WhiteCoat

Michael J Woods and Celebrity Malpractice Trials

ja1110_jwoods_2_11-10-09_BRGDBJEJohn Ritter died from a ruptured thoracic aneurysm. His family sued the emergency physicians for allegedly failing to treat him quickly enough.

Now another celebrity is suing emergency physicians. James Woods, brother of deceased Michael J. Woods, is suing a hospital and its emergency physicians for failing to treat Mr. Woods quickly enough.

Michael Woods went to the “fast track” part of the emergency department complaining of nausea and a sore throat. He began “sweating profusely” told doctors that he was having an “anxiety attack.” A doctor in the “fast track” side of the emergency department examined Mr. Woods’ throat and then sent him to the main emergency department when his throat was not inflamed.
When taken to the emergency department, the nurses attempted to give him medications and he stated “Stop doing this, I don’t need all this. This is ridiculous.” Eventually he allowed the medications to be given. An EKG was performed that showed “alarming” changes (that were never fully described in the articles) and cardiac monitoring was ordered, but the rooms with monitors were all full. Mr. Woods was then placed in a hall gurney next to the nurse’s station. Ninety minutes later, Mr. Woods slumped over in his bed and went into cardiac arrest. CPR was performed for nearly a half hour, but he was not able to be resuscitated. A coroner’s report showed that Mr. Woods had severe cardiovascular disease throughout his coronary arteries.

Experts alleged that Mr. Woods should have been placed on a monitored bed immediately and that the failure to do so cost Mr. Woods his life.

From what we are being told, this is just another example of a fallacy being fed to the jurors. There is nothing special about cardiac monitors. They alarm if there is an arrhythmia. They don’t warn medical providers of impending heart attacks or cardiac arrest. By putting Mr. Woods on a monitor, all that would have changed is that the medical staff may have gotten to him 30 seconds earlier when he slumped over in his bed.

From the testimony described, the care that Mr. Woods received was by no means perfect. The law doesn’t require “perfection.” The law requires that medical providers act “reasonably.” How do we quantify “reasonableness” when emergency providers are overwhelmed with patients or when there are not enough supplies available to meet the needs of patients?

What is reasonable in the midst of chaos?

I just hope that jurors keep the “reasonableness” standard in mind when deciding this case.

A link to multiple posts about the Woods trial, being held in Rhode Island, can be found on the Providence Journal site at www.projo.com using this link:
http://news.beloblog.com/cgi-bin/mt/mt-search.cgi?blog_id=1078&tag=Michael%20Woods

35 Responses to “Michael J Woods and Celebrity Malpractice Trials”

  1. Fyrdoc says:

    I love the article written right after his death that states 1. it was less than 1 hour from arrival to death, 2. He was in good health and 3. his chief complaint was a sore throat.

    Now keep in mind, this article I refer to was written right after the event and before a suit could’ve been filed. Thus, it is more likely an honest accounting of events.

    1. The national standard is 90 minutes from the time the patient arrives until the primary intervention in a cath lab in clearly demonstrated ST elevation myocardial infarctions (the most time sensitive of all heart attacks). If he died in less than 1 hour, the hospital had 30 minutes to go before the standard was violated. And that would be if it were a STEMI – unlikely as they had an ECG and these are easy to recognize.

    2. The patient was not “in good health”. He had undergone PCI with stenting in 2006. Stents can re-occlude rapidly.

    3. “Sore throat” is hardly a typical presentation of cardiac disease. The fact that they were assessing cardiac (over the patient’s objections by all reports) is laudable.

    I’m sorry, but a monitor wouldn’t have made a difference here. Immediate PCTA may have helped but based on the facts provided, he didn’t meet criteria – and remember the John Ritter family sued (and won) because the emergency department in that case went straight to the cath lab and the aorta was the problem. Mr. Woods was in the process of a work-up when he died, unfortunate – yes. Malpractice? No.

    • Fyrdoc says:

      Allow me to correct by the more detailed report. ECG time 17:44, CPR initiated at 19:10. 86 minutes. Even if they had activated the cath lab immediately (and risked the John Ritter fate), they only would have seen code on that table as opposed to the ED gurney. There is no question that the standard was met here as even applying the most restrictive standard (90 minutes door to balloon on typical presentations, 90 minutes diagnostic ECG to balloon in atypical presentations), he was 4 minutes under at the time of the code. There is absolutely no way to prove this death would not have occurred regardless of how the patient was treated. He was apparently given some medications in the period of evaluation – which he initially refused. There are no medications proven to forestall an MI in this setting.

