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Comments are accepted only from Surgery of the Hand (Orthopaedic Surgery) experts.
56yo F has trigger release on multiple fingers, complications lead to partial amputation.
Case Overview
Location: FL
56 years old, Female
Past Medical History:
HTN
Past Surgical History:
56 year old female with a previous history of carpal, cubital and radial tunnel release as well as previous trigger finger releases.
Recently undergoes WALANT left hand index, long and ring finger trigger release on May 17th of 2023. Immediately following the procedure, had severe pain and was developing discoloration and swelling of digits. OP note attached.
PC goes to the ER for pain and swelling. A doppler was performed and showed flow up to the DIP joint. The ER physician contacts the surgeon for guidance and the surgeon elects to see PC in office the next day for eval. No admission or further treatment given. Consult note attached.
PC followed up the next day and the surgeon recommended and performed Phentolamine injections to the index and middle finger bases. While monitoring her post injection, PC continued to have extreme pain and ischemic changes to the digits. She was sent back to the emergency room for further evaluation and admission.
During this admission, an angiogram was performed which revealed hyperemia of the second and fourth digit with minimal to no flow at the distal tips. They attempted thrombolysis with no success. She was started on Eliquis and was instructed to follow up with the specialist for arterial duplex in one month.
PC elected to have a second opinion from a different facility in which they diagnosed her with tissue necrosis to the left index and ring finger. They theorize that it could have been due to the digital nerve block. This provider also performed a debridement and burn dressings. 3 days after debridement, PC continued to develop excruciating pain and was taken to the or for excision and kerecis placement.
She was monitored for approximately 1 month and it was determined that the distal phalangeal segment of the index finger was to be amputated. A below DIP joint amputation was performed in June 2023.
In the subsequent year, PC developed hand neuromas, difficulty with range of motion, severe pain. Had additional graft in September of 2023 which appeared to take and heal well. Despite graft healing, multiple specialists have informed her that a more proximal invitation is possible.
Our concern is the original digital block being performed properly. Also the original emergency room visit when the surgeon was contacted, that Phentolamine should not have been given immediately with possibility of digital ischemia? Appropriate to see the next day?
Please see photos, consult and OP note attached. Thank you.
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Closed Cases
Comments are accepted only from Thoracic and Cardiac Surgery experts.
25yo F dx inappropriate sinus node tachycardia, undergoes thoracoscopic ablation. Has complications, req pacemaker.
Case Overview
Location: FL
25 years old, Female
Past Medical History:
psych, GI issues, syncope
Past Surgical History:
just as mentioned above
25 year old female with diagnosed history of inappropriate sinus tachycardia at the age of 17. Also, does have a significant history of psychological issues including bulimia/eating disorder, PTSD, chronic GI issues. Per the limit of records we have, she underwent EPS in Aug 2018 that was unable to trigger SVT, therefore an ablation was not performed at that time. Was placed on multiple rate control medications, however was intolerant secondary to low blood pressure. Additionally, had another mapping and an ablation in September of 2022. She was once again diagnosed with the inappropriate sinus tachycardia, however unknown etiology behind the possible SVT episodes. Attempted beta blockers, calcium channel blockers, and sodium channel inhibitors without improvement.
There was continued concern due to the fact that she was supposedly always “very symptomatic”. Her symptoms included palpitations, fatigue, inability to perform tasks or work, chest pain and shortness of breath. They occurred with and without activity. There nis mention of psychological etiology.
As a last resort, in December of 2022, underwent right thoracoscopic epicardial ablation of the sinus node region and right atrial wall.
The operative note for that procedure and office notes are attached in screenshots.
Should be noted that prior to the procedure, she was explaining the risks of the operation including possible postoperative pacemaker implantation.
Post-operatively PC continued to have symptoms and requested a second opinion due to worsening and frequent syncopal episodes and her holter monitor reported profound bradycardia with long pauses (apparently new onset).
In June of 2023, approximately 6 months after the epicardial ablation, she required an emergent pacemaker which was an Abbott single-chamber atrial. At this point, the second cardiologist suggested that the ablation was inappropriate and potentially not performed correctly. Was diagnosed with SSS and now has a programmed AAIR. This particular cardiologist removed her from the Propranolol she was given, as she was instructed to take a PRN (he deemed inappropriate), regular pacemaker interrogations. However, informed the PC that there's not much they could do at this point since it seems her sinus note is completely destroyed.
