This case involves a middle-aged male patient who had a medical history significant for diabetes and obesity who was being treated for a cardiovascular condition with a diuretic medication. The Plaintiff presented at the defendant nephrologist’s office after undergoing a series of lab tests, one of which revealed an imbalance in his blood urea nitrogen and serum creatinine. The nephrologist immediately discontinued the patient’s medication, without consulting with his cardiologist or ordering regular blood work to monitor the patient’s condition once the drug was discontinued. After a few weeks, the patient began to experience serious cardiovascular complications, including congestive heart failure, which eventually culminated in cardiac arrest. As a result, the patient was seriously and permanently injured, and will require a lifetime of ongoing care.
Question(s) For Expert Witness
- 1. Should the nephrologist have consulted with other physicians that were active on the patient's case before discontinuing the medication?
- 2. Should the nephrologist have ordered daily or weekly blood work for this patient, to carefully monitor her after reducing the medication?
Expert Witness Response E-001432
The Nephrologist may not have followed standard of care in this specific case for the following reasons: 1) Lack of clinical follow-up after discontinuing a high dose of the drug (this includes regular follow-up physical examinations to assess volume status as well as a laboratory assessment of renal function to determine when it might be safe to resume therapy. 2) Discontinuing rather than reducing the dose, given this patient’s known cardiac status. 3) Failure to coordinate the plan of care with the consulting cardiologist or primary care physician. A potential confounding in this case; namely cardiac tamponade, could be the result of a separate process that is not causally linked the sudden discontinuation of the high dose diuretics. Thus, this complex medical case requires attention to detail and a careful dissection of the available medical records.
This qualified expert has more than 25 years of full time experience as a nephrologist practicing both in the private practice and academic settings, specializing in the care of complex patients with multi-system diseases such as obesity, diabetes mellitus and heart disease as described in this case. He is also extensively published in his field, and has held both high ranking clinical and academic appointments throughout his career.