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Comments are accepted only from Orthopaedic Surgery - includes all subspecialties experts.
59yo male has foot surgery, has subsequent Achilles rupture
Case Overview
Location: FL
59 years old, Male
Past Medical History:
HTN, CAD
Past Surgical History:
previous foot surgery (unk)
59 year old male who was seen by orthopedic for ongoing right foot pain for 3 years. There was an unknown previous procedure attempted to address this in 2020, but there is no clarity on the details of the surgery.
According to the referred surgeon, he is diagnosed with 1: Right great toe end-stage arthrosis, 2: Right Second hammer/claw toe 3: Right gastrocnemius contracture 4: Right great toe retained deep implant and is offered surgical intervention in the form of first metatarsophalangeal joint arthrodesis as well Strayer procedure and second hammer/claw toe correction with hardware removal.
This procedure is performed in late December of 2022. The operative note is attached in two pages.
He has a follow-up appointment on January 3rd. It is a standard dressing change if he is told healing is appropriate with no signs of infection. Weight-bearing limited. Second follow-up is January 10th and no complications noted. January 17th, he arrives for suture removal and it is noted that the “second toe pin is halfway out of his toe” and it was removed without complication. Told to return in 4 weeks for revaluation and x-ray (this xr was normal, no hardware or alignment issues)
February 14th, PC continues to have increased discomfort to Strayer site. No physical therapy had been ordered to this point, but it is now recommended and initiated for range of motion and strengthening exercises. Will re-evaluate in 4 weeks. Physical therapy is started and sees improvement as of June of 2023.
July of 23 PC thinks that his gait is unstable and they recommend continued physical therapy. Another XR shows no abnormality.
This pain continues through August and PC is referred to a different group for second opinion.
In September of 2023, an ordered MRI revealed a chronic Achilles tendon rupture to the right foot. The measured Gap was 8 to 10 cm. REPORT ATTACHED.
He is presented with the option of surgical intervention which he accepts. That surgery is in January 2023 and the OP note is also attached in 2 pages.
Post-operatively, PC has had some improvement, however has had an overall decrease in mobility and has been forced to go on disability. Limited working. There is concern that the original procedure in December of 2022 was done incorrectly from the beginning that may have led to the Achilles rupture, or if it possible the rupture was unrelated or could have been traumatic at any point after the procedure and is a recognized complication.
Files:
2 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 seen this problem in my practice and patients do well with physical therapy and rare.y succumb to this surgery.
How often do you encounter cases similar to this one in your practice?
Sometimes. I have not performed this procedure myself but have seen patients with the problem.
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 fellowship trained orthopedic surgeon with several years of experience doing expert witness review and testifying for both plaintiffs and defendants.
How often do you encounter cases similar to this one in your practice?
In my clinical practice, analogous situations are not encountered very frequently, on the order of 1 every few months or so, often as second opinions. In expert witness work, however, cases such as these are more common.
Want to open a case or submit response?
Comments are accepted only from Obstetrics and Gynecology experts.
Unnecessary Hysterectomy and BSO
Case Overview
Location: FL
49 years old, Female
Past Medical History:
Past Surgical History:
This is not an obstetrics issue. This is a gynecological issue.
Plaintiff - Medical/Diagnostic Care with Defendant Doctor, pre-surgery
Plaintiff was referred by her PCP, to Defendant Doctor, GYN oncologist, to evaluate her history of vaginal bleeding during intercourse X3.5 years.
Plaintiff underwent Hysteroscope/D&C on 6/25/2018. Pathology revealed atrophic endometrium.
On 8/20/2018, Defendant Doctor performed a Condyloma Fulguration w/CO2 laser ablation under anesthesia and prescribed Estradiol .01 mg vaginal cream at bedtime, once a day for one month.
Plaintiff returned to Defendant Doctor on 10/04/2019 c/o vaginal bleeding after intercourse with pain on deep penetration. Defendant Doctor prescribed Estradiol Patch .05 mg to be worn 24/7. Defendant Doctor also recommended laparoscopic hysterectomy. Plaintiff agreed with surgery.
On 10/24/2019, Defendant Doctor performed a laparoscopic hysterectomy, bilateral salpingo-oophorectomy.
Plaintiff continued to experience vaginal bleeding after intercourse and ended up going to another GYN who told her that she did not need a hysterectomy and bilateral salpingo-oophorectomy; that Defendant Doctor amputated the last 2 cm of her vagina which did not resolve the vaginal lesion.
