CASE XII:    EVALUATION OF DELAY IN REVASCULARIZATION OF THE LOWER EXTREMITY

SUMMARY:

On 7/24/00, D.O., performed a right femoral artery aneurysmectomy, bilateral femoral artery patch angioplasties, femoral/femoral bypass, left axillary popliteal thromboembolectomy with conversion to femoral/popliteal bypass, right superficial femoral artery balloon angioplasty and operative angiography.

By 2/7/01,  M.D., vascular surgeon, noted the examinee, 81 year old male, had an infected graft of the right groin with a history of severe peripheral vascular disease, cough, TB, bleeding on Coumadin, loss of weight (12 pounds), an axillobifemoral bypass done out of state, femoral/femoral bypass done locally with non-healing of the right groin treated with Vancomycin over long period, and had extremities without palpable pulses, pigmentation … discoloration, muscle wasting, groin with exfoliative tissue with bleeding from the sinus tract and an easily palpable fem-fem bypass and remnant of the axillobifemoral going all the way down to the superficial femoral on the left side, all of which were occluded. Dr. apparently expressed his “concern about the complications which certainly would include among them amputation because of the possibility of ensuing difficulty in revascularization of the right leg particularly after the situation in the right groin has been reviewed.”  Dr. noted additional evaluation with possible angiogram or Doppler would be desirable and offered the examinee possibility of referral to a tertiary university hospital.

From 2/8/01-2/28/01, the examinee was evaluated by M.D., infectious disease, who took a wound culture right groin, restarted antibiotics and recommended considering removal of the graft; M.D., internist, cardiologist, who did a cardiac evaluation and cleared the examinee for proposed surgery for resection of his infected fem-fem bypass graft as a grade II anesthetic risk; and again by Dr. vascular surgeon, who did a pulse volume recording and segmental pressure analysis, which demonstrated severe aortoiliac occlusive disease bilaterally and bilateral superficial femoral popliteal trifurcation occlusion and noted the examinee had end stage peripheral vascular disease in addition to an infected graft and would be a high risk and might end up with amputation of one or both legs; the examinee again was offered referral to Dr. and mentioned that any further grafting could end up with infection and removal of fem-fem graft but removal of the graft was imperative as a life-saving measure, and his plan would be removal of graft plus revascularization to start with femoral/femoral removal and depending on the situation revascularization again with another axillary popliteal bypass going all the way down along the leg possibly bilaterally with watchful observation for possible complication of circulation addressed as soon as possible as potential complications would include kidney failure, respiratory failure, bilateral amputation, non-healing wounds.  

Prior to surgery on 3/8/01, diagnostic studies demonstrated bilateral upper lobe infiltrates chronic in nature and unchanged from 11/8/00, elevated BUN, 1^st degree AV block, Bacillus in the blood, S. Aureus in the groin, elevated PTT, anemia, and the examinee was transfused 2 units packed cells, O positive.

On 3/8/01, M.D., vascular surgeon, performed an exploration of the graft, femoral/femoral, removal of the graft, femoral/femoral, oversewing of the stump in the left groin, exploration of superficial femoral artery on the right, retroperitoneal exposure of the iliac limb of the graft and debridement with extensive debridement of the right groin wound and excision of femoral graft and part of the iliac graft and drainage and notes that during an intraoperative consultation with Mrs. Howell he informed her of the situation, the pros and cons and she preferred to wait  knowing that at this time the risk would be a single or multiple amputation and that if the patient improves and the culture is negative further consideration for revascularization could be done although the patient is a poor risk.

On 3/9/01, a doctor's progress note indicates the legs and feet are pale with decreased feeling and may need revascularization with an axillo/femoral bypass.  The hand written notes were difficult to read.   

On 3/9/01, M.D., evaluated the examinee, noted the pedal pulses were absent and recommended continuation of current regimen and resumption of Coumadin as soon as feasible.

On 3/10/01, a doctor's progress note was difficult to read though apparently indicated the examinee was afebrile in no acute distress and was awaiting transfer to Hospital.

On 3/11/01, a discharge summary by M.D., vascular surgeon, indicated the examinee had chronic atrial fibrillation with controlled ventricular response and over the course of the next several days the examinee was carefully monitored; by 3/11/01 the examinee had no complaints; his final status was stable; the extremity’s incision site was healing and at that time he felt the examinee would need to continue very close care, rehab and follow-up so was subsequently transferred to Hospital for further care and management of his MRSA sepsis and status post debridement and removal of graft.

By 3/11/01, the examinee was transferred to Hospital and was diagnosed with ischemic left lower extremity. A stat angiogram of the bilateral lower extremities and stat CT abdomen/pelvis to evaluation for perigraph fluid collections were ordered and IV antibiotics and Heparin were started.  The right groin was noted to be open, somewhat purulent for healing, the left anterior leg was ecchymotic with dorsal mottling of the left foot and cyanosis of the toes and absence of motor and sensation; the right foot was somewhat dusky with mild paraesthesia, weakness, limited dorsiflexion and contractures of the right heel. The Hospital intrafacility transfer summary was unreadable.

