New York State Court of Claims

New York State Court of Claims

WROBLESKI v. STATE OF NEW YORK, #2007-018-563, Claim No. 105593


The continuation of Heparin was not a deviation from the standard of care, but a medical judgment. The claim is dismissed.

Case Information

THEODORE WROBLESKI, Individually and as Administrator of the Estate of SHIRLEY WROBLESKI
Claimant short name:
Footnote (claimant name) :

Footnote (defendant name) :

Third-party claimant(s):

Third-party defendant(s):

Claim number(s):
Motion number(s):

Cross-motion number(s):

Claimant’s attorney:
Defendant’s attorney:
Attorney General of the State of New York
By: MICHAEL R. O’NEILL, ESQUIREAssistant Attorney General
Third-party defendant’s attorney:

Signature date:
March 20, 2007

Official citation:

Appellate results:

See also (multicaptioned case)

Claimant brought a medical malpractice action for the conscious pain, suffering, and wrongful death of his wife, Shirley Wrobleski. Claimant alleges that the doctors at State University of New York, Upstate Medical University (hereinafter referred to as University Hospital) were negligent in the care and treatment of Mrs. Wrobleski, the decedent. This was a unified trial addressing both liability and damages.
At the time of her death, Mrs. Wrobleski was 66 years old having been born on May 26, 1935. When Mrs. Wrobleski died, she and Claimant had been married 40 years, and they had three adult children.
Mrs. Wrobleski was described as a very independent woman who worked on and off during the marriage and devoted herself to her family. She had a history of diabetes, hypertension, and joint disease. Some time in 1999-2000, prior to her hospitalization at University Hospital, Mrs. Wrobleski developed a heel ulcer which required surgeries and ongoing treatment.
In April 2001, Mrs. Wrobleski had a surgical repair of her heel performed at Community General Hospital in Syracuse. She used a wheelchair and walker through July 2001. Claimant testified that by July, his wife was more involved around the house as her foot was improving.
On July 29, 2001, a Sunday, Mrs. Wrobleski was not feeling well. Claimant testified that he had to repeat what he said to her. The next day, Monday, July 30, Claimant and his wife went to visit their daughter, Colleen Andrews, near Auburn. She was not at home when they arrived, so they drove into Auburn where Claimant bought his wife a hotdog from a vendor and a frosty from Wendy’s. They returned to their daughter’s home. Ms. Andrews testified that her mother was just holding these items, not eating or drinking. Mrs. Wrobleski spilled the frosty on herself, and Ms. Andrews cleaned her up and then suggested Claimant take her for medical treatment. Claimant took Mrs. Wrobleski to the Northeast Medical Center, and from there, Mrs. Wrobleski was taken by ambulance to University Hospital. Claimant and Ms. Andrews both drove to University Hospital as well. They both testified that Mrs. Wrobleski was incoherent.
Claimant and Ms. Andrews stayed with Mrs. Wrobleski in the emergency room that night while she waited for a room. Mrs. Wrobleski was admitted to the hospital under the care of Dr. Sriram Narsipur, who was an attending physician specializing in nephrology. Tests were performed that night but neither Claimant nor his daughter was sure what they were.
Claimant went home and cleaned up the following day, July 31, around 10:30 a.m., after Mrs. Wrobleski was settled in a room. Ms. Andrews left the hospital at approximately 6:30 a.m. When Claimant returned to the hospital later that day, he thought his wife’s condition had improved. She had started to converse with Claimant although she still had periods of confusion. On August 1, Mrs. Wrobleski was moved to the Cardiac Intensive Care Unit (ICU) where she could be monitored more closely. Claimant did not understand why Mrs. Wrobleski was on a cardiac floor because she had never had heart trouble. Claimant went home that night.
On August 2, 2001, Claimant returned to University Hospital in the morning. He thought Mrs. Wrobleski was much better; she was carrying on a conversation with friends. Claimant left for a period of time to get his paycheck and receive a physical therapy treatment. Some time that afternoon, when he was back at University Hospital, a doctor asked him to sign a consent form allowing the medical staff to place a vascular catheter in Mrs. Wrobleski’s femoral vein. Claimant understood this to be a prelude to possible dialysis treatment. He testified that the doctor told him the odds of any complications were 1 in 500, and that an operating room team would be standing by in case they were needed. Claimant felt comfortable signing the consent. Claimant signed other consent forms that day, including one for a PICC
line and one for a blood transfusion. Claimant was also told the procedure to place the catheter would take 15 to 20 minutes. Claimant waited in the next room while the procedure was being done and it took much longer than he had been told. Ms. Andrews left the hospital around 8:30, and Claimant left at about 8:40 p.m. Claimant said he went into Mrs. Wrobleski’s room to kiss his wife goodnight and she seemed to be sleeping. She felt cold. There was a male nurse in her room disconnecting equipment. On his way out, Claimant told a doctor that Mrs. Wrobleski was cold and pale. The doctor said it was normal.
