Mr. V was a physician assistant who worked in a small office with Dr. W, a general practitioner. The clinicians prided themselves on their thoroughness and high level of patient care. Both were perfectionists and viewed challenging cases as puzzles to solve.

Mrs. E, a 64-year-old widow, had been a patient for the past four years. The petite woman was

5 ft 4 in tall and weighed 112 lbs. She originally came in with complaints of depression but was found to be hypertensive as well. Dr. W prescribed an ACE inhibitor and 150 mg of amitriptyline. After the original office visit, Mrs. E saw whichever practitioner was available.

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Mrs. E was in and out of the office frequently over the ensuing six months, first with a GI illness and then with bouts of dizziness and lightheadedness whenever she stood up too quickly. She told Mr. V that she’d had these symptoms for quite some time but had never been diagnosed. Mr. V attributed the symptoms to a variety of possible causes, including an ear infection with labrynthitis, side effects of her BP medication, and metabolic abnormalities. He referred her out for an evaluation with an otolaryngologist, but the results were inconclusive.

Dr. W and Mr. V discussed her situation and adjusted her BP medication. She soon began to feel well again with no further episodes of dizziness.

Two months later, Mrs. E was back, this time with repeated complaints of weight loss and anorexia (but no dizziness). She was referred to a gastroenterologist for a full GI workup and subsequently diagnosed with Barrett’s esophagus.

A few months after the diagnosis however, Mrs. E returned with intermittent dizziness and lack of appetite. This time, Dr. W met with the patient. She was still taking the amitriptyline and reported no depression. The physician ordered a Holter monitor to rule out a cardiac etiology for her dizziness, but the results were negative.

The next time Mrs. E showed up complaining of lightheadedness, Mr. V measured her BP at 164/84 mm Hg lying down, 146/80 sitting, and 90/50 standing.  He noted that she had significant orthostatic hypotension and autonomic dysfunction. He prescribed fludrocortisone to treat the orthostatic hypotension and instructed her to wear thigh-length compression stockings. Mr. V also noted that controlling her hypertension would have to be balanced with her orthostasis issues. Blood work was obtained, but an amitriptyline level was not included in the workup. The results were normal.

Four months later, Mrs. E was back, accompanied by her concerned daughter. The patient complained of nausea and vomiting. BP was 72/50 and significant orthostatic hypotension was detected. She was too weak to walk without assistance, and Dr. W had her admitted to the hospital, where she remained for a week until she felt better and was able to walk with no dizziness. Blood work was done in the hospital, but again, amitriptyline levels were not measured.

After Mrs. E’s discharge from the hospital, she continued to see Dr. W and Mr. V regularly for orthostatic hypotension and dizziness. The clinicians were stumped by Mrs. E’s continued complaints and were unable to achieve a balance between controlling her BP and preventing orthostatic hypotension. A month after her release from the hospital, she presented with complaints of lack of appetite, nausea, vomiting, watery diarrhea, and episodes of fainting. Dr. W admitted her to the hospital a second time.

On admission, Mrs. E was pale and cachectic, and her BP dropped to 60/40 when standing up. Tremors were also noted. Mrs. E was diagnosed with profound orthostatic hypotension with syncope/autonomic dysfunction with a question of Shy-Drager syndrome, a progressive central nervous system disorder that causes orthostatic hypotension. She was examined by a neurologist who felt that she had multiple system atrophy (MSA) with autonomic dysfunction (Shy-Drager), Parkinson’s, and dementia as well as spells suggestive of seizures. The neurologist did not obtain an amitriptyline level.

Finally, a covering doctor thought to order blood work to check the amitriptyline levels, which were abnormally elevated. The drug was discontinued, and the levels dropped back to the normal therapeutic range and finally to zero. Nevertheless, Mrs. E developed severe respiratory compromise with probable adult respiratory distress syndrome and was transferred to intensive care. She died three weeks later from respiratory failure.

Both Dr. W and Mr. V were shocked at their patient’s death, but neither felt that they had done anything wrong in the treatment. After all, they reasoned, amitriptyline overdose is extremely rare and almost always associated with suicide.

However, it wasn’t long before the patient’s family hired a plaintiff’s attorney, who filed a lawsuit against the two clinicians alleging that they had breached the standard of care in the treatment of Mrs. E and that this breach had ultimately caused her death.

Dr. W and Mr. V’s defense attorney explained the legal definition of standard of care and that they would need to get expert witnesses to testify that the clinicians had acted appropriately. After consulting with several experts, the defense attorney advised Dr. W and Mr. V that although they had a shot at succeeding at trial, it might be in their best interests to settle. The case settled for $1 million.

Legal background

The standard of care for determining medical malpractice is based on how a similarly qualified practitioner would have performed under the same or similar circumstances.  Standard of care is primarily established using expert-witness testimony. In this case, to succeed at trial, Dr. W and Mr. V would have had to introduce expert testimony showing that most clinicians in a similar situation would have treated the patient the same way.

The plaintiff would have to establish that the clinicians had breached the standard of care by doing (or, in this case, not doing) something that normally should or shouldn’t have been done. The plaintiff’s attorney in this case would have used expert testimony to prove that it was the standard of care to test for amitriptyline levels and that Dr. W and Mr. V were negligent in not doing so. Had the case gone to trial, the clinicians would have argued that the issue was so unusual and rare that most practitioners would not have tested for amitriptyline overdose. Everything would have likely come down to a battle of experts.

Protecting yourself

Although Mrs. E’s problem (amitriptyline overdose) was rare, the clinicians should have eventually tested for it. They had been treating the patient unsuccessfully for several years, and the symptoms were not resolving. The two practitioners obviously knew that Mrs. E was taking the amitriptyline because they were the ones who prescribed it. It was a mistake to overlook the fact that Mrs. E was taking amitriptyline when ordering blood work. Of course, the hospital and neurologist made the same mistake. However, as the prescribing clinicians, Dr. W and Mr. V should have paid more attention. Instead, they paid the price.