Savannah, GA—A Chatham County State Court jury returned a verdict in favor of a pain management physician and his clinic in a malpractice suit brought by a highly decorated former U.S. Army Ranger whose military career ended after receiving an epidural steroid injection administered by the doctor. Keith Morges and Crystal Morges v. Savannah Pain Management, Inc. et al. (STCV1200305)
On April 13, 2011, Keith Morges, a Sergeant First Class who had over ten overseas tours during his military career and was injured multiple times, visited Dr. Keith Kirby at the Savannah Pain Clinic to get relief for his back and leg pain. During the visit, Dr. Kirby administered a transforaminal steroid injection to Morges, who immediately experienced considerable pain. Morges was taken to Memorial Hospital for further treatment.
Morges currently is unable to urinate normally and self-catheterizes daily, a condition that is likely to be permanent. He received a discharge from the U.S. Army due to his medical condition.
In his suit against Dr. Kirby and the clinic, Morges alleged that the epidural injection caused a spinal cord stroke that resulted in nerve damage that, in turn, caused his bladder problems. He further alleged that the technique employed by Dr. Kirby violated the standard of care. Dr. Kirby denied that his treatment of Morges was negligent or that the bladder condition resulted from the injection. During the week-long trial, both sides called several expert witnesses to bolster their cases.
Dr. Andrew Shapiro, a Baltimore, MD, urologis, testified for the plaintiff that he began treating Morges in December, 2014, while Morges was visiting Maryland. He diagnosed Morges as suffering from a neurogenic bladder caused by damage to the spinal nerves. Dr. Shapiro said he had treated hundreds of patients with a neurogenic bladder during his career. He believed the condition prevented Morges from urinating normally, a condition known as urinary retention, requiring him to use a catheter. Dr. Shapiro said such an injury would not necessarily prevent a patient from walking or eliminating normally.
Dr. Shapiro also concluded, based on his examination of Morges and Morges’ medical history that the bladder condition stemmed from the spinal injection. He noted that Morges’ symptoms started at that time of the injection and that physical examination of Morges’ bladder revealed no evidence of a preexisting bladder condition. Dr. Shapiro noted that Morges had complained of bladder hesitancy (a slowness to urinate) before receiving the injection but said such a condition was not related to Morges’ subsequent bladder retention. Dr. Shapiro also opined that Morges’ bladder retention was not caused by any medications he had taken. On cross examination, he conceded that Morges was the only patient he had treated who had suffered this particular type of injury as a result of an epidural injection.
Dr. Mark Wallace, a pain medicine specialist, also testified for Morges. He opined that the greatest risk involved in epidural steroid injections such as the one Morges received was from injecting particulate material into an artery, which could result in a “catastrophic” spinal cord injury. In his view, doctors should take all reasonable and acceptable precautions to limit that risk.
In Dr. Wallace’s opinion, physicians could limit the risk of spinal cord injury by (1) using non-particulate steroids, (2) using an alternative to a transforaminal injection, during which the needle was in close proximity to the artery, and (3) by using digital subtraction imaging in addition to a standard fluoroscopy for greater visibility. He felt Dr. Kirby violated the standard of care by failing to take at least one of those precautions and that the steroid injection caused Morges’ bladder problems. However, on cross examination, he acknowledged that probably over a million transforaminal injections had been performed using particulate steroids, but his research only uncovered one case in which a patient suffered bladder damage without loss of motor or other functions.
Dr. Philippe Gailloud, an expert in spinal cord strokes, also testified for Morges. He said that a blockage in a spinal artery can cause a spinal cord stroke and nerve damage. He added it was very common in cases of spinal cord stroke for other doctors to read the MRI as normal because the signs of a stroke can be quite subtle. Dr. Gailloud confirmed that he had treated patients who had suffered bladder damage but could still walk. He reviewed one of Morges’ MRIs taken after the injection and determined that Morges had suffered a cord stroke and that the injection caused the injury. Although other MRIs taken after the injection did not show signs of a spinal cord stroke, in Dr. Gailloud’s opinion those MRIs were inconclusive because they did not show the area where the stroke occurred or were of low quality. He also felt that Morges’ symptoms were consistent with a stroke, especially the pain he suffered immediately following the injection.
Dr. Ross Rames, a urologist, testified for the defense. He noted that Morges had a history of urinary hesitancy dating back to 2009 and that it was connected with his use of the pain medication Dilaudid. Further, Morges also received Dilaudid after being admitted to the emergency room immediately after the epidural injection. In Dr. Rames’ opinion, the epidural injection did not cause Morges’ bladder problems, but it was instead caused by sensitivity to Dilaudid.
Dr. Rames believed that Morges would have had an immediate bladder problem with resulting urinary retention if he had suffered a stroke as a result of the injection. Instead, hospital notes two days after the injection indicated that Morges could urinate on his own with the use of Flomax. Dr. Rames also noted that the results of an EMG performed on Morges shortly after the injection that did not reveal any nerve damage. Dr. Rames added that he had never seen a case of a neurogenic bladder without any other neurological effects. On cross examination, he acknowledged that Morges had never complained of urinary retention prior to the injection.
Dr.Clifton Cannon, a neurosurgeon, also testified by video deposition for the defense. His assistant examined Morges two weeks after his injection, and Dr. Cannon found no evidence of a neurological injury at that time that could have caused Morges’ bladder problems. Specifically, he did not believe Morges suffered a spinal cord stroke during the injection, or Morges would have had more serious symptoms. Instead, Dr. Cannon believed that Morges’ bladder problem was caused by a reaction to the medications he had received.
Dr. Allen Elster, a neuroradiologist, testified for the defense. He reviewed Morges’ MRIs and found no evidence of a spinal cord stroke. In addition, he believed that Morges’ symptoms were not consistent with having suffered a stroke. He believed that Dr. Gailloud may not have been familiar with the most recent developments in MRI technology, which may have led Dr. Gailloud to make an incorrect diagnosis.
Dr. Richard Rauck, an expert in pain medicine, also testified for the defense. He felt that Dr. Kirby’s treatment of Morges did not violate the standard of care. He said that he commonly administered transforaminal epidural injections in his practice and would also have given Morges a transforaminal injection because that type of injection was more effective in alleviating the type of pain Morges suffered. In addition other types of injections also carried risk. Dr. Rauck estimated that about 20 million transforaminal injections had been given in the last 10 years in the United States with fewer than 10 reported catastrophic results.
Dr. Rauch also believed that particulate steroids were more effective than non-particulate steroids in treating pain. Finally, digital subtraction imaging was not in wide use in the United States at the time of Morges’ injection and, in Dr. Rauck’s opinion, was not required to meet the standard of care.
Following the trial, William Hunter, one of Dr. Kirby’s attorneys, praised Morges and his wife Crystal, who was also a plaintiff in the case, calling them “remarkable people.” He added that Morges’ distinguished military career made trying the case especially difficult. He described the trial as tough and hard fought and complimented Morges’ attorneys for doing a “great job” during the trial. Attorneys for Morges were not available for comment.
Attorneys involved in the case include Roy Kelly IV of Savannah's Kelly & Kelly and Owen Murphy of Savannah for the plaintiffs, and I. Gregory Hodges and William Hunter of Savannah's Oliver Maner representing the defendants.
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