Based on this second opinion, we do have concern that there was an issue with the epicardial ablation. PC never had documented SVT, and all EKG’s available to us show sinus rhythms, except for after the procedure in question. This yielded junctional bradycardia and long pauses, as mentioned above.
We do have very scattered and limited documentation, which explains lack of specific details.
We appreciate your opinions in advance and will answer any questions you have.
Files:
1 Response
Do you believe there might have been medical error?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
What makes you a good expert for this case?
I perform surgical ablations and I’ve been involved in transcatheter ablations as well
How often do you encounter cases similar to this one in your practice?
When I do an ablation, I always tell my patients there is a risk of requiring a PPM
Want to open a case or submit response?
Comments are accepted only from Pediatric Infectious Diseases experts.
Failure to diagnose and treat CMV infection in a newborn
Case Overview
Location: NY
10 years old, Male
Past Medical History:
Past Surgical History:
This case involves a delivery on 7/16/2012 at 12:33 pm by scheduled repeat C-Section at Hospital A. Apgars were 9/9. Infant was given ABX because the Mom tested positive for Group B Strep. Right after birth he was taken to the regular nursery. He was transferred to the special care nursery later that evening because he was noted to have petechiae on his back, trunk, buttocks and thighs. HC was 11-25 percentile.
Initial hematocrit and platelets were low at 66000 and maternal platelet count was 245,000. Hospital A called for a consult with Hospital B, which recommended a retest. 2nd test the platelets were at 11,000. Infant was transferred to Hospital B for a transfusion and possible IVIG however he was never given transfusions- only was monitored.
He was admitted to Hospital B at 2350 on the day of birth (7/16/2012). Petechiae noted in the chart. Retested at Hospital B on 7/17/12 which was a 57,000; 7/18/12 which was 54,000 and then again on 7/18/12 at 58,000. He was tested again on 7/19/12 and it was 54,0000. He was considered stable except for platelets- no head studies done. At discharge, he was recommended for follow up blood drawn by the pediatrician. At Hospital B he wasn’t given transfusions or IvIg done- only was monitored and had his blood drawn. Not tested for TORCH or any viral infection.
From Discharge (7/18/12 until the child was 4 months)- the mother would complain to the pediatrician, Dr. X that he wasn’t moving like the other kids, not smiling, not grasping, staring spells- Pediatrician did nothing.
At 5 Months of life- the infant had his first convulsive seizure. Pediatrician referred him to a neurologist. MRI was done at Hospital A on 1/4/13.
MRI taken on 1/4/13 IMPRESSION:
1. 1. INCREASED T1 SIGNAL INTENSITY IN THE PERIVENTRICULAR SUBEPENDYMAL
REGION SUSPICIOUS FOR CALCIFICATION.
2. VENTRICULAR DILATATION WITH GLIOTIC CHANGE AS DESCRIBED ABOVE. THERE
IS THINNING OF THE CORPUS CALLOSUM SUSPECTED AS WELL AS SUSPECTED
ABNORMALITY OF MYELINATION WITH THE GIVEN AGE OF THE PATIENT.
3. SUSPECTED PORENCEPHALIC CYST WITHIN THE RIGHT FRONTAL LOBE WITH A
PERIVENTRICULAR PSEUDOCYST WITHIN THE LEFT FRONTAL LOBE.
4. THESE FINDINGS ARE SUSPICIOUS FOR POSSIBLE CONGENITAL CMV. A
NONCONTRASTED CT STUDY MAY BE HELPFUL TO CONFIRM PERIVENTRICULAR
CALCIFICATION.
5. NO DEFINITE FINDINGS TO SUGGEST CEREBELLAR HYPOPLASIA.
After this MRI, CMV is suspected as the cause of the seizures and delays. On 1/11/13 and EEG was done which was abnormal and child started on phenobarbital.
On February 22, 2013, patient was admitted to Hospital A for seizures and then transferred to Children’s Hospital C and the pediatric Neurologist did more MRI’s which showed damage to brain consistent with CMV infection. Records state that CMV is the likely cause of Infant’s problems. Subsequent records all use a dx of congenital CMV.
Child eventually passed away on December 19, 2022 at the age of 10. Prior to his passing, he was diagnosed with right sided weakness, feeding tube dependence, epilepsy, non-verbal, Cerebral Palsy, wheelchair bound, totally dependent of his mother and siblings.
