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California – General Surgery – Laparoscopic Colostomy Complicated By Numerous Adhesions
On 6/25/2012, a general surgeon performed an elective laparoscopic colostomy revision with repair of a parastomal hernia on a 56-year-old female. The surgery was prolonged (5.5 hours) due to many adhesions. The colostomy couldn’t be taken down (re-attachment of the sigmoid colon to the rectum) laparoscopically and was revised from left to right side. The general surgeon didn’t consider converting the surgery to an open procedure to accomplish the colostomy takedown. On 6/27/2012, a Rapid Response Team was called for the patient, who was found to be in acute septic shock. The general surgeon performed an open procedure (partial colectomy, partial bowel resection, and colostomy).
In the operative report for 6/25/2012 procedure, the general surgeon failed to state where the stoma was re-sited to, why it was re-sited, what kind of rectal dissection was done before attempting the failed anastomosis, and how large an incision was made during fluorescence angiography. In the second operative report dated 6/27/2012, the general surgeon failed to state how much bowel was removed, why the stoma was re-sited, and to where (relative to the two other stoma sites), whether the skin was left open or closed, how the colon’s perfusion was assessed, and how much colon was removed. In the third operative report dated 7/16/2012, where the general surgeon replaced a large open area of the abdominal wall with an Alloderm biologic prosthesis, the general surgeon failed to mention whether this Alloderm biologic prosthesis was placed as an onlay, inlay, or underlay.
The Medical Board of California judged that the general surgeon’s conduct departed from the standard of care because he failed to convert his laparoscopic procedure to an open procedure on 6/25/2012 when he saw the adhesions, and he failed to maintain accurate records.
The Medical Board of California issued a public reprimand and ordered the general surgeon to complete a medical record-keeping course and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.
State: California
Date: June 2015
Specialty: General Surgery
Symptom: N/A
Diagnosis: Post-operative/Operative Complication, Sepsis
Medical Error: Procedural error, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
North Carolina – Radiology – Missed Finding Leads To Deterioration Of A Patient After A Gastric Bypass
On 10/17/2013, a professional liability payment was made.
A 45-year-old female underwent laparoscopic gastric bypass procedure by a general surgeon. Several weeks after the surgery, the patient was taken to the emergency department of another hospital with complaints of severe left-sided upper and lower abdominal pain and nausea. The emergency department physician ordered an abdominal and pelvis CT scan.
A radiologist was providing night teleradiology coverage to the hospital and was called to interpret CT scan. The radiologist reported that there was no free intraperitoneal air. The patient deteriorated and was transferred to the intensive care unit with sepsis.
An independent medical expert indicated that the presence of free air was visible on the CT scan and should have been communicated to the surgeon.
The Board expressed concern that the radiologist’s conduct was below the minimum standard of competence given failure to detect and report the finding of free intraperitoneal air on a CT scan.
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: May 2015
Specialty: Radiology
Symptom: Abdominal Pain
Diagnosis: Acute Abdomen, Sepsis, Post-operative/Operative Complication
Medical Error: Diagnostic error
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
California – Gynecology – Elevated WBC Count After Hysterectomy And Bilateral Salpingo-Oophorectomy
On 10/23/2007, a 70-year-old female underwent surgery at the hospital. The gynecologist performed a hysterectomy and bilateral salpingo-oophorectomy after a general surgeon performed a lymphadenectomy to explore whether the patient had cancer cells present in her abdominal lymph nodes. The general surgeon noted that exposure was difficult because of a small arterial bleed in the patient’s surgical field. The patient’s bleeding was controlled, and the gynecologist performed an uneventful surgery. Post-operative pathology showed that the patient had extensive cancer in the uterus that had not extended through the uterine walls, and the patient’s lymph nodes were negative for the presence of cancer cells.
