Full opinion text
OPINION TITUS, District Judge. On March 27, 2003, plaintiff Ruth M. Lawson (“Mrs.Lawson”) brought this action against the United States under the Federal Tort Claims Act, 28 U.S.C. §§ 1346(b), 2671-2680. In her Complaint, she asserted claims of medical malpractice relating to care during her second pregnancy that she received from health care providers at the Malcolm Grow Medical Center (“MGMC”) at Andrews Air Force Base. The two basic questions raised by this case are: (1) whether the applicable standard of care required Mrs. Lawson’s health care providers at MGMC to recognize that she had an underlying neurological disease or disorder known as Chiari Type I malformation that was being exacerbated by her second pregnancy, and (2) whether the failure to recognize Mrs. Lawson’s disease in providing her treatment during and after her second pregnancy caused her to suffer serious personal injury. The trial took place without a jury from February 7 through February 17, 2006. On June 7, 2006, the parties submitted proposed findings of fact and conclusions of law. Having considered the evidence and arguments of counsel, the Court concludes that both questions must be answered in the affirmative and now makes its findings of fact and conclusions of law. FINDINGS OF FACT 1. Chiari Type I Malformation Mrs. Lawson has Arnold Chiari Malformation Type I (“ACM Type I” or “Chiari I malformation”). This congenital abnormality is characterized by the underdevelopment of the bone at the base of the skull (posterior cranial fossa) and overcrowding of the normally developed hindbrain. As a result of the underdevelopment of the posterior cranial fossa and overcrowding of the hindbrain, individuals with this abnormality have a larger than normal opening at the base of the skull (foramen magnum), which permits the hindbrain/cerebellar tonsils to protrude, or herniate, into the spinal canal. The herniation of the hind-brain happens at birth or shortly thereafter. In its pure form, a Chiari I malformation shows the cerebellar tonsils down to the C1-C2 region, with normal brain stem location. Chiari I malformation exists in approximately one percent of the population, and most cases are diagnosed by MRI. Even though individuals are born with ACM Type I, those afflicted are generally unaware that they have the condition unless and until symptoms appear. Chiari I malformation can remain asymptomatic, or it can result in a gradual progression of symptoms over an individual’s life. While most Chiari Type I malformations do not result in any symptomatology and are never detected, some individuals develop headaches in conjunction with the condition. These headaches are typically occipital (at the back of the head) in nature and may be associated with nausea and vomiting. In some instances, age combined with triggering events such as trauma or pregnancy will cause a Chiari Type I malformation to decompensate. Decompensation produces significant cerebrospinal fluid (“CSF”) problems below the cerebellum in the posterior cranial fossa and the spinal cord. Decompensation with an associated syrinx leads to the progressive development of neurological symptomatology related to anatomical functions of posterior fossa brain structures, manifesting as vertigo, ataxia, focal neurological findings and severe headaches. These symptoms are similar and overlapping with symptoms of other intracranial problems, such as brain tumors. The treatment for decompensated Chiari I malformation with syrinx is neurosurgical and involves decompression flow by performance of a craniectomy at the level of the foramen magnum, producing space to allow normal CSF flow and reabsorption of syrinx and hydromyelia fluids. A dura-plasty is performed to create space around the brain tissues, thereby allowing long-term decompression and promoting CSF flow. Surgical decompression is recommended for patients with a decompensated Chiari Type I malformation and syrinx, because the presence of the syrinx portends a higher risk for problems. II. Ruth Lawson’s Personal History Mrs. Lawson was born on September 17, 1966. Her parents, Gilbert and Amparo Ferro, lived in Panama at the time of her birth. Mr. Ferro, a former aircraft mechanic for the United States Air Force, worked for the Panama Canal Commission as a shipwright, and Mrs. Ferro worked as a secretary. Mrs. Lawson enjoyed good health during her youth and adolescence. She actively participated in sports including aerobics, swimming, running, and weight training, and was an avid reader.' Mrs. Lawson completed her elementary and high school education in Panama. While English has always been Mrs. Lawson’s primary language, she is also' fluent in Spanish. She attended grades K-6 at Margarita Elementary School and grades 7-12 at Cristobal High School, from which she graduated in June 1983. Mrs. Lawson was a very good student, and participated in school activities without any physical or social limitations. She attended college at Old Dominion University in Norfolk, Virginia, receiving a B.S. degree in Business Administration and Marketing in August 1987 with a cumulative GPA of 2.7. Mrs. Lawson also apparently began working on a Master’s degree while living in Panama. From 1988 to 1989 Mrs. Lawson worked for a private travel agency in Panama, where she made regular use of her bilingual skills. She subsequently worked for the U.S. military from 1989-1995, first with the United States Navy as a lifeguard, and then with Naval Intelligence as a secretary. She then switched over to the United States Air Force, where she was employed as a secretary and then as a management assistant, progressing from a pay grade of GS-05 to a GS-08. In her most senior position, Mrs. Lawson was responsible for maintaining all of the records at Howard Air Force Base, Albrecht Air Force Station, which was on the isthmus of Panama and an air base in Honduras. Mrs. Lawson received several commendations for her work, the most significant of which was “Records Manager of the Year for Air Combat Command,” which commends the best performing records manager throughout the entire Air Force. While working for the Air Force, Mrs. Lawson met Erick J. Lawson, who was stationed in Panama for two years as an Air Force Intelligence Officer. They were married by a judge on November 29, 1995, and the couple was married again in a religious ceremony on March 2, 1996. After she married, Mrs. Lawson suspended outside employment to tend to her family. However, Mrs. Lawson planned to resume working when her children reached school age, finish a Master’s degree she had started in Panama, and pursue a career as a teacher or translator. Major Lawson has been an intelligence officer in the United States Air Force since 1992, and, at the time of trial, had been recently assigned to a temporary duty station in Qatar. III. Ruth Lawson’s Mledical Records The first symptom that gave notice that Mrs. Lawson could have a neurological disease or disorder developed around her nineteenth birthday, when she began to experience headaches that were more painful and frequent than normal. In July 1995, Mrs. Lawson also began to develop migraine headaches. Mrs. Lawson’s medical records document that she reported these headaches to her health care providers at the various Air Force facilities where her husband was stationed. In October 1996, Mrs. Lawson became pregnant with her first child, Dominick. During this pregnancy she suffered