James M. Wheeler, MD, MPH, JD
Consultative issue: Which patients should be screened for Factor V Leiden, Protein C deficiency, lupus anticoagulant or any of the other risk factors for thrombosis on oral contraceptives? Is baby aspirin enough of a preventative of thrombosis in all cases?
Is ultrasound always the best imaging test for assessing the ovaries? The uterus? How can these three modalities support the clinician in evaluating the given patient? When is ultrasound alone sufficient imaging?
Is there ever an appropriate use of TVM after the well-known litany of litigation? What are complications of TVM that reflect inappropriate use, vs. unforeseeable maloccurrences?
Issues: What is 'molecular mimicry' and how does it increase the risk of an autoimmune reaction to a particular vaccine? How do adjuvants affect the risk of complications after vaccines?
Issues: What is the limitation of following serial hCG levels before diagnosing an ectopic pregnancy? How about ultrasounds? Is methotrexate usually superior to laparoscopic treatment?
Issues: What gyn medications contribute to the causation of stroke? What combinations of medications may have synergistic effects in this regard?
Issues: Are supraphysiologic levels of testosterone worth the danger? Do physiologic levels of testosterone supplementation contribute to stroke or other complications?
A gynecologist recognizes he is very close to the bladder when dissecting the endopelvic fascia during a challenging hysterectomy. He discovers a stitch in the bladder serosa and removes it. He puts blue dye into the bladder via the Foley catheter and notices no leak. Postoperative symptoms of fever and flank pain develop. Presumptive urinary tract infection is treated; diagnosis, and surgical correction, of ureteral obstruction is thus delayed a week.
Consultative issues: What tests are appropriate when, and by whom, in which hysterectomies with varying degrees of risk of urologic injury.
A woman in her late 40’s had troublesome uterine bleeding. Fibroids were diagnosed by bimanual exam only; no ultrasound was done evaluating location/number of fibroids or endometrial thickness. No medical treatments were attempted. No hysteroscopic options were offered. At hysterectomy, the woman became septic, and very ill, despite timely diagnosis and treatment.
Consultative issues: Whereas preoperative evaluation and consent may have been modest, state medical panel found no negligence because bowel injury is a known complication of hysterectomy. Despite the panel’s findings, litigation was likely due to the very significant economic and noneconomic damages within the case.
A previously healthy woman was advised hysterectomy for annoying uterine bleeding. Hemorrhage was encountered, requiring transfusion and an open incision to complete the surgery. The woman suddenly died rising out of bed on the fourth postop day; clinical suspicion was of a massive pulmonary embolism.
Consultative issues: Preoperatively, the woman was not offered medical treatment with oral contraceptives, or less invasive surgical treatment of hysteroscopy, D&C, or endometrial ablation. Intraoperatively, discovery demonstrated the surgeon’s experience was modest. Postoperatively, there were questions of failing to consider pulmonary embolus based on two days of classic symptoms, and failing to admit the patient directly to the ICU due to the hemorrhage.
College-aged woman alleges sexual assault in the absence of any reported or demonstrable injury. No SANE exam, doctor visit, etc. College-aged man claims sexual consent was purely consensual.
Consultative issues: The relative strength, or weakness, of physical evidence in proving sexual assault vs. consensual sexual contact.
A very intelligent and well-researched patient contacts me directly two years after a hysterectomy for Stage IV endometriosis by a well-respected Houston colleague. In addition to being very upset over a delay in starting her case, numerous needle sticks and urinary catheter indignities, she suffered a neurogenic bladder apparently resulting from her 14 hour procedure involving the gyn surgeon, colorectal surgeon and urologist.
Consultative issues: I explained the medicine behind the surgery, including the appropriateness of removing the ovaries to reduce recurrence, and the need of GI and GU surgical consultation being a rarity. Although seemingly satisfied with my medical coaching and medicolegal analysis, woman was referred for further assistance, if desired, to a trusted local attorney.
