05 February 2008

Malpractice and John Ritter

Kevin and Dr Wes linked today to a news piece about John Ritter's case going to trial. To summarize, he experienced chest pain, dizziness and nausea on the set of his sitcom, was taken to a hospital, and subsequently died from a ruptured Thoracic Aortic Dissection (TAD).

It's always hazardous to try to read between the tea leaves and decrypt the media reports. But it's a lot of fun; there appears to be plenty of data out there at this time, so let's see what we can sort out from the available sources.

The first thing that jumps out at me is that Ritter was apparently diagnosed with a heart attack and taken emergently to the cardiac cath lab. One report states that "Around 7:15 p.m., a test showed abnormalities ... consistent with a heart attack. [The cardiologist] was at Ritter's bedside at 7:25 p.m." My interpretation of this is that most likely the ECG showed a ST-Elevation Myocardial Infarction (STEMI). That's the thing that gets you a cardiologist in 10 minutes. It's possible he just had an normal/nondiagnostic ECG with an elevated Troponin, indicative of a non-ST Elevation MI. This is generally less urgent with regard to treatment, but I suppose a movie star would get the VIP treatment with a cardiologist at the bedside in 10 minutes.

A point of contention was whether a Chest X-Ray (CXR) should have been done before Ritter went to the cath lab. The answer is debatable. If it was a STEMI, there is clear and compelling evidence that the door-to-balloon time is essential to outcomes, and many institutions dispense with the CXR in these cases, if it would delay cath. The diagnosis of STEMI is made on ECG. CXR adds little to the work-up. The plaintiffs allege that a timely CXR would have made the alternative diagnosis of a ruptured TAD. However, a CXR cannot be diagnostic of TAD; it can suggest it, but the vast majority of TAD cases show an non-specifically abnormal CXR. Even a CXR highly suggestive of TAD would require further tests to confirm, before treatment could proceed. The follow-on tests of choice would be a CT scan -- or a cardiac cath, which Ritter got.

On that basis, I think the plaintiff's allegation that failure to accomplish the CXR as ordered was responsible for his death is not substantiated. It was definitely not negligent, and probably would not have altered the outcome.

Another allegation was that the cardiologist's decision to anticoagulate Ritter with heparin, a blood thinner, was negligent and contributed to his death. Certainly, if he was bleeding already, a blood thinner would make it much harder to save him. The talking point their attorney uses is that he got "the exact opposite" of what he should have. In retrospect, that's true enough. But was it negligent? The American College of Cardiology's management guidelines for MI state, "Antithrombin therapy and antiplatelet therapy should be administered to all patients with an acute coronary syndrome regardless of the presence or absence of ST-segment elevation." The treatment Ritter got was standard for an MI; the question of negligence hinges on whether it was negligent to treat on the presumption that Ritter was having an MI.

MI's are very common. There are over 600,000 diagnosed annually, or 2 per 1000 Americans. Ritter was high-risk for an MI; he was 54, had high cholesterol, and was male. He may have had other risk factors; we don't know. MI is the number one killer for men Ritter's age, and there was evidence to suggest this was an accurate diagnosis. TAD, conversely, is terribly rare. A ruptured TAD occurs at a rate of about 5-10 per million Americans annually, with 2000 cases annually in the US. So it's several orders of magnitude less common than an MI. About 2% of these cases present with a myocardial infarction at the same time. So a back-of-the-envelope estimate would be that there are maybe 20-100 cases like Ritter's annually in the US. Contrast that with the 600,000 "standard" MIs. It's very, very, very rare, and notoriously difficult to diagnose. Patients with TAD can present with many different varieties of chest pain, or no pain at all.

The textbook answer is that doctors have to maintain a "high index of suspicion" for TAD. True, but how high? It's irrational and impossible for every patient with an MI to get a CT scan before cath. The dye alone would kill their kidneys, and the delay in revascularization would contribute to measureless death and disability.

Given that Ritter had a very rare disease, which presented mimicking another emergent diagnosis, it's very hard as a doctor to view the cardiologist as negligent. Most ER docs hear this story and say, "Thank God that wasn't me, because I would have done the exact same thing." Which is really the opposite of negligence, isn't it?

