The plaintiff, a 20 year-old female college student, developed a rash on her back, prompting a consultation with a dermatologist who prescribed the prescription drug Minocycline. Shortly thereafter, the plaintiff began to experience pedal edema and diarrhea. Lab tests revealed abnormal liver function and the plaintiff was referred to the defendant gastroenterologist for further evaluation.
The Defendant initially evaluated the plaintiff in February and noted at that time that the plaintiff had an acneiform rash over her back, right upper quadrant tenderness, hepatomegaly, an increase in liver span, and 2+ edema to her upper shin. Noting her recent use of Minocycline to treat her rash, the defendant believed that the plaintiff was suffering from autoimmune hepatitis, secondary to Minocycline toxicity, but included among his differential diagnoses were: Wilson’s Disease (patients do not release copper into bile, resulting in the accumulation of copper in the liver and resulting liver damage); Budd-Chiari Syndrome; and acute viral hepatitis. The Defendant ordered the plaintiff to immediately undergo several lab tests including a ceruloplasmin test, the sole purpose of which is to test for Wilson’s Disease.
Having failed to note that the results of the ceruloplasmin test had not returned from the lab, the defendant clung to his primary diagnosis of autoimmune hepatitisÓ, and continued the plaintiff on high dosages of immunosuppressive therapy (namely Prednisone and Medrol) hoping for improvement in the plaintiff’s liver function studies. Unfortunately, the plaintiff’s liver condition continued to decline.
After more than five months of intense immunosuppressive therapy, the plaintiff began to develop profound striae (dark striping) over her abdomen, back, arms, legs, and breasts.
As the plaintiff’s liver condition continued to deteriorate, she was referred to the hospital’s liver transplantation team for potential liver transplantation.
After she was deemed a candidate for liver transplantation the plaintiff’s name was entered into the UNOS system to await a suitable donor. However, as a result of her rapidly declining condition, the plaintiff was also urged to consider a suitable live liver donor, and as such, her mother was deemed a suitable match.
In April the following year, before the transplant was scheduled to take place, the plaintiff, at the behest of her older sister, sought a second opinion from another leading Massachusetts gastroenterologist. The consulting gastroenterologist like the defendant himself, immediately considered Wilson’s Disease as the potential diagnosis of the plaintiff’s on-going liver condition, and promptly noted that Wilson’s Disease should once again be ruled-out as a possible cause of the plaintiff’s cirrhosis.
The consulting gastroenterologist’s suspicion that the plaintiff may have been suffering from Wilson’s Disease was further buttressed by the fact that the plaintiff had not responded to the long-term immunosuppressive therapy prescribed by the defendant, as is typically seen in patients with auto-immune hepatitis. Once again, ceruloplasmin tests were ordered to rule-out or confirm the possibility that the plaintiff was suffering from Wilson’s Disease. In addition, a 24-hour urine test was ordered along with additional blood testing, and the plaintiff was instructed to have her eyes examined for the presence of Keiser-Fleisher rings a tell-tale sign of Wilson’s Disease.
As ordered, plaintiff had her eyes examined for the presence of Keiser-Fleisher rings, which were immediately evident, confirming Wilson’s Disease as the cause of the plaintiff’s end-stage liver failure. The ceruloplasmin test also came back positive, adding further support to the conclusion that the plaintiff was indeed suffering from Wilson’s Disease and not autoimmune hepatitis as the defendant had acted upon throughout the preceding year.
Once Wilson’s Disease had been confirmed, the plaintiff was placed on, and promptly responded to the appropriate treatment for Wilson’s Disease and by late July, the plaintiff’s blood tests had improved to the point where liver transplantation was no longer considered necessary.
The plaintiff contended that the defendant was negligent in two key respects: (1) in failing ensure that the ceruloplasmin test ordered by the defendant to confirm or exclude Wilson’s Disease as a potential cause of the plaintiff’s abnormal liver tests was in fact performed as ordered; and (2) failing to consider other causes of the plaintiff’s abnormal liver tests after her extended course of steroidal therapy failed to demonstrate the improvement typically expected.
As a direct and proximate result of the long term immunosuppressive medications prescribed by the defendant, including Prednisone and Medrol, the plaintiff sustained permanent body-wide striae, avascular necrosis of both knees, and severe joint pain in her hands and wrists. The physician who subsequently evaluated the plaintiff for her bilateral knee complaints concluded that the heavy doses of steroids administered to the plaintiff over the previous year resulted in severe avascular necrosis, (tissue death) of the femoral condyles in both of the plaintiff’s knees. As a result of her avascular necrosis, the plaintiff underwent arthroscopic removal of loose bodies, debridement of her femoral condyle, carta cell harvest of her left knee and arthroscopic surgery on her right knee. It was also believed that the plaintiff would likely require a total replacement of her right knee at some future point.
The plaintiff attempted to minimize the appearance of her body-wide striae by undergoing numerous costly laser treatments as well as surgery to remove loose skin about her arms and breasts. Unfortunately, neither of these treatments resulted in any significant improvement of the plaintiff’s disfigurement.
The plaintiff incurred special damages of approximately $91,000, which included past medical expenses and the cost of future anticipated medical procedures.
Practice Note: Following the filing of the plaintiff’s civil complaint, a Medical Malpractice Tribunal was convened in accordance with M.G.L. c. 231 ¤60B. During the Tribunal hearing, the medical panel member, himself a gastroenterologist, sternly challenged the plaintiff’s evidence on the issue of liability. The medical member emphasized that the plaintiff’s medical records clearly showed that the defendant had indeed ordered a ceruloplasmin test to rule-out or confirm Wilson’s Disease, and questioned plaintiff’s counsel as to the whereabouts of the results of the ceruloplasmin test ordered by the defendant. Plaintiff’s counsel responded that the Tribunal hearing was convened before discovery was underway, and that the plaintiff would not have a response from the defendant on the results of the ceruloplasmin tests until either interrogatories were answered or a deposition was taken of the defendant (the medical records obtained by plaintiff’s counsel did not include the results of the ceruloplasmin test). As a result, the Tribunal ruled against the Plaintiff, requiring the plaintiff to post a bond in the amount of $6,000.
Shortly after the bond was posted, plaintiff’s counsel received the defendant’s answers to plaintiff’s interrogatories and responses to plaintiff’s document requests.
In his answers to plaintiff’s interrogatories asking for the specific results of the initial ceruloplasmin test, the defendant replied that while a ceruloplasmin test was ordered, it was apparently never performed.
Despite numerous appellate decisions which have held that discovery in medical malpractice cases should not be stayed pending the outcome of the Medical Malpractice Tribunal, that practice is anything but uniformly followed. Delaying discovery until such time as a Medical Malpractice Tribunal has been convened and its Order issued can pose significant disadvantages for the plaintiff. Given the frequency of significant delays in convening Tribunal hearings, particularly in cases involving the more specialized areas of medicine, efforts to begin discovery promptly upon receipt of the defendant’s Answer to the Complaint, should be vigorously pursued.
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