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General Surgery

• Diabetic Patient With Acute Gallbladder Disease Develops Severe Pancreas Infections and Death from Failure to Perform Gallbladder Surgery.
  
  
• Misdiagnosis of appedicitis in adult by HMO, resulting in major abdominal abscess and loss of a critical piece of small intestine.
  
  
• Recurrent inguinal (groin) hernia operation causing gangrene to the testicle and chronic nerve pain.
  
  
• Repeat neck operation to remove lymph nodes for cancer diagnosis, causing damage to the spinal accessary nerve and paralysis to the trapezius muscle.
  
  
• Thyroidectomy operation with post-operative hemorrhage (bleeding) causing blockage of airway, delayed resuscitation, and death.
  
  
• Cancerous groin lump misdiagnosed as an inguinal hernia.
  
  
• Mistreated diabetic foot ulcer resulting in amputation.
  
  
• Colon surgery, postoperative hemorrhage and large gauze sponge left behind.
  
  
• Breast biopsy with gauze sponge left behind, causing a chronic infection.

Diabetic Patient With Acute Gallbladder Disease Develops Severe Pancreas Infections and Death from Failure to Perform Gallbladder Surgery

I have prepared the following confidential Case Evaluation for you at your request. This report sets forth our professional opinion based upon the medical records that were submitted. These records included a Statement of Facts as well as outpatient, Emergency Ward and multiple inpatient entries that spanned from 1991 to 2007. In all, approximately 663 pages of medical records were reviewed. Unfortunately, although the records were voluminous, it appears that all available records were not received as indicated by the comment in the Statement of Facts that the patient died but records leading up to his death are unavailable.

Salient aspects of this case are as follows:

1. The patient, formerly of the Kentucky area and now deceased was a 60 year old diabetic when a CT scan of the abdomen was ordered in the evaluation of right flank pain by his family practice physician. On November 2, 2006 this CT scan was obtained and demonstrated gallstones. The official report of this CT scan indicated that Dr. #1 had ordered the study and he would be the medical person responsible for its follow-through which should have included a Surgical consultation.
2. Indeed, it is well known that diabetics, unlike the rest of the population at large, are at a heightened risk for complications of gallstones. Whereas it is often acceptable to observe nondiabetics with asymptomatic gallstones for indications for cholecystectomy (gallbladder removal), a diabetic even if asymptomatic should be considered for gallbladder removal pre-emptively to avoid dreaded complications such as occurred in this case. The fact that the patient had already been symptomatic in October 2006 further heightened the need for Surgical evaluation for gallbladder removal at that time.
3. On May 5, 2007 he developed severe abdominal pain, nausea, vomiting and presented to the Medical Center the following day where he was diagnosed with gallstone pancreatitis. His amylase and lipase were markedly elevated at 1946 for his serum amylase and 8281 for the lipase. These enzymes are released during pancreatic inflammatory conditions and were elevated 20-200x baseline normal values.
4. He suffered from numerous acute relapses of his pancreatitis which required Emergency Ward and inpatient stays on May 28, 2007, June 7, 2007, August 1, 2007 and others and he had a myocardial infarction (heart attack) which required stent placement in his coronary arteries on a July, 2007 hospitalization.
   His acute pancreatitis eventually was complicated by chronic pancreatitis, necrotizing (gangrene and self-digesting) pancreatitis with pseudocyst and abscess formation. He underwent appropriate drainage, pancreatic resection and cholecystectomy (gallbladder removal) on September 24, 2007 by Dr. #2. He received antibiotic therapy and parenteral (intravenous) nutrition on several of his hospitalizations.
5. Further details surrounding his death are not available at this time.

In summary, an abdominal CT scan performed under the direction of Dr. #1 indicated that this patient suffered from symptomatic gallstones as early as November 2, 2006. The standard of care for diabetics with gallstones required that a Surgical consultation be obtained to electively consider gallbladder removal as diabetics are at increased risk of gallstone-associated complications including gallstone pancreatitis and cholangitis (bile duct infection), potentially fatal conditions that are completely prevented with gallbladder removal.

The failure to consider the patient for elective cholecystectomy (gallbladder removal) was the direct cause of his acute and chronic pancreatitis as well as contributing to his heart attack and necrotizing pancreatitis. Further, the failure to obtain an ERCP or similar procedure to remove the patient's gallstones on each of his hospitalizations prior to September, 2007 were further examples of deviations from existing standards of care that caused or significantly contributed to his severe pancreatic inflammatory conditions.

Since the gallbladder sits anatomically near the pancreas, and the outflow tracts ("ducts") are joined to each other, the presence of a stone within the gallbladder wall can acutely inflame the nearby pancreas and such inflammation is often accompanied by pancreatic phlegmons, pseudocysts and abscesses, all of which were present at various times in this case. Furthermore, until removal of the gallbladder, or, at the least, its stones is performed with procedures such as cholecystectomy (gallbladder and stone removal), cholecystostomy (removal of a portion of the gallbladder with stone drainage) or ERCP (an x-ray dye study, plus internal removal of common bile duct gallstones by cannulation of drainage ducts), the problem of acute pancreatitis with all of its attendant complications may recur, as happened in this case, over and over again.

While the presence of coronary artery disease can be a contraindication to some of these drainage procedures, it is not an absolute contraindication and a Surgeon, in conjunction with the appropriate Medical caretakers such as a Cardiologist should have been consulted to weigh the risks and benefits and timing of the procedures listed above as early as November 2006.

The failure of these procedures to have been considered were deviations that, more likely than not, caused this patient's multiple bouts of pancreatitis with its complications and contributed to his death. However, as noted, further information regarding the circumstances relating to his death is awaited.

Based upon the information in the records received it would appear that the above issues represent viable avenues of pursuit in this case and the potential to obtain supportive Expert Witness opinions supporting the issues of negligence does exist, and should not be difficult, although no guarantees to that effect can be made.

We continue to remain available to assist you in this case and have the Expert Witness specialties you require for this case. Expert Witness Reports are available through our Firm with the submission of appropriate funds as per our current Fee Schedule.

In this specific case, Expert reports should be strongly considered in the areas of Family Practice, Gastroenterology, General Surgery and Infectious Disease preferably after obtaining a more complete set of medical records as described above.

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Misdiagnosis of appendicitis in adult by HMO, resulting in major abdominal abscess and loss of a critical piece of small intestine.

