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Washington – General Surgery – Right Upper Quadrant Mass And Abdominal Pain With Suspicion For Hernia In Obese Patient With Thrombocytopenia

A patient’s primary care physician (PCP) referred her to a general surgeon for a right upper quadrant mass after suspecting a hernia. In his written referral to the general surgeon, the PCP stated that the patient’s present illness was “Abdominal pain in RUQ from hernia…Refer to surgeon to evaluate RUQ mass/pain.”

In October 2008, the general surgeon examined the patient and noted that the patient presented with “a painful bulge in the R lateral abdominal wall,” she was 75 years old, 5’4” tall, 240 pounds, and suffered from hypertension. The pre-operative note also indicated that the patient would not accept a blood transfusion. This is significant considering that the patient’s pre-operative laboratory report showed a low platelet count of 84,000.

Although the patient had been experiencing significant pain and her PCP had suspected and noted the likelihood of a hernia, the general surgeon believed the abdominal mass to be a lipoma. The general surgeon did not obtain any pre-operative image studies. Instead, the general surgeon scheduled the patient for surgery at an outpatient, ambulatory surgery center, where he works. The general surgeon did not take into account that complex hernia repairs that require bowel repair or resection are not appropriate for same day surgical procedures and outpatient centers are not equipped for such procedures. At a minimum, without a preoperative image study, the general surgeon should have scheduled the patient for surgery at the hospital so that whatever issue was encountered could be properly addressed.

In November 2008, the general surgeon attempted surgery on the patient at the ambulatory surgery center. The general surgeon used the subcostal approach and discovered that in fact, the patient had a hernia and not the lipoma he had anticipated. A hernia was stuck to the undersurface of the abdominal area where the general surgeon found dense adhesions.

The surgery had to be stopped 25 minutes after its start because the surgery center lacked the instrumentation and equipment for hernia surgery. As a result of the more difficult and involved surgery required, the conscious sedation started by the anesthesiologist was insufficient to control the patient’s discomfort, and a laryngeal mask airway was needed and provided. The patient was immediately transferred by ambulance to the hospital.

The surgery center’s anesthesiologist’s report stated that the patient had a “likely bowel perforation.” If the anesthesiologist’s note is correct, the requisite delay in repairing the perforation could potentially expose the patient to an increased risk of wound infection. A bowel perforation requires emergent repair, and any delay poses serious consequences.

The general surgeon denied perforating the patient’s bowel during the surgery at the surgery center but his own hospital admission report states that the patient had “a probable perforation of the hepatic flexure.” The hospital’s report also contains a contradicting note where the general surgeon states that the patient had begun outpatient surgery to remove a right-sided abdominal mass which “ended up perforating bowel.” This hospital’s report further acknowledged that the patient was admitted for “bowel resection as this could not be done at the surgery center.”

At the hospital, the general surgeon undertook the more extensive surgery which confirmed that the bowel was perforated. The general surgeon performed this second surgery with a subcostal retroperitoneal approach despite his recognition of dense adhesions and presumed bowel injury, as well as the earlier difficulty in exposing the large hernia in the morbidly obese patient.

The general surgeon’s discharge summary states that the patient had experienced purulent drainage from her incision. However, the general surgeon did not document his evaluation of the patient’s wound prior to discharging the patient from the hospital, nor did the general surgeon document the patient’s complaint of pain. The general surgeon discharged the patient to a rehabilitation center.

Within 24 hours of discharge, the patient immediately returned to the hospital by ambulance with a grossly infected wound. The patient appeared septic, experienced constant, intense pain, with fever, chills and brown, bilious-colored material draining from her surgical incision.

A CT scan showed draining fecal matter in her right abdomen. The patient stated that her abdominal pain and wound drainage began three days prior to discharge from the hospital. The scan also revealed the patient had a significant intra-abdominal process that likely festered for some time. This fact raises the possibility that the drainage in the abdominal wound was the continuum of a process that was occurring intra-abdominally.

The patient returned for a third surgery. The general surgeon again performed the surgery, this time using a midline incision. The general surgeon described the surgery as mildly bloody. During this surgery, in a purulent area in the right side of the abdomen, the general surgeon identified a perforation in the patient’s colon which was leaking air. The general surgeon resected the patient’s colon and broke down some hard adhesions. Because of the extensive peritonitis that had developed, the patient had to have a colostomy. The patient’s health rapidly declined following the third surgery.

