Kaylor v. Arrisueno

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APRYL KAYLOR ET AL., Plaintiffs, v. JUAN A. ARRISUENO, M.D. ET AL., Defendants.

CIVIL No. 21-01164-BAH

United States District Court, D. Maryland

May 8, 2024

MEMORANDUM OPINION

Brendan A. Hurson United States District Judge

This is a medical malpractice case arising out of Plaintiff Apryl Kaylor's onset of necrotizing fasciitis of the left arm and the alleged negligence of medical professionals at the UPMC Western Maryland Corporation (the "UPMC Hospital"), whose medical decisions allegedly resulted in a delay in Ms. Kaylor receiving the correct diagnosis and required surgical intervention.^[1] ECF 1, at 5-8 ¶¶ 10-17. Ms. Kaylor and her spouse, Stephen Kaylor, brought suit against numerous medical professionals at the UPMC Hospital and the UPMC Hospital itself, alleging Defendants' negligent failure to diagnose Ms. Kaylor's necrotizing fasciitis caused her. permanent disability and loss of consortium^[2] to Mr. Kaylor. Id. at 4, 17.

Defendants include Juan A. Arrisueno, M.D. ("Dr. Arrisueno") Robert Daniel Flint, Jr., M.D. ("Dr. Flint"), Pete Allen Kuhn, NP-C ("Mr. Kuhn"), Ravi Teja Pilla M.D. ("Dr. Pilla"), Diana L. Pepe, CRNP ("Ms Pepe"), Christine Sensabaugh, M.D. ("Dr. Sensabaugh"), Rameet Thapa, M.D. ("Dr. Thapa"), Richard O. Addo, M.D. ("Dr. Addo"), Mohammed Zulfequar Ali, M.D. ("Dr. Ali"), and the UPMC Hospital. ECF 1, at 1.

All the above Defendants, except Dr. Arrisueno, Dr. Thapa, and the UPMC Hospital, brought the present motion for summary judgment. ECF 86; ECF 89-1, at 6 n.l. For simplicity, I will refer to the movant Defendants of ECF 86 (Drs. Flint, Pilla, Sensabaugh, Ali, and Mr. Kuhn and Ms. Pepe) as "Movants." Pending before the Court is Movants' Motion for Summary Judgment (the "Motion"). ECF 86. Plaintiffs filed an opposition, ECF 89, and Movants filed a reply, ECF 90. All filings include memoranda of law and exhibits.^[3] I have reviewed all relevant filings and find that no hearing is necessary. See Loc. R. 105.6 (D. Md. 2023). For the reasons stated below, Movants' Motion is DENIED.

I. BACKGROUND

Necrotizing fasciitis is a deep soft tissue infection, ECF 86-1, at 5, that is "a Class 1 emergency," which, as defined by one of Plaintiffs' experts, is an emergency in which "life and limb are at stake." ECF 89-30 (Dr. Freed deposition), at 3, 75:10-12. Its fast progression requires surgical intervention and "[t]he earlier you operate the less tissue there is lost and the more likely it is that the patient will return to full function in the future." Id. at 4, 86:5-8; ECF 89-29 (Dr. Freed declaration) ¶9; ECF 86-1, at 5 (conceding as such). Ms. Kaylor's expert witnesses will opine that the standard of care for this condition requires a medical professional, upon a reasonable suspicion of the condition, to order urgent imaging and an emergency surgical consultation. See, e.g., ECF 89-26 (Dr. Takhar deposition), at 3, 84:7-13. The experts will opine that a reasonably prudent medical professional would have had a "high suspicion for [necrotizing fasciitis]" based on Ms. Kaylor's clinical and laboratory presentation and that a reasonably prudent medical professional would have acted quickly to assess and diagnose the condition. See, e.g., ECF 89-25 (Dr. Alan Van Opstal deposition), at 3, 73:17-21; ECF 89-27 (Dr. Itskowitz deposition), at 12, 126:9-12.

As the timeline of Ms. Kaylor's necrotic infection is important to Movants' causation arguments, I will briefly summarize the four days of treatment Ms. Kaylor received at UPMC Hospital, followed by Ms. Kaylor's eventual surgical treatment at a different hospital on the fifth day.

A. April 7,2020: Ms. Kaylor is admitted to the emergency room displaying signs of necrotizing fasciitis.

On April 7, 2020, at 10:57 a.m., Ms. Kaylor presented to UPMC Hospital with complaints of left-hand swelling, pain, and an inability to move her fingers. ECF 1, at 8 ¶ 18. Ms. Kaylor indicated that she had begun experiencing these symptoms for three days prior to visiting the emergency room and that her symptoms had progressively worsened. Id. Ms. Kaylor's expert witness, Dr. Jeffrey Freed, will opine that that Ms. Kaylor "had necrotizing fasciitis at the time she presented to [UPMC Hospital]," ECF 89-29 ¶ 8, and that she should have received surgery on or about the 7th, or immediately thereafter, ECF 89-30, at 5, 97:14-98:14.

Ms. Kaylor was first examined by Mr. Kuhn, a registered nurse practitioner and expert in emergency medicine. ECF 1, at 8 ¶ 18; ECF 86-2, at 1 (Mr. Kuhn notes). Mr. Kuhn noted "red streaking up the volar aspect [or palm side] of [Ms. Kaylor's] left arm extending to the elbow," as well as "redness," "swelling of [her] left hand" and the appearance of "bullae [or blisters] to the left hand," ECF 86-2, at 1-2.^[4] Mr. Kuhn also observed "lymphangitis that extended] from the hand up to the elbow," and decreased movement with normal sensation of the fingers.^[5] Id. Mr. Kuhn documented that Dr. Flint, an expert in emergency medicine, "contacted the hospitalist and discussed [Ms. Kaylor] with him." Id. Dr. Flint also examined Ms. Kaylor, ECF 89-6 (Dr. Flint notes), and ordered "appropriate diagnostic testing." ECF. 86-2, at 4. Ms. Kaylor's "Final [Emergency Department] Diagnosis" was: "Fever[,] Leukocytosis[,] Left hand vasculitis[,] and] Left hand cellulitis."^[6] Id. Ms. Kaylor was admitted for further treatment. Id.

