Knowing When to Stop Before You Start

Physicians and surgeons are trained to expect the unexpected. They know how to make decisions when confronted with unforeseen circumstances in the course of medical treatment.

A subset of these skills is the ability to know when conditions are not ideal and that a procedure should not begin until they are.

Dr. O is an ophthalmologist who performs elective refractive corneal procedures. He followed his patient, a 36-year-old pharmacist, for some 20 years for eye examinations, lens prescriptions, and other treatment. The patient’s history was significant for many years of problems with thick corrective lenses and broken contact lenses. Though her acuity was 20/20 with correction, an examination revealed the patient’s vision without lenses was “finger count only” at six feet. It was at this examination that the patient expressed interest to Dr. O in refractive surgery.

The patient returned two days later to further discuss surgery. On that date, Dr. O performed measurements in preparation for the surgery, which was scheduled for later that month. The measurements showed the patient’s eyes to have very thin cornea. Dr. O’s calculations showed his patient would need a correction of approximately 13.0 diopters – a very significant degree of correction. The patient signed a surgical consent form for LASEK.

Dr. O saw the patient again the day before the scheduled surgery for another examination. Dr. O discussed the “possibility of haze” with the patient and noted that she accepted the risks he raised.

Prior to the day of surgery, Dr. O discussed with a colleague the high degree of correction his patient would need. The physician recommended that Dr. O use diluted Mitomycin C solution, an anti-metabolite, after the surgery to prevent scarring.

The physician mentioned that Dr. O could obtain the diluted solution from a pharmacy in Oregon. That pharmacy, however, could not deliver the diluted solution in time for the scheduled surgery. When Dr. O’s local pharmacy was not able to supply a diluted solution, Dr. O sought someone at the laser vision center to dilute the solution that he had. When no one at the center was available to dilute the solution, Dr. O decided to personally mix the .01 percent concentration. Dr. O then performed the LASEK surgery at the laser vision center and applied sponges coated with the Mitomycin C solution on the surface of each eye for two minutes.

Dr. O saw the patient the day after surgery and felt that her complaints of pain were typical for the surgery. When Dr. saw the patient one day later, he noted that she was a lot more comfortable. On the third visit, however, the patient’s recovery and visual acuity had regressed. When further visits with the patient that week showed no improvement in the patient’s vision, Dr. O referred the patient to another physician for a second opinion. After examining the patient, the consulting physician told Dr. O that he felt the Mitomycin C was somehow impeding the healing process and suggested that Dr. O review his calculations for the dilution.

In doing so, Dr. O realized that he had miscalculated the mixture: The patient had been treated with a solution of somewhat less than .1 percent instead of .01 percent.

Subsequent examinations by other physicians revealed abnormally low endothelial cells, given the patient’s age. Residual conditions included acuity problems, dry eyes, fluttering eyelids, itchy eyes, and headaches. The need for corneal transplants in the future was a possibility.

In the ensuing lawsuit against Dr. O, the error of the dilution mixture was not in dispute, only the extent of the patient’s injuries attributable to the erroneous dose.

Without a doubt, Dr. O’s patient was excited about the prospect of improved vision from the procedure and would have been disappointed had Dr. O cancelled the surgery. Sometimes, however, a physician must make a tough call for a patient’s long-term best interests.

Gordon Ownby is general counsel at CAP-MPT.Comments on Case of the Month should be directed to gownby@cap-mpt.com