A woman alleges her interstitial cystitis was not diagnosed properly during pregnancy, and it has therefore worsened. She has history of prior Herpex and Chlamydia infections, vulvodynia from recurrent yeast infections, UTI’s, vaginal GBBS, cigarette smoking, psychosomatic complaints of back pain/chest pain/reflux and anxiety, and self reports that her genitalia “looks funny”.
Consultative issues: Proximate cause was difficult to evaluate in a woman with many competing causative factors other than the one the patient is focused upon.
A woman experienced 1st and 2nd degree burns of the female genitalia and thighs after laser hair removal at a skin care center.
Consultative issues: Practitioners’ training, experience, and marketing reviewed. Case law reviewed suggests cosmeticians fall under state laws as “providers” of care. Though facts suggest possibly per se negligence, expert review may nonetheless be warranted.
Issue: Is a single screen sufficient for all patients? How often does barely passing a GDM screen produce complications later in pregnancy typical of GDM? Is HgbA1c an appropriate substitute for the traditional two-step GDM screening?
Issues: Does the degree of apparent force and trauma correlate with the likelihood of injuring a pregnancy? Does this question vary from trimester to trimester? What is the appropriate use of a Kleihauer Betke test in this situation? Conversely, what are inappropriate uses of the K-B test?
Is fetal fibronectin testing valid in the late second trimester? If fFN contradicts the finding of a fern or nitrazine test, what course of action is most appropriate?
Defining Category II vs III monitor strips. Timing of birth with a Category II strip. How long does the OB wait on a Category III strip to improve?
Issues: Now that proteinuria is no longer a diagnostic criterion for preeclampsia, how do we screen patients in clinic? How often should we screen them – and with just blood pressure measurements?
A woman with four prior healthy uncomplicated fullterm pregnancies was in a MVC at 34 weeks’ gestation. Her only complication heretofore was well-controlled gestational diabetes. On the day of the MVC, her fetal monitoring strip was nonreassuring; attempted corrective measure of rehydration, antiemetics and correction of hyperglycemia failed to improve the fetal strip. Preterm Cesarean section was indicated and performed; neonate continued with developmental issues thought due to being born prematurely.
Consultative issues: Causation of the baby’s developmental issues: were they caused by preterm delivery, or some other antepartum or postpartum cause?
A morbidly obese 19 year old with otherwise normal prenatal course experienced a prolonged deceleration during labor. Progress in labor heretofore had been slow; a big baby was suspected. The EFM got progressively worse over the next 2 ½ hours and no further progress was made. Once urgent Cesarean was declared, the baby was delivered within 17 minutes; he weighed 8 ½ pounds and had a significant caput. Brain injury was noted in the child; birth injury was alleged.
Consultative issues: Causation of the brain injury: intrapartum vs. antepartum or postpartum causes.
Distraught mother alleges malpractice in 16 wk PROM and resulting stillbirth. Records analysis demonstrates two prior growth-retarded babies, minimal prenatal care, poor weight gain, but a normal ultrasound two weeks prior to PROM. Ultrasound on day of birth showed unusually collapsed fetal skull and large blood clot near the skull, suggesting traumatic cause.
Consultative issues: Causation of the fetal death was suspected to be very different than what was believed by the conscientious counselor/attorney advocating for his client.
A woman with multiple risk factors (smoking, strenuous work habits) presents with atypical symptoms of rupture of membranes; the leaking fluid is thrice identified by care providers as ‘pus-like liquid’ rather than the typically clear amniotic fluid. Patient has a history of carrying Group B Beta streptococcus, UTI’s, and recurrent bacterial vaginosis.
Consultative issues: The value of assessment tests of fluids including fetal fibronectin and ferning, vaginal exam and ultrasound in the evaluation of possible preterm rupture of membranes.
A young woman had elevated blood pressure beginning at 20 weeks’ pregnancy, responsive to hydralazine. She lacked hyperreflexia, blood lab abnormalities, or proteinuria. Fetal growth was at the lower end of normal growth. The baby died the day after a reassuring ultrasound. At birth, the baby was small, and the placenta was small with several small infarcts.
