It seems highly unlikely that ephedrine caused a massive brain bleed, even with her pre-existing preeclampsia and hypertension. There was extensive investigation to see if there were any contributing factors such as a venous malformation or an aneurysm. They even had her brain sent to Mayo for additional autopsy investigation, but were unable to turn up any contributing vascular factors. Overall this seems like an incredibly sad tragedy that was completely paradoxical. I don’t think any reasonable anesthesiologist or OB is going to rush someone to the CT scan scanner immediately after a C-section unless there are neuro deficits or they are unresponsive. Diagnosing this earlier may not have led to a better outcome. However, whether you believe ephedrine or Toradol played a role in this bleed or not, there is no denying the optics of the situation. Certain actions or medications are going to look bad when there is a poor outcome, and open yourself up to criticism and therefore liability. While defensive medicine shouldn’t control your practice, it is beneficial to reflect on these situations.

When a bad outcome happens related to a surgery, both the surgeon and anesthesiologist often get named in the lawsuit. Often times, the anesthesiologist is simply along for the ride, and eventually gets dismissed. This case was different, because the primary allegations about the cause of the patient’s brain bleed were medications that the anesthesiologist gave. The anesthesiologist had documented that she gave Toradol, but later went back to change the chart to indicate she did not actually give it. Making sure the medical record is accurate is important, but we all know that mistakes happen. There’s not a doctor anywhere who hasn’t made an error while charting and needed to fix it. My recommendation is to speak with your hospital attorney, someone from the risk management department (if your hospital has one), or call your malpractice insurance company before making an addendum on a high risk chart.

There were some interesting legal strategies in this case that might be useful to understand. The concept of “apportionment” played a key role. Even though the obstetrician had already settled, the jury was still given the opportunity to apportion some of the liability to her. While it may seem unfair that the jury is ignorant of the fact that their decision against the OB won’t actually occur in reality, it is to the remaining defendants favor. Instead of shouldering the entire $22M verdict, they were only found responsible for 35%. For the OB, it turns the trial into a low-stakes affair, because no matter what the jury decides, she doesn’t have to pay anything.

The interest applied to the judgment is another interesting twist, although this varies drastically from state to state. In some areas of the country, there are significant ramifications to refusing a settlement offer. In this case it caused the verdict to swell by over $3,000,000 more. To make matters worse, some areas also impose interest after a verdict. If the defense files additional motions or tries to appeal the verdict, additional interest applies, often at a higher rate than settlement interest. 6-10% is fairly common but I’ve seen as low as 3% (Georgia) and as high as 12% (sorry to those who live in Rhode Island). If you get sued it may be worth asking your attorney how this works in your area, and if the insurance company is going to pay it in the case of a verdict that is above policy limits.