Dr. Carolyn Lobo received a metaphorical “rectal exam” from two Boards of Medicine – first California; then Ohio.
Here’s what triggered the kerfuffle.
On December 4, 2010, at 11:47AM, patient R-1 was admitted to the ER with self-reported history of having inserted a bottle into his rectum two days earlier. He was in pain and went two days sans bowel movement. The physician’s assistant documented distention and diffuse tenderness. A plain abdominal X-ray showed a glass bottle in mid-pelvis. There was no free air, although the patient was in the supine position.
The surgeon arrived at 2:11 PM and ordered 25 mcg of Fentanyl for pain.
A year later, the surgeon was interviewed by investigator for the California Board of Medicine (yes, a complaint was filed). There, the surgeon explained she gave the patient two options. Going to the operating room- or manual extraction in the ER. The surgeon stated the patient chose the ER route, because he did not want to lose his new job. (Not sure if this was related to longer perceived recovery time, higher bill, or something else.)
During this same interview, the surgeon told the investigator she could feel the bottom of the bottle with one finger, but could not move it at all. But the history and physical documented something else – she “was able to palpate the bottle and was able to manipulate the bottle and move the foreign body around but was unable to rectally extract it.”
During the first part of her interview, the surgeon stated she placed her hand into the rectum to remove the bottle while the patient pushed.
Nursing notes indicated the surgeon placed her arm into the rectum up to her bicep and the patient was screaming in pain. This same nurse said the surgeon did not want the patient to receive any additional pain medication because she needed the patient to help push the bottle out.
Surgeon then performed rigid sigmoidoscopy which showed the sigmoid to be dusky and swollen. New abdominal X-ray suggestion perforation. Patient was taken to operating room for a laparotomy.
Now for the Board’s laundry list of bad things the surgeon did.
(a) Gross negligence: Excessive force while attempting to remove the bottle demonstrated disregard for patient safety and departure from standard of care and/or incompetence.
(b) Gross negligence: Decision to proceed with procedure in ER without securing appropriate assistance from nursing staff demonstrated disregard for patient safety and constituted extreme departure from the standard of care.
(c) Repeated negligent acts: Inadequate sedation during attempts to manually extract the bottle constituted departure from standard of practice.
(d) No informed consent and substandard documentation of procedure note.
(e) Did not perform “time out” before starting procedure. (Really? To verify it was the correct patient? Or make sure the procedure addressed the right rectum instead of the left rectum?)
(f) Dishonesty: Multiple story lines. Finger, hand, arm. Bottle mobile; not mobile.
Now for the agreed-upon penalty.
(a) 25 hours a year (for each year of probation) of education addressing the deficiencies outlined in the complaint.
(b) Complete an approved course on professionalism – at the surgeon’s expense and in addition to other CME requirements (No double dipping).
(c) Complete an approved course on Medical record keeping – at the surgeon’s expense and in addition to other CME requirements (No triple dipping).
(d) License revoked; but revocation stayed and surgeon’s license placed on probation for three years as long as she is good.
(e) Surgeon will pay the costs for monitoring her probation each year of probation – currently set at $3,999/yr.
Now for the pile-on.
Dr. Lobo apparently also has a license to practice in Ohio. The Ohio Medical Board learned of California’s imposed discipline. The Ohio Board wrote to Dr. Lobo stating that it was investigating whether to impose discipline. They gave her 30 days from the date of mailing to request a hearing. That deadline was May 12, 2014. The Board received Dr. Lobo’s letter on May 15, 2014 – and that letter did not include a request for a hearing. The Board revoked her license.
Lessons Learned:
I’ll start at the end and go backwards.
Many doctors have licenses in more than one state. Discipline in one state often triggers discipline in another state. Most, if not all, licensing boards mandate that the licensee has an affirmative obligation to notify them of discipline in any other venue (other state, Medicare, DEA, etc) within a couple of weeks. This means you should not wait for a letter in the mail. Most disciplinary actions are reportable to the Data Bank, which means your State Board(s) will eventually learn about it. If you address it upfront, it’s an explanation. If you address it after it is discovered, it’s considered an excuse.
Next, if you hear from a licensing board, don’t ignore it. Most of the time, they are just looking for your side of the story. Statistically, you are likely to prevail. But, if you miss a deadline to respond, you will have wasted an opportunity. Make sure you timely respond and document you sent your response with certified mail- return receipt requested or Fed-Ex/UPS with tracking. Note: Not all Boards will impose the same penalty as the first Board.
There are times and reasons for doing a procedure in the emergency room as opposed to the operating room. Timeliness, OR availability, cost, and patient preference. Make sure the record supports your rationale. Here, the surgeon was beaten up because the record was sparsely documented.
