[Cite as Camara v. Ohio State Univ. Med. Ctr. E., 2015-Ohio-5554.]

                                                         Court of Claims of Ohio
                                                                                      The Ohio Judicial Center
                                                                              65 South Front Street, Third Floor
                                                                                         Columbus, OH 43215
                                                                               614.387.9800 or 1.800.824.8263
                                                                                          www.cco.state.oh.us



AHMED CAMARA, Admr.

             Plaintiff

             v.

THE OHIO STATE UNIVERSITY MEDICAL CENTER EAST

             Defendant

Case No. 2013-00030

Magistrate Holly True Shaver

DECISION OF THE MAGISTRATE

          {¶1} Plaintiff, Ahmed Camara, brought this action as administrator of the estate
of his wife, Patreace Spruiel-Camara, alleging wrongful death. The issues of liability
and damages were bifurcated and the case proceeded to trial on the issue of liability.
          {¶2} On July 28, 2009, Camara1 who was 29 years old, presented to defendant’s
Emergency Room (ER) complaining of “9 out of 10 bone pain” due to sickle cell
disease, a genetic blood disorder that causes frequent episodes of pain referred to as
“pain crises.” According to Camara’s medical records, between 2003 and 2009, she
was seen in defendant’s ER approximately 60 times for sickle cell pain crises.
          {¶3} Camara arrived at the ER at 7:38 p.m., and was seen by nursing staff in
triage.     Camara was thereafter evaluated by Ann Haynes, M.D., the attending
physician. Dr. Haynes had previously treated Camara for pain crises, but she was not
Camara’s primary care physician. Dr. Haynes took Camara’s history and performed an
examination.       Dr. Haynes ordered a chest x-ray, bloodwork, and a urinalysis, and
started Camara on intravenous pain medication and normal saline. Approximately two
hours later, Camara reported her pain level had decreased to “5 out of 10” and she was


          1“Camara”   shall be used to refer to Patreace Spruiel-Camara throughout this decision.
Case No. 2013-00030                         -2-                                DECISION



discharged home with written instructions to return to the hospital if certain changes in
her condition occurred.       Camara was also instructed to schedule a follow-up
appointment with her hematologist, Ahmed Ghany, M.D. as soon as possible. Camara
left the hospital at approximately 10:20 p.m., and drove to the home of her aunt Marilyn
Cole.   After watching a movie, Camara spent the night at Cole’s home. The next
morning, Cole found Camara unresponsive.           Medics were called to the scene and
Camara was pronounced dead.             An autopsy was performed and the coroner
determined that the cause of death was “massive sickling of red blood cells due to
sickle cell disease.” (Exhibit 1 to deposition of Jan Gorniak, D.O.)
        {¶4} Plaintiff asserts that defendant, through Dr. Haynes’ treatment of Camara,
failed to meet the standard of care when she did not admit Camara to the hospital for
additional care.    Specifically, plaintiff asserts that Dr. Haynes failed to adequately
hydrate Camara, failed to order additional follow-up testing of her blood, failed to
consult Dr. Ghany, failed to admit her for further care, including a blood transfusion, and
failed to diagnose and treat a urinary tract infection (UTI).
        {¶5} In order to prove negligence, plaintiff must prove the existence of duty and a
breach of such duty, which proximately causes damages. Armstrong v. Best Buy Co.,
Inc., 99 Ohio St.3d 79, 2003-Ohio-2573. “To maintain a wrongful death action on a
theory of negligence, a plaintiff must show (1) the existence of a duty owing to plaintiff’s
decedent, (2) a breach of that duty, and (3) proximate causation between the breach of
duty and the death.” Littleton v. Good Samaritan Hosp. & Health Ctr., 39 Ohio St.3d
86, 92 (1988). Similarly, “[i]n order to establish medical malpractice, it must be shown
by a preponderance of the evidence that the injury complained of was caused by the
doing of some particular thing or things that a physician or surgeon of ordinary skill,
care and diligence would not have done under like or similar conditions or
circumstances, or by the failure or omission to do some particular thing or things that
such a physician or surgeon would have done under like or similar conditions and
 Case No. 2013-00030                          -3-                                   DECISION



