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California – Interventional Radiology – Pain And Cold Foot After Arteriogram, Angioplasty, And Atherectomy
On 6/26/2015, a patient presented to an interventional radiologist’s outpatient clinic for a left lower extremity arteriogram and intervention for a thrombosed left lower extremity bypass graft, originally placed in 2007. The patient had an extensive medical history including a renal transplant, diabetes, right leg amputation, and multiple revascularization procedures, including prior thrombectomies of the left lower extremity graft.
The patient reportedly had pain both at rest and with activity, and had a cold left leg prior to and immediately before the procedure. In order to improve blood flow in the patient’s left leg, the interventional radiologist performed an arteriogram, angioplasty, tPA administration, atherectomy, and stent placement within the left lower extremity, including an attempt to revascularize the native superficial femoral artery.
Images show an initially thrombosed femoral artery to popliteal bypass graft and deep femoral artery. Further images show balloons inflated in various parts of the graft and native arteries. Final images show flow through a patent common femoral artery (CFA), bypass graft, and peroneal and anterior tibial arteries. The deep femoral artery appeared occluded shortly beyond its origin.
After the procedure, a nurse noted the patient’s foot was cold. The interventional radiologist also assessed the patient post-procedure and found the foot to be cold, both two (2) and four (4) hours post-procedure. The interventional radiologist recommended to the patient that she travel to the emergency department of a university hospital.
The patient was then driven by her companion two hours to the emergency department, where she was assessed by an ED physician and a vascular surgeon. She was taken to the operating room where she underwent surgery, which included a left leg above-the-knee amputation and a deep femoral artery thrombectomy.
The Board stated that the standard of care for an interventional radiologist when performing an intervention is to recognize complications and to take appropriate steps to manage them. Although the patient’s foot was reportedly cold and painful immediately post-procedure, it can take some time for the foot to warm, and pain could be caused by reperfusion. However, it is clear that two to four hours after the procedure, the interventional radiologist recognized that the patient’s leg had not improved and was worsening and that further care was needed. Thus, when it became clear to the interventional radiologist that the foot was not improving, he recommended that the patient seek more treatment.
The records of the interventional radiologist’s care of the patient were inadequate in that they do not state whether the patient’s clinical status post-procedure was worse than before the procedure. A post-procedure pulse examination was lacking which would have helped in determining the patient’s clinical status.
The patient reported to the ED physician that the pain began after the procedure and steadily worsened, which indicates that the patient rethrombosed her bypass graft and deep femoral artery (source of collateral flow) immediately. This event should have been recognized by the interventional radiologist.
However, the interventional radiologist’s documentation for this patient was inadequate and sparse. The medical records lacked documentation of the change in the patient’s status post-procedure, the discussion with the patient leading up to the discharge from his center, and the patient’s disposition. The interventional radiologist discharged the patient to her own care directly from his clinic instead of calling Emergency Medical Services (EMS), which indicates that the interventional radiologist failed to recognize the gravity of what was occurring.
His conduct did not ensure that the patient would be attended continuously until definitive treatment was given. The patient arrived at the emergency department at approximately 8:00 p.m., two hours after the patient was discharged from the interventional radiologist’s clinic.
Had the process of discharge and transfer occurred earlier, it is possible that the outcome could have been different. The interventional radiologist failed to communicate with the ED physician ahead of the patient’s arrival. The interventional radiologist gave the patient a CD of the procedure, a copy of the medical records, and his phone number, as an attempt of communicating with the emergency department personnel regarding the events that occurred at the interventional radiologist’s clinic.
However, the interventional radiologist failed to telephone the ED physicians at the emergency department to give a verbal report on the patient and to provide a more informative transition and preparation for continued care. In expecting the practitioners at the emergency department to call the interventional radiologist to gain more information, the interventional radiologist improperly sought to shift his responsibility to provide needed information about the patient to the staff at the emergency department.
The interventional radiologist failed to maintain documentation regarding the change in the patient’s status post-procedure, the discussion leading up to the discharge from his center, and the patient’s disposition. He stated that he was not sure if he documented these events, and if he did, he sent them with the patient. Documentation sent with the patient has since been lost. Documentation of a change in the patient’s clinical status was lacking. The medical records lacked documentation of what was discussed regarding the patient’s disposition and where she was told to go for further care.
The Board judged the interventional radiologist’s conduct to have fallen below the standard of care for the following reasons:
1) The interventional radiologist failed to offer to transport the patient by ambulance or EMS services to ensure that she would be attended continuously until definitive treatment was given. His failure to do so indicates that he failed to understand the gravity of the situation which was occurring.
2) The interventional radiologist failed to adequately communicate with the emergency department, to call ahead of time to inform them that the patient was in transit, and to inform them of the circumstances.
3) The interventional radiologist failed to maintain adequate and accurate records.
The Board issued a public reprimand.