Finally, when it comes to causation, the critical question of "did the doctors' treatments cause or fail to prevent" Ritter's death, one thing should be taken into account. A ruptured TAD has mortality of 80%, and even with treatment, in the best cases, the operative mortality remains at 20% (which includes elective repair of non-ruptured aortas). He presented contemporaneously with the rupture; it would have been difficult under the best circumstances to save him. Ritter was unlucky enough to have a very rare and very deadly disease. His untimely death was sad. But the limited evidence at hand does not suggest that medical negligence contributed to his death.

Which begs the question -- if there was not negligence, then why have nine other entities settled for a total cumulative settlement of $14 million?

Because juries are not qualified to make the determination as to whether there was negligence. They are laypersons with limited knowledge of medicine, diagnosis, or statistics. They are swayed by the pathos: the suffering of the widow and small children, the sadness of the loss of a beloved star, and the righteous anger of the family who believe the doctors killed their loved one:

"You can't treat my kid's dad for something and kill him in the process," [Ritter's wife] said. "I think the money will show how angry the jury will be about what happened to John and what could happen to them."

They will listen to grey-bearded professors contradict one another, flip a coin as to who was more credible, and issue a verdict. And the plaintiffs are swinging a big stick -- a $67 million one. If you lose, you lose very big. Safer to settle for policy limits and walk away, rather than take that downside risk.

And the lay population wonders why doctors are cynical and mistrusting of the medical malpractice system.

41 comments:

  1. Wouldn't it be interesting if malpractice suits were judged (well juried I guess. Is that a word?) by medical professionals, or at least people with some science background?
    I think the saddest thing is that his widow has not properly (in my opinion) grieved. I saw her on the Today show, and she just wants someone to blame or as she said "to take responsibility." Terrible for her, and terrible for the way she's able to slosh around this system to make herself feel better when there really may have been nothing anyone could do with the information they had.

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  2. Sarah,

    Just for reference, I wouldn't support physician-only oversight. Doctors don't have the best record in policing themselves. Though, on the other hand, doctors are notoriously tough on one another -- as anyone who has ever attended a Morbidity and Mortality conference can attest.

    I would prefer something like they do for taxes -- an administrative law judge with special expertise in medicine, and independent experts.

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  3. If only there were some way to have it explained simply to a jury. That is what I dislike most about lawyers, their inability to simplify things. And I know this because I was raised by a lawyer, nothing in our house is simple ;)

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  4. A TAD dissecting down into the coronaries causing ST-elevation is the scariest clinical scenario I can think of -- as you illustrated above pretty much a death sentence hastened by our treatments. I'll see this once, maybe twice in my career?

    I think if a patient was fortunate enough to present classically, and was complaining of "tearing" pain and looked much more uncomfortable than a typical MI, I might send him to the scanner. Otherwise, probably best for both me and the patients to keep our fingers crossed and hope we don't have to deal with this all together.

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  5. I saw a case much like this (except it was a slightly higher dissection) at Major Los Angeles Teaching Hospital (site of one of the first EM residencies in California) in 1982. CXR was non-specific, of course. Fortunately none of today's interventions were available (the only CT scanner fit heads) and the course was naturally down-spiraling without any interventions to litigate about. An M and M suggested only better documentation around the subsequent code.

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  6. I think we may need to question the value of a jury in many, many cases. Medical malpractice and patent litigation are two areas that jump to mind. In these cases, it is unlikely the jury, or judge for that matter, has any idea of the basic issues at hand.

    But, I have done a lot of work in death penalty cases wherein a jury is supposed to decide if a particular murder is the type of murder that deserves the very worst penalty, death, or the second worst penalty, life in prison without parole. Hell, I've seen construction defect law suits settle because of fear of an unpredictable jury, and those facts are relatively straight forward.

    Avoiding a jury corrupted by the industry is a problem, though. In Arizona, we recommend judges with a panel of just about 1/2 lawyers and 1/2 non-lawyers. Maybe professional juries made up of 1/2 doctors and 1/2 lay people would be a good idea. Tricky though, because the professionals would obviously have so much sway.

