Robert Ricketson and the surgical screwdriver medical malpractice case: The medical records revisited

Robert Ricketson is a spine surgeon who was involved in a high profile 2003 medical malpractice case in Hawaii where a surgical screwdriver was implanted into a patient’s back. This is his account of the ordeal.

by Robert Ricketson

I am writing today out of frustration and anger, as I am frankly quite tired of passively going along as my name appears year after year in malicious “medical blogs” and Google hits that have effected my entire life.

I no longer practice medicine nor would I ever consider it again. I have erred, I admit, but I can no longer tolerate the degree of misrepresentation of facts and distortion of truths.

I would like the opportunity to relate what actually happened at Hilo Medical Center in 2000 and the subsequent events at Queen’s Medical Center in Honolulu so that those entities whose reputations were unjustly marred in this case may have their brief moment. This has been heard in court but never made public. I will leave the names of the specific individuals out.

In 2000, a man was referred to me at Hilo Medical Center with progressive paraparesis and bladder dysfunction secondary to a greater than 50 percent spinal stenosis at L4/5 with associated grade 1 degenerative spondylolisthesis. As his neurologic deficit had significantly worsened over six months, it was felt he may benefit from lumbar laminectomy and spinal fusion including transpedicular instrumentation. The indications have never been in question. His co-morbidities included severe coronary artery disease, poorly controlled diabetes and obesity.

At the time of surgery, he bled 1,500 cc within the first hour due to an unknown platelet dysfunction but remained hemodynamically stable at this point by anesthesia records. Two hours into the procedure, the laminectomy had been performed without incident and the initial two pedicle screws placed.

When I asked for the rods, the scrub nurse, who had at the beginning of the procedure had told the circulating nurse, recorded on deposition, that she had everything, now announced that she could not locate the rods. The representative was notified immediately but he reasonably would not be able to have a replacement for two more hours as he was in Honolulu on Oahu and we were in Hilo on the Big Island. This was now almost three hours into the operation.

I have been criticized for my decision, and I understand. This decision was made with significant difficulty as I fully understood the ramifications. However, even today I stand by this, despite ridicule. Judge as you may, but I felt, given the significant risks for waiting for the rods or closing and re-opening in two hours with yet another general anesthetic, was inappropriate given his blood loss.

So yes, I improvised by simply cutting out a 3 cm section from a surgical grade stainless steel screwdriver from the instrument set that was the same diameter as the missing intended rod. Did it really matter if it was titanium or stainless steel? No. I clearly informed everyone this was done in the patient’s best interest given the unfortunate situation and accepted full responsibility.

We closed, and he had no medical complications that may have occurred had the alternative been chosen. The family was clearly informed that evening, although this was denied at trial. My error was in failing to fully document the conversation. This was explained to be most likely temporary, but if it held to fusion, no further surgery would be required.

There were no neurologic changes postoperatively and that was documented. A routine foley catheter was placed. Three days later, he fell and fractured the implanted substitute. The family was present that evening and again the situation was fully explained as well as the need for replacement. No concerns were voiced. The rod was replaced the following morning without incident. The circulating nurse after the procedure retrieved the fractured pieces which were intended to go to pathology and delivered them to a local attorney. The media later described her actions as “brave and heroic.”

There was well-documented evidence of neurologic improvement throughout the postoperative period. Due to his pre-existent neurogenic bladder, it was felt he would benefit from an intermittent catheterization program. At trial, this was presented as evidence of neurologic injury as he didn’t require intermittent catheterization on admission despite several documented episodes on urinary incontinence leading to his admission.

The patient was discharged fully ambulatory from Hilo Medical Center with clear improvement of his presenting neurologic deficits. There were no significant medical complications despite his significant blood loss at the first surgery and significant co-morbidities. He was also discharged with hydrocodone for pain control. At trial, this was presented as evidence for unreasonable suffering. He required intermittent catheterization by home health care for six weeks until which time normal urine residuals were met. The home health records documented he remained continent after discontinuance.

So, where is the evidence he was paraplegic after discharge? There was none.

What happened two months after discharge from Hilo Medical Center is important but discarded at trial. According to the home health records, the patient fell five times in one day and began having increased back pain. Since the “brave and heroic” nurse told the family of the horrible things that were done to him as a patient at Hilo Medical Center, the family sought counsel with another spine surgeon who practiced at Queens Medical Center. Radiographs showed incomplete dislodgement one of the recently placed indicated rods. There was no documented evidence of any neurologic deficit at this point. The patient was then scheduled to have yet another surgery by this unnamed physician, this time at Queens Medical Center in Honolulu.

The following events were presented at trial, as well as the medical records from Queens Medical Center.

