In today's Baltimore Sun, reporter Tricia Bishop looks at the use of stents and the risks they bring. According to the article, until recently, use of cardiac stents to open blocked arteries has been all the rage and was seen as a relatively safe procedure when compared to open heart coronary bypass surgery. Since the 1990s, stents have been increasingly used and have generated more than $1 billion of revenue for Maryland's hospitals.

In the wake of close to 600 claims against Mark Midei, M.D.- the once preeminent interventional cardiologist at St. Joseph's Medical Center in Towson, Maryland -- for unnecessary stenting of patients with little or no artery blockage, the health care community is now taking a hard look at the risks and benefits of cardiac stents and is now trending away from using them in favor of medications or bypass surgery. According to statistics from the state Health Services Cost Review Commission, stenting procedures in Maryland will drop by 25% this year (from 14,255 to 10,650).

Some of the comments and opinions expressed by those interviewed are rather remarkable. Most striking are the comments of Dr. William O'Neill, executive dean of clinical affairs at the University of Miami's Miller School of Medicine. Dr. O'Neill, who was hired by St. Joe's to review Dr. Midei's patient charts, claims that he found "no unwarranted stents."

With all due respect to Dr. O'Neill, our firm and many others have hired top flight interventional cardiologists to review Dr. Midei's charts and in many instances, there was absolutely no blockages whatsoever. Many patients' own cardiologists have also reviewed Dr. Midei's films and reports and cannot reconcile the reported findings against the films.  The referring cardiologists have reviewed the data at the request of their patients who received the now well known yet cryptic letter from St. Joe's warning patients to consult with their physicians about possible harm.  In more than a few cases, patients report that the treating doctors have simply shrugged their shoulders in dismay and have offered apologies for referring them to Dr. Midei.

Dr. O'Neill is also quoted as suggesting that physicians who perform stenting on borderline patients, i.e., those with close to 70% blockage, will now "be afraid that some angry patient or angry attorney or disgruntled colleague or competitor is going to turn him in for doing unnecessary procedures." Once again, when the goings get tough, the defensive medicine argument rears its ugly head. Dr. O'Neill further justifies unnecessary stenting by stating that "[f]or some of these doctors, it was like, 'I'm here, so let me go ahead and put a stent in.'"

One must wonder whether Dr. O'Neill intends to offer the same opinions in court as he has in today's article in the Baltimore Sun. 

At least four studies over the last four years have found that stenting generally is not without some significant risks, even with the most recent development of the drug-alluding stent that was hailed a few years ago by Dr. Midei as the "hottest thing in cardiology in years."

The Baltimore Sun should be commended for its ongoing effort to bring to light the continuing issues related to the actions and possible harm caused by Dr. Midei. Many in the community are understandably perplexed and disappointed that a physician could invade his patients' rights and expose them to such unnecessary risks. Dr. Midei has many supporters, but he has many injured and very concerned patients as well.

Belsky, Weinberg & Horowitz continues to represent patients in medical malpractice cases, including those who have received stents unnecessarily. Please contact the firm for more information.

In an interesting article in today's Maryland Daily Record, the concept of a "Shadow Jury" is discussed. One is presently being used in a multi-month trial in Baltimore City against a hotel operator where 22 plaintiffs are suing for carbon monoxide poisoning.

Shadow juries are rarely used and typically are hired by jury consultants to watch the trial as it transpires to provide daily guidance to the attorneys who hired the consultant about the day's events. The consultants choose prospective shadow jurors to mirror as closely as possible the actual jurors who are selected to sit and hear the case. To what extent those consultants are provided with the real jurors' demographic information contained on the prospective juror pool list used by attorneys in identifying jurors' occupation, level of education, age, and spouse's occupation, is unclear. It is actually questionable whether dissemination of that information to third parties is permissible. What is clear, though, is that the use of a shadow jury is both controversial and not widely accepted.

Some lawyers believe hearing the shadow jury's perspective of the day's events is helpful in readjusting the next day's case presentation, while others find it distracting. What an attorney believes is a smooth, effective presentation or examination of a witness may well turn out to be a useless endeavor in the eyes of shadow jurors. Some attorneys find merit in such real time feedback, while others find it unnerving and potentially harmful.

Some lawyers are very instinctive about the look and feel of the evidence and the jurors' reactions and attentiveness. It is very possible to lose sight of the courtroom dynamic by micro managing the case through the eyes of people who, although paid hundreds of dollars a day to sit and listen, will not be the ultimate decision makers and do not have the vested interest in the outcome of the case as do real jurors.

