Hill v. Rhinehart

• Decision Date: 15 October 2015
• Docket Number: No. 02A03–1405–CT–146.,02A03–1405–CT–146.
• Citation: 45 N.E.3d 427
• Parties: John A. HILL, III and Susan Hill, Appellants–Plaintiffs, v. Steven N. RHINEHART, M.D. and Fort Wayne Medical Oncology and Hematology, Inc.; John F. Csicsko, M.D. and David P. Lloyd, M.D., as Individuals and Cardiovascular Associates of Northeastern Indiana, LLC, a Professional Corporation; and Thomas P. Ryan, D.O., Appellees–Defendants.
• Court: Indiana Appellate Court

45 N.E.3d 427

John A. HILL, III and Susan Hill, Appellants–Plaintiffs

v.Steven N. RHINEHART, M.D. and Fort Wayne Medical Oncology and Hematology, Inc.; John F. Csicsko, M.D. and David P. Lloyd, M.D., as Individuals and Cardiovascular Associates of Northeastern Indiana, LLC, a Professional Corporation; and Thomas P. Ryan, D.O., Appellees–Defendants.

No. 02A03–1405–CT–146.

Court of Appeals of Indiana.

Oct. 15, 2015.

Brian J. Hurley, Timothy Krsak, Douglas Koeppen & Hurley, Valparaiso, IN, Attorneys for Appellants.

C. Christopher Dubes, Barrett & McNagny, LLP, Fort Wayne, IN, Karl L. Mulvaney, Nana Quay–Smith, Jessica Whelan, Bingham Greenebaum Doll, LLP, Indianapolis, IN, Mark W. Baeverstad, Andrew L. Palmison, Rothberg Logan & Warsco, Fort Wayne, IN, Attorneys for Appellees.

RILEY, Judge.

STATEMENT OF THE CASE

[1] Appellants–Plaintiffs, John A. Hill (Hill) and Susan Hill, appeal the trial court's judgment in favor of Steven N. Rhinehart, M.D. (Dr. Rhinehart) and Fort Wayne Medical Oncology and Hematology, Inc.; John F. Csicsko, M.D. (Dr. Csicsko) and David P. Lloyd, M.D. (Dr. Lloyd), as individuals, and Cardiovascular Associates of Northeastern Indiana, LLC, a professional corporation; and Thomas P. Ryan, D.O. (Dr. Ryan).

[2] We affirm.

ISSUES

[3] Hill raises three issues on appeal, which we restate as follows:

(1) Whether the trial court properly granted judgment on the evidence in favor of Dr. Lloyd and Dr. Csicsko;

(2) Whether Hill was prevented from pursuing a theory of joint and several liability against all physicians by the entry of the judgment on the evidence against two of the physicians; and

(3) Whether the trial court abused its discretion in tendering Jury Instruction No. 23 and instructing the jury that physicians are not liable for an error in diagnosis or treatment when exercising reasonable care.

FACTS AND PROCEDURAL HISTORY

[4] On December 6, 1999, Hill was admitted to Parkview Memorial Hospital (Parkview) for a cardiac catheterization related to angina pain. Dr. Ryan, a board-certified cardiologist, performed the procedure, which revealed severe coronary artery disease with multiple blockages of two main coronary arteries. Because of the severity of the disease and Hill's risk of death from sudden heart attack, Dr. Ryan recommended immediate coronary artery bypass surgery for the following day. On December 7, 1999, Dr. Lloyd, a board-certified vascular surgeon, executed Hill's coronary bypass surgery. Hill was given the standard dose of 27,000 units of Heparin, “an anti-coagulant, used to thin the blood,” which helped to “keep the blood flowing through the heart pump.” (Transcript pp. 265, 292). He further received 5,000 units of Heparin subcutaneously twice a day until December 9, 1999. The coronary bypass surgery was pronounced a success and Hill was moved into the intensive care unit for recovery.

[5] As his recovery began, Hill manifested numerous complications. Immediately following surgery, Hill experienced a “natural drop in platelets¹ as a result of the surgery” because the “heart/lung bypass machine [used during surgery] simply ‘chews up’ platelets.” (Tr. pp. 636, 683). Over the following day, Dr. Ryan did not see the rebound from the low platelet count that he was expecting and, as a result, on December 9, 1999, he entered an order to “[s]top all subcutaneous Heparin.” (Tr. p. 637). At that point, Dr. Ryan suspected Hill to be suffering from Heparin–Induced Thrombocytopenia (HIT), which is a rare “immune mediated response to the presence of the Heparin antigen in the body.” (Tr. p. 639). Usually, HIT manifests itself “about five to ten days after exposure to the Heparin.” (Tr. p. 278). It “is an uncommon problem” and “mimics many other disease processes. It's very, very difficult to diagnose.” (Tr. p. 1468).² By discontinuing all Heparin —which was the recommended standard of care for treatment of HIT in 1999—Dr. Ryan expected to see “a slow rise in the platelet count back to its normal levels within three to five days.” (Tr. p. 640). Hill was not administered a non-Heparin anticoagulant as a replacement medicine, even though a non-Heparin option, Refludan, was available at Parkview. However, unbeknownst to Dr. Ryan, Hill continued to receive a minimal dose of Heparin because of Parkview's protocol that prescribed “Heparin flushes” of the IV lines. (Tr. pp. 649–50).

