VERDICT
Defense
CASE
Martin Collins and Virginia Mitchell Collins v. Stanford Hospital & Clinics
No. 2013-1-CV-247673
COURT
Superior Court of Santa Clara County, Santa Clara
JUDGE
Theodore C. Zayner
DATE
4/24/2015
PLAINTIFF ATTORNEY(S)
Paul V. Melodia, Walkup, Melodia, Kelly & Schoenberger, San Francisco, CA
Spencer J. Pahlke, Walkup, Melodia, Kelly & Schoenberger, San Francisco, CA
DEFENSE ATTORNEY(S)
Daniela P. Stoutenburg (lead), Dummit, Buchholz & Trapp, Sacramento, CA
Carolyn L. Northrop, Dummit, Buchholz & Trapp, Sacramento, CA
FACTS & ALLEGATIONS
On July 31, 2012, plaintiff Martin Collins, 71, a media production business owner, underwent the placement of a jejunostomy tube, or J-tube, a feeding tube that is surgically places directly into the small intestine to help with nutrition and growth.
Collins had a history of right lung lymphoma, resulting in the need for an Ivor-Lewis esophagectomy – an esophageal resection due to the surgical removal of the esophagus. He then began losing weight, but he was mobile and leading an active life. However, it was believed that Collins needed to temporarily supplement his diet with a feeding tube for three to six months. As a result, in July 2012, he was referred for a percutaneous jejunostomy with interventional radiology by Dr. Brendan Visser, a general surgeon with Stanford Hospital & Clinics. In Visser’s referral, the chart noted requests that the tube be placed at the site of Collins’ prior feeding tube (which Collins had removed himself). Visser also noted that if interventional radiology was not able to place the J-tube, then Collins could return to him for an open procedure.
On July 30, 2012, Collins presented for the J-tube placement at Stanford Hospital & Clinics with the attending interventional radiologist, Dr. David Hovsepian. However, Hovsepian was unable to place the J-tube on the first attempt, given Collins’ discomfort and technical issued with gaining access to the jejunum. As a result, Hovsepian did not want to continue with the procedure at that time and recommended that Collins return the following day for a second attempt with monitories anesthesia care (MAC), which is a planned procedure (similar to general anesthesia) during which the patient undergoes local anesthesia together with sedation and analgesia.
Collins returned for another attempt at the placement of a J-tube by Hovsepian and a first-year interventional radiologist fellow, Dr. Jay Desai, on July 31, 2012. This time, jejunum was accessed under fluoroscopic guidance with a T-tack needle. Positioning was confirmed with injection of contrast and the T-tack was deployed, but it was noted to be outside the bowel lumen. Using a French sheath and alligator forceps, the T-tack was then deployed to access the jejunum, and it was successful. However, the sheared string attached to the T-tack was sheared by the needle. The normal course is to cut the T-tack free five to 10 days post-procedure and allow it to exit the bowel in the normal course of bowel function. As such, the loss of the T-tack at this point was not of significance. After the J-tube’s position was confirmed, Collins was taking to the recovery unit.
Later the same day, Collins reported significant pain. While not typical, Collins’ level of pain was not surprising given that he was in a very weakened and malnourished state, had undergone two attempts at J-tube placement and several needle sticks, and would have likely had irritation from small amounts of bile leaking out of the jejunum during the placement of the J-tube. As a result, Collins was given pain medication, which controlled his pain very well. The amount and type of pain medication given was not unusual. In addition, Collins would have required more pain medication than the average patient, as he had been on chronic narcotic pain medication for the past year and, therefore, would have had a high tolerance to pain medication.
The following day, on Aug. 1, 2012, Collins was noted to have moderate abdominal pain and nausea, but his physical exam, including an abdominal exam, and general hemodynamic status were not noted to be worrisome. That trend continued into the morning of Aug. 2, 2012, when Collins was examined and his bowel sounds were determined to be normal. His abdomen was also noted to be non-tender and not distended. In addition, Collins reported that he had minimal pain and was feeling good. As a result, tube feedings were starting at 9 a.m. However, at approximately 2 p.m., after Collins was walking in the hallway, he reported increased and significant pain. Tube feedings were subsequently stopped and his pain medication was slightly increased. Collins was also seen by Desai and then Hovsepian, who believed that Collins’ pain was likely related to advancing the tube feedings too quickly and/or constipation, which is not uncommon in patients who have just started tube feeds.
At around 8 p.m. on Aug. 2, 2012, Collins began reporting persistent, moderate abdominal pain. At 8:30 p.m., he became short of breath and his oxygen saturation was noted to be 95 percent on room air. He was also noted to be tachycardic to the law 100s with a systolic blood pressure in the low 90s. As a result, the on-call attending physician, Dr. Anobel Tamrazi, was paged and he ordered the J-tube to be vented and fluids to be pushed. Shortly thereafter, Collins’ vital signs showed signs of improvement. However, at 2 a.m. on Aug. 3, 2012, the nursing staff paged Tamrazi with concern for sepsis. Tamrazi then spent two hours sitting on Collins’ bed, evaluating him. A chest X-ray was ordered, which showed no infiltration. Tamrazi considered sepsis as part of his deferential diagnosis, but the clinical picture did not support sepsis. When Collins’ pain did not improve, a CT was ordered at 7:59 a.m. on Aug. 3, 2012, and it was performed at approximately 11:44 a.m. The CT demonstrated extensive free air with a leak around the J-tube site. As a result, Collins was taken urgently to the operating room for an exploratory laparotomy. Intraoperatively, tube feeds, succus and pus were found throughout Collins’ abdomen. An approximate 1.5-centimeter in diameter bowel perforation was ultimately noted 40-centimeters from the jejunostomy site, through which tube feeds were entering the abdomen. A washout and primary closure of the jejunostomy were performed and a T-tack was found in the abdomen, next to the hole in the patient’s bowel.
