On September 30, 2013, the remaining defendant, my client’s cardiologist, settled all claims asserted against him during trial before he was scheduled to testify in our case in chief. Earlier, my client’s primary care physician settled all claims asserted against her the week before the trial began.
The plaintiff was a resident of Livingston, New Jersey, who suffered a stroke during prostate cancer surgery on June 11, 2007. The theory of the case was that his primary care physician and his cardiologist should have bridged him on Lovenox because his medical history revealed that he was hypercoaguable.
When we initially investigated the case, we determined that guidelines published by the American College of Cardiology, the American Heart Association and the European Society of Cardiology recommended that patients with atrial fibrillation who possess multiple risk factors for developing blood clots should be bridged on blood thinners when undergoing elective surgery to narrow down the window of time when they are off of anticoagulants to minimize the chance of developing pulmonary embolisms and strokes.
When patients have a propensity to develop blood clots, they are sometimes medicated with Coumadin, which thins their blood and decreases the chance that they will form blood clots. When these patients have to undergo surgery, however, the dangers posed by their clotting disorder competes against the danger that they will bleed excessively during an operation because their ability to clot has been diminished as a result of medication.
Patients who take anticoagulants like Coumadin usually take that medication orally. When doctors bridge patients who are on Coumadin, instead of taking a patient off of Coumadin five days or a week before surgery, doctors will substitute Coumadin with Heparin or Low Molecular Heparin which is easier to control because it is shorter acting. When patients are bridged, they can be kept on anticoagulants for up to a few hours before surgery, and they can be restarted on anticoagulants right after surgery. This reduces the time that patients have to be off of anticoagulants and decreases the window in which a patient’s hypercoaguability can cause a complication.
The plaintiff was placed on life-long Coumadin during a hospital admission in January 2006, after he developed a blood clot and a pulmonary embolism while on prophylactic anticoagulants following knee surgery. During that episode he also developed atrial fibrillation. He was seen as an inpatient by the defendant cardiologist. Unfortunately, the cardiologist’s partners rounded on the patient while he was in the hospital thereafter, and the cardiologist was not aware that the other physicians caring for the patient had determined that he was genetically hypercoaguable and that he needed to be on lifelong anticoagulants.
A year and six months later, the plaintiff was sent to his cardiologist and his primary care physician for preoperative clearance because he was scheduled to undergo prostate cancer surgery. Neither the cardiologist or the plaintiff’s primary care physician recommended that the plaintiff undergo bridging therapy, and the plaintiff was taken off anticoagulants a week before the surgery. While off anti-coagulants, the plaintiff experienced heart palpitations, which he ascribed to nerves in anticipation of surgery. According to some of his treating physicians and some of the experts who testified in the case, those palpitations were caused by recurring atrial fibrillation. As a result of atrial fibrillation, the plaintiff formed an embolus in his heart, which eventually went on to cause his stroke in the perioperative period.
The plaintiff’s primary care physician maintained that she recommended that the plaintiff see a hematologist when she provided preoperative clearance, but he refused. She also testified that she instructed the plaintiff to take Lovenox to bridge his anticoagulants, but he refused to do this as well. Finally, she testified that she spoke to the defendant cardiologist’s partner, who advised that bridging was not necessary. The plaintiff denied that this doctor gave such recommendations, and on this score, there was nothing in the primary care physician’s medical chart to suggest that any of these events took place. Furthermore, the defendant-cardiologist’s partner flatly denied ever speaking to the primary care physician about the subject of preoperative bridging. Finally, the primary care physician repeatedly contradicted her own sworn testimony when she was deposed, because she simultaneously took to opposing positions: (a) that she did not recommend bridging because the cardiologist’s partner said it was not necessary and (b) that she recommended bridging, but the plaintiff refused.
Obviously, the fact that the primary care physician’s testimony on the key issues in the case was contradicted both by her own testimony, her medical chart and another physician led this defendant’s attorneys to recommend settling all claims a week before trial. Make no mistake, however, even when a case breaks like this, plaintiffs still face significant uphill battles in medical malpractice cases. Notwithstanding the fact that it was clear that the primary care physician had zero credibility early on in discovery, she still hired two expert witnesses: (a) a doctor board certified in internal medicine who testified that this defendant did nothing wrong, and (b) a hematologist who testified that even if the plaintiff had been bridged, he would have still suffered a stroke. Finally, while this defendant eventually settled the case, this did not happen until six years after the plaintiff lost his vision.
The cardiologist maintained throughout the litigation that the decision about whether to bridge the plaintiff on Lovenox was one that should have been made by either (a) the plaintiff’s primary care physician, or (b) the doctor performing the prostate cancer surgery. His cardiology expert agreed with that opinion. Additionally, he hired a neuroopthalmologist to testify in the case.
The case was tried in Newark, New Jersey between September 23, 2012 and September 30, 2013. I was in the middle of our case in chief when the defendant cardiologist consented to settle and his carrier began to negotiate. We had already called the plaintiff, his wife and son as witnesses. One of our experts, an ophthalmologist had already testified. The plan was to put the defendant cardiologist on the stand and to call our remaining experts, a cardiologist and a hematologist, and then rest.
I always have mixed feelings about cases that settle during trial, because so much time and preparation takes place and after everything is lined up and ready, the goal is to obtain a jury verdict. In the end-analysis, however, the total settlement was in the range of the target goal we recommend to the clients. The plaintiff suffered a partial loss of vision. He suffered bilateral field defects that inhibit his ability to see detail and his ability to process information when he is moving. Without question this had a tragic impact on him and his family. His advanced age played a part in analyzing the value of the case.