I was an average resident. My national board scores were near the middle percentile; my technical skills were neither stellar nor inadequate; if anything, I suppose my bedside manner was my forte. However, there was one area in which I stood out. I had the distinction of being the first member of my residency class to be successfully sued for medical malpractice. In fact, I may have been one of the youngest individuals ever named to the NPDB, the National Practitioner Data Bank. The NPDB is a list of all the health care providers in the United States who have been successfully sued for malpractice—every physician, nurse, midwife, chiropractor, herbalist, osteopath, physical therapist, and acupuncturist who’s ever lost or settled a malpractice case for a dollar amount equal to or exceeding one cent. The list may be obtained by anyone who wants it. There’s a convenient Internet Web site; all you have to do is run a search on the name of the practitioner you’re interested in. You’ll forgive me if I don’t provide the relevant Web address—if you want a look at the list, I’ll leave you to your own research.
My own case involved a patient I saw during the second month of my residency. At the time, I hadn’t known you could sue a resident for malpractice. I figured, as residents, we were protected under the wings of the attending physicians who supervised our work. I was wrong about that.
The first news of the lawsuit came in the form of a letter delivered to my mailbox in the residents’ lounge. I was doing my rotation in surgery, putting in sixteen hours a day plus every third night on call in the emergency room. I wandered into the lounge that afternoon after having spent the morning holding retractors in the OR on a colon case. Immediately upon seeing the distinctly marked envelope in my box, I had a bad feeling. The return address read LAW OFFICES: QUENTIN, CARGILL, KETTLE, & AMES. The letter was addressed using my full name, sent in care of the medical center hospital. Most conspicuous of all were the words written just to the left of my name, three words written in bold, underlined, capital letters:
PERSONAL AND CONFIDENTIAL
I glanced around the room. I was alone. Tearing open the envelope, I unfolded the letter and read:
Dear Dr. Stookey:
This firm has been appointed to defend you and all other entities in the matter Nguyen v. The University of XXX. You were a treating physician in this case which involves alleged medical malpractice.
If you have not already done so, I would appreciate your creating a file separate from any medical records concerning this claimant. Please do not discuss this case with anyone other than myself or members of my firm. As long as you limit your communications this way, it is likely you will be protected under attorney/client privilege. If you receive a subpoena relating to the case, notify me immediately. Finally, please do not undertake any independent investigation regarding this action, either as to the facts which gave rise to it or as to the medical issues.
I will need to be in contact with you throughout the duration of this litigation. It is important that I meet with you at your earliest possible convenience for an initial interview. Please contact my secretary who will set up a meeting at a time and location suitable to your schedule.
Very truly yours,
Leslie R. Mazzella
Attorney at Law
My first reaction was disbelief. In fact, I imagined the letter had to be a malicious prank perpetrated by one of my fellow interns. Just the day before, another intern had handed me a phone, saying it was the coroner, who wanted to talk to me about one of my “former” patients (the call was actually from a nurse who wanted a clarification on an insulin order). But, reading through the letter a second time, I could see there was a disquieting ring of truth to it all, from the formal letterhead to the scratchy blue-ink signature.
Alleged medical malpractice. Christ, I was being sued.
I shoved the letter in my pocket. In five minutes I was scheduled to be in surgery clinic, where I had a full afternoon’s booking of patients to see. However, rather than head to the clinic, I went to the Quad, the grassy area between the two wings of the medical center. I needed to get outside for a minute and breathe some fresh air.
Sitting on the grass, I read through the letter again. I noted there were no details concerning the nature of the case, nothing about what I was being sued for. The only thing I’d been given was a name: Nguyen. I tried to remember. Nguyen. The name rang no bells, ominous or otherwise. I tried to recall a patient I’d seen who’d had a bad outcome, a case that had taken a disastrous turn. Of course, there’d been patients with the usual complications, but there was no case that stood out, no particular patient who’d prompted me to think: “God, this is going to end up in a lawsuit.” Nguyen. The letter didn’t even indicate if Nguyen was a man or a woman.
My pager went off. It was the surgery clinic wondering where I was. I stuffed the letter in my pocket and headed for the outpatient building.