The patient died less than thirty days after the general surgeon’s initial surgery. The general surgeon prepared the death certificate, and he failed to accurately reflect that the patient died of multi-organ system failure as a consequence of a bowel perforation that occurred from his abdominal surgery to repair a hernia. There was no mention for reason of organ failure and the only pathology mentioned were various organ system failures that occurred just before death. A death certificate should accurately reflect the course of events leading up to a patient’s demise. The general surgeon neglected to properly document the actual cause of the patient’s death.

The Commission stipulated the general surgeon reimburse costs to the Commission, arrange for the manager of the Quality Review Committee at all facilities where he provides patient care to submit quarterly reports addressing whether any surgical cases involving the general surgeon were discussed at the Quality Review Committee meetings, and write and submit a paper of at least 1500 words, with annotated bibliography, discussing the Communication and Resolution Program (CRP) principles and the importance of integrating these principles into practice.

State: Washington

Date: January 2017

Specialty: General Surgery

Symptom: Abdominal Pain

Diagnosis: Post-operative/Operative Complication, Sepsis, Procedural Site Infection

Medical Error: Underestimation of likelihood or severity, Failure to examine or evaluate patient properly, Lack of proper documentation, Procedural error

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 5

Link to Original Case File: Download PDF

Washington – Plastic Surgery – Platysmaplasty And Chin Reduction With Resulting Post-Operative Infection

A 58-year-old woman sought chin reduction surgery to improve her appearance. The patient found a physician’s practice by conducting an internet search for cosmetic surgery. During the pre-operative telephone consult on 7/23/2012, the physician suggested to the patient that a platysmaplasty, or neck lift, performed with chin reduction would achieve the best results. The patient felt pressured to consent to both procedures because she wanted to confirm her already-scheduled surgery appointment. Two weeks later, the patient arrived to have the procedures done.

On 8/6/2012, the physician performed a chin reduction with neck lift procedure on the patient. Though the operative clinical note is appropriate for the procedure, it is unreliable. There are no notated deviations specific to the patient, such as vascularity of the flaps raised, tension on the closure, or difficulty of hemostasis. The physician’s operative notes on the patient appear to be templated and are identical to the operative notes on a different patient who underwent a completely different surgery.

On 8/9/2012, the patient returned for her post-operative follow-up with the physician. The patient appeared to be recovering as expected with swelling and draining from the incisions behind both ears and on the right-side of her chin. The patient continued taking prescriptive antibiotics. The physician’s chart notes on the patient stated “normal post-operative findings” with “no evidence of infection, hematoma, or abnormal findings.”

By 8/11/2012, the patient experienced more pain, swelling, and incision drainage. The incision areas became more blackened. The patient sent the physician text messages conveying her concerns and attached photographs of her incisions. The photographs strongly suggested the patient suffered post-operative infection with incisional necrosis.

The physician met with the patient on 8/12/2012, where he applied topical nitroglycerin paste to the patient’s chin area and instructed her to continue using the paste throughout the night. Applying nitroglycerin in incisions following cutaneous surgery is not a recognized treatment of post-operative infection. The standard of care in addressing potential post-operative infection is to take an incisional culture swab of the drainage and to start empiric antibiotics with broader coverage. If palpable fluid is collected, the wound is opened, irrigated, and packed. There is no medical documentation of the physician’s clinical treatment of the patient on 8/12/2012. The physician failed to adhere to appropriate medical record keeping, and he failed to properly identify and treat the patient’s post-operative infection despite being sent photographs the day prior. Had the physician not been able to respond or see the patient on the day she sent text messages, the expected practice is to activate his on-call coverage by another licensed practitioner who could immediately address the patient’s complaint of increased pain, swelling, and drainage.

On 8/13/2012, the patient felt weak, ill, and experienced continued drainage when she returned to the physician’s practice for her one-week post-operative follow-up appointment. The notations were identical to those of the 8/9/2012 record, stating “wounds show no significant redness, swelling, pus…normal post-operative findings,” and “wound has no evidence of infection.” The physician then contradicts these statements by noting the patient’s developing chin abscess and performing suture removal. During this office visit, the physician manually expressed fluid and irrigated the incisions. The physician directed an unregistered surgical technologist (ST) to assist in re-suturing the patient’s incision. State law prohibits unregistered STs from practicing and treating patients. The patient became frustrated with the ST’s inexperience and asked the physician to complete the suture. The physician did not re-pack the patient’s wound or broaden her antibiotic treatment even though he told the patient “the neck area is infected.” The physician instructed the patient to continue the nitroglycerin paste usage, keep her neck area wrapped, and return the next day.