As with the first surgery in Hilo, the patient had significant intraoperative bleeding secondary to platelet dysfunction. However, the patient pulled out his drain in recovery. This was documented but not replaced. Over the next five days, the patient reported to the nursing staff he could not move his legs. No neurologic evaluation was performed for this time period according to records and testimony. On the fifth day of reported paralysis postoperatively, an MRI was obtained which showed, to no surprise, a large epidural hematoma. This was evacuated and the laminectomy extended. Postoperatively, the patient never recovered and remained paraplegic.

Since he now had no evidence of sacral nerve function, he required full time intermittent catheterization – this is well documented. He was transferred to a rehabilitation hospital on Oahu before he returned home to the Big Island. He never recovered any neurologic function after evacuation of the epidural hematoma in Honolulu, not Hilo.

The next two years truly were horrible for the patient as he suffered numerous complications, including urosepsis. At trial, it was the Hilo physician, myself, and the hospital – not Queens in Honolulu – that the blame was placed despite records to the contrary. The patient died two years later.

As expected, the jury returned judgment against me, Hilo Medical Center and its associates. The medical supply company that was responsible for the spinal fusion equipment and delivery of the rods was found to have zero liability. No claim against Queen’s Medical Center or any associated physician has arisen for the care of this patient.

During the trial, the expert witness for the plaintiff determined that my actions “killed him.” I was to blame for all his complications, including death. The incident in Honolulu, although presented, went largely ignored.

As I did not have a tail and could not obtain counsel due to financial duress, I acted as my own attorney – certainly not by choice.

I will always be known as the “screwdriver doctor.” I can live with that. The malicious blogs against me for supposedly paralyzing this patient have now gone down from ten pages to about three over the past three years. I became so depressed at one point I attempted suicide, stupidly, with cocaine. My license was revoked, of course. I am divorced. I have lost subsequent relationships when someone new researches me. Background checks love to go into detail with me. I have been asked how I feel about being responsible for a patient’s death.

So, for those of you that feel Hilo Medical Center and its affiliates, myself and the others intimately associated with this case were responsible for this man’s paralysis and death, consider the story above. This information was presented to the court at trial.

Obviously, however, it made no difference.

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  • A surgeon

    “No good deed goes unpunished.” My empathy is with you.

  • SarahW

    The physician’s error and events described above in the light most favorable to the physician.

    The need to reoperate stems from his negligence, this is the result of the original error. Nothing he relates excuses this error of the physician and Hilo Medical center.

  • SarahW

    I removed a large portion of the above post : apologies for the sentence fragment undeleted:

  • http://brucesmallsurveys.typepad.com/ Bruce Small

    SarahW: Specifically, what do you feel was his negligence and his original error? It may be obvious to you, but I’m not seeing it.

  • http://sideeffectsmayinclude.wordpress.com Whitny

    i’m not familiar with the whole story, but it is a sad situation all around and I’m sorry you’ve lost so much. I hope you find something to fill your life with joy and meaning again, so that you can put this behind you. What a horrible ordeal.

  • PAUL

    IBID whitney. A horrible ordeal indeed with no malice of forethought, just unfortunate suffering for those involved. I hope you find peace.

  • dud

    I am a frequent reader of this blog and enjoy it immensely. However, givng a forum to this version of the events that transpired is disapointing to say the least. Why not allow OJ to post his version of who is responsible for his wife’s murder. Read a liitle about this case people, look at the actions of the various state licensure boards. You will soon see it was not a grand conspiracy orchestrted by some trial attorney.
    To read the reactions of those I assume to be physicans is even more troubling. Is there any action of a doctor you will not excuse? Does your disdain for the legal system obliterate your objectivity?

  • http://advancedmediterraneandiet.com/blog/ Steve Parker, M.D.

    SarahW, is it Dr. Ricketson’s fault that the patient fell five times in one day, two months after Ricketson’s last surgery?

    I don’t see how.

    Cases like this make me think about quitting Medicine altogether. You do your best, but an adverse outcome – regardless of who’s fault – can lead to loss of everything you value.

  • Matt

    Why would you think about quitting medicine based on one doctor’s take of one case? You know at best half the story. At best. More likely it’s about 1/10th.

  • me

    two things definitely occurred as a result of this case-
    1) the hilo area now has less spine surgery coverage
    2) the lawyers for both sides got richer

    as stated above, since we only have “1/10 of the story” those are the only two conclusions i’m able to draw.

  • Matt

    Actually, we don’t know #1. He may have been replaced. We do know that a physician who had his license suspended in two states and had a history of narcotics abuse no longer practices.

    As to #2, we can assume they made money for doing their jobs, whether it was net profitable who knows.

    You may want to rethink your conclusions.

  • me

    you’re right. it’s far more likely that the lawyers saw an opportunity to “fight for the rights of victims” and did so at no financial benefit to themselves. i feel so warm and fuzzy!

  • David

    This fellow needs to be cut some slack. One option for him is to keep telling his story, even write a book about it, and expose some of the things lawyers do in court and how confusing cases are so misrepresented that the jury ends up awarding large judgments and ruining careers.