The clinic that afternoon seemed interminable. I couldn’t stop thinking about the letter. I moved in a daze, walking once into the wrong room and confusing a pre-op physical for a post-op wound check. I kept trying to remember. Nguyen. Nguyen. Between a wound dressing change and a suture removal on a child, I slipped into the bathroom and reread the letter yet again. You were a treating physician…What possibly could have happened? Had I missed a critical diagnosis, mistaken an appendicitis for a stomach flu, diagnosed rib pain in a patient having a heart attack?
The clinic finished up at 6 p.m. I still had to make evening rounds with the surgery inpatient team before going home. Stepping from the elevator onto the surgical floor of the main hospital, I should have started immediately into my pre-rounding work. Instead, I went over to one of the computer terminals and typed in a patient name search. N-g-u-y-e-n. I took a deep breath and pressed ENTER.
There were twenty-six people with the name Nguyen in the hospital data bank. Aaron Nguyen, Alice Nguyen, Bernard Nguyen…One of those Nguyens was my Nguyen. One of those Nguyens was suing me for malpractice. I read through all twenty-six names, down to Yvonne Nguyen. None of the names struck a chord.
My pager went off again. The surgical team was waiting for me. I abandoned my Nguyen search and headed off to rounds.
I got home to my apartment at ten o’clock that night. Sitting down at the table in my kitchen, I read through the Mazzella letter once again (how many times would I read that letter?). I noted now the many admonitions: don’t discuss the case with anyone, don’t undertake an independent investigation of the medical “issues” (why had the plural been used here?), don’t respond to any subpoena.
I had a hard time getting to sleep that night. My mind swam through a heaving sea of Nguyen scenarios gone bad: a fracture missed on X-ray, an overlooked lab result, an infected wound, a preventable blood clot. Nguyen had died. Or, worse, Nguyen had become permanently disabled. I imagined a middle-aged, unisex Nguyen existing in a nursing home on a ventilator, paralyzed, tethered to a tangle of tubes invading every orifice.
The numbers on the digital clock next to my bed progressed inexorably forward: 1:30, 2:00, 2:30. Morning rounds began in just four hours. I had to get some sleep. But my mind would not let go of the parade of horrors: missed breast lump, bleeding from the colon attributed to “just hemorrhoids.” Was Nguyen young or old? God, what if Nguyen was a child?
Sometime after three o’clock I dozed off—only to be awoken by the alarm blaring in my ear at five fifteen.
After rounds and duties on the surgical floor that next morning, I snuck away and phoned Leslie Mazzella. I didn’t want to make the call on the ward where the nurses and doctors could hear me. I still hadn’t spoken to anyone about the case. After all, Mazzella’s letter had warned, Please do not discuss this case with anyone. So, I went downstairs to the pay phones in the hospital lobby.
My heart pounded as I dialed the number. Although I was burning to know more about the case, I was also sick to my stomach in anticipation of learning the precise charges against me. A young woman answered the phone: “Quentin & Cargill.”
“Yes, I’m Chris Stookey. May I speak to Ms. Maz—”
“Oh, yes, Dr. Stookey.”
“Christ,” I thought, “she knows who I am.” I’d imagined Quentin & Cargill as some busy law firm located in a high-rise glass tower downtown. Yet the secretary had immediately recognized my name. It was as though she’d been sitting at her desk waiting for my call.
“I, uh, received a letter.”
“Yes, Ms. Mazzella would like to set up an initial interview regarding the Nguyen case.” She said it so nonchalantly—the Nguyen case. I made note of the phrase, “initial interview” (Mazzella’s letter had used the same phrase): it carried the implication of the first in a series. “Is there a day that would be convenient for you?”
“Yes, well—may I speak to Ms. Mazzella?”
“She’s in a deposition today. She’s free tomorrow, however—she could meet you at the hospital.”
My anxiety ratcheted up another notch. Tomorrow. So soon? They weren’t wasting any time. “Well, I suppose…at lunchtime.”
“All right. Twelve o’clock at the hospital? Where’s a good place to meet?”
“Well—how about…the library?” I said. “We could use one of the study rooms. They’re pretty private.”