We are seeking an opinion as to whether antiviral medication would have improved the outcome for this child? We believe we have a case for failure to diagnose and treat CMV infection in a new born. Please review and advise if you would be on board with this case.
Additionally could diagnosis referral and treatment by the pediatrician beginning at two weeks after birth have made a difference in the outcome? Are you able to comment on the progression of the child’s brain damage?
The infant was seem by multiple neonatologists during his stay at Hospital B. The admitting neonatologist suspected CMV due to the thrombocytopenia and petechiae but nevertheless did not order any testing. The neonatologists who treated him subsequently through discharge were not concerned with the persistent thrombocytopenia and he was discharged to his pediatrician who also did nothing.
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3 Responses
Do you believe there might have been medical error?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
What makes you a good expert for this case?
Pediatric infectious diseases specialist, I see CMV in my clinic, I have numerous scientific publications about congenital CMV epidemiology and policy.
How often do you encounter cases similar to this one in your practice?
I see newborns with CMV frequently.
Do you believe there might have been medical error?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
What makes you a good expert for this case?
I am a board certified pediatric infectious disease specialist. I have been an attending physician for 13 years, not including the 6 years in training before that. As a pediatric infectious disease physician, I have evaluated and treated many infants with congenital CMV, both symptomatic and asymptomatic at birth—probably on the order of a couple dozen. I have also been involved in research on CMV and am currently part of a multi-site consortium studying congenital CMV in NY state. This is a very sad case, but one I feel very equipped to handle as an expert witness.
How often do you encounter cases similar to this one in your practice?
See above—not infrequently. Congenital CMV occurs in 1/200 live births and infants symptomatic at birth are 10% of those, so about 1/2000 births. I have seen many infants with congenital CMV and treated many as well.
Do you believe there might have been medical error?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
What makes you a good expert for this case?
Many (20+) years of experience managing infants with congenital CMV, participation in clinical trial of valganciclovir for infants with cCMV and isolated hearing loss.
How often do you encounter cases similar to this one in your practice?
I see several cCMV infections every year, many with milder course of illness, patients with severe disease about 1 per year
Want to open a case or submit response?
Comments are accepted only from Cardio-Thoracic Surgery experts.
53yo male undergoes minimally invasive MV replacement w/ bypass (R femoral approach) and has immediate RLE weakness, possible nerve injury
Case Overview
Location: FL
53 years old, Male
Past Medical History:
ADHD
Past Surgical History:
the MV replacement as mentioned above
53-year-old gentleman who is seen at the emergency room for fatigue and tachycardia. A TEE is performed and he is found to have endocarditis and mitral valve abnormalities. A minimally invasive MV replacement w/ bypass (R femoral approach) is scheduled for approximately 8 days later. This is performed with right groin cannulation and intercostal block. Bypass time was 138 minutes. This was not robotically assisted.
There are no documented complications intraoperatively.
The record we currently have does not have a specific note detailing the cannulation procedure, however it was performed by the cardiothoracic surgeon. We do have an event/medication log from the operation, however we did not see anything directly related to this complaint so it was not included.
We have attached a screenshot of the U/S guidance for the groin access.
Later on that evening post-op, PC has no ability to lift his right leg. There's concern for nerve damage by the surgeon to the femoral nerve, as he also develops a post op seroma to the right groin area. Multiple consultations theorize that the injury is most likely due to the cannulation due to no other discernible explanation, despite multiple assessments and diagnostics (PC was made a stroke alert out of precaution, no findings. Bedside nerve testing, etc). PC claims never had any issues with this leg prior.
He is discharged approximately one week later. He completes a neurology follow up consultation and physical therapy. MRI of the brain and CT show no abnormalities.
9 months postoperatively, PC has an EMG nerve study completed. Results show right perineal, posterior tibial and bilateral sural neuropathy. Also suggestive of peripheral neuropathy. There's a denervation in the right vastus medialis muscle, right femoral neuropathy/lumbar plexopathy and no recovery in the right vastus medialis muscle.
This study is attached for review.
We are looking for an opinion concerning the femoral nerve injury in relation to the cardiac procedure. If you request any additional information or have questions please let us know.
Thank you in advance for your time and opinion.
