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ROSNER CASE: Surgeon bolsters plaintiff's case on necessity of surgeries

Dr. Domagoj Coric explains a surgical procedure to the jury in the Justus v. Rosner medical malpractice trial.

By Bill Moss, Published: August 15, 2014

The last surgeon to treat Pamela Jane Justus before her death testified Thursday that in his opinion the operations Dr. Michael Rosner performed on her were not warranted by the condition of her spine and were a contributing factor to her death 12 years later.

Dr. Domagoj Coric, a Charlotte neurosurgeon who operated on Pam Justus in 2004 and 2011, was called to testify on the fourth day of a medical malpractice trial in the lawsuit brought by Mrs. Justus's husband, Billy Bruce Justus, against Dr.  Rosner and Park Ridge Hospital and its parent company, Adventist Health System.
The case, which opened Monday in Henderson County Superior Court, is expected to last up to six weeks.
The plaintiffs' lawyers were in their fifth day of putting on testimony on Friday. They have shown a videotape of Pam Justus's deposition in 2012, five months before her death, and have called a public relations consultant who helped Dr. Rosner prepare for a "20-20" television news story, a medical ethicist and three physicians who treated Pam Justus.
The plaintiffs are trying to prove that Rosner performed unnecessary surgeries that instead of curing her headaches left her wheelchair-bound and unable to lift her head and that — by leaving her immobile and unable to exercise — contributed to her death.
Defense attorneys have framed their own case repeatedly throughout the week, promising the jurors that they will hear testimony from physicians, surgeons and other medical experts that rebuts the plaintiff's case. Pam Justus, the lawyers have suggested in pretrial motions and during cross-examination, suffered from multiple serious medical problems, was obese all her adult life and was a heavy smoker. Eighteen doctors in 12 different specialties, they say, had been unable to find a cure for her severe daily headaches by the time she walked into Dr. Rosner's office in 2000. Two surgeries, that June and the following February, they argue, were medically warranted and cannot be linked to her death 12 years later from diabetes-related fatty liver disease.

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Coric's testimony bolstered the plaintiff's case that Rosner's surgery was unwarranted.

"I stand by my statement that immobility from the two surgeries was a contributing factor" in her death, he said.
Mike Easley, the former two-term North Carolina governor and two-term attorney general who is a co-counsel for the plaintiffs, guided Coric through a lengthy presentation about the June 2000 surgery and Pam Justus's condition before that as shown on MRI scans.
Coric said he reviewed the pre-Rosner surgery MRI at Justus's request.
"You asked what specifically had changed and I would tell you the trigger to that was Mrs. Justus asking me to review her film," he said. "At some juncture she said to me, 'As a favor to me, your patient' — and I still had a relationship with her as my patient — 'will you review the film and give me an opinion.' And I felt like that was important to her peace of mind and I said, 'Yes, I will do that.' Once I reviewed those films it became obvious to me that in fact, I don't think that surgery was indicated and it was a departure from standard of care."
Coric said Justus's MRIs before the first Rosner surgery showed no physical condition that warranted the spinal decompression surgery the neurosurgeon performed.
"In order to justify that type of procedure you would need to see some sort of neurological compression on an MRI scan and that simply was not evident here," he said.

He pointed to a blowup of Justus's MRI sitting on an easel in from the jury.

"There's no evidence for any disturbance of the flow of spinal fluid and no evidence of compression lower down," he said. "I think what you're asking me is there anything that would warrant doing a major type of spine operation where you would be removing a bunch of these laminates in order to free up the spinal cord and the answer is no."