State: California
Date: December 2017
Specialty: Interventional Radiology, Vascular Surgery
Symptom: Extremity Pain
Diagnosis: Acute Ischemic Limb, Post-operative/Operative Complication
Medical Error: Diagnostic error, Delay in proper treatment, Underestimation of likelihood or severity, Failure of communication with other providers, Lack of proper documentation
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
California – Cardiology – Confusion, Fever, And Worsening Procedural Site After Right Femoral Artery Graft
On 12/21/2012, a 57-year-old male had a stent procedure. Complications arose, and on 12/27/2012, the patient returned to the emergency department with complaints of right lower extremity pain, numbness, and increasing inability to move his right lower extremity. An on-call cardiologist diagnosed a blood clot in the patient’s femoral artery of the right leg and took the patient to surgery in order to place a graft to open the artery to give the leg circulation. During the surgery, the cardiologist also performed a right femoral artery exploration, a right common femoral endarterectomy and patch, and a right femoral to above knee popliteal artery bypass.
On the fourth post-surgical day, 12/31/2012, the patient was noted to be confused and had an atrial fibrillation rhythm, by telemetry, which then returned to a normal rhythm the next day. On 1/1/2013, the patient had a swollen surgery site and complained of sweats and shakes. A low-grade fever was noted in the record. On 1/2/2013, there was documentation of increased erythema and drainage from the right groin wound. Wound cultures were obtained, which demonstrated large numbers of gram-negative species present. The patient was again suffering from confusion, which combined with the bacterial culture result, were clues to the patient suffering from systemic and graft infection.
On 1/5/2013, the patient was combative. A CT scan was performed, which identified fluid collection with bubbles. On 1/5/2012, the nurse notes documented a worsening wound. On 1/6/2013, the patient had a stroke while attempting to access the bathroom in his hospital room. Thereafter, from 1/9/2013 through 1/13/2012, the wound continued to worsen without any action by the cardiologist to remove the graft. On 1/14/2013, the patient was transferred to a rehabilitation center, but he had a fever, was delirious, and had an infected site. The patient had to be transferred back to the hospital on 1/16/2013 because of uncontrollable bleeding from the wound. On 1/17/2013, another vascular surgeon removed the graft from the patient and performed a right Sartorius myoplasty in order to address the infection.
The Medical Board of California judged that the cardiologist’s conduct departed from the standard of care because he failed to recognize and diagnose the signs of serious infection, adequately treat the patient’s graft infection, and remove the graft during the patient’s first hospital stay.
The Medical Board of California placed the cardiac surgeon on probation for 2 years and ordered the cardiac surgeon to complete an education course for at least 40 hours in the first year of probation.
State: California
Date: August 2016
Specialty: Cardiology
Symptom: Numbness, Confusion, Fever, Extremity Pain, Swelling, Weakness/Fatigue, Wound Drainage
Diagnosis: Procedural Site Infection, Acute Ischemic Limb, Cardiac Arrhythmia, Ischemic Stroke
Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Improper treatment
Significant Outcome: Hospital Bounce Back
Case Rating: 3
Link to Original Case File: Download PDF
Arizona – Interventional Radiologist – Timing Of Angiogram With Peripheral Vascular Disease And Worsening Leg Pain
On 07/12/2012, a 73-year-old man presented to the emergency department with left lower leg pain described as constant, worsening, and exacerbated by movement along with 2 days of left lower back pain radiating into the buttocks and back of the leg. The patient’s history included degenerative disc disease, lower back pain for more than 5 years, chronic pain syndrome on oxycodone/acetaminophen, peripheral neuropathy on gabapentin, and obstructive sleep apnea. The patient reported that during this admission that he had a history of peripheral vascular disease, a previous right leg amputation below the knee, hyperlipidemia, hypertension, coronary artery disease, and a prior coronary artery bypass.
An arterial ultrasound was completed with findings of occlusion of the posterior tibial-peroneal trunk and a patent anterior tibial artery. The interventional radiologist was called to address the occlusion, and he recommended a follow-up in the radiology clinic in 1-2 days. The patient was discharged home with a diagnosis of low back pain with exacerbation.
On 07/13/2012, the interventional radiologist diagnosed the patient with progressive non-acute peripheral vascular disease with worsening left leg rest pain and ordered an angiogram with intervention. The interventional radiologist documented that the patient’s pulses were absent on doppler with three seconds capillary refill.
On 07/19/2012, the patient returned to the emergency department with lower leg pain exacerbated by movement. The physical exam revealed a left lower extremity that was cool, a +1 dorsalis pedal pulse with good capillary refill, and a foot that was pink and warm. The ED physician diagnosed the patient with peripheral vascular complications without neurovascular compromise with good pulses. He ordered a CT angiogram and placed a call to the interventional radiologist who examined the patient. The interventional radiologist performed an examination that was not documented other than that he examined the patient, found that he did not need acute intervention, and recommended outpatient work-up. The interventional radiologist confirmed that the outpatient angiogram was scheduled for 07/26/2012 and re-scheduled it a day later so that he could personally perform it on 07/27/2012.