      • Max Kennerly says:

        I’d be a bit wary of the reporting on this (or any other) case. For example, one of the articles linked says:

        “James Woods, who sat at the defense table, repeatedly lowered his head into his hands during testimony about his brother’s death.”

        I’m certain he was not at the defense table.

        I’m sure the plaintiff’s expert has some sort of explanation for why the delay was a cause of Mr. Woods’ death. Any guesses what that explanation is?

      • Fyrdoc says:

        Max,

        They will allege that an arrhythmia occurred prior to his death. Had he been on a monitor, the arrhythmia would have spurred the treating team to further action. That is unless the “alarming” ECG is being read by their expert as indicating a STEMI. This would be a double edged sword – on the one hand, it would so a BIG miss by the treating team, on the other the 90 minute time standard would apply – and he died at 84 minutes. Ideally (for the defense team) the death would have occurred on the cath lab table, but as it sits, they were within the time.

        To sum up, my guesses
        1. If the ECG did not show a STEMI (a point of fact that could be agreed to by both parties):
        The Plaintiff – Had but the defendants realized the severity of the situation, they would have been monitoring him and would have picked up a number of (hypothetical) warning signs of the impending disaster.
        The Defendant – The patient was extremely ill. He had pre-existing disease that could lead to a number of pathologies. We were evaluating him in accordance with the standard of care. He unfortunately succumbed to his illness before we could complete that evaluation. There were no inventions indicated that would have altered this outcome that were not performed.

        2. If there was a STEMI: The Plaintiff – the standard of care clearly indicates the time between the diagnostic ECG and inflation of a intracardiac balloon be no more than 90 minutes. There was absolutely no way that the defendants were going to meet this standard. But had they been preparing to do so, the patient would have received a variety of medications in preparation for the PTCA and those meds would have saved his life.
        The Defense: Had we been prepared to perform the PTCA at 89 minutes (inside the standard), the patient would have died regardless. In short, yes, we erred, but this did not cause the injury.

      • Fyrdoc says:

        Max,

        It seems (on continued thinking about this case) that the defense is going to be forced into a position that the physician’s / nurse’s / hospital’s actions were not the proximate cause of the patient’s injury. Is this is more difficult defense to take (legally speaking) than one that denies an error occurred?

        Anyway you cut it, the Plaintiff is basing their case on a significant hypothetical – had he been monitored / been being prepped for a PTCA / had one-to-one nursing, some event would have been noticed in timely enough fashion as to change the outcome. I’m just not sure how they can prove such a hypothetical “warning” would have existed or that it would have or should have changed the actions of the treating team. There is an awful lot of conjecture needed here…

      • Max Kennerly says:

        “Is this is more difficult defense to take (legally speaking) than one that denies an error occurred?”

        It depends on the case. IMHO, the worst thing a defendant can do is dispute an error occurred where one obviously did – that primes jurors to hate defendants and believe they need to be taught a lesson.

        As to causation, jurors tend not to like causation defenses where the argument is that the patient would have died anyway. In a lot of states, the “loss of chance” is compensable anyway, so, unless it’s quite clear the patient definitely could not have lived, the jury will usually award damages if it seems the defendant’s error denied the patient a decent chance at survival.

        Some causation defenses work a lot better; e.g., jurors are usually receptive to a defense that challenges what the actual cause of death was, since they understand that medicine isn’t perfect.

        86 minutes without proper monitoring sounds like a long, long time to a jury. Keep in mind, although “90 minutes” may be standard of care in the time to get someone on the cath, that’s not actually the question here. The allegation is not that they didn’t do the cath process fast enough. The allegation is that they didn’t perform monitoring which would have started the process.

        Thus, if the plaintiff can prove monitoring was erroneously not done, and that monitoring would have gotten the ball rolling, all they need to show is that it’s “more likely than not” that the cath would have been performed in those 86 minutes and “more likely than not” the cath would have saved his life.

        I think a lot may actually come down to what that EKG showed; if it should have set off big warning bells, then the defense will have a big problem.