The two questions presented by this case are: 1) Was there a negligent failure to diagnose her ruptured appendicitis condition sooner? And, 2) What difference did it make?

In an adult, the appendix will often rupture (perforate) by 48 hours after the onset of symptoms. The appendix's hollow connection (lumen) to its connection to the large intestine (cecum) gets obstructed by a fecalith (hard concretion of feces), and since the appendix continues to secrete mucous, it distends up like a balloon. This stretches its blood supply vessels in its muscular wall, cutting off circulation, leading to localized necrosis (gangrene: death of its flesh).

The appendix contains fecal matter which is mostly bacterial germs. With its perforation, these germs enter the abdominal (peritoneal) cavity. This can spread throughout the abdomen causing peritonitis and eventually death, or a localized abscess (contained or "walled off" by any of the intra-abdominal intestines and/or omentum [fat pad that hangs down from the stomach] and the transverse [upper] large intestine [colon]).

This morbidly obese 50-year-old patient, with a history of coronary artery disease twice treated by the balloon angioplasty dilatation technique, was seen at the HMO on 12/27 with a four-day history of vomiting, chills and fever, and a three-day history of "lower abdominal pain around umbilicus." She previously called (missing that record) and was told to take Mylanta (an antacid) but that gave no relief.

Prescribing medication by telephone for a patient with a new onset of symptoms of abdominal pain is negligent care. If she would have been seen at that time (assuming it was within two days of the onset of that pain), and properly examined, a detailed medical history obtained (usually appendicitis begins as crampy [wave-like] mid-abdominal pain that often localizes to the right lower quadrant of the abdomen, and at the time of perforation the pain usually substantially diminishes [the distension is relieved: the "balloon" bursts], and then recurs with greater severity), there would have been a high likelihood (with a required surgical consultation), that the correct diagnosis (or a high suspicion of appendicitis) would have been made before her appendix would have ruptured, resulting in a simple operation (appendectomy), a two-day hospital stay, and uneventful recovery.

Obtain that missing record (between 12/23 and 12/27).

Then she was seen in the clinic on 12/27 by "Provider #1" whose name and degree is missing. Was this a nurse, a physician assistant (P.A.) or an M.D.? Did an M.D. ever see her and examine her? With her history of chills and fever, vomiting, and "complaining of (c/o) lower abdominal pain around umbilicus x 3 days," and "took Mylanta (an antacid) as suggested without relief" and with the physical examination (inadequate and incomplete) showing "positive epigastric (upper abdominal) pain, a diagnosis of "epigastric pain" and prescribing Zantac (a stomach acid preventing medication), was negligent.

With her entire medical history including chills and fever, and the three-day history of persisting abdominal pain, an infection condition within her abdomen (appendicitis or diverticulitis: infection of the weak outpouchings of the large intestine like a miniature appendicitis) should have been at the top of the differential diagnosis list to be considered and "ruled out." A surgical consultation was required on 12/27. In my opinion, that would have resulted in her hospitalization and exploratory surgical procedure, removal of her appendix and drainage of a probable small and localized area of infection (abscess), if it had ever developed to that degree on 12/27.

The examination was deficient and negligent. No rectal and pelvic examinations were done. Under the circumstances of the medical history they obtained, those examinations were mandatory. However, based on her examination by a Surgeon at her hospital admission on 1/2, which was negative, it most likely would have been negative on 12/27.

That "health care provider" stopped her aspirin (ASA) therapy, a weak anti-coagulant (blood thinner) she required because of the two recent angioplasty procedures, and placed her at risk for a heart attack (myocardial infarction). Apparently, that person was going to call her Cardiologist concerning her aspirin therapy, but the result of that call is not noted or missing. She did not, based on these records, develop a heart attack although was almost in shock in the hospital and required blood pressure raising medication in the operating room and the Surgical Intensive Care Unit (SICU) in the Hospital #1. Has she undergone evaluations of her heart and were they compared to the ones done before this illness? Was there any change consistent with further heart damage?

Also, on 12/27, an abdominal x-ray series (lying and standing) should have been done based on her four-day history of vomiting, abdominal pain, chills and fever. It may have shown areas of ileus (gas filled small intestine adjacent to an area of infection), which is pathologic. It may also have shown a calcified fecalith (a bone like concretion within the appendix) which, considering her symptoms, would have been another "red flag." Once her appendix ruptured and the large abscess developed, it may not have been seen. It is the size of a small pea when it occurs.

On 12/29, there was a "phone encounter" with Dr. #1 concerning: "Diagnosis: Abd (abdominal) pain." This doctor did not examine the patient (over the telephone), and since she had some relief with Zantac, had her double that dose and: "Told her most likely gastroenteritis (inflammation of the stomach and small intestines)." That is a negligent way to treat a sick patient, who was now sick for six days.

Did Dr. #1 see her medical records from the clinic, and note what was not done? Do they earn more money by saving the HMO money by not taking x-rays, obtaining consultations, and hospitalizing patients? Obtain the contract of Dr. #1. Surgery even on that date, would have been less complex and less extensive. She would have had a shorter, and less physically and emotionally painful stay.

She was seen in their Family Practice Clinic by Physician Assistant #1 on 12/31. He noted her history and treatment with Zantac, and that her WBC (white blood count) was 17,500 (17.5) on 12/27. That is higher than the normal of 4,000-9,000. And on 12/29, it was 16.5 (about the same) and the differential smear of the type of white blood cells showed "80% seg, 2% bands." This is called a "shift to the left," consistent with a bacterial germ infection (seen in appendicitis and diverticulitis) and not a viral infection that usually causes gastroenteritis. What was the differential smear of the CBC (compete blood count) from 12/27? Obtain all their laboratory tests from 12/27, 12/29 and 12/31.

This "P.A." prescribed two antibiotics (Flagyl and Cipro). His diagnosis was diverticulitis. No M.D. appears to have seen the patient, but in their "Urgent Care records" of 12/31 she was seen by providers numbers 2 and 3. Who are they, what are their credentials and what did each do for and to her? That sheet notes she had increased tenderness in the "right mid-quadrant" of her abdomen without rebound (the pain elicited upon suddenly letting go after pushing in on the abdomen, and if positive, would be consistent with the infection touching the inside [peritoneum] lining of the front abdominal muscles). It does not rule out a serious localized abdominal infection (abscess).