______________________________________________
In review of the records, it was confirmed that Plaintiff had normal ovaries, that Defendant Doctor removed 2 cm of her vagina when he surgically removed her cervix and that Plaintiff only consented to the hysterectomy and Bilateral Salpingo Oophorectomy (BSO). Plaintiff had a history of bleeding from a lesion in her vagina for three plus years prior to the hysterectomy and BSO. Defendant Doctor recommended Plaintiff undergo a Robotic Assisted Laparoscopic Hysterectomy and BSO. After the Surgery, Plaintiff continued to experience vaginal bleeding necessitating further medical treatment from Second Doctor.
According to ACOG, a hysterectomy is recommended when the patient has:
• Uterine fibroids (Plaintiff did not have)
• Endometriosis (Plaintiff did not have)
• Pelvic support problems (Plaintiff did not have)
• Abnormal uterine bleeding (Plaintiff did not have)
• Chronic pelvic pain (Plaintiff did not have)
• Gynecologic cancer (Plaintiff did not have)
Plaintiff did have vaginal bleeding due to a lesion in her vagina, and, she had painful intercourse, which is different than chronic pelvic pain. According to this information from ACOG, Plaintiff was not a proper candidate for a hysterectomy and BSO.
ACOG further states that a woman’s ovaries should only be removed if they are abnormal. Plaintiff’s ovaries were normal and Defendant Doctor knew this before he recommended and performed this surgery. Defendant Doctor removed healthy ovaries from a 49 year old woman. The fact that Plaintiff was menopausal is not a basis to perform this surgery.
Finally, ACOG states that you only remove a portion of the patient’s vagina if you are performing a radical hysterectomy. A radical hysterectomy is only performed if the patient has cancer. Per my reading of ACOG standards, Defendant Doctor should not have cut out 2 cm of Plaintiff’s vagina without her knowledge and permission and only then if he suspected cancer. Even after the Defendant doctor surgically removed 2 cm of her vagina during the hysterectomy and BSO, he failed to remove the lesion in her vagina which had been the cause of the history of bleeding from her vagina.
Files:
Questions & Answers
Q: What evaluation did the patient have prior to surgery to determine where the abnormal bleeding was from?
A: Information updated for case with pre-surgery care. Initial pathology from hysteroscope/D&C revealed atrophic endometrium.
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 have had 34 years of general, Ob/Gyn practice and concentrated strictly on Gyn the last several years up until my retirement two years ago. During this time I worked in a academic institution where medical students and residents were under my teaching. it has always been emphasized to these students and residents, that you must identify a specific cause before you go ahead and recommend procedures. Certainly if there is no reason to perform an invasive procedure such as was performed on this woman, then you simply do not do this.
How often do you encounter cases similar to this one in your practice?
Cases like this while not common, were seeing from time to time. It was always important to perform a full work up to make sure that the bleeding source was not within the uterus and cervix or ovaries. Certainly there was an identifiable lesion, such as in the vagina or the vulva region, a biopsy of these would be necessary to certainly rule out cancer.
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 OB/GYN and a board-certified reproductive, endocrinologist and fertility specialist with extensive surgical experience over the last nearly 25 years and a good understanding of the anatomy as well as as a board-certified expert and menopausal medicine understand the hormonal environments in a woman who has postmenopausal and the wrist and benefits Play in a situation like this as well as some of the challenges encountered in the operating room in a situation like this.
How often do you encounter cases similar to this one in your practice?
ThI’s is a very unusual case. Condylomas are often seen in our practice and understand how difficult they are to treat medically. Two centimeters of vagina is not significant to create a shortening of the vagina and the fact that it want tested surgically or medically goes to prove how difficult this condition can be to treat.
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 gynecologic oncologist, 10 years in practice, first 9 focused exclusively on surgical management, and evaluated similar cases and have performed numerous surgeries - hysterectomy, vaginal/cervical lesion ablation, etc, similar to this case.
How often do you encounter cases similar to this one in your practice?
Post-menopausal bleeding a couple of times a week. Vulvovaginal lesion/condyloma every other week or so. I perform about an average of 5 hysterectomies a week
Want to open a case or submit response?
Comments are accepted only from Obstetrics and Gynecology - Maternal and Fetal Medicine experts.
41 y.o. woman dies during C-section delivery
Case Overview
Location: FL
41 years old, Female
Past Medical History:
none
Past Surgical History:
none, 1st delivery was normal vaginal in 2019
Seek an opinion of a MFM expert with recent experience with similar cases.
Please note the delivery note and trauma team notes at the bottom of this summary. Preliminary autopsy is attached as screenshot.
41-year-old female G2P1 with an estimated due date of September 9th of 2023. In April of 2023 and ultrasound revealed the placenta is midline with complete previa. No other abnormal testing to this point.