from hyperemesis gravidarum (excessive vomiting) that moderated during the second half of the pregnancy, and had occasional complaints of dizziness, especially when she rose to a standing position. Aside from an abnormal maternal serum alpha-fetopro-tein finding and a single emergency room visit for dehydration, Mrs. Lawson had a normal number of prenatal visits and did not require any unscheduled or emergency visits during her first pregnancy. Mrs. Lawson gave birth to Dominick on July 29, 1997 at the Naval Hospital in Pensacola, Florida. During her first pregnancy and thereafter Mrs. Lawson was able to carry out her household duties and functioned independently, with only minimal assistance from others. She was healthy and had no medical problems requiring any special medical intervention. Mr. and Mrs. Lawson moved to Andrews Air Force Base in July 1998. Mrs. Lawson became pregnant with her second child, Nicholas, in March 2000. At that time, her husband was serving as an intelligence officer for the 89th Airlift Wing at Andrews Air Force Base. Mrs. Lawson received her prenatal care at MGMC, a facility with a residency program whereby first or second year family practice residents rotate through the obstetrics clinic for a month or two. At the time of Mrs. Lawson’s second pregnancy, the obstetrics clinic was staffed with seven attending obstetricians, two to three residents on a rotating basis, and two to three nurse practitioners. Under the system in place at MGMC, family practice residents often saw the patients outside the presence of an attending obstetrician. In theory, a staff obstetrician was designated to review each obstetrical patient’s chart on a trimester basis, but there is no evidence of who that designated person was for Mrs. Lawson. While a patient of the MGMC, Mrs. Lawson was seen by a team of health care providers including four attending obstetricians: Dr. Bruce Erhart, Dr. Gretchen Shaar, Dr. Tracey Golden, and Dr. John Buek; three residents: Dr. Gregory Sweitzer, Dr. Edgar Rodriguez, and Dr. Nghia Phan; and two certified nurse practitioners: Mary Warwick and Patricia Jones. Mrs. Lawson’s prenatal care during her second pregnancy is documented in extensive medical records, which are discussed below. At no time during the course of Mrs. Lawson’s pregnancy did any health care provider perform a neurological examination on her or refer her to a neurologist for evaluation. On May 3, 2000, at around the eighth week of pregnancy, Mrs. Lawson entered the obstetrical clinic. During this visit, she was seen by Dr. Erhart. An ultrasound performed that day confirmed a single fetus with an estimated date of confinement of December 10, 2000. Dr. Erhart placed her on Compazine 5mg three times daily (TID) for severe nausea. On May 17, Mrs. Lawson reported that the Compa-zine provided her with some relief from her symptoms. On May 25, 2000, Mrs. Lawson went to the MGMC emergency department, complaining of severe vomiting, body aches, and dizziness. She was treated by Dr. Shaar during this visit. On June 26, 2000, at approximately sixteen weeks of pregnancy, Mrs. Lawson was seen by Dr. Sweitzer, a first-year family practice resident. Mrs. Lawson gave a history of nausea and vomiting which was somewhat helped by oral Com-pazine. Her presenting complaint was severe nausea, for which she was administered Compazine 10 mg IV and Benadryl 25 mg IV. She also reported to Dr. Sweit-zer that she would get dizzy when she lies down, and the nurse’s notes from that visit reflect that Mrs. Lawson complained to her that “lying down makes me dizzy.” Dr. Sweitzer noted that Mrs. Lawson felt better after the administration of the intravenous medications. He also noted she had hyperemesis gravidarum, speculated that she should be tried on alternative medication if she did not improve, and instructed her to come back in two weeks or sooner if necessary. On July 11, 2000, at eighteen weeks of pregnancy, Mrs. Lawson called the MGMC Health Care Information Line and complained of abdominal cramping and severe dizziness, with the room spinning around her head. She reported that the dizziness abated somewhat after she drank fluids. She was advised to go to the emergency room immediately, but informed the provider that she did not want to go that evening. The next day, Mrs. Lawson had a prenatal visit with nurse practitioner Mary Warwick and received an ultrasound to determine the health of the baby. Nurse Warwick noted that Mrs. Lawson reported four hours of lower abdominal cramping during the previous night. On July 13, 2000, the day after her visit with Nurse Warwick, Mrs. Lawson called Dr. Erhart to ask whether she could continue taking Compazine and to complain that she was still feeling dizzy. Dr. Erhart prescribed Compazine, but indicated to her that this was for nausea. The record does not indicate any medical treatment or recommendations for her complaint of dizziness. On August 3, 2000, Mrs. Lawson had a prenatal visit and her Compazine prescription was again renewed. She indicated that Compazine provided her some relief from nausea. On August 17, 2000, at approximately twenty-three weeks, she was seen with continued symptoms of vomiting and use of Compazine. During this visit, she complained of left sciatic hip pain radiating into her leg and was prescribed Be-nadryl and Tylenol. On September 5, 2000, at the beginning of her last trimester, Mrs. Lawson saw Dr. Erhart and reported that she was experiencing lower back pain. The prenatal flow sheet documents that Dr. Erhart medicated her with Compazine and Tylenol, and also prescribed hot pads for back pain. On October 4, 2000, at 30$ weeks, Mrs. Lawson complained to Dr. Phan of lower back pain that was described as sharp, a “10” out of “10” on the pain scale, and persisting for several days. Dr. Phan diagnosed Mrs. Lawson with probable mus-culoskeletal back pain of pregnancy. She was continued on her medications, prescribed Tylenol every six hours for pain, and instructed to have twenty-four hours of bed rest. The following day, Mrs. Lawson called and spoke with Dr. Erhart and informed him that her back pain prevented her from sleeping. Dr. Erhart recorded her symptoms as pregnancy-related sciatica, and prescribed narcotic medication of Percocet to be taken one to two tablets by mouth every four to six hours as needed. On October 11, 2000 Mrs. Lawson called the MGMC to complain that the Percocet was aggravating her nausea and vomiting. As a result, Dr. Erhart switched her narcotic medication to Darvocet by phone the following day without seeing or examining her. On October 16, 2000, Dr. Erhart saw Mrs. Lawson and noted that her back pain had improved on Darvocet. On October 24, 2000, Dr. Erhart provided her with a refill of Darvocet for her back pain in response to a telephone request. On November 14, 2000, Mrs. Lawson was given a new prescription for Darvocet to be taken every four to six hours as needed, and it was noted that she was still having lower back pain. She was placed on modified bed rest. On November 15, 2000, at thirty-six weeks gestation, Mrs. Lawson met with Dr. Golden and continued to complain of back pain, this time with uterine contractions. She was recommended to do pelvic rocking on all fours to relieve the back pain. The next day, on November 16, 2000, she complained again of back pain to a Dr. Salgado. On November 22, 2000, Mrs. Lawson received another prescription for Darvocet, at which time she