Defendant's Attorney: Barbara Murcier Bowens

Description: Florence, South Carolina personal injury lawyer represented Plaintiff, who sued Defendant United States of America on a Government Tort Claims Act theory.


Plaintiff Loretta Gilbert, as the Personal Representative of the Estate of Anthony Lamont Johnson and on behalf of the wrongful death beneficiaries, for medical malpractice against The United States of America. The Plaintiff filed this action pursuant to the Federal Tort Claims Act (“FTCA”), 28 U.S.C. § 2671, et seq. The Plaintiff alleges that Anthony Lamont Johnson's (“Johnson”) death was caused by the negligent acts and medical malpractice of Victoria Ramsey (“Ramsey”), a certified adult gerontology nurse practitioner, and Dr. Jude Onuoha (“Dr. Onuoha”), a correctional medicine physician, with the Bureau of Prisons (“BOP”). A bench trial was held from April 27, 2022 to April 28, 2022. In addition, the parties submitted post-trial proposed findings of fact and conclusions of law. Further, the Plaintiff submitted a document titled


1. In January 2017, Johnson was 35 years old and an inmate incarcerated in the BOP at the Federal Correctional Institute - Bennettsville in Bennettsville, South Carolina. Johnson was serving a 15-year sentence.

2. During his initial BOP medical exam on July 18, 2012, Johnson was found to have benign essential hypertension. (J. Ex. 1, Gilbert118 - Gilbert127.)[1]To treat his hypertension, Johnson was prescribed Hydrocholorothiazide (“HCTZ”), Lisinopril, and Metoprolol. (Id., (Gilbert118).) In addition, an electrocardiogram (“EKG”) was ordered. The EKG results, which were read by a computer, were labeled abnormal due to an inverted T-wave. (Id., (Gilbert207).) Johnson's heart rate was documented as 58 beats per minute in the EKG. (Id., (Gilbert207).)

3. During Johnson's years in the BOP, Johnson was not evaluated by a cardiologist. (Tr. Trans. Vol. 2 at 47, ECF No. 75.) However, Johnson was monitored with periodic visits to the chronic care clinic. Johnson's medical records reflect that with the exception of a time period in 2015 when Johnson was noncompliant with his hypertension medications, his blood pressure was well controlled with medication. (J. Ex. 1, (Gilbert235, Gilbert298, Gilbert309, Gilbert347, Gilbert427).) Johnson's lab work from January 7, 2015, showed elevated cholesterol of 231. (J. Ex. 1, (Gilbert382).) In addition, Johnson's medical records reflect a

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history of smoking. (Id. (Gilbert153).) A subsequent EKG on August 18, 2015, did not show any inverted T-wave, but was labeled abnormal heart rate of 45 due to bradycardia, which is a low heart rate. (Id. (Gilbert437, Gilbert467).) A heart rate below 60 is labeled as bradycardia. (Tr. Trans. Vol. 1 at 43, ECF No. 74.)

4. Johnson was transferred from another BOP facility to FCI - Bennettsville on March 10, 2016. (J. Ex. 1, (Gilbert452).) Dr. Onuoha has been employed as a correctional medicine physician for the BOP for approximately the last thirteen (13) years. (Tr. Trans. Vol. 2 at 5, ECF No. 75.) Dr. Onuoha has been at FCI - Bennettsville since 2015. (Id., ECF No. 75.)

5. Dr. Onuoha testified that when an inmate presents for medical treatment, before addressing an inmate's present issue, he undertakes the following procedure: identify the inmate by comparison to the identification card, review the health problem list, check allergic history, review medications, and review prior visits. (Id. at 8-9, ECF No. 75.) Dr. Onuoha independently recalled that Johnson was an athletic, young man. (Id. at 12-13, ECF No. 75.)[2]

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6. March 17, 2016 was the first time Dr. Onuoha examined Johnson. On March 17, 2016, Dr. Onuoha performed a required intake evaluation of Johnson subsequent to his transfer to FCI - Bennettsville. (J. Ex. 1 (Gilbert389 - 391).) Dr. Onuoha's medical record reflects that Johnson had diagnoses for unspecified anemia, hyperlipidemia (elevated cholesterol), and benign essential hypertension. Further, the record reflects that Johnson was compliant with his hypertension medications. (Id. (Gilbert389 - 391).)