    I agree it is a serious problem.

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  7. The difficulty with Jury's deciding these issues is the first thing the plaintiffs lawyer does is excuse anyone with any medical knowledge from the Jury because it is assumed they will have previous experience that will bias their evaluation. Happened to me recently when on a Jury pannel that involved a case where medical experts were going to be a big part. Myself and one other Nurse, a Doctors wife, and a clinical researcher were excluded. What was left was scary. No wonder even cases with no merit get settled.

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  8. "The difficulty with Jury's deciding these issues is the first thing the plaintiffs lawyer does is excuse anyone with any medical knowledge from the Jury because it is assumed they will have previous experience that will bias their evaluation."

    FYI, if your defense attorney doesn't also strike jurors he thinks will be biased against you, you should fire him. Or punch him in the face. http://tinyurl.com/2amxx9

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  9. so much for a trial by a jury of our peers...

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  10. John Ritter's wife needs to let this go. All deaths can't be prevented. There could be a genetic trait here. John's father, Tex Ritter wasn't that old when he died from a heart problem.

    I know she is hurt and angry. I would be too. But Doctors are not Gods. No one harmed John Ritter on purpose.

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  11. In our area, if he had chest pain (or other cardiac-type symptoms) with ST-elevation while in the ambulance on the way to the hospital, he wouldn't even stop in the ER, he'd go directly to the cath lab. The medics can activate this protocol.

    If he came through the front door, he'd probably be at the cath lab in 15 minutes. I've never seen anyone stop and do more eval on someone with ST elevation and chest pain.

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  12. All the money in the Federal Reserve won't bring John Ritter back. Nobody gets out of here alive.

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  13. The jury will never even hear about the millions the family has already been paid.

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  14. Maybe a jury of medical professionals - not just MDs.

    As a nurse, I gotta say he was just terribly unlucky. The doctors made the best decisions they could.

    Even if they had gotten a CT and the TAD showed clearly, chances are he would have died anyway.

    It's sad - but true. The family needs to let this go. Shame on any medical professional who testifies for the plaintiff.

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  15. I have such an aversion for people who sue after losing a loved one.

    Nothing is more crass than trying to make money over someone's dead body.
    Despicable.

    Or maybe they are seeking revenge. Despicable.

    Some die young, others old. Such is life.

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  16. Great analysis of the case.

    Trial by jury makes sense when there is a question of fact. It makes no sense when a man dies of a lightning strike, the prototypical "act of God," or some event with the same frequency. What have we come to when any attempt we make to help a dying man can be judged in a court of law?

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  17. $67 million??? I thought California had a med/mal cap of only $250,000.

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  18. The "CAP" in california is only for pain and suffering. It does not include economic damages. So faimily will claim he would have so many millions while he was alive.

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  19. One thing that has always bothered me about the Ritter case is wondering whether the catastrophic dissection could have been prevented if he had been worked up better prior to the acute event resulting in his demise.

    His friends had been teasing him of late of how he was always feeling awful and being too tired. I suspect the aneurym ruptured with a very slow leak.

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  20. Or rather, began with a very slow leak some time before the acute, and ultimately deadly, rupture.

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  21. What I find interesting, working for over 10 years in CA in professional liability with direct responsibility for deciding whether to defend or settle these types of cases, is the fact that this one is going to trial. Given that policy limits on these docs is probably $1 million each, and knowing the intestinal fortitude for big damage trials of many of the insurers in this state, the defense must either feel they have a reasonably rock solid defense, or they are unable to settle the case for what they feel is a reasonable amount, or the amount of insurance coverage available, $2 million. My guess is the latter. MICRA (the CA tort reform that limits pain and suffering to 250K among other things) gives an insurer the ability to periodisize a large damages award over a long period of time by purchasing an annuity. It would not surprise me, having seen the comments of the widow (and the fact that she does not need the money) if she is demanding more to settle the case than the insurance company could periodisize the payments for in the event of a plaintiff verdict.

    I am heartened to see the number of comments about this case that are so supportive of doctors and healthcare in general...I am slightly less pessimistic about our litigious society :>

    BTW- this case is a plaintiff attorney's dream given the media exposure.

