Sample Case Evaluation Reports - Urology Expert Witness

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Adult Circumsision Complicated by Treatment for an Erection Causing Death

According to the records, the patient was 23 years of age and wanted a circumcision due to a tight foreskin (prepuce) causing difficulty with sex. According to the records, the past medical history was normal. Other than the tight foreskin, the physical examination was basically normal. Three days before surgery, on November 18, the patient underwent various blood tests. The blood count for anemia, the hemoglobin and hematocrit, were perfectly normal at 15.6 hemoglobin and 45.1 hematocrit. There was no evidence of any anemia. The studies for coagulation (clotting) of the blood, the prothrombin time and partial thromboplastin time also were normal. There was no request for the test for sickle cells. Since the patient had no history of sickle cell disease and was not anemic, that test would not be required. 

According to the anesthesia record, the patient arrived in the operating room at 9:50 a.m. An intravenous line was started in the right hand. There was a smooth induction of general anesthesia. The operation started at 10:15 a.m. The Surgeon noted in his operative report that the patient developed an erection that persisted in spite of time. However, in my opinion, the Urologist did not allow sufficient time for the spontaneous erection to pass on its own. As noted by the anesthesia record and in the operative report, the Urologist injected 1 cc of epinephrine (adrenaline) in the dilution of 1:100,000. I assume he injected this directly into the penis. In my opinion, that is a departure from the accepted standards of care for a few reasons. 

First of all, only five minutes initially passed, according to what would be relevant in the records, and that is not a sufficient amount of time to allow the spontaneous erection to dissipate. This was not an urgent operation. Furthermore, the injection into the penis of epinephrine is not indicated. It would cause a spasm of blood vessels rather than a relaxation of blood vessels, and thus impede the release of the erection. The injection of nor-epinephrine would be more appropriate if an injection was going to take place, but more time should have elapsed. 

Following that injection, only five minutes of time passed and there was no effect, and therefore he injected the same medication again. This time, the erection dissipated (detumescence), but the patient immediately developed a cardiac arrest. According to the anesthesia record, the cardiac arrest appears to have occurred at approximately 10:15 or possibly 10:20. Thereafter, cardiopulmonary resuscitation, including the use of a transvenous heart pacemaker, was attempted but was unsuccessful. The patient was pronounced dead at 12:15 p.m. 

From these records, I cannot tell if the M.D. Anesthesiologist was in the operating room during the clinical part of the induction, or if the care was given only by the Nurse Anesthetist. This needs to be evaluated. When a patient has an erection in the operating room, normally an additional amount of time is allowed to pass to see if, in fact, it would spontaneously diminish. Then, if that did not happen, the Anesthesiologist can be asked to change the anesthesia medication. If this does not work, then the operation could be canceled, or a small "butterfly" needle can be inserted into the penis to relieve the blood congestion. But in my opinion, the use of epinephrine under these circumstances is contraindicated. It is a departure from the accepted standards of care. 

Unfortunately, this patient had sickle cell trait. That is, part of the hemoglobin (the red blood cell pigment), instead of forming spherical, donut-shaped red blood cells, under certain circumstances, which can include low oxygen, acid build up and stress (which is a physiologic side effect of the injection of epinephrine into the body) can cause these cells to form a sickle, or banana shape. Those cells do not pass through the fine capillary blood vessels in the body and get stuck. This blocks up the circulation throughout the body, including the heart. 

If a patient has sickle cell disease, then they have usually had sickle cell crises in the past, and often are significantly anemic. This patient did not have pure sickle cell disease. He had a sickle cell trait with part of the hemoglobin that was of the normal type A, but part was of the type S (sickle cell hemoglobin). 

The autopsy shows that the patient had congestion in most of the organs secondary to the sickling of blood cells. The pathologist tested the hemoglobin and found out it was 78% hemoglobin A and 24.44% hemoglobin S. Furthermore, the sickle quick test was also positive, confirming that this patient had the sickle cell trait. 

In my opinion, the primary person responsible for the death of the patient was the Urologist. His name is not completely legible, but it looks like #1. The Anesthesiologist's name appears to be #2, and the Nurse Anesthetist appears to be Nurse #1. I am not sure of the spelling of these names. 

I want to point out that on the perioperative nursing records from Hospital, the anesthesia started at 9:50 a.m., the surgery started at 10:05 a.m. and concluded at 10:20 a.m. Thus, within 15 minutes, the patient had two injections of the epinephrine within his penis. In my opinion, that is too short a period of time before doing anything definitive, as I noted above. And the use of epinephrine, in my opinion, is contraindicated in any patient, and unfortunately in this patient with his unknown sickle cell trait, it created a sickle cell crisis that caused the death of the patient. 