7. Dr. Onuoha testified that he recalled that Johnson had isolated systolic high blood pressure, meaning that Johnson had an elevation only in the systolic pressure, which was considered stage one hypertension and was not severe. (Tr. Trans. Vol. 2 at 13, ECF No. 75); (J. Ex. 1 (Gilbert390).) Dr. Onuoha testified that stage one hypertension is 140 over 90 to 150 over 99. (Tr. Trans. Vol. 2 at 58-59, ECF No. 75.) Dr. Onuoha testified that he discontinued Johnson's Metoprolol and HCTZ and increased the Lisinopril dosage to treat Johnson's hypertension in order to obtain optimal dosing with one medication as opposed to three, which would improve compliance. (Id. at 14-15, 17-18, ECF No. 75.) (J. Ex. 1, (Gilbert391).) In addition, Dr. Onuoha testified that he had discontinued Metoprolol because Johnson's 2015 EKG showed bradycardia with a heart rate of 45, and Metoprolol is known to lower the heart rate. (Tr. Trans. Vol. 2 at 16-17, ECF No. 75.) Further, Dr. Onuoha testified that he had discontinued HCTZ because Johnson did not like that it was causing him to urinate frequently. (Id. at 18, ECF No. 75.)

8. Dr. Onuoha testified that he also reviewed Johnson's 2013 EKG and concluded that it was not abnormal, noting that the T-wave inversion present in the 2013 EKG was not present in the 2015 EKG, and the abnormal result was likely caused by the misplacement of the leads.

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(Id. at 15-16, 43-44, ECF No. 75.) Dr. Onuoha noted that the EKGs were interpreted by a computer. (Id. at 43, ECF No. 75.)

9. On October 12, 2016, Dr. Onuoha examined Johnson in the chronic care clinic and noted that Johnson was compliant with his hypertension medication. (J. Ex. 1 (Gilbert489).) Johnson's heart rate and blood pressure were normal. (Id. (Gilbert489).) Dr. Onuoha ordered lab work and a chest X-ray to check for cardiomegaly, which is an enlarged heart, because Johnson had unexplained anemia and an S3 heart sound.[3] (Id. (Gilbert491).); (Tr. Trans. Vol. 2 at 19, ECF No. 75.)

10. The chest X-ray revealed a mildly enlarged heart. (J. Ex. 1 (Gilbert536).) Dr. Onuoha testified that a mildly enlarged heart is common and was not a reason for Johnson to return for an evaluation immediately. (Tr. Trans. Vol. 2 at 20, ECF No. 75.) In addition, Dr. Onuoha testified that Johnson's high cholesterol did not qualify for any treatment with medication because of his age, and that the appropriate treatment was diet and exercise, with which Johnson was doing well. (Id. at 21-22, ECF No. 75.)

11. On January 28, 2017, Johnson presented to sick call and was seen by Ramsey, a certified nurse practitioner with eight years experience. (J. Ex. 1 (Gilbert485).) Johnson complained of nausea, vomiting, diarrhea, and abdominal pain in the epigastric region spanning over the previous twelve hours, beginning two to three hours after his last meal. (Id. (Gilbert485).) In addition, he complained of low back pain. (Id. (Gilbert485).) He reported his pain level was a ten on a ten-point scale. (Id. (Gilbert485).)

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12. Ramsey's physical exam of Johnson noted normal vital signs with epigastric tenderness. (Id. (Gilbert485).) Ramsey diagnosed Johnson with low back pain and unspecified abdominal pain and ordered 800 milligrams of Ibuprofen three times a day with meals, a single dose Promethazine suppository for nausea and vomiting, and a one-time 30 milligram injection of Toradol for pain. (J. Ex. 1 (Gilbert485).) Ramsey further advised Johnson to return for further evaluation if his symptoms did not improve. (Id. (Gilbert485).)

13. Ramsey testified that on January 28, 2017, Johnson was ambulatory and reported pain, primarily in the abdomen, and that his condition did not appear to be emergent. (Tr. Tans. Vol. 1 at 139-40, ECF No. 74.) Further, she testified that she reviewed his medical history, medications, and prior medical visits. In addition, she testified that she reviewed his commissary list to evaluate whether any foods might be an issue, “especially him with his hypertension.” (Id. at 141, ECF No. 74.) In addition, Ramsey testified that she listened to his bowel sounds, which also allowed her to hear heart sounds. She testified that she did not hear any “bruits, ” whooshing sounds that indicates that blood is not moving normally through the aorta. (Id. at 144, 154, ECF No. 74.) Further, she did not consider Johnson's very mildly elevated blood pressure of 148 over 60 to be alarming because of Johnson's prior hypertension diagnosis. (Id. at 149, ECF No. 74.)

14. Two days later, on January 30, 2017, Johnson presented to sick call at 9:34 a.m. Johnson's sick call request listed “stomach” as his medical problem. (J. Ex. 1 (Gilbert514).) Johnson was seen by Dr. Onuoha. (J. Ex. 1 (Gilbert481).) Johnson's blood pressure was 151 over 57. (Tr. Trans. Vol. 2 at 23, ECF No. 75.); (J. Ex. 1, (Gilbert514.) Dr. Onuoha testified that he was very familiar with Johnson and aware of his chronic medical conditions. (Tr. Trans.

