DR FAIL

[FireMedic65]

This is just.. terrible.

http://www.nydailynews.com/ny_local/2009/09/22/2009-09-22_systemic_breakdown_behind_woman_abandoned_in_operating_room_by_noshow_brain_surg.html

Doctors and nurses at a Long Island hospital violated 14 public health regulations in the case of a 32-year-old mom abandoned in the operating room by two no-show brain surgeons, investigators charged Monday.

The damning state Health Department report cited Manhasset's North Shore University Hospital for failing to follow professional standards for virtually every step of Jennifer Ronca's traumatic stay on April 10.

Ronca, a Pennsylvania mother of three, came to North Shore for two procedures: one for cervical traction, which was performed; another to insert a brain shunt to relieve debilitating headaches and fatigue.

Although Ronca was placed under general anesthesia for 90 minutes for the brain shunt, it was never inserted. Unbeknown to Ronca, her surgeon - Dr. Paolo Bolognese - was on a plane to Florida for a family vacation.

When the OR staff and assistant medical director realized Bolognese wasn't coming, they reached out to the chief of neurosurgery, Thomas Milhorat. He refused to cover for his colleague.

Both surgeons violated professional standards and hospital policy, the report said.

Ronca was awakened and told falsely that Bolognese had a family emergency and she would have to come back another time. She never knew the truth until the Daily News exposed the incident on May 6.

"This report reveals a systemic breakdown at all levels - surgeons, nurses, anesthesiologists, OR staff," said Mark Bodner, Ronca's lawyer.

"It shows a breakdown in patient care that is astonishing in its breadth and scope, particularly at a hospital like North Shore."

Among the 14 violations:

- The anesthesiologist violated hospital policy and put the patient under prior to the arrival of a neurosurgeon.

- The OR staff did not know who was operating on the patient.

- The orthopedic surgeon who performed the first procedure left the OR once he was done. Hospital policy says in multiple procedures the first surgeon stays until the second arrives.

- Milhorat dictated the operative report, even though he was not in the OR and did not participate in the surgery.

Milhorat, 73, and Bolognese, 49, were once the darlings of the hospital's profitable Chiari Institute. Hospital officials suspended them on April 17 for three weeks after the incident.

Milhorat, once the highest-paid neurosurgeon in New York at $7.2 million a year, then lost his clinical privileges and was forced to abruptly retire two days after The News' expose.

Bolognese, who is not board- certified and who earned $2.5 million in 2007, is still operating.

Reached at her home in Pennsylvania, a stunned Ronca said: "What they did to me was deplorable and should never happen to anyone."

A spokesman for North Shore said the hospital is reviewing the report and does not agree with a number of findings. Officials have until Oct. 2 to submit a plan of correction to the state, which can levy fines against the hospital.

hevans@nydailynews.com

Read more: http://www.nydailynews.com/ny_local/2009/09/22/2009-09-22_systemic_breakdown_behind_woman_abandoned_in_operating_room_by_noshow_brain_surg.html#ixzz0RswwjoPb

[itku2er]

What a shame that poor girl. This should never have happened to anyone.

[crotchitymedic1986]

People in glass ambulances should not throw stones, I wonder if this has ever happened where you work: Paramedic McDreamy calls out sick because he was out drinking all night and too hung over to come in (or he was up all night at his other full-time job). Captain(s) Whiteshirt are too lazy to get on the ambulance, so we make it a BLS ambulance, or we just shut it down, and then at some point in the day we do not have enough ambulances or ALS ambulances to handle our call volume. How are officers refusing to get on the truck any worse than the Doctor who would not take call for another Doctor; in both situations, patients suffer ?

[EMS49393]

People in glass ambulances should not throw stones, I wonder if this has ever happened where you work: Paramedic McDreamy calls out sick because he was out drinking all night and too hung over to come in (or he was up all night at his other full-time job). Captain(s) Whiteshirt are too lazy to get on the ambulance, so we make it a BLS ambulance, or we just shut it down, and then at some point in the day we do not have enough ambulances or ALS ambulances to handle our call volume. How are officers refusing to get on the truck any worse than the Doctor who would not take call for another Doctor; in both situations, patients suffer ?