circumstances, and that the injury complained of was the direct result of such doing or
failing to do some one or more of such particular things.” Bruni v. Tatsumi, 46 Ohio
St.2d 127 (1976), paragraph 1 of the syllabus. Proof of the recognized standards of
care must be provided through expert testimony. Id. at 131-132.
         {¶6} Ann Haynes, M.D., who is board certified in emergency medicine, testified
that she has been employed by defendant as a clinical assistant professor of medicine
since 1999 and is familiar with sickle cell disease. Dr. Haynes’ primary duty is patient
care at defendant’s hospital.        Dr. Haynes testified that there are a number of
recognized causes of sickle cell pain crises, such as stress, dehydration, extreme heat
or cold, and infection.    However, she also stated that often there is no identifiable
precipitator. Dr. Haynes testified that the protocol when a patient presents with a sickle
cell pain crisis is to identify the precipitator if possible and then treat the pain.
         {¶7} Dr. Haynes testified that there are a variety of sickle cell crises, the most
common of which is a pain crisis. An aplastic crisis is caused by an infection that
prevents bone marrow from producing new red blood cells. A splenic sequestration
crisis occurs most often in children, when red blood cells get trapped in the spleen.
         {¶8} With regard to the treatment that she provided to Camara on July 28, 2009,
Dr. Haynes testified that Camara arrived at the ER at 7:38 p.m., and was triaged by a
nurse.    Camara’s blood pressure was 115 over 76, which Dr. Haynes stated is a
normal reading for a woman. Dr. Haynes examined Camara at 7:50 p.m., at which
time Dr. Haynes obtained Camara’s history, ordered a chest x-ray, and ordered a
number of tests, including a complete blood count (CBC), electrolytes, liver panel, urine,
urine pregnancy test, and a reticulocyte count which is another measurement of the
blood. Dr. Haynes also ordered IV fluids of normal saline, IV medications including
Benadryl for itching, Dilaudid for pain, and Zofran for nausea. The medical records
show that Camara was given approximately 400 ccs of normal saline during her ER
visit, which is approximately one half of a liter. Dr. Haynes also ordered a chest x-ray
Case No. 2013-00030                        -4-                                DECISION



to rule out acute chest syndrome, a leading cause of death in sickle cell patients. Dr.
Haynes testified that the chest x-ray was normal and showed no evidence of acute
chest syndrome.
      {¶9} Dr. Haynes agreed that dehydration can precipitate a crisis, but stated that
based upon Camara’s clinical presentation, she did not believe that Camara was
significantly dehydrated. Dr. Haynes noted that Camara’s mucous membranes and
her tongue were moist, and that Camara had no complaints of vomiting or diarrhea.
With regard to Camara’s bloodwork, Dr. Haynes testified that Camara’s hemoglobin
level was low but consistent with her normal range from previous tests performed
during her prior visits to the hospital. Dr. Haynes testified that Camara’s bone marrow
was producing reticulocytes, which are immature red blood cells, and therefore,
Camara was not suffering from an aplastic crisis. Dr. Haynes testified that a blood
transfusion was not warranted because Camara was not exhibiting signs of anemia,
such as shortness of breath, and that there was no reason to order follow up
bloodwork.
      {¶10} Dr. Haynes testified that during her examination, she asked Camara
specific questions to determine whether she had any symptoms of a UTI, but that
Camara’s answers to those questions led to the conclusion that she did not.
Specifically, Camara denied any history of fever, flank, or bladder pain. Dr. Haynes
testified that she ordered a urinalysis to screen for pregnancy (which can be a problem
for sickle cell patients), assess for hydration, and screen for infection. Dr. Haynes
testified that two urine tests were conducted: a dipstick test, which gives an instant
reading; and, a microscopic urinalysis, which is sent to the lab and typically takes 30 to
40 minutes to process.       Although Dr. Haynes could not remember specifically
reviewing the results of the microscopic urinalysis, and admitted that her notes do not
reference that she did so, she testified that typically in her practice, the results of the
microscopic urinalysis are attached to the front of a patient’s file and would have been
Case No. 2013-00030                         -5-                                 DECISION



