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Ajala v. UW Hospital and Clinics

United States District Court, W.D. Wisconsin

November 6, 2019

MUSTAFA-EL K.A. AJALA, formerly known as DENNIS E. JONES-EL, Plaintiff,



         Pro se plaintiff and prisoner Mustafa-El Ajala is proceeding on claims that health care staff at Wisconsin Secure Program Facility and University of Wisconsin Hospital and Clinics failed to provide him adequate treatment for his hypercalcemia and hyperparathyroidism, in violation of both the Eighth Amendment and state law. Now before the court are motions for summary judgment filed by University of Wisconsin Hospital and Clinics, dkt. #81, and the state defendants (Sutchin Patel, Burton Cox and Sriharan Sivalingam), dkt. #73. For the reasons set out below, I will grant both motions.

         Also before the court are plaintiff's motions for an order compelling discovery from the state defendants (Sutchin Patel, Burton Cox and Sriharan Sivalingam) and for sanctions against them, dkt. #66, motion for default judgment, dkt. #95, and motion requesting permission to add citations to his summary judgment filings, dkt. #105. I will deny plaintiff's motions to compel, for sanctions and for default judgment, but will grant plaintiff's motion to add citations to his summary judgment filings.

         From the parties' proposed findings of facts and responses, I find the following facts to be material and undisputed unless otherwise noted.


         A. The Parties

         Plaintiff Mustafa-El Ajala was incarcerated at Wisconsin Secure Program Facility during the times relevant to this lawsuit. Defendant Burton Cox was a doctor at the facility, and was plaintiff's treating physician from January 2003 to May 2005, and again from February 2007 to November 2010. Defendant Sutchin Patel was a urologist, employed by University of Wisconsin School of Medicine and Public Health. Defendant Sriharan Sivalingam was a urology fellow in endourology and minimally invasive surgery, and a clinical instructor for University of Wisconsin School of Medicine and Public Health. Plaintiff was treated by Patel and Sivalingam at defendant University of Wisconsin Hospitals and Clinics. (Plaintiff says that Patel and Sivalingam were employees and agents of University of Wisconsin Hospitals and Clinics, but he has cited no evidence to support this.)

         B. Plaintiff's Medical Treatment

         Plaintiff began experiencing frequent and painful urination in approximately 2001. He also had high calcium levels in his blood starting in 2001 and blood in his urine in 2002. From 2003 to 2007, plaintiff had high calcium levels, occasional blood in his urine and frequent urination. Plaintiff asked defendant Cox to diagnose his condition and provide treatment for it. In 2010, Cox referred plaintiff to the UW Urology Clinic for treatment.

         1. 2010

         Plaintiff saw defendant Dr. Patel at the UW Urology Clinic for the first time on April 30, 2010. Plaintiff had been given a diagnosis of overactive bladder and was taking lisinopril, vitamin D, hydrochlorothiazide, calcium carbonate, naproxen and oxybutynin. When evaluating a patient with urinary voiding symptoms, Patel's practice is to discuss a patient's symptoms and complete a urinalysis. Patel discussed plaintiff's symptoms with him and conducted a urinalysis, which showed “unremarkable” results. Patel also checked a post-void residual bladder scan, which showed that plaintiff was emptying his bladder adequately. Patel recommended a cystoscopy, which is a procedure to examine the lining of the bladder, so that he could evaluate plaintiff's urethra, prostate and bladder, and determine a possible cause for plaintiff's symptoms, such as a urethral stricture or bladder tumor. There is no mention in Patel's notes that plaintiff was concerned with kidney stones or high calcium levels in his blood at this visit. Dkt. #79-1 at 3.

         Plaintiff saw Patel again on May 14, 2010. Plaintiff reported the same symptoms of urinary frequency and urgency. Id. at 9. Patel performed a cystoscopy, but he found no evidence of any stricture, lesions or tumors. Because these was no evidence of bladder outlet obstruction, Patel recommended that plaintiff stop taking Flomax and Doxazosin, which he had been taking to treat a potentially enlarged prostate. Patel recommended that plaintiff start taking Ditropan XL, which is a medication used to treat overactive bladder symptoms (primarily urinary frequency and urinary urgency). When plaintiff returned to the prison, defendant Cox requested Ditropan XL for plaintiff from the Bureau of Health Services.

         During plaintiff's third appointment with defendant Patel on August 20, 2010, plaintiff reported continued urinary frequency and urgency, dry mouth, hot flashes and occasional flank pain on his left side. He denied having urinary incontinence and told Patel that he did not have any history of having kidney stones. Id. at 13. Plaintiff was taking Ditropan three times a day, and Patel concluded that some of plaintiff's symptoms were likely side effects of that medication. Patel recommended that plaintiff change his medication to an extended release medication, such as Ditropan XL or Detrol, which would have fewer side effects. Patel conducted another urinalysis, which indicated that plaintiff did not have a urinary tract infection. The urinalysis showed “occasional calcium oxalate crystals.” (Calcium oxalate crystals are the most common cause of kidney stones. Calcium oxalate crystals may be caused by dietary choices, but also may be caused by overactive parathyroid glands (hyperparathyroidism)). Because plaintiff had crystals and flank pain, Patel ordered a CT-scan to evaluate plaintiff's kidneys for possible hydronephrosis (swelling of the kidney due to a blockage in the ureter) and possible nephrolithiasis (kidney stones). Id.