By late evening on 8/13/2012, and eight days after the surgery, the patient was desperate for immediate treatment and drove to a wound care clinic for evaluation, wound cleaning, and CAT scan of the neck swelling. The patient and physician communicated through multiple phone calls for the next two days. In one of the phone calls, the physician told the patient that he was the top of his class, making him the most appropriate person to treat the patient. He also told the patient that she needed fat grafting in her neck. The physician contacted the clinic and told them to involve him in her treatment. The clinic physician documented that he was unsure the patient would agree to the physician’s involvement. He also documented the physician also failed to supply the patient’s post-operative report to the clinic.

On 8/15/2012, the patient was admitted to the hospital with complaints of swelling spreading across her jaw. The hospital surgeon performed a transcervical incision and neck abscess drainage on the patient. Hospital records indicate the patient’s recovery postoperatively showed dramatic improvement with decreased pain and swelling. During the patient’s hospitalization, the physician continued to call and send unprofessional text messages to the patient requesting step-by-step updates. After the patient’s hospitalization, the patient continued follow-up care at the wound care clinic. The patient sustained irregular scarring behind her ears and on her neck. The patient had no detectable chin reduction despite the physician’s procedure.

The physician failed to appropriately identify the patient’s worsening infection and failed to provide timely treatment after receiving photographs and observing symptoms suggestive of post-operative infection. The physician allowed an unregistered surgical technologist to assist him in treating the patient. The physician’s inaccurate and inadequate medical records were unreliable in providing sufficient information justifying his deviation from standard of care infection treatment.

For these allegations and others, the Commission ordered the following:

1) The physician’s license is to be placed on probation.

2) Any surgical procedure performed by the physician requiring general anesthesia, deep sedation, moderate sedation, or minimal sedation must be conducted with the use of a board-certified anesthesiologist or certified registered nurse anesthetist.

3) The physician is to be proctored by a plastic surgeon certified in plastic surgery or otolaryngology.

4) The physician must appear before the Commission after the proctor has evaluated and observed the physician. The Commission may modify the order if the proctor concludes the physician cannot practice with reasonable skill and safety.

5) The physician must complete a course on medical record keeping, clinician-patient communication, post-surgical infection control and management, and management of moderate sedation.

6) The physician must make provisions for an after-hours and weekend call group of other physicians.

7) The physician must complete a thorough history and physical on every patient he treats.

8) The physician will allow a Commission representative to visit his practice biannually to review patient records and interview staff.

9) The physician must report all adverse events that occur at his facility.

10) The physician must pay a fine of $25,000 to the Commission.

State: Washington

Date: October 2015

Specialty: Plastic Surgery, General Surgery

Symptom: Head/Neck Pain, Swelling, Wound Drainage

Diagnosis: Procedural Site Infection

Medical Error: Diagnostic error, Improper treatment, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

Washington – Plastic Surgery – Cheek Implant Surgery And Post-Operative Infection

On 11/16/2010, a 51-year-old man underwent a cheek implant surgery to address midface hypoplasia. Chin implant surgery is an aggressive esthetic surgery that includes intraoral incision. The physician performed incisions through the patient’s eyelids and mouth then placed six midface implants with internal titanium screw fixation. The lengthy surgery lasted 5 hours and 44 minutes, which increased the risk of infection and of potential sedation complications. Though the documented operative note as recorded is consistent with planned surgery, the note appears templated and lacks patient specific information. There is no documentation of appropriate perioperative intravenous antibiotics. The standard of care for this surgery is to administer intravenous antibiotics within one hour of surgery start time and to re-dose in six hours. The physician only documented one antibiotic dose instead of two thereby increasing the patient’s infection risk.

On 11/29/2010, the patient sent emails to the physician describing eye swelling and “foul” drainage from the left side mouth and nose. The physician told the patient to continue using compression dressings on the entire face and to continue taking prescriptive antibiotics. The following day, the patient met the physician to address possible infection. The physician’s documentation of this visit states “no significant redness, swelling, pus….normal post-operative findings… no complications are noted at this time.” However, the documentation also contains contradictory statements: “edema, swelling in the lower left eyelid pitting, and cheek,” and “redness in the lower eyelid area.” The physician failed to take a wound culture despite continued drainage through the patient’s mouth and nose, and he did not administer additional antibiotics. Given the patient’s complaint of “foul” discharge, the standard of care is to carefully probe the oral incision and document intranasal examination. Instead, the physician performed simple visualization of the oral cavity which is insufficient in identifying abscess.

For the following two weeks, email communication continued with the physician asking the patient for photographs and recommend the patient continue using a compression garment and mouth rinse. Photographs sent on 12/1/2010 demonstrate periorbital lower redness and swelling even though the physician stated that the patient “looks better.” In a 12/2/2010 email to the physician, the patient reported continued nasal discharge and fluid retention under his eye. The patient asked the physician “would [it] help to culture the infection?” The physician failed to respond to this inquiry and instead prescribed the patient an additional antibiotic even though the only diagnostic justification was the emailed photograph.