[6] Dr. Ryan's anticipated bounce in platelet counts never occurred. Instead, Hill developed life-threatening complications, including Adult Respiratory Distress Syndrome (ARDS), Thrombocytopenia,³ failure to wean from the ventilator, Moraxella infection in his lungs, high fevers, sepsis, and extreme swelling throughout his body. Based on this “constellation of symptoms” on December 13, 1999, Dr. Ryan believed Hill to be suffering from Disseminated Intravascular Coagulopathy (DIC), which is “an extremely serious condition manifested by formation of clots in blood vessels coupled at the same time with the fall in the patient's platelet count.” (Tr. pp. 701, 685). However, due to the eighty percent drop in platelet count combined with a significant swelling of Hill's left arm, Hill's medical expert, Harry Jacob, M.D. (Dr. Jacob), testified that, at this point Hill's HIT had developed a Thrombosis component (HITT)⁴ and Refludan, the non-Heparin anticoagulant, should have been prescribed. In 1999, Refludan was a newly approved drug which was “not strongly supported by the medical community” as it could cause severe “bleeding into the brain tissue” and no reversal agent existed. (Tr. pp. 1479, 1480). “Refludan was [later] taken off the market because its safety profile did not match what current FDA standards would require.” (Tr. p. 1481).

[7] Throughout the day on December 13, 1999, Hill continued to experience a decrease in his platelet count and the swelling in his left arm worsened, with his hand becoming “cool and blue.” (Tr. p. 310). Dr. Lloyd ordered an ultrasound Doppler study for the following morning to auditorily evaluate the flow of blood in Hill's arm. On December 14, 1999, Dr. Csicsko, a board-certified cardiovascular surgeon, discovered that Hill had continued to receive Heparin through the flushing of his IV lines and discontinued the protocol. He ordered saline to be used instead.

[8] On December 15, 1999, at 1:00 a.m., the nursing notes indicated that Hill's “[r]ight foot is mottled and capillary refill is greater than three seconds. Both feet are cold to touch.... Left toes are cyanotic and blue appearing.” (Tr. p. 313). At 1:30 a.m., the notes reflected that Hill's “[r]ight leg is swollen and firm from the ankle to the groin.” (Tr. p. 315). At 8:30 a.m., the notes warned that Hill's left arm is swollen and blue. Dr. Jacob testified that all these symptoms reflect a worsening HITT. Later that day, Dr. Ryan consulted with Dr. David Goertzen (Dr. Goertzen), an orthopaedic surgeon, about the “extreme swelling in [Hill's] limbs” and his concern that “the swelling may compromise his arterial system.” (Tr. p. 697). After the consultation, Dr. Goertzen performed a “fasciotomy,” which is “a cutting of the skin to release the pressure on the skin and therefore allow the blood vessels not to be compromised by the swelling around it.” (Tr. p. 697).

[9] On December 16, 1999, Hill's clinical assessment remained essentially unchanged and was considered to be “very critical” because “his limbs were necrosing.” (Def.'s Exh. H, p. 40). A consult with Dr. Rhinehart, a hematologist, was sought that morning. Dr. Rhinehart's “differential diagnosis was Acute Respiratory Distress Syndrome, sepsis, DIC.” (Def.'s Exh. H, p. 38). To combat the presumed diagnosis of DIC, Dr. Rhinehart immediately ordered a 5,000 unit bolus of Heparin, to be administered intravenously, with an intravenous infusion of approximately 1,000 cc's of Heparin per hour for sixteen to seventeen hours thereafter. At certain times throughout the day, Dr. Rhinehart ordered the administration of additional platelets to control Hill's bleeding following his fasciotomy.

[10] On December 17, 1999, with Hill's condition unchanged, Dr. Rhinehart discontinued all Heparin and platelet infusions and requested “a Heparin induced antibody titer,” a specific test to “measure the antibody” and a confirmatory diagnosis of whether a patient suffers from HIT or HITT. (Tr. p. 352). In 1999, the closest testing center was located in Milwaukee. On the same day, Dr. Rhinehart also ordered the administration of Refludan, “to prevent further clotting from occurring.” (Tr. pp. 354–55). Once Refludan was administered, Hill's platelet count began to rebound.

[11] On December 20, 1999, the necrosis gangrene⁵ and swelling in Hill's right leg and left arm were too extensive and Dr. Goertzen amputated the left arm just below the elbow and the right leg above the knee. Hill continued to experience swelling problems in his left leg and, on December 28, 1999, Dr. Goertzen amputated Hill's left leg above the knee. Hill remained in critical care at Parkview until December 31, 1999, when he was transferred to I.U. Medical Center for six weeks. In mid-February, 2000, Hill was released to the Rehabilitation Institute of Chicago where he received in-patient physical therapy before returning home in early April 2000.

[12] On March 26, 2001, Parkview entered into a Settlement Agreement (Agreement) with Hill regarding all claims related to the health care provided by Parkview. Pursuant to the agreement, Hill released Parkview from liability in exchange for $250,000. On December 5, 2001, Hill filed a proposed Complaint for medical malpractice with the Indiana Department of Insurance pursuant to Ind.Code § 34–18–1–1. The Complaint alleged that Dr. Ryan, Drs. Lloyd and Csicsko, and Dr. Rhinehart violated their respective standards of care in providing Hill post-surgical care, resulting in the loss of three limbs. The medical review panel unanimously determined that the evidence did not support the conclusion that the...