Shortly after Claimant arrived home, the hospital called and said his wife had taken a turn for the worse. He called his daughter and son and then drove back to University Hospital. His wife had passed away before he returned. A doctor told Claimant she died from heart failure. Claimant was credible and sincere in his testimony; however, he understood very little of the medical information he was given, and based upon the other evidence, it is clear he had a limited recollection of what occurred.
Ms. Andrews described the events of July 30 through August 2 very similarly to her father, although she did recall some of the events in more detail. The night Mrs. Wrobleski was admitted to the hospital, July 30, she recalled blood and urine tests being performed. A nurse told Ms. Andrews and her father that some of her mother’s medications may be causing her kidneys to function improperly.
On July 31, Ms. Andrews said her mother’s condition was about the same, but by August 1, it had improved. She and her mother were able to have some normal conversations although Mrs. Wrobleski still had periods of confusion.
While the vascular catheter was being placed on August 2, Ms. Andrews heard her mother groaning and saying “ow.” Some time later, Ms. Andrews tried to enter the room but someone shut the door in her face. She could see a huge bruise from her mother’s groin to her knee. Thereafter she saw a doctor, who she thought was Russian, go to the telephone and make some calls. She heard him tell the people in her mother’s room to keep the pressure on. He told Ms. Andrews and her father that something like this only happens once in 500 times, and he was very sorry. Before leaving the hospital that night, Ms. Andrews sat with her mother and tried to keep her awake as the medical staff instructed. She also returned to the hospital, after her mother died, and recalled a doctor saying she died of heart failure.
On cross-examination, Ms. Andrews recalled the doctors telling the family they were checking Mrs. Wrobleski’s kidneys for infection. She recalled someone mentioning her mother receiving Heparin, a blood thinner, because of chest pain complaints and because there was a possibility of blood clots.
The Claimant also called two nurses who treated Mrs. Wrobleski at University Hospital. Robert McGarvey was her nurse from 11:00 p.m. on August 1 to 7:00 a.m. on August 2, and again from 7:00 p.m. on August 2 until she died. When he took over her care on August 1, he said she complained of abdominal pain, she was lethargic, confused, and required oxygen. Her heart rate was fast. By 5:00 a.m., on August 2, he felt her heart condition was improving. The amount of oxygen she was receiving was decreased, her potassium levels had decreased, her urinary output had increased, and her confusion had improved by 7:00 a.m.
When he returned to work at 7:00 p.m. on August 2, Mr. McGarvey learned that the doctors had difficulty placing the vascular catheter in Mrs. Wrobleski’s femoral vein and it took more than one attempt to insert it. The witness noted a large hematoma on her left leg from her groin into her thigh. Mrs. Wrobleski was pale and pasty with a fast heart rate and experiencing shallow breathing at the time. Her blood pressure had decreased significantly from that morning. Her oxygen level had dropped to 92%. Mr. McGarvey administered fresh frozen plasma at 7:30 p.m., and at 8:00 p.m., packed red blood cells were given. This treatment was to help replace the blood Mrs. Wrobleski lost as a result of the bleeding during the catheterization. The witness did not recall Mrs. Wrobleski complaining of chest pain that evening, but he did complete a cardiac injury panel.
A “PICC” line had been placed in her arm, which allowed access to Mrs. Wrobleski’s veins for medications or other needs. Dr. Narsipur testified this is usually done when a patient has small or difficult veins. Mr. McGarvey said the fresh frozen plasma was probably administered through it. Mrs. Wrobleski did have one peripheral IV.
After the blood products were given, Mrs. Wrobleski’s heart rate and blood pressure improved. She was responsive and remembered Mr. McGarvey from the night before. At 9:00 p.m., the witness said he went in to draw blood gases from Mrs. Wrobleski, a relatively painful event, and she did not respond normally. She was lethargic again. About 9:30 p.m., the nurse noted he could not get a blood pressure or pulse and her heart rhythms were abnormal. He called a code and personnel responded, but Mrs. Wrobleski was pronounced dead at 10:12 p.m.
Mr. McGarvey described the coronary care unit. Each room houses only one patient who is attached to monitors for heart rate, respiration, blood pressure, and oxygen saturation. These readings are displayed inside and outside the rooms and are watched in a separate room by other personnel. Alarms outside the room sound in the event of an abnormal situation. The readings are recorded by the nurses as well. There are at least three nurses for a maximum of six patients. Mr. McGarvey said Mrs. Wrobleski was his only patient on August 2.
Mrs. Wrobleski’s other nurse, Faye Kimball, came on duty at 3:00 p.m. on August 2, 2001, and was assigned to care for her. At that time, her vital signs were stable and she had no complaints. Between 3:00 and 4:00 p.m., a Doppler study was done to check for blood clots in Mrs. Wrobleski’s legs. Ms. Kimball testified there was concern about a clot in her lungs.