“Perfect. I’ll let Ms. Mazzella know. She’ll meet you tomorrow at twelve at the entrance to the hospital library.”
I was about to hang up, but I had to ask. “Say—”
“Yes?”
“Could you—?”
“Yes?”
“The Nguyen case. What’s it about, anyway?”
“Oh, Ms. Mazzella will fill you in on everything tomorrow.”
“But, I mean…What…Did someone die?”
“It’s really not my place to discuss the details, Dr. Stookey. I’m sure you understand.”
“Yes. Yes, of course.”
“Ms. Mazzella will fill you in on everything tomorrow.”
I slept poorly again that night, once again falling asleep after 3 a.m. When I awoke in the morning, I had a sore throat and felt achy all over. I have a tendency to get physically ill during times of emotional stress. I took my temperature: 100.1. No doubt about it, I was coming down with something.
On morning rounds, the attending physician mentioned I looked a little “peaked.” I felt nauseated, and my voice was becoming hoarse. I was assigned to light duty: third assist on a gallbladder case. The principal surgeon was a second-year resident, and it was only his second cholecystectomy. The operation started at nine, and the going was slow. Standing there holding retractors and suctioning, I kept looking at the clock. By eleven fifteen, we still hadn’t begun to close the case. The gallbladder was out, but the second year wanted to take a minute to “look around at the anatomy.”
Due to my fever, I found myself sweating profusely during the operation. The scrub nurse kept wiping my forehead. “Are you all right?” she asked several times. Finally, at 11:45 a.m., we finished the case. I left the operating suite and bolted for the showers.
I arrived at the library at precisely twelve o’clock. My hair was wet from the shower, and beads of water dripped down the side of my face. I’d changed into a fresh pair of green scrubs. A minute later, a woman—fortyish, immaculate in a blue suit, carrying a leather briefcase—walked hurriedly up to the entrance. I immediately knew it was Mazzella; she had a lawyer’s face and a lawyer’s demeanor: intelligent, genteel, predatory. I, too, must have had the anticipated appearance. The moment she saw me, she blurted out: “Dr. Stookey!” She reached out her hand. “Leslie Mazzella.”
“Hi,” I croaked. “Chris Stookey.”
“Touch of laryngitis, Chris?”
“Oh…I think I’m getting a cold.”
“You should see a doctor. Plenty of those around here!”
I forced a chuckle.
“So,” Mazzella said, “is there a place to sit down?”
We went inside the library and found an empty cubicle. Sitting down at the table, Mazzella opened her briefcase and took out a six-inch-thick, bound folder.
“Now,” she said opening the folder, “just how much do you recall about Jill Nguyen, a patient you saw six months ago, on August 12?”
My world tilted a little. Jill Nguyen. So—Nguyen was a woman. I still didn’t remember the name. I brushed back my wet hair. “Nothing,” I said. “I don’t remember her.”
“Good,” Mazzella said. “Tabula rasa, that’s the way I like it.” She began flipping through the pages of her folder. “You only saw her the one time. She was admitted to the obstetrical floor, eight months pregnant.”
My world tilted again, and my stomach tightened. Pregnant? This was completely unexpected, something I hadn’t considered in even my darkest Nguyen scenarios. Pregnant?
Mazzella continued. “Her prenatal care was sporadic. She missed two routine prenatal appointments. She was admitted to the OB floor on August 12 for labor contractions, placed on the usual monitors. The fetal heart tracing suggested some problems. Any of this ring a bell?”
“No,” I said. “Not at all.”
“A decision was made to send Mrs. Nguyen for a biophysical profile. As I’m sure you know, that’s an ultrasound test to measure parameters of fetal well-being: heart rate, breathing rate, limb movements. The plan was to move to an early Cesarean section if the profile was poor. Apparently, your involvement was pretty brief. There’s not much documentation, just something in the nurse’s notes.” Mazzella flipped to a tagged page in her folder. “Something about Mrs. Nguyen having a red eye. Here it is.” Mazzella folded back the page and slid the folder across the table.
Halfway down the tagged page was a brief entry in the nurse’s notes, highlighted in yellow: 12:10. Dr. Stookey at bedside to examine red left eye.
