to S.C. Reporter 6/28/19
PATRICK M. McGRATH JUDGE.
Plaintiff Jessica Keller's (Ms. Keller) complaint asserts
a medical malpractice claim based on medical care Defendant
University of Toledo Medical Center's (UTMC) employees
rendered to plaintiff. Ms. Keller's claims are based
primarily on the care rendered by Dr. Blair Grubb (Dr. Grubb)
and Nurse Practitioner Beverly Karabin (Nurse Karabin). Ms.
Keller tried her claims to the court on February 25-27, 2019.
As discussed below, the court finds UTMC is entitled to
judgment in its favor.
At trial, Ms. Keller, Dr. Grubb and Nurse Karbin all
testified regarding Ms. Keller's condition as well as her
treatment at UTMC. In addition, both parties presented expert
testimony. Dr. Mithilesh Das (Dr. Das) testified in Ms.
Keller's case in chief while Dr. Satish Raj (Dr. Raj)
testified on behalf of UTMC. In addition, the parties
presented the testimony of other treating physicians who
rendered care to Ms. Keller, Dr. Ian Elliott (Dr. Elliott)
and Dr. Jackie Vannuyen, via deposition.
The court makes the following factual findings. POTS is an
acronym for Postural Orthostatic Tachycardia Syndrome. Upon
standing, POTS patients retain fluid in their lower bodies
which leads to a variety of symptoms. POTS is not a specific
disease. It is a clinical syndrome, a constellation of
symptoms primarily characterized by difficulty upon standing
from a reclining position and a rapid increase in heart rate.
Those with POTS feel dizzy, light-headed and/or nauseous.
POTS patients can suffer from headaches, vomiting and
fainting and often have difficulty tolerating exercise. POTS
can be secondary to other underlying medical conditions such
as adrenal insufficiency. POTS can also precede the diagnosis of
other medical conditions, such as multiple sclerosis. A tilt
table test is routinely used to help diagnose POTS. It
involves securing a patient to a table which is then inclined
to a 60-degree angle, during which the patient's vital
signs are monitored and any symptoms are observed.
The cause of POTS in an individual patient is not always
clear. Treatment for POTS varies and includes medication,
exercise programs, and the use of compression garments. POTS
patients can experience symptoms for months and even years
with minimal improvement. It is not uncommon for POTS
patients to make frequent visits to the emergency room after
being diagnosed and treated. Even for those who experience
improvement, symptoms can fluctuate over time. Even with
effective treatment, few patients become completely
asymptomatic. Pregnancy can exacerbate POTS symptoms and
presents additional challenges in treating patients for POTS.
After a referral, Ms. Keller first presented to UTMC with
nausea, vomiting and dizziness on September 16, 2014 at which
time Nurse Karabin diagnosed Ms. Keller with POTS. Nurse
Karabin made her diagnosis based on Ms. Keller's
symptoms, the results of a tilt table test, and her own
clinical evaluation of Ms. Keller. Ms. Keller's symptoms
were consistent with POTS. After her initial diagnosis, Ms.
Keller returned to UTMC on October 28, 2014, at which time
Dr. Mujeeb Sheikh (Dr. Sheikh) treated her. After the October
visit, Ms. Keller did not return to UTMC until April 14,
2015. During the nearly six-month gap between these
appointments, Ms. Keller became pregnant. Ms. Keller saw Dr.
Sheikh at this visit. Thereafter, Ms. Keller saw Nurse
Karabin on June 3 and June 23, 2015. Dr. Grubb saw Ms. Keller
only once, on July 16, 2015. This was Ms. Keller's last
appointment at UTMC before she gave birth in December of
2015. No one at UTMC tested Ms. Keller for adrenal
Throughout this time, Nurse Karabin, Dr. Sheikh and Dr. Grubb
continued to treat Ms. Keller for POTS and she continued to
experience POTS-like symptoms and make frequent emergency
room visits. The records of Ms. Keller's June 23, 2015
visit with Nurse Karabin reflect some improvement as they
note, "[Ms. Keller] is relatively stable. Blood pressure
has improved. She has responded well to not only the
midodrine and fludrocortisone, but also the daily IV
infusions." During this time, Ms. Keller's
medications were modified at times through the addition of IV
fluids by Nurse Karabin and the prescribing of a nasal spray
by Dr. Grubb. However, Ms. Keller could not keep her
medication down due to vomiting and she declined to use the
nasal spray medication prescribed by Dr. Grubb.
In January of 2016, Dr. Elliott diagnosed Ms. Keller with
adrenal insufficiency. Symptoms of adrenal insufficiency are
similar to the symptoms of POTS. Patients can suffer from
adrenal insufficiency and POTS at the same time. After
treatment of Ms. Keller's adrenal insufficiency, Ms.
Keller's symptoms ceased. Ms. Keller returned to UTMC on
January 20, 2016, at which time Nurse Karabin removed the
POTS diagnosis. However, the date of onset of Ms.
Keller's adrenal insufficiency is unknown.
Ms. Keller bore the burden of proving her claim by a
preponderance of the evidence. As stated in Brothers v.
Morrone-O'Keefe Dev. Co., LLC, 10th Dist. No.
06AP-713, 2007 Ohio 1942, 2007 Ohio App. Lexis 1762, ¶
49: "[a] preponderance of the evidence is 'the
greater weight of the evidence * * * [it] means evidence that
must more probable, more persuasive, or of greater probative
The failure to diagnose a condition can serve as a basis for
finding medical malpractice "if a given set of
circumstances would lead a physician of ordinary skill, care
and diligence to reach a particular diagnosis" and the
physician's failure "proximately causes injury to
the patient. Katko v. Ohio State Univ. Hosp., 10th
Dist. No. 90AP-1117, 1991 Ohio App. LEXIS 3747, at *14 (Aug.
6, 1991). As stated in Reeves v. Healy, 192 Ohio
App.3d 769, 2011-Ohio-1487, ¶ 38 (10th Dist.):
To establish a cause of action for medical malpractice, the
plaintiff "must show the existence of a standard of care
within the medical community, breach of that standard of care
by the defendant, and proximate cause between the medical
negligence and the injury sustained." Deer v. River
Valley Health Sys., 4th Dist. No. 00CA20, 2001 Ohio
2662, quoting Taylor v. McCullough-Hyde Mem. Hosp.
(1996), 116 Ohio App.3d 595, 599, 688 N.E.2d 1078. Expert
testimony is required to establish the standard of care and
to demonstrate the defendant's alleged failure to conform
to that standard. Bruni v. Tatsumi (1976), 46 Ohio