Follow up on wrong-sided surgery


We recently mentioned Dr. Denise Crute, an American neurosurgeon in a November blog post, Wrong-sided surgery.  We quoted News of the Weird as our source, with the original source being ABC channel 7 news.  We mentioned her story to illustrate the importance of safety checklists in the operating room.  It would have stopped there, but now we’ve received a threatening letter from a lawyer in Phoenix, Arizona representing Dr. Crute.  (Since we last heard that she was practicing in New York – the Arizona lawyer must be for my benefit.  I wonder if she would have hired a Colombian lawyer if she realized that’s where I spend the majority of my time.)

Harming her reputation?

Her lawyer claimed that by republishing this information that I am liable for damages  caused by the harm to her reputation.

In my opinion, she’s blemished her reputation all on her own (but I’ll let you read the letter for yourself).

To make it easy on everyone – I’ve also linked to my original post, which was a quote from Mr. Shepherd, who stands by his story.

In my defense – Truth is the truth

I think my statements are fair, accurate criticism, particularly given the known facts of the case.  Now, the last thing I want to do is report something erroneously.  After all, I stake my reputation on my honesty and integrity, so if I have made a mistake – I will freely admit it – and will happy display it in ALL CAPS here on the blog.    Not only that, but I will happily travel out to see Dr. Crute and interview her for the blog, so she can set the record straight – if it needs correcting.  But I can’t be cowed by an angry surgeon looking for an easy target.

Litigious behavior doesn’t change the facts

Notably, the lawyer’s letter doesn’t even address the accuracy of the claims against her. But I did see her own personal blog, where she has a one page statement addressing the charges, so I will link to it here.  In it she claims to have been the victim of a one-person driven witch hunt.

Yes, that could happen – but the breadth and width of the charges (hundreds) and the collaborating witnesses in the statements argues against it in this case.

Now, the initial report to the medical board may very well have been the result of professional jealousies, or whatever, as Crute and her legal team claim.  But there are so many charges – with multiple supporting witnesses that it seems highly unlikely.

Her main argument is against the neurosurgeon that helped the medical board evaluate the claims.  She chalks up his decisions and statements against her behavior to competition, since she is the superior surgeon, apparently.  Fine, but that doesn’t account for the majority of charges which have nothing to do with actual surgery – but with the ethics of her practice.  (You don’t have to be a neurosurgeon to know that altering a patient chart and falsifying data is wrong.)

Another point to consider:

But it also may have also taken another neurosurgeon who was finally bold enough to speak up against repeated, repeated and repeated episodes of unprofessional, dangerous and injurous behaviors.

In fact, a recent poll of 24,000 physicians demonstrates the reluctance of doctors to criticize their colleagues.  The Medscape 2012 Ethical Dilemma Survey results showed that just 47% of physicians would caution a patient about a colleague they felt was practicing ‘substandard’ medicine.

While her statement makes it sound like these sort of complaints against providers and surgeons are common – they really aren’t.

While it may seem so for Dr. Crute (and neurosurgeons do have a high rate of malpractice), for another colleague, several nurses and the surgeon’s own PA to make these statements about Dr. Crute to a medical board means that it was more that a personality conflict.

Not having her license stripped away is not proof of innocence.  In most states, medical boards offer disgraced physicians the opportunity to inactivate their licenses.  It’s similar to hospitals (and other organizations) allowing  doctors, CEOs and such, to resign instead of being fired outright.  This practice has been clearly established and well-documented in several notable cases.

Doctor’s story led to changes in the Colorado Board of Medicine

In fact, many say that the recent stories about Dr. Crute (by Denver reporter, Ferrugia) have prompted changes in the licensure and disciplinary processes at the Colorado Medical Board.

But it’s more than that – attacking my blog for using well-publicized and reprinted information (available at multiple sources) to illustrate a discussion here on patient safety, just seems to me like bullying, especially when there are twenty other articles about Dr. Crute on much larger websites with a lot more viewers.  So I also contacted Mr. Ferrugia and Mr. Shepherd (of News of the Weird) to see if they, too, had been contacted by Dr. Crute and her legal team.  No, they haven’t.. Just me.