May of 2023 increased risk of placenta accreta spectrum disorder is noted. Patient is feeling well.
June 29th of 2023 has no abnormalities with the physical exam, however will be transferred to high risk OB due to material age and placenta location.
July 12th of 2023 sees MFM. Evaluation states that PC does have a complete placenta previa with a low probability of accreta. Good fetal movement and no other abnormalities noted. Plan was to do an MRI and follow up in 2 weeks. There are multiple notations stating that if the placenta does not deliver that she is aware of a possible C-section with hysterectomy if necessary.
July 26th, ultrasound still shows placenta the posterior and is complete previa. Placental lakes are noted.
MRI results come back and on July 31st she returns. The MRI shows a suspected placenta accreta. Notation states that despite no history that would indicate accreta was a high suspicion, they elect to admit to delivery hospital on the 10th of August for evaluation and schedule a C-section with possible hysterectomy on the 11th. At this point the PC is complaint-free and they're appear to be no abnormalities or concerns with fetus. No reason for not admitting that day or soon after.
August 6th. PC comes to delivery hospital for vaginal bleeding which started 30 minutes prior to arrival. The large blood clot noted in her underwear but no active bleed. Denied any contractions or fluid leakage. MFM is notified in he requests admission and plans for a C-section of hysterectomy on the 8th (2 days later). A few hours later, the PC begins to develop contractions and begins to actively bleed again. They agree to proceed with the C-section hysterectomy that afternoon. The operative note is unremarkable until after the child is delivered. They say it was a non-traumatic breech fashion, cord was cut and the umbilical cord was ligated and placed into the uterus. Immediately following this, a “massive acute bleed came vaginally estimated at 2000 cc's”. They report that the placenta was not traumatized or manipulated during the delivery. As they begin the hysterectomy, the hemorrhage worsens and Critical
Care surgery jumps in. CPR on progress and begin transfusions.
They attempt a thoracotomy and cardiac massage, internal defibrillation and multiple rounds of meds. After over 30 minutes of resuscitation efforts, they pronounce mother dead at 1513pm.
A preliminary autopsy (PLEASE SEE ATTACHED SCREENSHOT) reveals that there was “a retro placental hematoma associated with decidual necrosis consistent with abruption”. According to the report this “led to significant blood loss and disseminated intravascular coagulopathy”.
We do not have a final autopsy.
We do have all office visit info and U/S imaging available.
DELIVERY NOTE:
Patient was identified and consents reviewed. There was no active vaginal bleeding. Epidural anesthesia was placed without complication. The patient was then placed in the dorsal lithotomy position with a leftward tilt. The abdomen was prepared and draped in a normal sterile fashion. A midline vertical skin incision was made and carried through to the underlying layer of fascia. The fascia was then incised in the midline. The incision was extended inferiorly and superiorly with Bovie cautery. The right lateral aspect of the fascial incision was identified, elevated, and underlying rectus muscles were dissected off with Bovie Cautery. The rectus muscles were then separated in the midline and the peritoneum was identified and entered bluntly. This was extended inferiorly and superiorly with Bovie cautery. The uterus was then gently exteriorized. An area on the fundal aspect of the uterus was identified and marked. Using 2-0 vicryl, 2 stay sutures were placed on the lateral border of the marked lined at the midway point. Using the stay sutures to elevate the uterine wall from the underlying fetus, bovie cautery was used to enter the uterine cavity. The hysterotomy was extended superiorly and inferiorly with bandage scissors. Clear fluid was noted on entry into amniotic sac. Male fetus was delivered in breech fashion atraumatically. After a 30 second delay, the cord was clamped and cut, and the infant was shown to the patient and the father of the pregnancy, and the infant was passed to the waiting pediatric team. Using vicryl free ties, umbilical cord was ligated and placed back into uterus. At this time, it was noted that the patient had a massive acute bleeding from the vagina with approximately 2000cc of blood on the floor and in between her legs. Attention was turned back to the hysterotomy. Placenta was visualized in the posterior aspect of the uterus and was noted to be not bleeding. Placenta was not traumatized or manipulated during delivery. Hysterotomy closed with 0 vicryl in a running locked fashion in one layer and immediately attention was then turned to GYO team who replaced MFM team for attempt at hysterectomy. This report will come in a separate operative note.