reported that her sciatica was much better. On November 23, 2000, Mrs. Lawson reported to the labor and delivery ward with contractions and was admitted at approximately 10:30 p.m. Capt. Cheryl A. Burch performed a pre-anesthesia evaluation and noted that Mrs. Lawson had “BACK PAIN SINCE 6 MONTHS OF PREGNANCY, NO DEFINITIVE DIAGNOSIS, MEDICATED WITH DARVO-CET.” (Emphasis in original). The following day, November 24, 2000, Mrs. Lawson delivered her son Nicholas following a labor of slightly more than ten hours, with the first stage being nine hours and fifty-three minutes, and the second (pushing) stage being twelve minutes in duration. Mrs. Lawson was not given the option of undergoing a cesarean section delivery. Mrs. Lawson’s post-delivery medical notes from November 25, 2000 state that “the patient is doing well, however, c/o [ (complains of) ] dizziness and episode nausea with emesis last PM.” (sic). The record notes that Mrs. Lawson’s dizziness increased in the supine position (when lying on her back, or with her face upward), and that she complained of back pain with a history of chronic back pain treated with Darvocet during the pregnancy. The record also notes that following delivery, she developed a mild lateral nystagmus, an involuntary, usually rapid movement of the eyeballs (as from side to side), after rapid supination. The medical facility discharged Mrs. Lawson on November 26, 2000 with a diagnosis of uncomplicated vaginal delivery and recurrent chronic back pain. On December 7, 2000, Mrs. Lawson met with Dr. Durkin in the family practice clinic, who documented her complaints as back pain, moles, vertigo, that she could not lie flat in bed, and that her left leg felt very heavy. Dr. Durkin’s notes also indicate Mrs. Lawson reporting the “room spinning” which she documented as starting “while pregnant—last 2 days,” and that she could not lie flat, with vertigo worsening with position change. Dr. Dur-kin increased the frequency of her prescription for 600 mg of Motrin to four times daily for her back pain and referred Mrs. Lawson to physical therapy and a healthy back class. Dr. Durkin did not diagnose Mrs. Lawson with a foot drop during this visit. In connection with Mrs. Lawson’s vertigo symptoms, Dr. Durkin assessed a likely viral labyrinthitis, and advised her to try Meclizine, but noted that the safety of this medication when breast feeding was questionable. On January 4, 2001, Mrs. Lawson was seen again by Dr. Durkin for removal of moles on her upper shoulder and chest. At this visit, Mrs. Lawson again voiced a complaint about her vertigo symptoms, and Dr. Durkin clearly documented in her medical notes that Mrs. Lawson had a history of vertigo since her fifth month of pregnancy. Mrs. Lawson was taking Motrin at the time, but chose not to take Meclizine due to her concerns about contraindications while breast feeding. During the examination, Mrs. Lawson did not exhibit a nystagmus, but tested positive with the Hallpike maneuver, a procedure where the patient rapidly goes from sitting up to lying flat then back to sitting up in order to determine nystagmus and proxys-mal positional vertigo. Regarding Mrs. Lawson’s vertigo, Dr. Durkin thought it was likely that she had benign positional vertigo and referred her for a hearing evaluation and to neurology for an evaluation. On January 11, 2001 Mrs. Lawson was seen by a physical therapist who noted the onset of lower back six months into the pregnancy and chief complaints of right hip pain, left foot slapping, occasional numbness, and difficulty walking up stairs. The therapist noted that Mrs. Lawson required an immediate referral to neurology. On January 17, 2001, Mrs. Lawson was seen by Dr. Overfield, a neurologist at MGMC with a chief complaint of vertigo since approximately September 2000 with a “spinning sensation (when) lying flat and looking up.” Dr. Overfield also noted that she had a left foot drop since approximately September 2000 with onset at the same time as the vertigo, as well as back pain with sharp radicular pain to the posterior leg, and tingling in the bottom of the toes, Dr. Overfield noted that Mrs. Lawson had rotary nystagmus, and a positive Hallpike test, indicating a central nervous system and/or vestibular origin for her nystagmus. Dr. Overfield concluded that Mrs. Lawson suffered from (1) vertigo, (2) daily headaches (probably Motrin-induced), and (3) left foot drop, most likely lumbosacral instead of common peroneal, in view of her radicular pain. Dr. Over-field ordered an MRI and x-ray of the lumbar spine, and an EMG of her left sciatic nerve. For her vertigo, he instructed her on Brandt-Daroff exercises, and advised her to stop taking Motrin. On January 19, 2001, Mrs. Lawson obtained a lumbar spine series of x-rays which were normal. On January 30, 2001, Mrs. Lawson obtained the scheduled EMG/nerve conduction study of her left leg. Based upon the findings of this test, Dr. Overfield concluded that she had an “intracranial spinal lesion affecting the L5 root.” Mrs. Lawson reported to Dr. Overfield that she was unable to participate in the MRI scheduled for February 4, 2001 because of her claustrophobia and because of the extreme dizziness she experienced when lying flat. As a result, Mrs. Lawson required an open MRI, which had to be performed off base. The scheduling of this MRI and the logistics with the government-sponsored Tricare insurance plan took time to be resolved, and Mrs. Lawson did not receive the MRI of her lumbar spine until February 27, 2001. Dr. Edward N. Smith, who interpreted the scan, noted that “there is abnormal signal of the conus medullaris, suspicious of a mass lesion,” and recommended a dedicated thoracic spine examination. On the basis of this finding, Dr. Overfield ordered a complete MRI of the spine, which Mrs. Lawson was unable to do in light of her inability to lie flat. Mrs. Lawson was referred to Dr. James Eeklund, a neurosurgeon at Walter Reed Army Medical Center (“WRAMC”), who saw her on March 22, 2001. Dr. Ecklund noted in his evaluation that Mrs. Lawson exhibited lower back pain during pregnancy which traveled to the left lower extremity, she was placed on Darvocet, her pain was excruciating, Tylenol # 3 and Percocet did not work, and she suffered from left foot drop. He noted that Mrs. Lawson had multiple emergency room visits related to pain, that she could not lie flat on account of vertigo, could not look up or down rapidly, and that with the onset of vertigo the “room spins.” Dr. Ecklund further noted that Mrs. Lawson had worsening right neck pain, could not lie down flat without passing out, had daily occipital headaches, and needed to sleep sitting up since September 2000. He also noted that her gait was characterized by a slapping left foot, that she leaned to her left, and was unable to go up on her toes. He also noted a positive Romberg’s sign (unsteadiness when closing eyes) and positive ataxia (inability to coordinate muscles in the execution of voluntary movement). Finally, Dr. Ecklund noted that Mrs. Lawson lacked sensitivity in her left foot, and that she had paraspinous pain in the right neck shooting up to behind her right ear. In reviewing the February 27, 2001 MRI, Dr. Ecklund noted a questionable syrinx. Based on this history and physical examination, Dr. Ecklund concluded that Mrs. Lawson had a Chiari I malformation or other eord/brain lesion, and ordered an MRI of the head and of the spine to confirm his diagnosis. The