Presentation and physician action
A 29-year-old man with a long-standing history of abdominal pain was referred to general surgeon A for evaluation of a duodenal ulcer. After examination, General Surgeon A diagnosed a chronic peptic ulcer and recommended vagotomy and subtotal gastric resection.
The surgery was performed. A sponge count was completed at the end of the surgery, but an instrument count was not conducted and no instrument count was noted in the OR record. In the following weeks, the patient seemed to do well. He last saw General Surgeon A eight weeks after the surgery.
Approximately 18 months later, the patient came to Family Physician A reporting severe lower stomach pain for three or four months. This physician noted that the patient had undergone a partial gastrectomy 18 months prior. Over the next year, Family Physician A provided conservative treatment. When this failed to alleviate the patient’s abdominal symptoms, he was referred to a radiologist for an air contrast barium enema.
Radiologist A reported that the films demonstrated “a very large unusual radiopaque structure in the anterior abdomen. It appears very thin and flat and extends virtually the length of the abdomen. It is located anteriorly and may be superficial in the anterior abdominal wall, although its exact location and etiology is not known. It may be related to the patient’s midline incision, aside from this the patient’s abdomen appears unremarkable on the scout film.”
Two weeks later, the patient saw Gastroenterologist A on referral from his family physician. Gastroenterologist A did not have the patient’s records or radiographic studies available. He believed that the patient suffered from chronic abdominal pain syndrome, but he planned to locate the patient’s records and evaluate them. The records were relayed to the Gastroenterologist A, including the barium enema study that noted the radiopaque material in the abdomen.
Gastroenterologist A concluded this material was an unusual form of surgical mesh related to the patient’s surgical procedure. He believed the patient was suffering from prostatitis and felt there was not a GI source for the symptoms.
Three days after his final visit to Gastroenterologist A, the patient came to the emergency department (ED) of Hospital A. He reported lower scrotum and abdominal pain, and was seen by ED physician A.
An abdominal x-ray was ordered and was read by Radiologist B. She concluded “there is an anteriorly located ‘mesh’ in the subcutaneous tissue most likely related to an abdominal anterior wall hernia correction. There are several surgical clips in the left upper quadrant and surgical staple line to the right of the mesh at the L2 level. There are dense probably residual contrast collections either in the appendix or Secale region in the lower right quadrant. The bony structures are unremarkable. There are minimal degenerative changes.”
Radiologist B believed there were surgical changes in the abdomen with no evidence of acute abdominal process. ED Physician A diagnosed acute prostatitis, and advised the patient to continue taking the medication prescribed by Gastroenterologist A.
Over the next year, the patient continued under the care of Family Physician A. The medical records indicate the patient continued complaining of abdominal pain.
Three years and 10 months after the surgery, the patient came to the ED at Hospital B. ED Physician B’s impression was that the patient suffered from acute abdominal pain, left ureterolithiasis, and hematuria with a high grade left renal ureter obstruction. An intravenous pyelogram (IVP) was done. ED Physician B noted in his chart that there was an intra-abdominal metallic foreign body.
Urologist A examined the patient and reviewed the IVP with Radiologist C. They both noted a small distal left ureteral stone and observed a metallic density on the film, which they believed to be mesh related to the patient’s prior surgery. Urologist A discharged the patient, as he was pain free.
The patient returned to the ED five days later and was seen by Urologist A. He felt the patient was suffering from a left ureteral stone and admitted the patient. The next morning, the patient was pain free. Urologist A encouraged him to increase the pain medication to strain his urine and attempt to pass the stone. The patient was discharged and told to return to Urologist A in one week.
The patient did not return. However, after receiving a notice of claim regarding this patient, Urologist A made two additional entries into the patient’s chart indicating the patient failed to keep appointments.
Two years after the visit to Hospital B, (now five years and nine months after the surgery) the patient came to the ED at Hospital C. An x-ray was reported as unremarkable, but the patient reported that he was known to have a wire mesh in his abdomen. The impression by ED Physician C was acute abdominal pain.