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Vol. 2 at 25, ECF No. 75.) Ramsey informed Dr. Onuoha that she had seen Johnson on January 28, 2017. (Id. at 25, ECF No. 75.) Johnson complained that he had been vomiting all week. (J. Ex. 1 (Gilbert481).); (Tr. Trans. Vol. 2 at 25-26, ECF No. 75.) Further, Johnson reported that he passed a hard stool thirty minutes prior to the sick visit but otherwise had not had any bowel movements the previous two days. (J. Ex. 1 (Gilbert481).) He complained of continuing pain in the left flanks, [4] epigastric, and hypogastric areas of the abdomen that had not responded to pain medication. (Id. (Gilbert481).) Johnson reported that the epigastric pain was worse with deep breathing and that his pain level was a nine out of ten. (Id. (Gilbert481).)

15. Dr. Onuoha observed that Johnson was in pain. (Tr. Trans. Vol. 2 at 26, ECF No. 75.) Johnson's blood pressure was mildly elevated, his heart rate was 49 and 52, and his temperature was 98.4. (Id. at 23, 27, ECF No. 75.); (J. Ex. 1 (Gilbert482).) The medical record reflects that Johnson told Dr. Onuoha that he had not taken his hypertension medication that day. (J. Ex. 1 (Gilbert484).) Dr. Onuoha testified that he listened to Johnson's lungs and performed a cardiac examination and did not hear anything different from his October 12, 2016 examination. (Tr. Trans. Vol. 2 at 27-28, 40, ECF No. 75.) Dr. Onuoha testified that Johnson's primary complaint was pain in the epigastric region of the abdomen, and he believed that the Ibuprofen Johnson was taking for pain may have been irritating his stomach. (Id. at 27-28, ECF No. 75.)

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Dr. Onuoha testified that he examined Johnson's abdomen and ruled out appendicitis, as there was no rebound tenderness. (Id. at 28, ECF No. 75.) Dr. Onuoha prescribed Magnesium Hydroxide Suspension, also known as Milk of Magnesia, for Johnson to soothe his stomach. (Id., ECF No. 75.); (J. Ex. 1 (Gilbert483).)

16. After taking the Milk of Magnesia, Dr. Onuoha testified that Johnson was comfortable and at rest. (Tr. Trans. Vol. 2 at 28, ECF No. 75.) Dr. Onuoha decided to order some additional lab tests. (Id., ECF No. 75.) Dr. Onuoha ordered a urinalysis, chest X-ray, abdominal X-ray, blood work (complete metabolic profile), and urinalysis. In addition, Dr. Onuoha ordered that Ibuprofen be discontinued and replaced with Tylenol. (J. Ex. 1 (Gilbert483).) Dr. Onuoha testified that the BOP medical chart system, “BEMR, ” does not allow entry of differential diagnoses, which are potential diagnoses that a physician is considering. (Tr. Trans. Vol. 2 at 30, ECF No. 75.); (Tr. Trans. Vol. 1 at 296, ECF No. 74.)

17. Following the examination and administration of Milk of Magnesia, Dr. Onuoha testified that he asked Johnson to wait in the clinic waiting room for the results of the tests. (Tr. Trans. Vol. 2 at 31, ECF No. 75.)

18. According to the medical records, at 11:21 a.m., the results of the chest X-ray were transmitted and at 11:31 a.m. on January 30, 2017, Dr. Onuoha reviewed Johnson's chest X-ray, which found mild heart enlargement with no change from the previous chest X-ray taken October 27, 2016. (J. Ex. 1 (Gilbert529 - 530).) Johnson's chest X-ray showed normal mediastinal and hilar contours. (Id. (Gilbert529 - 530).)

19. At 12:32 p.m. the results of the abdominal X-ray were transmitted and at 1:21 p.m. on January 30, 2017, Dr. Onuoha reviewed the abdominal X-ray, which noted no significant

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findings. (Id. (Gilbert527 - 528).) In addition, Dr. Onuoha reviewed the urinalysis, which revealed dehydration and a moderate amount of blood in Johnson's urine. (Tr. Trans. Vol. 2 at 33, ECF No. 75.)