    If someone knows the case in detail and has other information to present, then do so. If not, then at least listen to the man who probably knows the most about it. A few comments:

    (1) It sounds like this physician made a reasonable judgment call, thinking outside of the box in a dangerous situation – the kind of person we would all want to be operating on us. In our day and age, thinking outside of the box has become ‘suspect’, at the outset. It is probably the unusual nature of the case and solution that allowed the lawyers to implicate this physician. A result of “sorry, but he lost too much blood during the operation and died on the table; but I did nothing unusual” would actually be more accepted by this mentality.
    (2) Many juries think that a bad outcome must be due to bad medicine – and attorneys generally try to give this impression.
    (3) I wonder why the nurse involved did not have a case against her, for taking a pathology item out of the hospital!
    (4) I have spoken with patients and families on countless occasions – and had them later deny that they were spoken to. The lack of memory many patients have is understandable. The anger, though, is not.

  • dud

    Hello!!! He got his license pulled.
    Did not have a lawyer. Ask yourself why! His version is not in accord with the version of other health care providers who were involved. I admit my knowledge is based on press accounts so it could be tainted.
    To take his version as the gospel and then hold it up as an example of how the “system” is out of whack is just unbelievable.
    Now, I’m sure the lawyers were in it for the money, but that in and of itself does not make the physicians actions reasonable.
    I’m mainly just saying, do not take any litigants version of the case as true. Do some research on this one and it will make your head spin.
    Put aside the jury verdict. Look at the outcome here. If it (use of a screwdriver)was really a reasonable action to an unforseeable intraoperative occurrence why is his license pulled?

  • D.Chi

    Is this posted anywhere else on the web? A Google search reveals this blog as the top hit? Was this not sent to the press?

  • dud

    D. Chi,
    Read the rest of the search results. This “guy would all like to have operate on us” (see above) had already had his ticket pulled in Oklahoma and Texas and was under review in Hawaii when this happened.
    This is not the type of care physicians should defend. It only give credibility to those who say doctors will do anything to protect “their own”.

  • Pingback: GruntDoc » Blog Archive » Robert Ricketson and the surgical screwdriver medical malpractice case: The medical records revisited | KevinMD.com

  • Matt

    “you’re right. it’s far more likely that the lawyers saw an opportunity to “fight for the rights of victims” and did so at no financial benefit to themselves. ”

    Do all doctors work only for free? I fail to see why it matters that the lawyers got paid. Don’t pretty much all of us get paid for the work we do?

  • D.Chi

    @dud (and for everyone else) — this post will be long, so forgive me.

    First, your response to my post doesn’t answer my question. The question I asked was “why was this not posted anywhere else”?

    Second, your comments ring of hypocrisy and lack both substance and warrants. Your arguments are defensive at best. Let’s take some of them, shall we?

    First, this statement destroys ALL credibility you have to offer: “I admit my knowledge is based on press accounts so it could be tainted.”

    Because to say that and then to assume that we are all “[taking] his version as the gospel and then holding it up as an example of how the “system” is out of whack” is “just unbelievable” as well. How can you say that everyone who is offering differing opinions from the public/press is in the wrong when you yourself are taking what you are told by the press as “the gospel”? That is hypocrisy.

    “I’m mainly just saying, do not take any litigants version of the case as true. Do some research on this one and it will make your head spin.” — all the research based on this will be based on the press. The only way to do true research is to review video tapes of the surgery (if this were a teaching hospital, for example, the OR may come prepped with video cameras) and ALL patient documentation as well as any audio recordings the surgeon and other medical care practitioners may have offered. In other words, look at the evidence not as it is presented to us, but in its raw form.

    In fact, let’s take a look at a press article here. Aside from mentioning his issues in TX and OK (which, for now, I will grant as most probably deserved given his history of drug abuse and the question of whether or not he was on drugs at the time then), the article then talks about the Hawaii case. In particular:

    “The suit alleges that Ricketson grabbed a stainless-steel screwdriver, used a hacksaw to cut off the handle and a piece of the blade, and then inserted the piece into Iturralde’s spine.

    Days later, the screwdriver snapped in half.”

    Now if you look at Ricketson’s account, his explanation that
    “given the significant risks for waiting for the rods or closing and re-opening in two hours with yet another general anesthetic, was inappropriate given his blood loss” was completely ignored. Further the fact that the patient fell and thus snapped the rods was also ignored in the press it seems. There are other facts missing as well, as his account will attest. To be sure, this is definitely biased in his favor, as he is trying to defend himself, but there are two sides to every coin and it is just unusual that someone like you would tell us not to take the litigant’s word for it when you have taken the press’s word as gospel even with the inconsistencies.

    In fact, it could be that even the press itself may not be entirely objective. If you take a look here at a Harper’s Magazine article, it seems that we need to careful (not skeptical/critical) of what goes on in the news. Writers are writers, not lawyers, medical ethicists(sp?), politicians, economists, etc; just as some of us who comment on this blog are everyday citizens who are knowledgeable in things other than medicine.