It was then the light switched on inside my head. Of course, Mrs. Nguyen. I remembered her now. Suddenly, there she was, plain as day: a young, petite, Asian woman on the OB deck, sweat on her forehead, a pained facial grimace during a labor contraction. Yes, Mrs. Nguyen, the pregnant woman with the red eye. It was my second month as an intern, and I was doing my obstetrical rotation, spending the month on the OB floor delivering babies. Mrs. Nguyen had not been one of my patients—she belonged to another intern. But I’d walked by her room just as she was about to leave for the biophysical profile Mazzella had mentioned. Mrs. Nguyen had called out as I walked by: “There’s a doctor. Can he look at it?”
The OB nurse called me into the room and explained Mrs. Nguyen was concerned about a painless red area that had developed in her left eye. I looked at the eye. The outer, lower quadrant of the white part of the eye was red. The diagnosis was easy. Mrs. Nguyen had a subconjunctival hematoma. A small blood vessel on the surface of the eye had burst, resulting in some bleeding into the lower surface of the eye. It was a common condition and entirely benign. Most likely, the straining Mrs. Nguyen was doing during her labor had caused the ruptured blood vessel. I reassured her about the condition, telling her it was nothing serious. The blood would gradually fade away, and the eye would be back to its normal white color in a few days. The nurse then mentioned the concern regarding Mrs. Nguyen’s labor and said Mrs. Nguyen was about to leave for the profile test. I said, by all means, go for the test—nothing needed to be done about the eye. And that was it. That was the full extent of my interaction with Jill Nguyen.
I explained all this to Mazzella, who rubbed her chin. “Hmm…,” she said. She turned to the next page in her folder. “Well…do you happen to recall looking at this while you were in the room?”
Mazzella slid her folder across the table again and pointed to a strip of paper. It was a fetal heartbeat tracing. The tracing was highly abnormal. Rather than the regular, spiked heartbeats you expect on a normal tracing, this tracing showed an undulating, sinusoidal pattern. Even a medical student could have instantly recognized this was the heart tracing of a baby in extreme distress. That tracing was what doctors call a “terminal rhythm.” It was the tracing of a baby about to die. A baby with that heart tracing needed to be delivered by Cesarean section. Immediately.
“Did you see the tracing?” Mazzella asked again.
“N-no,” I said. “I just looked at the eye.”
“All right,” Mazzella said. “That will be our defense, then.”
“Defense?”
“Yes. This was the tracing on the monitor when you were in the room. See the time mark?”
I looked at the time mark on the rhythm strip: 12:10. Precisely the time the nurse’s note documented I was in the room. I felt my stomach sink. “But I never looked at the monitor,” I said.
“Yes,” Mazzella said. “As I say, that will be our defense.”
A drop of moisture trickled down my forehead. “W-what happened?” I asked.
Mazzella flipped forward a couple pages in her folder. “Well, when Mrs. Nguyen arrived at the ultrasound suite for the biophysical profile…there was no heartbeat. Sometime between the labor room and the ultrasound suite, the baby died.”
I stared down at the undulating, sinusoidal heartbeat tracing. The nausea I’d felt throughout the day got suddenly worse, and the moisture was now running down both sides of my forehead. I requested a five-minute time-out and headed for the restroom. I vomited into the sink before I could even reach the toilets.
The rest of the meeting with Mazzella lasted half an hour. Mazzella filled me in on the additional details of the suit. Mrs. Nguyen was suing because she felt a Cesarean section should have been performed immediately. At the point when the biophysical profile was ordered, the baby was already in extreme distress. Only an immediate C-section could have saved the baby’s life.
Several other doctors were involved in the suit: the other intern taking care of Nguyen, the resident supervising the interns, the attending physician in charge of obstetrical floor that day. However, as Mazzella made clear, I was a key element in the plaintiff’s complaint. I was the last person to see Mrs. Nguyen before her baby died. I had been in the room when the fetal heart tracing had gone from “concerning” to “terminal.” I had done nothing about it.
