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Medication Negligence Leads to Methotrexate Overdose

Ohio Medical Malpractice Case: Background

Mr. Hope was a classic “eggshell skull” plaintiff, meaning he had underlying conditions that made him more susceptible than the average person to injury. Those conditions included diabetes, end-stage renal disease, coronary artery disease, and COPD. But he was receiving great medical care from a local healthcare system, and he was doing relatively well. He was living at home, driving, taking care of himself, and living a normal life.

In the course of taking care of himself, Mr. Hope went to see his rheumatologist for his rheumatoid arthritis. Unfortunately, despite Mr. Hope’s well-known and established renal failure, the rheumatologist prescribed Methotrexate at a dosage of 15 mg/week.

This medication is contraindicated for patients with renal failure, such as Mr. Hope, because his kidneys cannot clear it from his system. This means the medication simply should not be ordered for someone like Mr. Hope.

Mr. Hope did not know this, and like a good patient, followed the medication orders and started his medicine. After the first dose of methotrexate, everything changed. Within a few days, Mr. Hope developed body aches and a sore throat and cough that prevented him from eating, drinking, and taking medications. His wife took him a local hospital, where he was found to have mucositis (tissue swelling in the mouth) and neutropenia (low white blood cell count due to bone marrow suppression), and given the concern for protection of his airway, he was admitted to the hospital. The next day, he was transferred to the main campus of the healthcare chain for a higher level of care, with a diagnosis of mucositis and bone marrow suppression from methotrexate toxicity.

Mr. Hope was then transferred to the ICU due to chest pain and increased concern for airway compromise. He remained hospitalized over the next week with no improvement, and he developed constipation and an ileus (inability of the intestine to contract and work properly). His respiratory status deteriorated, and he required intubation and mechanical ventilation to support his breathing.

His course was further complicated by an extended requirement for mechanical ventilation, upper gastrointestinal bleeding, and steroid-induced hyperglycemia (high blood sugar). Three months after taking his prescribed methotrexate, Mr. Hope was finally discharged, to a skilled nursing facility and with a nasal feeding tube in place.

Mr. Hope remained frail and unstable, requiring several additional hospital admissions for possible sepsis. He also developed a pulmonary embolism, which required placement of an IVC filter (a device that “catches” blood clots before they can travel to the lungs).

It is well-known by physicians that methotrexate is cleared from the body by the kidneys. With impaired kidney function, however, Mr. Hope could not clear the drug from his system adequately. It was entirely predictable that the drug would build up in his body, and he would develop toxicity. The mucositis and bone marrow suppression that Mr. Hope suffered are two of the most common manifestations of methotrexate toxicity. This led directly to a chain of complications, all ultimately caused by the methotrexate overdose.

Mucositis, which is very painful, results in the inability to eat or drink, requiring feeding tube placement and maintenance. Mucositis can be caused – and exacerbated – by the lack of white blood cells (neutropenia) from bone marrow suppression. Because of the oral swelling and dysfunction, Mr. Hope required a tube to be placed into his lungs to breath for him.

Prolonged intubation and mechanical ventilation increase the risk for gastrointestinal bleeding, as occurred in Mr. Hope while in the ICU, resulting in the need for an endoscopy and treatment for his esophagitis. Steroid treatment for his oral swelling resulted in worsening of his pre-existing diabetes and very elevated sugar levels in his blood, requiring intensive monitoring of his blood sugars insulin treatment during his hospitalization.

Intensive care with mechanical ventilation predictably takes its toll on a patient’s body, resulting in weakness and immobility that is proportional to the severity and duration of the critical illness. This immobility leads to the formation of stasis blood clots and pulmonary embolism, which Mr. Hope had. Due to the gastrointestinal bleeding and his complicated medical condition, this required the placement of an IVC filter, an invasive procedure that carries multiple long-term complications and morbidity.

In addition, the neurotoxicity caused significant mental status changes and ultimately encephalopathy (brain damage). This chain of complications resulted directly, sequentially, and expectedly from the methotrexate toxicity. Moreover, these complications all carried the need for multiple and prolonged medical procedures and interventions, each of which carried its burden of pain and suffering. Mr. Hope was lucky to make it through all of this.

Unfortunately, Mr. Hope passed away in the middle of the night about one year after the medical negligence. The cause of death was listed on his death certificate as myocardial infarction (heart attack). There was no autopsy.