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  22. 20/20,

    Interestingly, Ritter had a full body scan not too long before his death. (A year or two, maybe.) It was supposedly negative, and the radiologist is also a defendant. They claim he missed the aneurysm, though apparently note was made of some calcium etc. I didn't blog about that because, honestly, nobody realy knows if it was there or not unless you've looked at the film, and that'll just be a battle of the experts.

    Anon 3:49:
    this case is a plaintiff attorney's dream given the media exposure

    Only if you win. Only if you win...

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  23. Apparently a jury of your peers only applies in criminal cases. Agree with Shadowfax, docs are much harder on each other; heard above two points @ Harvard malpractice course (excellent, BTW) - we are socialized to be the "smartest kid in the room", hence the M&M shark feed.

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  24. It's pretty obvious that Ritter's wife is just being ridiculously greedy. She already got $14 million?? I think Ritter would be ashamed to find out that he was married to such a money-grubbing golddigger.

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  25. Unamed-MD
    I am in interventional cardiologist and have often been called to the ED in such circumstances. On 2 occassions over the past 10 years I have taken a patient to the cath lab with ST-elevation who ultimately were identified to have a TAD. Both cases went to the OR successfully (fortunate) because I had a high index of suspicion going in. THere is great pressure on the system (ED and cardiology) to rush people off to the cath lab so as to make the 90 minute door-to-balloon time. This 90 minute mark is used as a surrogate for quality of care and does not take into account the actual outcomes. This has resulted in cutting corners. My own approach is to accept a slightly longer door-to-balloon time in order make sure that chest xray and lab work has been done.

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  26. Speaking of pathos, the self-pitying comments on this post must have had you reaching for a hanky.

    If jurors are not qualified to pass judgment on whether there was negligence, do you think that YOU are unqualified to pass judgment on the many aspects of the legal system you have little knowledge about? I didn't get that from reading what you wrote . . .

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  27. I am not an MD, but I can think.

    Perhaps the actress does need the money...

    It was reported in the AP that in opening statements the Defense attorneys will show that Ritter was turned down for life insurance 3 years prior to the incident because of "incredibly abnormal" blood levels --- triglycerides were 7 times normal. And after the body scan in question, he was advised to consult a cardiologist (there was some evidence of calcium).

    Ritter ignored the advice; and judging from the photos the media splashes all over the place with Fonzie, you can see that he was decidedly overweight.

    Ritter did nothing for THREE YEARS to take care of his own health despite warnings. When it came to a head, a Cardiologist was called to save him in the Emergency Room. Ritter's wife claims he was killed because of an x-ray (or lack there of). According to the Defense, when the Cardiologist had arrived, a code AMI had already been called. "In that situation, you don't wait around for an x-ray," the defense state.

    Perhaps an x-ray by Ritter's cardiologist BEFORE he was in the ER could have found the problem. That is, if he had bothered to take a little responsibility. Yasbeck should blame her negligent husband and not the doctor who was there to save him for his death.

    According to ABC news yesterday, Yasbeck's cardiac surgeon expert who was supposed to be an unbiased expert had a conflict of interest. Things got heated in the courtroom when the cardiologist's defense attorney revealed that the cardiac surgeon had held a symposium at which the actress had spoken. Not so unbiased is he then...?

    Also, the Cardiologist's defense attorney quoted from a book that the Cardiac Surgeon had penned himself which stated that finding an aortic dissection was like "looking for a needle in a haystack," and that essentially physicians should be offered some grace in malpractice situations considering how difficult they are to detect and easy they are to mistake for a heart attack. He conradicted his OWN book!

    Some doctors are naive. Some may believe that right is right and frivolous lawsuits will lose in a court of law. I believe that the plaintiffs chose not to settle because they did not want to be blackmailed by a money-hungry D-list actress who needs grief counselling and a job. Settling would make their premiums go up and tarnish their medical records when they did NOTHING wrong.

    I hope they are right.

    The malpractice system needs to change such that the jury can decide if a suit is frivolous and the doctors can receive damages for their time, money and damage to reputation if they prevail.

