Sample Case Evaluation Reports - Vascular Surgery Expert Witness
 

Please click on the titles below to go to the corresponding sample Case Evaluation Reports.

 

Eighteen Hour Delay For Surgery For Leaking Abdominal Aortic Aneurysm Increased Risk Of Death.

This 71-year-old male Attorney who was in good health and no history of kidney stones or infection, developed severe abdominal and back pain of a sudden nature on 4/18 and was taken to the Emergency Room of the VA Hospital at 5:00 PM with a shocky blood pressure of 80/55 and no elevated temperature.

A physical examination would be required without delay.  He was not seen by Dr. Belinda until after 6:29 PM and NO ABDOMINAL EXAMINATION was done.  That it is negligent.  It would have revealed a pulsatile abdominal mass of a ruptured/leaking abdominal aortic aneurysm premises (AAA), totally consistent with a history, and the first priority to rule out in a differential diagnosis.  Dr. Belinda only noted in the “Diagnostic Impressions: Left lower back pain” without doing any abdominal examination, and not even considering the shocky blood pressure, again consistent with a ruptured/leaking AAA.

It was not until Dr. Brittney came on duty and saw him at 3:00 AM was that an abdominal examination was performed revealing the obvious "pulsatile abdominal mass," which at surgery measured 10.5 x 12.0 cm (one inch equals 2.54 cm), and was present before rupture for years.  The risk of rupture rises dramatically after 5 cm. 

Obtain all previous medical records and copies of all previous abdominal x-rays to determine if any previous Doctor was negligent in failing to diagnose it when it was in its chronic expanding state.  How much did the patient weigh?  How tall was he, and what was his belt size?  The thinner the patient, the easier it is to feel (palpate) the mass.  However, its size would not have changed significantly in the ER where any abdominal physical examination certainly should have revealed it at 6:29 PM.

The CT scan confirmed its size and location and the presence of an abnormally located right kidney (which was in his pelvis).  Dr. Brittney was notified of the CT results at 5:15 AM and it was also discussed by the Radiologist with “Dr. Blake from surgery.”

Surgery began at 7:30 AM and ended at 12:15 PM (4 hours and 45 minutes), and was complicated by the size of the hematoma, the need to ligate (sever and tie) to the left renal (kidney) vein for exposure.  The aneurysm was opened and replaced by a graft.  Because of the hours of negligent preoperative delay, there was swelling (edema) of his intestines, which prevented the suture closure of his abdomen.  The intestines were placed into a "Bogota Bag” and it was sutured to the large incision.  After days, the swelling would decrease, and he was reoperated upon on 4/24 to remove the bag and with the use of mesh, the incision was sutured closed.  He had been receiving various antibiotics from 4/19.

He developed kidney failure, required hemodialysis, became more ill, and the family agreed to a DNR (Do Not Resuscitate) order.  He died on 4/29 at 5:17 PM.  The details of the cause of death are not fully delineated, but they claim he developed “septic shock."  This is an overwhelming infection that damages all vital organs.  I found no blood culture (laboratory) reports (including any showing germs in his bloodstream or elsewhere.)  No autopsy was performed.

The hemodialysis (kidney machine treatment) was used to remove excess bodily fluid and correct the acid condition of his body, but apparently was not beneficial to his general condition, as it to was hoped it would be.

When a patient has their intestines in a bag (even with attempts of sterility), and then requires a second operation, the risk of infection increases.

The longer the delay while shocky before AAA surgery, the more damage will result, including increasing the risk of kidney failure (which is also a risk of the AAA surgery).  But in the Emergency Room records, I found no other recording and therapy for his shocky blood pressure.  (The Nurses notes are missing, as are all the Hospital Nurses notes and Laboratory Reports.)

In my opinion, if he would have been timely seen, correctly diagnosed, and operated upon, he would have been in the Operating Room within two hours of arrival and would not have required the second operation to remove the intestinal bag and close the incision.  All his risks would have been less, including the risk of infection and the consequences of sepsis.  His risk of dying would have been less than 10 percent, but all their negligence, including not treating his shocky state for hours, increased his risk of death, which in his case became 100 percent.

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The Defense will argue that a ruptured AAA is highly lethal.  That is true for all those who before after arriving at hospital.  They will argue that his left renal (kidney) vein had to be severed for operative exposure, and that put his left kidney at risk for failure.  But his right kidney was in his pelvis, and its vein was not sacrificed.  They will argue that the Surgeon had to clamp across the aorta above both kidneys to prevent hemorrhage and that temporary clamping could cause kidney damage and failure.

The Anesthesiologist, at the Surgeon's request, must give 25-50 grams of the osmotic diuretic, mannitol, before the aorta is cross clamped in order to decrease the risk of kidney failure.  With the right kidney known in advance (by the CT scan) to be in his pelvis, the aorta would have to be clamped at least above it to insert the graft I have not seen the anesthesia and Operating Nurses notes records, and if mannitol (or even the diuretic, Lasix) was not given before the aorta was cross clamped, both of them would also be negligent.

