Search Cases

Found 80 Results Sorted by Case Date
Page 1 of 8

California – Gynecologist – Complications After A Laparoscopic Assisted Vaginal Hysterectomy For Irregular Bleeding And Abdominal Pain

Sometime prior to 2011, a gynecologist began treating a patient with a history of a prior myomectomy in 2011, pre-diabetes, and fibromyalgia.

On 3/8/2011, the patient presented to the gynecologist with complaints of irregular vaginal bleeding with some pain in her right lower quadrant that worsened when she was on her period. The patient informed the gynecologist that she was “ready for a hysterectomy.” Medical records for this visit do not document the extent of the bleeding, whether or not the bleeding contributed to any other symptoms, the patient’s level of pain, or whether or not the pain interfered with the patient’s lifestyle. At the conclusion of this visit, the gynecologist referred the patient for a pelvic ultrasound with plans to follow up after the ultrasound.

On 4/5/2011, the patient had a pelvic ultrasound which showed the uterus was oriented anteverted and located midline. A fibroid was visualized in the right lateral aspect of the uterus that measured 5.3 by 4.2 by 5.3 centimeters. The endometrial stripe measured 12 millimeters. No other fibroids were seen. The left and right ovary were normal. There was no fluid in the cul-de-sac. The fibroid had increased in size compared to a prior ultrasound in 2010.

On 4/11/2011, the patient presented to the gynecologist for a follow-up. The gynecologist went over the results from the ultrasound and discussed possible treatment options. The gynecologist did not recommend or perform an endometrial biopsy to determine the reason for endometrial thickening or repeat the ultrasound to watch this condition. The gynecologist did not consider or document that the irregular bleeding could be caused by endometrial thickening, endometrial hyperplasia, or endometrial polyp. She did not recommend a dilation and curettage. At the conclusion of this visit, a decision was made for the patient to undergo a hysterectomy, which was scheduled to occur on 6/27/2011. The patient indicated that she wanted a bilateral salpingo-oophorectomy, but the gynecologist advised her to leave in the ovaries.

On 6/24/2011, the patient presented to the gynecologist for a preoperative evaluation. The gynecologist offered the patient medical and surgical options and the patient chose a hysterectomy. The gynecologist explained various surgical options, including risk factors and complications. During the physical examination of the patient, the gynecologist noted the patient’s uterus was bulky and that it did not descend well. The gynecologist did not document any observable vaginal bleeding or any pelvic pain with palpation of the pelvic organs. At the conclusion of this visit, the gynecologist had formed a surgical plan to include a total vaginal hysterectomy and depending on whether the uterus was mobile in the operation room, possible laparoscopic assisted vaginal hysterectomy, possible exploratory laparotomy, and possible cystoscopy.

On 6/27/2011, the gynecologist performed a laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, cystoscopy, and lysis of adhesions on the patient. The medical records do not document a specific clinical reason for this choice in surgical technique versus a laparotomy approach.

During the surgery, the gynecologist encountered a web of filmy adhesions that were abundant along the back of both ovaries and continued along the back of the uterus. The adhesions connected the bowel to the uterus and ovaries.

There were also adhesions from the ovaries to the side walls. The gynecologist considered converting to an open procedure but opted to continue with laparoscopic dissection. After dissection of all of the adhesions, the gynecologist obtained a general surgery consultation as a precaution to review the small bowel, which had been adherent, especially near the right ovary. After observation through the monitor only, neither the surgeon nor the gynecologist noted any bowel injuries.

The gynecologist then proceeded with the vaginal hysterectomy portion of the surgery, which progressed “a bit more difficult than average but not remarkably so.”

Upon completion of the vaginal portion of the surgery, the gynecologist returned to the abdominal cavity. Upon doing so, she noted a slight oozing from the round ligament on the left, which she cauterized. The gynecologist then irrigated the pelvis and looked for any bleeding or injury but found none.

Prior to closing, the gynecologist requested a urology consultation. After cystoscopy and examination revealed no injury to the bladder or ureter, the gynecologist completed the procedure. The gynecologist’s detailed operative report does not specifically document the difficulties or complexities she encountered during the over eight-hour operation.

During the first three post-operative days, the patient experienced complications from the surgery that began to worsen. The patient’s symptoms included abdominal pain, distention, lack of appetite, bowel dysfunction, fever, tachycardia, weakness, emesis, and anemia.