On 12/8/2010, the patient emailed the photographs of overt purulent drainage from his left eyelid incision. The physician replied, “oh, that looks significant…I would continue on the antibiotics until further notice.”

From 12/2/2010 to 12/15/2010, the patient’s emails described: continued purulent drainage and swelling; increased despondence about his recovery; and progressive deterioration of his daily life activities. The physician encouraged the patient to give the implant “the best possible chance,” and changed the prescribed antibiotic.

At no time during these two weeks did the physician arrange to physically examine the patient or refer him to another practitioner for appropriate work-up. The physician prescribed successive different antibiotics without pursuing wound culture of physical examination even though the patient’s photographs demonstrated overt drainage and infection which are absolute indications for immediate implant removal. Prolonged infection from an untreated facial abscess is not only potentially life-threatening, but it is also associated with increased scar formation and injury to soft tissue of the lower eyelid.

On or about 12/14/2010, the patient sought a second opinion about his infection and self-referred to a facial plastic surgeon. The surgeon identified infection with impending necrosis in the cheek area, stated the need for immediate implant removal and reconstructive eyelid surgery. The surgeon recommended that the patient be evaluated by two experienced oculaplasty specialists. He discouraged the patient from returning to the physician for any reconstructive procedures.

On 12/17/2010, the physician surgically removed the patient’s cheek implants. The physician failed to culture the wound so that an appropriate post-operative antibiotic could be tailored for the patient’s recovery. Despite the patient’s subsequent complaints of a retracting eyelid and continued “discharge through nose and the taste of infection through mouth,” the physician maintained the prescribed antibiotic and compression dressing be continued. The physician failed to examine the patient for persistent infection and to assess a possible facial distortion.

On 12/27/2010, the patient became increasingly despondent about his appearance and sought an exam by an oculaplasty specialist referred by the plastic surgeon. The specialist changed the patient’s antibiotic to treat the cheek area “which may be a residual abscess.” The patient also sought opinions from other specialists about eyelid reconstruction. These specialists recommended the patient wait at least three months before proceeding with any reconstructive surgery. The patient continued to email the physician about infection symptoms and facial distortions.

On 12/29/2010, the physician emailed the patient recommending fat grafting to address eyelid deformities and stated it needs to wait “at least 2-3 months.” However, on 1/3/2011, the physician’s email to the patient referred to a fat graft procedure planned for in two weeks.

The physician’s assessment notes for 1/13/2011, one month after implant removal, states “normal post-operative findings, no complications are noted at this time. Would plan fat injections.” However, the patient had retained fluid in his eyelid with pain in the left cheek. The oculaplasty specialists that examined the patient discouraged early surgical interventions particularly during his inflammatory phase of healing. The physician disagreed with the specialists, calling their opinions “old school thought.” The physician claimed to be “thinking outside of the box” in his clinical plan for the patient’s fat grafting. The physician also asserted his expertise by asking the patient “how many of [the specialists] came up with the theory of facial beauty?” The physician appears to be referring to a research paper he co-authored while in residency training. The physician’s research paper had no relevance to the patient’s post-operative situation. Additionally, there is very limited medical evidence supporting fat grafting for eyelid retraction, and no reports supporting fat injection during the inflammatory phase of healing. The physician claimed that the patient’s eyes “can be improved drastically with very simple fat grafting procedures that can reverse things in a few hours.” This claim is unsupported by the medical literature. The patient did not pursue any further treatment with the physician.

On 2/15/2011, the patient established care with another facial plastic surgeon. The surgeon’s medical documentation indicated that the patient had severe ectropion and scleral show, synkinesis of his lower eyelids, and facial nerve paralysis. The patient required very complicated oculaplasty reconstruction. As a result of the cheek implant surgery, the patient is unable to work and suffers from depression and suicidal ideation.

In an attempt to get information from the patient, the physician sent an email on 4/27/2011 asking the patient for pictures. The physician revealed this self-interest by also telling the patient “that I’m the only one that can truly help you. I have to say that if the lawyers get involved, it may make it difficult for me to help you…”

The physician’s treatment of the patient failed to meet the standard of care by not providing perioperative antibiotic coverage; not properly and diagnosing and treating early post-operative infection; not conducting appropriate diagnostics or referring to other resources to treat facial abscess symptoms; not arranging for timely cheek implant removal; and not establishing an appropriate treatment plan. The physician’s substandard care and inappropriate communications resulted in the patient’s delayed infection treatment. The physician’s failed cheek implant surgery and removal resulted in the patient incurring additional expenses in seeking proper care by other providers.