Ms. Kimball noted that in placing the vascular catheter numerous attempts were made before the doctors were successful. It took about 1¼ hour to place the catheter. Thereafter, a hematoma formed and pressure was placed on the area to stem the bleeding. A sandbag was also applied. The area of the hematoma was marked so it could be determined whether or not the hematoma was growing. Ms. Kimball typed Mrs. Wrobleski’s blood in case she needed to receive blood products to replace what she had lost. Mrs. Wrobleski was awake during this time. The witness completed a hemoglobin and a hematocrit test. Both results were lower than normal, indicating a loss of blood.
Mrs. Wrobleski’s blood pressure dropped after the hematoma formed and she became pale. Ms. Kimball knew that she had been on Heparin because of concerns of a pulmonary embolism, and that the Heparin was discontinued after the hematoma formed. Ms. Kimball left at approximately 7:00 p.m. for another assignment and Mr. McGarvey came on at that time. Ms. Kimball agreed that Mrs. Wrobleski was not doing well at the time.
Three of the treating physicians were called by Claimant: Dr. Sriram Narsipur, the attending physician; Dr. Anthony Nappi, then a resident at the hospital, and Konstantin Millerman, M.D., who was a Pulmonary Critical Care Fellow at University Hospital. Drs. Narsipur and Nappi testified that Mrs. Wrobleski’s initial diagnosis was acute renal failure and probably urosepsis
with mental changes. She was placed on antibiotics and fluids. Dr. Nappi said some of her medications were withheld because they were thought to be contributing to her kidney problems.
On August 1, Mrs. Wrobleski complained of shortness of breath and chest pain leading Dr. Narsipur to suspect a cardiac event, so he obtained a cardiac consultation. Mrs. Wrobleski’s EKG and echocardiogram indicated the right side of her heart was working harder than normal; something was impeding the blood flow. The medical team suspected she had a pulmonary embolism, a blood clot, in the lungs. Blood clots that go to the lungs usually originate in the legs or pelvis and can be dangerous, even fatal. Mrs. Wrobleski was prescribed Heparin, an anticoagulant with a risk factor for excessive bleeding. She was transferred to the cardiac unit for closer monitoring and additional tests were ordered.
The tests Dr. Narsipur ordered were D Dimer,
a repeat echocardiogram, a VQ
scan and a Doppler which aid in diagnosing or ruling out a pulmonary embolism. The D Dimer results were elevated, suggesting a pulmonary embolism but were not conclusive. These results, Dr. Narsipur said, kept the concern of a pulmonary embolism high although other conditions can cause elevated results.
The VQ scan measures a patient’s ventilation and perfusion. Mrs. Wrobleski was unable to perform the ventilation portion of the test because of her shortness of breath. The results were a homogenous perfusion in both lungs which indicated a low probability of a pulmonary embolism.
A repeat echocardiogram was performed on August 2, and the results differed from the previous day, no longer supporting a diagnosis of a pulmonary embolism. A Doppler was ordered because it can detect blood clots in the legs. It was performed the afternoon of August 2. No deep vein thrombosis was seen, reducing the probability of a pulmonary embolism, but the Doppler does not include the pelvis so the diagnosis could not be ruled out. A renal ultrasound was unremarkable.
Dr. Narsipur testified that the only test that can exclude a pulmonary embolism is an angiogram but it was contraindicated for Mrs. Wrobleski. The chemicals used could damage her already compromised kidneys.
Dr. Nappi testified that on August 2, the suspicion of a pulmonary embolism still existed, although the test results of that day made the pulmonary embolism diagnosis less likely. Dr. Nappi testified that he ordered a second VQ scan that day, including the ventilation portion Mrs. Wrobleski could not perform before because he thought she would now be able to cooperate with the examination. However, Dr. Narsipur cancelled the test before it could be performed.
The medical records
from August 2, reflect that a cardiology consult at 8:40 a.m. recommended the continuation of Heparin until definite tests could be conducted. The cardiology consultation
later in the day also directed that all medications were to be continued for Claimant. Relying upon the medical records, Dr. Nappi testified at trial that the administration of Heparin to Mrs. Wrobleski was discontinued due to the hematoma. At his deposition, he said it was due to the lower suspicion of a pulmonary embolism. At trial, he said looking back, he was mistaken at the deposition.
Dr. Narsipur testified that on August 1, Mrs. Wrobleski was subjectively better, her mental status in particular but her laboratory results were not any better. She was suffering from hyperkalemia which is excessive potassium in her blood. The treatment to remove the potassium is the administration of glucose and insulin or dialysis. If the medications do not work, then dialysis is used. Dr. Narsipur considered dialysis if her condition did not improve. According to Dr. Narsipur’s note made after Mrs. Wrobleski died, Mrs. Wrobleski’s mental status and urine output improved during the day of August 2, 2001.
Dr. Narsipur directed Dr. Nappi to get someone to place a vascular catheter in Mrs. Wrobleski’s femoral vein as early as possible on August 2, in anticipation of Mrs. Wrobleski undergoing hemodialysis. Dr. Nappi contacted surgery to place the catheter. No one was available until 3:30 p.m.
