Opinion
Case No. 00 C 3435
November 29, 2001
FINDINGS OF FACT AND CONCLUSIONS OF LAW
Plaintiff Richard Espinosa has sued the United States under the Federal Tort Claims Act, 28 U.S.C. § 2671-80. The Court held a bench trial on November 26-27, 2001. The following constitutes the Court's findings of fact and conclusions of law pursuant to Federal Rule of Civil Procedure 52(a).
Findings of fact
Espinosa is a veteran who served in the United States Army from 1969 through 1971, including tours of duty in Vietnam and Cambodia, and received an honorable discharge. He had psychiatric problems following his return and eventually was diagnosed with post-traumatic stress disorder (PTSD), for which he was treated at various Veteran's Administration medical centers. Espinosa has also had an ongoing problem with alcohol abuse that began prior to his service in the Army, and following a severe automobile accident in 1975, he began using heroin intravenously, on occasion sharing needles with other heroin users.
As a result of his alcohol abuse, Espinosa developed cirrhosis of the liver, which in turn led to the development of esophageal varices, which are dilated veins at the lower end of the esophagus resulting from increased pressure in the portal vein caused by the cirrhosis-induced damage to the liver. Esophageal varices are subject to bleeding, even without any inducement by an outside agent, and this in turn can lead to vomiting of blood.
On September 25, 1994, Espinosa began vomiting blood and was admitted to the Hines VA Medical Center. He underwent an examination via endoscopy, which revealed the varices for the first time, as well as erosions in the walls of his esophagus. The varices were categorized as "grade 1," the least severe of the four grades used by physicians to describe them. Espinosa was given treatment referred to as sclerotherapy, a procedure aimed at scarring the varices to minimize the likelihood of bleeding. But the one treatment that Espinosa received was insufficient to treat all of his esophageal varices. While at Hines, Espinosa also underwent therapy for his alcohol problem. He was discharged from Hines on October 15, 1994.
On October 27, 1994, Espinosa was admitted to the North Chicago VA Medical Center for further treatment of his PTSD. On November 30, he complained to the nursing staff of pain from an arthritic condition. An attending physician, Dr. Kent Lewis, consulted with Espinosa at approximately 2:50 p.m. that day. Dr. Lewis, for reasons unknown to the Court (and not pertinent to our decision), did not testify at the trial. Espinosa testified, in substance, that he told Dr. Lewis about the pains in his bones and mentioned that in the past he had been given Motrin (a trade name for ibuprofen, a non-steroidal anti-inflammatory drug). In Dr. Lewis' notes of the consultation, he states that Espinosa said he had a history of degenerative joint disease and complained of generalized joint pain. He said that in the past the pain had been relieved by Motrin, which had been prescribed for him in 600 milligram doses to be taken three times daily as needed. Dr. Lewis' notes go on to state that Espinosa reported that the Motrin had been discontinued about one and one-half months earlier due to an ulcer, but that Espinosa was now requesting that he be given Motrin again. According to Dr. Lewis' notes, he advised Espinosa of the risks of taking Motrin with an ulcer, particularly the risk of gastro-intestinal bleeding, but that Espinosa still requested the drug. Dr. Lewis prescribed it for him. In fact, Espinosa had never been diagnosed with an ulcer, and there is no evidence that he had an ulcer at any time prior to November 30, 1994. If Dr. Lewis had investigated Espinosa's records from his recent admission at Hines, he would have learned that Espinosa had actually been diagnosed with esophageal varices.
Though Dr. Lewis prescribed a 600 milligram dosage, the pharmacy at the VA hospital provided Espinosa with 800 milligram pills, a discrepancy which Espinosa did not notice at the time. Espinosa took a single pill after receiving the prescription, presumably at some point soon after 2:50 p.m. Several hours later, he complained to a nurse of dizziness, and shortly after that he began vomiting blood and was transported to the emergency room. An endoscopy performed on December 1 revealed extensive esophageal varices, now at a level between grade 2 and grade 3, with one varix having characteristics suggestive of recent bleeding. Further sclerotherapy was performed, and after this was completed, Espinosa received a blood transfusion. The report by the surgeon directs that no more non-steroidal anti-inflammatory drugs be given to Espinosa until further notice.
