On January 6, 2009, an unemployed, 59 year old African-American man presented to the defendants’ medical facility for assistance. At that time, he was complaining of a fever, cough and an inability to keep liquids down. After examination, his physicians diagnosed him with pneumonia and he was advised to increase fluids tomorrow; take 2 Tylenol every 4 hours for fever; rest; and, [seek follow-up medical care] in 2-3 days. In addition, he was prescribed Levaquin and Robitussin. He was then released home.
Owing to his worsening symptoms, he returned to the defendants’ medical facility approximately 6 hours later with roughly the same complaints. At this time, it was recorded that he was now also suffering from diarrhea and vomiting. While at the defendants’ facility he exhibited increasing difficulty in forming words due to swelling in and around his mouth. The medical notes revealed that initially patient responded well to intervention for presumed hypersensitive reaction to Levaquin. Unfortunately, he soon became lethargic all the while complaining of pain, numbness and tingling in [his] feet. He eventually became unresponsive and a code was called. Despite CPR, he was declared dead later that same morning.
The plaintiff was prepared to show that the decedent initially exhibited a host of symptoms that should have alerted the defendant doctors of a worsening medical condition which demanded that they admit the decedent to a hospital and treat him emergently. The sum of these findings indicated that the decedent’s infectious process (pneumonia) was associated with acute multi-organ dysfunction, specifically five of his organ systems showed signs of damage: leukopenia (low white blood cell count) indicating immune dysfunction, worsening creatinine indicating acute renal failure, elevated bilirubin indicating hepatic dysfunction, thrombocytopenia (low platelet count) indicating coagulation dysfunction and hypoxemia (low arterial oxygen saturation) indicating pulmonary dysfunction.
The plaintiff asserted that the current standard of care for a patient with a severe sepsis is admission to the hospital for aggressive management. The plaintiff’s expert opined that had the defendant doctors recognized the signs of sepsis during the decedent’s initial emergency department visit, they could have intervened to halt and ultimately reverse the progressive disease process.
The defendants argued that the plaintiff was in fact offered admission to their facility, but declined preferring to simply return home. In addition, the defendants were prepared to demonstrate that the decedent possessed “co-morbidities” (which included but was not limited to severe alcohol and drug abuse). Indeed, the decedent’s autopsy revealed detectable levels of cannabinoids in the decedent’s system.