available to her before she ordered that Camara be discharged from the hospital. Dr.
Haynes testified that the results of both urine screens support her conclusion that
Camara was not suffering from a UTI on July 28, 2009.
       {¶11} Finally with regard to her decision to discharge Camara from the ER, Dr.
Haynes testified that if Camara’s pain had not improved, if she were dehydrated, if she
showed signs of a significant infection, had anemia and would have needed a
transfusion, or if she had been suffering from an aplastic crisis, Dr. Haynes would have
admitted Camara to the hospital. However, Dr. Haynes testified that none of those
scenarios occurred in this case. In Dr. Haynes’ opinion, Camara presented with an
uncomplicated sickle cell pain crisis which did not require her to consult Dr. Ghany.
       {¶12} Plaintiff presented the deposition testimony of Jan Gorniak, D.O., the
Franklin County coroner at the time of Camara’s death. Although Dr. Gorniak did not
conduct the autopsy herself, she testified that the cause of death was listed as
“massive sickling of red blood cells as a consequence of sickle cell disease.”           Dr.
Gorniak testified that during a forensic autopsy, a UTI is not something that a
pathologist would document or look for, so the lack of documentation of a UTI is not
dispositive of whether plaintiff’s decedent had a UTI at the time of her death.
       {¶13} Plaintiff also presented the deposition testimony of George Shaw, M.D.,
who is employed as an associate professor of emergency medicine at the University of
Cincinnati, and is board certified in emergency medicine. Dr. Shaw described a sickle
cell crisis as an acute sickling of red blood cells, which results in sickled red blood cells
becoming lodged in the small blood vessels of the body, and slowing down or
preventing blood flow to tissues and organs. Dr. Shaw reviewed Camara’s medical
records and stated that Dr. Haynes ordered the appropriate tests when Camara
presented to the ER. Dr. Shaw testified that a normal hemoglobin value is 15 and that
Camara’s hemoglobin level was 7.1.        Dr. Shaw stated that even though sickle cell
patients have blood values that reflect anemia, 7.1 was “on the low side for [Camara].”
Case No. 2013-00030                         -6-                               DECISION



(Plaintiff’s Exhibit 2, p. 19.) Dr. Shaw stated that although Dr. Haynes gave Camara
400 milliliters of fluid, he would have given at least twice that amount.
        {¶14} With regard to the urinalysis, Dr. Shaw stated that Camara’s urine tested
positive for nitrites, contained one to two white blood cells, and tested positive for the
presence of bacteria.     Dr. Shaw stated that those findings elevate the chance that
Camara was suffering from a UTI. Dr. Shaw stated that infections in sickle cell patients
can be very serious, and that an infection can ultimately result in a massive sickling of
cells. According to Dr. Shaw, the medical records show the results of the microscopic
urinalysis, but there is no indication that Dr. Haynes reviewed the lab results or made a
notation that the urine tested positive for nitrites and bacteria. Dr. Shaw testified that
he would have started Camara on an antibiotic and sent her urine to be cultured to rule
out a UTI.     Dr. Shaw opined that the standard of care required that Camara be
admitted to the hematology/oncology service based upon her presentation on July 28,
2009. Dr. Shaw opined that Dr. Haynes failed to recognize that Camara was suffering
from a UTI; that Dr. Haynes failed to recognize and treat how anemic Camara was in
that she very likely required a blood transfusion; and that Dr. Haynes did not administer
enough fluids to Camara. Dr. Shaw believed that a UTI was the cause of Camara’s
pain crisis and that it was left untreated when she was discharged from the ER. Dr.
Shaw opined that if Camara had been admitted and treated for all of her symptoms,
she more likely than not would have been restored to her baseline and would not have
died.
        {¶15} Dr. Shaw conceded that if a patient has an elevated level of bilirubin in the
blood, that condition can cause urine to become orange in color and can cause a false
positive for nitrites on a urinalysis. Dr. Shaw also testified that Camara’s white blood
cell count was within normal limits. Dr. Shaw agreed that Camara was not having an
aplastic crisis because she had an elevated level of reticulocytes. Dr. Shaw agreed
that the chest x-ray that was taken in the ER did not show fluid or congestion in
Case No. 2013-00030                         -7-                                  DECISION