20. After reviewing the abdominal X-ray, Dr. Onuoha spoke with Johnson and informed him that the test results that had been received at that point were fine. (Id. at 32, ECF No. 75.) Dr. Onuoha testified that he observed that Johnson had eaten his lunch. (Id. at 32, 36, ECF No. 75.) Further, Dr. Onuoha asked Johnson how he was feeling and Johnson reported that he felt better. (Id. at 32, ECF No. 75.) Dr. Onuoha testified that Johnson was hemodynamically stable and was able to rehydrate orally at this point. (Tr. Trans. Vol. 2 at 34, ECF No. 75.) Dr. Onuoha instructed Johnson to return to his unit and return to medical if he had any more problems. (Id. at 32, ECF No. 75.) The blood work results were not available until January 31, 2017. (J. Ex. 1 (Gilbert515).)

21. At 5:04 p.m. on January 30, 2017, a medical emergency was called to Johnson's housing unit. Johnson was found unresponsive, but still breathing. (Id. (Gilbert475).) Staff performed cardiopulmonary resuscitation (“CPR”). Upon arrival, emergency medical staff took control and initiated transport of Johnson. Johnson was transported to McLeod Health Cheraw Hospital. Johnson was pronounced dead at 5:51 p.m. on January 30, 2017. (Id. (Gilbert475).) The autopsy report found that Johnson's cause of death was cardiac tamponade due to ruptured aortic dissection due to hypertensive cardiac disease. (Id. (Gilbert538-541).)

22. An aortic dissection is rare and occurs when the inner layer of the aorta tears and allows blood to enter the middle layer of the aorta. (Tr. Trans. Vol. 1 at 31, ECF No. 74.) It usually

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occurs in the older population. The aorta is the large vessel that consists of the ascending aorta where the vessel leaves the heart and the descending thoracic aorta located in the chest area. (Id. at 33, ECF No. 74.) An aortic dissection is an emergent condition because it can rupture at any time, which is fatal. (Id. at 32-33, 38-39, 58, 91, ECF No. 74.) It is undisputed that a computed tomography (“CT”) scan is the best imaging for diagnosing an aortic dissection. (Id. at 35, ECF No. 74.) Cardiac tamponade is a condition in which fluid collects around the heart, compressing the heart and preventing it from adequately pumping. (Tr. Trans. Vol. 2 at 68, ECF No. 75.)

23. Dr. Charles Harr (“Dr. Harr”), Chief Medical Officer of WakeMed Health and Hospital in Raleigh, North Carolina, is a practicing cardiovascular thoracic surgeon and is board certified in surgery and thoracic surgery. (Tr. Trans. Vol. 1 at 23, ECF No. 74.) In addition, Dr. Harr had a career in the United States Navy Reserves and was the 18th Medical Officer of the Marine Corps for the United States Navy. (Id., ECF No. 74.)

24. Dr. Harr testified as an expert for the Plaintiff. Dr. Harr offered all of his opinions to a reasonable degree of medical certainty. Dr. Harr testified that Ramsey did not deviate from the standard of care on January 28, 2017. (Id. at 61, ECF No. 74.)

25. Dr. Harr testified that Dr. Onuoha deviated from the standard of care in not documenting a cardiac exam and in not ordering a CT scan on January 30, 2017, when Johnson was seen at 9:30 a.m. (Id. at 36-37, 65, 67, ECF No. 74.) In addition, Dr. Harr testified that Dr. Onuoha breached the standard of care in not ordering a CT scan after receiving test results on January 30, 2017. (Id. at 78-79, ECF No. 74.)

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26. Dr. Harr testified that Johnson exhibited signs and symptoms of an aortic dissection “mainly on his description of his pain and the severity of his pain, ” which is the most widely observed symptom of aortic dissection. (Tr. Trans. Vol. 1 at 34, 37, 39, ECF No. 74.) Further, Dr. Harr testified that back pain is the most common symptom, but that abdominal pain can also occur with an aortic dissection. (Id. at 50, ECF No. 74.) Dr. Harr testified that Johnson primarily complained of abdominal pain, but also complained of back pain. (Id. at 85-88, ECF No. 74.) In addition, Dr. Harr testified that Johnson had prior risk factors for aortic dissection including a history of smoking, hypertension, and high cholesterol. (Id. at 38, ECF No. 74.)

27. Dr. Harr testified that advanced imaging, such as a CT scan, is always required to diagnose an aortic dissection. (Id. at 34, ECF No. 74.) Further, he agreed that many other potential conditions are more common than an aortic dissection. Specifically, Dr. Harr testified as follows:

[Aortic dissections] are usually diagnosed incidentally. Most of us don't look at somebody and say, you have got an aortic dissection. But what we did say is that you have pain out of proportion to what you are showing with, and we really can't explain why that is. So, somebody comes in, we have gone through all of the normal things, you know, a 35-year-old who comes in, we are going to think of, one, the blood clot that has gone to the chest and causing pain; two, a kidney stone, . . . there [are] lots of things more common than what an aortic dissection is. But as we go down that list and we don't find those things, we say something is not right, and we keep looking until we find it.