On 10/24/2007, the patient had elevated WBC count of 18.3 with 84% neutrophils and no bands on the first post-operative day. On 10/25/2007, the patient had a WBC count of 17.7 with 81% neutrophils and no bands. On 10/27/2007, the gynecologist discharged the patient on the third post-operative day. The patient’s WBC count remained elevated at 17.7 at the time of discharge. The gynecologist’s progress notes for the patient dated 10/23-26/2007 were inadequately documented. In particular, the gynecologist’s progress notes for 10/23/2007 did not contain physical examination findings. The gynecologist’s progress notes for 10/24/2007 and 10/25/2007 for the physical examinations purportedly conducted on those dates stated only decreased drainage and abdomen without distension. The gynecologist’s progress notes for 10/26/2007 did not indicate the time of the examination purportedly conducted on that date.
On 10/27/2007 at 10 p.m., the patient presented to the emergency department in moderate acute distress with complaints of a fever and a foul odor emanating from her surgical site. The patient also had tachycardia of 120 and a fever of 100.4 F. A chest x-ray revealed gross free intraperitoneal air. The patient also had a WBC count of 13.6 with 51 segmented neutrophils, 33 bands, and 3 metamyelocytes. The physician assistant on duty called the gynecologist to apprise him of the patient’s condition. The patient was discharged from the emergency department on 10/28/2007 at 2 a.m. with a prescription for Augmentin and instructions to call the gynecologist in the morning.
On 10/30/2007, the patient presented to the emergency department with septic shock, acute renal failure, and an acute abdomen. On 10/31/2007, another surgeon performed an exploratory laparotomy and ultimately lysis of adhesions and a diverting colonoscopy. The operative report identified significant inflammation in the deep pelvis as well as possible small perforations in the junctional area of the rectosigmoid.
The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because he failed to appreciate and follow up on the patient’s serious and developing post-operative complications on 10/27/2007, consistently time his chart entries, adequately document patient’s clinical condition, maintain adequate and accurate records, and order a repeat WBC test prior to the patient’s discharge on 10/26/2007 or delay the patient’s discharge from the hospital.
The Medical Board of California issued a public reprimand.
State: California
Date: May 2015
Specialty: Gynecology
Symptom: Fever
Diagnosis: Procedural Site Infection, Acute Abdomen, Sepsis
Medical Error: Failure to follow up, Failure to order appropriate diagnostic test, Lack of proper documentation
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
California – General Surgery – Bilious Fluid From Drain After Sigmoid Resection And Primary Anastomosis
A 42-year-old female presented to the hospital for treatment of a rectal stricture and possible vaginal fistula due to diverticulosis. Her pre-operative history and physical examination indicated a main complaint of abdominal pain occurring every few minutes. On 3/26/2012, the patient underwent a sigmoid resection and primary anastomosis. The operation started out laparoscopically, and then was converted to an open procedure. According to the Hospital Peer Review Report for the patient, “[t]he anastomosis was hand sewn and not tested with air and saline.” The post-operative course was normal until 3/30/2012, when the patient began to drain bilious fluid from her drain, which was thought to be related to an anastomotic dehiscence.
The patient’s post-operative course gradually declined, and a second surgery was performed on 4/4/2012 to address the patient’s pre-operative diagnosis of peritonitis. The general surgeon performed open exploratory surgery (laparotomy), which included an abdominal lavage and a diverting colostomy. During the surgery, the general surgeon was unable to locate any intestinal leakage, anastomotic leakage, and/or any other source of the bilious drainage that was previously observed and noted. A drain was placed, the abdomen was closed, and the patient was transferred to the ICU.
The patient’s post-operative course following the second procedure was marked with signs of intra-abdominal sepsis associated with renal failure related to an uncontrolled intestinal leak. The patient was discharged and transferred to a higher level of care on 4/13/2012, which was followed by additional operations by others to treat multiple fistulas and leaks from the small bowel and the duodenal stump area. The patient was declared brain dead in August 2012.
The Medical Board of California judged that the general surgeon’s conduct departed from the standard of care because he failed to adequately evaluate the patient’s gastrointestinal tract during the exploratory surgery on 4/4/2012, and then terminating the surgery without determining and addressing the etiology of the drainage and/or leakage.