Court finds that this is the first time that Mrs. Lawson was told that her persistent and worsening symptomatology was attributable to a neurological problem. The Court also finds that Dr. Eeklund’s March 22, 2001 notes accurately reflect Mrs. Lawson’s history and the progress of her illness. On March 28, 2001 Mrs. Lawson was seen by Dr. Daniel J. Fleming at the MGMC Department of Otolaryngology. Dr. Fleming confirmed Mrs. Lawson’s history of dizziness when lying down since September 2000, with the sensation that she was remaining still while the room was spinning around her. He also noted her history of left foot drop, inability to walk on her heels, and numbness in her left lower leg, starting at the same time as the dizziness. He further confirmed the presence of nystagmus, as well as the positive Romberg’s sign. Dr. Fleming did not find any' evidence of hearing loss or any cochlear illness related to the internal ear to explain Mrs. Lawson’s history of recurrent dizziness and neurological symptoms. Dr. Fleming noted that he agreed with the absolute need for an MRI. On April 1, 2001 Mrs. Lawson underwent an MRI examination of her brain, cervical spine, and thoracic spine at WRAMC. The stated indication for the procedure was “34 yr. old female with progressive SXS [ (signs and symptoms) ], i.e., positional vertigo, occipital HA [ (headaches) ] QD [ (every day) ] over one year; r/o Chiari or other cord/brain lesions.” The MRI findings on April 1, 2001 were reported as follows: Both in coronal, FLAIR and sagittal T 1 w imaging there is fairly gross deformity of the combination of pons, medullary cervical junction and lower cerebellum which I believe includes the vermis in addition to the cerebellar tonsils. This caudal placement of cerebellar structures extends down to the lower aspect of C2, obliterating all of the usual posterior spaces at the cisterna magna. This is seen in combination with fairly striking syrinx formation through all cervical levels with particular dilation of the central canal at the T1 -2 level and immediately below. This dilatation of the central canal becomes very broad and smooth through the lower thorax to the termination of the cord at T 12-L 1. The dilatation of the central canal where it is broad in the upper thoracic level and just above the conus is in the order of 6.5mm. No vertebral axis bony abnormality is detected through the cervical or thoracic levels. The conclusion of the MRI study was as follows: CONCLUSION: STRIKING CHIARI MALFORMATION . TO INCLUDE THIRD VENTRICULAR AND POSTERIOR FOSSA CHANGES WITH THE CERVICOMEDULLARY JUNCTION AT C2 AND WITH BOTH CEREBELLAR, VERMIS AND TONSIL ECTOPIA DOWN TO LOW C2. THERE ' IS HYDROMYELIA THROUGH THE ENTIRE CERVICAL AND THORACIC CORD WITH MOST EXTREME DILATATION AT THE UPPER AND LOWER THORACIC LEVELS, AS DESCRIBED ABOVE. On April 3, 2001, Mrs. Lawson returned to Dr. Eeklund, who confirmed the diagnosis of a Type I Chiari malformation with tonsils down to C2 and a near total cord syrinx. At the time of this visit, Dr. Eck-lund noted that Mrs. Lawson was walking unassisted, but with a limp. In light of his findings, Dr. Eeklund advised her that she needed urgent neurosurgical decompression of her Chiari Type I malformation and a duraplasty procedure, and that without these procedures she would otherwise face further neurological deterioration and potentially death. Physical examination of Mrs. Lawson on April 12, 2001, by Dr. Richard Gullick, Dr. Ecklund’s chief/senior resident, revealed right neck pain, upward and lateral nys-tagmus, left foot drop, new onset lower extremity weakness on the right side, and cerebellar findings of positive Romberg test, positive ataxia, and a wide-based gait. That same day, Mrs. Lawson underwent Chiari decompression. During the procedure, Mrs. Lawson also underwent a right partial cerebellar tonsillectomy and a dura-plasty to close off the affected areas of decompression. Dr. Ecklund’s operative findings of April 12, 2001 were as follows: The patient is a 34-year old female with a progressive history of occipital neck pain and left lower extremity weakness along with headache. MRI revealed a Chiari I malformation with herniation of the tonsils down to the level of C2 as well as a syrinx within the spinal cord.... The craniectomy was 5 x 4 cm in diameter. The dura was opened in a Y-shaped fashion and flapped back utilizing 4-0 Nurolon sutures. A large venous lake on the right-hand side was occluded using titanium microclips. The subarachnoid space was entered, and sharp dissection was used to free the tonsils up from surrounding dura and other structures. The tonsils were freed up, and spontaneous CSF from the fourth ventricle was obtained. Bipolar electrocautery was used to shrink the tonsils away from the spinal canal and up towards the intercranial compartment, and a minimal debulking of the right tonsil which was particularly large was performed with bipolar electrocau-tery and suction.... The subarachnoid space was copiously irrigated with baci-tracin containing normal saline before closing. After completing the suturing, multiple Valsalva maneuvers failed to show any evidence of CSF leak. A CT scan of Mrs. Lawson’s head and posterior fossa on April 13, 2001, confirmed the Chiari I decompression without complicated findings. Mrs. Lawson returned to see Dr. Eck-lund on May 10, 2001. He noted that her limp had improved and that she did not appear to exhibit a left foot drop. She still exhibited nystagmus on her lateral gaze, but was able to look upward. In a second follow-up visit on June 5, 2001, she saw Dr. Ecklund again, at which time he noted that she had improved flexibility in her neck, but was unable to touch her chin to her chest. Dr. Ecklund noted that her gait remained wide-based, but appeared more steady. The Lawsons lived in Panama from mid-August 2001 to March 2002, and during, this time Mrs. Lawson received medical treatment from health care providers there. In a report dated February 22, 2002, Dr. Espinosa, a neurosurgeon, noted that he had examined Mrs. Lawson on August 22 and December 6, 2001. Dr. Espinosa recorded her initial complaint as cervical pain, migraine, and difficulty moving without a wide-base support, as well as weakness in the lower left extremity. Dr. Espinosa prescribed medications that included Percocet, in addition to other drugs. When she returned to Dr. Espinosa in December still complaining of migraines, he prescribed Neurontin and Lasix. In the December report, Dr. Espinosa also noted that Mrs. Lawson was walking with slight weakness of the left extremities. From August 2002 to 2004, Mrs. Lawson was treated at Womack AFB in Fayette-ville, North Carolina. The health care providers there assessed her status as post-surgical decompression, with catame-nial migraines (induced by menstrual cycles). During this time she reported pain in her neck at the surgical site and a wide-based gait. Dr. Albert Martins, Mrs. Lawson’s treating neurologist at Womack Army Medical Base, examined Mrs. Lawson on October 1, 2002, and did not find any evidence of brain stem injury. IV. Lay Testimony During the two-week trial, the Court heard extensive lay testimony regarding Mrs. Lawson’s medical condition and symptoms between May 2000 and April 2001. The Court is aware that not all of the symptoms described by this lay testimony were reflected in Mrs. Lawson’s prenatal medical records; specifically, the Court acknowledges that her