Head and Neck Surgery Sample Case 1.pdf

Over the next few months we will be adding more sample cases, covering all topics of Medical Malpractice.   Please check back very soon!

Head and Neck Surgery

• Premature removal of a neck lymph node and irreversible spinal accessory nerve damage with trapezius muscle paralysis.

Premature removal of a neck lymph node and irreversible spinal accessory nerve damage with trapezius muscle paralysis.

This case poses two questions: 1) Was the operation indicated? 2) Was it properly performed?

When a patient presents with an enlarged lymph node (bacterial filter of bodily fluids), a number of questions must be resolved before any operation takes place. In the hospital records it states: "Two enlarged lymph nodes - right side of neck - Noted two days ago." The checklist for physical examination says everything is normal on that "Short Form History and Physical Examination," except "two enlarged lymph nodes."

When and where did that complete physical examination by the Surgeon take place, including listening to his heart and lungs, feeling his abdomen, doing a rectal examination, examining his eyes, ears, nose and throat, etc?

First of all, the preoperative diagnosis on the Hospital #1 operative report says, "To rule out lymphoma" (cancer of the lymph system which includes all the lymph nodes of the body and spleen which can significantly enlarge). That is one reason a complete physical examination, including feeling for enlarged abdominal organs including the spleen is mandatory, and feeling in both inguinal (upper leg / groin) areas and axillae (armpits) for enlarged lymph nodes and a complete examination of the nose, mouth and throat for any signs of cancer must be done first.

The Surgeon's office notes are negligently deficient in that they only say: "Ref. Dr. #1 (obtain all of their medical records for this patient), 9/2. Complaint two lumps of neck; two lymph nodes right side of neck, Sept 9 (date for surgery)." Where in the neck? The anterior or posterior triangle? What size lymph nodes? Mobile or fixed? Tender or nontender? Any history of recent head, throat or ear infection that can usually cause a temporary enlargement of lymph nodes?

Thus, the medical history and physical examination are negligently grossly deficient.

Next, what is the result of the Complete Blood Count (CBC) and differential smear to look for infection, cancer of the blood (leukemia, etc.) and allergies? The failure to do it and note its results is also negligent.

One of the standard evaluations when considering a "lymphoma" is a chest x-ray to look for enlarged lymph nodes in the central area of the chest. The failure to obtain that study and note its results is further negligence.

He noted that the patient had insurance, thus he would get paid for this grossly premature operation, especially since the patient only noted the lymph node enlargement for two days! That alone should cause it to be evaluated over one or two months, if all of the studies he never did were all negative, including a skin test for TB (tuberculosis), which can also cause an enlarged lymph node!

Depending what the referring Physician did or did not do in this evaluation, their premature referral to a Surgeon is negligent, too. What was their purpose for the referral: For a thorough "work up," or to have it cut out and sent to the pathologist? How was their referral information given to the Surgeon: In writing, or by the patient making an appointment and showing up at the Surgeon's office? What is their pattern and practice with referrals to this Surgeon?

Therefore, performing this operation at that time was negligent for all the reasons stated above.

The "operation" was performed under local anesthesia, which is the anesthesia of choice for this procedure. The patient was 5'11" and weighed 240 pounds. Obtain photographs that show his neck prior to the operation. If his weight is the same now, note that and in any event, take photographs now that show his neck and shoulders, the incision, and muscle loss from the negligently cut or irreversibly damaged spinal accessory nerve.

That "jolt" the patient felt was the nerve, which is the size of a paper matchstick, being damaged. Where in his body did he feel that sensation and describe that sensation in more detail. The "operation" took 16 minutes from start to finish. At what point, from the start of the local anesthetic injection until the last skin suture was placed, did he feel that "jolt?"

An electrocautery (electrosurgery) unit #F3D21276T was used in Room #2 on 9/9 Obtain the hospital maintenance and repair record for that device to be sure it was properly maintained and not in an unsafe condition at that time.

The Surgeon, Dr. #2, said: "The lymph node was found. Meticulous dissection (separating layers of flesh) was performed. The lymph node removed completely. After the removal of the lymph node, bleeders were electrocoagulated."

In doing this operation, the spinal accessory nerve must not be cut or injured. It must not be burned (fried) by the electrocautery to "control bleeders." If there is any question, an electrical nerve stimulator can easily be used in this awake patient to "look" before tearing, cutting, or burning flesh grasped in a hemostat (locking needle nose pliers device). This is a preventable injury since there was no previous surgery at that site to entrap the nerve in a mass of scar tissue.

The Pathologist noted that the specimen "consists of a tan and red, firm tissue fragment measuring 1.5 x 1.0 x 0.4 centimeters (2.5 centimeters = one inch)." Their microscopic diagnosis was "Chronic lymphadenitis (right neck)." That is not cancer or tuberculosis, and is commonly seen after a previous infection and usually decreases in size over weeks. That means observation (while doing the basic detailed examination with details recorded, the chest x-ray and laboratory tests, and possibly an MRI or CT scan of the neck) would allow it to shrink in size "from whence it came" and therefore allow more watching. Cancer grows. Inflammation (lymphangitis) most often resolves, when the stimulus (infection) is resolved.

What was the patient told to get him to go into the operating room seven days after seeing this negligent and negligently aggressive Surgeon? What did the referring Doctor do in his office, and say to the patient?

Five months later, the electromyogram (EMG: electrical muscle test) and motor nerve study showed "persistent incomplete right spinal accessory nerve injury." When that muscle atrophies (shrinks) from inadequate nerve stimulation, there usually is weakness of the trapezius muscle on that side, and there can be an outward bulging of the scapula ("winged" shoulder blade).

This is a known and preventable complication with proper skill and care, as I noted above.

I do not believe the radial nerve injury, which is anticipated to improve, is related to this operation.

What is the training and Board Certification of the Surgeon, if any? Has he ever failed that examination? Has he been recertified? How does he advertise himself in the Yellow Pages, on his office door and office cards?

If the electrocautery unit was defective and not properly maintained, then the hospital is also liable. If the surgeon is not properly credentialed, or if he has had significant problems with his skill and care, then the hospital is also liable.

Obtain a current EMG and motor nerve study.

Obtain answers to all the above questions.

The Surgeon is negligent for his failings in the two questions I posed above.

The referring Doctor and their office may also be negligent, depending on the answers to my questions and concerns.

With all that information I suggest that I first do an Addendum Report, and then have us arrange for review by Experts in General Surgery, Oto-Rhino-Laryngology (ENT Surgery), Oncology (with regard to the proper evaluation for a patient suspected of having a lymphoma cancer) and Infectious Diseases.

Then have the patient evaluated by a local Clinical Psychologist with courtroom experience, who can examine and test him for any emotional damages relating to this negligent and abusive care.

I wonder if the patient would have been rushed into the operating room with such haste if he did not have adequate insurance to pay the Surgeon?

Back to Top