Susan Green v. Integris Health, Inc. d/b/a as Integris Baptist Medical Center

IN THE DISTRICT COURT OF OKLAHOMA COUNTY STATE OF OKLAHOMA Susan Green, Widow and Next of Kin to Randall Green, deceased Plaintiff, v. Integris Health, Inc. d/b/a as Integris Baptist Medical Center, James Lunsford, D.O., Vij Vikas, M.D. Defendants. ORIGINAL PETITION Plaintiff, Susan Green, as widow and next of kin of Randall Green, deceased, hereby alleges and states as follows as to the above-named Defendants. 1. Plaintiff is the widow of the deceased and brings the instant cause of action pursuant to 12 O.S. §1053 and §1054 or in the alternative, pursuant to 12 O.S. §1051. 2. Plaintiff resides in Oklahoma County, and Randall Green passed away in Oklahoma County on June 25, 2025. 3. Venue and jurisdiction are proper before this Court because at all times the alleged negligence which is the basis for Plaintiff’s cause of action against Defendants occurred in Oklahoma County, Oklahoma. 4. At all relevant times herein, Defendant Integris Health, Inc. did business as Integris Baptist Medical Center ("Baptist Medical Center") and held itself out as a health care provider and facility providing medical care and treatment in Oklahoma County, Oklahoma. 5. At all relevant times herein, Defendant James Lunsford D.O. ("Dr. Lunsford") was a licensed medical doctor in the State of Oklahoma holding himself out as a specialist in emergency medicine and as an employee and/or actual and/or ostensible agent of Integris Health, Inc. 6. Mr. Green came under the care of Dr. Lunsford through his emergency department visit to Baptist Medical Center on December 8, 2023. 7. At all relevant times herein, Vij Vikas, M.D. ("Dr. Vikas") was a licensed radiologist in the state of Oklahoma and acted an employee and/or actual and/or ostensible agent of Baptist Medical Center. 8. Mr. Green came under the care of Dr. Vikas through his emergency room department visit to Baptist Medical Center on December 8, 2023. 9. On December 8, 2023, Mr. Green was moving some things at his home to be donated when he experienced a traumatic fall outside his home, striking his head and face. 10. EMSA arrived to his home and noted a primary impression of "extremity pain" followed by a secondary impression of "injury of head." 11. EMSA positioned Mr. Green on a stretcher and noted that Mr. Green could not tolerate the C-Collar for his neck and transported him to Integris Baptist Medical Center Emergency Department. 12. Upon arrival to Baptist Medical Center, Dr. Lunsford was assigned as attending physician. 13. In the history of present illness, it is notated that Mr. Green fell "striking his head on the bumper" of his truck and had complaints of right hand and left shoulder pain along with "severe head pain and neck pain" that are worsened with "movement." 14. Mr. Green was assessed by Dr. Lunsford as having a closed head injury, accidental fall, laceration of scalp without foreign body, finger laceration, hand sprain, and sprain of left shoulder. 15. Even though Mr. Green presented on a stretcher with complaints of extreme pain to his entire body, lower extremity weakness, difficulty with moving his hands, and the inability to walk, this was not documented by Dr. Lunsford or the nursing staff. 16. Mr. Green was accompanied by his family at the emergency department, who informed the treating physicians and nursing staff that since the fall he could not walk and suffered from lower extremity weakness. 17. Mr. Green's inability to walk and difficulty moving his lower and upper extremities are objective symptoms which should have been readily identifiable to hospital staff and his treating physicians. 18. At the time of the fall, the family had a group chat to keep everyone updated on his condition. See below text messages. 19. A CT exam was ordered for Mr. Green’s head and cervical spine. 20. Dr. Vikas interpreted the CT scans and instead of creating a detailed report, merely noted that there appeared to be “multilevel disc-osteophyte complexes result in up to moderate spinal stenosis. Neural foraminal stenosis is severe at some sites.” In his impression, he notes “no acute fracture” and “multilevel disc degeneration.” 21. It is unclear if Dr. Vikas was informed that Mr. Green was experiencing weakness to his lower extremities. 22. It is unclear if Dr. Lunsford informed Dr. Vikas that Mr. Green had spinous process tenderness at C5-C6. 23. Severe neural foraminal stenosis and moderate spinal stenosis in a patient with lower extremity weakness and a traumatic neck injury should have prompted further testing, including an MRI of Mr. Green’s cervical spine and a referral to neurology. 24. Dr. Lunsford stitched up the laceration to Mr. Green’s head, sutured the injury to his right index finger, splinted that finger, and prescribed oxycodone-acetaminophen 5-325 MG per tablet to be taken by mouth every six hours as needed for pain up to five days and then discharged Mr. Green. 