prenatal records do not contain documentation regarding her left foot drop, describe the severity and occipital nature of her headaches, or reflect that she had to sleep upright in a chair due to her severe dizziness. Nonetheless, the Court finds the lay testimony to this effect to be persuasive. It is uncon-tradicted that multiple individuals observed these symptoms, and Major Lawson testified that he was with his wife when she reported these symptoms to her treating doctors. Additionally, once Mrs. Lawson was evaluated by board-certified physicians and other specialists, rather than primarily first and second year family practice residents, her treating physicians elicited the same history of extreme nausea, headaches, vertigo, vomiting, and foot drop that Dr. Ecklund thought suggested a Chiari I malformation when he finally saw Mrs. Lawson in March 2001. As was noted by Dr. Michael Ross, an obstetrician/gynecologist called to testify for the plaintiff, “[a]ny reasonable effort to put the whole package together and ask the right questions, every time it was done subsequent to her delivery, the same story came out ... [H]ad an attempt been made, they could’ve elicited it at any time during [her pregnancy].” Trial Tr. Feb. 8, 2006, 105:18-106:7. (“Tr.”). That some of Mrs. Lawson’s symptoms are not reflected in her prenatal medical records is therefore not the end of the story. The Court also finds at least one clear example in the record where the symptoms reported by the Lawsons were not fully documented. Specifically, regarding her June 26th visit with Dr. Sweit-zer, the Court accepts testimony that the Lawsons reported the severity of Mrs. Lawson’s dizziness, vomiting and headaches, and notes that despite these reports, Mrs. Lawson’s contemporaneous medical records do not clearly indicate these quite pertinent details regarding the severity of her symptoms and condition, and how different her symptoms were from those experienced during her first pregnancy. In short, it does not appear that all details provided to Mrs. Lawson’s treating doctors were fully documented. Therefore, the Court accepts the lay witness testimony provided in Mrs. Lawson’s case in chief, and finds that this testimony consistently supplements, rather than contradicts, the facts as set forth in her contemporaneously-written medical records. —Major Erick Lawson Major Lawson testified that his wife’s second pregnancy was far different than her first, in that she experienced much more severe headaches, severe dizziness, and the sensation that' the room was spinning around her when she would lie down. As a result of these symptoms, Major Lawson testified that she was unable to attend to her household or childcare duties and needed constant assistance. Major Lawson indicated that although he traveled as part of his job, he attended as many prenatal visits as possible with his wife, and was present when she reported her complaints to health care providers on multiple occasions. According to Major Lawson’s testimony, her doctors continuously reassured her that her symptoms were all pregnancy-related and would be relieved after delivery. Major Lawson specifically testified about Mrs. Lawson’s June 26, 2000 prenatal visit with Dr. Sweitzer, which he attended. Major Lawson indicated that at that time, she reported her persistent symptoms of dizziness when lying down, which required her to sleep in a recliner, debilitating posterior headaches, and severe nausea and vomiting. In relating these symptoms, he testified that Mrs. Lawson communicated to Dr. Sweitzer that all of these symptoms were very different than her first pregnancy. Major Lawson testified that Mrs. Lawson’s headaches in her second pregnancy were very different in that they were located in the back of her head (as opposed to a frontal headache) and required stronger medications which only dulled her pain. Major Lawson also stated that the dizziness his wife experienced was markedly different from that of her first pregnancy, in that it was severe, constant, occurred primarily when she was lying down, and resulted in the room spinning around her eyes. Finally, Major Lawson noted that although she experienced nadsea and vomiting in her first pregnancy, it was much worse during her second pregnancy, occurred daily, and was usually not triggered by anything in particular, whereas her nausea of her first pregnancy was always triggered by eating. Major Lawson testified that Dr. Sweit-zer reassured them that her symptoms were normal, pregnancy-related, and would go away after she delivered her child. Major Lawson also testified that Mrs. Lawson had numerous visits and telephone calls with MGMC, and testified that he was aware that his wife was repeatedly reassured that all of her symptoms were normal and secondary to her pregnancy. The Court finds this testimony persuasive, and consistent with Mrs. Lawson’s ongoing use of Compazine for nausea, multiple unscheduled visits and telephone consultations, and use of narcotics in an attempt to regulate her pain. Major Lawson also testified that beginning in September 2000, his wife began to experience excruciating back pain that she had never experienced in her first pregnancy, as well as left foot weakness and a loss of motor control that caused her to drag her left foot when she walked. Major Lawson testified that Mrs. Lawson would routinely inform him that she complained to her health care providers at MGMC about her symptoms, including her left leg weakness, difficulty walking, and severe back pain beginning in September. The Court finds Major Lawson’s testimony about Mrs. Lawson’s increased pain and symptomatology compelling, and notes that her medical records reflect several visits corresponding with this time period and these symptoms: an October 4th visit with Dr. Phan at which she complained of severe back pain, and she reported pain of a “10” on a 1-10 scale; a visit the next day with Dr. Rodriguez at which she reported that her extreme pain prevented sleep, and she received a prescription for the narcotic Percocet; her complaint on October 11 th that the Percocet aggravated her already severe nausea and vomiting, at which time Dr. Erhart switched her to Darvocet; her receipt of a Darvocet refill on October 28; and a November 14th visit with Nurse Practitioner Jones, at which she complained of continued back pain requiring Darvocet and heating pads. Major Lawson testified that despite his wife’s use of Darvocet, Compazine, and heating pads, her symptoms of pain, nausea and dizziness never subsided during her pregnancy, and that she had difficulty walking, and was unable to take care of her son, tend to her household tasks or sleep in a recumbent position. Major Lawson also testified that her symptoms did not disappear after her November 24, 2000 delivery, as she had been reassured by her health care providers throughout her pregnancy. Rather, all of the symptoms persisted and worsened, including her left foot weakness, difficulty walking, supine dizziness, occipital headaches, nausea, vomiting, and severe lower back pain. —Michelle Miller Michelle Miller, a registered nurse, is a friend and former neighbor of the Lawson family. Ms. Miller testified that both she and Mrs. Lawson participated in a carpool for their children in the September 2000 time frame. Ms. Miller observed many of the physical symptoms about which Major Lawson testified; specifically, she noted that.she suffered from