The vomiting episode on November 30 resulted from bleeding from Espinosa's esophageal varices. As a result of the gastrointestinal bleeding and resulting surgery, Espinosa's hospital stay was extended by two weeks.
Medical records from later hospital admissions reflected, as part of Espinosa's medical history, that he had experienced hematemesis (vomiting of blood) caused by ingestion of Motrin. The medical personnel who made these records were not called to testify. The context of these entries suggest that they constituted a recitation of Espinosa's history as he had reported it, not an opinion or a conclusion reached by the medical personnel who made the entries.
The evidence showed that it is extraordinarily unlikely that taking a single 800 milligram Motrin pill could cause the type of gastrointestinal bleeding that Espinosa suffered on November 30, 1994. The only mechanism by which Motrin ingestion could cause such bleeding would be through what takes place after the drug is absorbed into the blood stream. However, the amount of Motrin that would end up in the blood stream from a single tablet, generally speaking, would not be sufficient to cause the type of damage necessary to cause an episode of bleeding from Espinosa's esophageal varices.
Some months after the surgery and transfusion, Espinosa tested positive for hepatitis C, a liver disease that at the time was transmitted primarily through sharing of needles by drug users and by blood transfusions. Espinosa had previously tested positive for and had been diagnosed with hepatitis B, a different form of hepatitis. In October 1992 he tested positive for the hepatitis C antigen, but in March 1993 a similar test was negative. It is equally possible that the first test was a false positive or that the second test was a false negative.
Conclusions of law
Under the FTCA, a person may sue the government for a personal injury caused by the negligent or wrongful act or omission of a government employee acting within the scope of his or her employment. The government is liable in the same manner and to the same extent as a private person would be liable under the law of the state where the cause of action arose, in this case Illinois. 28 U.S.C. § 1346 (b), 2671 2674.
Espinosa has made a claim for medical malpractice. In Illinois, a plaintiff in a medical malpractice case must prove the applicable standard of care owed to the plaintiff; a breach of that standard, and proximate cause of the plaintiff's injury. E.g., Chambers v. Ingram, 85 F.3d 351, 355 (7th Cir. 1988); Borowski v. Von Solbrig, 60 Ill.2d 418, 328 N.E.2d 301 (1975). Based on the evidence submitted, Espinosa has proven that the United States breached the standard of care in two respects. First, in view of what Espinosa told Dr. Lewis about his medical history, namely that he had an ulcer and that his previous course of Motrin had been terminated as a result of gastro-intestinal bleeding, Dr. Lewis ought not to have prescribed the drug even if Espinosa wanted it, at least not without conducting further investigation of Espinosa's history beyond what Espinosa told him. Second, it was a breach of the standard of care applicable to pharmacists to fill Espinosa's prescription at a higher dosage level than what Dr. Lewis had prescribed.
Espinosa's claim fails, however, on the issue of causation. He failed to prove by a preponderance of the evidence that the taking of a single Motrin tablet (whether 600 milligrams or 800 milligrams) caused the bleeding and vomiting of blood that he experienced on November 30. The Court did not find the causation opinion testimony of plaintiff's expert witness credible in this respect, and for the reasons we have discussed, the later entries in his medical records are not evidence of causation. The Court found credible the opinion testimony of defendant's expert that the single Motrin tablet had not caused the bleeding and that if it had, the endoscopy performed the next day would have revealed signs consistent with damage caused by a non-steroidal anti-inflammatory drug, signs which were not found to be present. The fact that physicians took Espinosa off such medications following the bleeding incident was appropriate and prudent, but it does not constitute evidence that the Motrin had caused the bleeding in the first place. Esophageal varices commonly bleed on their own without any external insult, and that is what the evidence showed happened with Espinosa on November 30.
In short, Dr. Lewis and the North Chicago VA pharmacy breached their respective duties of care to Espinosa, but those breaches did not cause his injuries, including the extended hospital stay and the hepatitis C (if in fact that resulted from the transfusion). For these reasons, the Court finds in favor of defendant.
Conclusion
The Court directs the Clerk to enter judgment in favor of defendant.