Files:
5 Responses
Do you believe there might have been medical error?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
What makes you a good expert for this case?
I have 20 years of cardiac surgery experience and frequently use femoral cannulatikn
How often do you encounter cases similar to this one in your practice?
Femoral cannulation is common in my practice
Do you believe there might have been medical error?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
What makes you a good expert for this case?
I have been an academic cardiac surgeon in practice for 14 years and am currently division chief at a public, academic institution. I am the director of minimally invasive cardiac surgery at my center and have been performing minimally invasive cardiac surgery for over 10 years including minimally invasive mitral valve surgery. I have performed peripheral femoral cannulation both open and percutaneously dozens of times.
How often do you encounter cases similar to this one in your practice?
I have been doing minimally invasive cardiac surgery and valve surgery including minimally invasive mitral valve surgery for over 10 years. I have never encountered this complication in my practice.
Do you believe there might have been medical error?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
What makes you a good expert for this case?
I have been a cardiac surgeeon for over 20 years and have performed over 3,000 open heart surgeries like this one. I am familiar with the procedure and I am able to explain the technical nature of the case to the standard public.
How often do you encounter cases similar to this one in your practice?
I encounter mitral valve surgery cases about once a week
Do you believe there might have been medical error?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
What makes you a good expert for this case?
18 years in clinical practice, over 1600 groin cannulations as part of TAVI team, board certified aortic surgeon and fellowship in peripheral vascular and endovascular surgery
How often do you encounter cases similar to this one in your practice?
Very uncommon complication. Possibly, as some, but not all of the clinical findings are explainable by femoral nerve injury. See above. The quadricep findings may be explainable by femoral nerve injury, but not the peroneal or tibial nerve findings. Also, not clear why patient has not described sensory deficits as this is the most common complication from femoral nerve injury.
Do you believe there might have been medical error?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
What makes you a good expert for this case?
This case does not seem meritorious.
How often do you encounter cases similar to this one in your practice?
I’ve never seen this from cannulation. That’s why a pre-existing condition or stroke seem more likely causes.
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Comments are accepted only from Anesthesiology - includes all Subspecialties experts.
56yo has rotor cuff repair, initial supraclavicular block and second rescue block. Develops pneumothorax.
Case Overview
Location: FL
56 years old, Male
Past Medical History:
PE/DVT on thinners
Past Surgical History:
56-year-old male was getting a right sided rotator cuff repair in an outpatient setting. Prior to the procedure, the patient received a supraclavicular brachial plexus block that was documented to be ultrasound guided throughout. By all accounts, there were no complications during that time or intraoperatively. Postoperatively, PC continued to have right shoulder pain and a rescue block was ordered. PC was administered 100mcg Fentanyl and the second rescue block was performed (also ultrasound guided). PC’s blood pressure was elevated post-op with an oxygen saturation of 95%. Required 2L N/C as he did eventually desaturate into the 80s. Approximately 1 hour post-rescue block, PC was deemed stable for discharge. It was notated that he was experiencing relief of pain. Last documented vital signs were normal however O2 saturation showed 94% on room air and were approx 30 min prior to leaving the facility
The following evening, PC had slow onset but continued shortness of breath and went to the emergency room. Was found to have a moderate right pneumothorax. PC was treated with a chest tube and was eventually discharged two days later.
PC does not have any physical deficits currently but does claim to have substantial mental anguish from this event.
I have attached various screenshots of documentation of the nerve blocks, time in the PACU and other handwritten notes. We're looking to ensure that the pneumothorax was not preventable and/or the vital signs were sufficient for discharge and did not reflect the possibility of pneumothorax complication.
Appreciate your opinion in advance and please notify with any questions or concerns.
Files:
Questions & Answers
Q: We’re images saved
A: Unfortunately, we do not have that information. I would say likely not.
Q: Was the procedure done under general anesthesia in addition to the block, and if so, was patient intervention bated and on the ventilator
A: —
3 Responses
Do you believe there might have been medical error?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
What makes you a good expert for this case?
I am a double board-certified, anesthesiologist and interventional pain management position. I am the program Director for the pain management fellowship program in my institution. Although I wear many different hats and assume many different roles, we see these type of patients almost every day.
How often do you encounter cases similar to this one in your practice?
Almost every day. Although we don’t necessarily see pneumothorax, we do participate in these blocks very frequently.
Do you believe there might have been medical error?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?