Her "pain was 8 (out of 10)!! Her platelet count (clotting particles produced by the bone marrow) was elevated to 589 (two times normal), which put her heart arteries at risk for clotting (heart attack) as well as clotting in her leg veins (thrombophlebitis). When she was hospitalized, they properly used compression leg bandaging and the anticoagulant Heparin to prevent that complication.

Again, there was no rectal or pelvic examination, and no abdominal x-rays taken; further negligence. No Surgeon was called to see her; further negligence based on her entire history and all the findings. Surgery on that date would have been less involved.

On 12/27 her respiratory rate was approximately twice normal at 24. It was omitted on 12/31 (and, of course, could not be assessed by telephone on 12/29).

The use of the antibiotics may have prevented her from going into septic shock and dying, while her body enlarged the abscess cavity and cut off (by clotting) some of the blood supply to the last eight inches of her small intestine (terminal ileum which is the critical site for vitamin and essential nutrient absorption), placing her at future risk of a nutritional deficit form of "malnutrition." Have any blood levels of vitamins and minerals (tests) been done?

Although "diverticulitis" can sometimes be managed as an out-patient, based on her medical history and positive findings, she should have been under the care of a Gastroenterologist, who would have recognized the need for a surgical consultation, hospitalization and operation sooner than 1/2.

When she finally was hospitalized at the Hospital #1 on 1/2, she was very sick, dehydrated (with abnormal kidney function tests [BUN and creatinine] that returned to normal after she was treated by intravenous fluid resuscitation).

The CT scan of her abdomen showed "a high grade small bowel obstruction." The original Surgeon and the one who was requested to see her for a "second opinion" and who operated, recognized the urgent need for surgery that took placed on 1/2 from 1645 (4:45 p.m.) until 1930 (7:30 p.m.). Dr. #2 and Dr. #3 found: "There was no obvious fluid in the pelvis or the abdominal cavity; however, there was an extremely dilated proximal small bowel which was collapsed distally (from obstruction: blockage). As the small bowel was followed from the ligament of Treitz (where it begins) distally, it was stuck in the right lower quadrant. As these loops of bowel were extracted, a large abscess cavity was entered and approximately 450 cc (15 ounces) of purulent fluid (pus) was evacuated. A large abscess cavity was noted and was composed of the sigmoid (colon) laterally (on the left side), several loops of small bowel (intestine), the cecum (beginning of the large intestine, at the site of the ilium and appendix connections), and pelvic wall. The distal illeum, which composed a portion of the wall of the abscess cavity, was necrotic (gangrenous) because several (blood) vessels had thrombosed (clotted off secondary to the long-standing infection)."

They excised eight inches of the damaged ileum and two inches of the cecum with the perforated appendix ("the tip had been autodigested" from the infection and delay). The pathologist confirmed these findings grossly and did not find appendicitis microscopically because it (the blocked tip) had fallen off and had "autodigested."

Her unstable condition required blood pressure raising medication and the use of a ventilator, to save her life. The incision (a long midline one rather than a short diagonal one for an appendectomy) had to be left open until prior to her discharge on 1/13, at which time it was closed with tape strips.

All of her care at the Hospital #1 was excellent.

Her care by the health personnel of the HMO and that health care organization was negligent for all the reasons stated above. She should have had a surgical consultation and timely surgery which, depending on what the missing records show and upon a clarification of the onset and nature of her pain, may have resulted in an appendectomy even before its rupture, and certainly surgery before this large abscess developed, which destroyed her terminal ileum, requiring its removal and future nutritional consequences.

Also, with that extent of infection and surgery she had to undergo, there is an increased risk of intestinal obstruction (locked bowels), as if someone had poured rubber cement into her abdominal (peritoneal) cavity, creating bands of adhesions (fibrous web-scar tissue involving her small intestines). Is she having any symptoms of crampy mid-abdominal pain with distension? If so, that would be consistent with episodes of partial obstruction. But even without symptoms there is a higher risk from their negligent delay, and as she ages, based on her age, heart disease and weight, her risk of complications from future surgery for intestinal obstruction (should it occur) is much greater than average.

Her emotional damages from all the negligence and future potential risks should be assessed by a local Psychologist who can also administer psychological tests that are objective evidence for those damages.

She should be seen by a Gastroenterologist to evaluate her nutritional condition.

I would suggest the following Experts which our Firm could supply: General Surgeon, Gastroenterologist and Infectious Disease Physician.

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Recurrent inguinal (groin) hernia operation causing gangrene to the testicle and chronic nerve pain.

An inguinal hernia in a male comes in two types: indirect and direct. The indirect hernia is related to fetal development, where each testicle which normally originates near each kidney, finally moves down into the scrotal sac just before birth. Sometimes it will drag a part of the lining of the abdominal cavity, (peritoneum) with it, and if it remains open, is a potential space for the intestines to push into that site. Surgery peels off that peritoneal sac from the spermatic cord which contains the blood supply to the testicle, its sperm duct (vas deferens) and some muscle.

If the sac closed off at the abdominal side but remained open along the spermatic cord and/or next to the testicle, it can fill with fluid. That is a hydrocele.

If the hernia develops later in life, it usually is a direct hernia where the muscle wall of the abdomen is weak, and the weakest site is from the muscles surrounding the spermatic cord that passes through.

With any inguinal hernia operation, the standard of care is to try and identify and protect the two nerves in that location, each about the size of the lead in a number 2 pencil. These are the ilioinguinal nerve that sits on top of the spermatic cord, and the iliohypogastric nerve, somewhat more toward the midline. Severing these nerves causes localized numbness in the pubic and upper scrotal areas, that usually diminish over time as other skin nerves take over their function.

Suturing either nerve at the time of surgery causes persistent pain that is present as the patient awakens from the anesthesia. If either nerve is trapped in developing scar tissue, then the pain will begin days or weeks later. If the patient strains and causes nerve injury from its attached natural scar tissue, that pain can also develop even months later. Furthermore, although the use of a nylon (prolene) mesh strengthens the repair, it does not prevent all recurrences and causes more scar tissue at the operative site and to these nerves, too.

According to the medical records, this patient had a right inguinal hernia operation at age 10. I have not seen those records.

Any hernia operation (herniorraphy) will create scar tissue and make any subsequent operation more difficult and often obscure the location and identification of these nerves.

On 6/2/1997 Dr. #1 had this patient referred to him for surgery for bilateral (both sided) inguinal hernias. He discussed the proposed operations using mesh, which is more commonly done with adult surgery, especially if they had a recurrent hernia and/or if both sides were going to be operated at the same time. He said: "The procedure and potential risks and benefits as well as the infection (sic) were explained to the patient."

