On Nov. 18, 2008, the patient presented to the emergency room at Lewis Gale Hospital in Salem with complaints of sudden vomiting, chest pains and abdominal pains after eating a piece of banana. She was an obese patient who had had an adjustable gastric band placed almost two years earlier, but had not experienced any previous complications with it. She remained in the emergency room for about nine hours. The ER attending performed a cardiac work-up to rule out myocardial infarction, and ordered an abdominal x-ray, lab tests and an abdominal CT scan. The report for the CT scan was otherwise normal, but the radiologist raised concerns about the position of the band. The patient was diagnosed with gastritis with intractable vomiting and was admitted by a nocturnist.
The following day, the patient was seen and examined by the defendant attending hospitalist. The patient informed the hospitalist that she had flank pain just under her ribs; her abdominal pain was gone, but she had chest pain with breathing; and had calf pain two weeks earlier. The hospitalist consulted a gastroenterologist to determine whether the GI symptoms were related to the gastric band, ordered a kidney ultrasound to rule out kidney stones and ordered a CT scan of her chest to rule out pulmonary embolism. The gastroenterologist found no findings in the report of the abdominal CT scan to explain the abdominal pain and recommended no further GI work-up. A urinalysis was done, and it was abnormal. Culture and sensitivity was done on the urine, which revealed e-coli.
On Nov. 20, the gastroenterologist examined the patient again and reported that he doubted GI pathology. He recommended a urology consult. Later that day, the patient developed a sudden onset of chest and epigastric pain. The hospitalist transferred the patient to the ICU and consulted with a pulmonologist to evaluate the patient for a potential pulmonary etiology and a cardiologist to evaluate for cardiac etiology. The pulmonologist noted that the patient had a gastric band without any complications.
On Nov. 21, the hospitalist ordered an abdominal CT. The gastroenterologist re-examined the patient and ordered a CT angiogram. The CT angiogram revealed free air under the diaphragm. A surgeon was consulted, and the patient transferred to Roanoke Memorial Hospital where she underwent emergency exploratory surgery. She had stomach necrosis with perforation at the site of the gastric band. She underwent partial stomach resection, a lengthy hospitalization and extended recovery and rehabilitation.
At trial, plaintiff called Gary Salzman, M.D., a pulmonologist from Missouri, and Paul Lin, M.D., a general and bariatric surgeon, to testify on the standard of care for internal medicine hospitalists. Over the objection of defense counsel, Dr. Salzman and Dr. Lin testified that the hospitalist and nocturnist breached the standard of care by failing to consult a surgeon instead of a gastroenterologist. They testified that had a surgeon been consulted on Nov. 18 or Nov. 19, 2008, the surgeon would have diagnosed and treated lap band slippage before the stomach necrosed and perforated. The plaintiff also called the operating surgeon who testified that the patient had lap band slippage.
The hospitalist defendant called Alan Dow, M.D., a hospitalist, and Mohan Nadkarni, M.D., an internist, to testify on standard of care. The nocturnist defendant called Murat Gezen, M.D., a hospitalist, to testify on standard of care. All three experts testified that the nocturnist and the hospitalist complied with the standard of care, and that there was no clinical justification to consult a surgeon at any time before Nov. 21, 2008. The defendants jointly called Terrence Fullum, M.D., a general and bariatric surgeon, who testified the patient’s presenting symptoms were not confirmatory of gastric band slippage, and the reports of the CT scans did not include any information that would have caused a surgeon to diagnose gastric band slippage. Defendants called the consulting gastroenterologist who testified that he evaluated the patient for gastric band slippage and he found no clinical or radiology findings that would have diagnosed lap band slippage while the patient was admitted at Lewis Gale.
After a four-day trial, the jury deliberated for approximately one hour and 20 minutes before returning a defense verdict.[13-T-151]
Type of action: Medical malpractice
Injuries alleged: Failure to diagnose gastric band slippage led to stomach necrosis and perforation
Name of case: Palmer v. Salem Hospitalists, et al.
Court: Salem Circuit Court
Case no.: CL12-319
Tried before: Jury
Judge: Clifford R. Weckstein
Date: Aug. 9, 2013
Special damages: Medical expenses – $270, 543.42; lost income – $18, 325.44
Verdict or Settlement: Defense verdict
Attorneys for defendants: Brewster S. Rawls and Coreen A. Silverman, Richmond; M. Pierce Rucker and L. Thompson Hanes, Richmond
Attorneys for plaintiff: S. D. Roberts Moore and Les S. Bowers, Roanoke; Tommy Joe Williams, Roanoke
Defendant’s experts: Alan Dow, M.D., Mohan Nadkarni, M.D. and Murat Gezen, M.D., standard of care; Terrrence Fullum, M.D., causation
Plaintiff’s experts: Gary Salzman, M.D. and Paul Lin, M.D., standard of care and causation
CORRECTION: An earlier version of this V&S report identified M. Pierce Rucker and L. Thompson Hanes as attorneys for the plaintiff. They were, in fact, attorneys for the defendants. Virginia Lawyers Weekly regrets the error.