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Sammy Blackman, a 36-year-old male, with a history of traumatic brain injury (TBI), bipolar disorder, and suicide ideation and attempts, initially saw psychiatrist, Clark Hamm, MD, in March 2017, for follow-up after his discharge from a psychiatric facility. At that time, Mr. Blackman’s history included four inpatient psychiatric hospitalizations, the last one due to a suicide attempt.

Despite medication changes during his hospitalization, Mr. Blackman continued to have difficulty with mood stabilization, suicidal thoughts, and sleep. Dr. Hamm added Lithium to Mr. Blackman’s medication regimen with a dosage of 150 mg, 1 to 2 tablets twice a day. However, Dr. Hamm did not obtain any baseline lab work, discuss the potential risks and benefits of the medication, or warn of possible drug interactions. He instructed Mr. Blackman to return to the office in one month.

The next month, April 2017, Mr. Blackman returned to Dr. Hamm’s office. During the appointment, Mr. Blackman reported that Lithium helped his mood and overall functioning. He denied any suicidal ideation. Dr. Hamm increased the Lithium to 300 mg, 1 tablet in the morning and 1 to 2 tablets in the evening but again did not order lab work.

Mr. Blackman saw Dr. Hamm again in May 2017 and August 2017. At these visits, Dr. Hamm continued the same dosage of Lithium while making changes to other medications. Dr. Hamm failed to order or mention lab work to monitor Mr. Blackman’s Lithium level or kidney function. 

From the summer of 2017 until spring of 2018, Dr. Hamm continued to refill Mr. Blackman's psychiatric medications, even though Mr. Blackman did not return for a follow-up visit as instructed. Dr. Hamm also made changes to dosages and introduced new medications during this span of time.

Mr. Blackman eventually returned to see Dr. Hamm in May 2018, nine months after his last visit. This would be Mr. Blackman’s only office visit in 2018. No medication changes were made. At this visit, Dr. Hamm mentioned lab work for the first time, even though Mr. Blackman had been a patient for 14 months. He instructed Mr. Blackman to follow up with his primary care physician (PCP) to get “comprehensive labs.” Dr. Hamm did not provide an order for the lab work or contact the PCP about lab work. 

Nine months later, in February 2019, after several refills, Mr. Blackman saw Dr. Hamm for a follow-up visit. During the visit, Mr. Blackman reported seeing his PCP regularly; however, Dr. Hamm had not received any communication from the PCP. No changes were made to Mr. Blackman’s medications or dosages, including Lithium. When Mr. Blackman returned to the office in May 2019 and November 2019, Dr. Hamm continued his medications without any adjustments or changes. He did not mention obtaining lab work in the notes for these three visits.

In October 2020, Mr. Blackman returned to see Dr. Hamm, for what would be his only office visit that year. Dr. Hamm continued Lithium as previously prescribed but made changes to other medications. He instructed Mr. Blackman to return to his PCP for “comprehensive labs.” 

At Mr. Blackman’s office visits in February 2021 and May 2021, he reported several issues, including manic episodes, paranoia, increased irritability, racing thoughts, and homicidal ideation. To alleviate these problems, Dr. Hamm made changes to all medications except Lithium. Once again, there was no mention of lab work in the notes.

In June 2021, Mr. Blackman followed up with Dr. Hamm. He reported mood improvement but continuing paranoia. Dr. Hamm continued all the medications with no changes and “encouraged follow up with a medical doctor for comprehensive labs.” Dr. Hamm saw Mr. Blackman two more times in 2021, once in August and once in November. At the August 2021 visit, Mr. Blackman reported no complaints or issues and informed Dr. Hamm that he had seen his PCP. Dr. Hamm did not confirm whether lab work had been done with the PCP before continuing all the medications. Similarly, in November 2021, Mr. Blackman reported seeing his PCP on a regular basis. Dr. Hamm did not inquire or investigate about lab work before continuing Lithium.

In January 2022, Mr. Blackman returned for what would be his final office visit to Dr. Hamm. He had no complaints, and Dr. Hamm continued Lithium once more without mention of lab work. 

Approximately one month after his last office visit, in February 2022, Mr. Blackman, with no history of epilepsy, had a seizure while shopping with a family member. Bystanders called EMS, and he was transported by ambulance to the hospital where he would be admitted for two weeks. Initial lab work showed a Lithium level of 2.8 and a creatinine level of 8. The hospital’s care team diagnosed Mr. Blackman with End-Stage Renal Disease (“ERSD”) secondary to chronic Lithium. Due to the damage to his kidneys, Mr. Blackman required hemodialysis indefinitely.

In September 2022, an attorney filed a suit against Dr. Hamm on behalf of Mr. Blackman. The Complaint alleged that Dr. Hamm failed to monitor Mr. Blackman’s Lithium levels resulting in ESRD and the need for dialysis. At the outset of litigation, Dr. Hamm was adamant that he had not violated the standard of care. He felt strongly that the patient should bear some responsibility for not having his lab work drawn with his PCP. In addition, Dr. Hamm thought that the risk of self-harm or harm to others without Lithium outweighed any concerns about Lithium levels.

Defense counsel for Dr. Hamm sent the medical records out for review by other psychiatrists. Unfortunately for Dr. Hamm, none of the reviewers could support him on standard of care or causation. After the reviews and some initial discovery, including party depositions, it quickly became evident that this would be an exceedingly difficult case to defend. The parties agreed to mediate and subsequently settled at mediation. 

Although there may be occasions when the patient shares liability for failing to have lab work done, in this case, it was not so simple. In his deposition, Dr. Hamm appeared to blame Mr. Blackman for the lack of lab work and monitoring of his Lithium levels, an unreasonable and indefensible position to take. Mr. Blackman had a history of TBI, well-documented issues with overall functioning, and no medical background or training. It should not have been incumbent upon him to know what labs he needed, to ask his PCP for the labs, or to know how often the labs should have been done. Dr. Hamm had the responsibility to order the lab work or coordinate with the PCP.

In total, Dr. Hamm saw Mr. Blackman 15 times over 5 years—four times in 2017, one time in 2018, three times in 2019, one time in 2020, five times in 2021, and one time in 2022. Dr. Hamm knew that Lithium had the potential to be nephrotoxic and that levels should be monitored. Nonetheless, there was no evidence in the medical record that Dr. Hamm made any attempt to either order the lab work or contact Mr. Blackman’s PCP regarding the lab work in all that time. His statements to see a PCP or other medical provider for “comprehensive labs” were not defensible. 

There are several lessons to be learned from this case. First, whenever prescribing a medication with known potential for toxicity and organ damage, a physician should have a documented discussion with the patient regarding the risks and benefits of said medication. In some instances, a physician may even decide to have the patient sign a consent form. Second, any baseline lab work or diagnostic testing should be done before the patient begins the medication. Third, the prescribing physician should include any necessary lab work or testing in their plan of care and not rely on other providers to order or otherwise monitor the lab work. A tracking or recall system to remind the physician of when follow up testing is due should be utilized.  Finally, there should be thorough documentation regarding all testing, patient notification of results, any changes to dosing of the medication, and instructions given to the patient.