On 07/25/2012, the patient returned to the emergency department with acute left lower extremity ischemia with a cold, blue, and painful extremity with no pulses. The patient was transferred to a different hospital.
On 08/04/2012, he died with the cause of death listed as shock secondary to severe leg ischemia.
The Board judged the interventional radiologist’s conduct to be below the minimum standard of competence given failure to perform a semi-urgent angiogram on a patient with acute ischemia. He failed to document a vascular examination.
The Board ordered the interventional radiologist to be reprimanded.
State: Arizona
Date: August 2016
Specialty: Interventional Radiology
Symptom: Extremity Pain, Back Pain
Diagnosis: Acute Ischemic Limb
Medical Error: Delay in proper treatment, Lack of proper documentation
Significant Outcome: Death, Hospital Bounce Back
Case Rating: 4
Link to Original Case File: Download PDF
California – Vascular Surgery – Surgery For Ischemic Limb With Post-Operative Complications
On 1/27/2009, a 74-year-old female was brought to the emergency department by ambulance. She was diagnosed with exacerbation of congestive heart failure and admitted to the intensive care unit (ICU) for further care.
Her past medical history was significant for severe coronary, peripheral, cerebrovascular, pulmonary, and renovascular occlusive disease. The patient also had a history of previous myocardial infarction, hypertension, hyperlipidemia, and chronic obstructive pulmonary disease with more than twenty years of tobacco abuse. The patient’s past surgical history was significant for heart bypass with porcine aortic valve replacement, carotid endarterectomy, left femoral endarterectomy, renal and iliac stent placements. In the emergency department, it was noted that the patient had new onset of atrial fibrillation.
On 1/27/2009, the patient complained of left arm pain.
On 1/28/2009, doppler and CT angiogram were performed.
On 1/28/2009, a vascular surgeon saw the patient to evaluate the patient’s left arm acute arterial occlusion. “Thrombectomy +/- angioplasty” was recommended after cardiac clearance.
At 8:25 a.m. on 1/30/2009, surgery was performed. Percutaneous thrombectomy with atherectomy, angioplasty, and stent placement were done in multiple arteries of the left upper extremity. An Angio-seal closure device was used in the right femoral access site. A 6 mm x 10 cm Viabahn stentgraft was placed into the brachial artery and a 7 mm x 29 mm Cordis Genesis stent was placed into the subclavian artery. Clinically, the patient’s left hand was significantly worse after surgery and needed reexploration.
On 1/31/2009, the vascular surgeon recommended anticoagulation with heparin on and possible fasciotomy. Fasciotomy of the left forearm was subsequently performed with no improvement. The patient’s left forearm experienced clinical deterioration over the next few days.
On 2/2/2009, the patient was transferred to a different hospital by request of her family. The patient was unstable and required a blood transfusion on arrival. The patient’s left arm was non-viable, and no blood flow to the left forearm or hand was documented on angiography.
On 2/7/2009, the patient required an amputation just below the left elbow level.
After transfer to this different hospital, the patient also developed ischemic symptoms in both lower extremities. An attempt at endovascular treatment was unsuccessful.
On 2/10/2009, she underwent open bilateral iliofemoral thromboembolectomies with patch angioplasties. A malpositioned Angio-seal was found in the right common femoral artery. This operation was successful and the patient had no further ischemic episodes.
The Board judged the vascular surgeon’s conduct to have fallen below the minimum level of competence for the following reasons:
1) Failing to appropriately assess and document the condition of the patient’s arm and hand.
2) Failing to create an appropriate treatment, plan.
3) Failing to adequately perform a physical exam on the patient.
4) Deferring surgery until 1/30/2009, and not heparinizing the patient while she was awaiting surgery.
5) Using atherectomy in the arm for acute arterial occlusion instead of thrombolysis.
6) Using a stentgraft in the brachial artery rather than suture repair and failing to remove the embolic material in the hand.
7) Delaying transfer of the patient to the other hospital, where thrombolytic therapy was available.
8) Failing to recognize the progressive ischemia of the patient’s hand during the post-operative period.
9) Delaying commencing heparin in the post-operative period.
10) Delaying fasciotomy and lack of re-exploration with palmar arch embolectomy or thrombolysis to address distal embolization in view of a dying hand.
11) Failing to acknowledge the patient’s dead hand, which was documented on her arrival to the other hospital.
12) Failing to recognize a persistent, progressive limb-threatening situation in the post-operative period.
13) Failing to recognize that the patient had right lower extremity ischemia, which is a known and accepted complication after intraluminal placement of the Angio-seal closure device.
14) Failing to adequately note the condition of the patient’s hand during the early post-operative period and whether there had been improvement and then deterioration.
