• William Berry, MD, MPH; CRICO; Cambridge, MA


The following case abstract is based on closed claims in the Harvard system. Names and some details have been changed to mask identities.

A 20-year-old male with insulin dependent diabetes, injured his back on a submerged rock while jumping off a boat dock at a friend’s home.
In the ED, the patient was seen by a neurosurgeon and an orthopedic resident. A neurological exam showed upper leg weakness and no reflexes in his lower extremities; X-rays revealed a burst fracture of his lumbar spine at L-4. The resident placed the patient on steroids and had him admitted. Over the next 40 hours, the patient’s neurological condition improved, although he had decreased sensation below both knees, and no reflexes in either leg.

The accident was on a Saturday, and by Tuesday morning, the staff surgeon recommended surgery, discussing the risks with the young man and his mother. Risks included nerve and vessel damage, bleeding, infection, and non-union. Neither the surgeon, the patient, nor the record recall a discussion regarding the risk of vision loss.

The surgery started at 1:30 the next afternoon with the patient on his back. The attending orthopedic surgeon (assisted by a general surgery resident) removed part of the vertebra and bone fragments at L-4. Six hours after the operation began, the surgeon prepared for the second stage of the procedure, and the patient was turned face down. The surgeon then mechanically secured the spine, though he elected not to extend the surgery to remove a bone fragment in the spinal cord that was not pressing on any nerve roots. The posterior surgery ended 12 hours after the operation began. The patient lost nine liters of blood, which required administration of 23,000cc of fluid.

Post-op, the attending surgeon left for vacation, and the patient was taken to the ICU and remained intubated. His face was swollen from the fluid replacement and he did not open his eyes for most of the day. Around 7 p.m., the patient complained he couldn’t see. When the ICU staff was unable to reach the attending surgeon, they consulted with Ophthalmology and Neurology. Hyperbaric oxygen treatments were discussed. At midnight, another surgeon examined the patient, who was now blind. Testing revealed that damage to the posterior optic nerve—likely caused by the heavy blood loss during the spine surgery.

In addition to the permanent vision loss, the patient also suffered permanent paralysis of the front muscles of his right lower leg, causing foot drop. He sued the attending and resident surgeons, alleging that their decision to complete both stages of the procedure during one operating session was directly responsible for his blindness. The case was mediated and settled for more than a million dollars.

To discuss the patient safety and risk management aspects of this case, we are joined by surgeon William Berry. Dr. Berry is a surgical consultant for CRICO.

Bill, thank you for joining us. What could have improved the informed consent process in this case?

One of the things that’s always worth putting in the discussion of the alternatives is not to do anything. To continue with nonmedical and nonsurgical management in a patient is always an alternative. Even if that choice may lead to high risk of morbidity and mortality, it is still a choice. The real reason for the surgery itself was to stabilize the spine and prevent further damage to the spinal cord. Certainly, this surgery could have been delayed. The blindness as a risk of this particular kind of operation, I think first we need to understand that the landscape there has changed some. Because although this is a rare complication, it is a recognized complication of surgery done in patients in the prone position having operations where there is large blood loss, potentially low hematocrits during the surgery, and the time factor is probably important in terms of how often this complication occurs. It is certainly great in magnitude, and people will disclose it as a risk. That kind of counseling obviously isn’t going to change an outcome. But if it does happen, the fact that there was a discussion ahead of time probably helps manage the patient’s expectations afterwards and maybe will prevent a lawsuit from occurring.

When we look at the operation itself, is there a way to consider what went wrong for the patient, more from a perspective of organizing a system to try to prevent a similar outcome for future patients?

This is a very interesting case because there was a clear opportunity in the middle of the case, there was a natural break when the patient was turned to have the other half of the surgery performed. Half the surgery was done from the front, half the surgery was done from the back. So there was a natural pause built in there, and I don’t believe from the way that the record reads anyway that that pause was taken advantage of fully to reflect a little bit about how much the patient had already gone through and was it reasonable to extend the operation for another 4 or 5 hours to try and complete it all in one setting.

The Joint Commission has mandated a time out at the beginning of the operation of every surgical procedure basically, and the reason for this is to give…first it’s also a natural break, but it gives everyone on the operating team a chance to pause and reflect to make sure that it's the right patient, the right procedure and the proper operative site that everybody is working on. To me it would make sense to have another formal time out, if you will, in a staged procedure like this that goes on for a considerable period of time. Now, we will never know for sure if they had stopped the procedure halfway through, with the blood loss and the large volume of fluid the patient had received, whether the blindness would have occurred or not. There is just no way of knowing that, but certainly extending the operation and having additional blood loss and a lot more fluid given to the patient was not a positive thing.

When you get into these kind of settings, I think you have to remember the surgeon a lot of times performing an operation, and maybe rightly so, believes that his or her perspectives are the most important perspectives on how a surgery is proceeding, but there are multiple people in the operating theater when surgery is performed, and they also have important perspectives that sometimes, for a bunch of different reasons, aren’t really considered. Surgery is a team effort. No surgeon can perform this kind of complex surgery by themselves. They are not experts in getting instruments ready, and they are certainly not an expert in anesthesia when you’re standing on the other side of the screen, so the input of everybody on the team is important.

We don’t know because that kind of thing doesn’t get recorded in a record exactly what kind of communication there was over this patient, and whether they should continue or not between the anesthesiologist and the surgeon, but that kind of communication in these kind of complex cases is absolutely necessary. I think in general we don’t do it enough.

This page is an excerpt of a full issue of Insight.

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CME: The Massachusetts Board of Registration in Medicine has endorsed each complete issue of Insights or 30-minutes of podcast episodes as suitable for 0.5 hours of Risk Management Category 1 Study in Massachusetts. You should keep track of these credits the same way you track your Category 2 credits.

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