(Tr. Trans. Vol. 1 at 34, ECF No. 74.)

28. Dr. Harr testified that he agreed that Dr. Onuoha was considering differential diagnoses, which is reflected by Dr. Onuoha's ordering X-rays, urinalysis, and blood work, but “would have liked to have seen them order the next test, which would have been a CAT scan to see this.” (Id. at 67, ECF No. 74.) Dr. Hass testified that a chest X-ray is of limited use for

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evaluating a potential aortic dissection. Dr. Harr testified that “very rarely” the mediastinum will show widening on X-ray, which is a sign of an aortic dissection, but that “you have got to have a really good radiologist and it has to be a really big dissection or aneurysm.” (Id. at 69, ECF No. 74.)

29. Dr. Harr opined that Johnson's aortic dissection occurred on January 28, 2017, and his aorta ruptured at 5:04 p.m. on January 30, 2017. (Id. at 58, ECF No. 74.) Dr. Harr testified that Johnson had an 80 to 90 percent chance of survival if he had the CT scan and surgery was performed prior to the rupture of his aortic dissection. (Id.. at 59, 79, ECF No. 74.) Further, Dr. Harr testified that he was not familiar with the BOP procedures for obtaining a CT scan or how long it would take to obtain a CT scan and interpret the results. (Tr. Trans. Vol. 1 at 71, 93-94, ECF No. 74.) Dr. Harr testified that the hospital is approximately an hour away from FCI-Bennettsville. (Id. at 92, 96, ECF No. 74.) Further, Dr. Harr testified that timing of the CT scan is important. (Id. at 80, ECF No. 74.) Dr. Harr testified that a stat CT scan would have been performed within an hour of arriving in the hospital emergency department, and the actual CT scan would take approximately 30 minutes to perform. (Id. at 95-96, ECF No. 74.) In addition, Dr. Harr testified that a radiologist would read the CT scan and upon diagnosing an aortic dissection, contact cardiac thoracic surgery to review the CT scan. (Id. at 94, ECF No. 74.) Then, Dr. Harr testified that a cardiac team would need to be assembled for surgery, which would take an unknown period of time. (Tr. Trans. Vol. 1 at 89, 94, ECF No. 74.) Dr. Harr testified that during working hours if the cardiac team is present, a patient can be in the operating room and ready for surgery within 30 minutes. (Id. at 99, ECF No. 74.) Dr. Harr stated that Mcleod Regional Medical Center, in Florence, South Carolina currently has

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cardiothoracic surgeons on staff. (Id. at 96, ECF No. 74.) However, he stated that he did not know if the hospital had cardiothoracic surgeons on staff in 2017. (Id. at 100, ECF No. 74.) Further, Dr. Harr testified that the surgery itself would take an unknown period of time to perform. (Id. at 95, ECF No. 74.) Dr. Harr testified that Dr. Onuoha proximately caused Johnson's death because “at the time he came back on the 30th, there should have been urgency attached to that evaluation and we should have gone through on that. So, I do believe that his actions on the 30th [of January] contributed to [] Johnson's death, led to [] Johnson's death.” (Tr. Trans. Vol. 1 at 83, ECF No. 74.)

30. Dr. Susan Lawrence (“Dr. Lawrence”) testified via zoom from California as an expert for the Plaintiff. Dr. Lawrence is board certified in internal medicine and oncology. (Id. at 156, ECF No. 74.) In addition, Dr. Lawrence served as a staff physician and medical director at a federal immigration detention center for a period of three years from 2013 to 2016. (Id., ECF No. 74.) She testified that all of her opinions were to a reasonable degree of medical certainty. (Id. at 159-60, ECF No. 74.)

31. Dr. Lawrence opined that Ramsey violated the standard of care on January 28, 2017, in failing to conduct a cardiac exam and failing to schedule Johnson to return for reevaluation the following day, because his cardiovascular history should have raised her “index of suspicion” that his complaints “may be related to an underlying cardiovascular issue.” (Id. at 171-172, 174, ECF No. 74.)

