Deshazo was still experiencing pain. Dr. Preen adjusted Mr. Deshazo’s mid-thoracic spine in the standing position, and Mr. Deshazo felt better in this area. Dr. Preen then adjusted the patient’s cervical spine at C5-7, and Mr. Deshazo reported improvement. He set an appointment for the following Monday.
Later that same afternoon, Mr. Deshazo phoned Dr. Preen’s office, stating that his symptoms had returned. He asked if he could see Dr. Preen before the weekend as the treatment earlier that day had provided some relief. At approximately 5 p.m. that day, Dr. Preen adjusted Mr. Deshazo at T3-T8, and Mr. Deshazo noted that he obtained relief. Dr. Preen documented in his records that Mr. Deshazo was not experiencing shortness of breath during the visit. Dr. Preen reminded Mr. Deshazo to seek emergency room assistance if his back flared up again over the weekend. Mr. Deshazo thanked Dr. Preen and departed.
The next day, Mr. Deshazo’s wife called Dr. Preen and reported that Mr. Deshazo had driven a short distance from Dr. Preen’s office following the Friday afternoon appointment, and he experienced a massive coronary event. This resulted in a minor rear-end collison. The driver of the other vehicle called 911, at which point Mr. Deshazo was transported to the hospital and pronounced dead on arrival.
Mrs. Deshazo, on behalf of her deceased husband, filed a lawsuit against Dr. Preen, alleging that if not for Dr. Preen’s negligence, Mr. Deshazo would have been alive today.
Two chiropractors were retained for Dr. Preen’s defense to give their opinions relative to whether Dr. Preen’s treatment of Mr. Deshazo complied with the standard of care. One of the chiropractic experts supported Dr. Preen’s decision not to refer Mr. Deshazo on the first visit. This expert noted Mr. Deshazo’s symptoms improved with treatment and the pain seemed to have been caused by a musculoskeletal strain, based on the history provided by Mr. Deshazo. However, this expert also felt that Dr. Preen’s failure to refer Mr. Deshazo to an MD at the time of the second visit late that afternoon was likely a breach of the standard of care.
The second chiropractor who reviewed this matter indicated that, in his opinion, any potential cardiac problem should have been ruled out by way of immediate referral to an MD. He indicated that he could not support Dr. Preen’s care because of his failure to refer.
Upon vigorous questioning by plaintiff’s counsel at Dr. Preen’s deposition, Dr. Preen admitted that he didn’t record his observations contemporaneously, and that he had entered them after learning of Mr. Deshazo’s death. This turn of events seriously brought into question Dr. Preen’s credibility and certainly caused his records to appear self-serving in anticipation of litigation.
Several cardiologists and cardiac surgeons were consulted by the defense on this case. All formed the opinion that Mr. Deshazo was suffering from unstable angina when he treated with Dr. Preen, both in the morning and in the afternoon of the date of his death. They explained that stable angina is directly related to activity. For example, a person runs and feels chest pain that disappears when he or she stops running. Conversely, unstable angina is chest pain unrelated to activity.
The cardiologist experts further noted that the danger of unstable angina is that chest pain can begin when a person is at rest. Someone with unstable angina is susceptible to immediate hemorrhage of the coronary arterial walls, which in turn forms a thrombus, which causes the blockage of an already stenosed coronary artery. They explained that this propels the heart into ventricular fibrillation, which cuts off the heart’s perfusion and leads to death.
Every one of the cardiologists and cardiac surgeons who reviewed this case opined that had Mr. Deshazo received medical attention in either the morning or the afternoon when he visited Dr. Preen, there would have been a 98 percent chance that he could have averted the dysrhythmia that killed him.
The plaintiff retained an economist to assist with valuing the case. The economist estimated that from an economic-loss perspective, taking into consideration Mr. Deshazo’s lost earning capacity, pension benefits, health coverage, household services, and maintenance expenditures, the economic loss of the estate of John Deshazo was $1.5–$2 million. The defense economist retained did not challenge the opinions of the plaintiff’s economist.
As noted, Mr. Deshazo was the father of three children. What wasn’t mentioned was that one of his children had severe autism, and Mr. Deshazo had been a huge presence in the child’s life. If this case would have be en tried before a jury, jury sympathy could have been a significant factor for the plaintiff.
Because the Friday afternoon records were not entered contemporaneously and most likely would be construed to be self-serving for Dr. Preen, the possibility existed for an award of punitive damages. The defense team was concerned the jury would believe Dr. Preen fabricated his charts to support his actions.
Dr. Preen’s limit of liability with NCMIC for this case was $1 million. The plaintiff’s initial settlement demand was well in excess of the doctor’s policy limit. After nearly one month of negotiations, the plaintiff agreed to accept Dr. Preen’s policy limits to resolve this matter. NCMIC spent nearly $130,000 to defend Dr. Preen.
*Although this case study is based on a real case, all names are fictitious to protect patient and doctor privacy.
What Can We Learn?
By Jennifer Boyd Herlihy, Boston, Massachusetts, and Providence, Rhode Island
Timely and Accurate Recordkeeping
Always record your records contemporaneously. Although poorly documented records are not ideal, they are better than altered records. Altering your records only serves to anger jury members, encourage punitive awards and make the case indefensible.
Being cautious and being an alarmist are not the same things. If you feel a patient should be sent to an emergency room, don’t hesitate for fear of being “alarmed over nothing.”
If a cardiac problem or any other medical emergency is suspected due to the patient’s symptomatic picture, it is often prudent to call 911 instead of allowing the patient to leave the office independently. In this situation, if the doctor would have called 911, the outcome may have been different. Instead of the patient wrecking his car as a result of a coronary event, he could have been treated and stabilized by qualified paramedics.
Adequate Policy Limits
Having adequate malpractice insurance policy limits can be critical during a lawsuit. They give the defense the opportunity to negotiate the best possible outcome when the evidence and records suggest the plaintiff will prevail.
Consent to Settle
At NCMIC, the defense team conducts a risk-benefit analysis of the case, with the doctor having the right to settle or not settle. In this situation, the doctor’s best interest was served by settling for his policy limits, due to the potential for an excess verdict for which the doctor would have been financially liable.
"What Can We Learn?" author Jennifer Boyd Herlihy is a healthcare defense lawyer with the firm of Adler/Cohen/Harvey/ Wakeman/Guekguezian, LLP, located in Boston, Massachusetts and Providence, Rhode Island. She represents chiropractors and other healthcare providers in matters related to their professional licenses and malpractice actions.