News: In 2008, a young woman diagnosed with Sjögren’s syndrome began feeling ill and saw a physician. After the visit, the patient’s parents convinced her to seek additional medical care, and she presented to a hospital. The physician who examined her quickly determined that she was suffering from vasculitis. Because of an overflow of patients, the woman was transferred to the cardiac care unit rather than the intensive care unit.

At the cardiac care unit, the patient was given steroids but was never properly treated for vasculitis. Multiple tests and symptoms clearly indicated she suffered from vasculitis, but the treating rheumatologist did not treat her with the necessary medication. She was transferred to a different hospital and received treatment; however, because of the delay, nine of the woman’s toes and one of her fingers had to be amputated.

Background: A 25-year-old woman was diagnosed with Sjögren’s syndrome, a form of lupus, in 2008 and began taking medication to control the condition. In November 2008, the woman began feeling ill and saw a doctor. She then went home, where her parents urged her to seek medical care.

The woman was admitted on Nov. 21, 2008, to a hospital, where the physician wrote an order to admit her to the ICU for a diagnosis of vasculitis, an inflammation of the blood vessels that is treated with steroids and a drug called Cytoxan.

Despite the physician’s order, the patient was sent to the cardiac care unit because the ICU was full. The patient remained in the cardiac care unit for six days, but beds opened in the ICU during that time. The patient was given steroids but the treating rheumatologist failed to diagnose her with vasculitis, disregarding symptoms of the disease and biopsy results reported as “small and medium vessel necrotizing vasculitis,” according to the complaint. The nursing staff noted the patient had a bilateral foot drop on Nov. 25 and abnormal neurological assessments of her lower extremities.

The patient was transferred to a different hospital’s ICU on Nov. 28, where she was given Cytoxan two days later and showed immediate improvement. However, her toes and fingers were gangrenous; nine of her toes and her right thumb required amputation.

The patient filed suit against the first hospital and the rheumatologist for negligent treatment of her vasculitis, including failure to administer Cytoxan. The complaint alleged that the hospital’s nursing staff failed to report abnormal neurological assessments of the patient’s extremities. The complaint also claimed that the patient’s symptoms clearly indicated vasculitis.

The patient specifically alleged that the rheumatologist breached medical duties by failing to diagnose and treat her for necrotizing vasculitis in a timely manner after her admission to the hospital; failing to appreciate her bilateral foot drop caused by vasculitis on Nov. 25; failing to administer Cytoxan for the treatment of necrotizing vasculitis; failing to conclude that she had no contraindications to the administration of Cytoxan; failing to communicate with other physicians regarding the skin biopsies and other diagnosing criteria that indicated vasculitis; failing to transfer her to another institution that would have treated her in a timely manner; and failing to appropriately diagnose her medical condition.

The amputations forced the patient to cancel her plans to pursue a career in the performing arts and instead pursue a master’s degree in fine arts management. She now handles marketing at a performing arts center. The patient’s attorney argued that the biopsies were superfluous and that other criteria clearly indicated the patient’s medical condition.

After trial, a jury cleared the hospital of liability, but found the rheumatologist liable for $15.92 million: $5 million for medical expenses, $1 million for lost earnings, and $10 million for pain and suffering.

What this means to you: These circumstances reveal how diagnostic and treatment errors can result in significant injuries to patients and significant medical malpractice verdicts. While multiple physicians involved in this case recognized the patient’s vasculitis, the rheumatologist failed to do so and failed to provide the necessary medication.

Vasculitis is the inflammation of one’s blood vessels that causes blood vessel walls to thicken, weaken, narrow, and/or scar. These changes restrict blood flow, which can lead to organ and tissue damage. There are many different types of vasculitis, such as Behcet’s disease, Buerger’s disease, central nervous system vasculitis, cryoglobulinemia, eosinophilic granulomatosis with polyangiitis, and giant cell arteritis.

Vasculitis is more commonly seen in women over the age of 40, and some types may improve without any medical intervention. Other types require medications to control inflammation and to prevent flare-ups. Once vasculitis is diagnosed, treatment primarily focuses on controlling inflammation using medications and treating the underlying disease causing the vasculitis. Treatment thus commonly involves two phases: stopping inflammation and preventing relapse. Both phases involve the use of prescription drugs.

Symptoms of vasculitis vary greatly, but often are related to a decrease in blood flow throughout the body. Some more general symptoms include fever, headache, fatigue, weight loss, general aches and pains, night sweats, rash, and nerve problems; i.e., numbness or weakness. Given the different types of vasculitis, it is critical to diagnose and treat not only the vasculitis, but also the underlying issue or disease causing the vasculitis.

For example, Behcet’s disease causes inflammation of arteries and veins with symptoms including mouth and genital ulcers, eye inflammation, and skin lesions that resemble acne. Giant cell arteritis similarly involves inflammation of arteries in the patient’s head, often the temples; it may cause symptoms such as headaches, scalp tenderness, jaw pain, blurred or double vision, and blindness. Medical care providers must be aware of this variety and the importance of correctly diagnosing the vasculitis and underlying disease.

The practice of medicine is an art as well as a science. Physicians may not always agree on specific diagnoses, and making the wrong diagnosis is not automatically negligent, but if the physician fails to follow the standard of care and perform in the manner of a reasonably careful physician in the same or similar circumstances, then there may be negligence. Once a diagnosis is made, physicians must consider the patient’s response to treatment. If improvement is not seen within the expected time frame, then the physician must consider whether the original diagnosis was incorrect or incomplete, and further investigation and consultation is warranted.

Even if the initial incorrect diagnosis was not negligent, the failure to re-evaluate may be negligent. Consulting with other physicians, particularly specialists for complex matters or when symptoms may result in varying diagnoses, may greatly assist care providers with ensuring that their patients receive the correct and necessary treatment.

One of the missteps in this case was the rheumatologist’s failure to communicate with other physicians regarding the patient’s underlying symptoms. Open communication with colleagues should be encouraged at medical facilities and hospitals to foster a collaborative atmosphere and ensure the best care for patients.

Furthermore, such collaboration that results in multiple medical opinions and chances for review may later protect a physician in a lawsuit alleging medical malpractice, as reasonable physicians may reach different diagnoses given the same or similar circumstances. A care provider who objectively evaluates multiple potential diagnoses or treatments is more likely to be considered “reasonable” under the circumstances of a close call when compared to a provider who disregards other opinions.

Finally, autoimmune diseases such as Sjögren’s syndrome are complex and require the expertise of those specialties such as rheumatology. However, even within the specialty, different physicians can make different diagnoses. In this case, when the patient’s condition continued to worsen, the rheumatologist had the responsibility to re-evaluate the diagnosis and the treatment plan prescribed for it. Continuing treatment without considering why it was proving ineffective and why the patient was suffering increased damage resulted in a negligence and malpractice verdict.

REFERENCE

Decided on Oct. 31, 2017, in the Seventeenth Judicial Circuit Court of Florida; case number 11002290.