Opinion
Case No. 98-2280-JWL.
March 20, 2001.
MEMORANDUM ORDER
This medical malpractice action arises out of defendant's care and treatment of plaintiff in March 1997 during plaintiff's hospitalization for complications associated with her pregnancy. Specifically, plaintiff presented with symptoms of preeclampsia, including high blood pressure and severe headache. On March 9, 1997, defendant ordered the administration of Procardia and Imitrex in connection with his treatment of plaintiff's headache. Plaintiff claims that defendant was negligent in ordering the administration of these drugs and that the administration of Imitrex, either standing alone or coupled with the administration of Procardia, caused plaintiff to suffer a stroke.
Both parties having waived their jury demands, a trial to the court was held in this matter in February 2001. The court has thoroughly considered the evidence and arguments presented at trial and is now prepared to issue its findings of fact and conclusions of law pursuant to Federal Rule of Civil Procedure 52(a). For the reasons set forth fully below, the court concludes that plaintiff has not carried her burden to prove that any injuries she may have suffered were caused by any of the challenged care and treatment rendered by defendant. Moreover, because the court concludes that plaintiff has failed to establish causation, the court does not reach the question of whether defendant departed from the applicable standard of care in his treatment of plaintiff. Accordingly, judgment is entered in favor of defendant on plaintiff's claim.
By stipulation of the parties, the trial was bifurcated into two phases — a liability phase (including standard of care issues and causation issues) and a damages phase. The liability phase of the trial was held from February 6, through February 16, 2001. In light of the court's findings of fact and conclusions of law concerning liability, of course, the issue of plaintiff's damages is now moot.
Following the trial, both parties submitted deposition designations to the court. Specifically, plaintiff submitted designations of Dr. Zwibelman's deposition testimony and defendant submitted designations of Dorothy Hanrahan's deposition testimony and Dr. Donald Ayres' deposition testimony (in lieu of further cross-examination). The court has reviewed those designations, the objections thereto and the parties' cross-designations and objections thereto. Because the court's resolution of this case turns on the very narrow issue of whether plaintiff suffered a stroke on the evening of March 9, 1997, or the early morning of March 10, 1997, and because the vast majority of the parties' deposition designations have no bearing whatsoever on this limited issue, the court concludes that the most practical method of resolving the parties' numerous objections to the deposition designations is as follows:
With respect to defendant's objections to plaintiff's designations of Dr. Zwibelman's deposition testimony, although some of those objections may have merit, the portions of Dr. Zwibelman's testimony to which defendant objects do not bear on the court's resolution of the case. Thus, defendant's objections are overruled in an abundance of caution. Moreover, the court, in reaching its decision, has not relied on any of defendant's counterdesignations of Dr. Zwibelman's deposition testimony. Accordingly, in an abundance of caution, plaintiff's objections to those counterdesignations are sustained.
Plaintiff has not objected to defendant's designations of Dr. Ayres' deposition testimony. Defendant, however, has submitted numerous objections to plaintiff's counterdesignations. Again, although some of those objections may have merit, the portions of Dr. Ayres' testimony to which defendant objects do not bear on the limited issue on which the court's resolution of the case turns — whether plaintiff had a stroke on March 9, 1997, or March 10, 1997. Thus, defendant's objections are overruled in an abundance of caution.
Finally, the court sustains plaintiff's objections to defendant's designations of Ms. Hanrahan's deposition testimony, despite the fact that none of the portions of Ms. Hanrahan's testimony to which plaintiff objects relates to the limited issue of whether plaintiff had a stroke on March 9, 1997, or March 10, 1997. Defendant's objections to plaintiff's counterdesignations are overruled.
• Findings of Fact
On March 3, 1997, plaintiff was admitted to Overland Park Regional Medical Center in Overland Park, Kansas with symptoms of preeclampsia, including high blood pressure and severe headache. Plaintiff was twenty-eight weeks pregnant at the time. On March 5, 1997, plaintiff underwent cesarean section to deliver her baby. After delivery, plaintiff continued to suffer from high blood pressure and severe headache. Due to plaintiff's continued complaints of headache, Dr. Laura Kenny, plaintiff's treating obstetrician, ordered a CT scan of plaintiff's head. The CT scan was taken on March 9, 1997, at 4:40 a.m. and was initially interpreted by radiologists as normal ( i.e ., no evidence of stroke).