After attempting to treat the patient with antibiotics and observation, on 7/5/2011, the patient was taken in for an exploratory laparotomy.

During the surgery, several liters of feces were found in the patient’s abdomen, which were suctioned out. Then, the abdomen was irrigated. Further into the surgery, a 1-centimeter tear in the distal sigmoid and another 3-centimeter tear in the proximal rectum were identified, repaired, and treated with a colostomy.

From 7/5/2011 to 8/1/2011, the patient remained hospitalized and experienced complications including but not limited to nausea, vomiting, fatigue, fever, tachycardia, wound infection, anemia, and significant leukocytosis. During this time period, the patient had to undergo radiological drainage of intraabdominal collections and was on several courses of antibiotics. The patient was discharged from the hospital on 8/1/2011, approximately thirty-five days after her total hysterectomy.

Per the Board, the gynecologist committed gross negligence in her care and treatment of the patient by continuing with a long and complicated abdominal and pelvic surgery through laparoscopy without converting to laparotomy to prevent multiple intraoperative injuries.

In addition, the Board judged the gynecologist’s conduct to be below the minimum level of competence given the performance of a total abdominal hysterectomy and bilateral salpingo-oophorectomy without definitive clinical indication and without consideration of alternative treatments, prior to consideration of a major surgery, and given failure to maintain adequate and accurate records relating to her care and treatment of the patient.

The Board issued a public reprimand with stipulations to complete a medical record keeping course.

State: California

Date: July 2017

Specialty: Gynecology, General Surgery

Symptom: Abdominal Pain, Fever, Gynecological Symptoms, Nausea Or Vomiting, Weakness/Fatigue

Diagnosis: Post-operative/Operative Complication, Gynecological Disease

Medical Error: Procedural error, Unnecessary or excessive treatment or surgery, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

California – Gastroenterology – Fevers And Chills After Endoscopic Retrograde Cholangiopancreatography (ERCP)

On 6/22/2010, Gastroenterologist A provided a consultation for a patient after an abdominal ultrasound showed that the patient had cholelithiasis and choledocholithiasis. The patient’s elevated liver enzymes and dilated bile duct indicated a moderate to high probability of the possibility of stones and warranted a preoperative ERCP and sphincterotomy. The purpose of the consultation was to remove a suspected common bile duct stone prior to a cholecystectomy.

On 6/28/2010, Gastroenterologist A performed an ERCP with sphincterotomy and balloon sweeping of the common bile duct. He was unable to determine if he had successfully removed the suspected common bile duct stone from the patient’s dilated bile duct and placed an 8.5-French 5 cm stent into the common bile duct.

In the patient’s chart, Gastroenterologist A noted: “will pull the stent out in 2 months.”

On 11/24/2010, Gastroenterologist A next saw the patient in his office. A second ERCP was scheduled for 2/10/2011 to remove the stent. The patient’s medical chart contains no record of instructions given to the patient or his family members regarding the removal of the stent. The patient’s medical chart contains no explanation for the passage of time between the placement of the stent on 6/28/2010 and the removal of the stent on 2/10/2011. The Board noted that stents can be expected to occlude after six months and form a nidus for the formation of other stones, mud, and debris.

At 8:30 a.m. on 2/10/2011, Gastroenterologist A performed a second ERCP on the patient and removed the stent. During the second ERCP, Gastroenterologist A performed a balloon sweep. The patient’s medical chart contains no clear documentation that all ducts were swept. No antibiotics were prescribed or administered to the patient immediately before, during, or after the second ERCP. After the second ERCP, the patient was discharged from the endoscopy facility. Several hours later, the patient’s wife called Gastroenterologist A’s office to report that the patient was experiencing chills and pain in his back and stomach. Gastroenterologist A and/or his staff advised that the patient should be brought to Gastroenterologist A’s office right away.

At 6:00 p.m., after efforts to convince the patient’s wife to bring the patient to his office had been unsuccessful, Gastroenterologist A noted in the patient’s chart that he advised the patient’s wife to bring the patient to the office the following morning if the pain were to continue.

Thereafter, Gastroenterologist A prescribed amoxicillin 500 mg to be taken three times a day for the patient.