The Medical Board of California placed the general surgeon on probation for 7 years and ordered the general surgeon to complete an education course (at least 40 hours per year for each year of probation) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.
State: California
Date: May 2015
Specialty: General Surgery
Symptom: Abdominal Pain, Wound Drainage
Diagnosis: Post-operative/Operative Complication, Sepsis
Medical Error: Diagnostic error, Procedural error
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
California – General Surgery – Acute Abdominal Pain And Tachycardia In An Immunosuppressed Male
On 5/22/2010, a 60-year-old immunosuppressed male presented to the emergency department with acute onset of abdominal pain and tachycardia. A CT scan revealed that the patient had a perforated diverticulitis and pneumoperitoneum. The admitting physicians evaluated and determined that the patient would likely need surgery after his condition was optimized. The patient was managed with antibiotics and IV fluids and seen daily be General Surgeon A and other physicians through 5/25/2010. On that date, General Surgeon A noted that the patient had improved and signed off from the case. Also on that day, the patient’s heart rate had increased from normal to the low 100’s, and the patient’s lab work revealed concern regarding ongoing severe infection. However, General Surgeon A documented in his notes that the patient appeared much better and that he believed the patient’s perforation had sealed. General Surgeon A didn’t see the patient again until he became progressively unstable.
The patient’s condition worsened on 5/26/2010, including the development of atrial fibrillation, persistent tachycardia, worsening renal function, and other conditions consistent with ongoing sepsis. A second CT scan was ordered on 5/27/2010 but was not performed until the next day. It revealed worsening peritonitis from the known perforation. General Surgeon A was informed of the patient’s condition and the CT results at 10 a.m. on 5/28/2010, but the patient was not seen by a surgeon until 1:30 p.m. that day by General Surgeon B who was covering for General Surgeon A. General Surgeon B took the patient to surgery for a laparotomy and sigmoid resection with colostomy for perforated diverticulitis with fecal peritonitis. The patient remained critically unstable in the ICU on maximum support with respiratory failure, ongoing sepsis, cardiac ischemia with acute myocardial infarction. The patient ultimately died from fatal ventricular arrhythmia.
On the day General Surgeon A signed off of the case indicating the patient was so improved that his surgical services were no longer needed, there was indication of ongoing significant infection in spite of ongoing aggressive medical therapy. General Surgeon A failed to recognize the significance of the clinical picture. It was not until the patient’s condition worsened further that an additional CT scan was ordered and performed on 5/28/2010.
Although General Surgeon A was informed of the need for the additional CT scan, it was General Surgeon B who became involved and promptly took the patient into surgery, but the surgery was too late to save the patient. Because of the delay in recognition of the need for urgent surgical intervention, the patient experienced ongoing sepsis resulting in acute cardiac insult and progressive hemodynamic and metabolic instability.
General Surgeon A should have recognized that the patient’s immunocompromised condition would not only interfere with the patient’s ability to seal off the perforation and control the intraperitoneal sepsis but also compromise the patient’s ability to mount an effective response to the associated systemic sepsis syndrome. General Surgeon A did not appreciate the gravity of the signs of ongoing infection in this patient warranting urgent surgical intervention.
The Medical Board of California judged that General Surgeon A’s conduct was grossly negligent in the care and treatment of the patient because he delayed recognizing the need for urgent surgical intervention and didn’t appreciate the gravity of the signs of ongoing infection in this patient warranting urgent surgical intervention.
For this case and others, the Medical Board of California ordered General Surgeon A to surrender his license.
