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Rodman versus Stephens
Background Facts:
On March 1, 1999 Ms. Marcia Rodman went to the emergency room of the Mt.
Washington Hospital around 8 PM. Ms. Rodman complained of severe abdominal pain,
which she had been experiencing for approximately 12 hours. Early in the day Ms.
Rodman was not alarmed by the discomfort, because her children had the intestinal flu,
and Ms. Rodman figured that she was now coming down with it. However the pain
worsened during the course of the day.
The physician on duty at the hospital’s emergency room was Dr. Robert Stephens,
whose specialty was internal medicine. Dr. Stephens had been on the staff at Mt.
Washington Hospital for eleven years.
Dr. Stephens asked Ms. Rodman about her medical history. Ms. Rodman had not
had anything to eat during the prior 24 hours and had vomited three times during that
time. Dr. Stephens performed a physical examination and ordered several lab tests. Upon
physical examination, Ms. Rodman’s temperature was 100.5, she had a pulse of 106, her
blood pressure was 132/76, and there was tenderness in the lower right quadrant of the
abdomen. She stated that the pain seemed to ease when she lied down in bed. Upon lab
evaluation, she had a slightly elevated white blood count (10,500).
Dr. Stephens initially thought that Ms. Rodman had acute appendicitis, but he
noted that Ms. Rodman did not have a few symptoms that usually accompany
appendicitis. First, lab tests showed that Ms. Rodman did not have a neutrophil count of
more than 75%. Second, the pain associated with appendicitis usually starts in the area
directly above the stomach and then moves to the lower right portion of the abdomen. In
Ms. Rodman’s case, the pain began and remained in the lower right quadrant. Third, Ms.
Rodman did not exhibit the symptom called “rebound tenderness.” This is defined as the
patient experiencing pain after the doctor applies and then releases some hand pressure
on an area of the stomach. Stephens was unsure whether to arrange for a surgeon to
perform an appendectomy, because he was not certain concerning the diagnosis of
appendicitis at that time. He decided to calculate the “Alvarado Score. To use this score
a physician merely adds up points from the physical examination and lab tests. Here’s
how the Alvarado Score works.
Migration of pain from center to lower right quadrant
Anorexia
Nausea-vomiting
Tenderness in lower right quadrant of abdomen
Rebound pain
Elevation of temperature
White blood count above 10,000
Neutrophils of more than 75%
1 point
1 point
1 point
2 points
1 point
1 point
2 points
1 point
If the total points a patient has is 4 or less, the person’s condition is not
compatible with the diagnosis of acute appendicitis.
A score of 5 or 6 is compatible with the diagnosis of acute appendictis.
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A score of 7 or 8 indicates a probable appendicitis.
A score of 9 or 10 indicates a very probable appendicitis.
Dr. Stephens calculated the Alvarado Score for Ms. Rodman. Her score was
7, which is “probable appendicitis.” Although Dr. Stephens thought that there was
some chance that Ms. Rodman did not have appendicitis, he decided to follow the
recommendation of the Alvarado Score. Therefore Dr. Stephens called for a
surgeon, the appendectomy was quickly scheduled, and the surgeon began the
operation within the hour.
Unfortunately when the surgeon examined the appendix, he noted that it was
perfectly healthy. He therefore did not remove it. Unfortunately Ms. Rodman developed
a very serious post-operative infection, which incapacitated Ms. Rodman for several
weeks. She had to remain in the hospital for 12 days, four days of which she spent in the
intensive care unit. After being discharged from the hospital, she had to remain at home
in bed for two more weeks. She returned to work a week later.
The Beginning of the Lawsuit
Ms. Rodman contacted an attorney to determine what her legal rights were and
also to determine if she deserved any compensation due to Dr. Stephens’ failure to make
the correct diagnosis. Had the correct diagnosis been made, no operation would have
taken place, so there would have been no post-operative infection. Ms. Rodman could
then have been spared the expense, pain, suffering, and loss of wages caused by the
extensive infection. Ms. Rodman’s attorney, Leslie Maxwell, decided to sue Dr.
Stephens for malpractice.
Evidence
The following is an edited version of the information that was obtained during the
trial.
All persons agree to the facts in this case. The only dispute is whether Dr.
Stephens was negligent in not making the correct diagnosis of no appendicitis when Ms.
Rodman first appeared in the emergency room. There are two “expert witnesses” in the
case. First, you will hear the testimony of Dr. Arthur Monteith, who is testifying on
behalf of the plaintiff, Ms. Rodman. Then you will hear the testimony of Dr. Alan
McCauley, who is testifying on behalf of the defendant, Dr. Stephens.
[THE DVD STARTS HERE.]