The following morning, the patient’s condition had not improved. Further conversations took place between Gastroenterologist A and/or his office staff and the patient’s wife.

At noon on 2/11/2011, the patient arrived at the hospital.

On 10/7/2014, Gastroenterologist A testified that there had been several telephone calls between his office and the patient’s wife on 2/10/2011 and 2/11/2011. Further, he stated that he and/or his staff had impressed upon the patient’s wife the severity of the patient’s condition and that it was matter of life and death that the patient receive urgent medical attention, but that patient’s wife apparently failed to understand and/or take Gastroenterologist A’s comments seriously.

However, Gastroenterologist A did not document in the cart for the patient. He did not document the frequency of the conversations, the information given to the patient’s wife, or his wife’s failure or refusal to understand the information.

At 1:30 p.m. on 2/11/2011, the patient was admitted to a hospital and was found to be critically ill with severe sepsis.

Gastroenterologist A consulted Gastroenterologist B, who performed an ERCP on the patient on 2/12/2011. Gastroenterologist B found “clear evidence of a biliary obstruction as evidenced by darkly pigmented bile and extensive amounts of bloody liquid and sand-like material concerning for hemobilia.” Gastroenterologist B diagnosed “biliary obstruction resulting in ascending cholangitis and sepsis” and placed a stent in the common bile duct.

On 2/12/2011, the patient passed away.

On 2/16/2011, Gastroenterologist A completed a two-page note in the patient’s medical chart entitled “Death Summary” and marked “Final Report, ” in which he made the following comments.

“Endoscopic retrograde cholangiopancreatography was performed 2 or 3 months ago … for common bile stone retrieval with stenting of the common bile duct … His condition continued to deteriorate. During the night, his oxygen saturation began to deteriorate, suggesting acute respiratory distress syndrome. He was intubated and put on the machine. The blood pressure was kept on Dopamine and Neo-Synephrine. But, in spite of this, on 2/12/2011 after all the resources have [sic] been pulled out, I have a hunch that he would not make it because of multiorgan [sic] failure. Therefore, I called the family and explained the grave situation as best that I could. The patient finally expired on 2/12/2011.”

Gastroenterologist A listed the final diagnosis as “septic shock, death.”

Gastroenterologist’s “Death Summary” for the patient contained no mention of the third ERCP, performed on 2/12/2011, or Gastroenterologist’s B diagnosis of biliary obstruction.

After a hearing, the State Medical Board concluded that Gastroenterologist A committed repeated negligent acts given failure to ensure timely removal of the temporary stent, failure to ensure that the patient had a clear understanding of the importance of timely removal of the temporary stent, failure to ensure that the patient had an understanding of the risks associated with performing the second ERCP and the possible warning signs to monitor after the procedure, and failure to maintain appropriate documentation of his care and treatment of the patient.

The State Medical Board placed Gastroenterologist A on probation with stipulations to complete a professionalism program, complete a medical record keeping course, complete 40 hours annually of continuing medical education for each year of probation, and undergo clinical practice monitoring with an emphasis on medical record keeping. During probation, Gastroenterologist A was prohibited from performing ERCP procedures.

State: California

Date: May 2017

Specialty: Gastroenterology, Internal Medicine

Symptom: Fever

Diagnosis: Sepsis

Medical Error: Physician concern overridden, Delay in proper treatment, Failure of communication with patient or patient relations, Lack of proper documentation

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 4

Link to Original Case File: Download PDF

California – General Surgery – Nausea, Vomiting, And Diarrhea After Fissurectomy, Hemorrhoidectomy, And Sphincterotomy

A patient was referred to a general surgeon specialized in colorectal surgery by his primary care doctor. The patient presented to the general surgeon on 4/10/2012 as a 35 year-old-man with anal pain since age 16.

The patient’s medical history included a 12/30/2003 colonoscopy with biopsies by a gastroenterologist, who made a postoperative diagnosis of anal fissure, rectal polyp, and two small sigmoid polyps. The biopsies revealed benign hyperplastic polyps. In 2009, the patient had a lumbar discectomy at L4-L5. In October 2011, the patient was referred to, and seen by, a cardiologist. The cardiologist found “no evidence of any fixed coronary arterial disease in the left dominant system…elevated resting left ventricular end-diastolic pressure suggests left ventricular diastolic non-compliance likely due to history of hypertension and obesity.” In sum, the patient presented to the general surgeon with morbid obesity, hypertension, dyslipidemia, post-two back surgeries, with a resulting DVT, cardiac complaints, and a list of prescription medications; and a social history including a one pack per day smoking habit, cannabis use, and occasional alcohol use.