Dr. Patel and Dr. Millerman were called upon to place the catheter. Dr. Konstantin Millerman, who testified at trial, was at that time a Pulmonary Critical Care Fellow at University Hospital, and was asked to supervise the catheter placement. He understood that Mrs. Wrobleski was in renal failure and would need dialysis. Dr. Millerman was made aware that Mrs. Wrobleski was also septic,
might have a pulmonary embolism, had a fluid overload, and was hyperkalemic. Dr. Millerman testified at trial that after reviewing the chart, he asked if the Heparin had been discontinued and was told it was. This was different from his deposition testimony which indicated he didn’t know she was on Heparin. He ordered a 500-unit bolus
of Heparin to be given through the vascular catheter to prevent it from clogging.
Dr. Patel made several attempts to place the catheter in Mrs. Wrobleski’s right femoral vein. Dr. Millerman took over and was also unsuccessful. The autopsy reflects nine needle punctures to the right femoral area. Dr. Millerman then moved to the left leg and placed the catheter on his third attempt. He noticed a hematoma forming so pressure was applied to Mrs. Wrobleski’s left leg to stop the bleeding. Although some bleeding is usual with this procedure, typically pressure stops the bleeding. But in this case, pressure wasn’t working, and Dr. Millerman felt something was wrong. The hematoma continued to expand, and Dr. Millerman realized he was facing a significant problem. He immediately ordered tests to address it including checking the arterial blood gases. Dr. Millerman testified that Mrs. Wrobleski’s blood pressure dropped significantly. He ordered a hematocrit which indicated she had lost a lot of blood. At about this time, Dr. Millerman learned that the Heparin had not been discontinued and he ordered it stopped immediately. Dr. Millerman said if he had known Mrs. Wrobleski was on Heparin, he would have ordered the Heparin stopped prior to the procedure. Dr. Nappi called for surgical assistance, and when no one arrived after a period of time, Dr. Millerman paged Dr. Jahangir who was in charge of the surgical team. Dr. Jahangir arrived 45 minutes after the call
but before they realized the bleeding was not stopping.
Dr. Millerman thought Dr. Jahangir would take Mrs. Wrobleski to surgery but he did not. Dr. Jahangir and his attending physician, Dr. Sobol, thought the bleeding would stop on its own.
Dr. Millerman ordered fluids and blood to be administered as well as fresh frozen plasma. These treatments occurred at 7:30 and 8:00 p.m., respectively. He also ordered a test to determine if an artery was punctured instead of a vein. A CT scan was considered but Mrs. Wrobleski was not stable enough to get one. Although Mrs. Wrobleski’s condition later stabilized around 8:00 p.m., a CT scan was not ordered for her before Dr. Millerman left the hospital at approximately 8:30 p.m.
Mrs. Wrobleski had blood tests done on August 2, one test, the Partial Thromboplastin Time (PTT), reflects the amount of time it takes for blood to clot. A normal PTT is between 25 - 34 seconds in the University Hospital lab; with the use of Heparin, a therapeutic range for the PTT should be about 1½ to 2½ times normal coagulation. Mrs. Wrobleski’s laboratory results for August 2 indicate her PTT at 12:32 a.m. was 56.5 seconds, at 11:46 a.m., 48.5 seconds, and at 8:45 p.m., 74.8 seconds. The higher the time, the longer it takes to coagulate and the thinner the blood is. Since the Heparin was discontinued around 5:00 p.m., Dr. Nappi thought that the 8:45 p.m. lab results, although still in the normal range, were surprising. For that reason, Dr. Nappi speculated that the blood specimen for that test may have been drawn from the catheter which would have contained Heparin from the bolus and, therefore, affected the PTT results. Dr. Narsipur agreed, and he testified that it was routine to administer Heparin by bolus when placing a vascular catheter to prevent the blood from clotting and clogging the line.
Before the placement of the catheter, Dr. Nappi said he spoke with Claimant about Mrs. Wrobleski undergoing hemodialysis and the need to place a vascular catheter for that procedure. He explained the risks to Claimant, including excess bleeding, especially in patients with renal failure and undergoing Heparin treatment. Claimant signed the consent form at that time.
Dr. Narsipur testified that there was no emergent need for dialysis on August 2; he planned to initiate dialysis the following day. He clarified that the vascular catheter was placed on an urgent basis, meaning it should be done that day, as opposed to an emergent basis, requiring immediate action. If Mrs. Wrobleski’s condition had worsened during the night, Dr. Narsipur could be ready to perform dialysis. He agreed that when complications present with the placement of a vascular catheter, they can be significant - especially because of the Heparin. Dr. Narsipur testified that a vascular catheter can be placed in the neck, chest, or groin areas. It is easier to administer pressure if there is excessive bleeding if the catheter is in the groin. Dr. Narsipur added that because of the risk of complications, he chose to place the catheter in the femoral location.
When asked about the number of attempts made to place the catheter, based upon the autopsy report,
Dr. Narsipur testified that there were 12 needle sticks, of which he attributed four needle sticks to suture in the catheter and then two needle sticks to administer the anesthesia. He believes there were three catheter placement attempts on each side.