    Your final comment: “This is not the type of care physicians should defend. It only give credibility to those who say doctors will do anything to protect “their own”.” — to say this is the same thing as saying that anything we do that the public feels is wrong will be unjustifiable. For example, let’s talk about the lawyers in this case and noting that the lawyers who do the suing and the (lack of) lawyers who do the defending will always benefit no matter what because they’ll always get paid. If a lawyer (or anyone for that matter) were to say that a lawyer’s job is to represent his/her client in the court no matter the cost (after all, lawyers have to make a living), then under your rules, that would be considered “protecting their own.” And if one were to say that the lawyers really were in it for the money, then under your rules, that would be completely warranted.

    That. Makes. No. Sense. That’s simply a defensive argument designed such that only those who see things one way will be correct, and in this case, the article is posted because we are asked to see the other side of the coin, to notice that for this case, there are no winners and losers. In the quest for the truth, the real losers here would probably be the patient himself. To be sure, the doctor had a questionable past, but people can change and even if we did not want to accept that fact, I think in taking a look at the actual medical records, we can parse out the real facts and the timeline drawn in the press and the courts compared to the timeline drawn in the records will be drastically different.

    You are right on one thing: We should have let OJ Simpson tell his side of the story. And we should have teased out the inconsistencies when we matched it against counter-testimonies. Unfortunately, things like that can be a little harder, as OJ does not have a diary that he released to the public. However, the hospital does have the patient’s medical records and (as I mentioned above) maybe a video/audio recording.

    Medical professionals may seem to defend their own. I don’t know your background, but I would hope that any MD who commented was commenting AFTER considering “what would I have done differently here? or here? or here?…”

    I don’t mean to sound angry in this post nor do I mean to attack only one person. I just simply want to point out that in this case, and in many others, if we want to see/find the truth, we will have to try to find it for ourselves, and that can be done (other than personally going through the records) by reading more and more to try to get different viewpoints on the matter and coming to your own conclusions that you can base on that fact that you have taken into consideration the whole story.

    @KevinMD (and for everyone else) — thank you for taking the time to post this controversial article and for allowing comments to be posted here. I really do apologize for the length of this post but as someone who was once interested in going into the legal system and is now looking into biomedical research, two fields in which an objective truth is furiously debated over, I simply felt the need to write this.

  • D.Chi

    Sorry, I misrepresented myself in the previous post. In the interest of full disclosure, I’m in an MD/PhD program as a student at the moment.

    This, of course, may raise questions of my “bias” but I urge everyone to read the various articles I have posted and do their own searches to come to their own conclusions. I’ll keep mine to myself (I tried to stay in the middle in that post above) until I have done what I feel to be adequate reading on this.

  • Matt

    One thing this case does show us is that the claim that one malpractice suit “ruins” a physicians career is nonsense. This guy had 5 judgments when he got hired in Hawaii, and two suspensions from other states, at least one for drug use.

    And simply being named and then dropped from a lawsuit renders you unemployable they claim?

  • Lisa

    WOW, wait a minute on this one – this is so- part of a much bigger problem.

    Considering this guys history (allegations of drug abuse, multiple lawsuits, loss of license to practice in several states) aside from this incident here, where is the hospital’s responsibility in all this? Where is their due diligence in allowing this physician to practice within their facility? Where is the State medical board; what were they thinking in awarding a license to this physician?

    We, the public, can rest assured that our State licensing boards have our best interest at heart – NOT. We, the public, can rest assured that the hospital has our backs – NOT

    Physicians mess up and just move to another state, resume their practice and work until the brown stuff hits the fan again and move on… It happens all the time!
    Kevin MD, did you know the full story on this guy before you gave him a forum? If you did and you still gave him this forum – well, your part of the problem

  • Robet Ricketson

    I will address all the issues presented when I post tonight. All your issues are quite vaild. I only presented information to Kevin based on facts already presented at trial and not opinion or substance that cannot be validated. I will give you my e-mail f you would liketo contact me personally.

  • Anon

    Lisa,

    What you have said is definitely true. Bad physicians messed up and just moved to a different area. It happens all the time.

    Are we the medical professionals (I am one as well) all in part of this big plot to cover each other’s behaind with total disregrad of public safety and pateint welfare? I don’t beleive that. As a matter of fact. I do beleive in our profession there is always an effort to weed out bad seed, just hindered by the litigous nature of our society. A few examples:

    1. A medical school student was kicked out twice from medical school due to poor academic achievement and other issues (such as REFUSE TO SEE PATIENT AND PHYSICAL ALTERCATION WITH OTHERS. Both times he brought back a lawyer claiming discrimination (I think he is Italian or Greek, defenitely white) and school has to take him back just because there is no money for a trial.

    2. A residency program kicked out a resident due to complete imcompetence and danger to himself and patient. He is a minority. Of course, its discrimination and a lawsuit is on the way.

