Appeal from Circuit Court of McLean County No. 01L171 Honorable Charles G. Reynard, Judge Presiding.
The opinion of the court was delivered by: Justice Myerscough
In March 2005, plaintiff, Teresa Curi, special administratrix of the estate of Merle Bray, filed her second-amended complaint against defendants, Patrick B. Murphy, M.D., and Illinois Heart & Lung Associates, S.C., a/k/a Mid-Central Cardiology, S.C. (Illinois Heart), a group of cardiologists, pulmonologists, lung doctors, and critical-care specialists. At the time in question, Dr. Murphy was a partner in Illinois Heart.
In March 2005, the jury returned a verdict in favor of plaintiff and against defendants in the amount of $1,439,824. The trial court later reduced the judgment by $25,000. Defendants appeal, arguing (1) the court erred by refusing to give the specialist standard-of-care instruction, (2) the court erred by giving plaintiff's burden-of-proof instruction, (3) the court erred in excluding the testimony of Dr. Wattanasuwan concerning the appropriateness of heparin for patients such as Bray, and (4) the verdict was against the manifest weight of the evidence.
The jury trial commenced on March 18, 2005. Because the parties are familiar with the facts elicited at trial, we will set forth only those facts necessary for resolving the issues on appeal.
On October 28, 2000, at approximately 4 p.m., Merle Bray, an 82- year-old man, sought treatment at John Warner Hospital in Clinton, Illinois, for pain in his lower chest and upper abdomen. The physicians at John Warner Hospital started Bray on nitroglycerin and intravenous heparin (hereafter referred to solely as heparin). Later that afternoon, John Warner Hospital transferred Bray to OSF St. Joseph Medical Center (St. Joseph).
Heparin is an anticoagulant and prevents blood from clotting. The biggest risk with heparin is bleeding. Heparin is monitored by the use of a nomogram. A nomogram is a prepared set of guidelines or rules by which personnel can monitor the intensity of heparin. The St. Joseph nomogram required drawing and testing Bray's blood at regular intervals to determine the partial thromboplastin time (PTT) level, a measure of coagulation. When a patient's PTT goes up, the blood's ability to coagulate goes down. The therapeutic range of PTT is between 30 and 70. Depending on the PTT level, the heparin dosage is adjusted. Under St. Joseph's nomogram, a PTT above 100 requires a decrease in the heparin dose (which the nurse can do automatically). A PTT above 150 requires the nurse to notify the physician.
After being transferred to St. Joseph, Bray was seen by Dr. Dhanasarn Mongklosmai (Dr. Dhan), a cardiologist and partner in Illinois Heart. Dr. Dhan was in charge of Bray's care from October 28, 2000, to October 29, 2000.
While under Dr. Dhan's care, Bray underwent an EKG and an echocardiogram test. Various enzymes were also checked. Bray continued to receive nitroglycerin and heparin that was started at John Warner Hospital.
Dr. Dhan transferred Bray's care to Dr. Murphy on October 30, 2000. Bray had been Dr. Murphy's patient for several years prior. Dr. Murphy had last seen Bray in September 2000 for minor cardiac problems but was only providing him follow-up care as of October 2000.
Dr. Dhan left Dr. Murphy a voice-mail message advising him of a differential diagnosis of chest pain and possible acute coronary syndrome. A differential diagnosis is a list of those conditions that are consistent with the patient's history and symptoms. Physicians work through a differential diagnosis by putting at the top of the list those conditions that are immediately life threatening. Physicians rule out conditions that are immediately life threatening and then move on to those that are not immediately life threatening. Dr. Dhan reported to Dr. Murphy that the work-up on Bray was going to continue on the morning of October 30, 2000. Dr. Dhan also reported to Dr. Murphy that Bray's condition was probably gastrointestinal in nature.
On October 30, 2000, Bray underwent a Persantine Cardiolite Stress Test (Persantine test) supervised by Dr. Norrapol Wattanasuwan, a cardiologist employed by Illinois Heart. The Persantine test is a two- part test. The first part involves injecting an isotope and monitoring the patient's symptoms, heart rate, blood pressure, and electrocardiogram (EKG). The second part involves a nuclear scan. Dr. Wattanasuwan supervised the first part of the test. Dr. R. Puckett, a radiologist, interpreted and reported on the second part of the test. Dr. Wattanasuwan wrote a progress note in Bray's file that read, "negative stress EKG." Dr. Puckett's report was transcribed on October 30, 2000, at 3:33 p.m. His report indicated a normal study but noted Bray did not reach optimum exercise tolerance, which lowers the sensitivity of the study.