Camara’s lungs, although the autopsy showed that there was fluid in her lungs. Dr.
Shaw stated that Camara’s immune system was compromised because she suffered
from sickle cell disease, that her hemoglobin and hematocrit levels were low even for
her, and that her presentation was highly suspicious for a UTI. According to Dr. Shaw,
based on those conditions, she should have been admitted to the hospital for a blood
transfusion.    Dr. Shaw criticized Dr. Haynes for failing to consult Camara’s
hematologist and for her failure to diagnose and treat a UTI.
       {¶16} Plaintiff’s final expert witness, Robert Sklaroff, M.D., testified via deposition
that he is board certified in internal medicine, medical oncology, and independent
medical examinations.      Although his specialty is medical oncology/hematology, Dr.
Sklaroff is not board certified in hematology because he did not pass the board
certification test. Dr. Sklaroff testified that Camara was undergoing a sickle cell pain
crisis based upon a drop in her hemoglobin level and a rise in her reticulocyte count.
Dr. Sklaroff also noted that Camara had increased levels of bilirubin, which is a
breakdown product of the hemoglobin molecule. Dr. Sklaroff testified that Camara’s
urinalysis results were abnormal based upon the presence of nitrites, white blood cells,
and bacteria. According to Dr. Sklaroff, if a sickle cell patient shows signs of infection,
a urine culture should be taken and the patient should be placed on antibiotics because
an infection can trigger or perpetuate a sickle cell pain crisis. Dr. Sklaroff testified the
Camara’s hemoglobin level of 7.1 was not normal, even for her, based upon her past
hospital visits. Dr. Sklaroff also testified that a normal level of reticulocytes is 1 percent
and Camara’s was 14.2 percent, which he described as very high.
       {¶17} Dr. Sklaroff testified that despite the fact that Camara was given IV fluids to
hydrate her, her blood pressure should have increased but it decreased instead. Dr.
Sklaroff testified that Camara was very dehydrated upon presentation to the ER. Dr.
Sklaroff reviewed Camara’s prior hospitalizations for sickle cell crises and stated that in
the past, when her hemoglobin was approximately 7.1, and her reticulocyte count was
Case No. 2013-00030                        -8-                                 DECISION



approximately 14 percent she was admitted to the hospital. However, during her visit
to the ER under Dr. Haynes’ care, no follow up bloodwork or urine culture was ordered,
and Camara was discharged without being prescribed antibiotics. Dr. Sklaroff added
that there is nothing in the medical record to show that Dr. Haynes reviewed the results
of the microscopic urinalysis prior to discharging Camara. Dr. Sklaroff stated that if a
physician orders a test, it is incumbent to evaluate the results of the test prior to
discharging a patient.    Dr. Sklaroff opined that Dr. Haynes should have ordered a
second test for reticulocytes, hemoglobin, and a urine culture. Dr. Sklaroff testified that
the results of those three tests would have led to Camara’s admission to the hospital for
a blood transfusion and additional management.
       {¶18} On cross-examination, Dr. Sklaroff acknowledged that he does not serve
as an attending physician in an emergency room; that he has not worked in an
emergency room since his residency in the 1970’s; and that he does not treat many
sickle cell patients in his practice. Dr. Sklaroff testified that the presence of one to two
white blood cells in Camara’s urine suggests infection, the possibility of which should
not have been dismissed in Camara’s case, especially in conjunction with the nitrites
and bacteria in her urine.     Dr. Sklaroff was critical of Dr. Haynes’ decision not to
consult Dr. Ghany or to order a transfusion. Dr. Sklaroff conceded that it would have
likely taken eight hours for the correct type of blood to be available for a transfusion
based upon Camara’s blood type, which was difficult to match. Dr. Sklaroff testified
that Dr. Haynes should have placed Camara on antibiotics even though Camara did not
have a fever or any classic signs of a UTI.
       {¶19} Defendant presented the expert testimony of Martin Steinberg, M.D., via
deposition, a professor at Boston University School of Medicine who is board certified in
internal medicine and hematology. Dr. Steinberg has treated patients with sickle cell
disease for approximately 45 years and has headed the Center of Excellence in Sickle
Cell Disease at Boston University since 2000. Dr. Steinberg defined sickle cell disease
Case No. 2013-00030                          -9-                              DECISION



