On 12/24/2014, a 59-year-old female was admitted to a medical center for a Microscopic Extraforaminal Lumbar Discectomy of L4-L5. An orthopedic surgeon was assigned to perform the patient’s procedure. He began the procedure by utilizing image intensification to use a guidewire for initial placement of dilators in the patient’s spine.
After removal of the guidewire, the orthopedic surgeon noted that he felt the guidewire had gone into the disk space slightly.
After sixty percent of the procedure was completed, the orthopedic surgeon was advised by the anesthesiologist that there was a decrease in the patient’s CO2. It was subsequently noted that the patient’s blood pressure began to drop.
The orthopedic surgeon then placed an OpSite over the patient’s incision, turned the patient to a supine position, and called for assistance from a vascular surgeon.
On 12/24/2014, after becoming hypotensive and then experiencing pulseless electrical activity during the lumbar discectomy, the patient underwent an exploratory laparotomy with repair of inferior vena cava injury.
During the exploratory laparotomy, after approximately one hour of cardiopulmonary resuscitation and advanced cardiac life support protocol, the patient expired on the operating table.
At all times relevant to this case, the prevailing professional standard of care requires that when dealing with patients such as this one, a physician should place instruments into a patient’s body in a manner to do the least possible harm.
The Board judged the orthopedic surgeons conduct to be below the minimal standard of competence given that he allowed an instrument to pass into the patient’s cavity in such a way that injured underlying structures and by failing to recognize the penetration of the guidewire at the time of placement of the initial dilator, which lead to the injury of the patient’s inferior vena cava.
It was requested that the Board order one or more of the following penalties for the orthopedic surgeon: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.
Date: October 2017
Specialty: Orthopedic Surgery
Medical Error: Procedural error
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
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