Obtain the personnel records of “Dr. Belinda” to see what, if any, problems she had before and after this patient's care.  Obtain her medical school, internship, residency and Board Certification (if any) records, as well as all of her licensing records too.

Obtain the Death and Complication records from the Hospital regarding this case.

The more than 14 hours delay is unconscionable and negligent and markedly increased his risk of death.

What details were the family given when they agreed to a DNR (Do Not Resuscitate) order?

The Board Certified Medical Experts the Medical Review Foundation, Inc. recommends in this case includes: Emergency Medicine and Vascular Surgery and they are available through our firm.  The Medical Review Foundation, Inc. remains willing, able and ready to continue assisting you with this important case.  We await your instructions to proceed.

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A Diabetic Develops a Toe Infection, Which Soon results in a Below-The-Knee Amputation.

According to the hospital records, the patient had an infection involving his toe. He had cut open a blister during this six-week history of having a corn and blistering over the toe side part of his right fifth toe. The ulcer penetrated into the proximal interphalangeal (PIP) joint, which is the joint just beyond where the toe joins the foot. It drained blood and pus. He developed cellulitis (infection in the skin) and was started on the antibiotic, Cipro, by a Physician.

According to the progress notes, Dr. Bob said that he had not seen him in his office in over 10 years, but the patient recently saw Dr. Paul for his foot and "was told to check his sugar - which he did on his mother-in-law's Glucometer with results consistently in the low to mid 300s. He had not seen anyone for the diabetes mellitus (DM) yet."

He saw Dr. Ken on October 14 and he immediately hospitalized him. The hospital records document the obvious gangrenous changes to the fourth toe with skin breakdown over the top of the toe and into the joint. The fifth toe had some infection, and all toes had decreased sensation. He was unable to feel a pulse on the top of the foot. Apparently, this also involved the fourth toe, not the fifth as noted by Dr. Bob in his progress note five days after the original operation.

When a patient presents to a Physician's office with infection on the toe, having not seen a doctor for years, one of the concerns is the possibility of diabetes. In my opinion, it is a departure from the accepted standards of care not to rule out diabetes by simple blood and/or urine sugar tests. Having the patient go on his own to have his own blood sugar checked is generally beneath the standard of care. However, when the blood sugar came back elevated, I wonder why the patient did not return back to Dr. Paul or to some other Physician in a more timely fashion.

The use of antibiotics is acceptable, but when a patient is diabetic with an infection involving the toe and where there is absence of pulses on the top of the foot and inside of the ankle (dorsalis pedis and posterior tibial pulses), there should be a serious concern that the antibiotics will not reach the site of infection since it has to travel through the blood stream.

Most Physicians would hospitalize the patient and obtain an immediate diabetic and vascular consultation. Sometimes, vascular surgery is amenable to bypass or open up areas of blockage to increase blood flow down the leg. However, longstanding diabetes is also a small blood vessel disease, and even if the major blood vessels are open, sometimes the infection will still progress.

There were never any studies on this patient before hospitalization, and when he was hospitalized, there was an immediate need for operative intervention to cut out the area of gangrene to try to keep the infection from spreading up the leg and endangering the patient's life.

The day the patient was hospitalized, he was taken to the operating room for a ray amputation of the fourth and fifth toes of the right foot. This was done under spinal anesthesia with the use of a tourniquet, and the Operative Report dictated the same day of surgery would assure some accuracy. The procedure was correctly done, and the Pathologist confirmed the gangrenous flesh removed.

Dr. Bob was called in for consultation to help treat the patient's diabetic condition, and the patient also was receiving proper intravenous antibiotic therapy. No arteriogram (artery x-ray dye study) was performed and the patient was denied vascular surgery as an option. These would be departures from the standards of care. However, the infection began to spread, and there was a decision to be made with regard to a level of further amputation to be performed. This was discussed with the patient, and instead of the Syme amputation, which removes almost all of the foot, it was decided, and the patient agreed, to have a below-the-knee amputation. This was correctly performed on October 21, with the Surgeon again being Dr. Ken.

Following this operation, the patient was maintained on antibiotic therapy and diabetic medication. He received physical therapy and was able to walk with the use of crutches. He was discharged on October 25, in improved condition.

I have not seen the office records of Dr. Paul, or whatever Physician he saw in the week prior to the hospitalization (see addendum). I have not seen any follow up office records with regard to the healing of the amputation stump.

The records do include documentation that he was receiving outpatient physical therapy and understood the appropriate technique for wrapping and treating the amputation stump.

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With regard to his foot, diabetics have severe peripheral vascular disease involving both large and small blood vessels. Sometimes, the large blood vessels can be cleaned out (angioplasty) or bypassed, bringing fresh arterial blood around areas of blockage or substantially narrowed sites. It would be a debated argument to show that, even though the Family Physician treated the patient with oral antibiotics, and one would assume there were no pulses palpable, that the failure to refer to a Vascular Surgeon or hospitalize the patient for immediate care made that much of a difference. The problem is that there are no subsequent vascular studies to show what, if any, difference operative intervention on the blood vessels would have made. What does the circulation of the other leg show? By the time he was hospitalized, five days after a Physician saw him in the office, he already had significant gangrenous changes that would not be able to be reversed with earlier vascular surgery. Possibly, earlier vascular surgery could have prevented the spread of infection and the necessity for further amputation.

