Brown v. Koulizakis

• Decision Date: 14 June 1985
• Docket Number: No. 820473,820473
• Citation: 331 S.E.2d 440,229 Va. 524
• Parties: E. Blair BROWN, Executor, etc. v. E.N. KOULIZAKIS, et al. Record
• Court: Virginia Supreme Court

Page 440

331 S.E.2d 440

229 Va. 524

E. Blair BROWN, Executor, etc. v. E.N. KOULIZAKIS, et al.

Record No. 820473.

Supreme Court of Virginia.

June 14, 1985.

Allen S. Rugg, Alexandria, (Peter A. Dingman, Fagelson, Schonberger, Payne & Arthur, Alexandria, on briefs), for appellant.

Norman F. Slenker, Arlington, R. Harrison Pledger, Jr., McLean (Dennis A. Coryell, Slenker, Brandt, Jennings & Johnston, Arlington, on briefs), for appellees.

Present: CARRICO, C.J., COCHRAN, POFF, COMPTON, STEPHENSON and THOMAS, JJ., and HARRISON, Retired Justice.

COMPTON, Justice.

In this medical malpractice case, we review the action of the trial court in entering summary judgment for the defendants at the conclusion of the plaintiff's evidence.

Stefan Alexander Mader died of a pulmonary embolism in 1978 in The Fairfax Hospital. In 1980, Mader's executor filed this wrongful death action in the court below against appellees E.N. Koulizakis, an orthopedic surgeon, and Michael F. Ball, a specialist in internal medicine. The plaintiff alleged that each defendant failed adequately to examine, test, diagnose, and treat the decedent for pulmonary embolism.

In 1981, the case was tried with a jury. The plaintiff's evidence included testimony from a nurse, a medical examiner, an expert in the field of orthopedics, and an expert in the field of internal medicine. At the conclusion of plaintiff's case-in-chief, the trial court sustained defendants' motions to strike the plaintiff's evidence. We awarded the plaintiff an appeal from the December 1981 final judgment entered in favor of the defendants.

The testimony of plaintiff's experts was based on a hypothetical question, keyed to the actual facts of the case from the plaintiff's standpoint. The following recitation of the essential facts, viewed in the light most favorable to the plaintiff, is taken mainly from the hypothetical question.

On January 31, 1978, Mader, age 31, was admitted to The Fairfax Hospital for evaluation and treatment of severe low back pain. He had no recorded history of any injuries or disease to his heart, lungs, or circulatory system other than "several pneumonias" years earlier.

The hospital chart was introduced in evidence by the plaintiff. It covered the period of Mader's care and treatment during his last hospitalization, from January 31 to the date of his death on February 23, 1978, as well as during four previous hospitalizations. The hospital record included facts, findings, laboratory data, test results, and notations of the defendants made during the final period. In 1978, the hospital operated a full-time, 24-hour pulmonary function laboratory equipped and staffed to analyze the oxygen content of arterial blood.

On February 21, 1978, at 12:45 a.m. Mader was awake and complaining of "piercing discomfort" in the upper right quadrant of the abdomen. The patient's vital signs were good. He was given Maalox, and he went back to sleep. Later that morning, when Mader was awakened for his temperature to be taken, he requested an additional dose of Maalox for relief from the return of the upper abdominal discomfort.

In the afternoon of February 21, the patient was taken to the x-ray department for a discogram. This diagnostic procedure was postponed because of the patient's complaints of chest pain and shortness of breath, both of which arose when he was in the prone position for the discogram. Upon return to his hospital room, Mader complained of pain in the right anterior and posterior chest. At 6:45 p.m., the patient, still complaining of chest pains and shortness of breath, showed vital signs of blood pressure of 100 over 80, pulse of 74, and respiration of 34. Shortly thereafter, he was examined by a hospital physician who noted in the chart that the pain was definitely associated with respiration, and that there was no pain when the patient held his breath. An electrocardiogram and a chest x-ray at that time were normal. Prior to February 21, Mader had complained in the hospital only of back pain.

On February 22, after sleeping for intervals, Mader was awakened at 3:00 a.m. by the return of the chest pain. The pain was noted by a nurse to be localized in the upper right quadrant of the abdomen, running front to back, which the patient found prevented him from breathing deeply. The patient was noted to be hyperventilating because he said his nerves were "shot." Mader received pain medication and returned to sleep.