      • Fyrdoc says:

        “Thus, if the plaintiff can prove monitoring was erroneously not done, and that monitoring would have gotten the ball rolling, all they need to show is that it’s “more likely than not” that the cath would have been performed in those 86 minutes and “more likely than not” the cath would have saved his life.”

        It would be hard to say with any certainty that monitoring would have gotten the ball rolling. Some patients demonstrate arrythmias as a “warning” that something bad will happen. Others go without any change. There is no question he suffered a fatal arrythmia. All reporting seems to indicate this was the result of coronary artery disease. The question, which to my eyes is would the monitoring have mattered. I can not see how it could be proven that it would (or wouldn’t) have.

        That said, if a patient can not be monitored due to space or equipment limits, an ECG every 15 minutes is a reasonable sustitute. That will be hard to overcome.

      • Fyrdoc says:

        Sorry that last post was incoherant. I was interrupted several times. The problem with this case (and the reason I bring up the 90 minutes) is that I’m not sure that there is even 51% certainty that monitors would have changed the outcome. Let’s assume that the treating physician recognized the impending doom at the moment of the initial ECG and ordered an immediate PTCA, at most places, especially one so overwhelmed as this institution is described, could have easily taken 90 minutes to get that cath. Thus, no change in outcome (as within 90 minutes he was dead). If cath wasn’t indicated, then the question is what would the monitors have shown different? Few places have ST-T segment monitors with single task dedicated monitoring technicians. Most have standard monitors which would unlikely show any significant changes until death was immenent. But let’s assume, for the sake of arguement, that the monitor (or a repeat ECG) showed some major change 15 minutes after the first ECG. That would prove an evolving situation, the PTCA would be indicated, and again the patient would have died before it would likely have been done. So while I can’t defend (based on the reported “facts”) the fact that the patient wasn’t monitored, I can’t see how it can be proven, even to a low “51%” standard, that the use of a monitor would change the outcome…

      • Max Kennerly says:

        It sure would be nice to see the expert reports on the case.

        My speculation is that either (1) the pathology report showed less than total blockage, and the argument is that the decedent died of a NSTEMI that could have been detected and treated or (2) there’s a decent argument that intervening drugs would have helped or that the cath would have been done within 86 minutes.

        Here in the court house,
        The whole town was there.
        I see the judge,
        High up in his chair.
        Explain to the court room,
        What went through you mind.
        And we’ll ask the jury,
        What verdict they find.

      • Fyrdoc says:

        I agree Max, we are guessing. The issue I have, although somewhat esoteric, is that some components of the standard of care are not evidence based. It is difficult to know what effect, if any, a monitor would have had in this case. I agree, once the idea of cardiac pathology is entertained, monitors are the standerd. But, for example, the drawing of blood cultures in pneumonia remains a standard of care (in fact it is a TJC “quality measure”) despite the fact that study after study have demonstrated no net effect on patient care or outcome (other than increased expense).

      • Fyrdoc says:

        Max,

        What I don’t understand is that in Federal Trademark law, the definition of terms is considered a point of fact and too technical for a jury. Should not the standard of care also be considered a “fact”. If we, as physicians or lawyers, state something is a “standard”, then that standard should be definable and agreed to. I think physicians’ collective concern would largely disappate if the equivalent of Markman Hearing were held in MedMal. The findings could be applied by other physicans to improve overall care, and the plaintiff would still be free to avail themselves of the jury system to discuss to dispute over if the standard was breeched or if that breech caused injury. But asking a jury to decide what the standard of care is – that is a complex issue (but one that should be able to be answered outside of the trial).

      • Max Kennerly says:

        Markman hearings apply to patent infringement cases, but the point is the same.

        The core difference there is that patents (and trademarks, and insurance policies, and ‘integrated’ contracts [where the contract excludes all oral statements]) boil down to a single written document, which makes them squarely within the province of the court to interpret. To word that another way, courts are generally allowed to determine themselves, without fact-finding by a jury, what words on a paper mean.

        When it comes to a standard of care, there’s no underlying document – like a patent or a trademark filing – for the court to parse through for its legal meaning. It’s just one expert disagreeing with another.

