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Her cancer signs were ignored

For almost three years, Edith Ahle's doctors were baffled by the pain that gripped her gut.

They told the Largo resident she suffered from an "irritable bowel" and suggested she see a psychiatrist. Nurses called her a whiner. Out of frustration, she moved to Pinellas Park so her health plan would assign her a new set of doctors.

When they finally discovered that cancer was eating away her small intestines, it was too late. Ahle died in 1991 at age 40, leaving behind a disabled husband and two children.

Replayed in a Clearwater courtroom, Ahle's symptoms spoke forcefully to a new audience. A jury, deciding that two doctors had botched her care, awarded her family $3-million in damages.

"Somebody finally believed my mom, when she said nobody did their job right," son Gregory Ahle said last week. "She said before she died that she wanted us to make sure that nobody got away with it. She didn't."

William Jonassen holds a different view of Ahle's cancer. He represents Dr. Samuel Pettina, her primary care physician with the Humana Gold Plus plan.

Cancer of the small intestines is so rare that diagnosis often comes too late, Jonassen said. "This was a million-to-one case," he said. "Dr. Pettina didn't fail this particular woman. The science of medicine did."

"Overall statistics don't apply to this kind of family history," countered Wil Florin, a family attorney. "We have a lady with three family members who died of GI (gastrointestinal) cancer. When the average Joe goes to the doctor and says, "I have a stomach pain,' you don't necessarily think GI cancer. When a 38-year-old woman gives this history and says, "I have a stomach pain, you have to think GI cancer."

Stomach hurts all the time

Edith Lawless was only 15 when she met John Ahle in a small Texas town. They quickly married and moved to Minnesota, where she bore two children and he worked various jobs.

From early on, illness shaped the family fabric.

A debilitating spinal disease and injuries from an auto accident eroded John Ahle's physical and mental capacities. Now at 54, he walks with crutches and struggles with memory and emotion. Another auto accident crushed a disc in Edith Ahle's back.

When the family moved to Florida in the mid-1980s, both parents collected disability checks while Gregory and Michelle attended high school.

"We were rich in other ways. We were all happy together," remembers Michelle Good, now 25.

Edith Ahle "was a Betty Crocker, greeting card kind of mom," said Michelle. "She was always there with us kids. She enjoyed baking, she knit up a storm, she loved to tend to a garden and flowers."

Jean Kelly, a neighbor at Kings Manor Estates mobile home park, remembers Edith as a big woman with a big heart. They played penny-ante card games and joked about a meat and oatmeal concoction Edith fed her two dogs.

In December 1987, Edith Ahle began seeing Dr. Pettina. "Stomach hurts all the time," her chart reads.

Pettina was a general practitioner for Gold Plus, a health maintenance organization just emerging from years of turmoil. Forged out of a small Miami clinic, Gold Plus expanded rapidly into the nation's largest HMO for Medicare recipients. But along the way, hospital bills went unpaid and patients complained of spotty care. A few months before Dr. Pettina began treating Edith Ahle, state regulators took over Gold Plus and sold it to Humana.

In evaluating Ahle's stomach pains, Dr. Pettina noted a striking family history: Her mother had died of stomach cancer, her father of stomach and lung cancer, a sister of stomach cancer. Another sister, still alive, had undergone surgery for stomach and colon cancer.

Dr. Pettina immediately ordered an exploratory test for colon cancer, which detected no problem. But the lab report contained a clue that Ahle's lawyers later latched onto: Her hemaglobin and other blood indicators, though still within the normal range, were starting to drop.

One sign of cancer of the digestive tract is blood loss through the rectum. But Dr. Pettina never ordered the stool specimens that would have detected bleeding, said Dennis Rogers, one of the family's lawyers.

"Our experts tell us that chronic abdominal pain alone is enough to mandate a stool sample," Rogers said. "And here you had abdominal pain and blood loss and a family history" of intestinal tract cancer. "And they are still not doing stool samples."

Irritable bowel syndrome

Several times during 1988, Ahle complained to Dr. Pettina about vomiting and the persistent pain in her gut. She checked into the emergency room of Sun Coast Hospital three times. Her blood indicators continued their steady decline.

In January 1989, Dr. Pettina called in Dr. Dane L. Maxfield, a gastroenterologist on the Humana network. He tested her upper digestive system, which would have detected stomach cancer. Maxfield concluded that Ahle suffered from "irritable bowel syndrome," a common and painful disorder associated with psychological stress.

