A previously healthy twenty-four year-old medical student saw her university-based orthopedic surgeon for a tear in a ligament in her knee. In college she had been an all-American soccer player and had considered a career in professional soccer but had decided instead to go to medical school. She had injured her knee in a pick-up soccer game. When the pain did not improve, she sought help from the orthopedic surgeon on her medical school faculty with the best reputation for complex knee surgery. An MRI showed a tear in her anterior cruciate ligament, and he scheduled her for surgery.
Unbeknown to her, the surgeon was on retainer by a medical device company to try a new instrument they had invented to aid in knee surgery. He had been instructed in its use it but had never actually used it on a patient in surgery. This was his first case with the new tool, and he looked forward to seeing how it would perform.
During the surgery, because of his unfamiliarity with the new device, he accidentally placed a screw right through her popliteal artery, the main artery supplying the leg below the knee, without realizing it. Two days later she began to complain that her lower leg was cold, blue ,and painful. The surgeon was away, so his partner’s nurse practitioner, who knew nothing of the case, suggested pain pills and leg elevation. After two more days of increasingly excruciating pain, she went to the Emergency Department and was found to have almost no blood flow below the knee.
She was immediately admitted to the hospital as an emergency case. A vascular surgeon repaired the blockage caused by the screw and surrounding blood clot by bypassing the obstruction with a vein graft. Post-operatively she continued to have trouble with recurrent clots in the lower leg and foot. She dropped out of medical school because she missed so many classes and continued to have severe pain from local oxygen deprivation brought on by suboptimal blood flow.
She eventually sought a second opinion from a surgeon at another medical school who was an expert in vascular reconstruction. At that school she was evaluated by their clotting expert and found to have two problems: the Factor V Leiden mutation, an inherited disorder which predisposes one to clot; and anti-phospholipid antibodies, which also predispose to clotting. She was placed on long-term anticoagulation, had the blood supply to her lower leg repaired one more time by the new surgeon. It slowly improved.
She went back to medical school after a year but had to give up her dream of becoming a surgeon because she could not stand for long periods of time without getting leg and foot pain.
She sued the orthopedic surgeon who did the initial surgery.
Who’s To Blame?
In her lawsuit she claimed that the surgeon punctured her popliteal artery negligently and failed to recognize what he had done. She did not complain that he had failed to obtain a clotting consult when she kept clotting after vascular surgery, and she did not sue the vascular surgeon who did the initial repair.
After much legal maneuvering by both sides and numerous depositions, the case settled out of court for a considerable sum. Her career in surgery is ruined; she has gone into pathology, where she sits all day looking through a microscope.
As stated in previous blogs, many bad medical outcomes occur because of a series of mistakes, not just one. In this case the surgeon used a new tool (and did not notify his patient of this – not that he was obliged to do so) and committed the error of a neophyte – which he was when it came to using this device. He and the vascular surgeon who did the initial vein graft failed to appreciate that repeated clotting of her popliteal artery and then her graft reflected an underlying clotting disorder.
Ironically the failure to include the vascular surgeon in the lawsuit for not evaluating her clotting worked to the advantage of the orthopedic surgeon. I was retained to defend him and pointed out that his patient had no prior history of blood clotting and there was no way for him to divine that she had two coagulopathies that worked synergistically to make her clotting an even worse problem.
She inherited the abnormal Factor V, but at age twenty-four had not yet suffered her first clot. Most people with that mutation don’t have their first clot until provoked, e.g., by bed rest following major surgery. The anti-phospholipid antibody is part of a spectrum that includes systemic lupus and is acquired; she might have only recently developed it. I used the rarity of the two conditions in the same patient to try to exonerate the surgeon.
Had the plaintiff’s lawyer sued the vascular surgeon, who arguably should have had a higher index of suspicion that she had a clotting disorder, it would have been more difficult to defend him.
What Went Wrong?
Let’s look at this perfect storm which resulted in a ruined career and a life of pain.
Had the orthopedic surgeon not been on retainer by the device industry he probably would not have used the new instrument until it had been perfected, by which time its potential to puncture the artery might have been unmasked. There is nothing illegal about this relationship, but perhaps medical ethicists would suggest full disclosure before the operation. It is likely that our medical student would have trusted the surgeon and would have let him use the device anyway, but there would not have been deception. When unmasked, the business relationship with the device manufacturer made it more difficult for the two parties to settle the lawsuit amicably and probably cost the surgeon’s malpractice carrier additional hundreds of thousands of dollars.
Had her surgeon not been out of town he might have recognized the severity of her injury as opposed to his partner’s nurse practitioner, who missed the problem. If the patient had been evaluated by the surgeon, two additional days of altered blood flow to the leg might have been prevented. Arguably this delay injured the tissues of her lower leg and complicated every subsequent procedures she underwent. The vascular surgeon who fixed the blockage was so focused on the vascular anatomy of her lower leg that he forgot that there was a body attached to that leg and that the body might have a separate problem.
Finally it is very unusual for a patient to have both an inherited and acquired propensity to clot, even more unusual to have no symptoms from either. Having two different coagulopathies made it likely that she would have had problems after her knee surgery – even without the arterial injury. Nonetheless in a completely asymptomatic, otherwise healthy person with no history of blood clots, there was no reason to screen her for a clotting disorder pre-operatively.
The complexity of modern medicine can be overwhelming. All the current recommendations the medical community follows to minimizing complications, including the “time out” pause prior to the first surgical incision and the development of an experienced surgical team, which does high volumes of a small number of operations, would not have prevented this calamity. At the end of the case, I wondered whether the patient was even justified in suing her surgeon. Complications occur, and they are often no one’s fault.
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Dr. James Stark is the founder of StarkOncology, where he practiced Oncology in Hampton Roads for thirty-four years. He is now a health-care consultant specializing in topics such as breast cancer, colon cancer, lung cancer, chemotherapy complications, and failure to screen. In addition to this new venture he continues to serve as Professor of Medicine at Eastern Virginia Medical School.