At approximately noon on October 30, Dr. Murphy went to Bray's hospital room but found his bed unoccupied. After inquiring, Dr. Murphy learned Bray was having his endoscopic retrograde cannulation of the pancreas (ERCP) performed by Dr. Herbert Wiser. Dr. Murphy assumed Bray passed his Persantine test because he could not imagine Dr. Wiser would have taken him for the ERCP if Bray had not passed the Persantine test. Dr. Murphy left the hospital without seeing Bray.
Dr. Wiser, a gastroenterologist, performed the ERCP. An ERCP is a procedure by which a tube with a camera is inserted in the patient's mouth and passed down through the esophagus and stomach, into the second part of the duodenum where a structure that looks like a "pap" is identified and cannulated. A probe is put through the pap and dye is injected into the pancreas and bile ducts to visualize whether stones are present. Three common complications with an ERCP are bleeding, perforation, and infection. Dr. Wiser was able to see Bray's pancreatic duct but was unable to see the bile duct. However, he did make a small cut, a papillotomy, to allow for the passage of stones that might be in the bile duct. Dr. Wiser completed the procedure by 11:30 a.m. on October 30.
Prior to the ERCP procedure, Bray's PTT was barely in the therapeutic range. The heparin was stopped prior to the ERCP. The heparin was restarted at 2:20 p.m. following the surgery. Heparin was restarted at a higher level pursuant to the nomogram. By 10 p.m. on October 30, Bray's PTT was 110 and the rate of infusion was reduced.
At 6:30 a.m. on October 31, Bray spit up small amounts of dark red blood and had difficulty walking back to his bed. He also appeared jaundiced. Bray's blood was drawn at 4:42 a.m., and the results came in at around 7:15 a.m. Bray's PTT was over 150 and his white-blood-cell count was high. Deb Luker, the registered nurse, called Dr. Murphy, as required by the nomogram. Luker told Dr. Murphy that Bray was spitting up blood, suffering from weakness, and his PTT was greater than 150. Dr. Murphy told her to decrease Bray's heparin by 300 units.
At 11 a.m. on October 31, Dr. Murphy saw Bray for the first time since becoming his attending physician. Dr. Murphy noted Bray did not look well. After consulting with Dr. Wiser, Dr. Murphy believed Bray might have an evolving infection. Dr. Henry Naour performed an abdominal exploration on Bray. Dr. Naour found a retroperitoneal hematoma (blood collection in the retroperitoneum). Dr. Naour also removed Bray's gallbladder. Pathology found many gallstones in the gallbladder. No stones were found in the common bile duct.
At approximately 1:30 p.m. on October 31, 2000, Bray stopped breathing and a "code blue" was called. Bray was resuscitated but eventually died on November 8, 2000.
On October 5, 2001, plaintiff, Bray's granddaughter, filed suit against St. Joseph and Dr. Wiser. The complaint named Dr. Dhan and Dr. Murphy as respondents in discovery. On May 20, 2002, plaintiff amended her complaint and added Dr. Wattanasuwan, Dr. Murphy, and Illinois Heart as defendants. Plaintiff's second-amended complaint, filed March 16, 2005, named only Dr. Murphy and Illinois Heart.
The second-amended complaint contained wrongful-death and survival causes of action against both defendants as well as counts seeking funeral, burial, and medical expenses. Plaintiff alleged that Dr. Murphy breached the standard of care by failing to discontinue the administration of the heparin, failing to properly monitor the administration of heparin, and failing to communicate with other medical personnel regarding the status of Bray's condition. Plaintiff alleged that Illinois Heart, through its agents, servants, and/or employees, including but not limited to Dr. Wattanasuwan, Dr. Dhan, and Dr. Murphy, failed to discontinue the heparin, failed to monitor the administration of the heparin, failed to communicate with other medical personnel, and failed to facilitate proper communication between its physicians, and Dr. Wiser, nurses, and other hospital personnel.
C. Specific Testimony at Trial
1. Dr. Michael Ramsey's Testimony
Dr. Michael Ramsey, plaintiff's retained expert, testified he was a retired internal-medicine specialist. His practice included 26 years of private practice at Rush Medical Center in Chicago, Illinois.