If the patient had a sickle cell crisis secondary to the effects of being put under anesthesia, and that caused the erection (priapism), which it can do, the use of epinephrine still would be contraindicated. If with reasonable passage of time the erection persisted, then the use of a needle to remove blood from the erect penis would be the appropriate standard of care. 

The admitting record notes that the Physician is Dr. #3, but his name does not appear as the surgeon in the hospital record. I do not know what role he played in the care of this patient. 

During the cardiopulmonary resuscitation, at 11:25 a.m., a sample of arterial blood was drawn from his body for analysis. Carbon dioxide was only slightly high at 52, and the oxygen content, the pressure of oxygen (pO2) was 81, just below the normal range of 81, and the oxygen saturation was borderline-normal at 94%. Thus, the cardiopulmonary resuscitation, even an hour after it began, appears to have been done effectively. However, because of the massive amount of sickling that occurred in this patient's body and heart, he was unable to be resuscitated. 

Whether or not the stress of undergoing anesthesia caused a sickle cell crisis, or the two negligent injections into the penis of epinephrine caused the crisis, in my opinion, the epinephrine markedly worsened the crisis, causing the death of this patient. 

Is the treating Urologist Board-certified? Has he ever failed his Board examinations? If he was not properly trained in Urology, then in my opinion, the hospital would have some liability. 

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Laparoscopic Surgery to Remove Remaining Diseased Kidneys After a Successful Transplant, Severs Three Arteries with Two Not Sutured Closed and He Bleeds to Death in ICU.

This is an extremely disturbing case, which may blur the line between gross negligence and manslaughter. 

I will discuss all the facts and opinions below, but much discovery is needed, including obtaining missing records, before I can reach a final opinion. You need to obtain a certified complete set of the 2/15/01 Hospital records, including the admission History & Physical (as well as all the recent office records that lead up to this admission), the operative report, the anesthesia record, the Operating Room Nurses’ notes, including all cardiac arrest records, the AICU Doctor and Nurses’ notes, and the pathology report on his removed kidneys. 

This patient had a functioning kidney transplant two years before this admission because of hematuria (blood in his urine), presumably from a left kidney mass that might be a tumor. 

When there is blood in the urine, standard procedure is to look into the bladder (cystoscopy) to try to see what ureter (urine tube from each kidney to the bladder) the blood may be coming from, as well as sampling any urine flow from each ureter for analysis for tumor cells (cytology). Was that done?

A CT scan was done, which allegedly found “lesions” of the left kidney. On 1/10, five weeks before surgery, an MRI scan with contrast (Gadolinium) found a normal transplanted kidney in its usual pelvic location, and “an approximately 2-cm (1 inch = 2.54 cm) projection on the left kidney. In the “Impression” for the left kidney, Dr. #1 said that “the possibility of a tumor cannot be excluded. Follow-up CT scan in two to three months is recommended.” And in the text of his report, he said: “The characteristics of this lesion are also somewhat obscured by the motion artifacts.” Why wasn’t this MRI repeated in the next five weeks? Why wasn’t his recommendation for a follow-up CT scan done?

Since there was bleeding and a lesion, the probability that if this was a tumor (cancer) in continuity with the urine flow would be higher that most kidney tumors that are inside the kidney flesh and do not touch the main urine flow. Therefore the probability of a positive cytology, if it was cancer, would be greater. Were any cytology studies done, even with him urinating into a bottle? And those cells can be concentrated by a centrifuge to give a greater reliability for that histology study. Was it done and repeated? They had time. 

Also, with the concern for a tumor, an arteriogram (artery x-ray contrast study) of the renal (kidney) arteries to see the core of each kidney is valuable to evaluate each kidney for cancer. Cysts have no blood flow and tumors greater blood flow than the flesh of the kidney. Even with failed kidneys, the blood flow is patent. That catheterization of the artery can be done via his arm to reduce the risk of dislodging any cholesterol debris lining his arteries. Was it done?

What consent did he sign? With what informed consent (including the testing that should be done and may not have been done)? What experience did Dr. #2 and any assistants of his have with the performance of the “laparoscopic nephrectomy” (removal of the kidney via the use of a viewing and operating tube) at that time? Who operated (versus assisted) on each side? Why did they operate on the right side when the left kidney was the one in which the MRI raised the question of tumor? The chance of a kidney tumor on both sides would be remote. 