The patient appeared with his wife for his appointment with the general surgeon. The patient was given a two-page medical questionnaire to complete. The patient filled in page one of the questionnaire and the patient signed page two, leaving blank the box on page two asking the patient to circle symptoms applicable to their current condition (e.g., headaches, shortness of breath, chest pains, blood in stool, etc.). The patient was called out of the lobby by a medical assistant, who took his vital signs and questioned him about the information listed on the questionnaire. The medical assistant learned that the patient was allergic to penicillin, which the patient had not listed on the questionnaire. The medical assistant reported that the patient’s vital signs to the general surgeon on a yellow sticky note was as follows: “Temp-98.2 F, Weight-341 lbs., Height-72 in., BP [Blood Pressure]-139/77, Pulse-84, RR[Respiratory Rate]-21, BMI [Body Mass Index]-46.3.”

The medical assistant then escorted the patient to an examination room. The general surgeon entered and spoke to the patient. The general surgeon took notes by hand, indicating the following:

“hemorrhoids three times after laminectomy[1l in January; symptoms greatly increased over the last six months; Bowel Habits-small stools, tenesmus [urge to defecate, but cannot], and mucus discharge; hiatal hernia; colonoscopy negative; History of polyps; no sigmoidoscopy.”

The general surgeon and the medical assistant created the chart note for the patient’s visit, which reports out the following:

CC [Current Complaint]: Hemorrhoids

HPI [History of Present Illness]: The patient is a pleasant 35- year-old referred here by [his primary care physician]. He is here because of a 3-year history of hemorrhoids with progressive painful BM’s [bowel movements], tenesmus, BRBPR [bright red blood per rectum], and small stools last 6 months. Known history of fissure. Last colonoscopy negative.

ROS [Review of Systems]: General-denies fever, night sweats, weight loss; Neurological-denies loc [loss of consciousness], ha [headaches], diplopia [double vision], tinnitus [ringing in the ears], vertigo [dizziness], numbness, tingling, incoordination; Respiratory-denies sob [shortness of breath], wheezing, coughing, hemoptysis [coughing up blood]; CV [cardiovascular system ]-denies angina, palpitation, leg cramps, pedal edema, pnd [ difficulty breathing], nocturia [ excessive urination at night], orthopmea [shortness of breath while lying down], claudication [cramping leg pain caused by exercise]; GI [gastrointestinal system]-denies nausea, vomiting, hematochezia [fresh blood in stool], hematemesis [vomiting blood], jaundice, diarrhea, incontinence, heartburn, indigestion, dysphagia [difficulty swallowing], poor appetite, constipation; GU [genitourinary]-denies dysuria [painful urination], hematuria [blood in urine], incontinence, impotence, pneumaturia [passage of gas with urine], fecuria [fecal matter in the urine]; MS [musculoskeletal]-denies stiffness, arthralgia joint pain], weakness, atrophy, bone pain, Raynaud’s [severe blood flow reaction to blood vessels in the cold in fingers and toes]; Endocrine-denies heat intolerance, cold intolerance, dry skin, dry hair, hoarseness, polydipsia [abnormally large thirst], polyuria [production of abnormally large levels of diluted urine]; Hematologic-denies bleeding, bruising, ecchymosis [discoloration of the skin resulting from bleeding underneath], pk [Pyruvate kinase deficiency, one of the most common enzymatic defects of the erythrocyte].

PMH [Past medical history]: Medical-hypertension, dyslipidemia [high cholesterol]; Surgical-lumbar laminectomy, micro-discectomy.

SH [Social history]: Patient denies recreational drug use; Smokes 1 pack/day for 15 years; Occasional alcohol consumption.

FH [Family history]: Mother- 69 alive with hypertension [high blood pressure]; Father-DEC [deceased] at 65 heart attack; Siblings- 1 brother alive at 41 with CVD [cardiovascular disease], 2 sisters alive, 1 with diabetes another with CVD.

Allergies: Penicillin.

