Michigan Appellate Court Affirms That Cardiologist Contacted About Patient May Have Created Physician-Patient Relationship And Therefore Owed Duty Of Care To Patient

Cardiologist Contacted About Patient May Have Created Physician-Patient Relationship: Statistically, most heart attacks result from a reduction of blood flow in a coronary artery supplying oxygen to the anterior portion of the heart. But some myocardial infarctions—15 to 20%—involve the heart’s posterior wall. Jay Wesenick suffered a posterior wall infarction. His estate claimed that a delay in diagnosing and treating it caused Wesenick’s death.

The Estate sued Dr. Kuchunni Mohan, a cardiologist consulted by phone while Wesenick was in the emergency room. Dr. Mohan argued that the consult was not “formal” because it was not recorded in Wesenick’s chart as a “consult order.” Without a formal consult, Dr. Mohan claimed he had no physician-patient relationship with Wesenick and no duty of care. By the time the consultation was reduced to writing, Dr. Mohan insisted, it was too late to have saved Wesenick’s life.

Background Facts

Especially when accompanied by clinical symptoms, elevations seen in a part of the tracing called the ST segment signal a possible heart attack. Physicians call this finding a STEMI: an ST elevation myocardial infarction. When a STEMI is detected, the standard of care requires that a cardiologist see the patient within 30 minutes. Dr. Sorini explained, “[A]nybody who has a STEMI has to be anticoagulated and taken to the cath lab immediately.” Wesenick’s EKG showed ST segment depressions in leads V1-V3. Dr. Richard Konstance, one of the estate’s expert witnesses, explained that ST segment depressions in those leads are “equivalent” to ST elevations in other leads and are “indicative” of a STEMI. Another expert, Dr. Benjamin Freed, agreed that ST segment depressions in leads V1-V3 “create a suspicion” of a posterior wall myocardial infarction.

Wesenick’s blood also revealed evidence of a heart attack. Troponin is a protein that leaks from damaged muscle cells (and the heart is a muscle). Wesenick’s troponin level was 9.24 ng/ml. The top of the normal range for this test is 0.058 ng/ml. The estate’s experts testified that combined with the EKG, this finding demonstrated that Wesenick likely had suffered an infarction in the posterior wall of his heart.

Dr. Sorini believed that Wesenick had suffered an event called an NSTEMI—shorthand for a non-STEMI. A non-STEMI is a heart attack that does not display ST segment elevations on an EKG. It need not be treated as urgently as a STEMI. With the NSTEMI diagnosis in mind, Dr. Sorini called an internist, Dr. Ali, for permission to admit Wesenick to the hospital. Dr. Ali asked Dr. Sorini to call a cardiologist. Dr. Sorini called Dr. Mohan, who was on call for cardiology that evening. Dr. Sorini did not take notes during his conversation with Dr. Mohan. According to the medical record, the call took place at 10:24 p.m., about 2½ hours after Wesenick had entered the ER.

Dr. Sorini testified about the conversation, in part: “Q. Did you expect Dr. Mohan to come in and evaluate this patient? THE WITNESS: No. Q. You didn’t? A. No. I gave him the information, and I asked him what he thinks we should do, and he said put him in the stepdown unit and I’ll take it from there. . . . ” Dr. Sorini characterized the discussion he had with Dr. Mohan as a “consultation”: “Well, after consultation with a cardiologist, who I dare say knows way more than I do about that, he asked me to put the patient in the stepdown unit, and he’s done that many times before.” Dr. Mohan testified that he had no memory of his conversation with Dr. Sorini. He was certain, however, that he never reviewed Wesenick’s EKG tracing, despite acknowledging that he could have asked Dr. Sorini to “text” it to him.

At 8:30 that morning, an ICU nurse called another cardiologist about Wesenick. That cardiologist took Wesenick to the cardiac catheterization lab within 15 minutes of receiving the call. The catheterization revealed a complete occlusion of one of Wesenick’s coronary artery grafts, blocking blood flow to the posterior portion of his heart. During the procedure the clot broke free, causing a “no-flow phenomenon” and cardiac arrest. Wesenick died shortly after the catheterization.

The State of Michigan Court of Appeals (“Michigan Appellate Court”) stated in its unpublished opinion dated July 14, 2022: “The evidence and the estate’s experts’ testimonies refute these legal arguments, creating material questions of fact. The circuit court properly denied summary disposition on duty and proximate cause grounds, and we affirm … Here, Dr. Sorini called Dr. Mohan for advice regarding how to treat Wesenick, and Dr. Mohan responded by giving advice. Dr. Mohan could have said: “Write a formal consult and then I will decide whether to give instructions about the patient’s care.” Or, he could have told Dr. Sorini that he had no opinion about what to do and would not form one until someone wrote an order consulting him. Instead, Dr. Mohan listened to Dr. Sorini’s description of Wesenick’s situation and told Dr. Sorini to “put him in the stepdown unit and I’ll take it from there.” Unlike in Oja, Dr. Mohan “participate[d] in the patient’s diagnosis and treatment” by accepting that Wesenick’s cardiac event was an NSTEMI and that he should be placed in a step-down unit rather than undergoing immediate cardiac catheterization. The evidence supports that Dr. Sorini understood that Dr. Mohan agreed to undertake Wesenick’s cardiology care and had access to the EKG. This was not a “curbside consultation” in which one physician informally solicits another doctor’s opinion. Rather than merely offering courtesy advice, Dr. Mohan, the on-call physician for cardiac emergencies that evening, accepted the referral of and responsibility for a critically ill patient being admitted to a unit one “step-down” from an ICU. His instruction to admit Wesenick to the step-down unit was not perceived by Dr. Sorini as an informal recommendation that Dr. Sorini could accept or reject. When he called Dr. Mohan, Dr. Sorini was looking for cardiology assistance to unravel an “unusual” cardiac situation that Dr. Sorini could not figure out. Viewed in the light most favorable to the estate, the evidence supports that by affirmatively agreeing to direct Wesenick’s treatment, Dr. Mohan entered into a physician-patient relationship triggering a duty of care.”

Source Wesenick v. Mohan, M.D., No. 356558.

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