         Plaintiff saw defendant Patel again on November 12, 2010, and complained of lower back and left hip pain. Id. at 18. He denied any right or left flank pain. Plaintiff told Patel that his main symptoms were urinary urgency and frequency. Plaintiff had not yet received the Ditropan XL or Detrol, and Patel recommended that plaintiff start taking one of those medications as soon as he could to address his overactive bladder symptoms. Patel recommended that plaintiff follow up with the UW Urology Clinic after he had started one of those medications.

         Patel also discussed the results of the CT scan with plaintiff. The scan showed no evidence of infection, renal masses or hydronephrosis, but showed several very small kidney stones. Id. at 425. The stones were not obstructing the kidney and were asymptomatic, so Patel did not recommend any surgical intervention. Patel recommended that plaintiff increase his oral citrate intake with lemonade or lime juice and decrease his salt intake. Id. at 18. There is no indication in the notes that Patel thought plaintiff's kidney stones were related to his lower urinary tract problems.

         Asymptomatic kidney stones by themselves do not cause pain, so patients can have a stone in their kidney for many years without symptoms. The stone must be blocking urine flow to cause pain. An obstructing stone can cause the kidney to swell (hydronephrosis). Patel generally recommends surgery if a patient has an obstructing stone or a large stone with a low chance of spontaneous passage. Kidney stones that are not obstructing should be monitored every couple of years to assess interval growth and the need for intervention. Depending on the patient and underlying causes of the kidney stones, calcium-based kidney stones may be prevented through dietary modifications, medications and surgical management of the parathyroid glands.

         After plaintiff's appointment with Patel, defendant Cox did not prescribe oral citrate for plaintiff. (According to Cox, he thought plaintiff could purchase lemonade from the canteen, but plaintiff says he told Cox that he could not purchase it himself.)

         2. 2011

         On February 9, 2011, plaintiff had his blood drawn in the health services unit for lab work. The results showed a calcium level of 12 mg/dL (milligrams per deciliter), which is above normal levels. Dkt. #79-2 at 80. Cox ordered that the labs be repeated to check plaintiff's calcium levels again. Id. at 3. On February 16, 2011, plaintiff's lab results showed a calcium level of11.4 mg/dL. Id. at 79. On March 2, 2011, Cox ordered that plaintiff's blood be drawn again to check his calcium and parathyroid hormone levels. Id. at 3. The results showed calcium at 11.3 mg/dL, which was down from previous testing, and parathyroid hormone at 59.5 pg/mL, which is within the normal range. Id. at 78. (Records from 2009 and 2010 show calcium levels between 11 and 11.8 mg/dL. Id. at 84, 93, 97.)

         Plaintiff saw Dr. Patel again on April 29, 2011. Plaintiff reported that he had started taking Detrol LA, that the frequency and urgency of his urination had decreased by half and he was able to sleep through the night. Dkt. #79-1 at 24. He also denied any incontinence, painful urination, blood in his urine, abdominal pain or flank pain. (Plaintiff says he reported to Patel that his frequent and urgent need to urinate had “slightly” decreased, but that it was still occurring and had been ongoing for a decade.) Patel noted that plaintiff's overactive bladder appeared to be well controlled by Detrol LA. Patel ordered a uroflow test and a follow up appointment in one year.

         According to Patel, he did not think that plaintiff's symptoms warranted the work-up for the diagnosis of hypercalcemia or hyperparathyroidism. “Hypercalcemia” is the presence of an excess of calcium in the blood. “Hyperparathyroidism” is the presence of excess parathyroid hormone in the body, causing an increase in serum calcium, a decrease in inorganic phosphorus, loss of calcium from bone and renal damage with frequent kidney-stone formation. Hyperparathyroidism can cause hypercalcemia. Symptoms of hypercalcemia caused by hyperparathyroidism can be mild to severe, and can include nausea, vomiting, constipation, kidney stones, fatigue, weakness, confusion, frequent urination, headaches, abdominal pain, sensory deficits, obtundation and coma. Patients with mild and moderate hypercalcemia (calcium in their blood that is less than 14 mg/dL) may not need immediate treatment, but rather a methodical evaluation of the causes and effects of their condition. Patients with calcium higher than 14 mg/dL require immediate treatment.

         Patel thought plaintiff's primary symptom was urinary frequency, which has many common causes, and that plaintiff had no other obvious symptoms of hypercalcemia. The calcium oxalate crystals in plaintiff's urine had other potential causes, including diet. (Plaintiff says that his medical records show that he had experienced other symptoms of hypercalcemia, including high calcium levels in his blood, high blood pressure, an abnormal heart rhythm, abdominal pain, blood in his urine, kidney stones that were 100 percent calcium, calcification of his prostate and coronary artery and fatigue. However, he does not point to any evidence suggesting that he was experiencing these symptoms at the time of his appointments with Patel or that Patel was aware of these symptoms.)

         On August 22, 2011, plaintiff was taken to the emergency room because he was experiencing blood in his urine and pain. A CT scan showed that plaintiff had developed new kidney stones since his 2010 scan. He had a 3 millimeter stone and two very small stones in his left kidney and a 2 millimeter stone in his left ureter. There were no stones in his right kidney. Dkt. #79-2 at 161. He was given Vicodin and sent back to the prison to pass the stones. Id. at 41. When he returned, plaintiff asked Cox to treat his high calcium levels because they were causing his stones.

         3. 2012

         Plaintiff saw defendant Sivalingam at UW Urology for the first time on April 27, 2012. Dkt. #79-1 at 29. Plaintiff continued to complain of urinary urgency and frequency, though he reported that his urine stream was good and that his urinary frequency had declined since taking Detrol LA. He stated that he had been drinking lots of fluids to try to prevent the formation of new kidney stones. Plaintiff also told Sivalingam ...

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