Later that afternoon, Dr. Kenny requested a neurology consultation with respect to plaintiff's headache. Pursuant to that request, defendant examined plaintiff on March 9, 1997. Defendant ordered two drugs in connection with the treatment of plaintiff's headache-Imitrex (sumatriptan) and Procardia (nifedipine). Imitrex is a vasoconstricting antimigraine medication. Procardia is a vasodilating antihypertensive medication. Because Imitrex is contraindicated in patients with uncontrolled hypertension, defendant first ordered the administration of Procardia to lower acutely plaintiff's blood pressure. Thus, in preparation for the administration of Imitrex, a ten milligram dose of sublingual Procardia was administered to plaintiff at 4:22 p.m. on March 9, 1997. After plaintiff's blood pressure had significantly decreased, a six milligram subcutaneous injection of Imitrex was administered to plaintiff at 4:55 p.m. on March 9, 1997. A second six milligram injection of Imitrex was administered at 8:10 p.m. on March 9, 1997.
Plaintiff contends that she suffered a stroke on the evening of March 9, 1997. Plaintiff's primary evidence supporting this contention is the testimony of Gene Hanrahan, plaintiff's father. As the court will explain below, it does not find Mr. Hanrahan's testimony credible and, in fact, is not persuaded that plaintiff suffered a stroke on the evening of March 9, 1997, or the early morning hours of March 10, 1997. In any event, according to Mr. Hanrahan, he was in plaintiff's hospital room on March 9, 1997 when plaintiff awoke between 11:00 p.m. and midnight "screaming with pain." Mr. Hanrahan testified that he observed plaintiff's left foot "drawing in . . . like it was in a cramp." He further testified that plaintiff was complaining of pain in her left arm and left leg. Mr. Hanrahan stated that he and his wife (who was also present in plaintiff's room) immediately called for a nurse, who arrived "just a few seconds" later. According to Mr. Hanrahan, the nurse examined plaintiff's left arm, leg and foot and commented, "It doesn't look good at all" and that plaintiff's symptoms were "signs of a stroke." Mr. Hanrahan then recalled that the nurse administered pain medication to plaintiff. Although Mr. Hanrahan apparently believed that the nurse was going to contact a physician about plaintiff's episode, no physician ever visited plaintiff with respect to the episode and Mr. Hanrahan never contacted or attempted to contact a physician about plaintiff's episode.
While evidence was presented at trial that plaintiff may have suffered a stroke on March 12 or March 13, 1997 (as opposed to March 9, 1997), the court need not decide whether plaintiff had a stroke on these days or whether plaintiff had a stroke at all. The court need only decide whether plaintiff had a stroke in the late evening hours of March 9, 1997, or the early morning hours of March 10, 1997, for it is undisputed by plaintiff that the administration of Imitrex and/or Procardia could not have caused a stroke after March 10, 1997. Plaintiff's expert, Dr. Margulies, testified that the effects of Imitrex last between two and six hours. Plaintiff's other expert, Dr. Ayres, testified that the effects of Procardia last between one and a half and two hours.
The court does not necessarily conclude that Mr. Hanrahan intentionally provided false testimony at trial. While that is certainly one possibility, another possibility is that Mr. Hanrahan's emotional state during his daughter's hospitalization was such that his recollection of various events is not as clear as it otherwise might be. Mr. Hanrahan, for example, had just been invoked into the fourth degree of the Knights of Columbus on March 8, 1997 — an event that, according to the testimony at trial and his wife's diary, was obviously a significant and emotional one for Mr. Hanrahan. Moreover, upon Mr. Hanrahan's arrival at the hospital on March 9, 1997, he was informed that his grandson (the baby to whom plaintiff had given birth on March 5, 1997) "might not make it through the day" and that a priest had been called in the event that last rites needed to be administered.
Plaintiff's medical records are devoid of any description of or reference to the March 9, 1997 incident described by Mr. Hanrahan. Nurse Catherine Peck provided care to plaintiff from 3:00 p.m. until 11:00 p.m. on March 9, 1997. She testified that no one ever reported to her that plaintiff had a problem or incident on the evening of March 9, 1997; that she was not called to plaintiff's room for any incident; and that she had no knowledge of any incident where plaintiff woke up screaming in pain. Nurse Peck further testified that she would have recorded a note if plaintiff had complained of any left-sided pain or if plaintiff woke up screaming and that she would have contacted a physician if something like that had occurred. Nurse Mistie Farajolah provided care to plaintiff from 11:00 p.m. on March 9, 1997, until 7:00 a.m. on March 10, 1997. She testified that no one ever reported to her that plaintiff had a problem or incident at any time during her shift. She further testified that she was not called to plaintiff's room concerning any pain or problems that plaintiff was experiencing and that plaintiff never complained about any left-sided problems. Like Nurse Peck, Nurse Farajolah explained that she would have recorded a note about any such problems and contacted plaintiff's neurologist because such problems would have constituted a "significant change" in plaintiff's condition. Moreover, while Nurse Farajolah conceded that there could have been four or five nurses on duty during her shift, the applicable standard of care would dictate that any nurse who "covered" for Nurse Farajolah with respect to plaintiff would report to Nurse Farajolah any changes in any of Nurse Farajolah's patients. Nurse Farajolah did not receive any reports from any other nurses concerning plaintiff's condition on the evening of March 9, 1997, or the morning of March 10, 1997.