On the surgical specimen, the Pathologist examined only one blood vessel, the posterior tibial artery, and noted that there were no signs of atherosclerotic blockages. However, that was the only section he examined, and possibly, upstream, by the amputation site, that blood vessel may have been blocked off. In addition, the other two blood vessels going down the leg, the anterior tibial and peroneal arteries, may also have been blocked. If three blood vessels are open down the leg, and if there is blockage in the thigh (the femoral or popliteal arteries), then a bypass graft has a good chance of maintaining patency. But if only one of those blood vessels is patent, there is a minimal chance that any vascular surgery will maintain patency because it requires run-off (active blood flow through the smaller distal branches) to maintain a patent graft.

Once the patient was hospitalized, because of the problem with infection and gangrene, the operative procedure was indicated and, although no vascular procedures or studies were recommended (such as an arteriogram), and some might conclude that is a departure from the accepted standards of care, it is still somewhat conjecture as to whether or not the patient would have been amenable to vascular surgery and to what degree it would have helped this patient who could have both large and small blood vessel disease as a diabetic.

In addition to his elevated blood sugar, his cholesterol level was elevated, and good cholesterol (HDL) was low. This would increase the risk of significant peripheral vascular arterial disease.

Although there is some jury appeal in having the patient see a physician, be given oral antibiotics, and sent off to check his own blood sugar; when he checked his blood sugar and it was elevated, why didn't he come back to the physician right away? Obviously, the defense will raise issues of contributory negligence with regard to that aspect of the care, as well as the delay the patient had in cutting open the blister treating himself and until he finally saw a physician. In those five days, he progressed rapidly to gangrene, consistent with a diabetic condition that was not properly controlled plus he had severe peripheral vascular disease.

Overall, I believe it may be difficult to obtain supportive testimony although it may be possible on some of the areas.

If you want to proceed with Medical Expert reviews I would recomend having the Medical Review Foundation, Inc. obtain a Board Certified Family Practitioner and a Vascular Surgeon to review the medical records and related documents.

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Diabetic with Kidney Failure and Infected A-V Graft Fistula for Dialysis Has It Removed Four Days Later; Develops Sepsis and Knee Infection.

When patients have kidney failure, hemodialysis is required to remove the toxins (poisons) from the blood that their failed kidneys no longer can remove.  The test to measure the quantitative amount of kidney function is the creatinine clearance.  Under 15 cc (cubic centimeters) of blood cleansed per minute requires dialysis.  Over 20 usually can do without dialysis if they strictly follow a special low protein and low potassium diet.  Her creatinine clearance was 21 and she was noncompliant with her medications and diet.

Therefore, in this visually impaired chronic diabetic patient, the insertion of an arterial-venous (A-V) graft on 6/14 to make a fistula (high blood flow circuit) into which needles can be inserted for the few hours dialysis was indicated.  Through one needle blood is withdrawn and sent to the dialysis machine, and the blood is returned to her body through the second needle.

With each puncture, there is a risk of infection, even though the skin was “sterilized” with Betadine.  Germs can still persist in sweat glands and be pushed deeper, into the A-V graft.  Diabetics are at much greater risk for infection, and she received steroids during her 7/15 to 7/24 hospitalization for a painful gout problem with her foot that did not respond to other medical therapy.  Steroids further increase that risk, but its use was acceptable.

She had dialysis on 7/20 and 7/24 without any complications.  Her temperature during that entire JH Hospital stay was normal and she had no complaints re: the A-V site.  Therefore, she did not get the infection at the 6/14 graft operation (whose records I have not seen).  Most likely she became infected from the 7/24 dialysis procedure even though: “site prepped per protocol.”  And she signed the consent which specified many risks, including infection.  Prophylactic (preventive) antibiotics are not indicated for dialysis.

She arrived in the Emergency Room on 7/26 at 1125 a.m. with an obvious infection of her right arm A-V graft, and signs of sepsis (germs in her bloodstream) confirmed as Staphylocus aureus in her blood and arm site.  She had fevers over 103 degrees.

The standard of care is emergency surgery to remove that A-V graft, and intravenous antibiotics.  That surgery did not take place until the dialysis treatment of 7/30 was done, and the operation took place that evening by Dr. Mark.  All that time (four days) she was febrile through 8 a.m. on 7/29 when she spiked her temperature to 102.8 degrees.

In my opinion the delay to remove the obviously infected graft until 7/30 was negligent as was the decision to use it for dialysis on 7/30.  When she needed dialysis afterward, a temporary large needle catheter was inserted through her femoral (groin) vein.  It could have been done earlier instead of using an obviously infected A-V fistula site that was causing sepsis.