Consultative issues: Clinically distinguishing gestational hypertension vs. pre-eclampsia. During discovery, evidence of a thrombophilia (Protein S deficiency) was buried deeply in the chart, representing a more likely cause of placental infarcts than pre-eclampsia.
A 19 year old man alleged birth trauma caused his permanent neurologic injury. Indeed, some of his characteristics were consistent with cerebral palsy.
Consultative issues included assessing proper credentialing for delivering babies, minimum requirements of rural hospitals wishing to offer obstetric services, and demonstrating causation of birth injury two decades after a baby is born.
A woman accused her doctor of not warning her that SSRI’s can cause birth defects.
Consultative issues included: 1) comprehensive review of the medical literature; 2) briefing attorney’s staff on literature findings; 3) then injecting the opinion of the American Congress of Obstetricians and Gynecologists on subject, and 4) epidemiologic analysis that although some risk was present, it was quantitatively quite small.
A mother is sure stress caused her PTL. Pre pregnancy she had taken Adderall, Cymbalta, Prozac and Xanax for dysthymia, ADHD and GAD. She was given a diagnosis of incompetent CX, although she had two prior fullterm pregnancies.
Consultative issues involved proving proximate cause with “softer” cause-and-effect relationships involving the difficult to measure entity ‘stress’.
A 21 year old mother of four alleged that a poorly repaired cervical laceration contributed to her fifth baby’s being born at 23 weeks. Competing causative factors included GBS, BV, multiparity, history of progressively faster labors, and various socioeconomic issues. Competing intervening factors were drug use and an active sex life.
Consultative issues involved an epidemiologic/statistical balancing of these factors in causation.
A woman with two prior healthy deliveries now pregnant again had had five prenatal visits without complications, then suffered a significant MVC; she complained of headache, neck pain and lower back pain. Fetal evaluation was normal. Three weeks later, she went through a fairly normal labor; amniotic fluid was lightly stained with meconium. Four minutes before delivery, the fetus dropped her heart rate to the 50’s; Apgars were 0/1 and cord pH was 6.58 with a pCO2 of 131 suggesting respiratory acidosis. The neonate expired during transport; mother alleged negligent delivery.
Consultative issues involved causation analysis of multiple complex medical issues requiring careful acquisition of all records postmortem. Necropsy had been declined by family. However, various records were produced that various abnormalities were discovered in the baby but not present in initial records reviewed: a very elevated 17-hydroxyprogesterone level suggesting adrenal disease, slightly elevated TSH suggesting thyroid dysfunction, an MRI showing classic signs of hypoxic/ischemic encephalopathy (HIE, which could not have occurred within four minutes), and a remote report sent off from the hospital demonstrating multiple elevated neonatal serum amino acids. Postpartum, the baby’s demise was caused by pulmonary hemorrhage during transport – not an event typically due to respiratory acidosis/birth injury.
A mother is sure that a car accident caused her son’s deformed twisted neck. The accident was rather low impact. Mother’s pregnancy was complicated by placenta previa and preterm labor and the umbilical cord had a tight knot within it at delivery; two urinary drug screens were positive for cannabinoids. Child had a positive finding in his acylcarnitine profile as part of his metabolic profile.
Consultative issue was demonstrating proximate cause in the presence of multiple potential factors, some of which of a challenging nature to present to the finder of fact.
Issues: what are the foreseeable risks of multiples with clomiphene? IVF? Who will suffer ovarian hyperstimulation syndrome – and is it foreseeable?
Issues: The boon of home genetic tests has caused a plethora of cases of fraudulent insemination, where a doctor uses his own genetic material rather than a partner's. Surprisingly, this is only now becoming statutorily criminal, and persecution on the civil side is complex. What are the ethical issues involved in this situation? What are the consent issues involved?
Issues: When are embryo/oocyte/sperm freezer complications negligent, or simply maloccurrences? Who owns cryopreserved embryos in the face of a difficult family law situation?