Dr. Ramsey received training on the diagnosis of acute cardiac conditions and gastrointestinal disorders. He had experience in the use of heparin. According to Dr. Ramsey, all doctors are required to know the indications for heparin therapy.
Use of heparin is contraindicated in someone who is already bleeding because heparin stops the blood from coagulating. The risks of heparin include bleeding from any site, but three areas are most associated with heparin-related bleeding: the retroperitoneal, adrenal, and ovarian areas.
Heparin works almost immediately and reaches its peak in one to two hours. When stopped, the blood returns to normal coagulation within hours. According to Dr. Ramsey, a PTT over 150 means "they can't even measure how high it is; it could be 151, could be 190 or could be infinity, it may not be able to coagulate at all."
Continuous infusion of heparin is indicated in people with blood clots, abnormal heart rhythm, and acute cardiac disease. It is also proper to use heparin when a physician suspects a patient is having a heart attack and he or she is ruling that out. However, heparin is not used for routine chronic vascular disease, coronary artery disease, or valvular disease. Heparin is not used to treat gallstones or common- bile-duct stones.
Dr. Ramsey testified all doctors are required to know the indications for heparin therapy. Dr. Ramsey believed it was a breach of the standard of care to administer heparin in a patient without an indication for its use. Discontinuation is required after the indications for heparin's use are ruled out.
Dr. Ramsey noted Bray had mild aortic valve disease but stated that had nothing to do with coronary artery disease or myocardial infarction. Bray's EKG was normal and unchanged from one performed almost two years earlier. Bray's cardiac enzymes were totally negative. While Bray's myoglobin was elevated, myoglobin is not a specific cardiac enzyme. Myoglobin can come from any muscle. The specific cardiac enzymes were negative every time they were taken.
Bray's echocardiogram showed one of his valves was abnormal but that had nothing to do with the vessels of the heart "that we're talking about [with a] heart attack." Bray's Persantine test was normal. The significance of a negative stress EKG and normal Persantine test ruled out acute and chronic coronary artery disease. Dr. Ramsey concluded that by October 30, 2000, no evidence of significant cardiac disease existed.
Dr. Ramsey believed the administration of heparin resulted in Bray's massive retroperitoneal hemorrhage. The ERCP procedure had been performed in the area of the gallbladder, and the hemorrhage was in that area. Due to the hemorrhage, Bray suffered a huge blood loss that resulted in a lack of blood volume necessary to sustain organ function and led to multiple organ failure. Bray ultimately suffered a myocardial infarction due to the loss of blood.
According to Dr. Ramsey, the standard of care required immediate discontinuation of heparin when no indication for its use exists, a patient shows signs of internal bleeding, or a patient has an unduly prolonged PTT, such as over 150. Dr. Murphy failed to comply with the standard of care by not discontinuing heparin when coronary artery disease was ruled out. Dr. Ramsey believed Dr. Murphy's failure to comply with the standard of care caused or contributed to Bray's bleed, multi-organ failure, and death.
Dr. Murphy initially breached the standard of care by not discontinuing the heparin when he became aware of the results of the cardiac tests prior to noon on October 30, 2000. At that point, Bray's PTT levels were below the therapeutic range, and no hemorrhage would have occurred had the heparin been discontinued.
By 10 p.m. on October 30, Bray's PTT had risen to 110. Then the level rose to a toxic level of 150. On Tuesday, October 31, when informed of the PTT level over 150, Dr. Murphy should have discontinued the heparin, but he only reduced the dosage. This also breached the standard of care. Dr. Ramsey also noted a lack of communication among the "consultants" in the 36 hours from when Bray was admitted until he was seen by his attending physician.
2. Dr. Patrick Murphy's Testimony
Dr. Murphy testified both during plaintiff's case and defendant's case. His testimony established he was board certified in internal medicine, pediatrics, cardiology, nuclear cardiology, and interventional cardiology. He became the primary physician overseeing all aspects of Bray's care on the morning of October 30, 2000. Early that morning, Dr. Murphy received a voice mail from Dr. Dhan that Bray most likely had a gastrointestinal problem. Dr. Murphy did not know whether Dr. Dhan told him Bray was receiving heparin.
Dr. Murphy did not see Bray or his chart the morning of October 30 because Bray was not in his room because he was downstairs having the ERCP procedure. Dr. Murphy admitted that if he had believed Bray had an ongoing cardiac condition on October 30, he would have made an effort to see him that day because the standard of care would have required it. He did not believe, however, he had a compelling reason to see Bray that afternoon because Dr. Wattanasuwan had seen Bray that morning.