Meds:

acetaminophen-hydrocodone 325 mg.-7.5 mg. [Norco] oral tablet, folic acid 1 mg oral tablet, Xanax XR 0.5 mg oral tablet, extended release, zolpidem [ Ambien] 10 mg oral tablet.

Vitals: T [temperature]-98.2 F, Wt [weight]-341 lbs., Ht [height]-72 in., BP [Blood Pressure]-139/77, P [pulse]-84, RR [Respiratory Rate]-21, BMI [Body Mass Index]-46.3.

PE [Physical examination]: General-WD/WN [well-developed/well-nourished] in NAD [no abnormality detected]; HEENT[head, eyes, ears, nose, throat]-PERRLA [Pupils equal, round & reactive to light & accommodation], EOMl, [extraocular movements intact], ENT [ear, nose, throat] wnl [within normal limits]; Neck-not thyromegally [enlargement of the thyroid gland] or masses, no ND [jugular venous distension] or bruits [a systolic murmur heard in the neck]; Chest-clear to auscultation and percussion; Cardiac-no murmur or gallop; Abdomen-no masses or organomegaly [enlargement of the viscera], non-tender; Extremities-no clubbing, cyanosis or edema, full range of motion; Neuro-grossly intact; Anorectal: inspection showed posterior fissure, with spasm, no further exam. Large skin tag RPQ [right posterior quadrant]. Cannot rule out hemorrhoids.

A/P [assessment/plan]:

#ANAL fissure (565.0);

#HYPERLIPIDEMIA OT/UNSPEC (272.4);

#HYPERTENSION UNSPEC (401.9).

Fissurectomy, lateral sphincterotomy, possible hemorrhoidectomy. The risks, benefits, and alternatives, including the slight chance of incontinence, are discussed.

Following the examination, the patient signed two information and consent forms: Hemorrhoids-Surgical Hemorrhoidectomy and Anal Fissure-Fissurectomy and Sphincterotomy.

No surgery was scheduled, and the patient left the general surgeon’s office. The general surgeon did not request the patient’s medical file from the primary care doctor.

On 4/23/2014, at approximately 9:00 a.m., the patient called the general surgeon’s office, complaining of terrible pain and pleading for relief. At the time, the general surgeon was in surgery at a surgery center. The general surgeon was contacted in the operating room (OR) by his office on behalf of the patient. Although the general surgeon was scheduled for a full day of surgeries, he offered to operate on the patient at the end of his surgical schedule that day. The patient accepted. The general surgeon’s office transmitted a Pre-Admission form, with Physician’s Orders, to the surgery center at approximately 10:00 a.m., requesting the patient have the following tests prior to surgery: “EKG [electrocardiogram]; CBC [complete blood count], without Differential (includes Platelets); UA[urine analysis]/Culture if indicated.”

At 3:44 p.m., the patient was admitted to the surgery center for his surgical procedures. The Admission’s Nurse completed the Admission Profile with the patient and the wife, noting, among other things: “Previous hospitalizations/surgeries-microdiscectomy 2010, lumbar laminectomy 2009, with DVT after laminectomy; Comprehensive Pain Assessment pain scale 10, rectum, onset at 16 years old, burning; Cardiovascular-high blood pressure, weird heartbeat about 8 months ago at cardiologist; Hema/Hepatic/GI-hemorrhoids, fissure; Psychiatric-Anxiety; Social Habits-smoker 1 PPD [pack per day], alcohol 2-4 times per month.”

The general surgeon completed a Short Form history and physical for the patient, noting: “Chief Complaint-Anal pain; History of Present Illness-severe pain secondary to anal fissure. Past Medical/Surgical History: HTN [hypertension]; Current Medications and Allergies: See-home medication list; Physical Exam-Head/Neck-normal,-Airway normal,-Neuro normal, Chest/Lungs normal, Heart normal, GI normal, GU normal, Extremities normal; Significant findings-anal fissure with right posterior skin tag; Diagnosis-Anal fissure; Plan-fissurectomy, sphincterotomy, and hemorrhoidectomy; Pre-Sedation Assessment For Procedure Without an Anesthesiologist-ASA2 II – mild systemic disease.”

