MAY 15, 2009 • WWW.INTERNALMEDICINENEWS.COM PRACTICE TRENDS 45 THE REST OF YOUR LIFE Bicycling as a Way of Life

or Dr. Christiane Stahl, bicycling is Even Chicago’s harsh winter days America’s Bike the Drive, an annual bike not so much a hobby as a way of life. don’t stop her. “I have little booties that ride along scenic Lake Shore Drive that FShe’s been commuting by bike to I put over my bike shoes and big puffy benefits the Active Transportation Al- school or work since she was 8 years old. bike gloves and hats to wear under my liance (formerly the Chicagoland Bicycle “I use public transportation, but the helmet,” she said. Federation), a not-for-profit biking, walk- nice thing about a bike is you’re kind of No special tires are required during her ing, and transit advocacy organization. out there on your own,” said Dr. Stahl of winter commutes because the route she She noted that as more people take up bi- the department of pediatrics at the Uni- takes includes a network of bike lanes cycling as an inexpensive and environ- versity of Illinois at Chicago. “It’s a little that “get cleared out pretty well” by the mentally friendly commuting tactic, up- more individual and gives you more time city’s snowplows. However, degradation grades in the separation of auto and TAHL for reflection. You’re not distracted by all of the bike chain from road salt is an on- bicycle traffic will be needed. S the social interactions that are going on going issue. “Until we do that, we’re going to see when you take public transportation.” Among her favorite vacations are bike rising rates of injury, because I think She bikes 5 miles to work “if it’s not trips she’s taken through Germany, Wis- more people will turn to bicycling as a HRISTIANE . C R

actively precipitating and the wind is not consin, and South Carolina. Her easiest way of getting around,” she said. “Com- D more than 20 miles an hour against me.” and most spontaneous trip “was on the pared with Europe, we have so far to go back of a tandem bicycle around the in terms of creating safer bikeways.” OURTESY E-MAIL US YOUR STORIES Chicago area—taking advantage of the A devoted helmet wearer, Dr. Stahl had C great trail system, the outdoor concert one serious biking injury: a low-speed Dr. Christiane Stahl bikes 5 miles to The purpose of “The Rest of Your area of Ravinia Park, and views of Lake face plant when she dropped a wheel into work every day in Chicago. Life” is to celebrate the interests Michigan,” she said. “Plus, I was in beep- a sidewalk grate. “Fortunately, I was just and passions of physicians outside er range the whole time, and it’s easy to outside the hospital emergency room,” “For me, biking is not goal oriented,” of medicine. If you have an idea for make callbacks from the back of a tan- she said. “I got a fair number of facial lac- she said. “That’s one of the chief joys of this column or would like to tell dem so no cross-coverage arrangements erations, but I didn’t have any head injury.” riding my bike: to explore, look around, your story, send an e-mail to were required.” Although she knows bicyclists who and see things.” ■ [email protected]. An advocate for bike safety, Dr. Stahl has set goals to improve their speed or en- served as a medical volunteer for Bank of durance, Dr. Stahl just enjoys the ride. By Doug Brunk LAW & MEDICINE Gross Negligence Question: A patient developed postoper- as being different from ordinary negli- use the knowledge, skill and care ordi- Lois Jackson, who subsequently devel- ative paralytic ileus with intractable vom- gence, and the legal implications of that narily possessed and employed by mem- oped bleeding liver tumors allegedly iting. The attending doctor inserted a distinction. The vast majority of medical bers of the profession in good standing.” caused by the birth control pills. The nasogastric tube and administered intra- malpractice cases allege ordinary rather Gross negligence denotes a higher degree plaintiff’s expert testified that Dr. Taylor’s venous fluids in the form of 5% dextrose than gross negligence. While it is agreed of culpability than ordinary negligence, acts and omissions demonstrated his con- in water. The patient died 6 days later that gross negligence denotes something signifying “more than ordinary inadver- scious indifference to the welfare of his from hypovolemic shock and cardiac ar- more “substandard” than ordinary negli- tence or inattention, but less perhaps than patient (Jackson v. Taylor, 912 F.2d 795, rhythmias. Serum electrolytes gence, there is no precise legal conscious indifference to the conse- 1990). In another case, the Oklahoma were not measured