15) Failing to document evidence that the patient’s hand was viable as suggested by the vascular surgeon.
16) Failing to discuss all options and alternatives.
The Board issued a public reprimand with the stipulation for the vascular surgeon to enroll in a medical record keeping course.
State: California
Date: March 2016
Specialty: Vascular Surgery
Symptom: Extremity Pain
Diagnosis: Acute Ischemic Limb, Cardiovascular Disease, Post-operative/Operative Complication
Medical Error: Improper treatment, Delay in proper treatment, Underestimation of likelihood or severity, Lack of proper documentation
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
North Carolina – Physician Assistant – Bandage Wrap Applied To Patient’s Foot Before Surgery To Prevent Slippage Of The Leg
The Board was notified of a professional liability payment paid on 04/21/2015.
In March 2013, a patient had surgery as a result of a right hip fracture. The physician assistant was present in the operating room as the surgical assistant. Following the surgery, the physician assistant provided post-operative care for the patient. As a routine part of the surgical procedure, a bandage wrap was applied to the patient’s foot before surgery to prevent slippage of the leg out of a leg traction device. This bandage wrap is usually removed by the operating room nurse or the surgical assistant in the operating room after surgery. In this case, the physician assistant did not remain in the operating room following surgery. The operating room nurse did not remove the bandage wrap. The wrap was also not removed during the patient’s post-operative hospitalization or after her transfer to a rehabilitation facility.
The Board noted that it was the physician assistant’s responsibility to conduct post-operative assessments of the patient and that the physician assistant missed several opportunities during examinations to discover that the wrap had not been removed. The wrap was not removed for approximately six days after surgery causing the patient to develop vascular compromise resulting in foot ulcers. Ultimately, the patient required a lower leg amputation.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review. The independent medical expert judged the physician assistant’s conduct to be below the minimum standard of competence given failure to remove the bandage wrap in a timely fashion.
The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards. It was not reported to the National Practitioner Data Bank.
State: North Carolina
Date: February 2016
Specialty: Physician Assistant, Orthopedic Surgery, Vascular Surgery
Symptom: Extremity Pain
Diagnosis: Acute Ischemic Limb, Post-operative/Operative Complication
Medical Error: Procedural error, Failure to follow up
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
North Carolina – Orthopedic Surgery – Failure to Timely Diagnose Cause of Leg Pain
The Board was notified of a professional liability payment made on behalf of an orthopedic surgeon on 04/01/2015.
A patient was referred to an orthopedic surgeon for an evaluation after months of increasing lower left leg pain. An MRI scan was ordered for the patient. She was prescribed hydromorphone and celecoxib. At a follow-up visit, the result of the patient’s MRI scan was discussed with her, but a diagnosis of her medical condition remained uncertain.
Five days after this visit, the patient was seen by her family practitioner who referred her to a vascular surgeon. The patient was diagnosed with having an acute arterial insufficiency to her leg and three days later she required a below the knee amputation.
The Board obtained the patient’s records and sent them to a qualified independent medical expert for review. The independent medical expert judged the orthopedic surgeon’s conduct to be below the minimum standard of competence given failure to properly diagnose and treat the patient.
The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards. It was not reported to the National Practitioner Data Bank.
State: North Carolina
Date: February 2016
Specialty: Orthopedic Surgery, Vascular Surgery
Symptom: Extremity Pain
Diagnosis: Acute Ischemic Limb
Medical Error: Diagnostic error
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 1
Link to Original Case File: Download PDF
California – Vascular Surgery – Swelling Related To Ischemic Limb After Bilateral Total Knee Arthroplasty To Treat Bilateral Knee Arthritis
On 5/24/2010, a 62-year-old male was admitted to the hospital for elevated bilateral total knee arthroplasty to address severe bilateral knee arthritis. The operation was performed by an orthopedic surgeon and began at 11:00 a.m. The left knee was replaced first and that portion of the operation ended at 1:30 p.m. The right knee was replaced next with the entire operation ending at 4:00 p.m.
On 5/24/2010 at 8:45 p.m., the PACU nurse reported to the orthopedic surgeon that the patient was complaining of left calf cramping and observed his left foot was cooler than the right, and the patient had no Doppler flow in the left ankle area. The orthopedic surgeon instructed the PACU nurse to call the on-call hospitalist. The hospitalist examined the patient and confirmed the findings, which he noted were “concerning” for “possible left lower ischemia.” The hospitalist called Vascular Surgeon A at 10:00 p.m., who responded immediately. After discussing the case, Vascular Surgeon A instructed the hospitalist to order an emergency angiogram (radiographic imaging of the blood vessels to check for narrowing or blockage of arteries) with directions to report the findings back to him when the emergency angiogram was completed.