Back home, Ahle "was so sick she was doubled up in pain," Kelly said. "She would come over in the evening and try to play cards, but she couldn't even sit through a game. I would put out a snack, but she couldn't take a bite."

Kelly said she drove Ahle to Sun Coast Hospital five or six times. One night, Kelly said, she overheard two emergency room nurses talking about her friend: "One nurse said, "You take her. I'm not taking her this time. All she does is whine and cry that she is in such pain. And we can't find anything wrong with her.'

"

In November 1989, Ahle's hospital chart speaks of "constant pain" and "vomiting bright red blood for days." Her blood indicators had dropped way outside the normal range.

When she visited Dr. Pettina in his office, he diagnosed irritable bowel with emotional overlay and recommended a psychiatrist. "Patient became quite hostile, threw pills at me and stormed out of the office," he wrote.

In response, the Ahles complained to Humana headquarters and asked for a new primary care doctor. After examining her charts, Humana officials privately admonished Dr. Pettina for not ordering further tests. Among other things, Humana cited her abnormal blood levels.

Dr. Pettina did not return telephone calls. But his lawyer, Jonassen, said Ahle's frequent trips to the emergency room sometimes made things worse. Hospital officials did not pass along the results of her blood tests, he said, so Dr. Pettina couldn't see Ahle's full medical picture.

"Patients have to work better within the system sometimes," Jonassen said. "There are patients out there . . . who on weekends can't reach their family physician and . . . go to the emergency room or seek outside help. Unfortunately, in some cases, the loose ends don't get tied together."

Humana let Ahle switch primary doctors. But after two more trips to Sun Coast Hospital without relief, the family moved to Pinellas Park. That put them closer to Humana's St. Petersburg hospital and gave her an entirely new network of doctors on the Gold Plus plan.

A few months later, when she went to the emergency room bleeding from the rectum and spitting up bile, a sophisticated barium X-ray called enterocylsis found the cancer.

As Edith Ahle lay dying a few months later, her family gave her a parting gift. She had once taken night classes in Minnesota to earn a high school degree. Now, at the family's urging, school officials refigured the credits and granted the degree.

"Getting a high school diploma meant more to her than anything," said her daughter Michelle. "We gave it to her in a graduation ceremony, with pictures, cake, punch, streamers and banners."

The jury decides

In 1992, John Ahle sued Drs. Pettina and Maxfield and a radiologist on the Humana network, who quickly settled out of court for $90,000. Florin said the family did not sue Humana for negligence or wrongful death because legal precedent makes such suits against insurance plans difficult to win.

Among other things, the suit said, John Ahle depended on his wife to drive, shop, cook, clean and handle the family's affairs. Disabilities kept him from caring for himself, his lawyers said. Hiring help would cost him nearly $900,000.

Just before trial, Dr. Pettina settled out of court for $250,000, the limits of his medical malpractice insurance. That left Dr. Maxfield, the consulting specialist, as the lone defendant.

As Ahle's husband, children and neighbors described her last, painful years, Florin and Rogers hammered her doctors for overlooking her declining blood levels.

Dr. Maxfield did not return telephone calls. But Roland Lamb, his Tampa attorney, said stool specimens would not have altered Dr. Maxfield's care, even if they had shown bleeding. Dr. Maxfield was asked to administer a specific test for stomach problems, not to assume overall responsibility for her treatment, Lamb said.

"In the old medicine, a specialist who wants to get involved with abdominal pain takes over and has the patient come to his office for follow-up," Lamb said. "In the new world, with HMOs . . . the primary care physician does the follow-up. The specialist can't say, "I'll take over this patient from now on.' "

After 5{ hours of deliberation, the jury found Dr. Pettina 90 percent responsible for Ahle's death and Dr. Maxfield 10 percent responsible. One juror, a nurse, gave the family an emotional hug.

Of the total $3-million award, $1-million represented the economic damage to John Ahle for losing his wife's support. The jury awarded $2-million for the family's pain and suffering.

Under Florida law, all defendants are responsible for all economic damages. But pain and suffering damages are apportioned according to each defendant's share of the blame. Under that formula, Dr. Maxfield was ordered to pay all $1-million in economic damages because he was the only remaining defendant. He also must pay 10 percent of the pain and suffering award, or $200,000.

After adding in pretrial settlements and subtracting for standard attorney fees, the family stands to collect roughly $1-million.

The verdict represents vindication for all the nights Edith Ahle shuffled in and out emergency rooms, her husband said. "If a woman comes in with complaints, listen to her."

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