The Expert: Dr. Hugo Cheng, an internal medicine specialist at the University of California, San Francisco, testifies for the plaintiff on his belief that additional measures, such as a nasogastric tube CT scan and potential surgical consult, should have been implemented as part of the standard of care.
The testimony of Dr. Hugo Cheng in 2017’s Scoggins vs Smith, et al., was pivotal in obtaining a $6 million verdict for the family of a woman who died following complications from a bowel obstruction.
Ann Scoggins, 72, suffered a fatal heart attack in 2014 during a bout of vomiting while being treated by internal medicine specialist Dr. Daniel Moldoveanu for a bowel obstruction at Athens (Georgia) Regional Hospital.
Doctors believed Scoggins’ obstruction was caused by prescription pain meds following a recent knee replacement surgery. In the DeKalb County Georgia State Court trial, her family claimed Moldoveanu did not properly treat the obstruction when she was readmitted to Athens Regional.
Cheng, an internal medicine specialist from the University of California at San Francisco, took defendant Moldoveanu to task as he explained how standard investigations and treatments were omitted while the patient was instead given an oral laxative and enema.Those omissions, Cheng concluded, ultimately contributed to her vomiting, aspiration, and cardiac arrest.
In this video clip, Cheng explains the need to place a nasogastric tube into the patient’s stomach as soon as X-rays demonstrated an actual or functional blockage of gastrointestinal emptying. He explains that, under these circumstances, when there is the possibility of a bowel obstruction, draining the stomach and bowel secretions of air and liquid is key to alleviating the patient’s abdominal discomfort. More importantly, however, it would have prevented the vomiting and massive aspiration of that vomitus into the lungs that ultimately occurred.
Cheng memorably describes the fluid typically drained by nasogastric tube suctioning in such cases and notes that the appearance of the drainage can better inform a patient’s treatment. Cheng warns that when “what comes out is looking like stool,” that is “a huge red flag” that would have completely changed the course of treatment, by confirming a bowel obstruction of long standing rather than bowel sluggishness from prescription narcotic use.
Cheng explains nasogastric tubes are very commonly used, despite patient resistance to them and their discomfort during placement. He says, in his experience, a careful explanation of the tube’s importance and purpose usually convinces patients to accept it, and if not, then the patient is accepting the risk of aspiration by not draining their stomach of the caustic fluids. Still, he emphasizes the importance of the conversation with the reluctant patient.
Speaking directly to causation, Cheng explains that, even with the nasogastric tube, Scoggins may still have vomited, but the amount of emesis would have been far less than she actually did vomit because the stomach would have been emptied by the tube. “She would not have aspirated to the degree and severity that she had, that led to her cardiac arrest and eventual death,” Cheng says.
In explaining the autopsy findings, the expert spoke of the importance of adhesive scars within the abdomen. One, he says, blocked the large intestine, like “a hose” with “a bend or kink in it,” which was the actual pathology causing this patient’s condition. This obstructing adhesion led to dilation and inflammation of the intestine and set the stage for bacterial translocation, which the doctor explains in laymen’s terms to the jury. “The gut bacteria normally would stay in the bowel except when there is an opportunity [due to inflammation] to leak from the hollow part of the bowel into the circulation, and this is what caused her sepsis.”
When questioned about the need for a CAT scan of the abdomen, Cheng uses the opportunity to stress the importance of consultation with a specialist who deals with obstructions, the general surgeon. Having done everything that he could do as an internist, it becomes important to have this evaluation and input before things get worse. Stressing the urgency of the situation, Cheng says he would discuss the situation directly with the surgeon by phone to ask if there are any tests that should be done before the consulting physician arrives. He leaves no doubt that this consultation should have been done to comply with the standard of care in this case, and that failure to adhere to the standard led to the patient’s demise despite having a “survivable condition.”
Cheng comes across as earnest, confident, and knowledgeable. His testimony strongly supported the malpractice case, pointing to the failures by the treating physician to comply with the standard of care, discussing the damages that occurred, and connecting the breaches directly to those damages.
While jurors cleared another doctor who had cared for Scoggins before her admission to Athens Regional, it took the jury only three hours to find Moldoveanu negligent and grant the plaintiff a seven-figure award.
Gary Gansar, MD, is residency-trained in general surgery. He served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Touro Infirmary and Mercy Hospital in New Orleans, LA. Dr. Gansar was Board Certified in general surgery while in active practice. He joined AMFS in 2015 as a Physician Medical Director.
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