TRAUMA TEAM NOTE:
Trauma Assisted The Primary Operative Team (OB/GYN) With Continued Exploratory Laparotomy. The Bowel Was Eviscerated To The Patients Right And A Mattox Maneuver Was Performed Exposing The Aorta. The Aorta Was Clamped With A Satinsky Clamp. Supraceliac Aortic Control Was Then Obtained And Direct Pressure Was Held On The Aorta. A Left Resuscitative Anterolateral Thoracotomy Incision Was Made @ The Level Of The 4TH-5TH Intercostal Space And Carried Through The Subcutaneous Tissues To The Level Of The Intercostal Muscles. The Thoracic Cavity Was Entered Bluntly And Mayo Scissors Were Used To Extend The Incision By Dividing The Intercostal Muscles. A Finochietto Retractor Was Placed And Opened To Spread The Chest. Upon Entry, There Was No Active Bleeding Or No Gross Blood. There Was No Obvious Pulmonary Injury. The Pericardium Was Not Bulging / Tense. The Pericardium Was Opened Longitudinally To Avoid The Phrenic Nerve. There Was No Cardiac Injury. The Thoracic Aorta Was Clamped At The Level Of The Diaphragm With Care To Take Down The Left Inferior Pulmonary Ligament And Without Clamping The Esophagus Which Was Palpated With An OGT. Cardiac Massage Was Performed And Continued. MTP Transfusions Was Continued. ATLS Protocols Were Performed With Administration Of Epi x 1 Intra-Cardiac. Internal Cardiac De-Fib x3 2/2 VFib. At This Time, The Heart Was Full From Blood Transfusions But Stiff With No Cardiac Activity Despite x1 Intra Cardiac Epi, Defibrillation And Cardiac Massage. Decision Was Made To Pronounce The Patient After > 30 Minutes Of Active CPR/Resuscitation And Attempts At Hemorrhage Control.
Files:
Questions & Answers
Q: Did the physician choose to wait 2 days for planned CS after admission to administer late steroids?
A: YES, that is correct. Once she began to bleed again, they elected to not wait.
Q: Were coagulation studies performed on admission i.e. PT/PTT, fibrinogen?
A: Yes. In triage. PT was 13.3 and INR was 1.0
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 come from a strong academic general OBGYN residency and MFM fellowship training where I was exposed to many cases such as the one described. My career as an attending MFM Physician also gave me experience of managing such cases. These situations have helped hone my sense of the grey zones of perinatology.
How often do you encounter cases similar to this one in your practice?
I often serve as consultant to the general ob/gyn's in our health system. On average, we see a number of patients with accreta risk factors and about 2/month with utrasound findings of concern. Individualizing their delivery timing and antenatal followup plan is essential.
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Comments are accepted only from Surgical Oncology experts.
58yo male has multiple complications after Whipple, dies 4 days later.
Case Overview
Location: FL
58 years old, Male
Past Medical History:
HTN, DM, Cancer
Past Surgical History:
PC 58yo male that died after having had a Whipple procedure to address a diagnosis of pancreatic adenocarcinoma on December 6, 2023.
After PC’s surgery it was reported to the family that the surgery was successful, and that the tumor and several lymph nodes had been removed, and that clear margins were obtained. PC was clinically and hemodynamically stable post-surgery. He was alert and ambulatory. PC was transitioned to a clear liquid diet the next morning.
December 7th evening (approx 730pm), slowly begins to have hypotension, tachycardia and lethargy. On December 8 (approx 3am) treated with labs, fluid bolus and was upgraded to ICU for closer observation. 1 hour later, has a cardiac arrest event with down time approx. 9 minutes. There is concern for an aspiration event. When the NG tube was placed, 2 L of bilious gastric content was removed. They also aspirated a significant amount of fluid from his lungs. Lab work during this time did reveal a lactic acid above 8 but no other significant change. PCs abdomen noted to be increasingly and diffusely distended and swollen. CT scans revealed bilateral significant lung consolidations with small amount of free air in fluid in the pancreatectomy bed. Mild thickening of the CBD wall and severe bladder wall thickening. Due to this persistent hypoxic failure, surgeons elected to treat with ECMO and he was cannulated later that afternoon. They also initiated CRRT due to severe metabolic acidosis and renal failure with no urine output.
PC continued to decline the next day (Dec 9) and was maxed out on pressures. They diagnosed him with abdominal compartment syndrome and perform a bedside decompressive laparotomy with ABertha wound vac. No significant findings. (Lactic acid continues to climb to over 14 despite ABX, etc)
Dec 10: PC continues to decline and elect to have exploratory laparotomy which reveals no acute ischemia or active bleeding however the liver is noted to be very dark and discolored and theorized to be the source of the acidosis. Consensus among providers agree that the “severe metabolic arrangement” is not reversible and PC is continually declining. Family makes PC DNR and unfortunately the PC passes away in the late afternoon of December 10th.