At surgery he found the expected scar tissue on the right side which was excised (cut out). He had a large direct inguinal hernia on each side and he repaired it with the use of mesh. He did not note in his report finding and protecting both nerves on either side. However, the only pain he developed was on the right side, and those nerves would often be entrapped in scar tissue as I have explained above.

Sometime after that operation he developed pain in the right groin, but when, is unclear.

On 4/14/1999 Dr. #1 had the Anesthesiologist inject a numbing medication to try to treat the pain and identify its source (help to diagnose the cause of this pain). This nerve block did not help.

Dr. #1 performed surgery on 4/16/1999 for a recurrent right inguinal hernia and pain. It was believed the hernia was the cause of his pain, since the nerve block, which would usually numb those local nerves, was unsuccessful. At surgery he found that "the ilioinguinal nerve was trapped to the mesh and the scar tissue of the external oblique aponeurosis (the fibrous flesh of the muscle over the nerve and spermatic cord). He freed up the nerve "completely" by "neurolysis" (freeing up the scar tissue surrounding that nerve). He also re-repaired the direct inguinal hernia by sewing the musculo-fibrous flesh around the spermatic cord as it passes through the abdominal muscles. Care needs to be taken not to snug (tighten) the repair too much, because it can squeeze off the blood supply to the testicle. Usually the Surgeon tests the remaining space with his fingertip or the end of a clamp (hemostat). However, this is much more difficult to determine with a recurrent hernia operation, and this wa s his second recurrent operation (third operation on that side).

He developed pain in the operative site or testicle. When it began is not noted, nor is any swelling documented. If the hernia repair was too tight, often the scrotal area (including the testicle) will swell up immediately after surgery and that will persist for days or weeks. If the arterial blood supply in the spermatic cord is damaged at surgery, it will often result in a painful and gangrenous testicle. However, that could be an unavoidable risk because the spermatic cord with its blood supply would also be trapped in scar tissue and would have to be freed up. Injury to its blood supply would be a maloccurrance, and not negligence.

The patient had an ultrasound study done on 5/13/1999 that revealed no blood flow to the right testicle. Dr. #2, a Urologist, operated to remove that gangrenous testicle on 5/14/1999. He confirmed no blood flow and the gangrenous testicle flesh, also confirmed by the Pathologist. This incision was through the scrotum and he removed as much spermatic cord as was possible, and met the standard of care.

Unfortunately, his right groin pain persisted and two nerve blocks with a local anesthetic by Dr. #3 did not help so he underwent explorative surgery on 8/12/1999 at which time everything was encased in scar tissue. He removed much of that scar and what he hoped was the end of the spermatic cord and adjacent ilioinguinal nerve (although he did not see them in the scar tissue). The Pathologist found acute and chronic inflammation of the removed flesh, but could not specifically identify the spermatic cord or nerve.

On 8/23/1999 he was pleased with his pain relief. However, on 12/1/1999, after straining at work he developed severe right groin pain. He had a nerve block injection and as of 12/8/1999 "he had much improvement of his pain at this time."

For all the reasons stated above in detail, I do not find substandard care as the proximate cause of his recurrent and persistent pain, recurrent hernia, or gangrenous testicle. The left testicle it usually larger and can usually supply adequate sperm for fertility (which can be assessed by a sperm count), and the male hormone, testosterone (which can be evaluated by its blood hormone level test). If his testosterone level becomes deficient, hormone therapy is available.

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Repeat neck operation to remove lymph nodes for cancer diagnosis, causing damage to the spinal accessory nerve and paralysis to the trapezius muscle.

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Thyroidectomy operation with post-operative hemorrhage (bleeding) causing blockage of airway, delayed resuscitation, and death.

This is a tragic case and may have been preventable, as I shall discuss in detail below.

In 1993, she underwent a hysterectomy operation for the removal of a huge (2,590 gram = 5.5 pound) uterus. She was noted to have an enlarged thyroid gland, which was producing a normal amount of thyroid hormone (euthyroid). At surgery, the Anesthesiologist who inserted the endotracheal tube for ventilation and anesthesia had no difficulty but noted, "Trachea (windpipe) deviated to the right due to thyroid."

Apparently, there was a recent increase in size interfering with her swallowing (dysphagia). Surgical removal of most of that thyroid gland was indicated and performed by Dr. #1 on 11/30/98. The operation was difficult because of its large size and partial extension into her upper chest. At the end of that operation, a "final check was made for hemostasis (control of bleeding). No active bleeding points were seen." Most Surgeons would have inserted a wick drain to allow any accumulating blood to escape (but the clots remain) and serve as a visual indicator of excessive bleeding at the operative site, especially because of the difficulty of that procedure and therefore, the greater risk of postoperative bleeding.

Delayed postoperative bleeding is a known and feared complication for exactly the reasons in this case. The standard postoperative order is to have a tracheostomy instrument tray at the bedside in order to rapidly cut the sutures and release any blood clots causing choking of the patient, and if necessary to cut a hole into the windpipe to insert a tracheostomy breathing tube without any delay. I have not seen those Doctor orders.

All the Hospital records from admission until her death on 12/8/98 should be obtained and certified complete in the order that they keep them. Also, be sure they give you all the cardiac arrest/resuscitation records and all incident reports.

According to a consultation by Dr. #2, on the evening of 11/30, she had some respiratory distress and was transferred (by Dr. #1) to the Intensive Care Unit. She did not have any noticeable neck distention, respiratory distress or stridor (partial blockage of her airway). "But at approximately 5:00 a.m., she sat up in bed to use the bad pan (for urine or stool?) and developed acute respiratory distress which was followed very quickly by a respiratory arrest. Dr. #3 (who is he and what was the extent of his training on that date?) was then called, arrived and attempted to intubate the patient (put a tube through the mouth into her windpipe), but was unsuccessful secondary to a large amount of heaped up mucosa (swollen flesh lining her throat) and no vocal cords visible. The patient was mask ventilated at that time. Anesthesia was called (at what time and when did they arrive?) and intubated the patient on the first attempt. Immediately after the intubation, the patient had bradycardia (slow heartbeat from lack of oxygen) and then asystole (no heartbeat).