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  28. pharmdcandidate2/27/2008 3:59 PM

    I really enjoyed your analysis of the case, as I have been searching for a medical opinion about this since I heard of the civil trial. I think it is unfortunate that his widow is suing for 67 million even after the previous settlement, saying that that is the amount Ritter would have earned had he been alive today. Sadly, I doubt that she will ever listen to anyone speaking with reason and without bias to this case. I hope the jury and judge do, and that the family can finally grieve for their loss.

    I also agree that such cases should have a judge that is at least familiar with medical terminology and cases/statistics like this.

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  29. as a doctor, i too get heated when i hear this crap. the reality isn't what john ritter would make if he lived to be x years of age. the 'actual' reality is what would have happened to him had there been no cardiologist, no ER, no hospital....he would 'actually' be dead. the doctor did his best, as we all try to do-- it is NOT malpractice to work quickly with limited appropriate evidence to try and treat the most likely scenario, just one of many dangerous ones. real malpractice is treating hearing his story and treating him for hives, or diarrhea, or headache.

    our legal system in these cases is clearly a set-up for the plaintiffs...i agree totally with the collective 'pathos' of the grieving family. we are all humans and want to do something to help, something to heal...non-medical juries are ill-equipped to judge whether this doctor committed REAL negligence, despite their best intentions. i have long believed that physicians should sit as jurors for other physicians. ergo, how could i as a doctor sit in adequate judment of an airline pilot?

    there is really no downside in america for plaintiffs to sue anyone. this wealthy, greedy widow can afford to sue and afford to lose. she feels she is entitled to fight, entitled to scrutinize ex post facto, and pretend that the natural consequence of the 'right' help would be 20 more years of (mediocre) film-making for her husband. there is no real risk on the plantiff's part, aside from (possibly) legal fees. if she loses, there should be real financial risk, real accountability, and real damages for the real 'pain and suffering' this doctor has to endure and for the REAL stigma associated with his name for the rest of his life, win or lose.
    everyone wonders why medical care is so expensive....cases like this spur on the defensive practice of medicine with more and more tests, labs, consults, and we all pay for it eventually.
    the saddest part of it all is that trial lawyers see nothing shameful about this at all. they are paid regardless. i dont know how many of them sleep at night. none of it brings back john ritter, and the cardiologist keeps going to work, doing the best he can.

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  30. In California, the defendant has the right to ask for trial by jury or trial by a judge. Doctors may whine about the jury system, but they fail to mention that they win a vast majority of cases with a jury.

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  31. They're called "accidents", NOT "on-purposes" for a reason. No one is suggesting that anyone in the hospital had anything other than Ritter's health at heart (forgive the pun). The issue in a medical malpractice case is not whether the doctors are bad people, but whether, on the date of the occurrence, they deviated from the generally-accepted medical standards.
    Our "host" here has medical training and, as an emergency room physician has undoubtedly handled countless cardiac episodes. That being said, he is NOT a board-certified cardiologist. It is somewhat trite for him to stand on the sideline and suggest that another doctor should not be held responsible for taking a course of action that he would have taken. We have a Comment posted by an actual Cardiologist, who states that under the same circumstances he would have performed the Chest X-ray and, that in his experience, the condition is treatable and the life can be saved.
    Now, of course, neither opinion is conclusive in this case, since neither the original poster nor the Cardiologist commenter have reviewed Ritter's hospital records. However, I am inclined to put more stock in the Cardiologist's opinion here.
    That being said, there is no reason why a jury should not be permitted to hear expert testimony, from both sides, have the law explained to them and come to a verdict. The jury system is not perfect and yes, these are complicated issues that need to be explained in a way a layperson can appreciate them, but this is done all the time.
    Also, although it's not always true that "where there's smoke there's fire", keep in mind that the hospital and other doctors DID, in fact, settle the claim for $14 million. This is not, of itself, an admission of liability, but bodes well for Plaintiff's chances at trial.

    As for other commenters, I'd like to add:

    Aggie Sarah: HOW DARE YOU??!! How dare you judge the manner in which this woman is grieving?!! Trust me: Amy Yasbeck would far rather have her husband back than win this case! Seeing her on a morning show, SEVERAL YEARS AFTER HIS DEATH, talking about a legal proceeding does not, in any fashion, detract from her grief. Shame on you!