        There are, in theory, safeguards against bogus medical theories coming in (typically called a “Daubert” or “Frye” hearing depending on the state), but in practice these mean little, since there’s not much for the court to do there: presumably, the expert in question has some substance to the opinion, substance which the court is ill-equipped to review.

        Some have recommended adding a “neutral” expert to the process. But as I wrote before (see http://bit.ly/7FoIm4 ):

        “[C]hosing a “neutral” expert and the materials they opine on will probably make medical malpractice litigation more contentious, expensive, and uncertain because it will at best resemble the Markman process used in evaluating patent disputes. Markman hearings often involve the selection of a “neutral expert” in helping the judge determine the meaning of a patent, a process loathed by patent attorneys for adding “a whole new level of lawyering, cost, delay and, some say, uncertainty to patent litigation.”

        Moreover, there’s a fundamental question about how much probative value the neutral expert would add. What would they base their opinion on? Why, the same studies, experience and training that the parties’ experts do, all of which is already subject to cross-examination by the opposing party. Adding an expert might then end up doing little more than making medmal litigation more expensive than it really is, without doing much to change the overall process’ reliability.

      • Fyrdoc says:

        “Moreover, there’s a fundamental question about how much probative value the neutral expert would add. What would they base their opinion on? Why, the same studies, experience and training that the parties’ experts do, all of which is already subject to cross-examination by the opposing party. Adding an expert might then end up doing little more than making medmal litigation more expensive than it really is, without doing much to change the overall process’ reliability.”

        I guess my thought process goes like this. 1. There is never a clear “standard” of care if a “standard” is not generally agreed to. There is a “standard” for flying an instrument approach in a aircraft, a set checklist of things that must be accomplished at a minimum. In medicine, assuming you can find a paid whore to spout your case, you can argue the “standard”; but if it is arguable then it isn’t a standard. 2. As such, there is absolutely no utility in case analysis for physicians in terms of attempting to learn from or extrapolate the findings of any given suit. This leads to the almost superstitious, and as you and Matt have pointed out – often ineffective, changes to practice in the name of avoiding suits. 3. If a standard is defined, in short order, a clear cut pathway will exist for almost every presentation. This would allow physicians to cut down on unnecessary procedures and testing. 4. Defining a standard really is the practice of medicine and is a complicated procedure. Deciding if that given standard was violated or if that violation resulted in injury seem more like disputes best settled by a jury. 5. I have to believe that many of the physician complaints regarding lawsuits would disappear if there at least existed some guidance from the courts on what the appropriate actions are to be in a given presentation. While I agree with you that much of what constitutes “defensive medicine” is likely ineffective at reducing liability, I think that lawyers in general fail to see the stress the threat of lawsuits bring to physicians. While it is true that unmerited suits rarely pay out, it does happen. As such it is a subject of fear. There is no difference between a physician fearing suits and thus lawyers than an africian american fearing unjust incarceration and thus fearing the police. Yes, such events are rare, but they are so devastating and seemingly without any more provocation than “wrong place, wrong time”.

  2. Matt says:

    WC, when you get done fussing about celebs and malpractice (is this the health blog version of People magazine?), will you be posting any thoughts on probably the biggest issue for both patients and physicians, certainly far more important than malpractice and patient surveys, the healthcare reform bill that passed last week?

    How will it affect you as the provider? How will it affect your relationships with us the patients? Will you make more or less money? And so on.

    • Anonymous says:

      Matt,
      In which country are you? The HC bill did not pass! This was simply a vote to open debate. Get your facts straight!

      • Matt says:

        My bad. You’re right. It’s not important at all. Waste of time to get a physician’s thoughts on it. Carry on.

      • Fyrdoc says:

        Matt,

        Only a lawyer could believe that a cogent commentary could be provided on how a proposed, not yet even fully drafted or reconciled bill will affect us as providers, affect our relationships with patients or change our income. We do realize that you are used to spending inordinate amounts of time discussing hypothetical situations in subjects you know nothing about. In fact, you have made a career of it. We get that. Unfortunately, we haven’t. While those of us here who are emergency physicians are used to working with little information, it is far too early to discuss the status of a yet unedited bill that has yet to pass.

      • igloodoc says:

        fyrdoc
        ” it is far too early to discuss the status of a yet unedited bill that has yet to pass”

        Um… we need not worry because no matter what edits are made to the bill, the outcome will be the best medical care system the lawyers can design.