32. Dr. Lawrence testified that Dr. Onuoha violated the standard of care in not conducting a cardiac exam. (Tr. Trans. Vol. 1 at 172, ECF No. 74.) Dr. Lawrence testified that Dr. Onuoha failed to properly consider Johnson's cardiac history and fully assess Johnson's clinical picture

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based on his failure to document a cardiac exam, consider Johnson's history of “substantial” cardiovascular disease, and consider any differential diagnoses. (Id. at 180-81, 187-88, 195, ECF No. 74.) Dr. Lawrence opined that if something is not documented in the record, it did not happen. (Id., at 205-06, ECF No. 74.) Dr. Lawrence further opined that Dr. Onuoha breached the standard of care in failing to immediately send Johnson to the hospital emergency department on January 30, 2017, instead of waiting on test results upon seeing Johnson at 9:30 a.m and learning that his pain had not improved. (Id. at 189, 191, 195, 213, ECF No. 74.) 33. Dr. Lawrence based her opinions on her more than 45 years of medical practice and her training and experience in correctional medicine. (Id. at 213, ECF No. 74.) Dr. Lawrence testified that Johnson's prior medical history reflected substantial cardiovascular disease, including multiple abnormal EKGs, substantial bradycardia, an enlarged heart, and an abnormal heart sound, and substantial risk factors for cardiovascular disease and aortic dissection, including hypertension, a history of smoking, and high cholesterol. (Tr. Trans. Vol. 1 at 184-86, ECF No. 74.)

34. Dr. Lawrence testified that the fact that Johnson was taking three medications at one point for hypertension reflects that his hypertension was difficult to manage. (Id. at 165, ECF No. 74.) Dr. Lawrence testified that any heart rate below 60 is “substantial or severe” bradycardia. (Id. at 182, ECF No. 74.) Dr. Lawrence agreed that Johnson's heart rate at the October 12, 2016 visit was not substantially slow at 60 beats per minute, and on January 28, 2017, his heart rate was not substantially slow at 61 beats per minute. (Id. at 193-94, ECF No. 74.) Further, Dr. Lawrence testified that she did not expect Dr. Onuoha to diagnose the aortic dissection but to recognize that Johnson was very ill and needed emergency care.

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(Id. at 198-99, ECF No. 74.) Dr. Lawrence did not offer any opinions regarding proximate causation. (Tr. Trans. Vol. 1 at 195, ECF No. 74.) Dr. Lawrence testified that she has not personally diagnosed someone with an aortic dissection but has transferred patients for emergency care because she suspected an aortic dissection. (Id. at 200, ECF No. 74.)

35. Dr. Raymond Sauer (“Dr. Sauer”), an economics professor at Clemson University, testified as an expert economist for the Plaintiff. Dr. Sauer testified that had Johnson lived, upon his release from prison and earning minimum wage at $7.25 per hour, the present value of his future earnings would be $419, 164.00. (Id. at 216, 221, 227, ECF No. 74.)

36. Dr. Edward O'Bryan (“Dr. O'Bryan”), a board-certified internal medicine physician who is dually credentialed in South Carolina for both internal and emergency medicine, testified as an expert for the United States. (Id. at 236-37, ECF No. 74.) He has been practicing for 14 years and is currently employed as an assistant professor of emergency medicine by the Medical University of South Carolina (“MUSC”). (Tr. Tans. Vol. 1 at 231-33, ECF No. 74.)

37. As part of his practice, Dr. O'Bryan testified that he has routinely treated patients in the emergency department and the chest pain clinic. (Id. at 233, ECF No. 74.) In addition, Dr. O'Bryan testified that he is also the Consulting Chief Medical Officer of True Pill, which is a company that provides healthcare infrastructure. (Id. at 231-32, ECF No. 74.) Further, Dr. O'Bryan testified that he has significant past experience with the South Carolina Department of Corrections, including performing clinical work at Charleston County Detention Center for a number of years and conducting quality oversight for the detention center accreditation process. (Id. at 235, ECF No. 74) Dr. O'Bryan has past experience working with the South Carolina Department of Corrections on healthcare infrastructure. (Id. at 235, ECF No. 74.) Dr. O'Bryan

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testified the he recently also worked as Chief Medical Officer for Wellpath for a year and half. Wellpath is the largest correctional medicine company in the United States. (Id. at 236, ECF No. 74.) In his role as Chief Medical Officer, Dr. O'Bryan testified that he reviewed the care provided to persons incarcerated in correctional settings, and set standards for that care, “making sure that the care delivery paradigms are matching to national standards, ” to ensure “[t]hat it doesn't matter whether you are incarcerated or not, you deserve a high[] level of care, and that is for local detention, [s]tate detention centers, as well as Federal Bureau of Prisons.” (Tr. Trans. Vol. 1 at 236, ECF No. 74.)

38. Dr. O'Bryan testified that all of his opinions were to a reasonable degree of medical certainty. (Id. at 261, ECF No. 74) Further, he testified that he has “diagnosed several patients with aortic dissection in the emergency department” and treated several others on transfer from other hospitals to the chest pain center, and he has personal experience with an aneurysm rupture dissection, in that his father passed away from an aortic dissection. (Id. at 237, ECF No. 74.)