At 4:12 p.m., a patient provided a urine sample and blood was taken for labs. At 4:53 p.m., labs revealed normal sodium, potassium, hemoglobin, and hematocrit. At 5:11 p.m., a pre-anesthetic evaluation was completed on the patient by an anesthesiologist. At 5:29 p.m., the patient was placed under general anesthesia. At 5:46 p.m., the general surgeon performed a hemorrhoidectomy, fissurectomy, and a right lateral sphincterotomy on the patient. The surgery was completed at 6:42 p.m., and the patient was in the recovery room at 7:00 p.m. The general surgeon prescribed the patient “Norco 10/325 mg., one tablet every four hours, as needed for pain; Valium 2 mg., one every six hours, as needed for pain; and Toredal (sic) 10 mg., one every six hours.” At 8:15 p.m., The patient was discharged.

The general surgeon drafted an Operative Report, noting, among other things:

“Preoperative Diagnosis-anal fissure; Postoperative Diagnosis-anal fissure and hemorrhoids; Procedures Performed-hemorrhoidectomy, fissurectomy, right lateral internal sphincterotomy; Anesthesia-general; Findings-anal stenosis with deep posterior anal fissure with large 3-quadrent (sic) hemorrhoids in the usual distribution, in the right anterior quadrant hemorrhoidal group there with chronic strangulation and gangrenous changes.”

On 4/24/2014, Post-Surgical Day 1 (PSDl), the patient’s wife called the general surgeon’s office four times: at 9:46 a.m., 10:32 a.m., 3:10 p.m., and 4:38 p.m. At 9:46 a.m., the patient’s wife reported that the patient had blood in his urine; the patient’s wife was told that the patient had a urinary catheter during surgery and blood in the urine was normal on PSDI. At 10:32 a.m., the patient’s wife reported the patient was vomiting and had diarrhea; the patient’s wife was told this was normal for PSDl. At 3:10 p.m., the patient’s wife reported the patient was still vomiting; a prescription for Reglan (anti-nausea) was called in. The patient’s wife collected the prescription, but the patient could not keep the Reglan down.

At 4:38 p.m., the patient’s wife reported the patient was still vomiting, with diarrhea, and feels hot, although his temperature is normal; the patient’s wife was told that the symptoms are normal for PSDl, and get fluids into the patient. The general surgeon did not return the calls from the patient’s wife on 4/24/2014.

On 4/25/2014, Post-Surgical Day 2 {PSD2); at 5:58 p.m., the patient’s wife called the surgery center and reported the patient was still vomiting, with diarrhea, and feels hot; the patient’s wife was told the symptoms were normal for PSD2, but to call the general surgeon’s office. The patient’s wife called the general surgeon’s office, spoke to the answering service, and requested a callback.

At 6:40 p.m., the general surgeon telephoned the patient’s wife. The patient’s wife reported pus at the surgical site and that the stitches looked ripped open and yellow; the general surgeon said they were breakaway stitches and the appearance was normal for PSD2. They did not discuss the patient’ s symptoms from PSD 1.

On 4/26/2014, the patient began speaking nonsensically. He complained about pain in his legs. The patient’s wife called the general surgeon’s office at 12:36 p.m. and 12:40 p.m., but the office was closed for lunch and the patient’s wife did not leave a message with the exchange.

The patient’s wife then telephoned the surgery center at 12:46 p.m. and 12:47 p.m. The patient’s wife reported the patient was speaking nonsensically, with purple, blotchy legs, purple lips, and slurred speech; the patient’s wife was told to bring the patient into the hospital. At 12:58 p.in., 911 was called. Paramedics appeared and transported the patient to the surgery center.

The patient arrived at the surgery center at 1:35 p.m. In the ambulance, the patient was intubated and described by EMS as “acutely cyanotic and mottled.” Upon arrival, the patient was treated by an ED physician in the ED for two hours.

The ED physician drafted an ED Report, indicating, among other things: “This is a 36-year-old white male who comes to the emergency room by ambulance in extremis [at the point of death]. He was intubated in the field by the paramedics.”

“On arrival in the department he was purple mottled, unresponsive with a heart rate in the 60s which later proceeded to become bradycardic into the 20s.” ” … [A] temperature of 41 Centigrade [105.8 Fahrenheit] was noted.”

“Examination of the rectum revealed maceration and postoperative changes. It does appear consistent with an infection in the area.”

“Labs later returned showing renal failure with a creatinine of 9. Potassium was elevated.”