as a genetic disorder of hemoglobin, the substance in red blood cells that carries
oxygen from the lungs to the tissues of the body. Dr. Steinberg explained that when
sickle hemoglobin becomes de-oxygenated, it forms a crystal structure in the cell. The
crystal structure distorts the cell shape, and those distorted cells occlude blood vessels.
 When blood vessels are occluded, blood flow is impaired and tissue is damaged. The
pain associated with a sickle cell crisis is caused by occluded blood vessels.
Occlusions from sickle cells can result in strokes, bone damage, or acute chest
syndrome, depending upon the location of the occlusion.            Sickle cells are also
short-lived cells. While normal red blood cells function for approximately four months,
sickle cells function for approximately 5 to 10 days. Patients with sickle cell disease
typically have a high reticulocyte count.
       {¶20} Although he is not an ER doctor, Dr. Steinberg testified that when a patient
presents complaining of a sickle cell pain crisis, the standard of care requires that the
physician take a history from the patient to detect symptoms of dehydration or infection,
and then take vital signs and do some basic laboratory testing such as a blood count to
see what to do next. Dr. Steinberg stated that Dr. Haynes noted that there were no
abnormal findings on physical examination.         Camara had no shortness of breath,
complaints of coughing or abdominal pain, fever, chills, or sweats, and no signs of
abnormal or painful urination. Dr. Steinberg noted that Camara did not present with
clinical signs of dehydration, such as tachycardia, hypotension, dry mucous
membranes, or poor skin turgor. Dr. Steinberg stated that Camara’s vital signs upon
arrival were within a normal range.         Camara’s vital signs on discharge were also
normal and her pain level had decreased from 9 out of 10 at admission to 5 out of 10.
       {¶21} According to Dr. Steinberg, Camara’s hemoglobin level of 7.1 was
consistent with her levels from prior hospital visits, which ranged from 6.5 to 8.2.
Camara’s hematocrit level of 21.1 was also consistent with her previous results. Dr.
Steinberg testified that since her hemoglobin and hematocrit numbers were consistent
 Case No. 2013-00030                       - 10 -                              DECISION



with her baseline numbers, there was no need to consult Dr. Ghany. Dr. Steinberg
also testified that Camara’s clinical presentation did not warrant a transfusion.
       {¶22} Dr. Steinberg explained that a reticulocyte count is a measurement of the
production of new red blood cells by the patient’s bone marrow. A normal reticulocyte
count for a person without sickle cell disease is less than 1 percent. However, in sickle
cell disease, the reticulocyte level is always elevated, because the body continually has
to make new red blood cells. Dr. Steinberg described Camara’s reticulocyte count at
14 or 15 percent as consistent with her past readings and described it as chronic, as
opposed to a sign of any acute event. Dr. Steinberg added that a reticulocyte count of
14.2 was expected for Camara, and that he would be more concerned if it were very
low as opposed to being very high. Dr. Steinberg noted that Camara’s reticulocyte
count shows that she was not experiencing an aplastic crisis, which is when the bone
marrow stops producing red blood cells, and the patient becomes very anemic very
rapidly.
       {¶23} Dr. Steinberg described bilirubin as the end product of the metabolism of
hemoglobin which is metabolized in the liver and circulates through the bloodstream.
Dr. Steinberg was not concerned with Camara’s bilirubin level of 5.3, and noted that
during her past ER visits, she had had levels between 4 and 8. According to Dr.
Steinberg, an increased bilirubin level is a natural consequence of sickle cell disease.
With regard to the urinalysis, Dr. Steinberg noted that Camara’s urine was clear, as
opposed to being turbid or cloudy, although it had an orange color to it. Dr. Steinberg
explained that the orange color of the urine can be caused by bilirubin that is excreted
into the urine from the kidneys. Dr. Steinberg acknowledged that a positive test for
nitrites can be an indication of bacteria in the urine. However, he noted that urine with
a high level of bilirubin more often than not results in a false positive test for nitrites.
Dr. Steinberg also testified that the one or two white blood cells in Camara’s urine was
not significant for infection, in that it was within normal limits for a woman without an
Case No. 2013-00030                      - 11 -                              DECISION