Dr. Murphy knew when he took over Bray's care that an acute myocardial infarction had been ruled out. Dr. Murphy gave conflicting testimony about when coronary artery disease had been ruled out. On the one hand, he admitted coronary artery disease had been ruled out by approximately 11 a.m. on October 30 because Bray would not have had the ERCP if the doctors were still concerned about acute myocardial infarction or coronary artery disease. On the other hand, Dr. Murphy admitted he did not know the results of the second part of the Persantine test until October 31. Dr. Murphy also admitted the EKG, echocardiogram, enzyme tests, stress EKG, and nuclear imaging all gave a good picture of Bray's cardiac status and no more cardiac testing was performed.
Dr. Murphy did not know Bray was on heparin until the nurse called him on October 30 to report the PTT level of 150. Dr. Murphy admitted he should have known his patient was on heparin. The nurse told Dr. Murphy that Dr. Wiser ordered the heparin restarted after the ERCP. Dr. Murphy did not discontinue the heparin at that time because he believed it would breach the standard of care to change a medication regime initiated by Dr. Wiser. Dr. Murphy did not call Dr. Wiser to inquire about why the heparin was restarted. Dr. Murphy said Dr. Wiser should have called him after the ERCP.
Dr. Murphy claimed it was his understanding that Bray was going for his ERCP and his heparin would have been stopped. He was never asked or notified that his heparin would be restarted after the procedure. However, Dr. Murphy also admitted that Illinois Heart has a set of standing physicians' orders used at St. Joseph. The gastroenterology standing-order form for postendoscopy has a preprinted provision that provides: "Resume preop meds and orders except ." Bray's form did not contain an exception for any medications.
After the nurse's call, Dr. Murphy did not go see Bray immediately and did not stop the heparin. The nurse said Bray was doing fine and was in no acute distress. Although Bray had coughed up some blood, that was consistent with having had an ERCP. Dr. Murphy lived 1 1/2 miles from the hospital and could have been there by 7:30 a.m.
Dr. Murphy saw Bray at 11 a.m. on October 31. He admitted no compelling reason existed for Bray to be on heparin the morning of October 31.
Dr. Murphy agreed that Bray had twice had a PTT of over 150 (the second occurring at approximately 2:30 p.m. on October 31, 2000) supported the theory that Bray's bleed was heparin-related. Murphy agreed a retroperitoneal hematoma was one of the variables precipitating Bray's respiratory arrest on October 31. In fact, he admitted heparin may have contributed to Bray's death. However, Dr. Murphy also testified his actions did not violate the standard of care. Dr. Murphy testified the standard of care did not require the heparin be turned off.
3. Dr. Michael Blackstone's Testimony
Dr. Blackstone, a retired gastroenterologist and internist, testified as a retained expert for plaintiff. According to Dr. Blackstone, as of October 30, no indication for giving Bray heparin existed. Bray's tests and symptoms were indicative of gallstones passing into the common bile duct.
Dr. Blackstone testified that individuals on full heparinization will develop retroperitoneal hemorrhages 5% of the time. He estimated Bray bled two liters of blood into that space. Dr. Blackstone believed Bray's hematoma was caused by the use of heparin. The heparin should have been stopped by 7:15 a.m. on Tuesday, and, if that had occurred, it is likely the outcome would have been different. Bray died of the hemorrhage, which caused a massive myocardial infarction, then multi- organ failure precipitated by blood loss. Dr. Blackstone admitted he had never administered heparin but observed it being administered.
Dr. Blackstone found no indication in Bray's chart that the physicians involved in Bray's care were exercising clinical judgment to decide whether the heparin should continue after the ERCP. The exercise of judgment does not allow a physician to give a potentially lethal drug when there is no indication for its use. The original order for heparin was written by Dr. Dhan. By way of postendoscopy standing order, the heparin was restarted after the ERCP, regardless of whether Dr. Wiser questioned it. Only the attending physician, Dr. Murphy, was "in a position to change [the order]."
The material in this subheading and in subheadings 5 through 8 is nonpublishable under Supreme Court Rule 23. [The material in this subheading and in subheadings 5 through 8 is nonpublishable under Supreme Court Rule 23.]
Dr. Dhan testified that in October 2000, he was a partner in Illinois Heart. He was involved in the treatment and care of Bray ...