    Kim: If "all deaths can be prevented" (which I definitely disagree with), why not hold the person(s) responsible who are charged with such prevention, when they fail in that task?

    Ndenunz: True the jury will not hear about the prior settlement, but in most states (I do not live in California), prior settlements are an off-set against any final judgment entered.

    GENERAL: For all of you complaining about people attempting to "cash in" on loved ones' deaths, or being "greedy", I simply hope that you never have to be in the same place as most of these Plaintiffs. I've never met a plaintiff on a "catastrophic" case that, for one minute, would not have traded their 7-figure recovery for a chance to turn back time and make it so that the catastrophic event never occurred.
    If Ritter's death could have been avoided, by not deviating from generally-accepted medical practices, then the man would still be alive and earning millions of dollars. I have absolutely no objection to holding these people responsible.

    Finally, nothing I wrote here was intended to insult the medical profession, as a whole. There are many, many great, caring, skilled doctors. Ritter's doctors may even have been among them. The issue is negligence; nothing more. Also, it should be noted that most Plaintiff's attorneys will only go after insurance proceeds. Very few will attempt to enforce judgments against individuals. And, though doctors are deservedly paid extraordinarily high salaries, they are also aware of the need to pay for costly malpractice insurance, just in case, they one day make a fatal mistake.

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  32. As a cardiologist, this is the "nightmare" scenario that I dread. ABC played a clip of Mr.Ritter's phone message to his wife wherein he complained of gastrointestinal symptoms and profuse sweating. Since the ER docs apparently diagnosed him with an acute MI or heart attack by EKG (and his presenting complaints), emergency cardiac catheterization is warranted. However, if a patient suffers an acute ascending aortic dissection that extends proximally into the right coronary artery, the EKG findings and symptoms are identical. His presenting complaints of nausea and vomiting are typical of myocardial infarctions involving the right coronary artery. I think a clarification is needed as to whether Mr. Ritter had an ascending aortic aneurysm that dissected or a normal caliber aorta that dissected. In the latter case, a chest xray would not necessarily have helped; the radiologist who read his chest CT two years ago should be held harmless. I would be very surprised if a patient had a normal caliber aorta two years ago and suddenly develops an aneurysm that dissects. Medically speaking, given the known facts of the case, his cardiologist acted appropriately and conformed to standards of practice. ER docs usually have a low threshold at which to consider a dissection. Had Mr Ritter complained of pain between the shoulder blades or a tearing type of chest pain, a chest CT would likely have been performed.

    Medicine is still an art. Physicians must examine the data at hand and distill a solution. We face uncertainties every single day and try to make the best decision possible. Yes, sometimes that is a guess. A best guess based upon our experiences and knowledge of epidemiology. Common things occur commonly. Heart attacks are much more common than aortic dissections that mimic them. Had Mr. Ritter truly been suffering from a heart attach and his doctors wasted time in xray and the CT scanner looking for dissections, the outcome may have been equally poor.

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  33. To Anonymous dated 3/5/08:

    Why don't you try to take your own emotional issues out of this and look at the facts.

    The cardiologist who commented on this blog site said that he had enough information that made him suspect an aortic tear in his situations. Ritter had NO classic symptoms. He complained of nausea, diarrhea, and a squeezing sensation in his chest with a pain rating of 1-2 on a scale of 10. In 92% of aortic tear situations there is SEVERE pain and a tearing sensation. 92%! You want to blame the cardiologist for not considering the 8% chance when a code was called and the guy looked like he was having a heart attack? Also an aortic tear happens 1 in 600,000 cases. Do you think the cardiologist should have looked at this situation and said, "Gee, this has all the indications of a heart attack and it is an emergency, but let's just check for that 1 in 600,000 chance that it is an aortic tear even though I have asked him questions to rule that out and he does not have ANY classic symptoms. Let me waste precious time just in case someone might blame me for making a "mistake".