attempt for a clean-catch urine sample.           In Dr. Steinberg’s opinion, neither the
urinalysis nor Camara’s clinical presentation showed evidence that she was suffering
from a UTI.
       {¶24} Although Dr. Steinberg acknowledged that the results of the microscopic
urinalysis are not specifically mentioned in the discharge summary, he did not agree
that the lack of a notation shows that Dr. Haynes did not review the results. According
to Dr. Steinberg, upon Camara’s discharge, she was stable and was given appropriate
instructions to return if her condition worsened and to follow up with her hematologist.
Dr. Steinberg opined that it was within the standard of care to discharge Camara after
her treatment in the ER because her pain was managed and there was no need for any
further type of evaluation.
       {¶25} With regard to the cause of death, Dr. Steinberg opined that Camara
suffered an acute event, either a lethal arrhythmia or sudden cardiac decompensation
which prevented her from breathing and caused hypoxia, resulting in her death. Dr.
Steinberg also stated that once the acute event occurred, Camara suffered a massive
sickling of red blood cells because when patients with sickle cell disease are deprived
of oxygen all of their red blood cells will sickle. Dr. Steinberg strenuously disagreed
that the immediate cause of death was massive sickling.          Dr. Steinberg based his
opinion on the cause of Camara’s death on research studies that show that there are
three common sudden causes of death in sickle cell patients. One cause is a massive
pulmonary embolism from necrotic bone marrow. According to Dr. Steinberg, it is clear
from the medical records that Camara did not have a pulmonary embolism. However,
Dr. Steinberg stated that he could not distinguish the cause of her death between a
lethal arrhythmia and sudden cardiac decompensation.            Dr. Steinberg stated that
Camara also had pulmonary hypertension and myocardial disease which are conditions
related to her sickle cell disease.
Case No. 2013-00030                        - 12 -                            DECISION



       {¶26} Defendant’s final expert witness was David Talan, M.D., who is board
certified in internal medicine, emergency medicine, and infectious diseases. Dr. Talan
has been the chief of the ER department for 21 years at Olive View UCLA Medical
Center. Dr. Talan testified that he has managed patients with sickle cell disease in an
ER setting. Dr. Talan opined that Dr. Haynes complied with the standard of care and
made a reasonable decision to discharge Camara. Dr. Talan testified that a review of
the medical record shows that Dr. Haynes asked the right questions, specifically
regarding symptoms of infection; that she appropriately referenced Camara’s history of
hospitalizations regarding her treatment for sickle cell crises; that her physical exam of
Camara was well-documented; and that she made proper notes of vital signs, ordered
appropriate testing, and interpreted those tests correctly.
       {¶27} With regard to Camara’s hydration status, Dr. Talan testified that Camara
was not significantly dehydrated, based upon her clinical presentation of having moist
mucous membranes, and not complaining of diarrhea, vomiting, or an inability to take
fluids. With regard to the results of the CBC, Dr. Talan testified that Camara’s white
blood cell count of 9.0 was in the normal range. Dr. Talan stated that if a patient’s
white blood cell count is higher than normal, that is a sign of infection. With regard to
the urinalysis, Dr. Talan testified that the results do not show that Camara was suffering
from a UTI. Specifically, Dr. Talan noted that Camara’s urine was clear, despite it
being orange in color. According to Dr. Talan, if a significant amount of bacteria and
white blood cells were in her urine, the test result would have been “cloudy” instead of
clear. The urinalysis also noted that there was no blood in Camara’s urine, which is
another indicator of infection. Most importantly, Camara’s urine tested negative for
leukocytes, which Dr. Talan described as the sine qua non of infection.         Although
Camara had one to two white blood cells in her urine, Dr. Talan testified that that
amount is normal, and that an abnormal level would be 5 to 10 white blood cells. Dr.
Talan also testified that although bacteria was present in Camara’s urine, it was not a
Case No. 2013-00030                       - 13 -                              DECISION



reliable indicator of infection because the sample was not obtained through a clean
catch. He agreed that elevated levels of bilirubin make urine appear orange, and that
the orange color can signify the presence of nitrites. However, in this case, Dr. Talan
opined that the positive finding of nitrites was not dispositive of infection, because of
Camara’s elevated level of bilirubin, which more often than not results in a false positive
for nitrites. Dr. Talan also stated that there was no reason to order a urine culture
because there was not enough evidence to suspect infection based upon the results of
the urinalysis. In sum, Dr. Talan opined that there was no compelling evidence of
either a UTI or any significant bacterial infection based upon either the results of the
urinalysis or Camara’s clinical presentation.
       {¶28} Dr. Talan also opined that Camara’s clinical presentation and the results of
her blood tests did not warrant a blood transfusion. Dr. Talan agreed that Camara’s
reticulocyte count was abnormally high, but he considered that a good sign because it
showed that her bone marrow was producing additional red blood cells. Dr. Talan also
opined that Camara was experiencing a standard sickle cell pain crisis and that
consultation with Dr. Ghany was not warranted.         Dr. Talan testified that Camara’s
hemoglobin levels were not alarming and that they were within her normal range as a
sickle cell disease patient. Dr. Talan further opined that the standard of care did not
require Camara to be admitted to the hospital. In his opinion, Dr. Haynes understood
Camara’s condition and treated her appropriately. Dr. Talan also agreed that Camara
was stable when she was discharged.
       {¶29} Dr. Talan disagreed with Dr. Sklaroff’s opinion that Camara’s blood
pressure had “dropped” prior to her discharge. Dr. Talan stated that Camara’s vital
signs were stable throughout her visit to the ER. Dr. Talan stated that there was no
need for additional testing of Camara’s blood because her blood count would not have
been expected to change during her visit to the ER. In Dr. Talan’s opinion, Camara
Case No. 2013-00030                        - 14 -                              DECISION