Dr. Monteith’s Testimony (expert witness on behalf of Ms. Rodman)
Question (from Ms. Rodman’s attorney): What are your qualifications, Dr. Monteith?
Answer: I am a board-certified gastroenterologist. I have been practicing in this
community for over thirty years. I have been called as an expert witness in two prior
court cases.
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Question: In your professional opinion, did Dr. Stephens meet the standard of care in
mistakenly diagnosing appendicitis when Ms. Rodman appeared in the emergency room
on the evening of March 1?
Answer: In my opinion he did not. Given the fact that her children had intestinal flu, the
fever was not unusual. Ms. Rodman’s vomiting and failure to eat were not surprising
given the intestinal flu going around in her family, and abdominal pain is not unusual
with intestinal flu. Furthermore some symptoms that usually accompany appendicitis
were not present. First, Ms. Rodman did not have a neutrophil count of more than 75%.
Second, the pain associated with appendicitis usually starts in the area directly above the
stomach and then moves to the lower right portion of the abdomen. In Ms. Rodman’s
case, the pain began and remained in the lower right quadrant. Third, Ms. Rodman did
not exhibit the “rebound tenderness.”
Question: Should an appendectomy be scheduled even if there is a suspicion of
appendicitis?
Answer: It’s a matter of degree. If the appendicitis is not very likely, a physician should
not schedule an appendectomy. I don’t think the diagnosis of appendicitis could be
considered “very likely” on the evening of March 1. I’d say the diagnosis of appendicitis
would have been only “somewhat likely” at that time—not probable enough to go ahead
with the operation.
Question: What is your opinion of the Alvarado Score?
Answer: The Alvarado Score is a way of helping a physician make a decision as to the
likelihood of appendicitis. It cannot substitute for the physician’s own good judgment. It
merely provides a way of summarizing the information into one score. If a physician can
diagnose intuitively, then obeying the Alvarado Score represents “cookbook medicine,”
which is inferior, in my opinion.
Question (cross-examination from Dr. Stephens’ attorney): Isn’t it typical for a patient
suffering from appendicitis to have anorexia?
Answer: Yes, it is.
Question: Did Ms. Rodman have “anorexia?”
Answer: Yes, she did.
Question: Isn’t it typical for a patient suffering from appendicitis to have nausea and
vomiting?
Answer: Yes, it is typical.
Question: Did Ms. Rodman have a nausea and vomiting?
Answer: Yes, she did.
Question: Isn’t it typical for a patient suffering from appendicitis to have tenderness in
the lower right quadrant of the abdomen?
Answer: Yes, it is typical.
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Question: Did Ms. Rodman have tenderness in the lower right quadrant of the
abdomen?
Answer: Yes, she did.
Question: Can the Alvarado Score be helpful in diagnosing appendicitis?
Answer: Yes, it can be helpful.
Question: Wasn’t the Alvarado Score consistent with the diagnosis of appendicits?
Answer: Yes, it was.
Question: Besides the flu and appendicitis, what other diagnoses might have been
possible on the evening of March 1?
Answer: Acute mesenteric adenitis and ovarian cyst were two other possibilities, in my
opinion. There were other possibilities, too.
Question: Don’t these require surgery, and if so, Dr. Stephens’ decision to schedule the
appendectomy would have helped discover these other diseases. These other diseases
could be treated even if Ms. Rodman didn’t have appendicitis.
Answer: It is true that ovarian cysts usually require surgery. Acute mesenteric adenitis
generally does not.
Dr. McCauley’s Testimony (expert witness on behalf of Dr. Stephens)
Question (from Dr. Stephens’ attorney): What are your qualifications, Dr. McCauley?
Answer: I am a board-certified gastroenterologist. I have been the head of my
department for ten years. I have testified as an expert witness in this court three previous
times.
Question: In your professional opinion, Did Dr. Stephens meet the standard of care in
diagnosing appendicitis when Ms. Rodman appeared in the emergency room on the
evening of March 1?
Answer: In my opinion he did. Enough signs and symptoms were present for Dr.
Stephens to have concluded that appendicitis was a likely diagnosis. Even if Ms.
Rodman did not have appendicitis, many of the other possible diagnoses would have
involved an operation anyhow. Therefore there was really little to lose by assuming that
Ms. Rodman had appendicitis and proceeding with the appendectomy.
Question: In your professional opinion, why should a diagnosis of appendicitis have
been easy to make on the evening of March 1?
Answer: The most important signs and symptoms were present. Ms. Rodman had an
elevated white blood count, she had tenderness in the lower right quadrant of her
abdomen, she had a fever, she’d been vomiting, and she hadn’t wanted anything to eat.