severe nausea and vomiting, that she complained of severe and daily headaches to the back of her head, severe dizziness that forced her to sleep sitting upright in a chair, and left leg weaknesses that affected her gait. Ms. Miller testified that she observed Mrs. Lawson dragging her left leg when she walked beginning in September 2000, the same time she could no longer able to fulfill her carpool duties. She further testified that she often observed Mrs. Lawson looking quite ill, unable to play with her son Dominick, and unable to care for her family and home due to her physical symptoms. Ms. Miller indicated she was not aware that Mrs. Lawson, prior to her second pregnancy, had experienced such headaches in the back of her head, dizziness, difficulty walking, or difficulty caring for herself, her son, her family, or her household. Ms. Miller testified that she was aware that Mrs. Lawson had consulted her health care providers about her physical symptoms and was repeatedly reassured that they were normal pregnancy-related symptoms. Consistent with Major Lawson’s testimony, Ms. Miller noted that following the delivery of Nicholas, Mrs. Lawson’s symptoms persisted, she was unable to care for her family and home herself, and that she required the assistance of family from out of town. With regard to Mrs. Lawson’s current state, Ms. Miller testified that she remains unable to care for her family and home independently, exhibits short term memory deficits, and has visual impairments, an unsteady gait and continued pain. —Jean Rizzo Jean Rizzo, who has known Mrs. Lawson since their childhood in Panama, testified as another lay witness. Ms. Rizzo indicated that in approximately September 2000, she visited Mrs. Lawson and observed her looking extremely ill and swollen. Ms. Rizzo noted that during that visit she endured persistent explosive vomiting, became dizzy when she would lie down so she had to sleep in a chair, and experienced left leg weakness that interfered with her ability to walk. Like Ms. Miller, Ms. Rizzo testified that Mrs. Lawson’s symptoms interfered with her ability to care for her son Dominick and her household, and often required her to call upon neighbors for assistance. For these reasons, Ms. Rizzo testified that she would cook dinner and clean for Mrs. Lawson during her visits to the Lawson home during the summer and fall of 2000. Ms. Rizzo testified that Mrs. Lawson’s symptoms persisted through her second pregnancy. Ms. Rizzo also testified about her current observations of Mrs. Lawson. Ms. Rizzo indicated that Mrs. Lawson suffers from severe neck and back pain, visual defects, short-term memory loss, has difficulty walking and using stairs, that she cannot cook, has difficulty writing and is unable to play with her children. —Marcus Alexander Second Lieutenant Marcus Alexander, a close friend and former next door neighbor of the Lawsons, was a medical student during Mrs. Lawson’s second pregnancy. He testified that throughout the fall of 2000, Mrs. Lawson complained of severe occipital headaches, persistent and worsening nausea (despite her use of anti-nausea medications), and supine dizziness. Mrs. Lawson described her dizziness to Mr. Alexander as a “room-spinning kind of dizziness” that was so bad when she laid down that she had resorted to sleeping upright in a chair. Lt. Alexander also observed in the fall of 2000 that Mrs. Lawson was walking abnormally, and complaining about significant pain and weakness in her legs. Lt. Alexander testified that he urged her to report these symptoms to her health care providers, and that Mrs. Lawson acknowledged that she had done so, only to be told that all of her symptoms were related to her pregnancy. Despite these assurances, Lt. Alexander testified that he remained concerned, and examined Mrs. Lawson’s left lower extremity, noting some general weakness. Like the other lay witnesses, Lt. Alexander testified that Mrs. Lawson’s symptoms did not improve after she delivered Nicholas, and instead that she was still complaining of the same symptoms and that her leg symptoms were probably even getting worse. Lt. Alexander also testified that Mrs. Lawson currently cannot care for her children by herself, falls frequently, and requires assistance whenever Major Lawson is traveling out of town. Lt. Alexander noted that Mrs. Lawson now regularly repeats herself during conversations, including repeating whole stories, which she never did prior to her pregnancy with Nicholas. V. Ruth Lawson’s Present Condition Expert and lay testimony provided the Court with a bleak portrait of Mrs. Lawson’s current state, which was alluded to briefly in the preceding paragraphs. The Court finds that Mrs. Lawson’s neurological impairments have resulted in severe problems with balance and coordination. These problems are manifested by ambulatory difficulties, frequent falls, and a need for assistance in daily life activities. Mrs. Lawson endures recurrent weakness in her lower extremities, with occasional periods when her loss of strength is so great that she cannot ambulate on her own. Mrs. Lawson also experiences upper extremity weakness, poor fine motor coordination, and poor hand-eye coordination. In addition, Mrs. Lawson continues to suffer from persistent headaches that are primarily occipital in nature, and experiences cognitive and memory difficulties. Her impairments have resulted in severe depression. At trial, Thomas J. Spicuzza, M.D., a neurologist with board certification in neurological rehabilitation, summed up Mrs. Lawson’s condition following surgery as follows: When I saw her this past week, she was obviously depressed. She required assistance of her husband or the wall to get into the office. My thought watching her walk to the office was, the woman really ought to be in a wheelchair because she’s' dangerous to herself trying to ambulate without assistance. She has eye movements that are nonstop. She cannot look down. She can’t see down. She can see upwards, but she can’t read because her eyes are constantly moving. It makes life very difficult if you’re trying to focus on something. She still has generalized weakness that’s probably—I didn’t do any detailed muscle testing—a little greater on the left than the right and a little greater in the leg, particularly towards the foot, than in the arm. She’s just not the robust woman that was described by her husband when he first met her this morning when she was a lifeguard and running five miles a day. Her cerebellar examination was remarkable for what we call perpendicular tremors in both upper extremities and you try to get your finger to your nose and you go perpendicular to it and you may miss it altogether. And trunkle ataxia, which means she just has a real difficult time maintaining balance, and that’s complicated by diminished position sense in both feet. If you can’t tell where your feet are on the ground, you can’t send the message to your inner ear to your cerebellum and back down the spinal cord to make the minute corrections that we make when we stand, particularly with our eyes closed. That’s what causes a positive Romberg. It can either be vestibular or cerebellar or peripheral nerve in origin, and then by the history you’d start sorting out which one of these it is. Reflexes remain very active. Very brisk. She’s got three to four extra beats of clonus at each ankle which translates into functional weakness. She has got very brisk reflexes at the knees. They