Ohio Medical Negligence Case: Investigation and Preparation for Trial

Mr. Hope’s wife hired The Eisen Law Firm to represent them in their medical negligence claim. The Eisen Law Firm began by reviewing the key medical records from the rheumatologist’s office. It was readily apparent from the records that the rheumatologist should have been aware of Mr. Hope’s renal failure when he prescribed Methotrexate. It was also apparent from discussions with the family that the one-year statute of limitations for a potential medical negligence claim was only two days away. Counsel did not have time to obtain any additional medical records – or to have any records reviewed by an expert – before the expiration of the statute of limitations.

Ohio Medical Negligence Case: Litigation

The Eisen Law Firm was able to determine that this was in fact a potentially meritorious medical malpractice case and quickly filed suit on behalf of Mr. Hope. The Eisen Law Firm also filed a claim for loss of consortium on behalf of Mrs. Hope. The Eisen Law Firm contemporaneously filed a motion to extend time to file an “Affidavit of Merit.”

The Eisen Law Firm then obtained the medical records (all 11,657 pages), as well as records from the different rehab facilities. The firm does not utilize nurse paralegals. Instead, the attorneys review all medical records themselves – page-by-page. Attorneys at The Eisen Law Firm also perform their own exhaustive medical research. In this case, lead attorney Todd Gurney personally researched and analyzed several primary journal articles, texts, and other research materials in connection with his preparation of this case.

Once the firm developed a complete understanding of Mr. Hope’s medical history and the complex medical issues involved, they put together a team of experts to review and prosecute the case. This included experts in the specialty fields of Rheumatology and Pulmonary/Critical Care Medicine. After reviewing the medical records and discussing the matter with Mr. Gurney, the experts agreed to provide the requisite “Affidavits of Merit,” so the lawsuit could proceed.

Comprehensive written discovery requests were exchanged. Plaintiffs produced their discovery responses and scheduled the deposition of the defendant-rheumatologist. Discovery was delayed due to several factors, including the COVID-19 pandemic. The Eisen Law Firm used the delays to further develop and refine their case and to work with the expert witnesses in preparation for the depositions of the defendant and other healthcare providers involved in Mr. Hope’s care. Before the depositions went forward, however, the parties agreed to further pause discovery and attempt to resolve the matter through private mediation.

Ohio Medical Negligence Case: Negotiations and Proposed Settlement

Liability in this case was not straightforward. While the issue of negligence was not really in dispute, the issues of causation and damages were extremely complicated. First, there was no doubt that the defense would argue that Mr. Hope’s injuries were not due to the Methotrexate prescription; rather, they were the natural result of his extensive and progressive underlying co-morbidities. It may not have been too difficult for the defense to confuse the jury with medical jargon and persuade jurors to believe there is no way to distinguish the injuries Mr. Hope suffered from the Methotrexate vs. the injuries he was likely to experience anyway.

Second, despite the extensive injuries Mr. Hope suffered, he was making a recovery toward his baseline. In other words, it is doubtful that the jury would find a “permanent” injury, which means the non-economic damages would be limited to the lower level of the statutory “cap.”

Third, the fact that Mr. Hope passed away while the case was pending created a lot of uncertainty. He suffered a heart attack in the middle of the night. The death was unexpected and did not appear to be related to the Methotrexate toxicity that Mr. Hope suffered nearly two years earlier.

Armed with all the strengths and weaknesses of the case, Mr. Gurney went to mediation. After a full day of intense negotiations, the parties agreed to a settlement.

The Eisen Law Firm. Medical Malpractice. Exclusively.

The Eisen Law Firm has been handling medical negligence cases exclusively for decades. We are extremely selective on the cases we take because we only handle a few cases each year. We commit whatever time it takes to properly see our cases to completion, be it settlement or trial. And we do not hesitate to spend whatever is necessary to do this. We do not charge our clients for anything, not a penny, unless and until we win. That way, our financial interests are directly aligned with those of our clients. But most importantly, we know both the law and the medicine.

In this case, The Eisen Law Firm was able to provide some closure to the Hope family, to hold accountable those whose mistakes resulted in Mr. Hope’s injuries, and to maximize the recovery for the family, without forcing them to endure the emotional distress brought on by the uncertainty of a jury trial.