Prior to a subsequent surgery of 3/12/01, additional diagnostic studies indicated the examinee had a right upper lobe pneumonia, normal branching of the great vessels without proximal stenosis, occluded infrarenal abdominal aorta, reconstituted bilaterally superficial femoral artery and profunda femoral arteries below the inguinal ligament, occluded left superficial femoral artery with only faint opacification of the distal left popliteal artery and proximal peroneal artery, diffusely and severely diseased right superficial artery and popliteal artery, bilateral renal cyst, bilateral pleural effusions with compressive atelectasis, extensive vascular calcifications with probable thrombosed distal abdominal aorta, possible thrombosed left axillofemoral graft, no definite evidence of perigraft fluid collection, extensive vascular calcifications with significant discrepancy in the opacification of the distal abdominal aorta compared to the proximal which may be secondary to thrombosis, multiple clips retroaortic region, tubular structure along the left abdominal wall consistent with history of axillofemoral graft that has a lack of essential density which may represent thrombosis, multiple grafts appearing to be thrombosed, small amount of free fluid, multiple clips left inguinal region discontinuity of the abdominal wall in the area of the right groin consistent with the patient's history of excision of infected femoral/femoral graft and drainage catheter defect in the right groin.

3/12/01,  M.D., vascular surgeon performed a right axilla to deep femoral 6 mm. ringed PTFE arterial bypass graft with concomitant contralateral left above knee amputation and noted the examinee had been treated at another institution for infection involving the right groin which had progressed to anastomotic bleeding for which the examinee was brought to the operating room for ligation of aortofemoral graft limb and right groin as well as femoral/femoral graft producing bilateral lower limb ischemia without revascularization and subsequently was transferred to Hospital 3 days after presenting with advanced gangrene to the left lower extremity to the knee and critical ischemia with paraesthesias of the right foot; arteriography demonstrated infrarenal aortic occlusion and patent deep femoral artery in both groins and the examinee was recommended to undergo left above knee amputation and exploration of right thigh for possible axillofemoral bypass graft. Dr. noted because of diffuse femoropopliteal occlusive disease examinee may likely progress to non-viable right foot and require amputation.     

By 5/7/01, Vascular progress note, (name unreadable): "…  the right heel ulcer decreased in size, wounds were well healed.

On 5/23/01, M.D., performed surgery after the examinee was again transferred draining purulent material to Hospital because of having been over the last month or two.  The examinee was diagnosed with an infected left axillofemoral occluded bypass.

On 7/13/01, angiograms demonstrated a 2 cm. aneurysm involving the right common femoral artery, complete occlusion of the left common iliac artery, complete occlusion of the left subclavian to popliteal artery bypass graft, extremely poor run-off vessels bilaterally with single vessel run-off to the feet via a dorsalis pedis artery bilaterally, and minimal narrowing of the origin of the left common carotid artery. 

On 10/8/01, M.D., general and vascular surgery, noted in a follow-up that Groshong catheters placed for prolonged intravenous antibiotics were removed a couple of weeks ago, the wound was healing and the ax-fem and femoral-popliteal bypass graft both appeared fine.

On 12/02/01, Bessie and Peter Lyngarkos, Mrs. Howell’s brother and sister-in-law, noted when Paul Howell underwent surgery at Hospital they were with Mrs. Howell the entire time, and on 7/18/01, they note that “they were at Hospital while Paul Howell was being operated … hospital every day, all day … for the four days he was there … visited him in his room and in the Intensive Care … while there … observed … foot was cold and turning black … brought this to the attention of the nurse in charge who then checked his feet for a pulse. Immediately called the doctor … told he was not available at that time … told that he was to go to Hospital as soon as there was a bed available … stayed in Intensive Care until Sunday, 3/11, when they transferred him …. followed the ambulance to Hospital and the doctors there examined him and immediately arranged for surgery … told the leg had to be amputated … it was too late to save it.”

On 12/3/0(Blank), presumably 12/3/01, in a letter to attorney, unsigned though written by wife, she notes that " … Dr. … never came to the waiting room to talk to me before or after the operation … the first time we saw him at his office he told us that if the infected graft was not removed, the poison from the infection would reach … heart … and kill him so why would I or anyone else tell him to wait? … having infection slowed my husband down a little but he still played 18 holes of golf two days a week… never saw Dr. after we saw him in his office … brother and sister-in-law were with me through the entire time. We were in the hospital waiting room… the never saw Dr. after operation. In the first place he never should have removed the graft, I was told, unless he was prepared to put in a graft to restore blood supply to his legs … in Intensive Care for 3 days before he was transferred to Hospital. We kept asking the nurse, who was taking care of husband, if Dr. had been in to see husband.  She said Dr. was on vacation and they were waiting for Hospital to call when they had a bed available. Kept telling the nurse his feet are getting black.  She said … would call one of the doctors on call … then came back and told us he was operating and could not come. She was distressed but kept telling us as soon as Hospital called he would be transferred. … finally taken to Hospital … Dr. and his team said … leg had to be removed …  Discharged from Hospital to rehab … less than a hour later complained of pain … right leg … called 911 … to Hospital … after examining … airlifted to Hospital. On 11/11/01 … pain left side where graft had been removed … called Dr. … examined … that afternoon … made arrangements … sent to Hospital. Next day Dr removed a piece of infected graft which should have been removed when he was last operated on prior to being sent to Hospital in the first place … Paul had been treated for TB … was Okay … Dr. operated … some time in July or early August, 2000 … suing Dr. for … neglect of his patien, husband. He … should have seen to it that (husband) was sent to Hospital right away or made sure some back-up doctor was in charge … unfortunately Hospital has lost our records for the three days husband was in the Intensive Care Unit.” 

