Ms. Goodwin is manager of clinical risk and patient safety at Cambridge Health Alliance, Cambridge, MA.
The court found that treatment performance was below the standard of care.
Below is a review of a recent court case where the defendants were found to have deviated from the standard of care during a surgical procedure. This case helps to highlight important considerations around the level of involvement and supervision for trainees, and perhaps more importantly, what the patient knows.
The plaintiff had long-standing problems with urinary frequency and difficulty emptying his bladder, lasting nearly 30 years. He had undergone two transurethral resections of the prostate 2 years apart that provided some relief, in addition to taking a 5-alpha-reductase inhibitor.
The plaintiff sought treatment with a new urologist some 25 years after the TURPs had been done with complaints of nocturia, frequency, and urgency. A GreenLight laser procedure was recommended and performed. Postoperatively, the plaintiff experienced significant pain and bleeding, and more importantly, complete urinary incontinence. The plaintiff testified to soaking numerous adult incontinence pads per day.
A few months after the procedure, the plaintiff obtained his medical records from the hospital where the procedure was performed and learned that it had been performed by a third-year resident and not the physician he saw at the outpatient visit. In the complaint, the plaintiff alleged that the resident performed an unnecessary procedure, and that he performed it negligently.
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The appropriate standard of care in medical malpractice litigation is proven-or not-by way of expert testimony. In the jurisdiction where this case was tried, the applicable rule is that expert testimony must explain what a medical professional of ordinary skill, judgment, care, and diligence in the same medical specialty would do in similar circumstances.
Plaintiff’s expert covers key points
The plaintiff’s expert witness, a board-certified urologist, testified to a few key points:
As in most any medical malpractice case that reaches trial, the court and/or jury often must be educated by expert witnesses about the involved anatomy, pathophysiology, and surgical procedures, along with other medical jargon, to fully understand the issues at trial.
The plaintiff’s expert explained the three continence mechanisms that control urine in a male in great detail, and the critical importance of the external sphincter. He additionally testified as to the verumontanum’s importance as a urologic landmark that signals proximity to the external sphincter. The expert then provided a detailed explanation of a GreenLight laser procedure, describing how the laser and camera get into the bladder, that the laser is controlled by a foot pedal, and the importance of continuously monitoring anatomy as the device is withdrawn from the urethra.
This background, coupled with undisputed testimony that the plaintiff was continent prior to the procedure and completely incontinent after the procedure, led the plaintiff’s expert to opine that the defendant resident physician inadvertently ablated the external sphincter and that this was a deviation from the standard of care.
On cross-examination, the plaintiff’s expert also testified that at a post-procedure exam, the plaintiff’s external sphincter was wide open and the plaintiff could not squeeze it closed. The plaintiff’s expert went on to opine that the GreenLight laser procedure was not appropriate for the plaintiff due to the fact that he suffered from irritative symptoms and not obstructive symptoms.
Next -Defendants: Prior TURPs contributory to outcomeDefendants: Prior TURPs contributory to outcome
The defendants themselves (both the resident and the supervising attending) testified that the injury did not occur during the GreenLight laser procedure, and offered that the two prior TURPs were contributory to the outcome. The defendants’ experts also testified to that line of reasoning and added that urinary incontinence is a known risk factor of the GreenLight laser procedure.
Ultimately, the court found that offering the GreenLight laser procedure to the patient was within the standard of care. However, the court found that the performance of the GreenLight laser procedure fell below the standard of care and determined that the plaintiff’s injury resulted from a misapplication of the GreenLight laser, and this misapplication was the cause of the plaintiff’s urinary incontinence.
While the defense experts’ argument that urinary leakage is a complication of ablative procedures was entertained, the court was not convinced that the severity of the plaintiff’s injury-complete lack of urinary control-was the same as leakage. The argument that the TURPs were contributory to the outcome lacked strength given the temporal remoteness of those procedures to the injury.
Statistically speaking, defendants are more likely to prevail in medical malpractice cases that go to trial. However, that was not the case here.