Next, it’s OK to call it quits if you’re not succeeding. The patient may tolerate some amount of pain if the outcome is near-term success. At some point, that strategy may change – and it’s time to go to the OR. Think trial of labor that turns into C-section.
The nurse’s story was dramatically different than the surgeon’s story. The nurse documented her story. I am skeptical the surgeon was able to place her arm (up to the bicep) into the patient’s rectum. But, there was no competing narrative in the chart.
Finally, the penalty seems steep both in terms of cost and time. The question is how and why this matter evolved into a Board complaint. Perhaps a dispute over a residual bill; poor communication; verbal sparring with nurse that evolved into evening the score.
Most ER doctors and surgeons have seen such patients. Most of the time the patient states the bottle accidentally made its way into the rectum. Of course, it’s hard to dispute. And, what’s the point of debating the matter? But, if a surgeon ever sees a model ship in one of these bottles, he’ll finally have evidence it was no accident.
This is a sad story. Yet another reason to deem the ER and hospitals as dangerous locations to care for patients. It sounds like the assistant nurse skewered this doc, and I’ll bet the hospital uses EHR, and that is likely the reason for poor documentation by the surgeon who likely had other emergency consultations to contend with.
Who knew there were “standards of care” when treating a rectal foreign body? As far as consent goes, do you think the patient went to the ER for a trial of medication? He went for foreign body removal. I’m surprised there was no malpractice suit since there was a perforated viscus that required laparotomy. This surgeon saved foreign-body-boy’s life, plain and simple.
God please help and protect us. 🙂
Be kind to your fellow workers! We all learned as residents (or should have) that only bad things happen when you get a Nurse mad at you!
I have had an opportunity to act as a consultant for a physician who was required to utilize a defective Government constructed EHR system. She was facing sham peer review. The Quality Assurance manager had it out for her and was spraying like an angry leopard to mark her own professional territory. These kinds of people can do enormous damage. I’m not sure I can speak to the motives of the nurse who assisted the surgeon trying to remove the bottle, but it appears that the nurse was well out of her own level of competence.
But according to the article that was the only narrative, so there was no other to go by. EHR is constructed by computer people, not usually physicians. (They act as consultants). This often results in incomplete, inaccurate chart notes out of pure frustration and lack of time.
I was a limited licensed doctor. I refuse to be judgmental. I have never been exposed to the enormous treatment challenges associated with general surgical practice, even though I had exposure to it as a resident. The patient wanted to protect his new job opportunity. I do feel badly that the surgeon allowed the patient to shift his own poor behavior over on to her. She apparently accepted it.
The patient had some clear mental illness/psycho-sexual mal-function that led to his internal choice that resulted in the ER call. He might just as well have had a lit fuse connected to the bottle, in terms of difficulty in surgical management.
She allowed herself to try to rescue him for his new job and avoid an admission and general anesthetic. Anyone who “rescues” a person from their bad choices enters the “Karpman Drama Triangle.” (http://en.wikipedia.org/wiki/Karpman_drama_triangle). When you enter it, you will shift between the various locations: Persecutor, victim and rescuer. Physicians generally do not want to become a rescuer. Rescue for bad choices may be necessary….maybe not. But if you do, expect it to blow up from one or another unexpected site. That is lesson “one” for the rescuer.
I wish the surgeon had been aware of the Triangle and the implications of entering it. It has been my experience that once you understand it, you can see it coming from a mile away. Anyone who inserts a bottle into his rectum is a Drama Triangle “participant.” If allowed to, DT participants will suck you in like a vacuum cleaner. (Seems like the correct metaphor).
She was brutally treated by the two medical boards. The result I wish for her was:
1. A general surgical admission and general anesthetic
2. Removal of the offending bottle in the OR
Patient would have lost his job. The ER nurse would never have had a chance to write a scathing report against her. She never would have been censured. Sounds right to me.
Michael M. Rosenblatt, DPM
I have seen a bottle in the sigmoid removed in the OR with good anesthesia. The case I reference also was a case in which a male slipped, fell backwards, and a long neck beer bottle became lodged in the sigmoid.
The surgeon in this case inserted 3 30 cc Foley catheters at 10, 2, & 6 o’clock (No he didn’t drink Dr Pepper). He inflated the balloons ant then with gentle traction was able to extract the large end of the bottle to the point he could grasp the bottle to finally extract it.
I also suspect the assistant RN may never have seen this done and with the discomfort involved in the ER may have filed a complaint up the chain of command
Patients and Nurses like the one who gave intentionally misleading testimony should me put in their own database. Next time they show up for treatment, physicians should check the database and ‘treat’ accordingly. What goes around comes around. The database should include plaintifs attorneys, their staffs, politicians and lobbyists for ambulance chasing law firms and associations. There is no reason why we should continue to take this lying down. No need to treat patients who seek to destroy our lives and the lives of our families and staff that depend on us.