Found 5 Results Sorted by Case Date
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Florida – Emergency Medicine – Patient With Chest Pain Radiating To The Neck, Throat, And Back Discharged With Instructions To Follow up In 3-5 Days

On 11/15/2013, a patient complained of chest pain radiating to his neck, throat, and across his back.  The patient stated the onset of the pain was noted to be one hour prior to his arrival at the hospital while he was screwing something into the wall, and that the pain was exacerbated by movement.

An ED physician performed an initial EKG, labs, and a chest x-ray on the patient.

The ED physician initially treated the patient with nitroglycerin and a GI cocktail, and subsequently with diazepam, morphine, Toradol, and Dilaudid.

The ED physician’s final assessment of the patient noted that the patient was still complaining of left side neck pain and “trap pain.”

The ED physician discharged the patient with a diagnosis of “musculoskeletal chest pain” and prescribed naproxen, Norco, and diazepam, along with instructions to follow up with him in three to five days.

The patient returned to the hospital the following day in cardiac arrest and expired on 11/16/2013.

The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to perform a CT of the patient’s chest to evaluate for aortic dissection.  He also failed to adequately document bilateral pulses and/or blood pressures in the patient.  He failed to pursue other etiologies of the patient’s reported pain.  The ED physician failed to admit the patient for further observation.

It was requested that the Medical Board of Florida order one or more of the following penalties for the ED physician: 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 Medical Board of Florida deemed appropriate.

State: Florida

Date: December 2017

Specialty: Emergency Medicine

Symptom: Chest Pain, Back Pain, Chest Pain, Head/Neck Pain

Diagnosis: Aneurysm

Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment, Failure to examine or evaluate patient properly, Lack of proper documentation

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

North Carolina – Vascular Surgery – Abdominal Aortic Aneurysm 8.3 cm In Size With Large Type I Endoleak

On 3/31/12, a 76-year-old male with a history of heart disease, chronic obstructive pulmonary disease (COPD), prior endovascular repair of a large abdominal aortic aneurysm (AAA) in 2010 at an outside hospital (OSH) presented to the VA Medical Center emergency department with complaints of back, flank, and hip pain.

On 4/1/12 in the early morning, the patient had a CT scan with contrast which revealed an 8.3 cm AAA with large Type I endoleak.  There was retroperitoneal stranding consistent with an aneurysm rupture.  At 7:45 a.m., these findings were communicated to the emergency department physician.

At 8:00 a.m., the patient was evaluated by a vascular surgeon.  Based on the vascular surgeon’s interpretation of the CT films and the patient’s clinical presentation, the vascular surgeon recommended admission for observation with a follow-up consultation with orthopedic surgery and interventional radiology.

The patient was admitted to the medical ward for the next three days during which he continued to have severe ongoing pain that was managed with pain medications.

On 4/4/12, the patient had a precipitous decline in his clinical status with severe hemodynamic compromise.  A repeat CT scan demonstrated a ruptured AAA with aortocaval fistula.  The patient was taken to the operation room where the vascular surgeon performed an open repair of the aortocaval fistula and ruptured AAA.  However, the patient suffered extensive operative blood loss, perioperative myocardial infarction, and neurological injury.

The patient survived the procedure but remained critically ill.  Over the next several days, the patient improved to a certain degree, but it was felt that the patient had suffered brain injury with little chance for meaningful recovery.

On 4/9/12, supportive measures were withdrawn, and the patient died.

In January 2017, the Board received information regarding a medical malpractice lawsuit settlement payment related to the care provided by the vascular surgeon to the patient.

The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the vascular surgeon’s conduct to be below the minimum standard of competence given failure to adequately diagnose and aggressively treat the patient’s symptomatic, ruptured AAA despite evidence of the patient’s life-threatening condition.

The vascular surgeon was reprimanded.

The Board reported the Consent Order to the Federation of State Medical Boards.and the National Practitioner Data Bank.

State: North Carolina

Date: July 2017

Specialty: Vascular Surgery, Emergency Medicine

Symptom: Back Pain, Pelvic/Groin Pain

Diagnosis: Aneurysm, Post-operative/Operative Complication

Medical Error: Delay in proper treatment

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

Kansas – Cardiothoracic Surgery – Improper Surgical Procedure Of Abdominal Aortic Aneurysm Results In Anuria And Then Death

A 72-year-old male patient was admitted to a medical center with foot ulcer and foot pain. During the patient’s hospitalization, an ultrasound revealed an 8.5 cm large abdominal aortic aneurysm (AAA).  The patient was subsequently scheduled for surgical repair.