Dr. Narsipur did not see a hematoma; he was not there when the catheter was placed and when he arrived at Mrs. Wrobleski’s room, there was a sandbag over that area of her thigh to help stop the bleeding. However, because of the hematocrit results, Dr. Narsipur knew it was a serious bleed. Mrs. Wrobleski had lost a lot of blood. At least two of the attempts to place the catheter perforated her vein causing serious bleeding.
Dr. Narsipur testified that a better indication of whether Mrs. Wrobleski was still bleeding at 8:45 p.m., was her blood pressure and hemodynamics. Her blood pressure dropped significantly at 5:30 p.m. She was treated with fluids, fresh frozen plasma, and a blood transfusion. These treatments began about 7:30 p.m. It took two hours or so because Mrs. Wrobleski’s blood had to be typed and cross-checked before she could receive the blood. He agreed that two- to two-and-one-half hours between the “bleed” and the treatment can be a significant period of time.
There is a drug, Protamine, that can quickly reverse the effects of Heparin. Protamine is difficult to use and it can cause hypotension and anaphylactic shock. Dr. Narsipur felt he could have created a worse problem for Mrs. Wrobleski by using that drug. He felt Mrs. Wrobleski was improving for a period of time before she died. Between 7:00 and 8:00 p.m., her blood pressure was increasing and her mental status had improved as well. It was during this time that she was receiving blood products which caused the improvement. Her health then declined from 9:15 until her death at 10:15 p.m.
On cross-examination, Dr. Narsipur described in greater detail the problems Mrs. Wrobleski had upon admission. She had acute renal failure which causes potassium, acids, or other substances to build-up. That, in turn, stops the body systems from working properly including the heart and blood vessels. Fluid retention can cause a fluid build-up in the lungs and inflammation to the lining of the heart which can be fatal.
Mrs. Wrobleski was also diagnosed with urosepsis, due to e-coli, which begins as a bladder or kidney infection that spreads to the bloodstream. A broad spectrum antibiotic was administered and seemed to be clearing the infection based upon blood tests, although unbeknownst to the medical team, the autopsy results reflect that Mrs. Wrobleski had an infectious process that consumed both kidneys. There were pockets of infection that would not be eliminated by antibiotics because there was no blood flow to these areas. Eighty to 90 percent of the right kidney tissue was dead. Had Mrs. Wrobleski lived, Dr. Narsipur said both kidneys would have had to be removed. The mortality rate for patients with acute renal failure is 40 to 60 percent, and if there is infection involved, mortality can be as high as 70 percent. According to Dr. Narsipur, Mrs. Wrobleski’s prognosis on August 2 was critical to guarded. He was still concerned about the pulmonary embolism and did not want to stop treating her for it until he was sure she did not have one.
It is Dr. Narsipur’s opinion that Mrs. Wrobleski died because of the infection and kidney failure. In his note, written after Mrs. Wrobleski passed away, but before he received the autopsy results, Dr. Narsipur speculated about what happened, writing, “I suspect she had underlying [coronary artery disease] and stress of hypovolemic hypotension
(and sepsis and ACF [acute renal failure]) precipitated an acute state of cardiac dysfunction.”
At trial, he still agreed with this note but does not think the coronary artery disease played as big a role in her death because there was no evidence of “end organ effect.”
The autopsy results indicate congestion and fluid in her lungs, which is consistent with acute renal failure and mild coronary atherosclerosis but no major cardiac event such as heart attack or restriction of blood flow to her heart.
Dr. Narsipur modified his opinion that hypovolemic hypotension caused Mrs. Wrobleski’s death after receiving the microscopic tissue information from the autopsy report. That information indicated there was no major consequence of Mrs. Wrobleski’s hypotension.
The autopsy cause of death was urosepsis and renal failure with a contributory cause attributed to perforations of vein due to femoral vein catheter placement. The “manner of death” is listed as “therapeutic complication.”
Dr. Narsipur agreed with the primary cause of death. He did not understand what the Medical Examiner meant by “manner of death.” Therapeutic complication, in his opinion, is something that is done that results in a negative impact. In this case, the impact was loss of blood. He did not agree that loss of blood caused Mrs. Wrobleski’s death because there was no evidence of damage from the blood loss. Dr. Narsipur’s opinions stem from his interpretations of the autopsy without consultation with the Medical Examiner. Claimant’s expert’s testimony
was taken and the transcript was submitted. Dr. Aaron J. Gindea is Board Certified in Internal Medicine and Cardiovascular Disease. He is a Clinical Associate Professor of Medicine with New York University and has a cardiology practice on Long Island. It was his opinion that the treatment Mrs. Wrobleski received at University Hospital did not meet the standard of care. He believed that by failing to stop Heparin prior to placing the vascular catheter, the doctors caused a hemorrhage which was a proximate cause of Mrs. Wrobleski’s death.
Dr. Gindea reached his opinion after reviewing the hospital records and depositions of some of the doctors. He said that Mrs. Wrobleski’s kidney function had at least remained stable during her hospitalization. Her blood count also remained stable. Per the doctors’ notes, she was holding her own until the vascular catheter procedure. The Heparin she was receiving created a coagulation disorder and, as a result of the numerous attempts to place the vascular catheter, Mrs. Wrobleski hemorrhaged. Her blood count dropped from 34 to 25 and her systolic blood pressure dropped form 140 to 80. For most of the time thereafter she remained hemodynamically unstable.
Although Dr. Gindea agreed that there was a risk that Mrs. Wrobleski had a pulmonary embolism making the use of Heparin an appropriate treatment, he said the Heparin should have been discontinued for a few hours before the catheter insertion as the procedure was performed on a non-emergent basis. If this had been done, the coagulation disorder which led to Mrs. Wrobleski’s death would not have occurred.
Dr. Gindea opined that by the time of the catheter placement, the tests performed on Mrs. Wrobleski to determine if she had a pulmonary embolism should have lowered the suspicion of a pulmonary embolism. The risk/benefit analysis which should have been done should have warranted the discontinuance of Heparin for a few hours before the catheter placement. He felt the risk of bleeding from the vascular catheter outweighed the benefit of Heparin for a few hours. Dr. Gindea also said the administration of the Heparin bolus normally done with a catheter placement exacerbated Mrs. Wrobleski’s coagulopathy. This was ordered by Dr. Millerman who, at the time, was unaware of the Heparin drip.
On cross-examination, Dr. Gindea agreed that even after the tests of August 2, it would not have been appropriate to remove a pulmonary embolism from Mrs. Wrobleski’s differential diagnosis. Nor was he familiar with any standard or algorithm which would require a patient to be taken off Heparin when there is a suspicion of a pulmonary embolism and the patient is in renal failure. He did say that there is a standard recommendation to stop Heparin before any procedures.
Dr. Gindea did not know for certain how long Mrs. Wrobleski bled but believed she lost three units
based upon her hematocrit drop. Because venous bleeding is slow and based upon the amount of blood lost, Dr. Gindea estimated Mrs. Wrobleski continued to bleed for at least an hour.
Dr. Gindea disagrees with the autopsy report’s cause of death being acute renal failure. None of the considerations that would cause death by renal failure, i.e., refractory hyperkalemia, severe acidosis, fluid overload, or fluid around the heart were present. The only change in her clinical condition was a drop in her blood pressure caused by the bleeding from the catheter placement. He would make the cause of death the vein perforation, and the method of death, therapeutic complication.
Dr. Gindea read Dr. Narsipur’s note written right after Mrs. Wrobleski died (supra) and agreed with his assessment that the combination of the 50 percent blockage of three of Mrs. Wrobleski’s coronary arteries, the loss of blood volume, and the drop in blood pressure caused inadequate blood flow to the heart resulting in her heart stopping.
When asked about the autopsy report on cross-examination, Dr. Gindea agreed that Mrs. Wrobleski had acute renal failure and e-coli urosepsis. Also, he acknowledged that there was no evidence that her heart suffered an ischemic
event. However, he said that low blood volume and low blood pressure can cause the heart to become irritable without resulting in dead tissue in the heart. He believes the ischemic event was an arrhythmia.

