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eyes have it: infection

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  • Jurydoctor@aol.com
    Hi, I need your thoughts on this med mal case. You can email me privately, if you like at: _amysinger@trialconsultants.com_
    Message 1 of 2 , Oct 4, 2006
      I need your thoughts on this med mal case. You can email me privately, if
      you like at:
      _amysinger@..._ (mailto:amysinger@...) _ (
      (mailto:amysinger@...) )
      _www.trialconsultants.com (http://www.trialconsultants.com/_
      (http://www.trialconsultants.com (http://www.trialconsultants.com/) )

      Thanks (in advance),
      Amy Singer, Ph.D
      Litigation Psychologist

      any thoughts are appreciated. Names and places have been changed to protect
      the innocent!!

      Dr. Heidi is a 36 year old psychiatrist and wife of an ophthalmologist.
      suffered from chronic dry eyes for a number of years due to droopy lower
      eyelids. She tried creams, drops, and even tear duct plugs. Nothing
      relief. Her husband suggested she undergo a simple procedure to raise her
      brow with a couple of permanent stitches and tighten the lower eye lids.
      were referred to Coe, an oculoplastic surgeon with his own freestanding
      surgery center. Dr. Coe advertises heavily for cosmetic procedures and is
      known in big city.
      Dr. Coe advised that a stitch brow lift would not work. He recommended a
      mid facelift and also suggested a chin implant for a recessive chin. On
      15, 2003, Dr. Heidi underwent the procedure. The mid facelift was
      with an endoscope. Incisions were made below each eye lid and in an
      shape around the top of the forehead to each temple. The endoscope was
      placed in each of these incisions. The endoscope was not used in any
      for the placement of the chin implant.

      The entire procedure was supposed to take 1 ½ - 2 hours. It took over
      hours because Dr. Coe inadvertently nicked a facial artery and encountered
      excessive bleeding that was ultimately brought under control. One week
      the procedure, Dr. Heidi took Motrin several times for a headache.

      After the procedure, she was given post-op instructions which included an
      instruction not to shower and to take sponge baths only until after her
      appointment scheduled on July 23, 2003. Her husband took her home where
      remained in the bed recovering for one week. For the first three days, her
      eyes were too swollen to open. She did not shower and only took sponge
      baths. On July 23 she followed-up as scheduled. Dr. Coe noted positive
      swelling but otherwise healing well. All wounds were epithelialized
      over). She had no sign of infection. It is undisputed that bacteria
      penetrate an epitheliazed wound. She was taking percocet for pain and
      prednisone for inflammation, which also suppresses the immune system. She
      up again on July 30 and noted to be improving with no sign of infection,
      the right lower lid was pulling down due to edema. Dr. Cole advised the
      patient to be patient. Dr. Coe was aware that she and her husband left the

      next day for a ten day camping trip in a rented RV with their children out
      West (Grand Canyon, etc.). She was scheduled to follow-up in two weeks.
      followed-up on 8/13/03 and on 8/15 underwent a revision to the right eyelid,
      known and common post-op complication. She continued to have a problem
      her right eye. She was still taking prednisone.
      On September 10, Heidi saw another oculoplastic surgeon because the right
      lower lid was not healing properly. She had an abbreviated evaluation and
      returned on 10/3/03 where a culture and biopsy of her right eyelid. The
      cultures produced a virulent bacteria called mycobacteria chelonae. The
      lesion was
      surgically drained of purulent material. She also had 12-15 suspicious
      masses that appeared around her head where the endoscopic brow lift was
      She had no sign of infection in her chin (the area where the endoscope was
      used). On 10/8/03 her scalp was biopsied and cultures revealed greater
      100 colonies of mycobacteria. She was placed on antibiotics and followed
      closely and referred to an infectious disease doctor. Despite close
      and aggressive medication management, the masses became puss oozing lesions
      in her head and face. In late-November after consultation with several
      specialists, Dr. Heidi underwent two surgical debridements with drain
      Approximately 4 ½ months after the initial brow lift surgery, the
      was controlled and Heidi underwent two more surgical repairs of her right
      lower eyelid under the care of her new treatment team. She received
      care and has fully recovered with the exception of a slight eyelid
      and residual facila pain where the infection once was. She incurred
      approximately $100,000.00 in medical expenses. She was self employed as a
      ychiatrist and could not work regularly during an eight month period but
      demonstrate an amount of lost income with certainty because she had just
      her own private practice and had no earnings history.
      Mycobacteria is ubiquitous in the environment, especially in soil and
      contaminated tap water.
      Heidi has filed a lawsuit against the Surgery Center contending she was
      infected at the time of surgery by a contaminated and inadequately
      endoscope. She contends the Surgery Center failed to exercise reasonable
      to properly clean and sterilize the endoscope used in her procedure. It is