State: California
Date: March 2015
Specialty: General Surgery
Symptom: Abdominal Pain
Diagnosis: Sepsis, Acute Myocardial Infarction, Cardiac Arrhythmia, Acute Abdomen, Pulmonary Disease
Medical Error: Underestimation of likelihood or severity, Delay in proper treatment, Failure to follow up
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
Wisconsin – Pediatrics – Newborn With Respiratory Distress, Hypoxia, And WBC 24,000
On 9/22/2003 at 11:10 a.m., a patient had been delivered by C-section at full term. After several hours, he developed respiratory distress and hypoxia. He was transferred to special care nursery. Pediatrician A was called, arrived at the hospital at around 2:10 p.m., and saw the patient. It was noted that the mother had not received any antibiotics prior to delivery despite being Group B streptococci positive. Oxygen saturation was 90% on 80% oxygen. WBC was noted to be 24,000 with 8% bands. Differential diagnosis was noted to include cardiac etiology, transient tachypnea, respiratory distress syndrome, and infection. At around 3:45 p.m., blood cultures, chest x-ray, and placement of an IV line were ordered. Antibiotics were not ordered. At around 4:00 p.m., it was noted that the patient had a 5 minute episode of hypoxia with a choking episode. Pediatrician A presumed the diagnosis of transient tachypnea and then left the hospital.
At around 7 p.m., Pediatrician A was called and informed that the patient had increased oxygen requirements, increased respiratory rate, and increased mucosal discharge. She was notified that the staff had been unable to draw blood cultures. Pediatrician A returned to the hospital. The patient was found to be mottled with a respiratory rate of 130-150. Assessment was “respiratory distress, etiology unknown at this point, but need to consider sepsis, especially with mom’s history of group B strep.”
At 9:20 p.m. and 9:25 p.m., blood gases and blood cultures were obtained. At 9:30 p.m., ampicillin and gentamicin were ordered. At 10:15 p.m., the patient received the first dose of ampicillin. At 11:00 p.m., the patient received the first dose of gentamicin. The patient continued to be in respiratory distress with hypoxia. At 11:20 p.m., nasal continuous positive airway pressure was administered. The patient was intubated at 7:40 a.m.
At 7:55 a.m., Pediatrician A ordered transfer to a tertiary care referral center. The patient was transferred at 10:55 a.m. The patient remained hospitalized until 11/27/2003.
Diagnoses at time of discharge included streptococcus viridans sepsis, endocarditis, ischemic cerebral infarcts, status post right mainstem bronchus laceration and repair, and recurrent pneumothoraces.
Blood culture results dated 10/1/2003 revealed streptococcus mitis species group.
Pediatrician A was reprimanded for delay in administering antibiotics.
State: Wisconsin
Date: May 2014
Specialty: Pediatrics
Symptom: Shortness of Breath
Diagnosis: Sepsis
Medical Error: Delay in proper treatment
Significant Outcome: N/A
Case Rating: 3
Link to Original Case File: Download PDF
California – Pediatrics – Failure To Timely Diagnosis And Properly Treat 5-Week-Old Patient Presenting With Cough, Congestion, And Possible Fever
On 5/18/2009, a 5-week-old patient was seen by a pediatrician with symptoms of an upper respiratory infection. The pediatrician advised the patient’s mother to use a humidifier, Vicks vapor rub, and a nasal bulb suction.
On 5/27/2009, the pediatrician saw the patient for cough, congestion, and a possible fever. The pediatrician was informed that the patient had been exposed to sick siblings and that the patient had been given Xopenex, from a sibling’s prescription, prior to being seen by the pediatrician. The patient was noted to have low oxygen saturation, but no wheezing. The pediatrician conducted an examination which was stated to be unremarkable, and he did not hear any wheezing. The pediatrician diagnosed the patient with cold symptoms, RSV bronchiolitis, ALTE, and hypoxemia. The pediatrician prescribed Xopenex and Solu-Medrol. He admitted the patient to the hospital. The pediatrician ordered laboratory tests which included the basic metabolic panel (CHEM 7), RSV swab, influenza swab, chest X-ray, and a complete blood count (CBC).
Later on 5/27/2009, the pediatrician was informed of the lab results verbally by the pediatric floor nurse. The CHEM 7, RSV swab, and influenza swab were normal. The chest X-ray showed changes compatible with RSV Bronchiolitis. The CBC showed a white blood count of 7.2 with 59% neutrophils and 25% bands. The pediatrician was not verbally informed of the band count on that date. The lab results were also faxed to the pediatrician’s office and were received on 5/28/2009 at 7:54 a.m.