Dr. Mary I. Jumbelic, the Onondaga County Medical Examiner, testified by deposition
about the autopsy results. In her opinion, the excessive bleeding that occurred after placement of the vascular catheter resulted in insufficient blood reaching the heart, thereby causing Mrs. Wrobleski’s heart to stop. The autopsy report refers to Mrs. Wrobleski’s renal failure and urosepsis as the cause of death, but it was the therapeutic complication that resulted in her death at that time. According to Dr. Jumbelic, it did not appear that the bleeding ever stopped once it started; there was no clotting seen at the puncture sites during the autopsy.
The State also had an expert testify via deposition.
Dr. Sophia Socaris is Director of Critical Care and Director of the Surgical and Intensive Care Unit of Albany Medical Center. Dr. Socaris is Board Certified in both Internal Medicine and Critical Care. Dr. Socaris said the standard of care requires that when a pulmonary embolism is suspected, patients be placed on Heparin until the pulmonary embolism is ruled out. The tests given to Mrs. Wrobleski on August 1 all pointed to the possibility of a pulmonary embolism with no other explanation for Mrs. Wrobleski’s clinical symptoms. The Doppler and VQ tests done on August 2 also failed to rule out a pulmonary embolism.
It was Dr. Socaris’ opinion that it is within the standard of care to continue an anticoagulant drug on a patient who is to be catheterized when the treating physician believes the benefit of doing so outweighs the risk of discontinuing the drug. She noted that a vascular catheter can be placed in many areas of the body, and the physician can have it placed in the patient’s leg if concerned about excessive bleeding because direct pressure can be applied in that location to stop the bleeding. Dr. Narsipur testified that he chose to insert the catheter in Mrs. Wrobleski’s groin area for that reason.
As to the cause of death, Dr. Socaris opined that Mrs. Wrobleski died as a result of ischemia
based upon her history of arteriosclerosis, a previous carotid
occlusion, and an EKG that showed an abnormal heart function.
When asked on cross-examination how a pulmonary embolism could have been ruled out for Mrs. Wrobleski, she testified that the various tests should have been repeated, especially the VQ scan. Dr. Socaris was unaware that Dr. Narsipur had cancelled Mrs. Wrobleski’s VQ scan scheduled for August 2. Mrs. Wrobleski’s repeat echocardiogram did not show the abnormalities the first one showed. Dr. Socaris said under these circumstances, the decision to discontinue Heparin is based upon a doctor’s clinical judgment and the balancing of the risks and benefits of the therapy.