25. Mr. Green and his family had arrived at the emergency department at 8:05 p.m. and he was ordered to be discharged at 10:18 p.m. 26. Baptist Medical Center and Mr. Green’s treating physicians, including Dr. Lunsford, chose not to admit him for observation or more testing even though Mr. Green suffered a traumatic neck injury due to his fall. 27. Mr. Green was discharged with no recommendation to follow up with a neurologist. 28. Mr. Green was discharged without any treating physician, including Dr. Lunsford, ordering a cervical MRI. 29. Mr. Green was discharged with blood still on his face, hospital staff had to physically move him from the hospital bed to a wheelchair for discharge, and he was pushed in a wheelchair to his family’s vehicle where staff had to help pick Mr. Green up and put him into the vehicle to go home. 30. When Mr. Green and his wife got home, she had to place him in a computer chair with rolling wheels due to his inability to walk. Mrs. Green made Mr. Green a pallet on the floor because he could not physically get into the bed. 31. At home, he continued to deteriorate, did not regain any function to his legs, continued to lose function, and continued to be in immense pain. 32. Due to Mr. Green’s continued pain and inability to ambulate, on December 12, 2023, Mr. Green’s primary care physician was contacted who informed Mr. and Mrs. Green to immediately go to the hospital to get an MRI. 33. Given Mr. Green’s condition, EMSA was called to transport Mr. Green to Mercy Hospital on I-35. 34. The EMSA records from December 12, 2023, note that Mr. Green was experiencing “extremity pain” and “weakness” with an onset date of December 8, 2023. The comments go on to state that Mr. Green was experiencing “chronic neck pain from fall.” See below record excerpt: CC: 65 M General weakness Hx: Arrive on scene to find the Pt laying on the floor beside the bed inside the bedroom of the residence. Pt reports that he fell this past Friday and was evaluated at Mercy main. Since then he has been unable to ambulate. Pt has been crawling around his residence for the past 4 days and his primary care recommended he go via ambulance to Mercy I-35. A: Pt is A0X4, GCS 15. Skin is pink, warm and dry to touch. Airway is patent with Pt speaking in full sentences and no increased work of breathing. Pupils PERLRA 3 mm, lungs clear bilaterally to auscultation. Pt has various abrasions noted. Rx: Pt transferred to the cot via mega mover, secured with seatbelts x 5. General supportive care administered, BGL 93. T: Pt transported to Mercy I-35. Pt care transferred to ED staff with report given at bedside. 35. On December 12, 2023, Mr. and Mrs. Green presented to Mercy Hospital on I-35 before being transported to Mercy Hospital in Oklahoma City due to the immediately recognized need for Mr. Green to have a cervical spine MRI done based on his symptomatology and traumatic injury to his head and neck. See below EMSA record from the trip from Mercy I-35 to Mercy emergency department in Oklahoma City. AOS to find a 65 y/o male laying in bed at Mercy I35 ER. Pt. was brought in for lower back pain by EMSA ambulance earlier this afternoon. He had a mechanical fall on Saturday and was evaluated at BMC. He has had decreased mobility in his hands and upper extremities since this fall. He was not dx. w any specific vertebral fx, or spinal cord Injury at ER, and is being tx. to Mercy ER for further eval and an MRI. Pt. has no new complaints upon EMSA arrival. Upon assessment, pt. is A&OX4 w/ normal respirations. He is positioned on gurney. He remains A&OX4 w/ normal respirations en route to ER and he has no further complaints upon arrival to destination. He is tx. from gurney to bed. Report and tx. of care is given to facility RN. 36. The cervical spine MRI was ordered and performed at Mercy Hospital in Oklahoma City which showed the following below: IMPRESSION: 1. A 6 mm posterior disc herniation at C4-C5 level results in advanced 4 mm spinal canal stenosis and advanced cord compression at C4-C5 level. There is an increased T2 signal in the cord at C4-C5 level and C5 level, consistent with compressive myelopathy. Neurosurgery consult is recommended. 2. Moderate 7 mm spinal canal stenosis at C5-C6 level without cord compression. 3. Moderate bilateral C2-C3 foraminal stenosis, advanced left C3-C4 and C4-C5 foraminal stenosis, moderate right C3-C4 and C4-C5 foraminal stenosis, advanced bilateral C5-C6 and C6-C7 foraminal stenosis. 