This makes me suspect that this entire letter/ episode is just an attempt to bully someone smaller and less powerful, and that’s what makes me angry.  This would have been a good opportunity for Dr. Crute to rectify the record, if that’s truly the case (especially since legal action and media coverage appears to have ramped up in the last few days with more and more articles over the last week)  but she doesn’t appear interested in that.  (If she had, we would be seeing retractions from the other writers involved).

But – check out her site, read her defense, and let me know what you think.  It is also worth noting that despite all the ‘glowing’ quotes she has on her website, she doesn’t appear to be operating on patients in her new position.

I’m not sure that the fact that she volunteers or donates supplies to Central America holds any relevance to the discussion – but she put it out there, so I’m reporting it.

 Dr. Crute settlement agreement

documents related to medical practice

In the meantime, I stand by my statements in reference to safety checklists, etc. that a ‘time-out’ for patient safety can prevent many of these errors that are documented in the original papers, such as in 2004 when she performed wrong-sided brain surgery – which she is accused of, along with   then attempting to cover-up in her documentation (and actually had the gall to say that the patient “marked” the wrong-side.) The patient had a right subdural hematoma (and according to the notes on page 7 of attached document) – was in no condition to consent/mark or otherwise make any medical decisions.

Read the original documents – and see if it paints a portrait of someone who did whatever she wanted, when she wanted and thought that she could get away with it – like when she failed to come see an emergency surgical consult at night*.  She gave a telephone order for intubation, and still didn’t bother to come see this critically injured patient.   Then, after it was too late – came by at 7 am in the morning, and back-dated her notes.  (Yes, patient died).  Unfortunately, there is no checklist to address such an ethical lapse.

But in the spirit of honesty and integrity, and in pursuit of the truth, I have contacted the reporter of the original story, John Ferrugia to see if there have been any story updates, retractions or corrections. (Mr. Ferrugia also provided the supporting documents.)  I also offer Dr. Crute the opportunity to give a statement here.  She knows how to contact me, and apparently she’s reading the blog.

But – this isn’t what my blog is really about – so we will get back to our regular topics, like surgical checklists and surgical apgar scoring – on our next post..

Supporting documents – Mr. Ferrugia:

Dr. Crute 1

Dr. Denise Crute 2

Additional articles

Dr.Crute article by Melissa Westphal

* Just one of many incidents documented in the original documents.

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From news of the weird: Wrong-sided surgery


Admittedly, this is not where I usually look for information on medical quality and safety measures – but this case, as presented in News of the Weird for this week deserves mention:

Neurosurgeon Denise Crute left Colorado in 2005 after admitting to four serious mistakes (including wrong-side surgeries on patients’ brain and spine) and left Illinois several years after that, when the state medical board concluded that she made three more serious mistakes (including another wrong-side spine surgery).

Nonetheless, she was not formally “disciplined” by either state in that she was permitted merely to “surrender” her licenses, which the profession does not regard as “discipline.” In November, Denver’s KMGH-TV reported that Dr. Crute had landed a job at the prestigious Mount Sinai Medical Center in New York, where she treats post-surgery patients (and she informed Illinois officials recently that she is fully licensed in New York to resume performing neurosurgery). [KMGH-TV, 11-4-2012]”

This is an excellent example of the importance of the ‘Time-out” which includes ‘surgical site verification’ among all members of the surgical team.  This also shows some of the limitations in relying on the health care professions to police themselves.  Does this mean that I can absolutely guarantee that this won’t happen in any of the operating rooms I’ve observed?  No – but it does mean that I can observe and report any irregularities witnessed (or deviations from accepted protocols) – such as ‘correct side verification’ or failure of the operating surgeon to review medical records/ radiographs prior to surgery.

It also goes to show that despite lengthy credentialing processes and the reputations of some of the United States finest institutions are still no guarantee of quality or even competence.

What about Leapfrog?

This comes at the same time as the highly controversial Leapfrog grades are released – in which medical giants like UCLA and the Cleveland Clinic received failing marks.  (UCLA received an ‘F” for avoidable patient harm, and the Cleveland Clinic received a “D”.)

Notably, the accuracy of the Leapfrog scoring system has been under fire since it’s inception – particularly since the organization charges hospitals for the right to promote their score.