    Also, I believed Yasbeck was grieving until I saw her forcing tears whenever she could. She may have started out actually feeling sad about her loss, but now she may be grieving for her lack of money and floundering career. She has no income and no insurance. That might make a woman living in Beverly Hills cry.

    Yasbeck's attorney lies and makes stuff up as he goes along all for the almighty dollar. It might be interesting to note that Ritter's own son stopped coming to court eveyday. It was after the Cardiologist testified. Perhaps it is because Ritter did a good job and raised an honest son. The son felt ashamed to be dragging this Cardiologist good name (and father's name, mind you) in the mud. This fine Cardiologist who has THREE Board Certifications in Internal Medicine and Cardiology --- whose name and face is plastered all over the news with little support from the Media and is only referred to as the cardiologist who is accused of substandard care. I find it disgusting that it is almost impossible to find any real reporting going on anywhere. It is sexy to say that Ritter was misdiagnosed and that the widow wants $67 million. It gets people's attention. It is not so interesting to know the reality: Ritter had a strong family history. His father died young of heart disease. Ritter ignored doctor's advice to go under the care of a cardiologist. Ritter was turned down for life insurance because they believed the odds were that he would NOT live long. Despite this knowledge, Ritter was VERY OVERWEIGHT and worked long hours on a sitcom. When he went to the hospital complaining of classic heart attack symptoms, a cardiologist rushed in to try to save his life. What has not been reported is that there was a change in Ritter's EKG which indicated that he was having a heart attack --- caused by the dissection, but a heart attack. This doc did everything right. The situation was just wrong and VERY VERY RARE. Every expert in the country except for the whore from Yale who has a personal relationship with Yasbeck agrees that the Cardiologist did not make a mistake. He made an educated guess. There was NO WAY for him to know that Ritter was having an aortic dissection and there was no way of saving him. There was nothing that could have saved Ritter's life. If celebs want to risk having no one want to treat them because there is the threat of a suit and a PR campaign to try to get INJUSTICE then they can go ahead. Let their lawyers treat them.

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  34. A defense verdict, 9-3, just came in for both doctors. The truth is that nothing could have been done to save John Ritter with this (TAD) condition. The decision by the jury was the right one.

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  35. The initial post by shadowfox is the best analysis I have seen on the web about this issue. I agree 100%. It seems that the lawyers, media and even the jury don't really have a real sense of what is honestly pretty straight forward to medical professionals. I am relieved to hear that the jury made the right decision.

    One question I do have is: Did John Ritter have a rupture of his thoracic aortic dissection which made him crash or a Stanford type A dissection with involvement of the coronariesor both? I could not find this anywhere in the blogs or news.

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  36. This is a comment regarding the post by the interventional cardiologist and ML.

    I am a radiologist, and I can tell you for a fact that a Chest X-ray, especially a portable Chest X-ray would not have made much of a difference.

    It really depends on exactly what John Ritter actually had. If he had a Stanford type B dissection, a portable CXR would be usually normal or very non-specific. If he had a Stanford type A dissection (involving the ascending aorta), a portable CXR would also be probably be normal or show subtle but still non-specific findings. Certainly, a portable CXR would never give me confidence to say this is "definitely" or even "most likely" a dissection to buy a trip to the OR. You would always want a Chest CT.

    If John Ritter had a true rupture of his thoracic aortic dissection, we may see widening of the mediastinum which would be more suggestive of a catastrophic event. But this would still require a follow-up CT unless the patient is unstable. If he had a rupture, however, his chance of survival would already be slim, no matter what anyone did.

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  37. Take it from someone who is living the nightmare for a year now. My husband went to his trusted doctor and told him he was having chest pains, and that they came only when at rest, i.e in bed or when relaxing in his chair. My husband had a history of high blood pressure, and chorlestoral. His doctor told him that it was all the stress he was under and sent him home. No ekg, no xrays nothing. Turns out that my husband's atories were 50% clogged and he needed a triple or double by-pass. In Feb of 2007 4 months after that visit, I went to wake my husband for work and found him dead. He had a massive heart attack in his sleep. By the time of autopsy, his artories were 95% clogged, he was just 52 years old. We have a nine year old daughter together, and between us both there are four children all together.

