Ms. Q, age 28 years, worked as a physician assistant in a family practice clinic in a small Southern town. She had been working at the clinic for the past two years and enjoyed the autonomy of seeing patients on her own. The work also provided diversity since her patients ranged from children to the elderly.

One afternoon, a patient came in for an appointment. Mrs. G, age 21 years, was pale, and her face was tight and stressed. Glancing at her chart, Ms. Q noted that the patient had a one-year-old child. Shortly after the child was born, Mrs. G began using medroxyprogesterone (Depo-Provera) shots for birth control. Two months ago, she switched to levonorgestrel and ethinyl estradiol (Nordette-28) tablets. Her BP and pulse were normal, and her record indicated only minor illnesses in the past.

“What brings you here today?” asked Ms. Q.

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“I have terrible headaches,” replied the patient. “They make it hard for me to take care of my baby.” Mrs. G described how the headaches were often accompanied by nausea and vomiting. She reported trying aspirin, acetaminophen, and ibuprofen at various times to ease the pain, but to no avail. The headaches began several weeks ago and were an almost daily occurrence. She’d had a brief respite of about a week without headaches, but then they returned.

“When you get these headaches,” asked Ms. Q, “are your eyes particularly sensitive to light? Do you notice that sounds bother you as well?”

“Sometimes,” the patient responded. “The baby’s crying makes it worse. She’s getting a tooth and screams all the time. Sometimes she spends the whole night crying.” Mrs. G looked dejected. “I try to be patient with her, but I’m not getting enough sleep. Then she starts screaming and the headaches return.”

“Can anyone help with the baby so you can get some rest?” Ms. Q asked.

“My husband is usually exhausted when he gets home. We have no family nearby,” explained Mrs. G. “I had to hire someone to watch her so I could come here today, but that’s not something I can do often.”

“I understand,” said Ms. Q. “I’m going to prescribe something to help with the pain and the nausea.” She sent Mrs. G home with prescriptions for promethazine (Phenergan) and acetaminophen/butalbital (Phrenilin).

Mrs. G filled the prescriptions and returned home. Two days later, however, she was taken to the emergency department (ED) of a local hospital with complaints of numbness, nausea, vomiting, and dizziness. The doctor in the ED noted that Mrs. G was somnolent, difficult to rouse, and unable to obey commands. She was admitted to the ICU.

A brain MRI revealed blood clots, with the superior sagittal sinus vein completely occluded. She also had brain herniation. Despite the efforts of the medical staff, her condition was deemed terminal and she died shortly thereafter. An autopsy revealed the cause of death as recent thrombus of the superior sagittal sinus with bilateral acute cerebral infarcts associated with secondary thrombi of tributary veins. When her husband questioned what this meant, he was told that she had died from a blood clot in the brain, caused as an adverse reaction to her birth control pills.

The grieving and angry husband called a plaintiff’s attorney. “She was so young, and we have a baby,” he said. “She shouldn’t have died. Someone is responsible, and I want them to pay.”

After getting a copy of Mrs. G’s medical records, the plaintiff’s attorney consulted with a physician who told him that Ms. Q should have immediately taken Mrs. G off the birth control pills and ordered tests to make sure she wasn’t suffering from thromboembolism. “It was inexcusable for her not to suspect the pills,” said the doctor.

The attorney accepted the case and began the lawsuit against Ms. Q. Mrs. G’s husband would not consider any settlement, and the case progressed to trial.

The plaintiff’s attorney’s first witness was a PA who testified as to what the standard of care should have been. “In my opinion,” said the witness “all the information in the patient’s record pointed to the birth control pills as the trigger for the headaches. They began shortly after she was switched from her previous method of birth control to the pill, and headaches are a known warning sign for adverse reactions to pills that contain estrogen.” The witness went on to state that cerebral thrombosis is a known adverse reaction to birth control pills, and that patients who have recurrent or severe headaches should always be taken off that form of contraception immediately. “Every medical professional knows that,” she stated.

Other witnesses followed, including a pathologist who testified as to the cause of death, another PA expert, and finally, Mrs. G’s husband.

The defense introduced its own medical experts, including another PA, who testified that Ms. Q had followed acceptable protocol in her treatment of the patient and that there had been no breach of the standard of care.

Ms. Q herself testified as to the conversation with Mrs. G that led her to believe that she was suffering from tension headaches.

The jurors reached a verdict in 35 minutes. They found for the plaintiff and awarded Mr. G $7 million in damages.

Legal background

To prove negligence in a medical malpractice case, a plaintiff must show that the defendant failed to adhere to the standard of care that a reasonable medical professional would have in that same situation and that this failure caused an injury. The fact that a plaintiff has an injury does not in itself mean that malpractice was committed. Some injuries are unavoidable even with the best care. However, if a clinician failed to meet the standard of care leading to an injury that could have been prevented, a jury can find that malpractice has occurred.

Protecting yourself

Practicing medicine is often like being a detective. Clues have to be examined to reach the proper diagnosis. Ms. Q neglected to consider some important and obvious clues. Estrogen-containing birth control pills are known to put patients at risk for blood clots. Headaches, especially severe and persistent headaches, are indications of a potential cerebral thromboembolism. When Ms. Q ignored these clues, she deviated from the standard of care expected from a PA, and therefore she was found liable at trial. A patient’s record and the information you glean from a conversation are valuable clues that should be examined both separately and together to come to the best possible solution. n

Ms. Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.