She had a left knee replacement operation 15 years earlier.  They are always at risk of sepsis, where germs can “seed out” at that foreign body site.  On admission, her left knee range of motion was good and she had no pain or swelling there.  But at 2130 (9:30 p.m.) on 7/26: “voiced complaint of (c/o) left lower leg pain in calf just below knee.  No redness, swelling or increased warmth noted.

On 7/27 at 0700: “unable to lift left leg.” 

On 7/28 at 1045:  “complains of left knee pain,” and at 1130: “The pain meds never fully relieves my pain.”

On 7/29 0750: “Slow to move s/p (status post) left total knee replacement.”  But that was a new finding, not present on 7/26.

On 7/30 1110 “Complains of left knee pain.”  At 1455 she was sent to the operating room to have the infected A-V graft finally removed.

On 7/31 “c/o pain to left knee area.”

On 8/1 one ounce (30 c.c.) of pus was removed with a needle and syringe from that knee by Dr. Frank.  The laboratory gram stain found no bacterial germs but many WBC (white blood cells).  And the culture of that fluid for germs after three days had no growth.  He concluded that it was infected on 8/1, but her temperature remained normal from 7/30 – 8/9 when she was transferred to FT Hospital.  With no germs seen on the gram stain and none growing out, it seems that the antibiotics may have “sterilized” that site.  I have not seen any FT Hospital records to know if she had to have that knee joint prosthesis removed because of infection.  That would be the only damages caused by their negligent delay in removing the obvious (on 7/26) infected A-V graft site.

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The Defense would contend that on admission she had sepsis, and then received potent antibiotics (Vancomycin) to which that germ was sensitive, so the greatest chance of live germs to enter the knee joint took place prior to that re-hospitalization.  And in support of that position, they would refer to the Nurse’s notes I quoted above from as early as the night of 7/26. 

Therefore, because of her creatinine clearance of 21 and her noncompliance, dialysis was indicated.  Unfortunately (and NOT negligently, unless you can show breach of sterile technique: perhaps obtaining the personnel records of the involved Nurses and technicians from 7/24 and also 7/20, I cannot read their signatures) it became infected.  The sepsis brought her back to JH Hospital on 7/26 where despite negligent care, she survived.  And the arm infection resolved.  The cause of the knee “infection” is speculative for the reasons noted above. 

If you want to proceed, after further discovery, I would suggest authorizing the Medical Review Foundation, Inc. to obtain Board Certified Medical Experts in Infectious Disease and Nephrology.

The Defendants would be Dr. Wade, who admitted her to the hospital on7/26 but did not call Dr. Mark until 7/29, and even he negligently delayed one day until “after dialysis tomorrow.”  Also, Dr. Maury, the Nephrologist (Kidney Specialist) is also liable.

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Arteriogram Via the Oxillary (armpit) Artery Causes Injury With no Repair Done.

Certain salient aspects of this case are summarized below.

1) This Patient was 64 years old on March 3 when he underwent a balloon angioplasty of the proximal superficial femoral artery due to an ischemic left leg. This procedure was performed by Dr. Smith of Hospital #1. The details of this hospital admission were incomplete and no Informed Consent form was available for review. The signs and symptoms that he experienced due to this left leg arteriosclerosis, or "hardening of the arteries", were also unavailable.

2) The technique that Dr. Smith used was an axillary artery approach through the armpit, into the aorta and through the previous graft of the proximal superficial femoral artery. During this procedure, Dr. Smith noted a stenosis, or blockage, with difficulty passing this catheter, but an eventual successful balloon angioplasty with restoration of good arterial blood flow was achieved. During such a procedure, a narrowed artery is expanded using a catheter, which inflates a balloon-like device to widen the diameter of this blood vessel. Follow-up left leg ultrasound scanning on March 17 revealed improved blood flow, or at least a partially successful procedure.

3) Almost immediately in the postoperative period, he experienced left arm pain which was treated with pain medication. These records are also incompletely available and should be obtained. On March 6 he was evaluated by Dr. #2 of the Emergency Ward for continued left arm pain. Examination revealed motor and sensation abnormalities of several of his fingers. The case was discussed with Dr. #3 following a duplex-imaging scan revealed a partially clotted pseudoaneurysm of the left axillary artery. This is a known and usually preventable complication, but since it was causing symptoms, urgent surgery was indicated. For reasons that are unclear, no acute intervention, such as a decompression was felt to be indicated at that time, although the report of Dr. #4, the Radiologist, indicated a possible need for surgical repair.

4) This patient has been suffering from significant left arm weakness and median as well as ulnar nerve denervation symptoms since that time. He has been evaluated by several physicians, including Dr. #5 of the Hospital #2. In his note dated September 20, Dr. #5, a Neurosurgeon, recommended a probable need for decompressive surgery of the brachial plexus. Unfortunately, no further medical records were available following this date. 