These should have been sufficient to alert Dr. Stephens to the fact that Ms. Rodman
probably had appendicitis.
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Question: You say that Ms. Rodman “probably” had appendicitis. Why wasn’t it proper
for Dr. Stephens to wait until he was “sure” Ms. Rodman had appendicitis?
Answer: It’s too dangerous to wait. Once these symptoms were apparent, there is a
danger that the appendix might soon rupture. Of course, a ruptured appendix spreads
infection throughout the abdomen. There’s too much to lose and not much to gain by
waiting for a certain diagnosis. In my opinion the standard of care requires that a
physician should operate when this many symptoms were apparent.
Question: Isn’t it generally helpful for a physician to obey the diagnosis recommended
by the Alvarado Score.
Answer: Yes, it is helpful, because the Alvarado Score can indicate whether appendicits
is probable, and it was in this case.
Question (cross-examination from Ms. Rodman’s attorney): Isn’t it typical for a patient
suffering from appendicitis to have “rebound pain.”
Answer: Yes, it is.
Question: Did Ms. Rodman have “rebound pain?”
Answer: No, she didn’t.
Question: Isn’t it typical for a patient suffering from appendicitis to have a neutrophil
count of more than 75%.
Answer: Yes, it is typical.
Question: Did Ms. Rodman have a neutrophil count of more than 75%?
Answer: No, she didn’t.
Question: Isn’t it typical for a patient suffering from appendicitis to have pain “migrate”
from the area above the stomach to the lower right quadrant?
Answer: Yes, it is typical.
Question: Did Ms. Rodman have pain “migrate” from the area above the stomach to the
lower right quadrant?
Answer: No, she didn’t.
Question: You testified that calculating the Alvarado Score would have been helpful. Is
the Alvarado Score 100% accurate?
Answer: No, it isn’t 100% accurate. It provides valuable guidance. It cannot guarantee
the correct answer.
Arguments to the Jury
Lawyer for Dr. Stephens
We do not contest the fact that Ms. Rodman really did not have appendicitis. We
do not contest the fact that she became very ill due to the unnecessary operation. What
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we do contest is the assertion that Dr. Stephens should have known Ms. Rodman did not
have appendicitis when she first appeared in the emergency room on the evening of
March 1. Several symptoms often present in cases of appendicitis were present.
Dr. Stephens’ behavior was consistent with the standard of care when he told Ms.
Rodman that she had appendicitis. He should not be found guilty of malpractice because
he asked a surgeon to perform an appendectomy when Ms. Rodman first appeared in the
emergency room. Dr. Stephens is sorry that he did not diagnose her correctly, but he was
looking out for Ms. Rodman’s best interests by consulting a surgeon to perform the
appendectomy.
Lawyer for Ms. Rodman
Ms. Rodman’s case was not difficult. Ms. Rodman had several symptoms not
consistent with appendicitis. No one recommends surgery for intestinal flu. Unnecessary
surgery causes discomfort and great expense, and there is always the risk of
complications, which occurred in this case.
The facts are quite straightforward: Ms. Rodman was unnecessarily exposed to a
serious infection due to the unnecessary operation. Had Dr. Stephens made the correct
diagnosis on the evening of March 1, Ms. Rodman would have been sent home, and there
would have been no serious, life-threatening infection. We believe that Dr. Stephens did
not meet the standard of care expected of physicians. Dr. Stephens should be held
responsible for his failure to diagnose correctly. Therefore we believe Dr. Stephens is
guilty of medical malpractice, and Ms. Rodman should be compensated for her medical
expenses, her lost wages, plus her very substantial pain and suffering.
Judge’s Instructions to Jurors
The issue in this case is whether Dr. Stephens is guilty of medical malpractice.
Medical malpractice is defined as the failure of a health care professional to exercise on
behalf of a patient the knowledge, ability, and skill and standard of care commonly
applied by similar members of the profession. You should consider the facts of this case
and decide if Dr. Stephens did or did not meet this standard.
If you decide that Dr. Stephens did meet this standard, then you should vote “not
guilty of malpractice” on your ballot.
If you decide that Dr. Stephens failed to meet this standard, then you should vote
“guilty of malpractice” on your ballot. Only if you decide Dr. Stephens is guilty should
you go on to the rating scale. On this scale you would indicate how deserving Dr.
Stephens is of financial punishment. You should circle the number which indicates your
view. Of course, if you think Dr. Stephens is not guilty of malpractice, you would not
use the rating scale at all, because he would not be deserving of any punishment.
You should now indicate your verdict for Dr. Stephens. Only if you think he is guilty of
malpractice should you use the rating scale.
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