Issue: When could hormone replacement treatment be expected to cause, or contribute to, breast cancer? How about a breast cancer occurring years after an in-situ lesion – either ductal or lobular? Does progesterone contribute to breast cancer risk? How about testosterone?
A 36 year old with three prior late first trimester miscarriages has attempted pregnancy for 7 months. Consultation with a general ob/gyn results in surgery scheduled the next day, and attempted excision of a “nodule” from the uterus; adenomyosis is histologically confirmed. The operation causes severe intrauterine adhesions requiring several attempts at repair, now by reproductive endocrinologists.
Consultative issues: Was the initial surgery indicated? The timing of surgery is potentially troublesome. The consequences of postoperative intrauterine adhesions were very likely to make future reproduction improbable at best.
A weight loss clinic in Houston’s barrio allegedly lightened only women’s wallets. Twenty-eight cases were collected and analyzed; none of the ladies had lost weight despite taking controversial, and potentially dangerous, medications. Non-physician providers presented themselves as doctors, and had no physician supervision. Once it proved difficult to communicate with the clinic’s physician owner, the state Medical Board became involved.
Consultative issues included defining standards of care for medically-supervised weight loss programs, and office practice of providers.
A man in his 30’s claims residual bacteria in a carpet soaked with a backed-up toilet weeks earlier caused infection temporally associated with toe clipping. Man had poorly controlled diabetes; cultures proved infection with Strep and Staph bacteria. Despite multiple antibiotics, gangrene set in, and the man lost his lower leg.
Consultative issues included classical epidemiologic analysis of contributing causes and characteristics of demonstrated bacteria, as well as medical knowledge of diabetes and its complications.
A 70 year old man was recommended to have a total knee replacement. Allegation was made that negligent use of a tourniquet resulted in loss of the limb; medical negligence and products liability causes of actions were being evaluated.
Consultative issues included determining the elective nature of the surgery, with significant assumption of risk by the man. Further, the device in question was well-documented to have been properly used in this case. Finally, serious comorbidities were present of diabetes, heart and kidney disease, and morbid obesity. Consultation included damages analysis due to man’s preexisting disability with minimal function and modest quality of life preceding surgery.
A man saw his PCP then a urologist for recurrent fever for several weeks’ duration. Two different ER doctors also saw the man, and each included Guillain Barre Syndrome (GBS) in their differential diagnosis, but did not refer him to a neurologist. Evaluation by a tertiary center neurologist confirmed atypical GBS, with EMG demonstrating severe demyelinization, and resulting rapid decline to death.
Consultative issues involved referral standards for non-specialists for a well-known, yet very uncommon, clinical disease associated with high mortality.
Issues: What is the best way to define "fertility success"? What is life table analysis? Is it better than proportions in describing fertility rates? How important is it to define denominators before focusing on the numerator of a particular proportion?
Issue: What is 'generalizability'? When can a study be applicable to the individual patient being counseled at a particular moment? What are the limits of applying any one study to any one patient?
Issue: What are known groundwater contaminants hazardous to reproductive health? What are the notice requirements when corporations are aware of contaminant issues? What steps are appropriate in industry to protect pregnant women from hazards?
Issue: How "informed" does 'informed consent' have to be in order to be valid? What is recommended if consent is required for the anesthetized patient?
Issue: Do patients have to accept a midlevel provider when they are expecting to see a physician? How has the hospitalist movement affected perceptions of potential medical malpractice?
‘I now see why we needed such a comprehensive (28 p) expert report in this case. We are suing a leader in the field, and only such a comprehensive review of the literature – including the defendant's own publications – would be likely to have him view the case a bit more objectively.’
— Pennsylvania attorney
‘My dad (a storied senior trial attorney) was impressed with your work, and said you were among the best he’d ever seen. Thanks for helping us prevail in our unusual med mal case.’
— Tulsa attorney
‘Thanks for explaining to us the many aspects of domestic violence in our country. We had no idea of the many areas of impact this issue had on us.’
— U.S. Congressional staffers