        Whatever passes, I know I will be as happy to see it as a New Yorker with a jury duty summons for a “long” trial…

      • Fyrdoc says:

        Igloo,

        I agree completely. Matt asked “How will it affect you as the provider? How will it affect your relationships with us the patients? Will you make more or less money? And so on.” There is simply no way to know yet. With HUGE issues like the public option and opt-outs still in the air, how do we even begin to respond – other than to say what has been said here many times before – none of the currently proposed plans seems very good for healthcare as a whole.

    • Fyrdoc says:

      Hey Matt, if you don’t like the blog – LEAVE!

      • Painless says:

        Fyr,

        Now now, behave. Don’t you know that the suite brought on by James Woods has nothing to do with money or perceived wrongdoing? It’s just an attempt to find out what really happened and what could have been done to prevent it. And of course if it was preventable but wasn’t due to the evil ED staffers, they should be held accountable so they learn not to let it happen again. Ever! It was a terrible thing that happened, and the only way to make sure physicians and nurses all over the country don’t make the same mistake is to discover the facts, prove they could have done better and then award damages. If the ED staff had only had their x-ray goggles or crystal balls working (I’m sure they were in the shop that day.. or being cleaned… something) then this terrible malady would never have happened. So get off your high horse and start discussing things that actually matter – like the health plan that is in the planning stages as it might affect how you eventually get paid if it ever actually gets out of the planning stages and into law.
        Now maybe if the ED staff had one of those fancy retrospectrascope monitors handy this would have never happened….

      • Matt says:

        Painless anyone who tells you a civil suit is not about the money is kidding themselves. With limited exceptions, money is essentially all you can ask for. You can’t sue to turn back time, you can’t sue for an apology. Is it a crude substitute? Yes, at times, but we have decided that for some wrongs we are not going to jail people, but at the same time we believe they have a value. Money is the only way to value it in court. That’s why even physicians, when they file a civil suit, generally sue for money.

        Likewise with the claim that it’s done to improve medicine. While that may be the occasional ancillary benefit, that is certainly not the purpose of a civil suit, again with limited exceptions. It’s between just the parties involved, and they are the only ones who matter to each claim. Medicine will have to improve itself.

        Now, if you don’t think the bills in the House and Senate are important right now, that’s your business. For while they will affect me from a tax perspective and on the few times when I am a patient, they will affect you EVERY DAY. If you don’t think that matters, that’s fine. But to suggest that even if one cares one can ignore these because it’s “in the planning stages” is foolish and reflects a lack of understanding of how policy is made. Right now billions are being spent, by every stakeholder, to shape this debate. And it’s not being spent by people who are foolish with their money and don’t think anything is going to come of it.

        As far as you’re criticism that people are always looking back, well, if your position is that we should never judge any act because it happened in the past and we’re always looking back, then say so. Otherwise, your comments on that don’t make much sense.

  3. Elizabeth says:

    “The law requires that medical providers act “reasonably.” How do we quantify “reasonableness” when emergency providers are overwhelmed with patients or when there are not enough supplies available to meet the needs of patients?”

    This is actually an interesting legal question. I believe that the typical standard is that if being overwhelmed was not reasonably foreseeable, then it is an excuse (although it sounds like in this case no excuse was needed – the standard of care was probably met anyway). But if you know that the ED gets slammed every Saturday night with regularity and the hospital doesn’t adjust staffing levels to prepare for it, then the hospital may be on the hook. I don’t think it would be likely to affect an individual doctor’s liability.

  4. […] This post was mentioned on Twitter by rlbates, EPMonthly. EPMonthly said: Actor James Woods sues hospital for failing to treat his brother quickly enough. http://bit.ly/8EhcCh […]

  5. Adan R Atriham says:

    Concur with all comments. I just would like to add one thought. If we all agree that the US health care system is broken (and we all do), the safety net is (and will continue to be) the emergency departments. Our ED’s are chronically overwhelmed, overcrowded, understaffed and underfunded. If this reality is not shown to the public, we’ll continue to be blamed for not being “fast enough or good enough”.
    I really hope that this undergoing reform will provide some very much needed relief for our emergency systems.