On 5/25/2010 at 1:22 a.m., a physician completed the emergency angiogram, which indicated that there was an occlusion of the left popliteal artery approximately 4 cm above the knee joint space, which appeared to be due to an arterial dissection. There was distal reconstitution through a tiny corollary artery. The physician crossed the occluded popliteal segment and then noted “slow-in-line flow” with distal stenosis. The physician called Vascular Surgeon A immediately after the results were available, and Vascular Surgeon A scheduled the patient for left femoral-popliteal bypass surgery that was scheduled for that morning at 5:30 a.m.
Vascular Surgeon A arrived at the hospital on 5/25/2010 at some time between 5:00 a.m. and 5:30 a.m. According to Vascular Surgeon A, when he examined the patient, he found the patient’s left foot was warmer than he expected, and Vascular Surgeon A “was able to hear dorsalis pedis Doppler flow that was of moderate degree [but] could not hear the posterior tibial at that time.” Vascular Surgeon A, however, also noted that patient “was not able to dorsiflex the foot or the left big toe” (which Vascular Surgeon A attributed to peroneal palsy that occurred during the course of the knee surgery). Vascular Surgeon A further noted the patient “had no significant pain in the calf.” Based on his examination, Vascular Surgeon A “therefore, decided to postpone the [femoral-popliteal bypass] surgery and ordered a repeat angiogram, surmising that he [the patient] had amelioration of the perfusion of his left lower leg.” According to Vascular Surgeon A’s Consultation Report, which was dictated 2 days later on 5/27/2010 at 1:40 p.m., “[t]he repeat angiogram by the physician showed that there was indeed flow through the previously occluded popliteal artery, but it was still suboptimal, in that, there was still areas of about 50%, perhaps even 60% narrowing…” In justifying his decision to cancel the previously scheduled surgery, Vascular Surgeon A noted the following in his Consultation Report:
“…[B]ecause there was much better perfusion of the flow pulse the fact that he had a warm sweat, and felt much better with no pain in the foot or the calf region, I canceled the operation. I should mention that overnight, the patient, after discussing the program with one of our hospital based physicians, the decision was made to heparinize the gentleman until I had seen him about 4 hours from his first angiogram.
When I left the gentleman at about 9:30-10 o’clock in the morning on the 25th of May, his food was warm. He had moderate-to-good flow by ultrasound, but I still could not hear the posterior tibial, or if there was, it was a very faint one. The patient felt much better, and I felt we could simply observe him without having to proceed with the planned femoropopliteal bypass using his own saphenous vein.
The lack of dorsiflexion of his foot and big toe suggested that there was peroneal nerve palsy or injury most likely at the time of manipulation of the knee during surgery, rather than a compartment syndrome, although we will need to watch out for the development of this entity in the next day or two.”
On 5/26/2010 at 7:50 p.m., the patient was seen again by Vascular Surgeon A. Vascular Surgeon A noted the patient’s left foot was warm with Doppler flow in the dorsalis pedis and posterior tibial arteries at the foot. The patient was also noted to have considerable swelling above and below the knee and leg and still had peroneal nerve palsy.
On 5/27/2010 at 7:00 p.m., the patient was seen again by Vascular Surgeon A. Vascular Surgeon A thought the patient was “borderline” for compartment syndrome, his left lower extremity was still swollen, and there was still a peroneal palsy. Vascular Surgeon A signed out to a colleague that evening as he was going on a scheduled vacation and had no further involvement in the care and treatment of the patient.
On 5/28/2010, the patient underwent a four-compartment fasciotomy (surgical procedure to release increasing tissue pressure) performed by the orthopedic surgeon to address a preoperative diagnosis of “[c]ompartment syndrome, left lower extremity” that developed after the popliteal artery dissection.
On 6/1/2010, the patient underwent another surgical procedure performed by Vascular Surgeon B, which included “stent placement to treat the popliteal artery lesion and hopefully improve the left lower extremity arterial perfusion” in an attempt to save the patient’s left lower leg. According to the procedure note, this included, among other things, the placement of a “stent graft to treat the vessel from the patient superficial femoral artery down into the patent popliteal artery.” This procedure temporarily resulted in “adequate tissue perfusion pressure and patent arterial inflow into the left lower extremity.”
On 6/11/2010, after one of the follow-up procedures to treat the patient’s wound area related to his prior fasciotomy, the patient “was found to have a distinct change in his Doppler signal and loss of the previously palpable pulses” with a repeat angiogram suggesting “thrombosis of the stent graft.” After a detailed informed consent, the patient underwent a thrombectomy (surgical procedure to address arterial thrombosis) performed by Vascular Surgeon B “as a final step to try and prevent the need for left lower extremity amputation.”
On 6/12/2010, the Vascular Surgeon B requested a consultation from Vascular Surgeon C for a “second opinion” as to whether there were any viable treatment options to save the patient’s left lower leg, which now objectively appeared to be “cadaveric and nonviable.” After this consultation, it was determined there would be no “functional recovery” of the leg, and there were no viable options to save the patient’s left lower leg. On 6/15/2010, the patient underwent a below-knee amputation and was ultimately discharged to a rehabilitation facility on 7/9/2010.