On 5/28/2009, the patient was reported to be lethargic, irritable, and inconsolable. The patient also exhibited abnormal seizure-like movements and was given oxygen to keep the O2 saturation above 93%. The pediatrician ordered EKG/EEG and upper gastrointestinal (UGI) exams and for the patient to be evaluated for gastroesophageal reflux disease (GERD). The pediatrician also started the patient on Zantac. The patient experienced repeat episodes of bradycardia and cyanosis later that day.
On 5/29/2009, the patient continued to have apnea, with bradycardia and cyanosis, and increasing lethargy and irritability. The patient was also reported to have a firm and bulging fontanelle with left eye deviation. The pediatrician ordered a blood culture, and upon receiving the results, ordered ampicillin and cefotaxime. The patient continued to become increasingly irritable and lethargic, and had eye twitching and jittery movements. The Rapid Response Team was called twice to evaluate the patient. The pediatrician ordered Gavage feeding and Reglan.
On 5/30/2009, the patient was bagged and given a loading dose of phenobarbital. He was noted to have photosensitivity, clenched fists, a bulging Fontanelle, and repetitive bicycling motions. The dose of phenobarbital was increased, but the patient’s seizure-type episodes continued. The pediatrician performed a lumbar puncture and obtained a cloudy and yellow cerebrospinal fluid. The pediatrician ordered an infectious disease consult, CBC, CRP, and MRI of the head. The patient was diagnosed with sepsis and meningitis. The patient was thereafter transferred to a different medical center.
The pediatrician committed gross negligence in his care and treatment of the patient, which included the following: the pediatrician failed to appropriately evaluate, diagnose, and treat the patient’s signs and symptoms of sepsis and meningitis; he prescribed Reglan and Gavage feeding when it was not appropriate based on the patient’s signs and symptoms; and he failed to consider the most likely cause of the patient’s presenting symptoms in making the decision for the treatment.
The Medical Board Of California ordered that the pediatrician be placed on probation for a period of three years, complete a medical record keeping course, and complete a clinical training or educational program equivalent to the Physician Assessment and Clinical Education Program (PACE).
State: California
Date: January 2014
Specialty: Pediatrics
Diagnosis: Meningitis/Encephalitis, Sepsis
Medical Error: Failure to examine or evaluate patient properly, Improper medication management
Significant Outcome: N/A
Case Rating: 5
Link to Original Case File: Download PDF
Washington – Physician Assistant – Chronic Ulcerative Colitis Presenting With Mouth And Rectal Ulcers
A patient was an inmate at a state penitentiary and had chronic rectal bleeding from late 2009 and continuing through September 2010. It was diagnosed as chronic ulcerative colitis on 10/14/2010. The Board comments that serious complications of ulcerative colitis may include death of colon tissue, sepsis, massive bleeding in the colon, and perforation of the colon. Signs and symptoms may include abdominal pain, rectal pain, blood in stools, diarrhea, fever, joint pain, mouth sores, nausea and vomiting, and weight loss.
The patient was treated for ulcerative colitis on 10/18/2010 and 11/11/2010. On 11/11/2010, the patient’s condition was declared a medical emergency with symptoms of “burning up”, vomiting, aching body, and an elevated temperature. The physician assistant later treated the patient for a rash on 12/24/2010 and again on 12/27/2010.
On 12/31/2010, the patient had a swollen throat or mouth. On 1/9/2011, the patient complained of a fever and sore throat. On 1/10/2011, the patient presented with white ulceration inside his lip and on each tonsil. The patient’s condition continued to worsen over the next two days, including the development of papules around his anus and white plaques on each of his inner cheeks.
On 1/13/2011, at 2:10 p.m., the patient presented to the clinic with mouth and rectal ulcers. He had been complaining of increasing pain for approximately six days and of rectal ulcers for approximately three days. Other providers noted the patient had a large excoriated area at his rectum consisting of two blistered areas.
On 1/15/2001 at 8:00 a.m., a physician assistant examined the patient. The physician assistant discussed with the patient administration of antibiotics and ketorolac for pain.