The records concerning this hospitalization are vast, however I did attach screenshots of the original Whipple procedure and final diagnosis/amended findings of the autopsy.
We take an opinion concerning the original surgery and any subsequent treatment plans up until PC death. PC was recently retired and had no significant medical history prior to pancreatic cancer diagnosis a month prior to this admission.
We think in advance for your opinion and your time. Would be happy to answer any clarifying questions.
Files:
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Comments are accepted only from Gastroenterology experts.
General Surgeon With Upper GI Bleed Requesting Urgent Upper Scope To Be Told By GI To Place Patient In ICU Until The Morning.
Case Overview
Location: FL
66 years old, Female
Past Medical History:
Obesity, COPD, see details of case
Past Surgical History:
ERCP
Patient, 66-year-old female with a past medical history of hypertension, hyperlipidemia, uterine cancer status post hysterectomy 5 years ago, recent necrotizing pancreatitis status post laparoscopic cholecystectomy on 10/20/22, bilateral lower extremity DVT on Xarelto status post IVG filter on 11/17/22 who presented to an Emergency Department complaining of worsening abdominal pain.
Patient was previously admitted for abdominal pain on 11/01/22 in the setting of complex previous laparoscopic cholecystectomy with multiple ERCPs, she was noted to have necrotizing pancreatitis, she was seen and evaluated by GI and was discharged on 11/19/22.
According to her wife and daughter at the bedside, the patient was discharged on tramadol and Zofran and still was complaining of abdominal pain, she also has been having loose stools, shortness of breath with exertion and has been very weak since she was discharged. According to her family, she looked pale and jaundiced and had worsening abdominal pain the day prior to December 03, 2022 (Date of Incident).
However, patient returned to the Emergency Room on December 03, 2022. In the emergency room, she was found to be in septic shock and hypotensive with systolic blood pressure in the 60's and a lactic acid of 8.6.
While in the emergency room, she started vomiting bright red blood. Kcentra was given for reversal of xarelto and 2 units of PRBCs and 1 liter of fluid given and she was started on protonix gtt. The ICU intensivist APRN was consulted. An NG tube was inserted, she was started on Levophed and vasopressin and was intubated to preserve her airway.
General surgery and GI were consulted. While in the ICU, the patient condition worsen, the intensivist spoke to the spouse and daughter at the bedside about DNR code status, they both agreed with DNR and no escalation of care as well as withdrawal of all life support.
During the Summary on December 03, 2022, the General Surgeon noted that “The patient presented today with upper abdominal pain and nausea and gastrointestinal bleeding…I was contacted by the emergency room doctor with whom I discussed the case. I explained my recommendation which included…I also explained to them the urgency of gastrointestinal endoscopy to determine the source of the bleeding and the GI consultation was urgent.”
The General Surgeon also noted that “I contacted GI Doctor #1 [employed by hospital] to discuss endoscopy and the need to identify a mechanical source of this gastrointestinal hemorrhage, and I discussed with the intensivist the need for serial hemoglobins and prompt establishment of some source of this bleeding with an attempt at either endoscopy, interventional radiology, or surgical control of the acute hemorrhage.”
Due to the immediate need for the upper GI scope, several attempts were made to GI Doctor #1 which went unanswered, and a voicemail was left requesting a STATE return call.
Another STAT call was made to GI Doctor #2 who was on for GI Doctor #1. The initial call was made at 2:23 am on December 03, 2022. However, GI Doctor #2 did not return the STAT request until 2:50 am. During the conversation, GI Doctor #2, after knowing the immediate need for a upper scope, requested that the patient be placed in the ICU for "stabilization and that he would see the patient in the morning when he was able to see her."
Patient ultimately succumbed to the injuries after only a few hours in the ICU prior to a GI being able to perform an upper scope.
1. Was there a deviation from either GI Doctor #1 or #2 in disregarding the urgent need for the upper GI Scope? If so, how did they fall below the standard of care?
Files:
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 have been handling complex GI bleeders for 30 years. I have taught in multiple universities. I have extensive experience working with ED and ICU attending with these kinds of cases.
How often do you encounter cases similar to this one in your practice?
Once a month maybe more given certain months.
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?
20 years of hospital based GI experience
How often do you encounter cases similar to this one in your practice?
Fairly frequently 3-4 per year
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'm a published expert in cases of GI bleeding and maintain a near 50-50 balance of defendant/plaintiff counsel matters, which I've handled at local, county, and federal levels
How often do you encounter cases similar to this one in your practice?
In general terms, several times per month. With these specific facets, less frequently, maybe a few times per quarter
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