On 10/24/2010, a cardiothoracic surgeon admitted the patient to a medical center and completed a history and physical.  The cardiothoracic surgeon also signed pre-operative orders at that time.

On 10/25/2010, the cardiothoracic surgeon performed an endovascular AAA stent repair on the patient using an Endologix stent graft.  After surgery, the cardiothoracic surgeon returned to Wichita, Kansas.  The cardiothoracic surgeon’s first assistant an ARNP, signed the post-operative orders and monitored the patient’s recovery along with other hospital staff.

Post-surgery the patient began to have decreased urine output on 10/26/2010.  The patient was oliguric and then anuric.  The patient failed to respond to large doses of diuretics so a nephrologist was consulted for dialysis.

A CT scan on 10/26/2010 showed bilateral renal artery occlusion and segmental occlusion of the proximal superior mesenteric artery.

Eventually the patient was transferred to Wichita, Kansas for further care where he later died on 10/29/2010.

The Board judged the cardiothoracic surgeon’s conduct to be below the minimum standard of competence given his failure to perform proper endovascular surgery on the patient

The Board ordered that the cardiothoracic surgeon have a cardiac surgeon and/or radiologist with adequate experience in endovascular abdominal aortic aneurysm repair participate and assist the cardiothoracic surgeon on his next ten endovascular abdominal aortic aneurysm repair cases.  Also, the Board ordered that the cardiothoracic surgeon complete at least eight hours of continuing medical education courses with emphasis on endovascular abdominal aortic aneurysm repair.

State: Kansas

Date: June 2016

Specialty: Cardiothoracic Surgery, Nephrology

Symptom: Pain

Diagnosis: Aneurysm, Renal Disease

Medical Error: Procedural error

Significant Outcome: Death

Case Rating: 2

Link to Original Case File: Download PDF

Arizona – Radiologist – Symptoms Of Pain, Sprain, Right Leg Numbness, And Thigh Burning With Incidental Finding On Lumbar X-Ray

On 10/05/2012, a 65-year-old man presented to the emergency department with “pain, sprain, right leg numbness, and thigh burning”  The radiologist’s report documented degenerative changes of the lumbar spine, right hip, and right knee.

On 04/22/2014, the patient was found unresponsive with apnea, asystole, and a Glasgow coma score of 3.  Emergency medical technicians administered cardiopulmonary resuscitation and transported him to an emergency department

A CT scan showed a ruptured large fusiform abdominal aortic aneurysm of the mid- to distal abdominal aorta/aortic bifurcation and a large associated retroperitoneal hematoma.  The patient was transferred to another hospital where he died later that day.

The Board’s consultant reviewed the radiograph taken on 10/05/2012 and noted that the image clearly shows an abdominal aortic aneurysm with calcified AP diameter of 9.6 cm on the coned-down view of the lumbosacral junction.  The consultant noted that on the full lateral view, which is collimated, only the calcified posterior wall of the abdominal aorta is visualized.

The Board judged the radiologist’s conduct to be below the minimum standard of competence given failure to identify and report the abdominal aortic aneurysm on the lumbar spine x-ray.

The Board ordered the radiologist to be reprimanded.

State: Arizona

Date: June 2016

Specialty: Radiology

Symptom: Extremity Pain, Numbness

Diagnosis: Aneurysm

Medical Error: False negative

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

Wisconsin – Radiology – CT Scan Of A Saccular Aortic Aneurysm

On 9/15/1997, a radiologist read a CT scan of a 71-year-old patient as demonstrating a saccular aortic aneurysm.  He did not read it as leaking.

While there was a difference of professional opinion as to whether the CT scan indicated that the abdominal aortic aneurysm was leaking at the time the scan was performed, the radiologist conceded that there was sufficient basis for a reasonable physician to conclude that the aneurysm was leaking.

On 9/20/1997, the patient collapsed in his bathroom and was transported to the hospital where he was pronounced dead after undergoing cardiopulmonary resuscitation.  An autopsy determined the cause of death to be the rupture of an abdominal aortic aneurysm.

The Board ordered that the radiologist pay the costs of the proceeding, be reprimanded, and complete 8 hours of continuing education in the interpretation of CT scans with an emphasis on vascular findings.

State: Wisconsin

Date: January 2004

Specialty: Radiology

Symptom: N/A

Diagnosis: Aneurysm

Medical Error: False negative

Significant Outcome: Death

Case Rating: 3

Link to Original Case File: Download PDF

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