A man is hospitalized with a pulmonary embolism. And after three doctors failure to treat him, a cardiologists gives his heart a stress test, killing him.

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Stephen Schaak, an otherwise healthy 51-year-old merchant marine, husband and father of three sons, went to the emergency room exhibiting clear signs of pulmonary embolism – a blockage of the oulmonary artery or one of its branches to the lung.  The emergency room doctor suspected as much and ordered a CT scan to confirm.

Inexplicable, the results of the CT scan were misinterpreted as being negative when they in fact were positive.  The radiologist claimed that he told the ER physician that the results were positive even though the ER physician clearly wrote “negative” in the records.  If the scan had been noted correctly, the life saving anticoagulation treatment would have been started immediately and maintained until he was out of danger.

Sadly, though, anticoagulants that were started shortly after admission to the hospital were stopped hours later and not restarted because of a communication breakdown between various doctors.  While waiting for an additional test to be performed to further look for pulmonary embolism, a cardiologist who knew nothing about a suspected pulmonary embolism put Stephen on a treadmill to stress his heart.  If the cardiologist had communicated with the primary care physician, he never would have performed a cardiac stress test because of the elevated risk it presented for a patient like Stephen with suspected pulmonary embolism.  The simple and essential communication never occurred and within one minute of starting the exercise treadmill test, Stephen Schaak dropped to his knees and could barely breathe.  

Roughly twelve minutes later he was dead.

One of the expert witnesses in the case remarked that the events were akin to three fielders in baseball watching a pop up fall between them – except in this case the fielders were doctors with a patients life at risk.

The horrific chain of events led to his death just short of his 26th wedding anniversary.  Stephen’s condition was treatable and he should have enjoyed a normal life expectancy for himself, his wife, his sons – and his newborn grandchild.

At the time that this was resolved in 2013, the claims of Stephen’s wife and three surviving sons were still limited to the maximum amount of $250,000 to share between them for their emotional loss – this inadequate limit being the  result of the legal restriction imposed in 1975.

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