Speak for yourself. Unless I am physically unable to continue to work because of fatigue, I will remain at work to cover until I can get someone else to relieve me. My station has two ambulances, a MICU that runs 24 hours a day and a day shift BLS ambulance. I'm not deserting my post as the sole ALS provider on shift until I find someone to cover me. Besides, my supervisor isn't a tool, and he routinely works shifts that he can't cover with part time providers (attempting to save overtime for when it is really necessary).

There are still people out there that value their integrity.

[tniuqs]

People in glass ambulances should not throw stones, I wonder if this has ever happened where you work: Paramedic McDreamy calls out sick because he was out drinking all night and too hung over to come in (or he was up all night at his other full-time job). Captain(s) Whiteshirt are too lazy to get on the ambulance, so we make it a BLS ambulance, or we just shut it down, and then at some point in the day we do not have enough ambulances or ALS ambulances to handle our call volume. How are officers refusing to get on the truck any worse than the Doctor who would not take call for another Doctor; in both situations, patients suffer ?

OFF TOPIC .... again.

[FireMedic65]

It's called "DUTY TO ACT". Something also called the Hippocratic Oath.

If I am requested to respond to a patient, I go. Plain and simple.

[VentMedic]

It's called "DUTY TO ACT". Something also called the Hippocratic Oath.

EMT(P)s have their own oath and it is not called the Hippocratic Oath although some wording was borrowed. Although, there are probably not many that paid attention to this little announcement of responsibility that is found in more EMT(P) textbooks.

If I am requested to respond to a patient, I go. Plain and simple.

If you are impaired in anyway and that includes fatigue (as mentioned previously and in other threads), it is your responsibility and/or your partner's to see that you are taken out of service.

Of course, EMT(P)s also work on one call at a time and are notified at the time of the call. ORs may schedule several days or even weeks in advance. Neither computer or paper scheduling are infallible.

Now for this news article, regardless of the scheduling error there are check lists to follow to prevent this type of incident from occurring. No patient should have anything done to them until a TIME OUT is done. This is done to prevent screw ups such as wrong patient and wrong body part being cut on or off. If one had been done someone should have noticed they were missing the surgeon.

For Paramedics, there have been an increasing number of medication errors or at least more are now being admitted or caught. A Paramedic should also take a few seconds to check if all the "Rights" are in place.

Edited September 23, 2009 by VentMedic

[ERDoc]

Vent, you bring up a good point. Did anyone check to see if the surgeon was there before they sedated the pt?

Scalpel? Check

Gas? Check

Skull saw? Check

Surgeon? Oh, wait a sec.

Let's not even start talking about time-outs. Another good idea, taken too far, destorying the smooth practice of medicine.

[VentMedic]

Let's not even start talking about time-outs. Another good idea, taken too far, destorying the smooth practice of medicine.

After the messes at the Tampa hospital a few years ago we take the TIME OUT very seriously in the hospitals here. From working in the ICUs, I also know some of the screwups at the hospitals I hang around.

I had a little surgery on my right foot a couple years ago. I even wrote "NO" on the other leg and foot. At least the word "NO" means the same in English and Spanish since English is not always our primary language in the hospitals.

I also like the practice of scanning the equipment and supplies used for a more accurate count.

[ERDoc]

After the messes at the Tampa hospital a few years ago we take the TIME OUT very seriously in the hospitals here. From working in the ICUs, I also know some of the screwups at the hospitals I hang around.

I had a little surgery on my right foot a couple years ago. I even wrote "NO" on the other leg and foot. At least the word "NO" means the same in English and Spanish since English is not always our primary language in the hospitals.

I also like the practice of scanning the equipment and supplies used for a more accurate count.

I agree that time-outs are very important in certain parts of the hospital. Unfortunetly, the administrators who have no pt care experience whatsoever, have decided that it is such a good thing that it should be done everywhere in the hospital, including the ER. It is a completely different environment in the OR where people are sedated and unable to speak. If I come at you with a big spinal needle to do a spinal tap, in the ER you may say, "Doc, it appreciate your concern, but really, I don't think that will help figure out if my toe is broken." If I go in the wrong room to suture someone, I will probably realize I am in the wrong room when I cannot find that gaping wound that was there 5 minutes ago. I'm pretty sure I can identify who the multi-system trauma pt is that is circling the drain and needs some help without aking everyone in the trauma bay (including said pt) if we have the correct pt. I could go on, but I think you get the point. It is the typical story of administrators seeing a good thing and taking it too far.