On 1/16/02, Esquire, noted (in letter) on 7/15/01 C. submitted a written request to Hospital for a copy of his medical records from his admission of 3/7/01; hospital responded intensive care records temporarily lost. On 9/17/01, Esquire, sent a request to Hospital for complete medical records, date of admission 3/7/01, said request signed for on 9/19/01; records sent to Esquire; received 10/2/01, from the hospital were not the complete records as requested; hospital advised "lost"  portions of the chart such as nurses' notes, operative reports, etc.   Esquire, followed-up this request by making an on site visit to Hospital to review the complete chart on 10/17/01; medical records provided on that date and time did not have physician's orders for 3/7 and 3/8/01 or the 24 hour nursing flow sheet for 3/7, 3/9, 3/10 and 3/11/01, no nursing notes and note reading "reconstructed record, nurses' notes missing, waiting on LEA." Interfacility transfer summary, yellow carbon copy, was difficult to read (hospital should have retained white original in file).  No operative report nor anesthesia record, preop and postop records.  Records were the same as what had been mailed to Esquire, although this purported to be the original records on C.. The doctor progress notes in the file were photocopies, not originals.  Subsequently, when Esquire, received Dr. records, he provided a copy of the operative report, which appears to have been faxed to him on 9/5/01.

CONCLUSION: 

1.    Examinee, according to the medical record of Dr., was advised of his high risk status, of the likelihood of amputation of one or both legs and of the possibility of referral to a tertiary medical center.

2.    Examinee, an 81 year old male with a history of severe peripheral vascular disease with multiple operations, cardiac arrhythmia and chronic obstructive lung disease, had a staphylococcus aureus resistant infection of the right groin and septicemia and may, within a reasonable degree of medical probability, have succumbed to the complications of an infectious disease.

3.    Examinee lost essential vascularization to the lower extremities after surgery on 3/8/01 by Dr. leading to subsequent amputation of the left leg and right axillo/femoral bypass.

4.    The examinee had residual infected left graft removed on 5/23/01 and sustained additional morbidity, which may not have been more than was expected as a consequence of not having the entire infection debrided though, within a reasonable degree of medical probability, the extent of infection may have been such that not all of the infection may have been able to be debrided during prior surgeries.

5.    Discrepancy exists in the medical record with regard to notes by Dr. and notarized statements of Mrs. brother and sister-in-law insofar as to what transpired intraoperatively during an alleged consultation with Mrs. about her husband, which Mrs. and her relatives state did not occur.

6.    A complete medical record is unavailable for review, and according to attorney, the medical record was not provided as requested; records provided at an onsite visit were missing including various physicians’ orders and nursing notes, and a note suggested the record was reconstructed and nursing notes were missing; also the interfacility transfer summary was a carbon copy (difficult to read), and the operative report, anesthesia , pre-op and post-op records were not available; Hospital has advised portions of the chart have been lost.

7.    The doctor’s post-operative progress notes subsequent to the surgery of 3/8/01 were difficult to read though indicate the need for revascularization, and the discharge summary on 3/11/01 by Dr. indicates the examinee had no complaints, his final status was stable, and the extremity’s incision site was healing and that very close care, rehab and follow-up should be continued at Hospital.

8.    A lack of understanding with regard to post-operative treatment exists with the notarized statement by Mrs. the unavailability of a complete medical record and the inability to read and understand completely the available post-operative doctor’s notes subsequent to the surgery of 3/8/01, especially with regard as to whether Dr. was available post-operatively or was on vacation and if on vacation what doctor was taking the responsibility for Mr. post-operative care.

9.    The infection was noted to be in the right groin, however no additional revascularization was performed for the left lower extremity, which subsequently became gangrenous and was amputated.  In consultation with a Board Certified Vascular Surgeon:

a.       An angiogram should have been performed prior to the surgery of 3/8/01 in order to know ahead of time the flow through the aorta and iliac vessels and especially the role of the right aorto-femoral graft in supplying donor blood  and use this information to plan for further revascularization.

b.      A conscious decision should have been made within 48 hours with regard to revascularization despite of the potential  higher risk of infection.

1.  The lack of available medical records, discrepancy with regard to the available medical record and notarized statements, absence of angiography prior to surgery on 3/8/01 in conjunction with delay in potential revascularization and consequent amputation of the examinee’s left leg, suggest, within a reasonable degree of medical probability, that the examinee did not obtain the requisite standard of care.

The review of additional pertinent medical records may have the effect of modifying the aforementioned conclusions.

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