The Medical Board of California judged that Vascular Surgeon A’s conduct departed from the standard of care because he failed to respond in a timely and appropriate manner to the patient’s acute limb ischemia when he, among other things, failed to personally evaluate the patient on a timely basis between 5/25/2010 at 9 a.m. to the evening of 5/26/2010, review the emergency angiogram on a timely basis, take the patient to surgery immediately after the emergency angiogram results were reported, perform a timely fasciotomy after he noted swelling of the patient’s left leg on 5/26/2010 and 5/27/2010 and suspected the patient was at risk of developing compartment syndrome.
For this case and others, the Medical Board of California ordered Vascular Surgeon A to surrender his license.
State: California
Date: July 2015
Specialty: Vascular Surgery, Orthopedic Surgery
Symptom: Swelling
Diagnosis: Compartment Syndrome, Acute Ischemic Limb, Musculoskeletal Disease, Post-operative/Operative Complication
Medical Error: Delay in proper treatment, Delay in diagnosis
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
California – Vascular Surgery – Guidewire Tip Breaks When Attempting To Revascularize 1st And 2nd Right Foot Toes
On 7/9/2013, a 44-year-old male, with a past history of renal failure after a failed kidney transplant, insulin-dependent diabetes, coronary and peripheral vascular disease (PVD), and dry gangrene of the 1st and 2nd right foot toes presented to a dialysis center for a follow-up visit. At that time, a vascular surgeon examined the patient and noted in the patient’s chart that it was ok to proceed with a “right 1st toe amputation.” This notation, however, was subsequently crossed out by the vascular surgeon as an error. The vascular surgeon ordered that the patient undergo a repeat arterial duplex scan of his right posterior tibial artery (PTA), peroneal artery (PA), anterior tibial artery (ATA), and a dorsalis pedis artery (DTA) as he had no improvement in the dry gangrene of 2 toes on his right foot.
On 7/11/2013, the patient presented for the arterial duplex scan, which showed improved blood flow in the PTA and PA, but the ATA and DPA were re-occluded. As a result of these findings, the vascular surgeon recommended that another angiogram be performed with possible balloon angioplasty in an attempt to revascularize the occluded arteries.
On 7/26/2031, the vascular surgeon performed an arteriogram of the patient’s right lower extremity. The PTA pulse was documented at +1 both pre and post-procedure. The images of the arteriogram showed widely patent circulation to the patient’s foot via the PTA, but the TA was occluded, and the DPA was not seen. The vascular surgeon documented, in his procedure note, that he was unable to gain guide-wire access due to the occluded ATA. Upon removal of the guide-wire, it was discovered that the distal tip of the wire had broken off and remained in the occluded ATA. The vascular surgeon, however, failed to document the retained tip of the wire in his operative report or procedure note, and he failed to notify the patient of the retained wire fragment. Another employee, who assisted during the procedure, filed an Incident Report concerning the retained wire fragment.
On 7/29/2013, the patient returned to the dialysis center for a mapping of the greater saphenous vein to see if the vein could be utilized for a bypass graft. The vascular surgeon determined that the vein was viable for the bypass graft and scheduled the patient for a femoral distal bypass of the right lower extremity in an attempt to revascularize the lower leg and foot. At that time, the vascular surgeon did not inform the patient of the retained wire from the arteriogram performed on 7/26/2013.
On 8/1/2013, the vascular surgeon performed the vein bypass surgery of the patient’s right lower extremity. In his operative report, the vascular surgeon documented that there was a strong biphasic signal of the distal ATA at the completion of the procedure. On this same date, the vascular surgeon dictated an addendum to his 7/26/2013 arteriogram operative report regarding the retained tip of the guide wire, but the vascular surgeon did not inform the patient of the retained wire tip.
On 8/6/2013, the patient returned to the dialysis center complaining of a lot of pain, and it was noted that the dry gangrene of his 2 right toes had progressed into wet gangrene. Also, the vein bypass procedure, performed 5 days earlier, had failed to revascularize the patient’s lower right leg and foot. As a result of the failed vein bypass and the other previously failed endovascular attempts to revascularize the area, the vascular surgeon determined that the patient required the amputation of his right leg below the knee. Had the patient’s 1st right toe been amputated as originally documented in the 7/9/2013 office visit, his right lower leg would have been salvaged. On 8/20/2013, the vascular surgeon saw the patient, who was complaining of increased devitalization of his right foot and pain. At that time, the patient was scheduled for a below the knee amputation of his right leg. At this visit, the vascular surgeon informed the patient that the distal tip of the guide wire had broke off during the 7/26/2013 procedure and was retained in the occluded section of his ATA. Thereafter, the patient had his right leg amputated below the knee.