They say there are two types of physicians when it comes to the reality of malpractice lawsuits in today’s world. Some physicians hardly blink an eye at being named in a suit. It’s part of doing business, they say. The average physician gets pulled into a malpractice case once every seven years. Medicine is not an exact science; some patients have bad outcomes. Things go wrong. Lawsuits happen. It’s unavoidable. Why worry about it? Just accept what’s inevitable and move on.
The second type of physician finds it difficult to be so casual about being sued. At the very least, a lawsuit is a painful, time-consuming nuisance: there are meetings with lawyers, depositions, chart reviews, phone calls, and perhaps even a jury trial. On top of this, being sued for “bad practice” is inevitably a blow to one’s self-esteem, a time of embarrassment, humiliation, and self-questioning. Have I made an error so egregious I deserve to be sued over it? Am I that incompetent? Do I even belong in this profession?
When I got home that night after the Mazzella meeting, I went straight to bed. My cold was worse: my fever was higher; my throat was on fire; I had stomach cramps. Plus, I was exhausted. I’d gotten less than five hours of sleep over the last two nights.
Yet I still couldn’t get to sleep. I couldn’t stop thinking about Mrs. Nguyen’s baby.
I suppose I might have been a little relieved by what I’d learned from Leslie Mazzella that day. My involvement in the case had been minimal. I’d been asked to look at Mrs. Nguyen’s eye. I’d done that. I’d made the proper diagnosis: subconjunctival hematoma. I’d made the proper recommendation: do nothing.
My reaction, however, was not one of relief. My reaction was one of unmitigated remorse. That heart tracing—I should have looked at it. Just a brief glance, that’s all it would have taken. We were taught to look at the fetal monitor every time we entered the room of a patient in labor. Had I looked, I would have immediately recognized the baby was in deep trouble. I would have notified the senior resident. An emergency Cesarean section would have been performed. The baby might well have been saved.
Over the next several days, my cold got worse, and I had to call in sick. Moreover, my insomnia continued, unabated. Some nights it seemed I didn’t get any sleep at all. I just couldn’t stop thinking about that baby. I just couldn’t stop asking myself: why hadn’t I looked at that tracing?
About ten weeks after the meeting in the library, I got a second letter from Leslie Mazzella. Once again, the letter came to my mailbox in the residents’ lounge, and once again, the envelope was marked PERSONAL AND CONFIDENTIAL. It was the first I’d heard from Mazzella since our one and only meeting. I took the letter outside to the Quad and sat down on the grass.
Dear Dr. Stookey:
This letter is to inform you the above referenced matter has been concluded. While the co-defendants continue to believe grounds supporting the accusation of medical malpractice are lacking, the university has decided to settle the case. The university, acting in consultation with this law firm, believes such an out of court settlement is in the best interests of all parties involved.
I wish to thank you for your assistance in this matter. I also wish to personally extend my best wishes to you and your future medical career.
Sincerely,
Leslie R. Mazzella
Attorney at Law
It’s been nearly two decades now since the Nguyen case. I’ve stayed with being a doctor, although Mrs. Nguyen and her baby did cause me to question my future as a physician. If I could make a mistake as basic as not looking at a heart tracing, what other mistakes—worse mistakes—would I make over my career?
I still think about them, Mrs. Nguyen and her baby, to this day. That undulating heart tracing still pops into my head from time to time, often at seemingly random moments: while I’m standing in line to get a cup of coffee, listening to music, jogging the fire trails with my dogs. The memory also comes at more predictable times: for example, when I step into an exam room with a pregnant patient.
As to the National Practitioner Data Bank, I have never checked to see if my name got placed on the list after Mazzella settled the case. I’ve never logged on to the Web site and run a search on my name. The thought of seeing my name pop up—well, what’s the point? It wouldn’t change anything. Mrs. Nguyen’s baby would still have died, and I still would have been the last doctor to examine Mrs. Nguyen while her baby was alive.
If Mrs. Nguyen’s baby had lived, she’d be in her late teens now. I say “she” because I learned the baby was a girl (a prenatal ultrasound had determined the sex). Sometimes I wonder what she would have made out of life. Where would she be living? What would she look like? Would she be college bound? Starting a family of her own?
If only I had looked at that tracing.