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Still suffering from headaches and unable to walk or lift her head, she traveled to Charlotte to see Dr. Coric in 2004.
"After Mrs. Justus's previous operation, she developed what we call chin-on-chest deformity," he said. "She came to me with her chin literally on her chest, and was in a wheelchair, she couldn't ambulate because she couldn't see straight. What had happened was she developed a deformity because of the removal of the supporting structures from the back of the spine — the lamina and the way it protects the muscles — a known complication where your spine begins to move forward. That's exactly what occurred with her." Using screws and rods, he performed an operate that "takes her head and brings it back and fixes it in that position." It worked until 2011, when a rod in her back broke, a failure the defense attributed to her smoking. Coric operated again to repair the damage.
"It was not quite as large a surgery as the first one but still in the big picture a huge surgery," he said. "But she was adamant again that she had lost the little quality of life she had and she wanted to regain that back and she was adamant that she wanted to be ambulatory. She had insight into her condition. I think she understood toward the end that she was not going to be able to survive for long but she wanted to be able to have some quality of life towards the end of the walk."

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Rosner's lead defense attorney, Scott Stevenson, raised a vigorous objection to Coric's testimony, accusing the plaintiffs of "trial by ambush" because his comments linking the Rosner surgery to her death went beyond views he had expressed in three different pretrial depositions. The under-oath interviews by lawyers are designed to forecast the testimony of witnesses who will provide trial evidence. Judge Zoro Guice overruled his objections.
Regrouping, Stevenson used his cross-examination of Coric to get in the record — for the jury's benefit — the opposing view.
The jury, he told Coric, will hear a much different story from Dr. Peter Jannetta, a neurosurgeon at the University of Pittsburgh who has testified for Rosner before the North Carolina Medical Board.
"You know that Dr. Peter Jannetta has a good reputation," Stevenson said. "In fact, you've heard that the North Carolina Medical Board referred to him as a world renowned neurosurgeon. You're aware that Dr. Jenetta is going to come in and disagree with your opinion and support Dr. Rosner's operation and tell this jury that it was within the standards of care. Are you aware that there's going to be some testimony ... and that the expert for the North Carolina Medical Board said that he found nothing wrong with this first operation — the C2 to C7 laminectomy — thought that it was within the standards of practice?"
Coric responded that the operation might have been conducted fine.
"My opinion as her treating physician is that that surgery was not indicated," he said. "What I am saying is over the course of having both of those operations over that period of time and having subsequently developed the problems that she had, that (operation) needed to be justified by some sort of neurological compression, which was not evident on her scans before either of her surgeries. ... The question is whether there's an indication for it. It's not the problem with the procedure, it's the problem with the indication."
Stevenson tried to draw a parallel between Corek's surgery and Rosner's — suggesting that both undertook major, potentially high-risk surgeries to relieve Pam Justus from her "intolerable" situation. His peers might question his surgeries, Stevenson said, just as Coric questioned Rosner's. Coric wouldn't bite. The difference, he said, was that her actual physical condition at the time justified his surgery.
"It's conceivable that they might question the operation," he said. "I don't think it's conceivable that they would characterize it as a deviation from the standard of care. The worse off you are — in other words the more potential benefit you would have — the more open you are to risk. If you're doing so very poorly, if you have an obvious mechanical problem, if there is an ability to address that I think that has to be taken into consideration. ... If the risk is going to be that large, but the benefit is that I can give you a semblance of a normal life then you would potentially take that risk."
Stevenson again pressed the point about operating to relieve extreme pain — in Justus's case on a patient described as suicidal and "at the end of her rope." Coric resisted the comparison.
"If a patient comes into my office and says, 'My arm hurts, will you chop it off?' I don't feel the need to offer to chop their arm off. If they come in and they say 'I've got a disk bulge and it's pinching on that nerve, would you operate?' I think that's a different discussion."
"A reasonable person would not look at those films and not say there was obvious structural pathology" in Justus's spine when he operated in 2004, he said. "I'm here to tell you I don't think she had any type of significant pathology before Dr. Rosner and I think there's a lot of reasonable doctors who would say the same, even though some reasonable doctors may say the contrary. There might be some argument there. There is no argument if you showed the film before my operation. I literally would tell you that 100 percent of people should tell you that there is a structural problem there."