    3. An internal medicine residency is doing his 5th year in the residency, why? again, he is minority and nobody dares to try to kick him out. One of the people I would avoid like a plague if I am a patient.

    4. Remember Dr. King in West Virginia. Apparently you cannot even write a negative reference because that’s defamation.

    Most times you are talking about a multi-million lawsuit due to the “potential lifetime earning” of these people. As hospital, you try to get rid off these people anyway you can, even with a good reference, so at least he is not doing any harm to the people in this region any more.

  • HospiceDoc

    I find it interesting that he got licenses so easily when I just went through a traumatic prolonged ordeal to get one in my fourth state. As an american citizen from a US school with no malpractice issues and not a single issue/red flag…how do they do it?

  • Anon

    The state of affairs for all involved is sad, the patient and his family, the dr, the other healthcare professionals involved on that day… the hospital. I doubt that the doctor woke up that morning and said let me see how many people I can harm today… he has accepted his mistakes, maybe he was negligent, but he is just a human being like the rest of us and prone to making mistakes, some very costly mistakes. Any one on here who is perfect raise your hand? OTOH, maybe the dr should have stopped practicing until he got the other issues in his life sorted out. Many of us fall and fall terribly, it is just that our failures are not so public. I wish you well…

  • Robert Ricketson

    I have read everyone’s blog entries. It would be best at this time to answer your concerns as to my past disciplinary/malpractice issues. For obvious reasons there is no reason to fabricate. Nor will I pull any punches on myself.
    One consistent issue I have seen expressed is the difference between what I reported here and the prior internet reports. The “1/10th rule” I suppose. Since I knew this would come up, the information presented was taken solely from the medical records and testimony presented at trial. The reason why no prior attention was given is simply because:
    1) at no time were the defendants asked for their version of the event and
    2) The press version sounds so much better for the public. Just ask Dr. Williams.
    Now here are the issues of my disciplinary history. In 1998, I became addicted to hydrocodone-in Oklahoma not Hawaii. I did not “flee” to Hawaii to avoid disciplinary action. It wasn’t until I started practice there that I was contacted by the medical board of Oklahoma, not Hawaii. I entered into a recovery program in December, 1998. In January, 1999, I went before the Oklahoma Board where my license was suspended from the time I was in recovery until February, 1999 for a total of 60 days. For those of you familiar with the respective disciplinary histories of your states you can read between the lines. Texas: I was in Texas in 1993 for my fellowship. I maintained an active license (but did not practice) in Texas until I moved to Hawaii. When the Texas Medical Board received notification of the Oklahoma Board decision, they also took action against my license (I hadn’t seen a patient in Texas for 5 years). I was given the option of revocation or a $45,000.00 “administratative penalty”. As this seemed to be just a little extreme I let it go. So no I didn’t “flee” to Hawaii. As for Hawaii, I mentioned in my report that I took cocaine. I reported this to our Physician Health Committee and received treatment for depression. The plaintiffs attorney became aware which was then reported to the Hawaii Board three years later at which time Hawaii took action. No excuses here. Bottom line is that none of the above would have happened if I didn’t have an initial problem with hydrocodone.
    Malpractice history: 1) Third assistant on case in my fellowship. I held the retractor. 2) Fusion of two levels instead of one so fusion of an unintended level 3) Pedicle screw class action 4) Pedicle screw class action 5) Idiosyncratic reaction to Duramorph 6) Iliosacral screw placed during traumatic pelvic reconstruction (S1). Pt had lumbar plexis involvement at time of injury and entire leg remained weak. Go figure. 7) Neurologic injury during arthroscopic microdiscectomy-surgical misadventure. Me. 8) This case.
    So that’s why I was credentialed. Whether or they are or not relevant to the case in question is your decision.
    For Dud. When I left Hawaii, I naively thought I didn’t need a tail. So two years later when this case hit the news, you can well imagine how many takers I had on this. That’s why I didn’t have an attorney.
    Well, that’s it. Sorry it was so long winded. I’d be happy to answer any questions here or by private e-mail.

  • Anon

    This is Anon 7:01pm. What would you do different? I want to believe that aside from the monetary gain, you did love medicine and helping your patients. Can you objectively voice what could be done differently to protect patients from instances like yours? For your part in all this, are you now able to look back and see where the system failed the patient? Is there a system for rehabilitated doctors to come back into the system? Would you approved of a dr with a history such as yours operating on a loved one?