      undisputed that a patient can suffer a post-operative infection even when
      those attending her and the Surgery Center exercised due care. However,
      according to her treating infectious disease doctor and her retained expert
      including another infectious disease doctor and a nurse who works in
      hospital infection control, the amount of bacteria and the degree of her
      prove that the endoscope had not been properly cleaned and sterilized. She
      contends that the absence of any infection at the site of the chin implant
      rules out any realistic possibility that she was infected after surgery
      from some
      other source. Heidi can demonstrate that the employee responsible for
      cleaning and sterilizing the endoscope did not follow the manufacturer’s
      sterilization instructions for cleaning the endoscope before sterilizing it
      in the
      autoclave. This endoscope was an autoclavable endoscope. The biological
      monitor of the autoclave reveals no problem with the autoclave. However,
      the ink
      cartridge was out on the machine at the time the endoscope was placed in
      autoclave so there is no printed or legible documentation confirming
      successful sterile processing. Additionally, the infection control log
      reveals that
      another patient of Surgery Center suffered a mycobacteria infection 10
      before Dr. Heidi’s surgery although an endoscope was not used during that

      patient’s procedure.
      The Surgery Center contends that it properly cleaned and sterilized the
      endoscope. It contends that after every surgical case, it takes all
      and places them in a double sided metal sink to soak in tap water and an
      enzymatic solution. A tech scrubs each instrument and places them in the
      side of the metal sink to soak in plain tap water. Then all instruments
      placed in an ultrasonic bath and laid out on clean towels to dry. The
      endoscope is rinsed in tap water one more time after coming out of the
      bath. Then the instruments are placed in the steam autoclave for
      The endoscope manual says “do not soak endoscopes with other instruments
      prevent damage to the endoscope.” It also recommends distilled rather
      tap water for cleaning and rinsing. It further says “do not clean the
      endoscope in an ultrasonic bath.” It also provides many other details
      for cleaning
      the lens including that all endoscopes should be triple-rinsed for a
      of one minute for each rinse with distilled water. The rinse water has to
      be discarded at the end of each rinse, as it will be contaminated with the
      cleaning solution. "Thorough rinsing of the endoscope is necessary for
      any debris or detergent which could interfere with sterilization". Before
      sterilization, the manual cautions that the endoscopes must be thoroughly
      cleaned and all organic material, blood, and cleaning solution completely
      Plaintiffs™ experts say that since the cleaning process outlined in the
      manufacturer's manual was not followed, that permitted a biofilm to form on
      lens of the endoscope with bacteria beneath it. The autoclave could not
      completely penetrate the biofilm and permitted the bacteria to survive and
      deposited into Heidi's face during surgery. The delayed presentation of
      infection is a combination of being a part of the natural course for this
      particular bacteria and the prednisone. Prednisone reduces inflammation
      and it
      comprises the immune system so that the manifestation of the infection from

      inflammation was not prevalent and the infection was permitted to become
      without notice over time because of the compromised immune system.
      The Defense has retained a credible and well-credentialed epidemiologist
      retired from the Centers for Disease Control (CDC) in big city, an
      disease doctor, a plastic surgeon, and an autoclave expert who all contend
      (1) the Surgery Center’s practice of cleaning the instruments was
      and in fact, exceeded the minimum standard of care; (2) the endoscope was
      sterile since it was placed in the autoclave; (3) Dr. Heidi was not
      at the time of surgery, and that is it more likely than not that she was
      infected at home by tap water on while on vacation; (4) If she was infected
      at the
      time of surgery, it was a very small inoculum and her motrin use caused
      excessive bleeding, which created an environment for the bacteria to thrive
      the prednisone masked the presentation for a sufficient length of time to
      permit the very small inoculum to multiply into a virulent, raging
      Plaintiffs do not have the instrument and cannot conclusively prove that
      endoscope was contaminated. All they have is circumstantial evidence
      outlined above.
      Questions (help me out here folks):
      1) Does the circumstantial evidence support a verdict against
      2) Which is more likely : Heidi was infected after surgery or during
      3) If she is entitled to recover money for her injuries and damages,
      what is the reasonable range that can be expected for her?
      please" play "with these questions and add as many as you like. I have
      photos if you want to see her during the infection. Private email)