For these allegations and others, the Commission ordered the following:

1) The physician’s license is to be placed on probation.

2) Any surgical procedure performed by the physician requiring general anesthesia, deep sedation, moderate sedation, or minimal sedation must be conducted with the use of a board certified anesthesiologist or certified registered nurse anesthetist.

3) The physician is to be proctored by a plastic surgeon certified in plastic surgery or otolaryngology.

5) The physician must complete a course on medical record keeping, clinician-patient communication, post-surgical infection control and management, and management of moderate sedation.

6) The physician must make provisions for an after-hours and weekend call group of other physicians.

7) The physician must complete a thorough history and physical on every patient he treats.

8) The physician will allow a Commission representative to visit his practice biannually to review patient records and interview staff.

9) The physician must report all adverse events that occur at his facility.

10) The physician must pay a fine of $25,000 to the Commission.

State: Washington

Date: October 2015

Specialty: Plastic Surgery, General Surgery

Symptom: Wound Drainage, Swelling

Diagnosis: Procedural Site Infection

Medical Error: Diagnostic error, Improper treatment, Lack of proper documentation

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 2

Link to Original Case File: Download PDF

Washington – Plastic Surgery – Lip Augmentation, Face Lift, Neck Lift, Chin Reduction, Chin Implant, And Cheek Implantation Complicated By Persistent Facial Swelling

A 47-year-old professional musician underwent cosmetic surgery in an attempt to improve his appearance so he could pursue his career goals of live performance. On 10/28/2010, a physician performed a lip augmentation, face lift, neck lift, chin reduction, chin implant, and cheek implants. The patient was given intravenous sedation during the 10 hour surgery. The physician fixated six implants with titanium screws into the patient’s midface even though there was no record documenting the patient’s awareness or consent about the number of implants to be used. There was no documented administration of antibiotics, which is necessary before and every six hours during surgery when an intraoral procedure is performed. The physician’s sub-standard antibiotic coverage increased the risk of post-operative infection particularly for a long surgical procedure. The patient spent less than an hour in the recovery room before being discharged with instructions to apply Vaseline to the incisions and to use a compression.

On 10/29/2010, the patient returned for a post-operative exam with the physician. The medical notes state “normal post-operative findings” with a plan to “follow-up in 6 days for suture removal.” There was no record indicating the patient returned six days later or had his sutures removed.

On 11/8/2010 and 11/21/2010, the physician’s staff documented additional antibiotics prescribed to the patient. The medical notes lacked any information indicating the need for administering more antibiotics. The patient stated he suffered from facial swelling for three weeks following surgery, which suggests why the physician would prescribe additional antibiotics. However, the physician failed to document the patient’s complaints of facial swelling, and he failed to arrange for a physical exam to address possible post-operative infection.

On 12/3/2010, the physician documented the patient’s assessment as “normal post-operative findings,” with “no evidence of infection, hematoma, or abnormal findings.” The physician’s evaluation stated the patient would continue antibiotics and return for “follow-up in 1-3 months.” Again, the physician’s substandard medical charting omitted information related to antibiotic treatment. The patient’s statement indicated he experienced pus “oozing” from his eyelid in addition to increased facial swelling.

Between 12/30/2010 and 1/22/2011, the patient communicated with the physician multiple times using email. The patient reported continued episodic facial swelling to which the physician told the patient to continue the antibiotics until told to stop. The patient complained that adhesions around his eyes were “tight and pull strangely” when he smiled and that the cheek implants were “very high and protruding oddly.” He was also concerned about continuing antibiotics three months after surgery and asked the physician about the possibility of infection from the implants. The physician never addressed the patient’s infection inquiry. Instead, the physician suggested fat grafting to address the patient’s appearance. The physician failed to document in the medical records his communications with the patient.

The patient consulted another plastic surgeon because of concerns about his appearance caused by the physician’s procedures. The surgeon’s opinion strongly suggested revision surgery to correct eyelid retraction and to address possible implant misplacement. After three months of antibiotic treatment and no follow-up exam by the physician, the patient still complained of facial distortion with discomfort, inability to pursue his career, and treatment for depression.

In treating the patient, the physician failed to meet the standard of care by not appropriately administering perioperative antibiotics before and during the lengthy surgery; not maintaining accurate medical and treatment notes; not arranging for a physical exam upon reporting signs of post-operative infection; not culturing the eyelid drainage before starting antibiotic treatment, and not timely addressing facial swelling and considering implant irrigation despite the patient’s continued antibiotic treatment.