All the above concerns are about negligence in his preoperative evaluation and informed consent. 

The autopsy report in the middle paragraph of page two is shocking as are the “arterial vasculature” findings on pages four and five. The left side went uneventfully. But then someone proceeded to operate on the right side. Although one renal (kidney) artery is most common, second (accessory) renal arteries are found in 25% of kidneys (see: Lloyd, L.W. (1935). The Renal Artery in Whites and American Negroes. American Journal Physical Anthropology, vol. 20: page 153, and Grant’s Atlas of Anatomy by James Anderson, plates 2-113: anomalies of the kidney and ureter). A Surgeon does NOT cut without a clear view to be sure he is not severing an artery or vein that has not been ligated (tied off) or clipped closed on both sides of the site chosen for his cut. 

In the autopsy description, it says: “The right kidney was removed, but the bleeding continued.” The reason is found on the bottom of page four: There are two right renal ostia (openings from the aorta: main artery in the body) identified. The lower ostium is probed into an attached 3.0-cm segment of renal artery, which has been ligated with silk suture material. The upper ostium is probed into an attached 2.3-cm segment of artery, which is opened at the transected (severed) end.” That is why he hemorrhaged. No one secured it before cutting it. And the renal vein also was not ligated and would hemorrhage. 

If an arteriogram would have been done, that common anomaly would have been found. If they would not have needlessly operated on the right side (based so far on the records I have reviewed), none of this catastrophe would have occurred. But it gets much worse. 

They opened the abdomen or his flank area to reach the kidney and did not get control of that bleeding site, and somehow managed to cut across his right common iliac artery (the aorta divides into the right and left common iliac arteries) in the lower abdomen, nowhere near (in surgical terms) the renal artery. This transection was 2.1 cm distal (downstream) from the aortic bifurcation (division into both common iliac arteries). They managed to gain control by stapling that negligent blunder cut at both ends (but it cut off artery blood flow to this downstream kidney transplant, but that obviously is moot now, except as a measure of punitive damages). 

The horror is that: “There is a nearly complete vascular laceration of the right common iliac artery located 1.3 cm distal to the aortic bifurcation and 0.8 cm above the proximal (on the upstream) surgical staple line.” Therefore with each contraction of his heart, blood poured out of this neglected-to-be-repaired artery hole!

He went into cardiac arrest (and temporarily did not bleed until resuscitated) but: “The wound was closed (abdominal incision, not the hole in both arteries: right accessory renal and right common iliac), and the patient was taken to the AICU at approximately 10:25 p.m. He arrived in the AICU with a heart rate of 40 (in profound shock and almost dead) followed by asystole (no heartbeat: death). 
To not control such major arteries (unligated accessory right renal artery and transected right common iliac artery) is gross negligence, but to suture his abdominal wound closed and ship him to the AICU to die, in my opinion, is manslaughter! 
Unless their operative report, other records and detailed discovery from everyone who was in that Operating Room on 2/15 gives an honest and rational explanation, they all should have their licenses revoked.
The Defense would claim he had a shortened longevity from his significant coronary artery disease with generally 90-95% narrowing (stenosis) of all his coronary arteries. Did he have any chest pain with exercise or sex? He had no heart attack. He had no cancer found at autopsy or any other life-threatening or shortening disease. 
Was the laparoscopic procedure videotaped? They often are. Was there a death conference (it had to occur) and can you obtain these records, or at least depose everyone who attended it? Were any sanctions given to anyone? Were any changes made at that hospital because of this “complication?” Was the State Board of Medical Examiners advised of this case and did they investigate? Did they Joint Commission on Health Care Organizations (from Chicago) that certifies hospitals do any investigation?
After final review of the documents noted above, I would recommend Board Certified Experts we have available in Urology and Vascular Surgery to give you their Expert opinions on negligence and causation and an opinion by a Board Certified Cardiologist on longevity re: his heart. 
Thank you for allowing our organization to assist you with this very important case. We remain available to continue assisting you and the family.

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Bladder Suspension Operation For Cystocele Performed with Excessive Surgery Causing Urine Retention Problem.

At age 67, this patient had a large cystocele and a prolapsed vagina from her three previous vaginal deliveries stretching the support tissue of her bladder and vagina. She had a hysterectomy in 1982. 

She saw Dr. #1 on 4/27/00 when he diagnosed her condition noting her third degree cystocele (her bladder hanging down into the outer opening of her vagina) as well as her large vaginal prolapse. She refused surgery. 