At 8:20 a.m., the patient was admitted to the inpatient clinic. The physician issued medication orders at 8:40 a.m. The physician assistant’s assessment of the patient notes his history of ulcerative colitis but diagnosed cellulitis. Prescriptions in the assessment and plan included ketorolac, hydroxyzine, and trimethoprim/sulfamethoxazole. The physician assistant noted that he anticipated that the patient would improve and return to inmate housing within a few days.
Between 8:40 a.m. and 1:15 p.m., the physician assistant received two phone calls from nursing staff regarding the patient. The first call was at approximately 11:00 a.m. and the second call was at 1:15 p.m., at which time the physician assistant agreed that the patient should be transferred to a medical center.
The patient was transported by ambulance to a medical center where he was admitted at 2:15 p.m. The patient was subsequently airlifted to another medical center at 7:15 p.m. The patient coded at 9:25 p.m. and was resuscitated, after which emergency debridement surgery was performed. Nevertheless, the patient died on 1/16/2011 at 2:02 a.m. due to sepsis caused by perirectal necrotizing fasciitis.
The Commission stipulated the following terms for the physician assistant:
1) He must reimburse costs to the Commission.
2) He must complete 4 hours of continuing education on the study of the diagnosis and management of sepsis, 2 hours on the study of colitis, and 2 hours on the study of necrotizing fasciitis.
3) He must submit a paper of at least 1000 words, plus bibliography, addressing the diagnosis and management of sepsis, colitis, and necrotizing fasciitis, incorporating information from his coursework.
4) He must research and submit a paper of at least 1000 words, plus bibliography, addressing the importance of teamwork in a co-managed patient care environment with specific reference to community and correctional clinics and components of a respectful working relationship between providers.
5) He must make a presentation to the daily group provider meeting at the correctional facility clinic regarding his research about the importance of teamwork in a co-managed healthcare environment with specific reference to community and correctional clinics and components of a respectful working relationship between providers.
6) He must have his sponsor physician write and submit reports to the Commission every 6 months regarding the physician assistant’s performance.
State: Washington
Date: January 2014
Specialty: Physician Assistant, Internal Medicine
Symptom: Bleeding, Fever, Nausea Or Vomiting
Diagnosis: Necrotizing Fasciitis, Sepsis
Medical Error: Delay in proper treatment, Diagnostic error
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
California – Family Medicine – 13-Year-Old Patient Treated With Over 70 Medications For Lyme Disease
A family practitioner began treating a 13-year-old patient in 2006. In February 2006, the patient’s mother filled out a Lyme Disease Questionnaire in which she stated that the patient had tested positive for Babesia and Bartonella in November 2005. The family practitioner’s medical records did not include any positive laboratory results for Babesia or Bartonella.
The family practitioner’s notes from 1/17/2007 showed an assessment of Lyme and Bartonella. However, there was no evidence that the family practitioner conducted any laboratory tests prior to making such diagnoses. IgG and IgM Western Blots, conducted on 5/31/2007, were both negative for Lyme disease. Subsequent IgG and IgM Western blots conducted on January 2008, February 2009, and July 2010 were again all negative for Lyme disease. A Bartonella FISH test, conducted in October 2010, was also negative.
The patient continued to see the family practitioner on approximately a monthly basis through at least March 2012. During this time, the family practitioner prescribed numerous IV and oral antibiotics, in various combinations, including IV doxycycline, IV Invanz, IV Rocephin, IV Zithromax, IV cefuroxime, rifampin, minocycline, Avelox, Septra, Moxatag, nystatin, Tindamax, penicillin, and Zyvox. The patient was also treated with numerous homeopathic remedies, including IV glutathione, IV Freamine, and numerous supplements, anti-microbials, and detoxification remedies. There was no evidence that the family practitioner obtained informed consent to treat the patient with IV glutathione or IV Freamine.
