On Nov. 16, 2010, plaintiff Leeann Standlee, 54, presented to a physician at the Scripps Clinic Medical Group Inc. with symptoms of a sinus infection. She was subsequently prescribed Augmentin, an antibiotic, and instructed to follow-up with the Coumadin Clinic, located at the Scripps Clinic, as antibiotics may have adverse interactions with Coumadin, an anticoagulant, which Standlee had been taking since 1998. Standlee had a complex medical history requiring the use of Coumadin, which requires the monitoring of one’s international normalized ratio (INR) for assessing the thickness or thinness of blood: too low of an INR can result in a clotting risk, while too high of an INR can result in a bleeding risk. Standlee’s anticoagulation therapy was managed briefly by the Coumadin Clinic at the Scripps Clinic in 2000 before being managed by various outside providers. However, in March 2009, she returned to the Scripps Clinic’s Coumadin Clinic for anticoagulation management. Standlee initially went to a lab to obtain INR values, but she had substantial difficulty going to the lab due to child care responsibilities. As a result, she missed multiple lab appointments. Due to Standlee’s difficulty finding time to go to the lab, the Coumadin Clinic assisted her in arranging for a home INR monitor for ease of testing. However, she eventually presented to the Scripps Clinic with symptoms of a sinus infection on Nov. 16, 2010, was prescribed Augmentin, and told to follow up with the Coumadin Clinic. Standlee did not follow up with the Coumadin Clinic, but, instead, returned to the Scripps Clinic on Nov. 24, 2010, again complaining about sinus pressure. However, this time, she also complained of eye pain. Standlee was subsequently seen by another physician and prescribed another course of Augmentin. She was again advised to follow up with the Coumadin Clinic. Two days later, on Nov. 26, 2010, Standlee tested her INR value and obtained an elevated value of 8.0. A pharmacist at the Coumadin Clinic called Standlee the next day and left a message to inquire as to the cause of the elevated INR. The pharmacist also advised Standlee to go to an emergency room if she had any severe bleeding or bruising. On Nov. 28, 2010, the day after receiving the call from the pharmacist, Standlee presented to an emergency room with complaints of a severe headache. She was ultimately diagnosed with a subdural hematoma. As a result, she underwent craniotomy that day. Standlee sued Scripps Clinic Medical Group Inc., alleging that the Scripps Clinic was negligent in her treatment and that this negligence constituted medical malpractice. Gemma Herrera, and Doctors David Clayton, Shah Sanjeev, and Shipra Khushu were also at one time named in the suit. However, Sanjeev and Khushu were let out on summary judgment, and Herrera and Clayton were dismissed from the case prior to trial. Thus, the matter continued against the Scripps Clinic only. Plaintiff’s counsel argued that the care and treatment by Scripps Clinic’s Coumadin Clinic fell below the standard of care. Standlee testified that she did not recall any physicians discussing with her about the risk of bleeding with use of Coumadin or the risk of drug interactions between Coumadin and antibiotics. She also testified that she did not know that she was obligated to inform the Coumadin Clinic of any newly prescribed medications due to potential drug interactions. The plaintiff’s internal medicine expert opined that the Coumadin Clinic had a duty to reach the patient on Nov. 26, 2010, when an elevated INR value of 8.0 was obtained, rather than wait until the next day. The expert also opined that the pharmacist was obligated by the standard of care to review Standlee’s medical record at that time, which would have revealed a complaint of headaches from two days prior. Thus, plaintiff’s counsel argued that Scripps Clinic’s Coumadin Clinic violated of policies and procedures, and had a deficient on-call system for INR values drawn over the weekend, which purportedly resulted in the subdural hematoma and related damages. Defense counsel contended that during Standlee’s management by the Coumadin Clinic, Standlee had several instances in which she unilaterally took unprescribed medications without advising the Coumadin Clinic. Counsel contended that, on one occasion, Standlee ingested excess doses of Coumadin and had a headache. Defense counsel argued that Standlee was subsequently told by the Coumadin Clinic of the possibility of an intracranial hemorrhage and urged Standlee to seek medical attention at Urgent Care. Thus, during cross-examination, the plaintiff’s internal medicine expert characterized Standlee’s actions of ingesting excess Coumadin and disobeying physician recommendations as “crazy,” and asserted that intervention was required. Defense counsel contended that on Nov. 16, 2010, Standlee was warned that the prescribed antibiotic, Augmentin, may have adverse interaction with Coumadin and that was why she was told to follow up with the Coumadin Clinic, but that Standlee failed to do so. Counsel also contended that Standlee was again warned about potential drug interactions and told to follow up after she was given another course of Augmentin on Nov. 24, 2010, but that Standlee again failed to do so. Thus, counsel argued that various physicians warned Standlee of the risk of bleeding with use of Coumadin and the risk of drug interactions between Coumadin and antibiotics, but that Standlee failed to follow the physicians’ recommendations. The medical director of the Coumadin Clinic testified that the policies and procedures were both adequate and followed by the Coumadin Clinic’s pharmacists, as it pertained to the care of Standlee. The Coumadin Clinic’s pharmacist also testified about the message she left for Standlee on the morning of Nov. 27, 2010, and claimed that the message was pursuant to, and consistent with, the Coumadin Clinic’s protocol. The pharmacist further set forth other instances in which Standlee was advised of the need to report medication changes and to seek medical attention at an Urgent Care or an emergency room in the event of a persisting headache with elevated INR values. The plaintiff’s treating physicians testified that due to potential drug interactions, Standlee was instructed on the need for her to follow up with the Coumadin Clinic in the event of newly prescribed medications. They further testified that Standlee exhibited acknowledgment and understanding of such instructions. The defense’s internal medicine expert opined that the standard of care was met in all respects and that the on-call system was appropriate and offered more accessibility than most Coumadin Clinics. He also testified that while there is a recognized interaction between Augmentin and Coumadin, Augmentin would not typically elevate the INR to 8.0. Thus, based on Standlee’s past history of self-medicating on various occasions, the expert believed that the cause of the elevated INR on Nov. 26, 2010, was due to excess ingestion of Coumadin, not due to a drug interaction with Augmentin., Standlee presented to an emergency room with complaints of a severe headache and was ultimately diagnosed with a subdural hematoma. She subsequently underwent a craniotomy on Nov. 28, 2010. Standlee claimed that she now suffers from persistent, severe, left-sided headaches due to the craniotomy. Thus, Standlee sought recovery of approximately $35,000 in total out-of-pocket medical bills. She also sought recovery of non-economic damages for her past and future pain and suffering. Her husband, plaintiff Frank Meram, 58, an insurance salesman, presented a derivative claim, seeking recovery of damages for his loss of consortium. The defense’s internal medicine expert testified that Standlee had a history of somatization and severe pre-existing headaches. Thus, the expert opined that the craniotomy did not cause the headaches currently reported by Standlee.