64yo M elective peripheral angiogram, had arterial injury that req repair. Had CVA and other multiple complications. (Case #392)

• Medical Probability: 2 / 10
• Medical Error Summary: This has been a complication from the puncture site, an unlucky one. But it is possible for this complication to occur. The complication has been handled according to standard of care. The hypotension...
• Causation Probability: 1 / 10
• Causation Summary: This is a well known complication, in calcified vessels, and smokers to have retroperitoneal bleed from the arteritomy site. Bleeding causes hypotension. This predisposes to stroke. The only question ...
• Expert Summary: I have done hundreds of cases like this and encountered the same complication. This is unfortunate. But I am expertly trained in these cases.
• Similar Summary: Yes, I have. Early detection is key. First sign of abdominal pain and hypotension should prompt a CT. Type and cross and fluids. Emergent vacular surgery consult.

Unnecessary Venous Ablations leading to consistent pain, swelling, and more (Case #476)

• Medical Probability: 9 / 10
• Medical Error Summary: I do venous ablations. If the patient is asymptomatic, there is no indication for this procedure. Also it appears that the doctor documented that the patient wore compression stockings even though she...
• Causation Probability: 9 / 10
• Causation Summary: The procedure itself is painful, and if not done in an indicated manner, may cause life long pain and swelling. Also if needed, those veins can not be used now for any upcoming cabg. The procedure ca...
• Expert Summary: I have done more than 5000 procedures of venous ablation. I also train other doctors for this procedure.
• Similar Summary: I encountered quite a few, when the patients suffer from post op infections and pain. Also thermal injury to the nerves can cause lifelong neuropathy, which is mostly untreatable.

Cardiac arrest during elective outpatient ablation for a-fib. (Case #505)

• Medical Probability: 9 / 10
• Medical Error Summary: From this initial look up, it appears that the patient was already in florid CHF. These patients need to be optimized and diuresed before any anesthesia induction. The vasodilation caused by the ablat...
• Causation Probability: 9 / 10
• Causation Summary: The spiraling down LV failure was compounded by general anesthesia. When it is an elective case, you have time to evaluate and see if the patient is stable to be generally induced. In emergency, obvio...
• Expert Summary: I do a lot of structural cases with general anesthesia, most of which are already complicatsled with CHF.
• Similar Summary: Rarely, because florid CHF is caught always and treated with GDMT first. If we see the slightest inclination of decompensation, we stop and go back to square 1.

F/T diagnose and treat myocarditis in a 17-year-old resulting in severe heart dysfunction with a subsequent heart transplant (Case #532)

• Medical Probability: 8 / 10
• Medical Error Summary: This young patient has had multiple visits with nonspecific symptoms, but progressive tachycardia. This should have alarmed the provider, to get cardiac studies, an EKG, and an echocardiogram. If th...
• Causation Probability: 8 / 10
• Causation Summary: Early diagnosis in this case may have changed the outcome drastically. If myocarditis was caught at the initial stage, targeted GDMT may have preserved the heart function, and treat the underlying dis...
• Expert Summary: I have been practicing for more than 2 decades in the field of cardiology and have a teaching position as well. My interest includes CHF, and myocarditis, and have treated countless cases of viral m...
• Similar Summary: I remember a 19 year old gentleman, with tachycardia and abnormal EKG with tachycardia who presented to our ER. Rapid diagnostic testing, and echo provided us the diagnosis. Medications were started...

AV fistula during venous venoplasty and stenting of left common Iliac vein & left external Iliac vein. (Case #539)

• Medical Probability: 3 / 10
• Medical Error Summary: This is a DVT case with May Thurner syndrome. Endovenous repair and stenting is a known and well established technique. Access with Seldinger technique. It is a known complication to develop a AV f...
• Causation Probability: 3 / 10
• Causation Summary: There is a causation between symptoms and the AV fistula. And the fistula is caused with the Seldinger access. But this does not show a medical mistake, because anytime you get access in lower extremi...
• Expert Summary: I have done tens of thousands of Seldinger accesses. And I have run into my share of AV fistulas. They are hard to treat but treatable. If you recognize it, and follow the guidelines, you have done y...
• Similar Summary: I have done tens of thousands Seldinger technique sticks in arteries and veins. AV fistulas happen. And in informed consent papers, these are all included. Patients know these things can happen. So I...

Right BKA for failure to treat sepsis with necrotizing RLE cellulitis and abscess. (Case #541)

• Medical Probability: 8 / 10
• Medical Error Summary: After the post op follow up, it is obvious that the clinical picture and the labs scream impending sepsis. I can not with full confidence tie the intervention and the infection, but even if there is a...
• Causation Probability: 8 / 10
• Causation Summary: Two things. There could be a causation from the procedure, with hospital stay and AV puncture. Also DM has always the higher risk of infection. Ischemic PVD worsens the infection risk. It may have bee...
• Expert Summary: I have dealed with many peripheral angiograms, and had my share of infections. I do an aggresive and broad spectrum antibiotic therapy. At the same time I do have a very low threshold for ICU admissio...
• Similar Summary: Rare. But I see them. So far I remember only one patient who lost a leg, but his medical issues were much more complicated, intubated and cardiogenic shock. But I have not a patient who lost an extrem...

Cardiology Plan of Care (Case #567)

• Medical Probability: 9 / 10
• Medical Error Summary: This patient has all the risk factors for severe CAD. Sometimes, in clinic setting, patients do not disclose their symptoms completely. They may not want to share. That is where clinical intuition c...
• Causation Probability: 8 / 10
• Causation Summary: In this case, further testing should be considered. There is definite indication for ASA. And a statin. These should have been handled during the initial visit. During ER visit, the consultant...
• Expert Summary: I have taken countless ER calls, and worked with thousands of patients like this. This is my typical patient portfolio. I make sure that these patients do not leave the office without testing schedu...
• Similar Summary: Almost on a daily basis. In my clinic, at least 4-5 patients a week have almost identical histories. And in my ER calls, I have encountered many NSTEMIs that convert to STEMIs. You need to be vigi...

Potential negligence in the management of cardiogenic shock (Case #572)

• Medical Probability: 8 / 10
• Medical Error Summary: The problem here is nationwide. The kneejerk reflex of starting diltiazem on any afib RVR or aflutter with RVR is a major mistake. Once the patient comes with afib or aflutter RVR, you do not know wha...
• Causation Probability: 8 / 10
• Causation Summary: If the patient was started on amio rather then diltiazem, the outcome and the speed of recovery would be different.
• Expert Summary: I take call at least 50 days a year. I deal with cardiogenic shock daily. I am trying to change the culture about using diltiazem across my state.
• Similar Summary: Many times. I have encountered many arguments with ER attendings regarding their kneejerk use of diltiazem.