Ms. H, 41, had been a physician assistant in an Air Force clinic for nine years treating not only servicemen and women, but families as well.
Among her patients was Mrs. F, 36, the wife of an airman and mother of two young boys. Over the previous six months, she had been diagnosed with endometriosis, hypothyroidism, insomnia, headaches, anxiety, and diffuse cellulitis. Mrs. F was taking oxycodone and acetaminophen (Percocet), hydrocodone and acetaminophen (Vicodin), and hydromorphone (Dilaudid) for pain; temazepam (Restoril) for insomnia; and lorazepam (Ativan) for anxiety.
Before her fateful visit with Ms. H, Mrs. F consulted an endocrinologist about her thyroid condition. The doctor set up a peripherally inserted central catheter (PICC) to facilitate repeated blood draws.
Mrs. F went to the base clinic two weeks later, complaining of vomiting, dehydration, “the same symptoms I always have,” including pain, and a “heat” sensation in her right arm.
Ms. H recorded these complaints and the patient's slightly elevated temperature of 99°F. Then Mrs. F asked for refills on her Ativan and Dilaudid prescriptions. She claimed that her husband had lost the original bottles, each of which contained 60 pills.
The request made Ms. H uneasy. Mrs. F had been prescribed large quantities of painkillers and anti-anxiety agents, and Ms. H was starting to suspect Mrs. F was becoming addicted. She decided to consult her supervising physician, Dr. D.
After a quick conference in the hall, Dr. D went into the exam room to talk to the patient directly.
“Where is your husband right now, Mrs. F?” the physician asked.
“Out of town,”she replied.
“Why don't I just wait until he returns, and I can ask him about the lost pills,” Dr. D suggested. “Have him call me when he gets back. In the meantime, take ibuprofen for your discomfort.”
Four days later, Mrs. F was brought to the emergency department (ED) complaining of shortness of breath and continuous pain in her arm. Noting “inflammation and a foul-smelling drainage,” the ED physician diagnosed necrotizing fasciitis and rushed Mrs. F into surgery for an aggressive debridement. This procedure was followed over the next two months by several others that left Mrs. F with a disfigured, largely useless right arm and constant, debilitating pain.
She then consulted a plaintiff's attorney about suing the clinic. The lawyer believed she had a strong case but warned that because the clinic was on a military base, she would have to sue the federal government rather than the individual clinicians.
By the time the case went to trial several years later, Mrs. F had divorced. Now a struggling single mother, she was unable to get a job because of her damaged arm and the amount of medication she was taking.
At the plaintiff's request, the trial was conducted before a judge but without a jury. The first witness was an expert in primary care who described necrotizing fasciitis. Early detection is essential, she said, because the infection is often deadly. This physician listed early symptoms as “pain in the general area where the infection was introduced; flulike symptoms, such as nausea, fever, general malaise; and intense thirst.”
“Could vomiting and dehydration be considered early symptoms?” Mrs. F's attorney asked.
“Oh, yes,” the expert replied. “Those symptoms are followed shortly by swelling and discoloration, along with a putrid fluid discharge and then by toxic shock. Once it reaches this stage, the infection is considered advanced.”
“Was the plaintiff's infection advanced?”
“Yes, and treatment almost always involves removal of tissue and/or amputation of affected areas, as was done in your client's case.”
The plaintiff's attorney produced a slew of other expert physicians, who outlined the damages already inflicted on Mrs. F, her need for further medical treatment, and her continued suffering. Several physicians testified that had they been presented with a patient with an elevated temperature, pain at the PICC site, vomiting, and dehydration, they would have examined her more carefully to rule out necrotizing fasciitis.
When the plaintiff's lawyer rested his case, the defense attorney put Ms. H on the stand. She told the judge that Mrs. F was taking at least four pain medications and had asked for refill prescriptions to replace controlled substances that she claimed had been lost.
“Considering how often patients try to con prescriptions from clinicians,” Ms. H said, she believed Mrs. F was “a drug seeker.” So she conferred with Dr. D.
But under cross-examination from Mrs. F's attorney, the PA conceded that her exam might not have been as thorough as it could have been and that she might have discounted the patient's pain as a ruse to get more medication.
Dr. D testified next. He agreed that Mrs. F appeared to be looking for drugs and didn't remember her mentioning any pain or swelling in her arm. But he also conceded that those complaints would have prompted a more thorough exam.
The judge awarded Mrs. F $8.6 million in damages. Dr. D and Ms. H may have been nobly motivated by concern that Mrs. F was becoming or was already an addict, he said, but the patient presented actual symptoms that the clinicians ignored because of their preoccupation.
Legal background
Parties in a lawsuit can opt for a “bench trial,” in which the judge hears a case without a jury. At first glance, this case looks like it should have gone the traditional route. After all, a disabled, single mom is likely to evoke plenty of sympathy. But Mrs. F's attorney chose a bench trial because jurors, like the defendants, might be distracted by the number of controlled substances Mrs. F was taking. A judge hearing the case alone would be more likely to look at the facts and apply the law without being swayed by emotions, the lawyer reasoned.
Protecting yourself
Ms. H and Dr. D had no direct liability in this particular case, because technically, the defendant was the federal government. But had they been practicing in a civilian setting, they would have been named as defendants and been held liable for the multi-million-dollar judgment.
As a clinician, you will probably encounter patients who invent or exaggerate claims of pain in order to obtain controlled substances. When you suspect such behavior, it's easy to believe the worst and give their complaints short shrift.
But sometimes, as was evidenced here, that can be a grave mistake. Before you write off a patient as a drug seeker, be sure to do a thorough exam. You may find a serious illness.
Ms. Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.