Plaintiffs allege that Ms. Kaylor's clinical presentation was "consistent with necrotizing fasciitis, which should have been included on a differential diagnosis and pursued."^[7] ECF 1, at 9 ¶ 19. However, neither Dr. Flint nor Mr. Kuhn obtained a STAT^[8] surgical consultation, a STAT CT^[9] or an MRI scan.^[10] Id.; see also ECF 86-2, at 1-4; ECF 89-6, at 2. Dr. Alan Van Opstal will. opine that Dr. Flint and Mr. Kuhn breached the applicable standard of care in this manner. ECF 89-25, at 5, 95:9-15; see also ECF 89-26, at 3-4, 84:4-97:17 (opining that Mr. Kuhn and Dr. Flint breached the standard of care in the same manner).

At 2:05 p.m. on April 7, 2020, after Ms. Kaylor was moved to a different unit, she was examined by Dr. Pilla, an expert in hospital medicine. ECF 1, at 9 ¶ 20; ECF 89-7 (Dr. Pilla notes). Dr. Pilla noted Ms. Kaylor's past medical history, her laboratory results, and her clinical condition in the emergency department before opining that Ms. Kaylor was "[s]ep[tic] [with] no clear source of infection." ECF 89-7, at 2, 5. Dr. Pilla suspected that her "leukocytosis ... could be reactive secondary to a [venous thromboembolism]." Id. at 5. Dr. Pilla indicated her condition was "very concerning for DVT" so he placed her on "Lovenox for therapeutic anticoagulation."^[11] Id. Dr. Pilla ordered an "upper extremity duplex, [which was] negative," and a "chest X-ray." Id. Dr. Pilla planned to "have [Ms. Kaylor] on broad-spectrum antibiotics," "[c]ontinue IV fluids," and "avoid [radiographic] contrast until further improvement in [Ms. Kaylor's] kidney function." Id. Dr. Pilla's notes do not indicate that he suspected necrotizing fasciitis. Id. Further, Dr. Pilla's notes indicate he did not order CT imaging of Ms. Kaylor's arm, or a surgical consultation. See id.

Plaintiffs allege that Dr. Pilla breached the applicable standard of care by failing to evaluate, assess, diagnose, and treat Ms. Kaylor for necrotizing fasciitis when she presented with signs and symptoms of this illness. ECF 1, at 5 ¶ 10,10 ¶ 22. Plaintiffs'.expert Dr. Itskowitz will opine that Dr. Pilla breached the standard of care in this manner. ECF 89-27, at 5, 77:14-78:1.

B. April 8,2020: Ms. Kaylor's symptoms worsen and a CT scan is ordered, though not on a STAT basis.

On April 8, 2020, Ms. Kaylor was examined by Dr. Sensabaugh, an expert in hospital medicine. ECF 1, at 10 ¶ 23; ECF 89-8 (Dr. Sensabaugh dictation). Dr. Sensabaugh concluded that Ms. Kaylor was suffering from "[s]epsis secondary to cellulitis." ECF 89-8, at 3. Dr. Sensabaugh requested "consultations] with infectious disease as well as plastics." Id. Dr. Sensabaugh indicated Ms. Kaylor "may benefit at least from a CT, but. .. [that Dr. Sensabaugh] w[ould] discuss with Infectious Disease and plastics first." Id. Pursuant to Dr. Sensabaugh's consultation request, during the afternoon of April 8, 2020, Ms. Kaylor was examined by Dr. Thapa, an expert in infectious disease medicine. ECF 1, at 10-11 ¶ 24. Plaintiffs allege Dr. Sensabaugh "negligently failed to request a STAT surgical consultation, negligently failed to order a STAT CT while waiting for surgery to arrive, and negligently failed to rule in or rule out the necrotizing fasciitis from which [Ms. Kaylor] suffered." ECF 1, at 10 ¶ 23.

Dr. Thapa observed Ms. Kaylor's worsening symptoms which included "constant, severe pain and redness of her entire upper extremity which was exacerbated by movement." Id. at 11 ¶ 24. Dr. Thapa noted "prominent blister formation and erythematous patches on [Ms. Kaylor's] left hand." Id. Finally, he noted that Ms. Kaylor continued to be febrile, tachycardic, tachypneic, and hypotensive despite the administration of antibiotics.^[12] Id. Dr. Thapa opined that Ms. Kaylor had "sepsis secondary to left upper extremity cellulitis," and planned to continue the antibiotic coverage. Id. Additionally, Dr. Thapa was the first medical professional to consider the possibility that Ms. Kaylor's condition could be necrotizing fasciitis and recommended a CT scan. Id. Ms. Kaylor alleges Dr. Thapa negligently failed to recommend that imaging study on a STAT basis and failed to recommend a STAT surgical consultation.^[13] Id.

After Dr. Thapa's consultation, at approximately 3:30 p.m.; Dr Sensabaugh ordered a CT scan of Ms. Kaylor's left forearm. Id. ¶ 25. Dr. Sensabaugh allegedly failed, however, to order the CT scan on a STA...