How long did Dr. #3 persist in trying to get that endotracheal tube in? How many attempts and exactly how long was each attempt? One must ventilate the patient adequately between attempts and it appears that a mask/bag ventilation was successful. Therefore, why did she have a brain death (anoxic encephalopathy) proven clinically and by CT scan? Did he over-persist in trying to put the tube in and not properly ventilate her? It appears to be the case. What was his/her expertise in intubation at that time? What other Doctors were in, or on call, to the ICU at 5:00 a.m. on 12/1? Why didn't he cut the sutures and evacuate the clots while someone was using the mask/bag ventilator? Who else was present and what did they do, not do and see?

Physician Assistant #1, noted in a consultation that "it is documented in her chart that she had pulseless electrical (heart) activity for 10 minutes."

In a detailed discharge summary, Dr. #1 saw her postoperatively and "She had a strong voice and no apparent swelling. At that time, the patient was complaining of some tightness in the neck. This was expected in light of the extensive dissection (separation of layers of flesh in surgery). At approximately midnight, I was notified that the patient was having some tightness in the throat. The Nurse did not feel that the patient was in any significant distress at that time, but given the extensive nature of the operation and the fact that significant postoperative swelling can ensue, the patient was placed in the Intensive Care Unit (good care). I placed a phone call to the head Nurse in the ICU to explain the reason for the transfer and explained that patients such as this can have upper airway problems, namely obstruction and the intensivist (who was that doctor and was he/she in the hospital?) should be made aware of this patient and the potential for this problem (good care). At approximately 2:00 a.m. I was called again by the ICU stating that the patient had some more tightness in the neck, but was resting quietly. (He failed to have a Doctor see her and report their findings to him if there was any problem. That is bad care.) At 5:20 a.m. I was called and told that the patient had a respiratory arrest. Apparently the intubation had been very difficult."

Many details are needed and I need to see the entire record to see what it shows and does not show.

He took her back to the Operating Room on 12/1 and found a total of 100 cc (3.5 ounces) of blood clots, both superficial and deep. Also, "The patient had active bleeding from a blood vessel (artery or vein??) where the strap muscles (superficial neck muscles over the thyroid gland) had been reapproximated (after they had to be cut to take out her thyroid gland).

Postoperative bleeding is a known and often unpreventable complication. However, if she was straining to pass feces (stool) on the bed pan, and was not given an enema by the Nurse, that would be negligent since it would markedly raise the venous (vein) pressure and could cause a ligature to pop off or expel a clot (thrombus) that had sealed off a vein, and raise her blood pressure and dislodge a clot in a small artery.

Did she take any aspirin within a week of this operation and was she warned not to? That significantly increases the risk of bleeding but at the first operation on 11/30 the blood loss was only 100 cc (3 ounces).

Her husband visited "during this course and developed acute chest pain. He subsequently had to be emergently cardiac catheterized and was found to have significant disease." He underwent a PTCA (percutaneous trans-luminal coronary (artery) angioplasty), balloon dilation procedure to open up a very narrowed coronary artery. His disease was from long-term meat and dairy consumption and? smoking. But the shock precipitated the need for his procedure.

After she was confirmed brain dead by a "flat EEG," she was evaluated to be a heart donor and she underwent a cardiac catheterization that showed "non-obstructive coronary artery disease in the proximal left anterior descending (artery)." She would have lived a long longevity.

Was an autopsy done? If so, obtain that complete report. Was she a heart donor?

For all the reasons stated there appears to be negligence on the part of Doctors #1 and #3 and the Hospital through its Nurse employees. I need to see all the records to further clarify this opinion and then suggestion additional discovery as I noted throughout this report.

At the appropriate time, I would recommend that you authorize us to obtain the Expert opinions of a General Surgeon (with thyroid surgery experience), an Intensive Care Unit Physician Expert and a Nurse with Surgical Intensive Care Unit experience, and possibly an Anesthesiologist, depending on my findings in the entire set of records.

Does her husband also have a claim for his emergency cardiac problems witnessing his wife in an acute coma amidst all that turmoil?

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Cancerous groin lump misdiagnosed as an inguinal hernia.

At age 46 this male patient noticed a lump in his left groin and was referred by his private doctor and Physician's Assistant to a Surgeon, Dr. #1, who believed it was an inguinal (groin) hernia. That is a weakness in the abdominal muscles through which pass the spermatic cord containing blood vessels and the sperm duct for that testicle. The intestines can bulge outward with straining, making the hernia's presence known and may cause some discomfort. However, with lying down, it will reduce (the intestines will go back into the abdominal wall cavity). If it does not reduce, we call it "incarcerated" and that requires an urgent operation because that segment of the intestine's blood supply can become blocked, causing death of its flesh, perforation, infection, and potentially patient demise.

When Dr. #1 examined him he concluded he had a hernia, and since the patient wanted to go hunting, he suggested the patient contact him weeks later. Obviously it was not an incarcerated hernia in the doctor's opinion. However, his physical examination was substandard in that he did not document that this lump was inconsistent with a hernia, and more consistent with an enlarged lymph node (lima bean shaped bodily fluid filter). The differential diagnosis would include an inflammatory reaction, but he had no infection in his leg and was not scratched by a cat. Therefore lymph gland cancer (lymphoma) should have been high on his differential diagnostic list.

As a timeline, on 10/10 the physician assistant felt a weak ring (site at the spermatic cord's passage through the muscles). On 10/14 the surgeon believed he had a hernia. On 11/20 the Surgeon spoke to the patient on the telephone and scheduled the hernia surgery for 12/4.

Initially he tried to operate with a local anesthetic, but since that was not totally effective they added a general anesthetic, which allowed surgery without pain. He describes performing the inguinal herniorrhaphy operation uneventfully and used a piece of mesh to aid the repair. No mass was looked for or found. Since the lump was large, in my opinion Dr. #1 was also negligent on 12/4 for failing to remove it for a definitive biopsy.

On 1/19 (six weeks later) he was referred to a Clinic where they noted that enlarged lymph node and its failure to respond to 10 days of antibiotics. They had him seen by their surgeon, Dr. #2 on 1/29 who obviously found it and the patient claimed it was "getting bigger." It was the only enlarged lymph node palpable, was "in the left groin beneath the inguinal crease on the left side." That would be about one inch below the hernia incision, but with the hernia operation, the layers of flesh are peeled back to that site, so it should have been more easily felt and seen.

