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.
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
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
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
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
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
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.
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.
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.
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.
“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
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
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.
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.
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
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
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
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
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
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
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.
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
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.
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
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.
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
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
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
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
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.
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
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.
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
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
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 State also had an expert testify via
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
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
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,
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
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
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
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
The claim is DISMISSED. LET JUDGMENT BE ENTERED