In summary, patient underwent a balloon angioplasty procedure by Dr. Smith on March 3. It is unknown if this procedure was performed following proper informed consent, including the risks, benefits and alternative treatments to this procedure. It is also unclear if this procedure was performed using optimal precautions, and techniques, such as fluoroscopy, to avoid such complications as damage to the axillary artery and resultant nerve compression of adjacent nerve trunks. Following this postoperative complication, negligent Emergency Ward care appears to have been delivered by Drs. #2 and #3 as decompression surgery was delayed or omitted. Finally, he was evaluated on several occasions by Neurologists such as Dr. #6 and definitive decompressive surgery was again delayed or omitted.

In this specific case, Expert opinions in the areas of Vascular Surgery, Emergency Medicine, Neurology and Neurosurgery should be strongly considered to further bolster the merits of this case. However, it will also be helpful to obtain a more complete set of medical records.

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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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Knee dislocation with severely torn popliteal artery with delays in surgical artery repair, and incomplete fasciotomy (muscle tension release procedure) resulting in amputation.

The patient was at the time of the accident a 19-year-old white Caucasian male. He was riding a dirt bike where he was living. He was possibly under the influence of alcohol, and he popped a wheelie and lost control of his bike at that point. There was no collision with anything, and after losing control, he injured his left knee, most probably with an hyper-extension mechanism.

He was complaining of severe pain in his left leg, he was not able to use it, and then the emergency crew or medical services were brought. After being transferred to another ambulance on his way to the hospital, for unknown reasons, he was admitted to Hospital #1 on the night of March 17. His admission was around 7:00 p.m., and the reported incident or his first pickup by the ambulance service was around 5:45 p.m., if the records are accurate for that particular time report.

A final diagnosis at the Emergency Room by the Physician, Dr. #1, was of a left knee dislocation with possible associated vascular injury. This was confirmed by Dr. #2, the Orthopedic Surgeon who was asked to consult. He was there within 40 minutes of the arrival of the patient and, based on the x-ray and his clinical assessment, immediately diagnosed a dislocated left knee and that it was imperative to immediately remove the patient from the Emergency Room department and to send him to the Operating Room. The patient was given general anesthesia, and a closed reduction of the anterior dislocation of the left knee was performed by Dr. #2.

Review of the operative report says that prior to his reduction, he was not able to find any distal pulse in the arteries of the left leg, and that the pulse did not return after the closed reduction. Although it was clinically obvious that he had a vascular injury, the patient was extubated and sent to the radiology suite for having a full angiogram (artery x-ray dye study) performed. This took about two hours which, I think, is an unnecessary delay since it was obvious clinically, he had an arterial injury. Vascular exploration should have been commenced immediately in the operating room under the same anesthesia, and if needed to be, an on table arteriogram could have been performed prior to the definite surgery.

I cannot find through the records if the angiongram, as performed in the radiology suite, was standard procedure or it was originating as a direct order from Dr. #3, the Vascular Surgeon. Anyway, this constituted an unnecessary delay, standard tests pointed that it was obvious clinically, as reported by Dr. #2, that there was an arterial injury that needed immediate exploration, and to send the patient down to the radiology suite for having an angiogram constituted an unnecessary delay and seems to be departing from usual standards.

The Surgeon who performed the vascular exploration was Dr. #3, assisted by Dr. #4, and the surgery was done the same night after the arteriogram. The day of surgery is listed as March 18, but since the surgery ended up after midnight and was dictated after the surgery, the date of surgery is actually the continuation of the surgery started on March 17.

Report of the surgery shows that a left popliteal artery was found to be avulsed (torn) from its distal insertion, and there was a large hematoma (blood clot). Exploration of the popliteal space was done, repair of the popliteal artery avulsion with a reverse left saphenous vein graft was done, and medial and lateral fasciotomy (severing the fibrous flesh surrounding the muscles) were supposedly performed. We don't know the details about the fasciotomy as mentioned, and an on table intraoperative arteriogram was performed during surgery.

I reviewed the arteriograms and, although there was some reperfusion (blood flow), there was a lot of spasm at the saphenous vein graft site, and there was no evidence of any good distal perfusion after that surgery. It was reported that a good flow was obtained, and the patient was sent to the ICU, where the vascular assessment was done. Apparently, after an hour or two, they were able to find a distal pulse and a slight recoloration of the limb and an improvement of its warmth.

The patient's case did not progress well after the surgery and as expected, and he progressively showed signs of ischemia (poor blood flow) or arterial insufficiency. Two days later, March 20th, he was returned to surgery because of a thrombosis (clotting) of the bypass graft. Dr. #3 performed an embolectomy (clot removal) but was not successful in completely returning the flow. The surgery was performed by Dr. #3 on March 20, and was started at 10:30 a.m. and finished at noon. The surgery shows that a blood clot was found in the left popliteal artery bypass graft, and that a Fogarty catheter was inserted proximally and distally to remove the blood clots. Good pulsation was noted in the popliteal artery, as reported, and it seems that the graft as well as the popliteal artery were reperfused.