At the 2/6 operation he said: "The node appeared to be quite massive measuring approximately 4 x 4 x 8 centimeters (one inch = 2.54 centimeters). The bottom of that lymph node extended around the saphenous vein and its adjacent femoral vein and artery. He correctly cut into the lymph node, leaving behind the part that was dangerously entwined with those blood vessels. The Pathologist noted the flesh removed in total volume measured 5 x 5 x 3 centimeters with the largest piece up to 4 centimeters in maximum diameter. He concluded that this was a lymphoma (lymph gland cancer), a non-Hodgkin's lymphoma. A consulting Pathologist agreed and put it into the category of a Burkitt-like lymphoma.

Studies showed that the only identifiable site for cancer also involved the lymph nodes nearby, the iliac lymph nodes in the pelvis. None was found elsewhere.

He underwent chemotherapy which gave him a complete remission (absence of any noticeable disease), had blood clot in his leg that broke loose and flowed into his lung (pulmonary embolus), and within a few months had this cancer involve his lower thoracic (chest) spine and lumbar spine for which he also had chemotherapy placed in to his spinal fluid for proper therapy. And within a year of his lymph node biopsy operation underwent a bone marrow transplant from his brother, with apparent successful results at the end of a few months, and no cancer seen in his spine by the MRI examination. There is a risk of recurrence.

In my opinion, Dr. #1 was negligent in his physical examination in October, again negligent in that examination prior to surgery in December, and at that operation, for the reasons stated above. This caused a two to three month delay in the correct diagnosis and therapy. During that time, this medium to high grade (aggressive) cancer (growing rapidly physically and by microscopic examination with mitotic [cell dividing] figures seen) increased to some small degree the amount of cancer cells ("tumor burden") left behind that would make the chemotherapy somewhat less successful. It to a small degree increased the risk of that cancer spreading to his spine, causing his temporary paralysis (which responded to steroids and chemotherapy), and slightly increased the need for the bone marrow transplantation procedure.

However, the defense will correctly point out that those other (iliac) lymph nodes were most likely involved with this cancer, and because of the short interval (8 months from the operation, or 10 to 11 months from when it should have occurred: that is a 2 to 3 month negligent delay), the cancer cells had most likely already spread to his spine and were stunted in their growth by the initial chemotherapy.

All of the care after the hernia operation was good. The care by his private Physician and Physician's Assistant also was good.

To proceed in this case I would first suggest that you authorize us to obtain an Expert opinion from one or more Oncologists to see to what degree they would testify that a 2 to 3 month delay contributed to his increased risk of failed therapies and need for the bone marrow transplant. If that opinion is as strong as you prefer, then I would also suggest an Expert opinion by a General Surgeon concerning the negligence of the first Surgeon.

I suggest that the patient be evaluated by a local Clinical Psychologist with courtroom experience for any residual emotional (psychological) damages. Administration of standardized tests such as the M.M.P.I. (Minnesota Muliphasic Inventory) which have been given to millions of people would further support that opinion before a jury.

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Mistreated diabetic foot ulcer resulting in amputation.

This obese, non-insulin dependent diabetes mellitus (NIDDM) patient of 25 years developed an ulcer/blister on the bottom of his right foot which became infected, and resulted in an amputation of his foot, and then leg below the knee.

Diabetics have an impaired immune system and large artery and small artery disease (blood vessels carrying the red oxygenated blood and antibiotics to their flesh). When there is any infection of the foot, all the pulses in both legs have to be assessed by feel (palpation). These include the femoral pulse in the groin, popliteal behind the knee, the posterior tibial inside side of the ankle and the dorsalis pedis on the top of the foot. If they can not be felt, or if there is any question, then a blood flow meter (doppler ultrasound) is used to measure the arterial flow. Also capillary refill, measuring the quality of blood flow to the toes is easily tested by pinching the toe nail and then seeing how many seconds it take to "pink up" again. Normal is a few seconds. None of this was done, and is negligent.

On 3/6 he initially had problems with his left leg (painful swelling from his knee to top of his left foot). There was 2+ (out of 4) edema (swelling) of his right lower leg (pre-tibial: shin bone). They did a venous (not arterial) study of his left leg and the veins were patent. There were no blood clots.

On 3/13 he had his nails trimmed and that podiatrist noted: "Vascular DP/PT (dosalis pedis/posterior tibial) bil (bilaterally: both legs) CFT (capillary filling time) less than 3 seconds x 10 (all 10 toes). Based on this, his major arteries were patent, and the microcirculation to his toes was normal. Therefore, I would conclude that it would not dramatically change in 10 months. This means he had a much better opportunity to heal the neglected infection with proper intensive care.

He had varicose veins (distended veins with damaged one way valves) which most likely was the cause of his swelling. The fact that they noted it was "postural" is consistent with that chronic venous problem. Elastic stockings (Ted hose) were correctly prescribed.

The inflamed flesh (cellulitis) on the front of both knees was successfully treated with the antibiotic Keflex.

On 4/2 his venous stasis dermatitis, from his chronic venous insufficiency, was resolving.

On 7/28 the Podiatrist noted that he had flat feet and wears orthotics (arch supports). Did they cause the blister? Were they properly fitted? Did he use them?

On 9/8 blisters had popped and were draining on his left leg. He had a shallow ulcer on his left shin and was treated with the antibiotic Keflex. This is acceptable care. This ulcer had dried up by 9/18. They continued his diuretic medication (Lasix) to try to control his chronic fluid swelling (edema) condition. This is acceptable care. On 10/1 he was "doing better". His blood sugar levels were under good control at home. There was 3+ edema of his left leg and 2+ on the right.

On 10/1 the dermatologist ordered greater strength compression bandages to 30 millimeter pressure. This is good care.

On 10/2 the Podiatrist noted "Infected plantar area" of his right foot, prescribed the broad spectrum antiobiotic Cipro. But, no pulses were tested. No capillary refill was evaluated. He was sent to the Primary Care Clinic that same day. The Physician Assistant noted that this was a new problem for this patient and: "bottom right foot is an = 4 centimeter (1 inch = 2.54 centimeters) blister type lesion with white skin - it appeared it possibly has pus but none was expressed (squeezed out). This appears to be a resolving blood blister". He continued the antibiotic and told him to keep his foot clean and to "stay off foot". No pulses or capillary refill were checked. He was to return on 10/9.

On 10/9 "No infection was noted and it appeared to be an old blister of some sort". It had resolved. Did his shoes and/or orthotics cause it??