37. The doctor at Mercy notes the following regarding the history of Mr. Green's complaints: REEVALUATION: 0030 -I assumed care of this patient at 2100 while attempts were being made at obtaining an MRI of the cervical spine. The patient's history was reviewed. The patient recent medical issues were discussed with his wife. The patient reportedly had a fall on Friday where he was evaluated at Baptist Hospital. He had a CT of his head and neck done at that time. The CT of his head showed a dermoid cyst with some mild mass effect on his frontal temporal lobes. There is also some evidence of fat globules in his cerebrospinal fluid indicating past rupture of the dermoid. The wife reports that the dermoid did rupture when he was approximately 38 years old. He had a severe headache and altered mental status at that time. She reports that since then he has had occasional episodes of confusion and hallucinations. He does have a history of both bipolar disorder and suspected partial seizures. She reports that in the past week the patient just started back on the Zoloft in addition to his other medications which included Lamictal and Depakote. She reports that Friday he was given a prescription for oxycodone and started taking that. The CT scans from Baptist Hospital were reviewed. The patient does have some Moderate cervical spinal stenosis. He did not have any obvious fractures. The wife notes that the patient has been unable to ambulate since that fall on Friday. She reports that he was having significant weakness in his arms and legs as well as severe burning sensations in his upper extremities and trunk. The wife reports that they had to lift him from the wheelchair at Baptist Hospital into the truck to take him home. He was basically carried and placed on the couch in his house. She reports that his confusion would get worse when he was taking the oxycodone. She said it seemed at times like he may be having hallucinations. She reports that he continued to fall off the couch and would just lay on the floor. The family placed cushions on the floor for him to lay on. The wife states he has had trouble controlling his arms since Friday. She reports he has been unable to ambulate since Friday. The patient was seen initially tonight at Mercy I 35. He was transferred here for MRI of his cervical spine given his recent symptoms. His symptoms are highly suspicious for central cord syndrome. The mental status changes may be multifactorial given his history of bipolar disorder, partial seizures, and recent medication changes. Prior to me taking over care of this patient, he was sent to MRI the first time. Dr. Edwards reported to me that the patient was extremely agitated and MRI and was punching staff. They sent him back down to the ER where he was given Ativan 2 mg IV for sedation in an attempt to get the MRI. I took over at that time with the patient after he was sedated waiting for the second attempt at MRI. The patient was again taken to MRI but again was found to be combative and agitated. He was punching staff. I do not feel he realized what he was doing and it was simply secondary to his agitation. The patient was brought back down to the ER. On his exam at that time he is oriented to person only. He does not understand why he is in the ER. He does not know where he is or the month. He is extremely agitated and flailing his extremities on the bed. He continues to stick his arms and legs through the bed rails and attempt to get out of bed. I continued discussing the situation with the wife. I feel like it is extremely important to obtain the MRIs not only of his cervical spine but his head is well to guide care and appropriate treatment of this patient. I felt like the only way to do that safely at this time would be to place the patient on mechanical ventilation and use sedation and paralytics to complete his MRI studies. After discussions with the wife and the daughter over the phone regarding the risk and benefits, they have agreed to allow me to continue with this course of action. 0321: The patient’s workup was completed at this time. I have discussed the findings with the patient’s wife. Unfortunately, his MRI of his cervical spine shows herniated disc with significant compressive myelopathy on his cervical spine. These findings and his symptoms have been relayed to Dr. Stetson with neurosurgery. The plan at this time is for urgent neurosurgical decompression this morning in the OR. The patient will be admitted to the ICU with a goal of keeping his mean arterial pressures above 85. While the MRI findings explain the patient’s inability to ambulate and the weakness in his arms and legs since Friday, it does not explain his worsening altered mental status in the ER. At this time I suspect that he had a adverse reaction to the Ativan which made his mentation much worse. I discussed this with the wife. She does not believe the patient has ever had Ativan in the past. At this time, I feel like his worsening mentation may simply represent a paradoxical drug reaction to the Ativan that he was given in an attempt to obtain his MRI. Given the findings on his cervical MRI, we will keep the patient sedated and on the ventilator at this time. Will try to limit his movement and keep his c-collar in place. 38. Mr. Green was assessed with having acute traumatic central cord syndrome which is a sudden injury to the spinal cord caused by trauma and a C4-5 and C5-6 anterior cervical discectomy and fusion was recommended and performed. 