But then – as the linked article points out – so do most of the organizations ‘touting’ to have the goods on the facilities such as U.S. News and Reports and their famed hospital edition.

Guess there aren’t very many people like me – that feel like that’s a bit of a conflict of interest..

In the operating room with Dr. Enrique Davalos Ruiz, Neurosurgeon


Dr. Enrique Davalos Ruiz, Neurosurgeon

Spent the morning in the operating room with Dr. Davalos.  As we discussed in a previous post, Dr. Davalos is one of just a few neurosurgeons here in Mexico to specialize in both adult and pediatric neurosurgery procedures.  He performs a wide range of procedures such surgery for cerebral tumors, spinal bifida, hydrocephalus, trauma, spinal surgery and epilepsy.  But one of the procedures he is best-known for here in Mexicali is the surgical repair of craniosynostosis.  However, if you’ve ever watched this intricate procedure – ‘repair’ really isn’t the word that comes to mind to describe the procedure.  ‘Rebuild’ is much more appropriate.

Craniosynostosis is a congenital cranial deformity caused by the premature fusion of the cranial sutures.  (These sutures allow for the babies head to be slightly compressed during natural childbirth).  Many new moms can attest that their neonate’s head was temporarily ‘squashed’ looking at birth, but normalize over the first few days as the bones relax into their natural position.  In normal development, these sutures (or ridges where the bones come together) are not yet fused  – and fuse over the first few months of life.

When the bones that comprise the skull fuse early, it can result in a significant cranial abnormality.  (Luckily, in most cases of [primary] craniosynostosis – the patient’s brain functions normally despite this.)

To treat this surgically, Dr. Davalos had to essentially rebuild part of the skull (the coronal sections of the parietal and frontal bones).   He did this by removing and reshaping the skull in separate sections and then rejoining the pieces to conform to a more natural shape.  (As a someone who sews, it reminded me of lacing a corset to get curved shaping).   In a child of this age – the bones should fuse/ heal within approximately six weeks – with no long term limitations for activities.

Sterility was maintained during the case, and everything proceeded in a rapid and appropriate fashion.  Anesthesia was proficient during the case, with excellent hemodynamic stability and oxygenation.

Dr. Davalos beveling a portion of the skull

Dr. Enrique Davalos Ruiz, MD

Pediatric and Adult Neurosurgery specialist

Calle B No 248

entre Av. Reforma and Obregon

Zona Centro

Mexicali, B. C.

Vice President Angelino Garzon undergoes surgery


Bogotá’s neurosurgeons are certainly staying busy.   Several days ago, the mayor of Bogotá, Gustavo Petro underwent emergency neurosurgery at Fundacion Santa Fe de Bogotá.  Now comes news that the vice-president of Colombia, Angelino Garzon underwent a similar surgery this week for a hematoma at Clinica Reina Sofia.  Details on English language news sites are somewhat sketchy as to his actual medical condition (which sounds like a hemorrhagic stroke), the surgery itself and his prognosis.

VP Garzon, who has a history of cardiovascular disease, underwent emergency heart surgery with Dr. Hernando Santos at Clinica Shaio just two days after he (and President Santos) took office in 2010.

Most recently, he was being treated for a urological condition and it was during follow up medical examinations that his condition was detected.

Update: 23 June 2012

The mayor of Bogota – Gustavo Petro is back at work after successful neurosurgery.

Meanwhile, Vice-president Angelino Grazon remains in guarded, if stable condition after being placed in a medically induced coma while he recovers from a recent stroke and subsequent surgery.

 

Neurosurgery at Santa Fe de Bogota


Dr. Fernando Hakim Daccach (left), neurosurgery – Santa Fe de Bogota

As you can imagine, millions of pairs of eyes are turned towards Santa Fe de Bogota – and the department of Neurosurgery after the mayor of Bogotá, Gustavo Petro was admitted with a subdural hematoma, and subsequently underwent surgery.

Many people don’t know that Bogotá is actually the home to modern neurosurgery.  Dr. Salomon Hakim, one of the founders of modern neurosurgery and inventor of the Hakim shunt for hydrocephalus called Bogota home.  (Sadly, he died just last year.)

But neurosurgery in Colombia doesn’t begin or end with Dr. Salomon Hakim.  With five neurosurgery residency programs and over 150 practicing neurosurgeons in Bogotá – new innovations and treatments are being developed here everyday.