  6. Nurse K says:

    They might be screwed if the initial EKG had concerning changes (but presumably not a STEMI) and they didn’t repeat it even without having a cardiac monitor available.

    PS Some ERs now have continuous 12-lead monitoring with ST segment monitoring (which is annoying because it alarms every time the patient moves, but whatever)…

  7. Robert McNamara, MD says:

    The doctor, Dr. John Schriver, chief of emergency medicine at Rochester General Hospital in Rochester, N.Y., said that Kent doctors and staff did not meet the accepted standard of care for the profession when they treated Woods in the hospital’s emergency room on July 26, 2006.

    And, of course, in every case like this there is an EM expert willing to say a colleague screwed up.

    • Max Kennerly says:

      It’s appalling whenever doctors assist the civil justice system. Don’t they know that justice and responsibility are lower priorities than protecting a “colleague” they’ve never met who screwed up?

  8. Soronel Haetir says:

    I am only going to address the overwhelmed issue. I agree with the poster above that whether the traffic is foreseeable or not is the critical question when making that avaluation. I would suspect that population served guidelines would be an important factor in such a determination and if a facility does not respond to a growing population they may well be in trouble.

    A facility, staffing and material levels that suffice for 50k population will almost certainly fail at some point as that population expands.

  9. […] this post of White Coat’s blog about a celebrity lawsuit against ER doctors who apparently did not have a patient on a monitor that […]

  10. Fannin says:

    I’m neither a doctor nor a lawyer, so I apologize if the answer to this is obvious to everyone else. But it’s my understanding that emergency departments typically lose money because a lot of the people who show up for treatment can’t pay for it.

    So wouldn’t there be some limits on the requirement to be prepared to cope with anticipated traffic? It would seem to me that such a requirement would end up costing at least some hospitals so much money that they’d be forced to close their emergency rooms. Sure, I can imagine situations in which a hospital just doesn’t bother to provide enough rooms for cardiac monitoring even though they could, and many people die as a result, but I can also imagine situations in which, a hospital especially an older hospital in a poorer area coping with not enough space and not enough money and too much need, does the best it can but finds that that’s not enough for all comers.

    Those of us fortunate enough to have good insurance are definitely in a position to obtain a lot of good routine medical care, but I’ve always assumed that the fact that so many people don’t have good insurance combined with doctors’ and hospitals’ responsibility to provide lifesaving care even if the patient can’t pay for it means that when it comes to emergency rooms and lifesaving therapies there will be rationing and it won’t be based on what insurance plans patients have.

  11. Trish says:

    Your care isnt based on your payment options or insurance. But it is limited if there are not enough beds. And no matter if you have 100 monitored bed, there will be THAT night when you have 101 actual MIs come in. Then what do you do? Short staffing in ERs isnt always based on anything other than the fact that there are no other nurses to work there. The staff you have cannot work 7 days a week, even if you want to. That would drive anyone insane(er). Anybody who works ER can tell you that those days off are crucial to keep you sanity!

  12. Rogue Medic says:

    It is interesting to read the way a reporter describes medical care. There is no mention of the medication, only of the route of administration. There is no mention of what was seen on the ECG, only that someone described it as alarming, while someone else stated that it was ambiguous.

    Since he was not on a monitor, we do not really know what his heart was doing during all of that time. was he in an arrhythmia? Was he in and out of an arrhythmia? With panic attacks, it is not uncommon for the patient’s rhythm to be sinus tachycardia, which sounds bad, but is a normal response to panic.

    The witness for the plaintiff claimed that he knows with certainty what happened, because he had all of the information the doctor had. He admitted that he had not read any of the statements from the nurses. He also did not have an opportunity to examine the patient, which can be the most important piece of information available to the doctor. He does not have that information, so he denies that assessment is important. I guess being a hired gun means being psychic.

  13. the golden profession says:

    The bottom line is that the team was in the process of working up the patient.woods is gonna lose this case.I think all would have happened anyway .the staff in this case did nothing wrong.and In the 20yrs of emergency care I have seen a lot of wrong sadly.I am sorry for Mr. woods loss.

  14. Amanda says:

    Its actually scary to see those in the healthcare field forget that their patients and patients family and friends are human. Apparently some doctors, surgeons, and other healthcare professional staff need to be brought back to the real world and perhaps knocked down several pegs. This is sickening to read.

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