are approximately symmetrical now. They weren’t the last time I saw her. She had more on the left than the right. So, that’s calmed down a little bit, but this is after six years. She’s not going to get any better, and the aging process is not going to help her along either as she gets older. Tr. Feb. 9, 2006, 175:20-177:17. Mrs. Lawson’s treating physicians have noted her impairments and have attempted various treatments with limited success. She has been medicated with many different drugs, and for daily living she currently requires such medications as Lexapro, To-pamax, Maxalt, Skelaxin, and prescription-strength Motrin. —Mental and Cognitive Limitations On the cognitive level, Mrs. Lawson has been diagnosed with significant memory, attention, and concentration problems. She is also slow in processing information. Thus, she has trouble remembering things, has to double-check everything she does, and is plagued with insecurity and fear that she is making a mistake. She has lost the ability to make decisions, and has many periods when her mind turns blank, leaving her greatly confused and anxious. She also has periods where she is extremely somnolent or where her level of consciousness is severely depressed. Paul Fedio, Ph.D., an expert neuropsy-chologist and former Chief of Clinical Neu-ropsychology at the National Institute of Health, Neurological Disease and Stroke Division testified that in neuropsychological testing, Mrs. Lawson exhibits intact vocabulary and reasoning ability, but scored very low on intellectual performance tests. She ranked in the fifth percentile in reading comprehension and in the first percentile in reading speed. She demonstrated no evidence of malingering. Dr. Fedio testified that Mrs. Lawson suffers from cerebellar cognitive and emotional syndrome resulting in cognition, memory, speech, language, and emotionality deficits. Dr. Fedio noted that Mrs. Lawson has a very unsteady gait, tends to repeat herself several times, has difficulty with her visual and spatial skills, is disfluent, exhibits memory problems, and has a dysexecutive dysfunction that interferes with her ability to successfully complete normal life tasks. Mrs. Lawson also suffers from poor attention span and an inability to concentrate on specific issues. She is confused during most of the day, experiences organizational difficulties, and suffers from short-term and long-term memory problems. It is difficult for her to respond to questions with precise answers. Mrs. Lawson’s disabilities have also affected her mental health and have caused severe depression. Major Lawson travels frequently on work-related trips, during which time she is dependent on her children or other family members for assistance, as she cannot be alone in the house for any extended period. For her depression, she has been placed on anti-depressant medications such as Zoloft, Prozac, Celexa, and Lexapro, but despite adhering to these medications, she remains extremely depressed. Dr. Thomas Goldman, plaintiffs psychiatric expert, presented a troubling description of her psychiatric diagnosis: [T]he major one is major depressed mood and typical neuro-vegetative signs, loss of sleep, loss of energy and inability to concentrate and pay attention, loss of ability to experience pleasure or anhedo-nia and general decline in functioning, along with depressed mood, sadness, diminished self-esteem, diminished self-confidence, frequent crying [-][a] pretty classic picture of major depression. Tr. Feb. 10, 2006, 203:1-9. The Court finds that this state is “very much so” related to Mrs. Lawson’s neurological disability. Id. at 206:3. —Physical Limitations Mrs. Lawson displays significant nystag-mus in all directions. She has tenderness in the occipital area of the head, as well as limitations in the range of motion of her neck. She displays a wide-based gait and is unstable on her feet, a condition known as ataxia. She exhibits poor fine and gross motor coordination. She has generalized weakness in her arms and legs, greater on the left side, as well as decreased position sense in her feet. As a result of her loss of sense of space, it is difficult for her to use her hands and perform manual tasks that require speed and coordination. Further, she frequently falls when she attempts to walk without a cane or outside support because she does not know the position of her body. Repetitive falls have left bruises all over her legs and body. She reports being dizzy when she lies down and often feels like the world is rotating around her head. When standing up she feels a pressure headache in the back of her head, which forces her to lie down or sit. Her inability to keep her balance makes it impossible for her carry children in her arms or even small items from one room to another, or walk short distances. In many cases, when she stands, she begins to sway back and forth and will fall down if she does not stretch out her arms to hold her body erect. She is also unable to stand with closed eyes. Mrs. Lawson continues to experience constant headaches. The pain is in the back of her head, and sometimes radiates down her neck or seems to shoot out her ears. Major Lawson testified that she takes medicines that help to dull the pain, but they do not alleviate these headaches. Finally, Mrs. Lawson, who is left-handed, has a feeling that the left side of her body is slightly paralyzed. Her left foot feels heavy and she has a tingling sensation as if her foot is “asleep” all the time. Her left and right upper extremities, from shoulder to hand, are also very weak, especially on the left side. She also has a constant sense that her upper extremities are numb and sleeping, with a feeling of tingling and reduced sensation, which is worse on her left side. Her left grip is very weak, whereas her right hand grip is a little stronger. VI. Expert Testimony; Breach of the Standard of Care The Court also makes findings of fact regarding the nature of Mrs. Lawson’s condition and how her treating health care providers should have managed her care consistent with applicable standards of care. These findings are based on expert testimony heard by the Court. —Chiari I malformations ACM is a congenital condition that is not often encountered in pregnant women. Dr. Michael Ross, plaintiffs obstetrical expert, testified that he had treated only one pregnant patient with ACM in his twenty-five year career, and defense expert Dr. Robert Knuppel, who supervised over 100,-000 births as the Chairman of Obstetrics at the College of New Jersey, testified that he had never encountered ACM in a pregnant patient. However, ACM is not a particularly rare or unusual neurological disorder. The Court accepts the testimony of Dr. David Yousem, chair of neurora-diology at Johns Hopkins University Hospital, who noted that “Chiari I is not an uncommon disorder,” and that “as far as congenital malformations or congenital abnormalities of the brain go, this is one of the more common of those and it is something that is readily detected and diagnosed by MRI scanning.” Tr. Feb. 7, 2006, 124:17-20. A person’s temporary status as a pregnant individual cannot serve as a basis for doctors to disregard the symptomatology of the “not uncommon” ACM disorder, and when neurological symptoms are presented by a pregnant patient, a neurology referral is required. —Need for a differential diagnosis At no time during Mrs. Lawson’s pregnancy with her son Nicholas did any of