The size of the shadow jury may vary from one or more hired individuals to a mirror image of the size and "shape" of the jury actually sitting. Many more lawyers use jury consultants to arrange for "mock trials" where a mock jury comprised of paid individuals with similar demographics to the jury likely to sit at an upcoming trial hear the full case presentation in advance and render a verdict. The lawyers can then take their ques from what they hear from the mock jurors about the effectiveness of witnesses, evidence, lawyer demeanor and tactics and readjust their case in advance of opening statements.

This writer is in the camp of lawyers who would not use a shadow jury, as the instinctiveness factors is of paramount importance in understanding how the evidence is being received by the jury. Not only would it be a distraction likely to result in more second-guessing than is already inherent in the trial process, but it may also create a distraction for the real jury who will realize very quickly that they are being watched by a similar group of people whose true role and purpose of being in the courtroom everyday they will not understand until the case is over. 

The attorneys at Belsky, Weinberg & Horowitz regularly litigate large medical malpractice and catastrophic personal injury cases.  Please contact the firm for more information about its lawyers and services.

A Montgomery County jury Thursday afternoon reached a $5.6 million verdict after a nine day medical malpractice case against an osteopath for causing nerve and spinal injuries during a high velocity cervical manipulation performed upon his patient. The claims were brought by Nancy and James Marquez against Hadi M. Rassael, D.O. and Advanced Medical and Cosmetic Group, Inc. The jury deliberated 7 hours before reaching its verdict. Approximately $2.7 million of the award was for past and future lost earnings of Ms. Marquez who was a physical therapist at the time of the improper manipulation, and who was never able to return to her profession due to her nerve and back injuries. Ms. Marquez continues to suffer intractable pain and has undergone two surgeries to repair her damaged brachial plexus and to replace a disrupted disc at level C5-6 in her neck. Approximately $276,000 of the award was for past medical expenses. The remaining $2.5 million was awarded for noneconomic loss to Ms. Marquez and her husband. That award is subject to Maryland's cap on noneconomic loss.   Marquez, et ux, v. Rassael, et al, Case No. 298673-V (Circuit Court for Montgomery Co.).

In February 2005, Ms. Marquez presented to Dr. Rassael's office for purposes of receiving a very light, non-twisting osteopathic manipulation to her hip joint know as "muscle energy technique." Since her days as a Division One swimmer on the Michigan State swim team, and her participation in numerous triathalons, many of which she had won, she suffered from periodic hip pain which was resolved through use of the muscle energy technique. She presented to Defendant Rassael's office after specifically asking whether he was familiar with that technique and was told he was. After arriving at the office, however, the doctor laid Ms. Marquez on an exam table and proceeded to examine her back. When his hands got to the back of her head, he suddenly and without warning twisted her neck in both directions in a forceful manner, causing injury to the nerves in her neck and a rupture of one of her vertebral disks at C5-6. Ms. Marquez, now age 33, has never recovered from her injuries which plague her with pain and muscle atrophy that prevents her from participating in competitive sports of any type. She underwent a brachial plexus decompression surgery and a disk replacement surgery in Germany.

Of significance, during the trial, the defendants intended to call a neuroradiologist, Charles Citrin, M.D., as an expert. Believing Dr. Citrin was a "professional witness" whose opinions were suspect, the plaintiffs sought discovery of Dr. Citrin's financial records to prove he was a "hired gun" expert. After three attempts to obtain this information to no avail, the presiding judge, The Honorable Marielsa Bernard, ordered Dr. Citrin to appear before her. After considering his testimony as to the whereabouts of his financial records as "disingenuous" and his honestly questionable, she refused to allow Dr. Citrin to testify.  This is one of the first reported cases that were are aware of where an expert was stricken for failing to produce financial information as to his/her income as an expert witness.

The plaintiffs were represented by Alan J. Belsky and Valerie A. Grove of Belsky, Weinberg & Horowitz. The Defendants were represented by D. Lee Rutland and Robert S. Morter of Wharton, Levin, Ermantrout & Klein of Annapolis.

This case is an example of the difficult cases Belsky, Weinberg & Horowitz have taken to trial with incredible results. The case also typifies the tenacity of our lawyers in obtaining justice for our clients. Please contact our firm for more information about this case or any questions you may have of our attorneys.

On April 15, 2010, a jury in Baltimore County awarded a Parkville man over $38,000.00 for injuries he sustained as a result of negligent dental care. The jury found that the dentist improperly designed and placed a number of crowns that resulted in an uneven bite and did nothing to repair his gum disease.