It was decided to continue with heparinization (a blood thinner: anticoagulant) of the patient, and the patient was taken to the recovery room in stable condition. Blood loss was reported as 250 ccs (8 ounces). This operative report was dictated on the following day, March 21, at night. It seems that the patient was not able to reperfuse his left leg, and severe life-threatening ischemia was developing. Arrangements were made to transfer the patient to Hospital #2 for further assessment and treatment.

I didn't find details about how the transfer was done, but apparently the patient's condition deterioriated on March 20th. From comments picked up from the patient, the nurses, and the family, it seems that Dr. #3 told the patient's mother that discussions were made to eventually transfer the patient to a more specialized center. Dr. #2 was in surgery and actually was not the one who made the decision since the limb threatening ischemia was the result of vascular problems, and Dr. #3 had to make the decision. The patient finally was transferred late that night to Hospital #2.

In the recovery room, at 12:15, the patient's peripheral pulses were absent upon on return from surgery, contrary to what was reported in the operative note, and there seems to be definite discrepancies in between the way the Surgeon reported it and the way it was clincally assessed in the recovery room.

After being transferred to Hospital #2, the patient came under the care of Dr. #5. He was immediately rushed to the Operating Room because of the seriousness and acuteness of his condition.

Dr. #5 mentioned in his indication for procedure that the patient arrived by helicopter approximately 7 hours after the initial arrangements have been made. I cannot explain such a long delay in between the discussion over the phone and the actual transfer of the patient.

I have found a few notes that the patient was not stable and was bleeding, but also have reports that Dr. #3 was not actually in the hospital at the time where the orders were originating, and I think that the limb threatening situation was quite acute and was necessitating a very rapid transfer by helicopter to Hospital #2.

When he arrived 7 hours post ischemia, it was already too late to do anything, and the limb was probably almost dead, since the golden rule is that there is some chance of revascularization of a limb if there is less than 6 hours of ischemia. From the records and reports, we have indications pointing that the limb was not vascularized from mid morning until the time he arrived to Hospital #2. Although they attempted a salvage procedure, I think that the limb was already almost dead and, if ever revascularized, would have been the source of severe problems and residuals which probably would have lead anyway to an amputation above the knee.

Also, the operative findings of Dr. #5 are quite interesting in saying that he had significant occlusion of the bypass graft, cadaveric appearance of the foot, attesting to my previous comments, and also that the fasciotomy was shown not to go completely down below the leg and were stopping at about the mid third of the calf and actually were not considered as a complete fasciotomy. He also found that the lateral compartment has not been released, and that the medial and anterior compartment was not completely released.

These incompletely released fasciotomities showed that there was muscular tension underneath, possibly muscular necrosis (gangrene) since it was going on for about two days, and those are contributing factors to prevent distal perfusion of the limb, since there is excessive pressure in those compartments.

I do think from the operative findings at Hospital #2, that there was incomplete compartmental release through the fasciotomies; this incomplete release of the compartment of the left leg could have contributed in someway in preventing distal perfusion of the left lower extremities, and constituted also, a source of muscular compromise since it seems that the muscles were under tension and quite bulging after Dr. #5 completed the fasciotomies.

Unfortunately, the revascularization or attempts in salvaging the limbs were unsuccessful and, although the patient had a debridement (cutting out of flesh) of Clostridial gangrene, which is a serious infection originating from dead tissue, he eventually had to go through an above-the-knee amputation in a standard fashion on March 25. This is quite sad, and it seems that this limb could have been saved earlier.

There is also report of a laceration at the popliteal vein, but this was most likely done at the time of the attempt in removing the blood clot on the morning of March 20th.

This case is very complex and interesting and, although he had a very sad and tragic outcome, it raises a few questions. There is definitely indication of a few departures from the accepted standard of care, mainly in the field of Vascular Surgery.

Although there was a transfer of ambulances on the way to Hospital #1, from what I could pick up from the records, which is due to the fact that he needed to have injection of IV drugs to control his pain and symptoms, and this was not available in the first ambulance he took, he was adequately rushed to Hospital #1 in a timely fashion.

The assessment in the Emergency Room by the doctor and by Dr. #2 was done in a timely fashion, and Dr. #2 pointed out that he was suspecting a vascular injury, which is the most common complication and associated injury with anterior dislocation. It happens in about 25-30% of the anterior knee dislocations as reported in the literature.

Closed reduction was done in a standard fashion and timely manner but, what is surprising and could be a source of unnecessary delay and could be departing from the accepted standard of care, is the fact that the patient was extubated, sent to the radiology suite for having a full angiogram, which constituted about two hours delay before starting the actual vascular exploration.

I think there was sufficient clinical evidence and objective findings to attest that there was no pulse returning to the leg, and that the most common cause to it was a vascular injury. This is delineated in every standard textbook, and I think that at this time a vascular exploration should have been decided right then after the closed reduction and without having to go through two hours of delay in performing an angiogram. An on table angiogram could have been done, since it was done by Dr. #3 later on that night, and would have prevented unnecessary delay. We still have to obey by the rules of no more than 6 hours of arterial ischemia to be able to save a limb or to avoid serious residuals or complications.