To establish medical malpractice, Claimant must show that the medical professionals involved did not possess the requisite knowledge and skill ordinarily possessed by practitioners in the field or neglected to use reasonable care in the application of the requisite knowledge and skill or failed to exercise their best judgment (Pike v Honsinger, 155 NY 201; Hale v State of New York, 53 AD2d 1025, lv denied 40 NY2d 804). For liability to be imposed, there must be a showing that the medical provider’s treatment decision was “something less than a professional medical determination” (Darren v Safier, 207 AD2d 473, 474; Ibguy v State of New York, 261 AD2d 510). A physician’s duty is to provide the level of care acceptable in the professional community; every case is not going to be successful and the doctor cannot be held liable for mere errors of professional judgment where a choice is made between medically acceptable alternatives or diagnoses (Schrempf v State of New York, 66 NY2d 289, 295; see also Oelsner v State of New York, 66 NY2d 636; Nestorowich v Ricotta, 97 NY2d 393, 399). The “line between medical judgment and deviation from good medical practice is not easy to draw” (Schrempf, 66 NY2d at 295).
Claimant argues that the medical providers were negligent by failing to discontinue Heparin therapy before placing a vascular catheter in a non-emergent situation. Because the Heparin prevented Mrs. Wrobleski’s blood from clotting, she continued to bleed, causing her blood pressure to drop significantly and ultimately her heart to stop. This failure, according to Dr. Gindea, was a deviation from the standard of care.
Defendant contends that the possibility of a pulmonary embolism, a dangerous potentially fatal condition, required the continued use of Heparin and that the risk/benefit assessment made regarding the placement of the vascular catheter was a medical judgment for which liability will not attach.
This case rests upon one critical, primary, contested issue: Was it malpractice to place a vascular catheter in Mrs. Wrobleski while she was still receiving Heparin? After careful review of the exhibits and testimony, the Court finds it was not malpractice.
Mrs. Wrobleski was admitted to the hospital undisputedly with hypertension, Type II diabetes, and atherosclerotic disease. The parties agree she suffered from acute renal failure, urosepsis and e-coli. It was quite likely that she would need hemodialysis at some point, described by all the medical professionals as urgent, not emergent. Placement of the catheter, necessary before dialysis could begin, could have occurred at another time; however, Dr. Narsipur indicated he didn’t want to wait until placement of the catheter was an emergency or necessary in the middle of the night. No one disputed the reasonableness of his decision to place the catheter before such circumstances arose. Yet even within those parameters, placement could have been postponed a few hours.
None of the experts disputed Dr. Narsipur’s clinical suspicion that Mrs. Wrobleski had a pulmonary embolism on August 1. She had unexplained symptoms of shortness of breath and chest pain consistent with that diagnosis. Tests were performed and some of the results from August 2 suggested a lower probability for a pulmonary embolism. It is at this point the experts diverge. Yet this is not a case of merely opposing views of experts, which in itself would not substantiate Claimant’s burden; rather, although both credible professionals, the Court found Dr. Socaris’ testimony more persuasive.
Dr. Socaris, in her practice, regularly places catheters for dialysis. Her testimony, that in every catheter placement there is some degree of bleeding, was particularly persuasive given her experience, and seems a logical likelihood when placing a catheter into a vein. It stands in contrast to Dr.Gindea’s unequivocal response that bleeding is not expected with the performance of this procedure, a procedure he has never performed.
Both agree that the location for placement of the catheter, in the groin, was the most ideal under the circumstances, offering at least the possibility to apply pressure and stop any bleeding.
Dr. Gindea’s position that it was a deviation from the standard of care to continue the Heparin during the catheter insertion is called into question upon closer analysis of his testimony and within the context of his expressed surprise that no pulmonary embolism was revealed during the autopsy. Dr. Gindea acknowledges, in agreement with the other medical professionals, that a pulmonary embolism diagnosis is a very serious, life-threatening condition, difficult to diagnose, and Dr. Narsipur could not perform the best diagnostic test, a pulmonary angiogram, because of Mrs. Wrobleski’s compromised kidneys. Dr. Gindea testified that after reviewing the results from the various tests that were performed a lower index of suspicion for a pulmonary embolism was warranted; yet, he finds reasonable Dr. Narsipur’s clinical assessment that there was still a high probability of a pulmonary embolism, even after the tests.
He acknowledges no test is perfect. He, however, would have felt more comfortable stopping the Heparin after seeing the test results, based upon his risk/benefit analysis, a position which seems incongruous with his opinion that keeping Mrs. Wrobleski on the Heparin was not a judgment call, but a deviation from the standard of care. No algorithm or written standard requires the discontinuance of Heparin before this type of procedure is performed. Although Dr. Gindea noted that the standard recommendation is to stop Heparin several hours before “any procedure” [emphasis added] is performed, he specifically referenced cardiac catheterizations.
It seems only logical that the standard recommendation would have to yield to a doctor’s evaluation of his particular patient’s circumstances/condition: a risk/benefit analysis: a judgment call. Clearly, what would, as standard, be appropriate for a cardiac catheterization, would not necessarily be the same for a vascular catheterization in a location where options for stopping a potential bleed exist. Dr. Socaris testified that the decision whether or not to discontinue the Heparin, under the circumstances here, was a clinical judgment, not a deviation from the standard of care.
The Court finds that Mrs. Wrobleski’s death that day was caused by an ischemic event directly attributable to her extensive loss of blood; a bleed which apparently never stopped, as no signs of clotting were apparent at the site from the autopsy report. The failure to remove Mrs. Wrobleski from Heparin before the procedure contributed to the excessive bleeding, a decision which was tragically incorrect. Yet, Dr. Narsipur’s decision to continue the Heparin was reached after an analysis of Mrs. Wrobleski’s condition and the competing risks. To continue the Heparin was not a deviation from the standard of care, but a medical judgment. Unfortunately, a good result cannot be guaranteed. As long as the doctor, in reaching his medical decision, uses his best judgment, even if with the benefit of hindsight that decision was incorrect, it is not malpractice (Pike v Honsigner, 155 NY at 210; St. George v State of New York, 283 App Div 245, affd 308 NY 681).