39. Dr. O'Bryan testified that Ramsey did not breach the standard of care and acted the way “most [] nurse practitioners . . . would have acted in the same situation. And certainly in regards to the care that is carried out in the correctional institution, . . . [Johnson] received similar, if not the same, care that he would have gotten in the community.” (Id. at 242, ECF No. 74.) Dr. O'Bryan opined that there was nothing in Ramsey's findings that indicated Johnson had an immediate life-threatening condition. (Id. at 246, ECF No. 74.) Further, Dr. O'Bryan testified that the medical record did not reflect that Ramsey performed a cardiac exam, but that it was not warranted because a focused physical exam of Johnson for a focused problem was more reasonable. (Tr. Tans. Vol. 1 at 282, ECF No. 74.)

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40. Dr. O'Bryan testified that it was extremely unlikely that any medical professional would have had an aortic dissection as a differential diagnosis for Johnson. (Id. at 242-43, ECF No. 74.) He testified that the incidence of aortic dissection is twenty to thirty in a million for all ages and over 80 percent of the cases are over 62 years old. (Id. at 242-43, ECF No. 74.)

41. Describing the risk for Johnson, Dr. O'Bryan stated that for a 35-year-old to have a dissecting aorta is incredibly unlikely and far lower than one in a million in a patient presenting with mainly abdominal pain with nausea and vomiting, which are uncommon symptoms of aortic dissection. (Id. at 243, 258, ECF No. 74.) Further, Dr. O'Bryan testified that nothing in Johnson's past medical history of benign essential hypertension and mildly enlarged heart altered his opinion because the EKGs were benign and the chest X-ray showing a mildly enlarged heart is normal with longstanding hypertension. (Tr. Trans. Vol. 1 at 244, ECF No. 74.) Dr. O'Bryan testified that Johnson's hypertension was not severe, as it was well-controlled benign essential hypertension. (Id. at 305-07, ECF No. 74.) Further, bradycardia on EKGs is expected in a young person without comorbidities. (Id. at 248, ECF No. 74.) Dr O'Bryan opined that Johnson did not have “substantial” cardiovascular disease. (Id. at 247-48, 261, ECF No. 74.) Further, Dr. O'Bryan noted that Johnson had high cholesterol, but did not have any dangerous atherosclerosis. (Id. at 262, ECF No. 74.)

42. Dr. O'Bryan testified that hypertension, smoking, and high cholesterol places a person at risk for aortic dissection. (Tr. Tans. Vol. 1 at 262, ECF No. 74.) However, Dr. O'Bryan testified that this risk is a cumulative risk which is why

most dissections occur in elderly populations because when you are 35, sure you can have those things, you are probably not going to have a dissection . . . . You might have with those conditions possibly untreated, you might have a dissection when you

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are 75 . . . . [A]nd that is why there is no recommended screening for aortic insufficiency until age 65, and only then in smokers.

(Id. at 262, ECF No. 74.)

43. With respect to Dr. Onuoha, Dr. O'Bryan testified that “[a]lthough Mr. Johnson reported a subjective pain scale rating of ten, his ambulatory nature without a rapid deterioration or progression of symptoms, normal vital signs, nonsurgical abdomen on physical examination, and a paucity of significant risk factors altogether meant that there was no breach of [the] standard of care.” (Id. at 303-04, ECF No. 74.) Further, Dr. O'Bryan testified that on January 30, 2017, Johnson's chief complaint was abdominal pain, and in addition, Johnson complained of flank pain, which is located in the lower lateral aspect of the side/back. (Id. at 250-51, ECF No. 74.) Abdominal and flank pain, described as cramping, are not typical symptoms of aortic dissection, which most commonly causes chest pain and is “almost universally described as a tearing pain.” (Id. at 251, 258, ECF No. 74.) Dr. O'Bryan testified that Dr. Onuoha did not breach any standard of care in not sending Johnson immediately and emergently for a CT scan at 9:30 a.m. on January 30, 2017.

44. Dr. O'Bryan testified that it

is an improper utilization of resources. . . . [I]t is part of our mission and well within the standard of care to treat patients appropriately at the appropriate site. . . the analysis that he underwent was very appropriate for his constellation of symptoms. He had had nausea and vomiting and now moving to the flank, so . . . looking for things like kidney stone, or small bowel obstruction, or, . . . gastroenteritis, all of the things he was looking for, which his orders basically formed the differential diagnosis, . . . was completely appropriate.

(Id. at 252-253, ECF No. 74.)