      [Non-text portions of this message have been removed]
    • suesarkis@aol.com
      Amy - It appears you have a lot of smoke and mirrors here. I will try to make my response a lot briefer than your outline. I see a series of no-nos mostly
      Message 2 of 2 , Oct 4, 2006
        Amy -

        It appears you have a lot of smoke and mirrors here. I will try to make my
        response a lot briefer than your outline. I see a series of no-nos mostly
        stemming from the surgeon.

        For starters, the sterilization of the instruments has no bearing at all on
        whether the water was tap or distilled. Distilled is used to protect the
        integrity of the lens since tap water contains abrasive salts. The fact that
        the ink was gone is probably irrelevant if the written notes indicate that the
        proper temp was set. However, that is definitely an issue to be raised with
        the Joint Commission on Accreditation of Healthcare Organizations who will
        not be very happy little campers.

        Was the doctor aware that she had taken Motrin pre-op? If not, why not? He
        should have asked.

        Why did she, an MD and her husband, an MD, allow her to take the Motrin

        What antibiotics were used prophylactically either pre or during surgery?
        Hopefully 1 gm Ancef or something similar which is the norm in most facilities.

        What did they clean her hair with post-op? The norm would be peroxide and
        distilled water. Did they use tap water?

        Implants are much more subjective to infections because of the introduction
        of foreign matter. This is a unique situation. However, I believe the
        plaintiff does have a hard row to hoe since both she and her husband have MD after
        their names and a jury is not going to be as sympathetic as it would be
        toward a normal lay person..

        Since the surgery lasted more than twice as long as it should have, I would
        bet that there was cross-contamination on the surgical tray between the chin
        and eyelid instruments. Regardless, because of the excessive bleeding, it
        would be my guess that they did not get all of the blood out of all of the
        pockets as well.

        There are many, many species of mycobacteria. Most are environmental
        organisms and are ubiquitous in that they are everywhere. However, they are only
        responsible for opportunistic infections which is almost non-occurring in
        immunocompetent individuals. The Prednisone, I believe, is as guilty and
        responsible as the contamination itself.

        They thrive in wet environments (bloody instruments/used gauzes, etc) and
        they have an insatiable appetite for oxygen. The longer the bloody surgical
        instruments are exposed to the environment, the more apt they are to become
        contaminated. No folks, medical facilities are not aseptic contrary to what one
        would think and that is why so many people contract infections in the

        1) Excessive bleeding
        2) Extended exposure due to lengthier procedure caused by the surgeon’s error
        3) Prednisone as a steroid is KNOWN to delay wound healing AND suppress the
        immune system.
        4) No immediate post-op culture and sensitivity when prolonged swelling
        first realized.

        In closing I will say that I do not believe it was the endoscope. Although
        there might have been improper cleansing of the surgical incisions post-op
        coupled with a cross contamination of the actual surgical instruments, I
        believe it was a combination of many factors. However, the Prednisone was the
        biggest mistake in my opinion. Also, remember that even though the endoscope
        was sterilized, it still had instruments inserted in it during surgery. I
        would say that the liability is on the surgeon and that the bleeding was a very
        significant factor. Delayed surgery results in longer exposure to aerobic
        pathogens. Hello, it is a medical facility with sick people.

        I would suggest you back off the improperly sterilized endoscope and
        emphasize more on the cross-contamination due to the overall surgical procedure and
        the lack of ordinary care and treatment under the circumstances presented.

        Sincerely yours,
        Sue Sarkis
        Sarkis Detective Agency

        (est. 1976)
        PI 6564
        1346 Ethel Street
        Glendale, CA 91207-1826
        818-242-9824 FAX

        If you can read this, thank a teacher. If you can read it in English, thank
        a military veteran !

        [Non-text portions of this message have been removed]
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