On 10/23 he returned to the Primary Care Clinic and the doctor noted: "Area in right foot has now opened". It was 15 by 10 millimeters (25 millimeters = one inch). And "there is also an area where patient pulled off skin with tape". The loose skin was debrided (cut off). No therapy was prescribed and he was given and appointment to return in two weeks. Both are negligent. This raw open ulcer needed topical antibiotic therapy to prevent an invasive infection, and he should have been seen in a few days (or home visiting nursing care arranged on a daily basis). No instructions to return if any change occurred was recorded in that clinic visit record.

He returned as scheduled on 11/10. Apparently he had been taking Afloxacin 400 milligrams, two times a day. Who prescribed it, where, and when? Was it the previous prescription, refilled? Antibiotics should not be given as a refill. Patients who need more antibiotics need to be seen by a doctor. That note said: "May need debridement". He had "right foot pain". That is an ominous change in a diabetic patient who often have nerve damage and decreased pain sensation.

The doctor said: "Patient was changed from Cipro to Ofloxacin more than two weeks ago". The Podiatrist said to continue the Ofloxacin. And the note says: "Patient feels the Ofloxacin not as good as Cipro. He's had increased drainage since medication change". And no doctor saw him for two weeks!

The note went on to say: "bottom right foot with black eschar (scab/dead skin), foul smelling wound, no change in size (except now it extended deeper into his foot)". The doctor planned to change the antibiotic to Cipro and "refer to dermal wound clinic" and RTC (Return to Clinic), which is a grossly negligent note and plan. He required immediate hospitalization, operative wound deep debridement and intensive intra-venous (by vein) antibiotics, so a higher blood level could be achieved to help kill the germs.

All of this had a strong chance of being avoided if, with a raw ulcer, he would have been seen more often and carefully instructed to return with any changes: pain, fever, red streaks up his foot or leg, drainage, or wider or deeper progression. This note above was certified by a Physician Assistant (PAC) #1. How did he ever become certified and put in that clinic? He was not fit for the purpose intended as it relates to this patient. Obtain all his schooling and previous and current employment records.

As is common in my experience in reviewing records from our government's hospital system, often key records are missing. Obtain the Dermal Wound Clinic and all records until his November 13 hospital admission. Also obtain the missing admitting history and physical, first operative report, both surgical pathology reports, and all nurses notes and all records until the day after the second operation. Have them sequentially number them, and certify them to be complete.

On November 13 he was admitted to the Hospital #1 with: "…a 3 to 4 centimeter (1 1/5 to 1 3/5 inch) ulcer on the plantar aspect of the fight foot that was fluctuant (soft because of pus within) with necrotic (dead) muscle underneath, and a foul odor".

He received intra-venous antibiotics, and on November 14 his foot was amputated. On November 20, because of persistent fever and infection he had a below the knee amputation. His stump healed.

He was next hospitalized at the same hospital because of "osteomyelitis (bone infection) left ankle" and received six weeks of IV (intra-venous) antibiotics. He was admitted with left ankle pain and the x-ray showed osteomyelitis and his foot revealed an obvious charcot joint (bone destruction in a diabetic caused by decreased nerve sensation to feel pain and joint position while walking).

This time it appears they did the right thing and even cured osteomyelitis which is difficult to cure. Therefore, I also conclude that if they would have treated him properly (timely and intensively) for his right foot infection of "soft tissue" (skin and fat and eventually, from neglect, muscle) he would not have needed an amputation. He would be walking on his own two legs, instead of one leg and a prosthetic leg.

For all the reasons noted above, his treating Physicians and Physician Assistants, and the Hospital #1 and Clinic, were negligent, and their negligence was the proximate cause of his amputation.

I would recommend Experts in the fields of Infectious Disease, Podiatry and General Surgery. They are available through our Fee Schedule.

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Colon surgery, postoperative hemorrhage and large gauze sponge left behind.

With any surgery the standard of care requires that the surgeon and their assistant not leave any sponges (gauze pads) inside the body. The standard of care also requires the operating room nurses and technicians maintain an accurate count. If any instrument, sponge or absorbent cloth pad is missing, an immediate x-ray is required and its removal through the original incision is required. Foreign bodies can increase the risk of infection (it takes fewer germs to potentiate an abscess) and increases the risks of scar tissue. This scarring, in some locations, can increase the risk of intestinal obstruction ("locked bowels").

At age 49 he strained at work and saw Dr. #1 on 2/3 who diagnosed a right inguinal (groin) hernia. Surgery on 2/14 revealed a benign fatty tumor (lipoma) of the spermatic cord. This is a common finding and can be reasonably confused with a hernia. He did have some muscle weakness, an early direct inguinal hernia, and it was correctly repaired with the use of nylon mesh and sutures. He recovered without complications.

From 3/10 to 3/14 he was hospitalized with a kidney infection and had kidney and ureteral stones (in the tube that conducts urine from the kidney to the bladder). The CT scan "showed a question of diverticulitis" (large intestine inflammation). No other pathology was seen. There were no enlarged lymph nodes or enlarged spleen. This conservative care was good.

On 5/16 a follow-up CT scan raised the potential for colon (large intestine) cancer. The colonoscopy (using a flexible lighted telescopic device) found a stricture (narrowing) and could not fully evaluate the colon.

Because of all of the above, surgery was indicated to remove that part of his sigmoid colon (large intestine). Inside his abdomen, no cancer was felt or seen in liver, spleen, or lymph nodes. The frozen section (immediate biopsy) was negative for cancer and the 23 centimeters (10 inches) of his scarred sigmoid colon was correctly removed.

Just after his abdomen was sutured closed, there was evidence of abdominal hemorrhage (low blood pressure: mild shock), so his abdomen was re-opened by taking out the suture. The blood was removed and the entire abdomen was inspected. A bleeding sigmoid artery was sutured.

Postoperative bleeding of this nature is not negligent. Arteries do go into spasm and sometimes spontaneously stop bleeding, and since they are often covered by intestinal fat, are not seen and not sutured. The body does dislodge clots and starts to dissolve them. This results in postoperative bleeding. This was timely recognized and controlled.

At all intra-abdominal operations, laparotomy ("lap") pads are used. They are cloth washcloths 13 x 14 inches (33 x 35 centimeters). They have a six-inch long cloth corner tab that is usually secured at its end by a hemostat (self-locking pliers) which is left to hang outside the abdomen to decrease its risk of loss. Even if a clamp is not used it must be counted before, and two times after use by the operating room technician and nurse. Those records are missing. Leaving that "lap pad/tape" in his abdomen was a clear departure from the standards of care.