Then the surgery was done, but retrospectively by analysis of Dr. #5's operative note, it seems that the fasciotomies were not done completely and that the lateral compartment was not released, and this would constitute a departure from at least the standard of care, or the state-of-the-art decompression fasciotomy.

Usually, fasciotomies have to liberate the medial, the anterior and the lateral compartment, and the incision should be carried out down to the distal third of the leg so that all the muscular masses are decompressed. If you leave part of the muscle not decompressed, pressure will build up and the intra-muscular pressure will be superior to the arterial pressure, and will occlude the vessel leading to severe ischemia and eventual necrosis of the muscle. This also constitutes a severe obstacle for reperfusion since the muscles exert extreme pressure and prevent the distal arteries from being reperfused after the bypass surgery was done. So, this constitutes, at least techically, a departure from the state-of-the-art technique.

The follow-up and postoperative care in the first two days seems to be adequate, always there is some detail that could be found, but they don't constitute any major deviation from the accepted standard of care and I don't see any evidence of negligence.

The diagnosis of a thrombus on March 20th was appropriate, the surgery to try to do an embolectomy seems to be adequate, but what I find to be quite suspicious is the fact that the operative reported noted that there was a good distal arterial pulse, and there was completely opposite findings when the patient came to the recovery room. Then, the way the arrangements were done to transfer the patient to Hospital #2 are not quite clear, and there is definitely negligence or departure from the accepted standard of care when you have a limb-threatening ischmia to have nearly 7 hours before the patient arrives at destination, the operating room, for urgent surgery.

For the reason mentioned earlier, I think that the limb was already dead at that time, and they only tried to do a salvage procedure without real chances of success. The fact that Dr. #5 mentioned the 7 hour time frame is basically to point out that he was already beyond the usually accepted time frame for revascularization of a threatened limb.

Basically, the deviation from accepted standard of care and negligence was the way the vascular injury was dealt with. I don't find any deviation from the standard of care from the way the Orthopedic Surgeon did his part, and the only thing that I would question is why didn't he ask for the Vascular Surgeon to come right away and to perform the exploratory surgery while he was having the patient under general anesthesia and still in the operating room the night of March 17th, instead of letting the patient go to the angiogram suite in radiology.

Based on information and records provided, it would appear that the above issues represent viable avenues of pursuit in this case, for negligence or deviation from the accepted standard of care.

Because of the complexity of this case, and also the fact that it involves mainly vascular repair, a Vascular Surgeon would be recommended since most of the deviation from standard of care or the negligence seems to be pertaining to the diagnosis, repair and treatment of the vascular injury resulting from the anterior left knee dislocation.

I don't see any major issues regarding the way the Orthopedic Surgeons handled that case, and I would focus my attention on the vascular portion of that particular case.

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Carotid artery endarterectomy with bovine pericardium patch graft, infection, hemorrhage and death.

The carotid arteries, one on each side of the neck, supply 80 percent of the arterial oxygenated blood to the brain. There is normally a cross connection between these two arteries at the base of the brain, called the Circle of Willis. If one carotid artery is blocked by a build up of cholesterol, called an atherosclerotic plaque and the other one is open by 30 percent or more, usually the blood flow is adequate. But if both only have a small opening, then even in the absence of symptoms, surgery is justified to prevent a potential stroke.

This patient was advised of the 3 percent risk of stroke with surgery, and 10 percent risk over time with conservative care. He was taking the anticoagulant (blood thinner) Coumadin which is the standard of care, particularly because of the severe atherosclerosis involving his legs end the artery bypass grafts to his right leg nine years before. He was also taking a cholesterol-lowering drug, for an unknown amount of time, with an unknown effect on his blood cholesterol. I have not seen those records.

Dr. #1, his Surgeon was performing ultrasound (doppler blood flow studies using sound waves) to monitor his diseased carotid arteries blood flow. The carotid arteries had "bruits" when listened to using a stethoscope because the stenosis (hourglass deformity) causes a whistling sound, which was noted in the surgeon's office records. The blood flow is altered and that is the basis for the ultrasound study.

The ultrasound study showed 15-20% stenosis on the right and 40-50% on the left.

The next year it increased to 25-30% on the right and 45-55% on the left.

The next year it was 25-30% on the right and was 30-35% on the left. The study is a rough guide, and if indicated, the arteriogram (artery x-ray dye study to evaluate the inside of the artery, the "gold standard") can be done as it was subsequently performed three years later.

The next year the right side stenosis increased to 30-35% and the left was 35-40% by ultrasound.

Another way of determining the degree of blood flow impairment is to calculate the ratio of blood flow in the internal carotid artery (going to the brain) divided by the common carotid artery blood flow (going to the face through the external carotid artery branch plus the internal carotid artery). This is the ICA/CCA ratio. On the right side which was finally operated on, the ratio was first documented to be 1.53 (minimal impairment of flow), in the next year it was 1.26, in the next year it was 1.27, in the next year it was 1.29, but two years later it was very high at 7.17. This was a critical stenosis which markedly impaired blood flow and could suddenly block off. The left side had a value of 2.15 which is a moderate to severe stenosis.