March 20, 2007
Syracuse, New York

Judge of the Court of Claims

[1].A peripherally inserted central catheter.
[2].Urosepsis, according to Dr. Nappi, is a urinary tract infection that has spread to the blood stream.
[3].According to Dr. Narispur this is a test that looks at “breakdown products of a number of blood factors” (transcript, p. 239, lines 19-21).
[4].A ventilation/perfusion scan.
[5].Exhibit 1, page 32.
[6].Exhibit 1, page 36.
[7].The decomposition of organic matter caused by the toxic condition resulting from the spread of bacteria or their products from a focus of infection, here a urinary tract infection that had spread to her blood. (Merriam-Webster Medical Desk Dictionary).
[8].A quick infusion of medication.
[9].Transcript, page 323, lines 3 - 5. Dr. Millerman’s testimony regarding the time it took Dr. Jahangir to arrive and immediately preceding events was inconsistent and confusing.
1[0].Exhibit 2.
[1]1.This does not reconcile with the autopsy report (Exhibit 2) which notes on page 3, item (5) that there were nine needle punctures in the right femoral area. The catheter was sutured in the left leg.
1[2].Low blood pressure from decrease in the volume of circulatory blood (Merriam-Webster Medical Dictionary, 366 [1996]).
1[3].Exhibit 1, page 49.
1[4].Transcript, page 294, lines 21 - 24.
1[5].See Exhibit 2.
1[6].Exhibit 7.
1[7].He defined a unit as 250 ccs of packed red cells or 500 ccs of whole blood.
1[8].Localized anemic tissue due to an obstruction of the inflow of arterial blood (Merriam- Webster Medical Dictionary, 402 [1996]).
1[9].An altercation in rhythm of the heartbeat either in time or force (Merriam-Webster Medical Dictionary, 54 [1996]).
2[0].Exhibit 8.
2[1].Exhibit C.
[2]2.Dr. Socaris defined this as a decrease in oxygen being delivered to tissue relative to what is needed.
2[3].Either of two main arteries that supply blood to the head (Merriam-Webster Medical Dictionary, 115 [1996]).
2[4].See Exhibit 7, page 26, lines 15 - 20; page 22, line 25; page 23, lines 1 - 4.
2[5].See Exhibit 7, page 20, lines 15 - 18.
2[6].See Exhibit 7, page 21.