was having an uncomplicated sickle cell pain crisis that was treated appropriately by Dr.
Haynes.
       {¶30} With regard to the cause of death, Dr. Talan opined that Camara died as a
result of an acute event, most likely an arrhythmia, because she suffered from chronic
myocarditis. Dr. Talan agreed that a massive sickling at death is not unexpected in a
sickle cell patient, but that the massive sickling would have naturally occurred after the
acute event caused her heart to stop. Dr. Talan also found it significant that there was
no evidence of infection on the autopsy.
       {¶31} Upon review of the evidence, the magistrate finds that the testimony of
defendant’s medical experts was more persuasive than the testimony of plaintiff’s
medical experts.     Based upon the testimony of Drs. Steinberg and Talan, the
magistrate finds that Dr. Haynes’ treatment and care of Camara met the applicable
standard of care in all respects. The magistrate finds that Dr. Steinberg’s experience
in the field of sickle cell disease, and Dr. Talan’s experience as an ER physician and his
research in the field of infectious diseases lend greater credibility to their opinions that
the standard of care was met in this case. In contrast, the magistrate finds that the
testimony of Dr. Sklaroff, whose CV shows that his research is more focused in the field
of oncology, who is not board certified in hematology, and has not practiced medicine in
an ER setting since the 1970’s, was not particularly persuasive regarding the standard
of care for treatment of patients with sickle cell disease. The magistrate finds that
defendant’s experts clearly had superior knowledge of both sickle cell disease and
infectious diseases in general. In sum, the magistrate finds that Dr. Steinberg and Dr.
Talan’s testimony that Camara was not suffering from a UTI on July 28, 2009 is credible
and persuasive. The greater weight of the evidence support’s defendant’s theory that
Camara did not have an active infection during her July 28, 2009 ER visit, and,
therefore, that an untreated UTI was not the cause of her death.
Case No. 2013-00030                        - 15 -                              DECISION



       {¶32} Moreover, with regard to proximate cause, the magistrate further finds that
defendant’s experts presented competent, credible evidence to rebut the coroner’s
finding that Camara’s cause of death was a massive sickling of cells. See Vargo v.
Travelers Ins. Co., Inc., 34 Ohio St.3d 27 (1987), paragraph one of the syllabus
(holding that a coroner’s findings are non-binding and may be rebutted by competent,
credible evidence.) Defendant’s experts’ testimony persuades the magistrate to find
that the massive sickling of red blood cells was more likely than not a result of her
death, not the proximate cause of it. For the foregoing reasons, the magistrate finds
that plaintiff has failed to prove his claim of wrongful death by a preponderance of the
evidence, and judgment is recommended in favor of defendant.
       {¶33} A party may file written objections to the magistrate’s decision within 14
days of the filing of the decision, whether or not the court has adopted the decision
during that 14-day period as permitted by Civ.R. 53(D)(4)(e)(i). If any party timely files
objections, any other party may also file objections not later than ten days after the first
objections are filed. A party shall not assign as error on appeal the court’s adoption of
any factual finding or legal conclusion, whether or not specifically designated as a
finding of fact or conclusion of law under Civ.R. 53(D)(3)(a)(ii), unless the party timely
and specifically objects to that factual finding or legal conclusion within 14 days of the
filing of the decision, as required by Civ.R. 53(D)(3)(b).




                                           _____________________________________
                                           HOLLY TRUE SHAVER
                                           Magistrate
 Case No. 2013-00030               - 16 -                              DECISION



cc:


Chris C. Tsitouris                   Daniel R. Forsythe
150 East Mound Street, Suite 206     Assistant Attorney General
Columbus, Ohio 43215-5429            150 East Gay Street, 18th Floor
                                     Columbus, Ohio 43215-3130

Filed February 13, 2015
Sent To S.C. Reporter 12/31/15