On 2/9/2012, the patient was admitted to the hospital with fever and chills. She was diagnosed as having sepsis due to a Hickman catheter infection, which had been in place for 4.5 years. According to the emergency room physician, the patient’s mother presented a medication list that identified over 70 medications and homeopathic remedies, including IV cefuroxime, IV glutathione, and IV Freamine, as well as oral penicillin, and Zyvox. The Hickman catheter was removed, and the patient was discharged from the hospital on 2/12/2012.
The family practitioner’s overall conduct, acts, and omissions with regard to the patient constitute unprofessional conduct through gross negligence and repeated acts of negligence and incompetence. More specifically, the family practitioner was guilty of unprofessional conduct with regards to the patient as follows: he continued to prescribe multiple courses of antibiotics for over a five-year period, even though there were no signs of improvement; he failed to obtain informed consent regarding treatment with IV glutathione and IV Freamine; and he failed to routinely assess and document the patient’s vital signs.
The Medical Board of California ordered that the family practitioner be publicly reprimanded and attend 65 hours of an education course.
State: California
Date: November 2013
Specialty: Family Medicine, Internal Medicine
Symptom: Fever
Diagnosis: Sepsis
Medical Error: Improper medication management, Failure of communication with patient or patient relations, Failure to properly monitor patient
Significant Outcome: N/A
Case Rating: 2
Link to Original Case File: Download PDF
California – Family Medicine – IV Glutathione, IV Amino Acids, IV Silver, IV Garlic, And Multiple Herbal Treatments Administered For Suspected Lyme Disease
A family practitioner operated a private practice. According to his website, his practice focused on diagnosing and treating Lyme disease and other tick-borne co-infections.
On 1/14/2009, a 26-year-old female patient was seen at the family practitioner’s office for evaluation of possible Lyme disease. An initial history and examination was conducted by a physician assistant. The patient reported a tick bite in December 2008 as well as prior tick bites in 2005 or 2006. She did not recall developing any rash or lesions. She reported numerous complaints, including memory problems, fever, headaches, mood swings, poor sleep, muscle and joint pain, slurred speech, and numbness and tingling in her extremities and face. She reported having been diagnosed with attention deficit disorder as a child. She reported seeing a psychiatrist for depression and questionable borderline personality. She was taking Adderall and Ambien. The physician assistant’s assessment was “multisystemic complaints with recent tick bite.”
Zithromax, an antibiotic, was prescribed, and laboratory tests were ordered. There was no evidence that the family practitioner examined the patient during this initial visit; however, the family practitioner initialed the patient’s chart.
The patient returned to the family practitioner’s office on 2/3/2009 to review laboratory results. Immunoglobulin M (IgM) and Immunoglobulin G (IgG) Western Blots were negative for Lyme disease under the Center for Disease Control (CDC) criteria. Additionally, laboratory results were negative for Babesia; negative for Bartonella; negative for Human Monocytic Ehrlichiosis (HME); and Lyme Polymerase Chain Reaction (PCR) was negative. However, the physician assistant noted that the IgM Western Blot was positive (apparently under a lower criteria) and that Human Granulocytic Ehrlichiosis (HGE) was positive. Her assessment was “lyme,” “HGE,” and “possible co-infections despite neg tests.” The patient was continued on Zithromax and was also prescribed doxycycline, another antibiotic. She was also started on BLT (Bartonella-Lyme Tincture) and Enula, both herbal remedies. The family practitioner initialed the patient’s chart.
The patient was next seen by the physician assistant for a follow-up examination on 3/9/2009. The patient continued to have multiple complaints, but no significant objective findings were noted. No vital signs were recorded. The patient was continued on Zithromax, discontinued doxycycline, prescribed Bicillin, another antibiotic, and prescribed Plaquenil and Malarone, both anti-malarial drugs. The patient was continued on BLT and started on a “stress buster kit,” “detox and drainage” kit, and “pinella” — all homeopathic and/or herbal remedies. The family practitioner initialed the patient’s chart.