To further evaluate this stenosis he had the arteriogram study on March 23. Dr. #1 performed the study and confirmed the critical stenosis on the right and a severe stenosis on the left. His drawings show what he found. The Radiologist also evaluated these x-rays and found that the stenosis on the right was greater than 95% and had plaque formation (irregular interior from atherosclerosis, increasing the risk of blood clot formation), and at least 90% narrowing on the left. This confirmed the previous evaluation.

The patient was informed of the 3% risk of stroke with surgery and 10% risk without the operation to clean out the blockage (carotid endarterectomy). I do no know if he was informed of other risks such as infection, bleeding and death. If he was not, that would be lack of informed consent. But the over all risk was greater without surgery, and the operation was indicated.

The plan was to operate on the right side and then the left side a few months later. That was reasonable.

A Cardiologist evaluated this patient as a surgery candidate on April 28, modified his blood pressure medication and felt that his coronary (heart) artery disease was "stable". He was also taking the anticoagulant Coumadin as 10 milligrams daily and 15 mg. on the weekends. This was discontinued a few days before surgery as was proper, but the note by the surgeon said he had been taking 5 mg. per day, which is in error.

The operation took place on May 8, and after using the iodine skin preparation to try to sterilize the skin, the surgery was done in the standard manner with the use of a temporary shunt (blood tube conduct inside the artery to maintain blood flow to the brain during most of this operation). The surgeon said: "….because of the size of the artery we elected to use an oval piece of Bovine (cow) pericardium (heart sac) which was then sutured to the artery…". This allows the artery to be sutured closed without narrowing its hollow passageway (lumen). It should have been obtained by the supplier ("manufacturer") sterily and its sterility tested and maintained.

The Pathologist confirmed that "the vessel wall shows heavy atherosclerotic changes including calcifications (bone like changes").

The patient awoke after surgery and had no neurological damage (stroke). He was discharged home on May 10 "on Coumadin", but I do not know what dose. He "left for home with scripts (prescriptions) and instructions which he understands".

I have not seen any further office or hospital records except for a few laboratory reports. They show that there was not any overdose effect from the Coumadin (The INR was 1.07 on May 17, which shows very little Coumidan anticoagulation effect). He came in anemic from blood loss (HCT of 31) that became dangerously low (25) by 1:30 pm on May 17. It increased to 27 on May 18 and to 28.8 on May 19. I do not know how much blood he received, but this amount of anemia is dangerous for a cardiac patient.

The blood clot (hematoma) and carotid graft site had tests for germs (culture and sensitivity studies) and both showed the presence of the germ "coagulase negative staph". This is a common skin germ but can be pathologic (cause infections) in the body, as it appears to have done here.

Without seeing the in hospital records from May 17 through his death on May 22, I will give you some opinions that may change when all of those records are supplied.

When a graft site becomes infected, there is a risk of rupture of the suture line, which results in massive bleeding into the neck. Sometimes there is leakage with local pain and swelling increasing over time, and that requires urgent hospitalizations and tests such as a CT Scan, MRI and/or arteriogram to confirm the diagnosis, and emergency surgery to control the bleeding, to prevent death.

It is possible that the Bovine pericardium patch graft was not obtained under sterile conditions or not properly handled and sterilized. This would be a manufacturer product liability problem. Possibly the hospital violated sterile precautions and technique in opening the package.

There is always the possibility that the surgeon's or assistant's glove tore from a needle stick and contaminated the operative site. That can happen in the absence of negligence.

I do not know if prophylactic (preventive) antibiotics were used. If this was surgery to put in a synthetic graft, or artificial hip, for example, then antibiotics are given immediately prior to surgery, and for one or tow days thereafter. With a small piece of Bovine pericardium, which is natural flesh, in my opinion, antibiotic use would normally be optional. However, he was a diabetic on insulin, which means that he was much more susceptible to infection, and there would be more reason to use prophylactic antibiotics. Others would say that this was a "judgement call".

In addition, to the question of product liability, I do not know how long he was on cholesterol lowering medication. This would be especially important in his case, since he had severe known vascular disease with arterial grafts inserted ten years earlier, and because of his diabetes which causes atherosclerosis (cholesterol deposition in the walls of all arteries including his heart and carotid arteries) whose disease was known for some years. The failure to try to control his blood cholesterol level would be negligent.

It may be worthwhile to review the May 17-22 hospital records to determine if there were any departures from the standards of care, including failure of timely transfusions that may have caused or increased his risks of dying.

The office records of his medical doctors, including #2 and the Cardiologist Dr. #3, both Osteopathic Physicians, should be obtained to determine how they treated his elevated cholesterol. Without progression of his carotid artery disease, he would not have had that operation, whose delayed complication resulted in his premature death.

Was an autopsy performed? If it was obtain a complete copy of that report.

After review of those missing records, it may be reasonable for us to obtain opinions by Experts in Infectious Disease, Cardiology and Vascular Surgery, pursuant to our current Fee Schedule.

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