Kelly on Malpractice

 In White v. Premier Medical Group, 2007 WL 4207868 (Tenn.Ct.App.), Ms. Wastille Jones was admitted to Gateway Medical Center suffering from bilateral flank pain, as well as elevated blood urea nitrogen (BUN) and creatinine levels.  Dr. Scott William McLain, the defendant, was her admitting physician.  Initially, Ms. Jones was given a Demerol patient-controlled analgesia (PCA) pump for back pain, and numerous diagnostic tests were performed.  Within a few days, Ms. Jones’ BUN and creatinine levels had returned to baseline, but her back pain continued.  On the fifth day, Dr. McLain discontinued the Demerol PCA pump and ordered 7.5 mg of Lortab together with 25 mg of Demerol on an as needed basis for breakthrough pain.  Later, Dr. McLain ordered a narcotic transdermal patch known as Duragesic at a dosage of 50 mcg/hour.  Three days later, the Duragesic patch was increased to 100 mcg/hour and Flexiril 10 mg, a muscle relaxant, was additionally ordered to be given every eight hours around the clock. 

Dr. McLain had planned to discharge Ms. Jones to a rehabilitation facility; however, she was not discharged because she was noted to be unstable when ambulating and having difficulty getting out of bed without assistance.  Dr. McLain felt that Ms. Jones was getting too much pain medication and discontinued the Lortab.  During his early morning rounds, Dr. McLain found Ms. Jones lethargic but arousable and in about the same condition as the previous day.  Her occupational therapist noted that Ms. Jones was so unarousable that she could not participate in therapy. 

Ms. Jones’ condition continued to deteriorate during the day; however, Dr. McLain was not notified about her condition until being paged shortly before 7:30 p.m.  Finding her unresponsive and in respiratory distress when he arrived, Dr. McLain ordered Narcan, a medication designed solely to reverse the effects of narcotics.  After the third dose of Narcan, Ms. Jones awakened and was able to speak with Dr. McLain. Because her oxygen level was low and her carbon dioxide level high, Dr. McLain intubated Ms. Jones and immediately transferred her to the intensive care unit (ICU) of the hospital.  Dr. Jatin Kadakia, a pulmonary and critical care specialist, was the physician responsible for patients in the ICU at the time of Ms. Jones’ transfer to the ICU. Within the first hour, the pressure reading on Ms. Jones’ ventilator was above the acceptable level, and the levels continued to increase throughout the evening. By 12:30 a.m., the alarms on the ventilator sounded, indicating a blockage in the endotracheal tube that was impeding the flow of oxygen to Ms. Jones. The alarm repeatedly sounded over the next few hours and at 1:40 a.m., Ms. Jones went into cardiopulmonary arrest. 

Dr. Kadakia was not advised of any of these developments until after Ms. Jones went into cardiopulmonary arrest.  Dr. Kadakia was first called at approximately 2:25 a.m. and arrived at the ICU at 3:15 a.m., at which time he performed a bronchoscopy which disclosed a significant mucous “plug” that was obstructing the endotracheal tube.  Removal of the mucous “plug” cleared the endotracheal obstruction, immediately following which the pressure on Ms. Jones’ ventilator dropped to an acceptable level.  Unfortunately, Ms. Jones died the following day, February 2, 2002, after life support was withdrawn. The jury found for Dr. McLain.  The central issue on appeal was the superseding cause jury instruction.  Plaintiff contended that Dr. McLain’s mismanagement of Ms. Jone’s care, the negligent administration of an overdose of Duragesic, was the sole cause of her death.  Dr. McLain alleged that the development of a mucus plug in the ICU was medically unforeseeable such that it broke the chain of causation.  The Court of Appeals reminded us all that the essential elements of the defense of superseding cause are as follows: (1) the harmful effects of the superseding cause must have occurred after the original negligence; (2) the superseding cause must not have been brought about by the original negligence; (3) the superseding cause must actively work to bring about a result which would not have followed from the original negligence; and (4) the superseding cause must not have been reasonably foreseen by the original negligent party. See Godbee v. Dimick, 213 S.W.3d 865, 882 (Tenn.Ct.App.2006).  The Court of Appeals found material evidence to sustain the charge because the defendant won at trail. 

 Mucus plug cases are tough, but they can be won.  Beware of the superseding cause defense in these cases when the negligent doctor has little or no responsibility in the ICU.