The Medical Board of California judged that the vascular surgeon’s conduct departed from the standard of care because he failed to document the retained tip of the wire fragment in his operative report and procedure note on 7/26/2013 and failed to timely notify the patient. He also made multiple failed attempts at lower extremity revascularization, which resulted in below the knee leg amputation of the patient’s right lower leg.
For this case and others, the Medical Board of California placed the vascular surgeon on probation for 1 year and ordered the vascular surgeon to complete an education course (at least 20 hours per year for each year of probation), a medical record keeping course, and a professionalism program (ethics course). The vascular surgeon was also prohibited from supervising physician assistants.
State: California
Date: June 2015
Specialty: Vascular Surgery
Symptom: Extremity Pain
Diagnosis: Acute Ischemic Limb
Medical Error: Delay in proper treatment, Ethics violation, Failure of communication with patient or patient relations, Lack of proper documentation, Retained foreign body after surgery
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
Wisconsin – Orthopedic Surgery – Right Foot Cool After Total Knee Arthroplasty
On 10/11/2004, a patient presented to the orthopedic surgeon with moderate bilateral knee pain, which he diagnosed as bilateral knee osteoarthritis. After considering her treatment options, the patient scheduled a right total knee arthroplasty (“TKA”) with the orthopedic surgeon.
On 12/7/2004, the patient presented at the hospital for her TKA with the orthopedic surgeon. At 8:18 a.m., a tourniquet was applied to the patient’s right leg. At 9:35 a.m., the surgery was complete and the tourniquet removed.
At 9:40 a.m., the patient was transferred to the recovery room. At this time, the nurses noted the patient’s right foot was cool with no movement or sensation, and they were unable to palpate a right pedal pulse or obtain one with the Doppler. At 10:30 a.m., the patient’s foot was still cool, despite the use of a warming blanket, and the nurses were still unable to obtain a right pedal pulse with the Doppler. The orthopedic surgeon was notified of these findings at this time, no steps were taken to establish adequate blood flow to the patient’s right foot. At 10:50 a.m., the nurse asked a physician in the recovery unit to attempt to obtain a pulse via Doppler and palpitation. The patient’s foot was still cool and based on the inability to obtain a pulse by Doppler or palpitation, a vascular injury or complication was included in the physician’s differential diagnosis.
At 11:05 a.m., the orthopedic surgeon was informed of the inability to find a pulse in the patient’s right foot. No action was taken at that time. At 11:25 a.m., the patient was transferred to a different floor per the orthopedic surgeon’s order. The nurse was unable to palpate a pedal pulse and noted the foot was pale. At 1:00 p.m., the nurse is still unable to obtain a pulse with the Doppler, the patient reported pain in the back of her knee, and her toes were dusky. The orthopedic surgeon was paged at or around this time.
At 2:00 p.m., the orthopedic surgeon performed a neurological evaluation on the patient and noted she had right knee pain, decreased sensation in the dorsum of the foot, no sensation to the toes in the plantar surface of the foot, and a slight decrease in motion of her toes. The orthopedic surgeon did not attempt to obtain a pulse in the foot and noted, “Will observe as most of this is probably due to spinal.”
At 4:00 p.m., the patient reported calf pain at the popliteal area and pain when raising her toes toward the ceiling; pedal pulses were palpable. The information was relayed to the orthopedic surgeon. At 5:00 p.m., the patient still complained of pain behind her knee. At 6:30 p.m., the patient’s toes remained cool, she had a burning pain her right foot, and a palpable pedal pulse. On 12/8/2004 at 12:09 a.m., the nurse noted the patient was unable to wiggle her toes, her right foot was slightly dusky, and a pulse could not be obtained via Doppler or palpitation. At 8:50 a.m., the orthopedic surgeon evaluated the patient and noted she was having moderate to severe pain and worsening of the sensation and motion symptoms, which he believed were caused by tight dressings. He did not attempt to obtain a pedal pulse. At 4:10 a.m., the orthopedic surgeon evaluated the patient and noted slightly more sensation to the dorsum of the foot but, despite the slight improvement, he was concerned about the patient’s sensation changes.
On 12/9/2004, the orthopedic surgeon ordered an arterial Doppler evaluation in the vascular lab, which was later changed to an arteriogram by the patient’s primary care physician. The arteriogram revealed that the patient had an ischemic leg due to blockage of the popliteal artery, which resulted in compartment syndrome. The patient was taken to the operating room on an emergent basis where a clot from the popliteal artery was removed and fasciotomies were performed to relieve pressure in the patient’s lower leg.
The orthopedic surgeon agrees in failure in conduct to order a Doppler study or a vascular consult on 12/8/2004, despite the fact that the patient’s neurological symptoms were worsening, the patient was unable to wiggle her toes, and a pedal pulse could not be found.
The Board has reprimanded and fined the orthopedic surgeon.