Collins sued Stanford Hospital & Clinics. Collins alleged that the staff of Stanford Hospital & Clinics was negligent in the performance of the percutaneous J-tube placement on July 31, 2012, and in the post-operative and follow-up care and treatment provided to him following the procedure. He also alleged that this negligence constituted medical malpractice.
Plaintiff’s counsel contended that no lab tests were ordered between the afternoon of July 31, 2012, and the evening of Aug. 2, 2012, while Collins was receiving intravenous Dilaudid and other medication to manage his post-procedure pain. Counsel also contended that even after alarming lab results were received, 12 hours elapsed before a CT scan of the abdomen was performed and a surgical consult was obtained.
According to plaintiff’s counsel, their liability case was compromised by the fact that, despite a nationwide search, no interventional radiologist who had experience with performing percutaneous jejunostomy would step forward to criticize the care given by Stanford Hospital & Clinics. Specifically, counsel claimed that there are only a handful of academic interventional radiologists who perform the procedure and that even those professions seldom have the opportunity to perform it. As a result, the plaintiff’s sole liability expert was a general surgeon who does not perform percutaneous jejunostomies, so the expert was not in a position to comment on whether the technical difficulties encountered during the two procedures to insert the J-tube complied with the standard of care.
Defense counsel argued that all of the care and treatment provided by Stanford Hospital & Clinics’ staff to Collins was within the standard of care. Counsel also argued that a bowel perforation was a known risk of the procedure and that Collins was closely monitored and cared for post-procedure.
INJURIES/DAMAGES
adult respiratory distress syndrome; kidney; loss of consortium; sepsis
Collins underwent an urgent exploratory laparotomy, during which he was found to have a bowel perforation, measuring approximately 1.5-centimeter in diameter and located 40-centimeters from the jejunostomy site. As a result, tube feeds were found to be entering Collins’ abdomen. As a result, a washout and primary closure of the jejunotomy were performed, and a T-tack was found in the abdomen, next to the hole in the bowel. Post-operatively, Collins was taken to the Intensive Care Unit in critical condition. He developed peritonitis and sepsis. He also had several episodes of atrial fibrillation with rapid ventricular response. As a result, Collins continued to do poorly post-operatively and on Aug. 10, 2012, he was started on BiPAP for support.
Plaintiff’s counsel contended that on the first attempt at placement, Collins had travelled to Palo Alto from Santa Cruz on July 30, 2012, with the expectation that he would spend one night in the hospital and would be discharged the following day. However, by the time the hole was discovered, Collins had developed widespread peritonitis, sepsis and septic shock. Counsel also contended that after surgery, Collins was taken to the ICU, where he clung to life for the next 49 days. On Aug. 11, 2012, Collins was diagnosed with acute respiratory distress syndrome – a lung condition that leads to low oxygen levels in the blood – secondary to abdominal abscesses. He subsequently required intubation and high ventilator settings. During his post-operative course, Collins had four drains placed in his abdomen by interventional radiology, all og which were removed prior to discharge.
The last CT scan, which was performed on Sept. 11, 2012, during his initial stay at the hospital, showed small residual rim-enhancing fluid collections, which were noted to be smaller when compared to previous studies. He also had an acute kidney injury, secondary to septic shock.
Collins spent a week at Kindred Hospital San Francisco Bay Area, located in San Leandro, before beginning a six-week stay at Kentfield Rehabilitation and Specialty Hospital, in Marin County. However, his treatment at Kentfield was interrupted by two hospitalizations at Marin General Hospital, in Greenbrae, and he was finally discharged from Kentfield on Dec. 4, 2012. At that time, Collins was ventilator dependent, on around-the-clock tube feeding, and unable to care for himself.
Collins returned to Santa Cruz, where he has had multiple hospitalizations, numerous surgeries, and further life threatening events. He was ultimately weaned from ventilator at home. However, Collins alleged that he continues to require ongoing medical care, which he related to the bowel perforation and subsequent sepsis.
Plaintiff’s counsel contended that Collins is totally dependent on tube feedings and still requires oxygen around the clock. Counsel also contended that Collins operated a media production business with the assistance of his wife up to the day he went in for his procedure, but that Collins is now an invalid and requires assistance with most of the activities of daily living. In addition, medical experts were in general agreement that despite the fact that there has been no recurrence of his cancer, Collins has a life expectancy of only one to two years.
Thus, Collins sought recovery of past and future medical costs, past and future loss of earnings, and damages for his past and future pain and suffering. His wife, plaintiff Virginia Collins, sought recovery for her loss of consortium.
RESULT
The jury rendered a defense verdict, finding that Stanford Hospital & Clinics was not negligent in the treatment of Mr. Collins.
DEMAND
$2,000,000 (at mediation)
OFFER
$90, 000 (conditioned upon the plaintiffs resolving a Medicare lien that exceeded $500,000)
TRIAL DETAILS
Trial Length: 15 days
Jury Vote: 11-1
Jury Composition: 2 male, 10 female