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  38. If we have heart attacks now is our care going to be delayed because we're going to have to wait for a chest Xray before definitive treatment in the cath lab? How much cardiac tissue will die as a result of this case? Usually the CXR can be done before the pts ready to roll to the cath lab but not always. But now its going to be another delay just in case you're that 5 per million vs the much bigger chance that its an MI.

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  39. Hi.. I have a similar story to the whole aortic disection,,, my healthy 34 year old wife.. worked out.. ate good.. she was top of her class at collage for nursing..
    2 days before she started at a local hospital.. had massave, tearing chest pains...confussion
    i drove her to er... after 45 minites there the er doc, confirmed inner wall of aortic artery was tore from top to bottem
    things started going very fast...mass people came in,, ivs,,atrial line in neck...10 ivs in arms and legs.. they prepped her for immediate surgery...
    life-flight showed up.. loaded her up.. flew to a trama hospital...
    after over 2 hours in waiting room,, they said we could see her...confused.. we followed nurse to her waiting room...
    after 15 minutes standing next to her..2;30am.. the head nurse informed me... she will be having surgery between 6-7 am...she ruptured about 2 minutes after the nurse said that...

    i have alot of questions i would like to ask.. and i will judge no one for being right or wrong
    i

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  40. more on my 34 year old wife....

    4 years ago my wife at age 34 was getting ready to take a bath.. she had sharp tearing chest pains.. i was talking to her and she became confused. she was not answering me or finishing her sentences..

    I rushed her to our local ER.. told them very bad chest pains and confusion. after about 45 minutes to a hour of the ER doctor trying to figure what was wrong.. he came in and said ,,, I believe her aortic artery is tore...but he needed to send her for a test to confirm..
    she was gone for a maximum of 15 minutes. they brought her back to the room.. they opened up all the doors, and the ER doctor told me things are gonna start going very fast,, in came several nurses, other doctors, Iv tecs...ect..they started bringing in several big machines.. they put 10 or more IV lines in her arms and legs.. including a atrial line in her neck...when he got a second from the caoss he then told me... I have confirmed it... he aortic artery ... the inner wall was tore from top to bottom..she needs immediate surgery to replace the artery and the valve..( open heart surgery )he then told me he called in a local cardio-thurasic ) surgen to second look the test..
    he arrived and took over the show...told me your wife is very very very sick.. she needs immediate surgery.. she he already called the helicopter and allerted his surgical team that she was coming....( 9:30 pm )
    the helicopter arrived and preped her for the 15 minute flight to this truma hospital.
    he informed us .. do not be speeding or driving fast you are not gonna be able to see her.. she will land and go stright into surgery...when they all got into the helicopter, we drove away..
    after a hour drive, we arrived at hospital..they put us in a waiting room.. after 45min to hour a lady cam in and asked me if i had insurance.... I said no... she left..approx 1 hour or so later a nurse came in and said.. you can see her now.. I looked at my mother in law and we were all confused,,, we were told 10-12 hour surgery.
    she escorted us to the waiting room she was in.. I gave her a kiss and asked her how her flight was.. she said ..I couldnt see anything. i was all wrapped up...
    The head nurse said,, shes doing good ,,, all her numbers are good... she will be having surgery between 6-7 am....after 10-15 minutes in the room my wife asked if she could have some water,,, the nurse replied, no ..you are having surgery in the morning,, but she could get her some ice chips or a sponge..her sister was standing at the foot of the bed next to the head nurse.. and her sister yelled ..shes crashing..2:38am....the head nurse said... No shes not !!! she began clapping and yelling her name... after about 30 seconds.. she hit the code blue/alarm button.
    they cleared us from the room and continued to work on her... she was pronounced dead at 3;08 am

    other factors that bother me...
    when they loaded her in the helicopter.. it did not start..they were down for 33 minutes for ( emergecy mechanical assistance )
    the surgens did not show up... they ordered 2 tests for in the am..

    to all you doctors,,, nurses out there... I would be happy to hear your comments,,, responses...or theorys of why this happend this way...

    Thank you for reading my story...
    lost and confused..

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