At 9:15 a.m. on February 22, Mader was seen by the defendant Koulizakis, his treating physician and orthopedic surgeon. The patient complained to Koulizakis of discomfort in both lungs and spoke in a low voice while rolling his eyes back in his head. Koulizakis called another physician, the defendant Ball, who was a board-certified internist, in consultation to consider the chest pain and breathing difficulties.

During the afternoon of February 22, Mader's scheduled physical therapy was cancelled at the patient's request because he could not roll over or move for the treatment. In the late afternoon, the patient still complained to a nurse of chest pain and inability to breathe deeply.

The defendant Ball saw Mader in the late afternoon of February 22. He took a medical history and performed a physical examination, noting vital signs of blood pressure of 100 over 60, pulse of 88, and respiration of 20. The physician noted that the pain "is pleuritic in type and markedly aggravated by deep breathing." According to Ball, the patient "showed a few scattered rales at both bases and no wheezes, no pain on palpation over right side of his chest cage." The internist further noted, as "a working diagnosis," that the "most logical possibilities were an infectious process such as pneumonia or pleurisy and less likely a pulmonary embolus."

At that time, Ball ordered "complete blood chemistries" to be performed that evening, blood chemistry reports "in the morning," a chest x-ray "in the morning," blood gases "in the morning," and a lung scan to be performed at no specific time.

During the morning of February 23, the patient was seen by Koulizakis who noted on the hospital chart that Mader was "still being investigated" by the internist regarding "chest pains." At 9:15 a.m., Mader reported to a nurse that he had "coughed up a mucousy plug of blood." At 11:45 a.m., arterial blood was drawn for the arterial blood gas analysis. At 1:45 p.m., the patient was taken to the nuclear medicine department for the lung scan.

The results of the blood gas analysis were furnished to Ball by telephone. While the patient was in the nuclear medicine department, the lung scan was analyzed as showing a pulmonary embolism. The patient suffered acute respiratory distress, and cardiopulmonary arrest at 3:05 p.m. An emergency cardiopulmonary resuscitation effort was unsuccessful and Mader was pronounced dead at 4:00 p.m. Upon autopsy, the cause of death was determined to be: "Massive, acute, 'saddle-type' pulmonary embolus occurring as terminal event in association with recurrent, severe, low back pain."

The plaintiff's expert witnesses described a pulmonary embolism as a solid body, such as a blood clot or tumor, that has moved from a vein into the arteries of the lung. According to the testimony, nearly all such emboli are blood clots that form in a vein, break off, and eventually obstruct the arteries and the lung. The lung tissue is damaged, resulting in the person's inability to oxygenate blood. The oxygen-carrying capacity of the blood is thereby decreased which, if significant enough, adversely affects the physical condition of the patient.

Based upon the foregoing information, as well as study of the hospital record and the autopsy report, the plaintiff's expert witnesses were asked to evaluate the conduct of the respective defendants, considering the statewide standard of care applicable within the defendants' individual specialties. The plaintiff's orthopedic expert was Dr. Robert S. Adelaar, a Richmond physician who was an associate professor of surgery at the Medical College of Virginia and Chief of the Orthopedic Division at the McGuire Veterans Hospital.

Adelaar testified that Koulizakis deviated from the standard of care applicable to a reasonable, prudent orthopedic surgeon in the Commonwealth in February of 1978. He opined there were "significant delays in the diagnosis, treatment and management of a potentially lethal condition, ... a pulmonary embolism." Noting that Mader complained of a new clinical condition for the first time on February 21, as reflected by complaints of chest pain and shortness of breath, Adelaar stated that Koulizakis should have begun making a diagnosis of the cause of the complaints when he saw Mader at 9:15 a.m. on February 22 and that pulmonary embolism should have been considered in that diagnosis.

Adelaar noted that Mader had been at prolonged bed rest during his final stay in the hospital and that an epidural venogram had been performed upon him on February 14 in which a vein had been penetrated with a catheter. These circumstances, according to Adelaar, placed Mader "at risk" and predisposed him to "thromboembolic problems" which should have been anticipated by Koulizakis. Adelaar stated that, when a person is inactive, the blood "pools and does not move through the venous system," thus increasing the propensity of the blood to clot. Adelaar considered a venogram to be a surgical procedure that is an "insult" to one of the veins which may cause a clot to develop at the irritated site in the blood vessel ten days or two weeks after the insult. According to the witness, the...