her health care providers entertain a differential diagnosis to explain her persistent symptoms of dizziness, • nausea, and back pain. Four different physicians testified that a differential diagnosis is a method used by physicians to rank the potential diagnostic possibilities most consistent with a patient’s complaints, and the Court finds that a differential diagnosis should have been made no later than September 2000 to diagnose Mrs. Lawson’s severe occipital headaches and persistent vertigo. —Need for a neurological evaluation of Mrs. Lawson In light of the quality, severity and duration of her symptoms, the Court finds that Mrs. Lawson should have had a neurological evaluation as early as July 2000 and no later than the end of September 2000 in order to comply with reasonable standards of care. Mrs. Lawson exhibited symptoms including persistent supine dizziness, explosive vomiting, severe occipital headaches, severe lower back pain, radiating sciatic pain, and left foot drop. The significance of Mrs. Lawson’s symptoms was confirmed by the frequency of her unscheduled visits and calls to the MGMC and the variety and amount of narcotics and non-narcotic medications she was prescribed. These prescriptions, including Benadryl, Compazine, Darvocet, and Percocet, support the finding that her signs and symptoms were far in excess of what is seen in a normal pregnancy. Dr. Eeklund, the neurosurgeon at the WRAMC who ultimately performed her decompression surgery, stated that headache is the most common symptom of Chi-ari I malformation, and that usual symptoms include dizziness, vertigo and rotary nystagmus. A neurological examination was clearly warranted during her pregnancy. Mrs. Lawson’s doctors should have been on notice as early as June 2000 that her symptoms suggested a need for a neurological evaluation. As discussed above, in addition to complaining about her vertigo and excessive vomiting, Mrs. Lawson complained to her health care providers at that time about severe and unrelenting headaches in the back of her head. Dr. Yous-em testified that patients receive MRI scans for headaches “very, very frequently, and [that] the typical presentation or the typical reason for getting an MRI scan in a patient who has headaches is there is either increased frequency of headaches from their baseline ... or a change in the nature of the headaches from the baseline.” Tr. Feb. 7, 2006, 151:16-25. Although Mrs. Lawson had a history of headaches, the Court accepts the testimony that her headaches became more persistent, intense, and changed in nature to become occipital. Additionally, the dizziness experienced by Mrs. Lawson—vertigo—is not the type of dizziness typically seen in pregnant patients. The Court accepts the testimony of Dr. Ross that vertigo tends to be a short-term phenomenon, usually lasting ten days to two weeks. In both pregnant and non-pregnant patients, a six to seven week history of vertigo is highly unusual, suggests a chronic condition, and needs to be evaluated. The persistence of Mrs. Lawson’s vertigo also counseled in favor of neurological workup and MRI. Dr. Yous-em explained that “[i]t seemed that she was having vertigo over a lengthy period of time that, by its description, was not what ... we would expect from dehydration, in that there w[ere] no orthostatic components to it and that it was worse when she was lying down, rather than sitting up. On the basis of that, she should have a neurologic evaluation. If it was—came to imaging, which is my field, it would be an MRI scan.” Tr Feb. 7, 2006, 172:24-173:7. Even Dr. Allan Genut, the defendant’s expert neurologist, noted that “most reasonable physicians would [ ] get a neurology consultation” in situations where “vertigo fails to respond to normal therapy,” which, as discussed repeatedly, occurred with Mrs. Lawson. Tr. Feb. 15, 2006, 149:21-24. The Court finds, consistent with the testimony of Drs. Yousem and Spicuzza, that at the point at which it became clear that Mrs. Lawson’s dizziness was actually vertigo, and when the vertigo did not resolve after two weeks, she had a symptomology that warranted a neurological evaluation. Despite these changes, her doctors failed to recommend neurological evaluation or MRI. Mrs. Lawson also experienced persistent and severe nausea and vomiting throughout her pregnancy. Dr. Ross testified that it is unusual for a pregnant woman to have hyperemesis gravidarum after six months of pregnancy, and that explosive vomiting is not normally seen in obstetrical hypere-mesis. The Court finds, consistent with this testimony, that such a condition required thorough investigation. Independently, and taken together with Mrs. Lawson’s other symptoms, the development of extreme back pain and foot drop in the AugusNSeptember 2000 time frame also required further investigation and neurological evaluation. The Court accepts Dr. Yousem’s unequivocal testimony that “if a patient has a foot drop, it means they have a neurologic deficit on the motor side .... and therefore they get evaluated.” Tr. Feb. 7, 2006, 178:6-9. Dr. Ross concurred in this assessment: She now has new onset back pain that is severe.... There are several things that needed to be done. She needed to have some reasonable neurologic exam to see what the cause of the back pain was. Was she having a kidney stone? Did she have [polio]? Did she have any weakness in her legs? Were her reflexes normal? She needed a reasonable evaluation of this. Ross Tr. Feb. 8, 2006, 75:14-22. Of course, Mrs. Lawson not only developed a foot drop, but also experienced severe ánd “unremitting pain to the point where she’s taking narcotics virtually around the clock.... [I]f you’re talking about someone who for months is having back pain for which they require narcotics, that in and of itself might be a reason to do an MRI scan.” Tr. Feb. 7, 2006,180:14-22. This back pain was atypical, according to Dr. Ross; he testified that most back pain seen in pregnancy is unilateral, while Mrs. Lawson experienced midline pain radiation to both flanks. The Court also accepts the testimony of Dr. Ross, and finds that the medical records from MGMC detailing Mrs. Lawson’s prenatal care were inadequate and left large gaps in the evaluation of her condition; this testimony further supports the Court’s finding that Mrs. Lawson required a neurological evaluation for her serious symptoms. The Court accepts Dr. Ross’ testimony regarding how the health care providers in ,MGMC fell short in their treatment of Mrs. Lawson, specifically in failing to elicit adequate histories: [E]ach encounter or many of the encounters—certainly the gross majority of both the phone conversations, the patient examinations, the emergency visits seem to be blinded. They were dealing with an individual problem, never followed up on preexisting problems, that problems that she had never completely resolved ... everything was just said to be, gee, this can happen with pregnancy. It’s okay. And there w[ere] no special physical exams, there were no follow up questions. Everybody appeared to operate in a vacuum. Tr. Feb. 8, 2006, 102:17-103:4. In this case, there was no continuity of Mrs. Lawson’s care or acknowledgment of the severity of her symptoms, which clearly required neurological referral and evaluation; “[everybody was [ ] looking at [Mrs. Lawson] with blinders. There’s no follow up, no continuity to make sure what happened before has resolved.” Tr. Feb. 8, 2006, 73:10-12.