The patient was next seen by the physician assistant on 4/6/2009. Examination revealed “slight inflammation of cuticles on forefingers.” No vital signs were recorded. The patient’s dosage of Bicillin was increased, and she was continued on Malarone, Zithromax, and Plaquenil. Alinia, an antiprotozoal drug, and Singulair, a drug to treat asthma, were also added to her treatment regimen. The family practitioner initialed the patient’s chart.
The patient was next seen by the physician assistant on 5/11/2009. No vital signs were recorded. The patient was continued on Bicillin, Zithromax, Plaquenil, and Alinia. Mepron, another antiprotozoal drug, was added. The patient was also started on “200 mg of [Z]en,” and the family practitioner initialed the patient’s chart.
On 6/10/2009, the patient was seen by the family practitioner. The family practitioner noted that the patient was “doing poorly with significant fatigue, malaise, weakness, headaches, irritability, and tremors.” No vital signs were recorded. The family practitioner’s assessment was “Neurologic Lyme and likely Babesia.” The family practitioner’s treatment plan included: “continue Bicillin for now,” “use Cat cream and fish oil,” “stop Plaquenil,” “follow-up with [a chiropractor],” “obtain thyroid, PTH, vitamin D, and neurotransmitters,” and “consider colon hydrotherapy and vitamin D as well as Adrena Calm cream.”
The patient continued to see the family practitioner and the physician assistant on approximately a monthly basis through at least March 2011. The patient’s vital signs were not recorded during these visits. The family practitioner’s last office visit notes for the patient dated 3/30/2011, which showed an assessment of Lyme, Bartonella, and Babesia. During this time, the family practitioner prescribed numerous additional medications, supplements, and herbal remedies, including intravenous (IV) Rocephin, IV Glutathione, L-Drain, K-Drain, UltraInflamX, Biaxin, minocycline, Darvocet, Chlorella, enzyme, HCL betaine, Actigall, Bactroban, Burbur, Notatum/Quentens nasal spray, Bronchi Pertu, Lyrica, Trental, IV amino acids, Zenpep, IV Zithromax, IV Invanz, bee venom injections, IV doxycycline, IV Silver, Cortef, Nuvigil, IV ketamine, Tindamax, Cipro, amoxicillin, Artemisinin, and IV garlic.
At the family practitioner’s recommendation, the patient also consulted with and received treatment from a naturopath.
There was no evidence that the family practitioner received informed consent from the patient regarding treatment with IV glutathione, IV amino acids, IV silver, or IV garlic. On 5/3/2011, the patient developed acute and severe symptoms, including abdominal pain, nausea, and vomiting, after self-administering IV garlic received from the family practitioner’s office. On 5/4/2011, the patient’s parents took her to the emergency department where she was admitted to the ICU. She was found to be hypotensive secondary to bacterial sepsis. She was diagnosed as having catheter-related polymicrobial septicemia; candida fungemia; mild renal impairment; mild hepatitis; cavitary lesions/microabscesses; and herpetic cold sores. She was hospitalized for 8 days and discharged on 5/11/2011.
The family practitioner’s overall conduct and acts and omissions with regards to the patient constituted unprofessional conduct through gross negligence and repeated acts of negligence as followed: the family practitioner subjected the patient to unnecessary and unconventional therapeutic regime, including IV garlic, which resulted in serious harm; he prescribed IV ketamine without medical indication; he did not obtain consent regarding treatment with IV glutathione, IV amino acids, or IV garlic; and he failed to routinely assess and document the patient’s vital signs.
The Medical Board of California ordered that the family practitioner be publicly reprimanded and attend 65 hours of an education course.
State: California
Date: November 2013
Specialty: Family Medicine, Internal Medicine
Symptom: Fever, Headache, Nausea Or Vomiting, Numbness, Pain, Abdominal Pain, Joint Pain, Psychiatric Symptoms, Weakness/Fatigue
Diagnosis: Sepsis, Infectious Disease
Medical Error: Improper medication management, Failure of communication with patient or patient relations, Failure to properly monitor patient, Unnecessary or excessive treatment or surgery
Significant Outcome: N/A
Case Rating: 1
Link to Original Case File: Download PDF