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Robison v. Medical University of Ohio At Toledo

October 6, 2011

ROBISON, PLAINTIFFS,
v.
MEDICAL UNIVERSITY OF OHIO AT TOLEDO, DEFENDANT.



The opinion of the court was delivered by: Judge Alan C. Travis

Cite as Robison v. Med. Univ. of Ohio at Toledo,

The Ohio Judicial Center 65 South Front Street, Third Floor Columbus, OH 43215 614.387.9800 or 1.800.824.8263 www.cco.state.oh.us

DECISION

{¶1} Plaintiffs brought this action alleging medical negligence and loss of consortium. The issues of liability and damages were bifurcated and the case proceeded to trial on the issue of liability.

{¶2} On January 17, 2007, plaintiff*fn1 was attempting to hang a light above a stall in a horse barn when she lost her footing and fell approximately four feet to the dirt floor below. Plaintiff sustained an open compound fracture of her left tibia and fibula at the ankle. Initially, plaintiff was taken to the emergency room at Bellevue Hospital but shortly thereafter she was life-flighted to defendant's medical center. Nabil Ebraheim,

M.D., head of defendant's department of orthopedic trauma, treated plaintiff for her injuries over a ten-day period, during which time he performed multiple surgeries, including an open reduction and internal fixation of plaintiff's ankle.

{¶3} Plaintiff's ankle fracture was classified as a type 3B, meaning that there was severe soft-tissue damage with substantial environmental contamination from bacteria found in horse manure. The parties do not dispute that Dr. Ebraheim's initial treatment of plaintiff's injuries met the standard of care. However, plaintiffs assert that as plaintiff's treatment progressed, Dr. Ebraheim was negligent when he failed to diagnose a deep tissue/bone infection which resulted in chronic osteomyelitis.

LAW

{¶4} "In order to establish medical malpractice, it must be shown by a preponderance of evidence that the injury complained of was caused by the doing of some particular thing or things that a physician or surgeon of ordinary skill, care and diligence would not have done under like or similar conditions or circumstances, or by the failure or omission to do some particular thing or things that such a physician or surgeon would have done under like or similar conditions and circumstances, and that the injury complained of was the direct and proximate result of such doing or failing to do some one or more of such particular things." Bruni v. Tatsumi (1976), 46 Ohio St.2d 127, paragraph one of the syllabus.

MARK GOODMAN, M.D.

{¶5} Plaintiffs' first expert, Dr. Goodman, testified that he is board-certified in orthopedic surgery and that he is the chief of orthopedic surgery at the University of Pittsburgh School of Medicine. Dr. Goodman explained that osteomyelitis is an infection of the bone which can be categorized as acute, intermediary, or chronic. Dr. Goodman stated that skin contaminants such as bacteria are either Gram-positive or Gram-negative, and that specific antibiotics are prescribed to treat each type of organism. Dr. Goodman noted that in a farm setting, Gram-negative bacterias such as E. coli and Pseudomonas are prevalent. Dr. Goodman stated that plaintiff was treated with intravenous antibiotics for both Gram-negative and Gram-positive bacteria while she was in the hospital and that she was discharged on Keflex, an antibiotic which is effective against Gram-positive organisms only.

{¶6} Dr. Goodman's criticisms of Dr. Ebraheim's care begin with the office visit on March 26, 2007, when plaintiff complained of swelling, redness, and increasing pain.*fn2 Dr. Goodman opined that Dr. Ebraheim erroneously diagnosed plaintiff with a surface infection of the wound, which was, in fact, a deep infection. In Dr. Goodman's opinion, the standard of care required a needle aspiration deep into the ankle to obtain a culture at that time. According to Dr. Goodman, if a culture of the deep tissue had been obtained on March 26, an infection would have been diagnosed; that by failing to obtain an aspiration and culture at that time, Dr. Ebraheim allowed an infection to "brew" for two months, and that as a result, plaintiff now suffers from chronic osteomyelitis. Dr. Goodman also opined that it was a deviation from the standard of care to continue to prescribe Keflex after March 26 and that Dr. Ebraheim failed to follow up with the results of lab tests that he ordered at the March 26 and April 12 visits.

{¶7} On cross-examination, Dr. Goodman acknowledged that even with the best of care, a patient with an injury such as plaintiff's can develop chronic osteomyelitis and that the bacterial infection most likely originated at the time of plaintiff's injury.

LARRY RUMANS, M.D.

{¶8} Plaintiffs' second expert, Dr. Rumans, testified that he is board-certified in internal medicine and infectious diseases and that he is an associate clinical professor at the University of Kansas School of Medicine. Dr. Rumans explained that inasmuch as plaintiff sustained trauma with bone penetrating the skin, she was exposed to a contaminated environment, which can cause infection. Dr. Rumans explained that an open reduction means moving bones and internal fixation means placing hardware. In addition, Dr. Rumans noted that hardware itself is a foreign body and many times a slime deposit forms around the hardware which harbors bacteria. Dr. Rumans noted that a surgical incision also creates a risk of infection because it exposes the body to contaminants. Dr. Rumans explained that upon discharge, plaintiff was prescribed Keflex, an oral antibiotic, to prevent development of infection due to Staphylococcus aureus, a Gram-positive bacteria found on healthy skin. Dr. Rumans explained that Keflex is not effective against Gram-negative bacteria.

{¶9} Dr. Rumans opined that Dr. Ebraheim failed to meet the standard of care on March 26, when he did not obtain an aspiration and deep wound culture, did not consult an infectious disease specialist, and did not start a different antibiotic treatment. Dr. Rumans opined that as of March 26, plaintiff suffered from a deep wound infection, and to assume that it was a superficial wound infection was to "ignore the origin of the injury." Dr. Rumans opined that plaintiff in all likelihood had acute osteomyelitis on March 26; that the standard of care on April 12 required Dr. Ebraheim to pursue an evaluation regarding abnormal lab values and a worsening of the inflammatory process; and that by approximately May 3, plaintiff's acute osteomyelitis became chronic.

{ΒΆ10} Dr. Rumans also stated that plaintiff should not have been discharged on Keflex or any other antibiotic. In his opinion, Keflex allowed Pseudomonas bacteria to progress into chronic osteomyelitis. However, Dr. Rumans acknowledged that even under the best of care, a ...


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