“Diagnosis-septic shock, renal failure, perineal infection, status post hemorrhoidectomy. His prognosis seems exceedingly poor.”

“Total critical care time 120 minutes.”

At 2:50 p.m., the ED physician contacted the general surgeon regarding the patient, reporting sepsis, renal failure, hyperlipidemia, recent hemorrhoidectomy with local infection. The general surgeon telephoned the surgery center to reserve an OR for the patient, scheduling the first available OR at 5 p.m.

At approximately 3:30 p.m., the patient was admitted to the surgery center and his care was transferred to an internist. After 5:00 p.m., the patient was taken to interventional radiology (IR) for placement of an IVC [inferior vena cava] filter (5:35 p.m.) and a temporary dialysis catheter (5:43 p.m.).

At 5:50 p.m., the patient was moved from IR into the OR, where the general surgeon waited. On arrival to the OR, the transport staff reported a change in heart rhythm. A Code Blue was called at 6:05 p.m. Resuscitative measures commenced but were unsuccessful, and time of death was called at 6:41 p.m.

The internist charted a Discharge Summary, noting: “Discharge Diagnosis-(1) patient died, (2) severe septic shock, (3) most likely perirectal phlegmon [inflammatory process with pus] versus fasciitis [inflammation of connective tissue]. History of Hospital Stay-This was a 36-year-old gentleman admitted at [the hospital] with septic shock. He was hypotensive, unresponsive, intubated in the field. While in the emergency room, the patient had episodes of bradycardia [abnormally slow heart action]. He was found to have multi-organ system failure with acute kidney insufficiency. He was taken to the OR for an emergent exploratory laparotomy [a surgical incision into the abdominal cavity, for diagnosis or in preparation for surgery]. Unfortunately, he coded on the OR table.”

The general surgeon wrote a Death Note in the chart, indicating: “Patient came in with septic shock. Code blue called in route to OR. CPR commenced in the OR per ACLS [advanced cardiac life support] protocol. Planned perineal debridement and colostomy never took place. Code was called after 22 min of resuscitative effort then resumed after seemingly having spontaneous cardiac electrical activity and pulse, but this was transient, and soon patient became pulseless without meaningful cardiac activity. Patient after hemorrhoidectomy and has perineal gangrene.”

An autopsy was performed on April 28, 2012, at the Fresno County Coroner’s Office. A blood culture was taken, revealing gram-negative rods isolated [bacterial infection]. The cause of death is listed as probable cardiac arrhythmia due to idiopathic hypertrophic cardiomyopathy.

The general surgeon was placed on probation for three years with stipulations of completing an education course and undergoing monitoring by another physician.

State: California

Date: May 2017

Specialty: General Surgery, Internal Medicine

Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Fever, Nausea Or Vomiting, Pain, Urinary Problems

Diagnosis: Sepsis

Medical Error: Delay in proper treatment, Failure of communication with patient or patient relations, Improper treatment

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF

Page 1 of 8

Florida – Obstetrics – Lack Of Maternal Serum Alpha-Fetoprotein Testing With Pregnancy Complications

Vermont – Emergency Medicine – Suspected Ventricular Tachycardia Not Addressed In A Patient With Respiratory Distress, Fever, And An Elevated Heart Rate

Florida – Pediatrics – Cough, Post-Tussive Emesis, Fever, Elevated Heart Rate, And Elevated Respiratory Rate

California – Gynecologist – Complications After A Laparoscopic Assisted Vaginal Hysterectomy For Irregular Bleeding And Abdominal Pain

California – Gastroenterology – Fevers And Chills After Endoscopic Retrograde Cholangiopancreatography (ERCP)

California – Pediatrics – Long Term Regimen Of Compounded Dexamethasone Cough Syrup For Pneumonia And Asthma

California – General Surgery – Nausea, Vomiting, And Diarrhea After Fissurectomy, Hemorrhoidectomy, And Sphincterotomy

North Carolina – Physician Assistant – 10-Year-Old With Cough, Fever, High Blood Pressure, and Sore Throat Diagnosed With Strep Throat

Florida – Emergency Medicine – Fever, Cough, Sore Throat, And Shortness Of Breath With An Oxygen Saturation Of 91%

California – Internal Medicine – Rectal Cancer With Metastatic Disease, Fall, And A Perineal Wound