  • Robert Ricketson

    What would I do different? Good question. Money wasn’t the issue in my decision to study medicine. I wanted to make a difference somewhere I guess. Looking back, I was a teenager from 1967-1972. Those years affected how I perceived society and how we as a human race could improve the lives of others. During my clinical years, I never turned down a referral for lack of money. I didn’t come from money.
    You know, we should always remember the times we didn’t get sued but very well could have. We have all heard a patient from time to time present some part in their medical history that represented a questionable decision/action/inaction on the part of a physician. Fear. It prevents us from being ultimately honest with our patients and even ourselves. It’s painful to look at ourselves critically even though we should. If you really care about what you do it should hurt. At one point I thought detachment was a necessary part of the job. That was wrong. You’re less human.
    How did the system fail the patient? What could be done differently? I think confronting the problem when it happens and treat each party as equally responsible would be a good approach. Set a committee that investigates any event that may be a problem, have an open meeting and discussion with both parties presenting their views at the same time, same room including the patient and or their representative. Document the opinions and any remedial action before it becomes a serioous problem. That way it’s done before the patient leaves the hospital.
    At least 10% of all physicians have an issue with substance abuse. Good doctors. Great doctors. Leaders. There needs to be a better way for physicians to get in the system early before it becomes a Board issue. I didn’t even know there was a choice. I knew I had a problem. And I was too afraid to ask. Then it was too late.
    As for your last question, frankly I don’t know of an unbiased response. All I can say is there are problems and there are problems. Is that informed consent? Or is giving a list of successes also informed consent? I have no clue. all I can say is somewhere accept honesty as a part of the job. Answer the question when asked-you don’t really have to go into great detail with the patient about an adverse outcome.It happened and what did you do about it/change. And if they leave, so what? It’s better for everyone. I’ll leave it at that.

  • ninguem

    Dr. Ricketson, what are you doing these days? You found a career outside medicine? Just wondering.

  • Anon

    Same Anon – Thank you for answering our (my) questions. Would you practice medicine again? I find the profession is very unforgiving. I have been in and out of hospitals several times over the last five years. I got absolutely amazing care from all the healthcare professionals involved in my care. That does not mean, there were no times I questioned what was going on but all in all, I believe they wanted to help me. I find myself very saddened by what happened to you because it could happen to any of my doctors. I think of my current doctors, I do not know everything about them other than the facts available to me when I chose them, (which are the same you present when you used to see patients). If they had an a questionable past, and I knew about it, would I still chose them? I feel bad because I cannot answer that question honestly and say I would. Yet had they not been my drs, I feel I might not have had the positives outcomes I have now. I am sure that you had patients that would say very wonderful things about you. All I am saying (rambling actually) is that human beings forget all the good an individual does and focus on the negative, I included.
    I think as a society we have brought this on ourselves. Drs are scared every single thing they say will be used against them. We have started assuming that drs should not make mistakes, that they are infallible. Is it not a wonder that drs will not admit to being less than that because the public will not come to him/her for treatment.
    And yes, there are many great people out there using who knows what. There has to be a better way to take care of both patients and doctors… the current system is not working.

  • Anonymous

    To ninguem
    There’s always life after medicine but we never truly leave it. I still keep up with my CME’s and volunteer at a free health clinic. I’m not licensed of course so it’s limited. It’s very rewarding. I’ve volunteered time doing molecuar genetics bioinformatics. I’d really like to get involvedin clinical rersearch at this time-just looking for the right oportunity.
    To Anon
    Great comments. Keep posting and asking questions.

  • Robert Ricketson

    To niguem
    Thee’s always life after medicine. I still keep up with my CME’s and volunteer at a local free health clinic. I’m limited in what I can do but it’s very rewarding. Have done volunteer work with bioinformatics and molecular genetics. Would like to do some clinical research if the right opportunity came up.
    To Anon
    Great comments. Keep asking question. Tough ones. Makes for a great discussion.

  • EM

    This bothers me a little:

    “Did it really matter if it was titanium or stainless steel? No.”

    How do you know? Are you sure that the titanium rods would have snapped just the same? This was a screwdriver shaft, yes? Subjected to substantial torque from time to time? How did you ascertain that there was no metal fatigue that would have rendered the modified instrument prone to failure?

    Also, I presume the titanium rods you should have used would have been quality tested for that specific purpose. The screwdriver blade certainly was not. Did you take that into consideration when you determined that hastily modified surgical stainless is an adequate substitute for purpose-built titanium? Considering that titanium is way more expensive than surgical stainless, is there perhaps some issue related to strength and durability that leads the manufacturer to make them out of titanium (I don’t know the answer to this)?

    Here’s the thing. You don’t have what you might call a pristine background, so you really needed to be doing it cleaner than everybody else. But, you took a giant risk and did something completely unorthodox and, most importantly IMHO, well outside the standard of care. It turned out badly for your patient, and now you are taking heat for it.

    You are not a victim.

  • Anon

    I notice that in our society we have selective rights and wrongs. You know what is the irony, had that screwdriver held, Dr. Ricketson would be hailed a genius who thinks out of the box. Would he have been sued if it had worked?
    I do not think he has presented himself as a victim as regards the actual activities that led up to the lawsuit. But he is a victim in that we are sitting here discussing our view and opinions of something that we are not even a part of and consequently passing very negative judgement. He has accepted his mistakes, what do else do we want? I think in cases like this, one cannot change the opinions of others since their minds are already made up. I think the tone of his posts indicates remorse, granted we cannot be sure since we cannnot see him. Everybody involved was a victim…

  • EM

    “Would he have been sued if it had worked?”

