Wickline v. California

239 Cal.Rptr. 810 (1986)

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Nature of the Case

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Facts

P was being treated by Dr. Daniels for problems associated with her back and legs. Dr. Daniels had P admitted to Van Nuys Community Hospital and brought in another physician, Dr. Polonsky, a specialist in peripheral vascular surgery, to do a consultation examination. Dr. Polonsky diagnosed P with arteriosclerosis obliterans with occlusion of the abdominal aorta, more generally referred to as Leriche's Syndrome. The only treatment for Leriche's Syndrome is surgical. P's disease was so far advanced that Dr. Polonsky concluded that it was necessary to remove a part of her artery and insert a synthetic (Teflon) graft in its place. P was discharged home to await approval of her doctor's diagnosis and authorization from Medi-Cal for the recommended surgical procedure and attendant acute care hospitalization. Medi-Cal authorized the surgical procedure and 10 days of hospitalization for that treatment. Dr. Polonsky performed a surgical procedure in which a part of the plaintiff's artery was removed and a synthetic artery was inserted to replace it. Dr. Polonsky characterized that procedure as 'a very major surgery.' Later that same day Dr. Polonsky was notified that P was experiencing circulatory problems in her right leg. He concluded that a clot had formed in the graft. P was taken back into surgery, the incision in her right groin was reopened, the clot removed and the graft was resewn. P's recovery was not good. She had a lot of pain, some spasms in the vessels in the lower leg and she experienced hallucinating episodes. P was returned to the operating room where Dr. Polonsky performed a lumbar sympathectomy. Dr. Polonsky was assisted in all three surgeries by Dr. Kovner, a board-certified specialist in the field of general surgery and the chief of surgery at Van Nuys. P was scheduled to be discharged on January 16, 1977, but Dr. Polonsky concluded that 'it was medically necessary' that plaintiff remain in the hospital for an additional eight days beyond her then scheduled discharge date. Drs. Kovner and Daniels concurred. Dr. Polonsky felt that he was going to be able to save both of P's legs and wanted her to remain in the hospital where he could observe her and be immediately available, along with the hospital staff, to treat her if an emergency should occur. Medi-Cal was solicited to pay for the extra stay. All of the physicians who testified agreed that the 180 form prepared by Nurse Spears was complete, accurate, and adequate for all purposes in issue in this matter. Futerman, a registered nurse employed by Medi-Cal had the authority, after reviewing a 180 form, to approve the requested extension of time without calling a Medi-Cal Consultant. If for any reason, she felt she could not approve the extension of time in the hospital as requested, she was required to contact a Medi-Cal Consultant and that physician would make the ultimate decision on the request. Futerman had trouble approving the request. She opined that there was nothing in P's case that would have warranted the entire eight additional days. Dr. Glassman, one of the Medi-Cal Consultants, rejected the request but authorized an additional four days beyond the originally scheduled discharge date. Dr. Glassman did not actually see the 180 form itself until after he had acted on it when it is forwarded to him for his signature. There are appropriate places provided on the 180 form to indicate what the on-site nurse's recommendation is and the reason given for disapproval of the requested hospital stay extension by the Medi-Cal Consultant, both of those places were left blank on P's 180 form. Dr. Glassman could not recall why he granted a four-day extension rather than the eight days requested by the plaintiff's treating physician. Dr. Glassman testified that the factors that led him to authorize four days, rather than the requested eight days, was that there was no information about the patient's temperature; nothing was mentioned about the patient's diet, nor was there any information about P's bowel function. That P was able to ambulate with help and that whirlpool treatments were to begin that day caused Dr. Glassman to presume that the patient was progressing satisfactorily and was not seriously or critically ill. P was discharged on January 21, 1977. P looked ok to everyone involved. After discharge P's leg 'kept getting grayer and then it got bluish.' P was in excruciating, pain. P returned to Van Nuys on January 30, 1977. On February 8, 1977, Dr. Polonsky amputated P's leg below the knee because had he not done so 'she would have died.' On February 17, 1977, the doctors went back and amputated P's leg above the knee. If P had remained for the extra time Dr. Polonsky's medical opinion was he would have observed her leg change color, would have formed the opinion that she had clotted, and would have taken her back into surgery and reopened the graft to remove the clot again, not an uncommon procedure in this type of case. P sued D. D claimed it was not negligent as a matter of law and that the decision to discharge was made by each of P's three doctors and that decision was based upon the prevailing standards of practice and was justified by her condition at the time of her discharge. D's expert Dr. Kaufman supported Dr. Glassman's decision. He testified, based upon his examination of the MC-180 form in issue in this matter, that Dr. Glassman's four-day hospital stay extension authorization was ample to meet the plaintiff's medically necessary needs at that point in time. P got the jury verdict and D appealed.