The jury deliberated more than 7 hours and during that time informed the judge they were unable to reach a verdict.  Judge S. Ann Brobst gave them an "Allen charge", instructing the jurors to re-examine their views of the evidence.  The verdict encompassed an award of $8,800 in past dental bills (1/2 of the actual bills), $30,000.00 for future care  and only $1.00 for pain and suffering.  The dentist's attorneys have filed a motion for a new trial, arguing the jury's verdict may not have been unanimous and represented a "compromise" on liability.  The plaintiff's attorney said his client was both "vindicated and disappointed" in the verdict, as is will cost between $30,000 and $60,000 to repair the damage caused by the dentist.

The wife and children of a man who died after waiting six hours to be admitted to St. Joseph's Medical Center in Towson were awarded $1.44 million in compensation today, by a jury in Baltimore County.

Thomas Murphy, 59, had gone to Patient First on June 9, 2007, complaining of fever and chills.  He was seen and sent home. The next day, Mr. Murphy presented to St. Joseph's at approximately 5:30 p.m.and was seen by the defendant ER physician who failed to diagnosis sepsis and instead gave him an antibiotic and a liter of IV fluids for suspected pneumonia. A CT scan was performed which the family argued, would have shown Mr. Murphy did not have pneumonia by 8:30 that evening.  For reasons that were never explained by the defendant, Murphy remained in the ER until after midnight.  Despite being transferred to the intensive care unit at 3 a.m the next day, and going to surgery 11 hours after that to attempt to discover the source of the sepsis, Murphy died of septic shock the next afternoon.

The defendant maintained that once he called the hospital's admitting floor physician at 9:10 p.m. the night Murphy came to the hospital, Murphy was no longer his responsibility and that the ER nurses failed to communicate the patient's worsening condition to him.

Murphy's widow was awarded economic damages of $840,000.00, which included future lost wages, and $300,000.00 for her pain and suffering. His children were each awarded $100,000.00, as was his estate.  The physician at Patient First, the hospital and the floor doctor all settled before trial for confidential amounts. An appeal by the defendant may be filed for, among other reasons, the family's refusal to disclose the prior settlements with the remaining ER physician defendant.  The defendant argued he had the right to know the amounts of these settlements prior to trial.

Ordinarily, the benefit of receiving a cardiac stent far outweighs the risks of stent surgery and the necessary postoperative treatment. There are however sizeable risks to consider if you are fortunate enough to have the time and accurate information about your condition to do so. Recently, more than 500 patients at St. Joseph's Medical Center in Towson, Maryland were advised they may have received cardiac stents unnecessarily and to consult with their private physicians. These patients didn't have the time to realize they didn't need the stents to begin with and are now faced with questions about their medical future.

Stents when needed do save lives. They are deployed to open clogged arteries and allow greater blood flow to the heart. The need for a stent is based in part on the level of occlusion or interruption of normal blood flow in the particular vessel at issue. Some vessels are primary and are thus critically important to the heart's vitality and need good blood flow at all times. Other vessels are secondary or "collateral" and a blockage there is less significant and often requires no treatment.

Approximately 30 percent of stent patients form scar tissue around the stent. Over time, the scar tissue captures plague that flows naturally through the vessels and is what usually has caused the clot formation necessitating the stent placement. Studies have show that a second clot or blockage is more likely to occur at the stent site than in other portions of otherwise smooth vessel. Many interventional cardiologists who perform stenting procedures now use a "drug eluting" stent, which slowly emits a drug over time to prevent or diminish the scarring and clotting that may occur at the stent site. Because these drug eluting stents are relatively new to the market, the long term consequences to patients is uncertain. Indeed they are FDA approved, but as we have seen in other drug recall cases, FDA approval does not guarantee safety.

A clot that forms in a vessel may travel to the lungs or the brain and cause an embolism or stroke. These events are frequently life threatening and can, at minimum, change significantly the quality of a patient's life. Patients usually are prescribed blood thinning agents such as Plavix ® after stent surgery to prevent clots and stroke. Again, although FDA approved, the long term use of such drugs may cause complications and may interfere with the need for emergency surgery should that become necessary. Surgeons must deal with those on blood thinners and must take emergency action to normalize the patient's coagulation factor before operating. Otherwise, a patient may bleed to death on the operating table.

Allergic reactions have also been reported following stent surgery. One study conducted by researchers at Northwestern Memorial Hospital found instances of reactions to the polymer used in the stents and reported instances of severe complications and death. An allergic reaction such as those reported may require premature discontinuance of the anti-coagulation drugs such as Plavix®, which can cause other complications.

Weill Cornell Medical College has an excellent online resource for questions about stents. We encourage our readers to review that site and its references for further information.

The lawyers at Belsky, Weinberg & Horowitz, LLC are representing individuals with claims against St. Joseph's Medical Center and Dr. Mark Midei.