In addition, at midnight on March 9, 1997, Nurse Farajolah checked plaintiff's mental status to ensure that plaintiff was alert and oriented as to where she was. Nurse Farajolah's notes indicate that there had been no change of any kind in plaintiff's mental status. Finally, Nurse Farajolah checked plaintiff's strength by pressing her hand against plaintiff's right foot, then left foot, "to see if there's any difference from one side to the other as far as weakness." Nurse Farajolah's notes do not reflect any weakness in either foot and she could not recall finding any weakness in either foot. In short, after examining plaintiff at midnight on March 9, 1997, Nurse Farajolah had no reason to believe that plaintiff was having any problem or difficulty. At 12:45 a.m. on March 10, 1997, Nurse Farajolah again checked on plaintiff. She did not perceive any change in plaintiff's mental status at that time. Nurse Farajolah checked on plaintiff again at 2:00 a.m. on March 10, 1997, but did not wake her. At 4:15 a.m., Nurse Farajolah woke plaintiff from her sleep and found her to be alert and oriented. Again Nurse Farajolah performed the strength test with respect to plaintiff's feet. She did not note any difference in strength in plaintiff's right foot as compared to plaintiff's left foot.
Nurse Farajolah also checked plaintiff's ankle deep tendon reflexes periodically during the late evening hours of March 9, 1997, and the early morning hours of March 10, 1997. Other nurses continued to check plaintiff's deep tendon reflexes throughout the day on March 10, 1997. At no time was there any evidence or notation of asymmetry in plaintiff's reflexes. In other words, plaintiff's reflexes on her right side were the same as her reflexes on her left side. According to Dr. Louis Dyll, one of defendant's experts, the symmetry of plaintiff's reflexes is highly significant and indicates that plaintiff did not suffer a stroke on the evening of March 9, 1997, or on March 10, 1997.
Later in the morning on March 10, 1997, Dr. Arthur Allen, another neurologist in defendant's practice group, examined plaintiff. Dr. Allen did not observe any left-sided abnormalities during his examination of plaintiff and plaintiff did not complain of any left-sided abnormalities. During Dr. Allen's visit, however, plaintiff complained of double vision and, upon bedside examination, Dr. Allen observed that plaintiff had weakness of the right eye when plaintiff looked to the right. Concerned about possible pressure on the sixth cranial nerve and a possible stroke in the brain stem, Dr. Allen ordered an MRI of plaintiff's head. The MRI was taken at 4:00 p.m. on March 10, 1997. It is undisputed that the MRI reflects a right parietal deep white matter stroke. According to one of defendant's experts, Dr. Solomon Batnitsky, the infarct or lesion reflected in the MRI was chronic. That is, the lesion had to have existed for at least a month if not longer. According to Dr. Batnitsky, the chronicity of the lesion was indicated by the sharp margins of the lesion on the MRI and the shape of the lesion. Dr. Batnitsky also testified that neither the appearance nor the size of the lesion reflected in the March 10, 1997 MRI changed in subsequent MRIs of plaintiff's brain, including MRIs taken on April 7, 1997, and August 1, 1997. According to Dr. Batnitsky, this is further evidence that the lesion reflected in the March 10, 1997 MRI was chronic. According to Dr. Batnitsky, then, the MRI did not reveal any new, or acute, infarcts in plaintiff's brain.
This, of course, calls into question the "normal" CT scan taken on March 9, 1997. In fact, even Dr. Batnitsky in his preliminary review of plaintiff's records misread the CT scan as normal. With the benefit of the March 10, 1997 MRI and subsequent MRIs, a closer examination of the CT scan reveals the same lesion in the right parietal lobe as revealed in the March 10, 1997 MRI. As explained by Dr. Batnitsky, he had mistaken the right parietal infarct for the upper part of the lateral ventricle on the right side. The court found Dr. Batnitsky's testimony to be particularly credible.