State: Wisconsin
Date: February 2012
Specialty: Orthopedic Surgery, Internal Medicine, Vascular Surgery
Symptom: Extremity Pain
Diagnosis: Acute Ischemic Limb, Compartment Syndrome, Post-operative/Operative Complication
Medical Error: Underestimation of likelihood or severity, Delay in proper treatment, Failure to order appropriate diagnostic test
Significant Outcome: N/A
Case Rating: 4
Link to Original Case File: Download PDF
Wisconsin – Cardiothoracic Surgery – Post-Operative Arm Pain And Swelling After Radial Artery Endoscopic Harvest
On 02/23/2005, a 74-year-old man with a history of coronary artery disease was admitted with a myocardial infarction.
On 02/27/2005, the patient was taken to the operating room where a cardiothoracic surgeon performed a 4-vessel coronary artery revascularization. As part of the procedure, the cardiothoracic surgeon performed a radial artery endoscopic harvest from the patient’s left forearm.
After the procedure, the patient developed swelling of his left forearm.
At 4 p.m. on 02/28/2005, the patient complained of significant pain in his left hand and forearm. Nursing staff noted the forearm to be swollen and taut. Doppler of the ulnar artery revealed a pulse. Doppler of the palmar arch was quiet. The patient’s sensation and mobility were decreased at the fingertips and fingers. The hand was warm. The cardiothoracic surgeon gave instructions to keep the arm elevated and not bandaged. He intended to reevaluate the arm the following morning when the swelling decreased. He was thinking that some swelling is not to be unexpected. At 6 p.m., the nurses’ notes reflected a slight improvement in sensation and movement of the left upper extremity.
At 7:30 a.m. on 03/01/2017, the cardiothoracic surgeon reassessed the left arm. There appeared to be a hematoma in the area of the endoscopic incision. Ecchymosis was noted on the forearm and the palm. The cardiothoracic surgeon performed a bedside hematoma evacuation under local anesthesia. Dark blood was evacuated with no active bleeding. The hematoma was presumed venous. The patient’s hand function appeared to be preserved at that time.
At 9:45 a.m. on 03/01/2017, the patient’s left hand showed increased ecchymosis. The nurse was unable to obtain pulses of the palmar and ulnar arteries by doppler. The patient was unable to move his fingers. The cardiothoracic surgeon was notified of the change, and he scheduled a re-exploration surgery for 4:00 p.m. that day, following completion of another scheduled surgery for a critically ill patient. The physician assistant came to see the patient. The vascular lab performed a study in anticipation of the re-exploration.
At 3:20 p.m. on 03/01/2017, while he was in the operating room, the cardiothoracic surgeon was notified of mottling of the patient’s left arm with concern for decreased blood flow. The cardiothoracic surgeon was involved in a complex surgery and indicated that he would complete the current surgery and then attend to the patient.
At 6:30 p.m. on 03/01/2017, the re-exploration was performed. The patient was found to have been bleeding from the stump of the radial artery. Hemostasis was achieved. Doppler signals of the ulnar artery and palmar arch were noted. Hand color had improved.
On 03/11/2005, the patient developed loss of Doppler signals of the ulnar artery and palmar arch. The cardiothoracic surgeon performed a left brachial and ulnar artery thrombectomy with a removal of a small amount of thrombus. Debridement of the left forearm musculature was also performed as it appeared necrotic in several areas.
On 03/12/2005, the patient’s wound appeared to be worsening. Plastic surgery consultation was obtained.
On 03/14/2005, the patient was taken to surgery for additional wound debridement. Orthopedic surgery was consulted, who agreed that the patient’s prognosis for left forearm recovery was poor. Amputation of the arm was recommended.
On 03/20/2005, a left elbow disarticulation and primary stump closure were performed by the orthopedic surgeon.
The cardiothoracic surgeon testified that he did not detect the patient’s compartment syndrome as early as he would have liked. He reported performing over a thousand radial artery harvests without the complication of compartment syndrome. He believed that when he evacuated the patient’s hematoma, there was no evidence of arterial bleeding. Part of the delay was due to him being preoccupied in surgery. He has instituted measures where colleagues can attend to an emergency patient issue if he is unavailable.
The Board judged the cardiothoracic surgeon’s conduct to have fallen below the standard of care by failing to more promptly diagnose the patient’s compartment syndrome.
He was ordered to complete 6 hours of education in the diagnosis and treatment of postoperative complications of vascular surgery, including the diagnosis and treatment of compartment syndrome.
State: Wisconsin
Date: February 2010
Specialty: Cardiothoracic Surgery, Internal Medicine, Orthopedic Surgery, Vascular Surgery
Symptom: Extremity Pain, Bleeding
Diagnosis: Compartment Syndrome, Acute Ischemic Limb, Post-operative/Operative Complication
Medical Error: Delay in proper treatment, Failure to properly monitor patient
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF