This case involved a 65-year-old woman, Rita Epps, who died at Southside Regional Medical Center (SRMC) because of untreated acute kidney failure and resulting acidosis. The patient’s condition prior to admission was not particularly noteworthy: coronary artery disease (4 stents), controlled diabetes and mild chronic kidney disease.
In the week before her admission to the hospital, Ms. Epps had been having increasing episodes of vomiting, chest congestion and sinus problems. She had been to her primary care provider and an urgent care center, and had been diagnosed with an upper respiratory infection.
Ms. Epps arrived at the SRMC emergency room a little before 9:00 a.m. on Saturday, December 10, 2016. The initial laboratory studies and evaluation showed that she was in acute kidney failure with severe anion gap metabolic acidosis and high potassium. She was admitted to the hospital and evaluated by the first hospitalist defendant. This doctor started medical treatment. She also ordered a lactic acid level and ordered a nephrology consultation.
The nephrologist on call, Sajid Naveed, M.D., claimed he never got the consultation on Saturday. The nephrologist’s phone records showed a call from SRMC’s general number about 40 minutes after the consult was placed in the EMR. However, the hospitalist testified that she never called the nephrologist herself and there is no evidence in the medical record that he took any action Saturday afternoon or evening.
The first hospitalist handed over care around 7:00 p.m. to the overnight hospitalist, the third defendant. Ms. Epps was experiencing increased pain so the nocturnist ordered Dilaudid on top of the morphine and oxycodone already given during the day. Around 11:00 p.m., the patient had respiratory difficulties necessitating the administration of Narcan to reverse the effects of the narcotics.
Around that time, the lactic acid was reported with an extremely high level of 22.2. The nocturnist thought this result was an error and reordered the test. No effort was made to contact the nephrologist, who had still not made an appearance in the case.
The nocturnist ordered an arterial blood gas which came back shortly after midnight. It showed that Ms. Epps was severely acidotic. Her pH was 6.6, a level that multiple experts described as incompatible with life. It also meant that the medical management of her acidosis, primarily fluids and bicarbonate, had not worked. At this point, the nocturnist had an ICU nurse call the nephrologist and advise him of Ms. Epps’ condition. This phone call is recorded in the medical record and two minutes later, the records show that Dr. Naveed ordered more bicarbonate. The nephrologist did not come to the hospital, nor did he order emergency dialysis.
Dr. Naveed came to the hospital around 7:00 a.m. Sunday. He ordered Continuous Renal Replacement Therapy, a form of dialysis. Unfortunately, it was too late and upon returning from having her dialysis catheter placed, the decedent suffered cardiac arrest and permanent brain damage. Life support was removed several days later.
The trial of the matter was unusual. Everyone agreed that Ms. Epps needed dialysis shortly after her admission to the hospital. Only a nephrologist can order dialysis. The hospitalists argued that Dr. Naveed had responsibility for Ms. Epps from the time of the Saturday afternoon consultation order. Everyone also agreed that the high lactic acid and pH of 6.6 constituted an emergency. Again, the hospitalists took the position that they relied on Dr. Naveed’s expertise, and they had no reason to question his continuation of medical management (more bicarbonate).
Dr. Naveed tried to make a case that he was never contacted, and that he first found out about Ms. Epps when he came to the hospital around 7:00 Sunday morning. While the records showed a consultation order on Saturday afternoon, there was no indication that the doctor did anything that afternoon. Likewise, with regard to the call and order in the early morning hours of Sunday, there was only an indication that a call was made and a single order from Dr. Naveed. There were no explanatory notes from either the nocturnist or the nurses. Even after the arrest later that day, there was nothing in the record explaining what had transpired.
Plaintiff’s hospitalist expert testified that Ms. Epps’ condition was obvious and that the hospitalists should have taken affirmative steps to make sure the patient was evaluated by a nephrologist. The plaintiff’s nephrology expert testified that Ms. Epps needed dialysis early on and that should have been obvious to any nephrologist. Had the patient started dialysis even as late as 5:00 on Sunday morning, she likely would have survived.
The hospitalists both put on multiple experts to say that their orders were appropriate, and it was reasonable for them to assume that the nephrologist was on the case. Even with just the order of bicarbonate, reliance on Dr. Naveed’s expertise was reasonable.
Interestingly, neither hospitalist seriously challenged causation even though there was not a good explanation for the cause of Ms. Epps’ acute kidney failure.
Dr. Naveed did call a nephrologist who testified that by midnight there was nothing that could have been done to save Ms. Epps.
No evidence of economic losses or medical bills was presented. In closing, the jury was told that the family had sued for $10,000,000.
The trial lasted seven days. There were relatively few legal issues that arose. The jury was out a little over three hours before returning a $10,000,000 verdict against the nephrologist only. The verdict apportioned 55% to Ms. Epps’ husband and 15% to each of her three children. Following the verdict, the judge reduced the verdict pursuant to the Virginia cap on medical malpractice damages. The Court immediately overruled Dr. Naveed’s motion to set aside the verdict.
About three weeks after the verdict, plaintiff settled with Dr. Naveed for a nominal discount. The settlement was approved by the Court on November 9, 2021.