ER doctor wins defense verdict in Wise County

A jury in Wise County returned a defense verdict for an emergency room doctor in late February after a patient filed a medical malpractice suit seeking millions of dollars in damages.

The plaintiff, Michael Mitchell, presented to the emergency department of Mountain View Regional Medical Center in Norton in September 2009 believing he was having a stroke. The defendant, Dr. Jack K. Cox II, was the ER doctor on call that day and tended to Mitchell.

Cox and his staff placed Mitchell on stroke protocol, calling for a CT scan of Mitchell’s head, an EKG and blood work.

James N.L. Humphreys of Kingsport, Tennessee, who along with Jimmie C. Miller represented Cox, provided an account of the case.

While Mitchell was experiencing symptoms of a syncopal episode, which includes general weakness and difficulty speaking, and a headache, Cox diagnosed Mitchell with a migraine after test results came back normal.

Cox gave Mitchell two shots of Imitrex, a migraine medication, and later discharged Mitchell after his condition appeared to improve.

About 13 hours later, Mitchell returned to the ER with a worsening condition; Dr. Mary Duncan was the treating physician the second time. A CT scan revealed Mitchell had an ischemic stroke, and Mitchell was later transported Holston Valley Medical Center in Kingsport.

After initially improving, Mitchell had a deep vein thrombosis episode while hospitalized at Holston Valley. Doctors gave Mitchell Heparin to combat the DVT, but his condition worsened. A CT scan then revealed Mitchell was having an intracranial hemorrhage. Emergency surgery was performed, and Mitchell survived. He suffered some neurological trauma as a result, but was able to regain some use through therapy later. Mitchell was hospitalized at Holston Valley for six weeks.

Differing accounts

Mitchell and his family’s accounts of their interaction with Cox on the initial emergency room visit differed than the notes and accounts of Cox and the nurses that helped treat Mitchell.

Cox testified that it was Mitchell alone in the examination room that day, while the family said they were in the room and intensely questioned Cox as to whether Mitchell was having a stroke.

Humphreys said the family also said on the day in question Mitchell reported to the ER unable to walk or talk.

“There was a pretty dramatic difference in the accounts,” Humphreys said.

The family disputed that Mitchell’s condition improved after the shots of Imitrex, while Cox and the nurses’ notes showed Mitchell walked himself into the examination room and was able to talk to Cox.

DVT

Another question raised was whether Mitchell told Cox about his previous history of DVT.

About a month earlier, on a cross-country plane trip, was when Mitchell initially developed deep vein thrombosis.

Mitchell’s mother was a CNA at the nursing home at Mountain View Regional, and according to the nurses, the mother asked to see if Mitchell reported his history of DVT to Cox. According to testimony he did not.

Battle of the medical experts

At trial, the interpretation of studies outlining the effectiveness of a protein introduced to combat strokes was hotly contested between medical experts on both sides.

Mitchell’s family believed he was having a stroke, and instead of Imitrex, Cox should have given Mitchell a tissue plasminogen activator (tPA).

“The plaintiff’s side believed the tPA would have dissolved the blood clot and would have made for a better improvement overall,” Humphreys said. “But there was a pretty big debate between the experts about the effectiveness of tPA. The plaintiffs relied on the more optimistic studies where we on the defense side disagreed with the methodology of those studies.”

The defense claimed that there was a 14 percent or higher chance based on their studies that administering the tPA would have prevented further complications for Mitchell.

But ultimately it would have been clear Mitchell was having a stroke at that time in order for Dr. Cox to take further action. And Humphreys says the fact that Mitchell started to improve after receiving the Imitrex was enough to rule out a stroke.

“All the experts agreed that there are certain conditions that mimic a stroke,” he said. “And all the experts agreed that if someone is improving, even if they have a stroke, that’s an appropriate exclusionary factor. And it’s a fact that Mr. Mitchell improved with migraine medication.”

Additionally, Humphreys says there’s no way to know if Mitchell was even an appropriate candidate for something like tPA given the varying effectiveness in studies and the fact that tPA is not meant to prevent hemorrhagic strokes. It is believed the Heparin given to Mitchell was a factor in his hemorrhage.

The jury ultimately found in favor of Cox after the trial lasted eight days.

Mitchell was represented by Mary Lynn Tate of Abingdon, who could not be reached for comment.