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45. Dr. O'Bryan opined that “as an emergency medicine physician [who] receives these patients on a day-to-day basis and has for 14 years, ” in a 35-year-old man with no other significant medical history, “[i]n this scenario, in the morning, . . . seeing the patient with this constellation of symptoms, getting the tests and awaiting the results of the tests . . . is completely appropriate.” (Tr. Trans. Vol. 1 at 254, ECF No. 74.) Dr. O'Bryan testified that Dr. Onuoha's diagnosis in the medical record of “abdominal pain unspecified” is a diagnosis of exclusion and is a diagnosis used while a physician is continuing a work up of a patient. (Id. at 260, ECF No. 74.)

46. Further, Dr. O'Bryan testified that there was nothing in the record that raised a higher index of suspicion for aortic dissection. (Id. at 255, ECF No. 74.) Dr. O'Bryan opined that Dr. Onuoha did not breach the standard of care in not sending Johnson for emergency care after receiving the test results. Dr. O'Bryan opined that later in the day, some of Johnson's test results raised suspicion for a kidney stone, but “that is an urgent, not [] emergent” issue and would not require Johnson to be transported emergently for care. (Id. at 256, ECF No. 74.) Dr. O'Bryan noted that given the lack of mediastinal hilar widening in the chest X-ray on January 30, 2017, it was more likely than not that there was no aortic dissection at that time, or that any dissection was not large enough to be visualized on X-ray. (Id. at 257-58, ECF No. 74.)

47. Dr. O'Bryan testified that the standard of care did not require Dr. Onuoha to perform a cardiac exam because Johnson's cardiac history was not significant to Johnson's complaints, and a focused history and physical of Johnson by Dr. Onuoha “is exactly the standard of care.” (Tr. Trans. Vol. 1 at 291, ECF No. 74.) Further, Dr. Onuoha did not breach the standard of care

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in not listing differential diagnoses in the medical record and that it “is rare to have a fully fledged-out differential diagnosis in most reports.” (Id. at 295, ECF No. 74.)

48. Dr. Marc Katz (“Dr. Katz”) is a board certified thoracic surgeon employed as the Chief of the Division of Cardiothoracic Surgery and holds the Fred Crawford Chair in cardiothoracic surgery at MUSC. (Tr. Trans. Vol. 2 at 63, ECF No. 75.) Dr. Katz testified that his practice sees one to two aortic dissections per month. (Id. at 63, ECF No. 75.) Dr. Katz offered all of his opinions to a reasonable degree of medical certainty. (Id. at 79, ECF No. 75.) Dr. Katz testified that aortic dissection is “rare acute event” that he described as a “medical catastrophe.” (Id. at 70, ECF No. 75.) With respect to Johnson's 2015 EKG showing a low heart rate/bradycardia, Dr. Katz testified that athletic people frequently have lower heart rates and that Metoprolol can lower a person's heart rate. (Tr. Trans. Vol. 2 at 66-67, ECF No. 75.) Further, Dr. Katz testified that a diagnosis of hypercholesterolemia (high cholesterol) “really does not have much to do with aortic dissection” and “the only evidence of any cardiovascular disease” was mild hypertension and mild cardiomegaly. (Id. at 67-68, ECF No. 75.)

49. Dr. Katz referenced the International Registry of Acute Aortic Dissection as the organization with the largest breadth of information on aortic dissections and cited its 2018 Report in support of his opinions. (Id. at 69, ECF No. 75.) Dr. Katz testified that the textbook presentation of aortic dissection is a “stabbing or searing chest pain” that pierces “through to the upper back, frequently associated with extreme hypertension, like blood pressures of 200 or more.” (Id. at 70, ECF No. 75.) Dr. Katz further testified that nausea and vomiting are unusual with an aortic dissection and less than 5 percent present with abdominal pain. (Id. at 71, 83, ECF No. 75.) Further, Dr. Katz testified that the in-hospital survival rate for patients that are

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candidates for surgical repair of an aortic dissection is 78 percent. (Tr. Trans. Vol. 2 at 88, ECF No. 75.)

50. Dr. Katz testified that in his opinion, Ramsey did not breach the standard of care because nothing in her record would cause him to consider the differential diagnosis of aortic dissection. (Id. at 74, ECF No. 75.) Dr. Katz testified that with respect to January 30, 2017, Johnson's vital signs did not raise any concern for aortic dissection. (Id. at 75, ECF No. 75.) In addition, Dr. Katz testified that 80 percent of patients with aortic dissection have a widened mediastinum on chest X-ray. (Id. at 76, ECF No. 75.) Dr. Katz testified that Dr. Onuoha's exam on January 30, 2017, did not contain any evidence of aortic dissection. (Id. at 79, ECF No. 75.)...
Gilbert v. United States (D. S.C. 2022)

Outcome: ORDERED that the court finds for the United States on Plaintiff's medical malpractice claims. The Clerk is directed to enter judgment for the United.

Plaintiff's Experts:

Defendant's Experts:

Comments: