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Keller v. University of Toledo Medical Center

Court of Claims of Ohio

May 1, 2019


          Sent to S.C. Reporter 6/28/19



         {¶1} 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.

         {¶2} 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.

         Findings of Fact

         {¶3} 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.[1] 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.

         {¶4} 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.

         {¶5} 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 insufficiency.

         {¶6} 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.

         {¶7} 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.

         Conclusions of Law

         {¶8} 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 value."

         {¶9} 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 ...

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