39. Mr. Green continued to have some residual compression, and a second surgery – a posterior C4-C7 decompression and fusion – was ordered and performed to alleviate the residual stenosis in order to “provide him the best chance possible for recovery.” 40. Unfortunately, Mr. Green had a complicated post-surgical recovery including excessive respiratory secretions with dysphagia and the need for oxygen. He was transferred out of the ICU post-surgery but due to his breathing difficulty, he was transferred back into the ICU on December 23, 2023. 41. Mr. Green also developed aspiration pneumonia of both lungs, sepsis, and a gastric tube was placed due to his dysphagia. 42. Mr. Green was discharged January 20, 2024 to the Mercy Logan County Swingbed Unit. 43. He ultimately was discharged home; however, he never regained his functionality he had before the fall including the ability to walk or use his hands properly. 44. Mrs. Green’s new reality was to provide 24-hour care to her husband who was now bed bound and required assistance with all activities of daily living. 45. Home health care would come occasionally to assist Mrs. Green; however, the majority of the patient care was up to her. 46. Before the fall, Mr. Green was independent and able to walk and had full use of his upper and lower extremities. 47. Unfortunately, Mr. Green never recovered and passed away on June 25, 2025 due to complications from pneumonia and dementia. 48. All Defendants owed a duty to provide reasonable and necessary care to the deceased while he was under their/its care and control, which Defendants failed to do. 49. Defendants knew or should have known that Mr. Green required admission to the hospital and at the very least a cervical MRI which would have shown the acute traumatic central cord syndrome due to Mr. Green’s fall. 50. A CT exam of the cervical spine alone cannot identify myelopathy and based on Mr. Green’s lower extremity weakness, pain, difficulty with fine motor skills, the cervical CT findings, and the acute traumatic injury to his neck, an MRI should have been ordered to rule out the possibility of spinal cord compression. 51. Failure to order an MRI of Mr. Green's cervical spine was a violation of the standard of care. 52. Failure to consult neurology was a violation of the standard of care. 53. By conducting the proper imaging, neurology could have been consulted in a timely and appropriate manner and the necessary treatment for this emergent condition could have been provided to Mr. Green which would have greatly enhanced his quality of life and improved his recovery. 54. Instead, he was sent home with no recommendation to consult neurology, no neck brace, and no instructions to his family on how to proceed or signs and symptoms to watch out for. 55. Once spinal cord compression begins to cause symptoms, the damage usually progresses from reversible, to minimal, to substantial. The failure of nursing staff to notify the treating physicians of Mr. Green's lower extremity weakness caused a significant delay in the diagnosis which directly led to substantial injury to Mr. Green in the form of permanent and substantial weakness / paralysis to his arms and legs and inability to ambulate. 56. Defendant Baptist Medical Center failed to properly chart and notate Mr. Green's symptomatology and communicate this to his treating physicians. 57. Defendant Dr. Lunsford failed to properly chart, notate, and take into consideration Mr. Green's very obvious lower extremity weakness leading to him being improperly discharged with a compromised and unstable cervical spine. 58. Defendant Dr. Vikas failed to properly document the compression Mr. Green had in his cervical spine and inform the treating physicians of the seriousness of the stenosis. 59. Defendants' individual and concurrent actions constitute negligence, gross negligence, and a reckless disregard for the safety of the deceased and all others so situated. 60. Defendants' individual and concurrent actions caused the deceased pain and suffering, medical expenses, burial expenses, mental pain and anguish, loss of consortium for Mrs. Green, grief and loss of companionship for Mrs. Green and their children, and other economic and noneconomic damages. WHEREFORE, Plaintiff demands judgment against the Defendants for compensatory and punitive damages in an amount that will exceed the amount required for diversity jurisdiction and all further relief that she may be entitled to in law and equity. Respectfully submitted by: [signature] Riley M. Bisher, OBA # 32734 Rick W. Bisher, OBA # 12215 Ryan, Bisher, Ryan & Simons 4323 NW 63rd St. Suite 110 Oklahoma City, Oklahoma 73116 (405) 528-4567 (405) 525-2123 Facsimile [email protected] [email protected] ATTORNEYS FOR PLAINTIFF ATTORNEY LIEN CLAIMED AND JURY TRIAL DEMANDED DISCOVERY SERVED WITH PETITION AND SUMMONS