until the definition. In some jurisdic- quences.” The California Supreme Court Supreme Court ruled that a 6½-inch last day, when severe hypona- tions, such as Connecticut, approved the definition of gross negli- clamp left in a surgical incision “might be tremia and hypokalemia be- gross negligence may consti- gence as “the want of even scant care or construed to support a willful, wanton came evident. A lawsuit for tute an exception to the need an extreme departure from the ordinary conduct amounting to gross negligence” wrongful death alleged gross for expert testimony, which is standard of conduct” (Van Meter v. Bent (Fox v. Oklahoma Memorial Hospital, 774 negligence and sought puni- otherwise a requirement to Construction Co., 297 P.2d 644, 1956). P.2d 459, 1989). tive damages, but no expert establish medical negligence. Likewise, the law in Texas stipulates: A recent decision favoring the defen- witness was called to testify. In the above scenario, the jury “Gross negligence means more than mo- dant involved a penicillin-allergic patient Which of the following best may be allowed to determine mentary thoughtlessness, inadvertence who died from massive hemolysis after re- describes the situation? liability without expert testi- or error of judgment. It means an entire ceiving ceftriaxone (Rocephin). Relying on BY S.Y. TAN, mony only if the doctor’s mis- want of care as to establish that the act or the gross negligence exception, the plain- A. This is a clear case of gross M.D., J.D. conduct was so obvious as to omission was the result of actual, con- tiff failed to call an expert witness and lost negligence, a standard of care constitute gross negligence— scious indifference to the rights, safety and the case. The Connecticut Supreme Court so low as to shock the conscience. by no means a foregone conclusion. welfare of the person affected” (Texas Civ- decided that “the defendant’s conduct in B. The plaintiff will win; expert testi- Compensatory damages are the norm il Practice & Remedies Code § 41.001[7]). administering Rocephin to the decedent mony is unnecessary because a reason- for medical plaintiffs who prevail. Puni- Gross negligence does not have to and subsequently refusing to treat or to able layperson would conclude that there tive damages may occasionally be award- amount to willful, wanton, or malicious readmit the decedent does not meet the was substandard care. ed when gross negligence is proved, but misconduct. It does not even have to high threshold of egregiousness necessary C. Punitive damages are commonly courts in several states have discouraged reach the level of “reckless disregard.” to fall within the gross negligence excep- awarded in medical malpractice cases, es- such awards, absent a malicious intent, Thus, in the Restatement (First) of Torts, tion” (Boone v. William W. Backus Hospital, pecially when negligence has caused so choice C is incorrect. Choice E is also an authoritative source of law, the au- 864 A.2d 1, 2005). ■ death or severe neurologic injury. incorrect. To encourage aid to strangers, thors differentiate reckless disregard from D. Gross negligence is something more “Good Samaritan” statutes immunize gross negligence by stating that the for- DR. TAN is professor of medicine and than ordinary negligence, but less than aid-givers from liability should ordinary mer creates a degree of risk “so marked former adjunct professor of law at the reckless or wanton misconduct. negligence result in harm, but such im- as to amount substantially to a difference University of Hawaii, Honolulu. This E. Good Samaritan laws encourage aid munity is typically forfeited if there is a (from gross negligence) in kind.” article is meant to be educational and does to strangers by providing immunity for finding of gross negligence. Court decisions on the issue of gross not constitute medical, ethical, or legal a defendant who would otherwise be li- In the medical context, the operational negligence, predicated on inconsistent advice. It is adapted from the author’s book, able for ordinary or gross negligence. definition of negligence is best referenced standards, can cut both ways, some fa- “Medical Malpractice: Understanding the in Prosser’s Textbook on Torts: “The for- voring the plaintiff and others the defen- Law, Managing the Risk” (2006). For Answer: D. This hypothetical scenario in- mula under which this usually is put to dant. In Jackson v. Taylor, Dr. James Taylor additional information, readers may troduces the notion of gross negligence the jury is that the doctor must have and prescribed birth control pills for plaintiff contact the author at [email protected].