The patient was seen again in the ED of Hospital C nine days later. The x-ray report noted metallic clips in the upper portion of the abdomen due to the prior surgery with two wide plates superimposed over the right paravertebral region, possibly representing a back brace. The x-ray results were again reported as negative.
Following these two visits to Hospital C, the patient came to General Surgeon B who ordered a CT scan and reviewed the previous abdominal x-rays. General surgeon B diagnosed a retained metallic foreign body, probably a surgical ribbon retractor, as the cause of the patient’s pain. The patient was taken to surgery, and General Surgeon B found and removed a 3-inch-wide x 13-inch-long surgical ribbon retractor.
The patient’s medical records indicate that he had not undergone any other abdominal procedures other than the vagotomy and subtotal gastric resection. It appeared that the retractor was left at the time of this surgery. The patient testified that since the removal of the retractor he has not experienced any abdominal pain.
A lawsuit was filed against General Surgeon A and the hospital where the surgery took place, alleging negligence in leaving a ribbon retractor in his abdomen during the surgery. The patient also filed suit against all the physicians who treated him after the surgery, alleging negligence in failure to diagnose the retained retractor.
Named in the suit were Family Physician A, Gastroenterologist A, Urologist A, ED Physicians A, B, and C, and Radiologists A, B, and C. This incident was featured in a news story on medical mishaps and aired on a network investigative news program.
The plaintiffs in this case effectively developed their case to pursue two claims: the act of leaving the retractor and the subsequent failure to diagnose it. The surgeon who removed the retained retractor provided a report critical of all those involved in the first surgery.
Defense radiology experts were critical of Radiologist B for describing the metal as “mesh,” and that this description led to a delay in diagnosis and removal of the foreign object. This report should have triggered further work up by the referring physician. The consultants also concluded that Radiologist A’s report fully described the retractor, and that the referring physician should have followed up on the report.
Other defense consultants were not entirely supportive of the actions of Urologist A and Gastroenterologist A. The main weakness in the case against Gastroenterologist A was the lack of follow up on the cause of the patient’s abdominal pain and the radiology report submitted by Radiologist A.
Regarding the actions of Urologist A, he was under the impression that the previous treating physicians and the patient were aware of the foreign object based on the previous radiology studies. However, other urology experts were critical of his failure to recognize the retained object as a surgical retractor. Urologist A’s alteration of the medical record also undermined his defense.
As is sometimes the case when claims involve multiple defendants, finger pointing became an issue. The plaintiff’s attorney was able to develop conflicting testimony and criticisms between the various subsequent treating physicians. This, coupled with the damaging testimony from the plaintiff’s own experts, made the defense of this case difficult.
This case was settled with the consent of the physicians. Settlement was made on behalf of General Surgeon A, Gastroenterologist A, Urologist A, and Radiologist B. The case against Radiologist A was dropped. The hospital where the surgery took place also settled this case. The outcome of suits against the other defendants is unknown.
Risk management considerations
In this case, there are several areas where the care of this patient broke down. When the patient was first taken to surgery, a sponge count was completed but an instrument count was not. Hospitals have protocols to prevent the retention of foreign objects in surgical patients. Physicians and their surgical staff should follow these protocols.
Compounding the initial error was the lack of follow up by the subsequent physicians. Radiologist A accurately described the foreign object, but his report did not trigger follow up. Radiologist B’s use of the term “mesh” in a later report sent the physicians in a different direction and affected their interpretation of the patient’s symptoms.
When a patient has continuing symptoms of unknown origin, further testing may be warranted. Would further testing (i.e., an abdominal CT) have helped the physicians diagnose the cause of the patient’s recurring abdominal pain? Likewise, would contacting General Surgeon A to carefully correlate the patient’s surgical history have alerted these physicians to the reason for the patient’s symptoms?
Altering the medical record seriously jeopardizes a physician’s credibility. Upon reviewing the medical record when served with a notice of claim, physicians may be tempted to add information that they believe will assist in their defense. While the information may be accurate, the addition of such information after the event is detrimental to the defense.
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