Because of a worsening of the pressure and size of the cystocele, she agreed to have surgery. She signed a consent form on 11/8/00 for the “anterior repair, sacrospinous vault suspension.” The anterior repair is a standard and effective operation to repair a cystocele. An incision is made lengthwise in the upper vagina exposing the bladder and its supporting fibrous flesh (fascia). The excess (lax) vaginal lining is excised and the loose bladder support tissue is brought together with sutures, like tightening shoelaces. The vagina is sutured to deep pelvic ligaments to hold it in place (sacrospinous vault suspension).

As the bladder hangs down, it pulls upon the urethra (urine egress tube) and its sphincter muscle, often creating a degree of urine incontinence (stress incontinence with laughing and coughing). She did NOT have this problem, therefore her sphincter muscle and its support was very strong to overcome this pull of the large cystocele. 

On 11/14/00 at 0800, 40 minutes before she was taken into the anesthesia “holding area” and presumably before she had any sedative or narcotic medication, she also signed another consent form allowing Dr. #1 to perform: “anterior repair sacrospinous vaginal vault suspension with possible suburethral sling with bone anchors.” It is not grammatically correct. Also Dr. #1 noted in his postoperative office visit notes on 12/13/00: “The patient is still questioning, at this point, why a sling procedure was performed. She had expressed concern over having the procedure done in the first place. Again, I explained to her I felt as though she would have urinary incontinence after the initial procedure because of the appearance of the bladder at the time of the surgery.” I disagree. 

With no incontinence with such a large cystocele pulling down on her sphincter muscle, its repair by the standard “anterior repair” would eliminate that abnormal sphincter impairing force and would do the opposite of the “explanation” noted by Dr. #1 above. 

His plan noted in his preoperative “History and Physical” dictated on 11/13/2000 (the day before surgery was for “an anterior repair and possible suburethral sling with bone anchors. The patient was informed of the risks and benefits of the surgery preoperatively and wishes to proceed.” This is not entirely true since she signed that “sling” consent at 8:00 on 11/14 and as he noted on 12/13 she had “expressed concern” and it appears that the added procedure and explanation occurred after the 11/13 dictated “History and Physical.” 

This discrepancy needs to be clarified by a detailed Affidavit of your Client and any witness to this issue, and her concerns. 

On 11/14, he notes for the first time in the operative report, “Large third degree cystocele and urethrocele.” A urethrocele is the downward dislocation of the urethra caused by its weakened support tissue and pull by the cystocele. However, she did not have any stress incontinence as he noted preoperatively. And the “anterior repair” would also repair the weakened support tissue of the urethra. Adding that cadaveric sling of fibrous flesh (fascia) would only add to the urethral closure pressure and inhibit bladder emptying. And over time scar tissue thickens which would further constrict the urethra and impair bladder emptying. After six months to one year, that scar tissue would tend to soften, but it was not needed in the first place. 

Technically it appears to have been done correctly, including the use of a urethral / bladder catheter (rubber tube) to locate and protect it from having sutures placed into its flesh. The tension on the sutures held in place by bone screws is unknown, but its result, combined with the anterior repair in a continent patient was excessive and not necessary. 

Her bladder residual urine (which should be close to zero) was 800 cc (30 cc = 1 ounce) on 11/16/, 300 cc on 11/21 and 120 cc on 11/27. 

She then saw Dr. #2 on 12/26. At that time, because of the bladder irritation from the operation and urine retention, she developed “urgency incontinence which was totally nonexistent prior to surgery.”

On 1/12/01, her residual urine was 50 cc. He noted that the urethral / bladder angle “is excellent” and “there is no erosion from the sling. The bladder looks fairly healthy. I think we are probably seeing some problems with the bladder becoming accustomed to the increased pressure necessary for voiding.”

Medication did not help, therefore Dr. #2 properly dilated her urethra on 2/8/01. On 2/13, her residual urine was 40 cc. 

On 6/11/01, Dr. #3 of another Hospital operated and incised (cut) the cadaver fascia sling to free up the urethra, repaired some residual or recurrent bladder prolapse (cystocele) in areas, and resewed the vaginal support. 

I have no follow up or current information. 

I believe that this patient did not need the added procedure of the cadaver fascia urethral sling with bone screws for the reasons stated above, and that this departure from the standard of care (including proper informed consent) resulted in her bladder dysfunction from excessive urethral sphincter compression and tone, which required the urethral dilatation by Dr. #2 and the urethrolysis procedure by Dr. #3. 

Please supply details requested above and then authorize our office to have these records and those statements reviewed by a Board Certified Expert in Urology on our Independent Consulting Staff. 

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