Many of these fine surgeons practice at Fundacion Santa Fe de Bogota such as Dr. Aristizabal – Chief of the Neurosurgery residency program, or Dr. Carlos Cure, Dr. Enrique Jimenez and Dr. Fernando Hakim .

Others such as Dr. Pedro Penagos or Dr. Juan Fernando Ramon are scattered throughout the city – treating brain cancers at the National Cancer Institute, or caring for the families of policemen at the Hospital de la Policia – and innovating in the field of neuronavigation.

While my heart goes out to the Mayor of Bogotá, and his family – hopefully the international media stories on his health will give some well-deserved attention to these fine (and humble) neurosurgeons.

 

References and additional information: Updated 17 June 2012

Gustavo Petro webpage

According to their website, they anticipate the mayor will be discharged home soon (in a statement dated today, June 17th.)  We are glad to hear he is making such a speedy recovery.

 

In the OR with Dr. Hakim


Had an interesting day with Dr. Fernando Hakim, Neurosurgeon, over at Santa Fe de Bogota, for a tumor resection.  A lot of the stereotypes are true; neurosurgery is a  precision-based specialty (not that the other specialties aren’t – but at least in most cases, there is a margin to work with**.) but some of them aren’t.. In this case, with a tumor pressing against the spinal cord – there is no margin to work with, no border area around the tumor, so to speak.. but then again this petty much describes a lot of neurosurgery.. requiring careful, painstaking process..something I would find inherently, and incredibly stressful – but Dr. Hakim and his team didn’t; they were focused, precise, but relaxed and well-coordinated with each other.. Definitely not the uptight, high stress stereotype.. (You’d think I would have known better – I’ve seen plenty of surgery, and some spine cases# before – but nothing of this magnitude, and as I’ve said before; neurosurgery is a bit of a final frontier)

(not to give you the wrong impression – surgery is always serious, this just wasn’t the melodrama that stereotypes/ stories sometimes suggest)

Dr. Fernando Hakim Daccach (left), neurosurgery

** ‘margin of tissue’ or area surrounding the tumor, not ‘margin of error’

# cartagena neuro cases were ‘back cases’ or spinal cases for chronic back problems..

Dr. Hakim, neurosurgeon using the OR microscope for precision work

To switch gears a bit, I met with Dr. Fabio Andres Mejia, a plastic surgeon specializing in rhinoplasty and breast procedures (augmentation/ reduction).  He’s a former fellow (and current member of the) Dr. Ralph Millard (Society) and has been in practice since 1998.
He’s no longer working three jobs or taking emergency plastic surgery calls all over the city – and is now focused solely on private practice (and having a livable schedule)

Dr. Juan Fernando Ramon, Neurosurgery


Spent the morning with Dr. Juan Fernando Ramon, neurosurgeon at Hospital Centro de la Policia. (He also operates at two other hospitals). Dr. Ramon is one of only a handful of neurosurgeons in Colombia who performs neuroendoscopy.

We toured the hospital – and then I watched him perform a small procedure for radiculopathy (in a patient with chronic back pain.)  The hospital has a fully-equipped $4 million dollar neuro-suite (not seen in photo below.)

The patient kindly gave permission for the use of the photos

 
 
Dr. Ramon (and patient)
Met with Dr. Camilo Osorio, Thoracic surgeon this afternoon, for patient consultations.  He was great – spent a lot of time with patients explaining procedures, and answering questions.  He also calls all of his patients a few days before and after surgery – just to see how they are doing.  I’ll see Dr. Osorio in the operating room soon.
 
Ran into Dr. Rincon (cardiac surgeon) from SaludCoop – literally.   I plan to go back over to SaludCoop and see him and Dr. Mauricio Jimenez again.
 
I’ve decided to cease my pursuit of Dr. Camilo Prieto- after several emails, phone calls (by other surgeons vouching for me) and a visit – I just have to assume he isn’t interested in participating.  I only pursued him so far because besides being heavily advertised, and well-known here, I never actually got to speak to him personally, and never got a “no” from anyone.. But now that others have contacted him on my behalf – I’ll definitely take that as a ‘no’..