    No, because there would not have been any damages.

  • Robert Ricketson

    @EM
    The biomechanical concerns were brought up. The general feeling was that, given the same circumstances, both would have failed. Also the battery effect would be minimal if any at all (in vivo study). Stainless steel rods have been used in spine surgery for 100 years. That said, it seemed a bit ridiculous at the time to ask the rep about the comparative biomechanical properties of surgical grade stainless steel vs. titanium.
    It wasn’t the “heat” from the rod substitution that bothered me. But it was being wrongfully accused of the paralysis and death of my patient that did bother me. Reread the records. Epidural hematomas if not evacuated within 12 hours result in permanent neurologic injury. Sorry, but I get a little defensive when things get tangential.
    @Anon
    Right. Nobody walked away smiling. It was just a little too lopsided and inaccurate for me to just to let it go anymore.

  • EM

    With all due respect, please bear with me as I’m still trying to get my head around this–this is in fact the first I have ever heard of this case.

    “Reread the records.”

    I don’t have access to your patient’s records–I only have your word as to what transpired.

    Regardless of the metallurgy issues, your decision still bothers me. In which class, in what year of your fellowship were you taught the proper procedures for modifying surgical instruments to replace orthopedic devices? Is there a text, some manual or compilation of peer-reviewed articles that gives you sufficient instruction to make such a substitution? Is the FDA cool with substituting a hack-sawed screwdriver shaft with a titanium device?

    The way I see it, you had three choices that day. The first would be to look at your anesthesiologist and say “Your call–can we keep him down an extra two hours?” If yes, then wait. If no, then choice two was to close him up and go back another day. The fact that he did, in fact, require another surgery a few days later and survived testifies to the wisdom of this approach.

    Your third choice was to do what you did, which amounts to an unsanctioned experimental procedure with no IRB oversight whatsoever, completely out of bounds of proper protocol. And let’s be clear, this was not a TV “tracheotomy performed in a restaurant with pen and a Swiss Army knife” or a M*A*S*H episode where they need to do “meatball” surgery for the patent to survive. You had reasonable choices, but you chose to be MacGuyver.

    So the jury saw a guy with a drug history and a history of having his ticket revoked who decided to “wing it” in the OR leading to a chain of events ending in the death of the patient.

    BTW, let’s try on this scenario. Imagine if you will an airplane crash where your wife or child was on board and was killed. And then suppose you found out that a technician couldn’t find the titanium nuts, so he ground down some stainless nuts and used those instead in direct violation of airline and FAA rules. And let’s suppose that the failure of those nuts, while not immediately precedent to the crash, was a major contributing factor to the loss nonetheless. Are you telling me that you would not join in *that* class action suit?

  • David

    EM,

    I can’t agree with you.

    (1) The relationship between the ‘suspect’ surgery and the eventual decline of the patient is not clear at all.
    (2) You’re analogy to putting defective bolts on a plane is silly. Imagine if the plane were in danger of going down, unless something is done immediately – now you have a similar situation. A mechanic realizes he can improve the odds of everyone’s survival if he takes bolts from the seat and uses them for another part of the plane. For your information, that is what thinking people do in dangerous situations. They don’t consult the FAA, FCC, FDA, or other bloated regulatory group and wait three months for their considered opinion. Unsanctioned experimental procedure? Let’s hope not everyone has as atrophied an ability to think on his feet as you advocate!

  • Robert Ricketson

    @EM
    Now I think I understand well where you are coming from. You made a couple of key statements that clarified things for me. So here goes. In your first sentence you said, “this is in fact the first I have ever heard of this case”. I apologize if I’m wrong, but frankly I’m not quite sure that’s actually true. I’ll tell you why.
    You, very interestingly, used the descriptor “hack-sawed screwdriver shaft”. Now where have I heard that before? That exact phrase was only used by the plaintiffs attorney to conjure up an image of a frenzied surgeon bending over a workbench using a “hacksaw”. If you hadn’t described it that way I may not have put it together right away. That wasn’t the case of course. I used the standard rod cutter.
    For someone who didn’t hear about the details of this case, you also seemed to be aware of the very alternatives that were discussed at trial.
    Finally, you also said, “wing-it”, also a phrase I remember quite well.
    And “chain of events”. That was also used by the plaintiffs attorney. Following that logic, should we say, gosh, if my patients CABG hadn’t restenosed so he couldn’t exercise, resulting in obesity, resulting in spinal stenosis, that resulted in his surgery, etc. That kind of “processing” was exactly what I meant by distortion of facts.
    As David (above) undoubtably noticed, there was no clear association with my surgery to his eventual decline. In fact, just the opposite-the medical records and court documents are very consistent. The very clear association was the impact of the unrecognized epidural hematoma in Honolulu, not in Hilo. My patient went in Queens Hospital moving his legs and left paralyzed and incontinent. And he died as a direct result-that was the conclusion at trial. Wrong surgeon though. That was difficult to prove at trial in that the plaintiffs attorney successfully objected to any scientific evidence (hearsay) I attempted to present due to “lack of foundation”. The Rules of Evidence are very specific specific on that.
    So, I am quite sorry if this was just a simple coincidence…..