Although the initial pathology examinations did not find colon cancer, there were abnormalities of the lymphocytes (a form of white blood cell). Sophisticated studies eventually (by 9/20) revealed a non-Hodgkin's lymphoma (lymph cell cancer).

On 6/1 the same surgeon, Dr. #2 reoperated after an abdominal x-ray revealed the presence of the lap pad. It was located above the spleen (between the spleen and the diaphragm: breathing muscle separating the abdomen from the chest). It was easily removed. No intestinal scar tissue would form from its location. No abscess (infection) was noted nor developed. The abdomen was re-closed using the original "running suture." All this is good care after the negligently retained "sponge" was found. It did not complicate his care.

Even if it was left behind during the immediate re-operation for hemorrhage, that does not excuse the surgeon, the assistants, the hospital employees, and the hospital. If there was any question a full abdominal x-ray should have been taken in the operating room. It is radiopaque (shows up on an x-ray).

At that colon surgery they felt a prostate nodule, which was correctly biopsied on 7/19. It was benign (not cancer).

Because of his recurrent kidney stones, tests were done which revealed a para-thyroid tumor adjacent to his thyroid gland, in his neck. It was correctly removed on 8/31 and was benign. Because of his diagnosis of non-Hodgkins lymphoma (a diffuse lymph gland and lymph cell cancer) he had a Port-A-Cath indwelling venous catheter and device inserted for chemotherapy. This also was good care.

The only issue is the negligence of leaving that "lap pad" behind on 5/26 which required another abdominal operation on 6/1 to remove. That caused added pain, suffering, and expense, and a few extra days of hospital stay.

The defense will contend that there was an emergency operation from the hemorrhage and that the "lap tape" location was not in easy view or easy to feel. That is no excuse, only some defense jury appeal. They will correctly claim that it had no long-term effect on his health.

To proceed in this case please supply all the intra-operative and peri-operative records from 5/26, and a copy of the x-ray and report that revealed its presence. Obtain the hospital protocols for sponge, lap tape and instrument counts. You may want to obtain all the personnel records from all the responsible staff from that 5/26 operation. Obtain their training school records, previous employer, and subsequent employer (if any) records as well as all incident reports.

I suggest that the patient be evaluated by a local Clinical Psychologist with courtroom experience for any residual emotional (psychological) damages. Administration of standardized tests such as the M.M.P.I. (Minnesota Muliphasic Personality Inventory) which have been given to millions of people would further support that opinion before a jury.

We can supply General Surgery and Nurse Experts pursuant to our Fee Schedule.

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Breast biopsy with gauze sponge left behind, causing a chronic infection.

At age 44, on 5/18 this patient had an abnormal mammogram (her first one, and was a screening study since there was no mass felt). It showed microcalcifications and was interpreted as: "Suspicious abnormality -- biopsy should be considered." That was a reasonable suggestion.

On 6/11 she had a wire inserted into the abnormal site by mammography and through a 5 centimeter (2 inch) incision had a 1.2 x 5.3 x 3.3 centimeter piece of breast tissue excised. The specimen had a mammographic examination to confirm that the suspicious area was removed. The pathologist confirmed that it was benign and contained the calcifications, but also was diseased with "papillary apocrine metaplasia" and "florid ductal hyperplasia" that some consider potentially pre-malignant.

Surgery was performed by Dr. #1 with the assistance of Dr. #2, who dictated the report, and at this teaching hospital may have actually performed the surgery under supervision. Did Dr. #1 remain until the skin was sutured closed? The operation was under local anesthesia. The scrub (sterile) Nurse was #1, the circulating Nurse (who obtains supplies as needed and handles the specimen) was #2, and the O.R. Attendant was #3 (what was that person's role?). The initial and first (and last) sponge count were by "#1 and #2" each time and is checked off as "correct." That was in error, and is negligent.

If the Surgeon and his Assistant properly did their job, the Raytex gauze sponge, a sterile gauze with a radio (x-ray) opaque wire (thread) would not have been left deep within her breast biopsy site. If the nurses counted correctly, the missing sponge would have been documented and the Surgeons would have reopened the sutures, or obtained a breast x-ray which would have shown its presence, resulting in reopening the sutured surgical incisions, removing it, and resuturing that wound, with no complications.

Although the Operating Room is a sterile environment, germs are present in the air and even on the skin of the patient (in sweat glands) and on the skin of the surgeon under his gloves as time passes, and needle punctures do occur. When any foreign material is in the body and is exposed to any germs, it takes about 1000 times fewer germs to initiate and prolong any infection. The body has difficulty fighting any infection in the presence of this foreign material (Raytex gauze sponge), and once infection sets in, it will not be cured until the gauze is removed.

Initially it seemed as if she had a common wound infection. But after not responding to time and antibiotics (and initial drainage on 6/19 in the Emergency Department), she came under the care of Dr. #3 on 8/18 and in the office had an incision and drainage where he reopened the incision and found: "a 4 x 8 surgical Raytex sponge is pulled out, covered with purulent material (pus)." He preserved it in a jar. He gave good wound care and it eventually healed, with it almost healed by 9/1.

These Raytex sponges are exclusively used in operating rooms. However, obtain billing and other records from the Emergency Department to confirm exactly what type of sponge gauze they used, and how she obtained her wound therapy supplies, and what they consisted of.

In my opinion, the Surgeon, the Assistant, the Operating Room Nurses and Technicians and their employer, Hospital #1 were negligent for the reasons stated above, and their negligence was the proximate cause of her contracting a persistent wound infection which lasted more than two months. Also, the residual scar may be more misshapen from scar tissue formation and contracture than it otherwise would have been without the infection.

It was not negligent for them to treat her for a limited wound infection for 4 to 6 weeks, before an incision and drainage (I&D) would be needed, and to re-culture the pus to identify the type of germ(s) and the best antibiotics to use. However, once the gauze was found, it had to be removed without delay, and would allow her body to heal.

After you obtain the answers to the questions I raised, and photographs of the wound with the patient lying, sitting, and bending over (from different views), I would suggest that you authorize us to have all these records reviewed by Experts in General Surgery, Infectious Diseases, Nursing, and Plastic Surgery.

I suggest that the patient be evaluated by a local Clinical Psychologist with courtroom experience for any residual emotional (psychological) damages. Administration of standardized tests such as the M.M.P.I. (Minnesota Muliphasic Personality Inventory) which have been given to millions of people would further support that opinion before a jury.

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