Big-name surgeon, big goof
By Christine Giordano
4/7/2009 © Health News Florida
Juan Asensio-Gonzalez, one of the most respected trauma surgeons in the country, found himself in an unaccustomed role on Friday, trying to explain to the Florida Board of Medicine how he could have left a 13-inch clamp inside a patient.
Asensio, director of the Trauma Critical Research and Training program at Jackson Memorial Hospital and a professor at University of Miami, literally wrote the book on trauma surgery, on cases like the one that led to the official complaint.
He’s renowned for more than technique. Before moving to UM in July 2006, he was profiled by several newspapers for his attempts in Los Angeles to quell gang violence, not just patch up the results. He was even featured on the CBS newsmagazine 60 Minutes.
So for Asensio to commit such a ridiculous goof was unthinkable, both to him and to members of the board. When he came before them Friday at their meeting in Orlando, he said he was more scared than he’d ever been, even operating in combat.
“Regardless of my credentials, I take full responsibility for this,” Asensio said. “There’s absolutely no question in my mind that this is my responsibility.”
Legally, he’s right. But the board was split. A scrub nurse and surgical tech had miscounted the clamps, twice, according to the case records.
Board members expressed outrage that the health care system doesn’t require more accountability from other members of surgical teams. They said it’s time that Department of Health and the Agency for Health Care Administration changed their approach to dealing with errors in health care institutions.
“Clearly it’s a system problem,” said board member Steven Rosenberg.
The case under discussion involved a 20-year-old girl who came to Jackson Memorial Hospital one night after midnight in May 2007 vomiting and in abdominal pain. Asensio did an exploratory operation, using clamps to hold the intestines in place while he removed a bowel obstruction.
Finishing the surgery, before stitching up the patient, he called out for the “count” of sponges and tools used in the procedure. Records show he was told the count was correct and all of the instruments had been returned. A recount was done, as well.
A few days later, the patient returned, complaining of pain. Asensio was then in Japan, making a presentation to Japanese trauma surgeons. A covering physician took X-rays of her abdomen and found that a clamp had been left behind.
The surgeon who removed it said it was difficult to find, even with the x-ray, the records said.
During Friday’s hearing, board member Robert Nuss expressed disbelief that a clamp more than a foot long would be truly invisible.
But board member Jason Rosenberg, a surgeon, said it’s not difficult to lose even a large object inside a body. He added, “I know to the general public this will sound remarkable.”
Board member Robert Cline cast blame on the team members in charge of counting the foreign objects. “I think it’s totally unfair to this doctor. I think he did everything correctly.”
A few of the board members called the situation a “systems problem” that needed to be addressed.
Board Member Steven Rosenberg said there was clearly something wrong with the hospital staff if they had done two incorrect counts. “He cannot personally do those counts. There’s no way. To hold him accountable for the errors of the staff that are hired by the hospital, I think is very unfair to the physician.”
Asensio said Jackson Memorial changed its practices after the incident. He himself no longer uses the clamp, called a malleable retractor.
He told the board he will be writing about the incident in the sixth edition of his textbook. As an educator, he said, it’s important “to talk about my mistakes. So that it serves, so that others do not commit them.”
He had accepted a DOH settlement of the case that called for a $5,000 fine, a letter of concern, some training and community service.
But the board tossed out that settlement on a 7-5 vote. The charges were dismissed.