Furthermore, it was undisputed at trial that stroke does not usually cause pain; rather, stroke manifests itself through loss of strength or loss of sensation or some other motoric deficit. Every witness who testified about this issue was consistent — Dr. Allen testified that stroke does not usually cause pain; Dr. Dyll testified that stroke presents as loss of strength or loss of sensation, but not as a "cramp"; Dr. Dubinsky testified that he had never seen hyperreflexia as an initial manifestation of stroke without motoric deficit. No witness testified that plaintiff's initial symptoms as described by her father (screaming in pain; cramping left foot; pain on left side) were consistent with stroke.
Finally, despite the fact that Mr. Hanrahan characterized the incident that he testified occurred on the evening of March 9, 1997, as the "most significant" event that occurred during his daughter's hospitalization, the incident appears nowhere in his wife's diary. While at first blush this fact might seem trivial, a review of Ms. Hanrahan's diary reveals that she memorialized in painstaking detail the events of each day of her daughter's hospitalization. Ms. Hanrahan, for example, memorializes each and every meal that she and her husband had, including what they had to eat and the times at which they ate. She notes her own sleeping patterns and her daugher's sleeping patterns. She seems to note every time she showered, washed her hair and put on make up — as well as the times her daughter showered, washed her hair and put on make up. She memorializes loads of laundry — including descriptions of the types of loads she washed ( e.g . , whites; jeans). She carefully tracks her daughter's blood pressure and information she receives from various health care providers at the hospital. She records her daughter's complaints of headache and other pain. She records an incident in which her daughter started coughing terribly after using a nasal spray and the nurse was called into plaintiff's room. She writes about the CT scan and MRI that were taken. She records the health status of her grandson. She details the names of every person who visits her daughter at the hospital and those who call to check on her well-being. None of this is meant to criticize Ms. Hanrahan in any way — it is simply meant to demonstrate that Ms. Hanrahan kept careful track of all events that occurred (of which she was aware, of course) during her daughter's hospitalization — regardless of how significant or insignificant that event might be. The entries for March 9, 1997, and March 10, 1997, are devoid of any reference whatsoever to an incident where plaintiff wakes up screaming in pain. They are devoid of any reference to plaintiff experiencing left-sided pain or discomfort on March 9, 1997, or March 10, 1997. They are devoid of any reference to plaintiff experiencing a left-foot cramp on March 9, 1997, or March 10, 1997.
Ms. Hanrahan does note that she observed plaintiff's foot "turning down" on March 14, 1997. This indicates that the incident that allegedly occurred on the evening of March 9, 1997 would have been the type of thing that Ms. Hanrahan would have recorded had it occurred.
• Conclusions of Law
The plaintiff in a medical malpractice case bears the burden of showing not only the doctor's negligence, but that the negligence caused the injury. Hare v. Wendler , 263 Kan. 434, 440 (1997) (citing Bacon v. Mercy Hosp. of Ft. Scott , 243 Kan. 303, 307 (1988)). Here, plaintiff has not persuaded the court that defendant's conduct caused any adverse consequences to plaintiff. Simply put, the court does not believe that plaintiff suffered a stroke on the evening of March 9, 1997, or on March 10, 1997. Despite Mr. Hanrahan's recollection, the alleged incident appears nowhere in the medical records. Nurses Peck and Farajolah were both very credible witnesses — the court is convinced that had an incident occurred like the one described by Mr. Hanrahan, it would have been recorded by the nurse on duty and a doctor would have been called. Moreover, the uncontroverted evidence at trial demonstrated that stroke presents with loss of strength, loss of sensation, or some kind of motoric deficit — not pain or cramping. In her neurological checks of plaintiff, Nurse Farajolah did not note any weakness in plaintiff's left side. She also noted that plaintiff's mental status remained unchanged. This, too, then, suggests that plaintiff did not suffer a stroke on March 9 or March 10, 1997. In addition, the symmetry of plaintiff's reflexes as measured on March 9 and March 10, 1997 suggests that she did not suffer a stroke on either of those days. The MRI is also extremely significant to the court's conclusion. Although plaintiff suggested at trial that the MRI supports the conclusion that plaintiff stroked on the evening of March 9, 1997, plaintiff's experts were simply not persuasive on this point. In fact, Dr. Batnitsky, defendant's expert, was the only witness at trial to explain the MRI findings in any detail whatsoever. He credibly testified that the lesion was chronic. Finally, the court is convinced that had the screaming incident occurred on March 9, 1997, the incident would have been recorded by Ms. Hanrahan in her journal.
For all of the foregoing reasons, plaintiff has not met her burden of proving causation. Judgment in favor of defendant is entered on plaintiff's claim.
IT IS SO ORDERED.