  • Robert Ricketson

    If any you you would like a private discussion, go to this link>contact us. It’s a “work in progress”.
    http://seaspineedu.web.officelive.com/contactus.aspx

  • EM

    @Robert

    Dude, you are paranoid.

    ” If you hadn’t described it that way I may not have put it together right away. ”

    Aha!!! AAHHHHAAAA!!! Gotcha!!! You are part of the evil cabal that is out to get me.

    After reading your article I did Google the story to see if there was any other opinion out there. “Chain of events” and “wing-it” are a part of my lexicon and I claim originality on the use of those terms in this instance. I’ll admit I got hacksaw from a press source, so I stand corrected. Rod-cutter.

    So.

    You decided that you were uniquely capable of fabricating an orthopedic device in the OR, experimenting (I know you hate the term winging-it) without, as I said, any due regard for little things like Institutional Review Boards and informed consent protocols.

    Where is that incorrect?

  • EM

    @David

    I’ll disregard the ad hominem attacks.

    Your analogy is the one that is specious, however.

    The patient was hemodynamically stable by the doctor’s own admission. This was not a life or death emergency where extraordinary measures were needed to save the life of the patient (if you had read my post you would have noted my reference to ballpoint pen tracheotomies and MASH episode “meatball” surgery.

    Dr. Ricketson was too clever by half, and got in trouble for it, and rightly so. The ethical rules that constrain a surgeon’s behavior exist for a reason.

  • David

    EM,

    My statements were not ad hominem. An idea can be silly. I didn’t say you were silly. I also said “Let’s hope not everyone has as atrophied an ability to think on his feet as you advocate!” I didn’t say you had no ability to think. I didn’t say others had no ability to think. I just don’t want people to take your ideas seriously and, thereby, atrophy their ability to think. Good clean argumentation without any informal fallacies.

    Your analogy is flawed because it does not take into account that their is simple risk in having a patient stay under general anesthesia with ongoing bleeding. In addition, closing again and having to redo the surgery (at another time) would probably be of even greater risk. The doctor has already explained “given the significant risks for waiting for the rods or closing and re-opening in two hours with yet another general anesthetic, was inappropriate given his blood loss…”

  • EM

    @David,

    Implied ad hominem then. Whatever.

    Then you followed up with this:
    “I just don’t want people to take your ideas seriously and, thereby, atrophy their ability to think. ”

    Taking my ideas seriously atrophies the ability of others to think is not ad hominem?

    “Your analogy is flawed because it does not take into account that their is simple risk in having a patient stay under general anesthesia with ongoing bleeding”

    I am well aware of the risks and did take them into account. The risk of keeping him anesthetized for two hours or closing are calculable risks, however. The risks associated with jury-rigging a screwdriver could not possibly be calculated at that moment, and therefore it was not ethical to experiment on the patient without the patient’s informed consent.

    “In addition, closing again and having to redo the surgery (at another time) would probably be of even greater risk.”

    Really? Ricketson himself says “Three days later, he fell and fractured the implanted substitute. … The rod was replaced the following morning without incident.” This belies the statement that redoing the surgery was a greater risk.

    You clearly aren’t capable of producing a reasoned analysis from the facts presented.

    Now THAT is ad hominem!

  • David

    Em,
    “You clearly aren’t capable of producing a reasoned analysis from the facts presented”

    Wow. That does qualify as ad hominem. You have issues, my friend, but not of the usual kind.

    Just in case your errors are simple confusion, and not malicious misunderstanding, let’s foray one last time. You said “Taking my ideas seriously atrophies the ability of others to think is not ad hominem?”

    No, not really. If you recall the conversation it has to do with whether and how people think on their feet. It has to do with creativity under fire, which is itself a skill and a habit one can and should develop. There are a lot of people around (especially today) who are bureaucrats. They know all the rules they should follow and which authority to consult – but they aren’t really doing much thinking on their own. They can ‘smell’ when things are ‘wrong’ – when people are thinking ‘outside the box’, and they don’t like it. Compare the CEO of a company to an IRS agent. The mentalities are quite different. So it is not ad hominem – I am focused on your ideas – or the implication of your ideas – that in this serious situation, a physician would actually have to consider IRB approval rather than focus on the life and health of the patient he is treating. If the world generally accepted your approach, it may very well fall apart. The minds would atrophy (or become stale) from lack of use. You may be a very fine person with the best of intentions – but what you are saying can lead to badness all the same!

    You also commented: “Ricketson himself says ‘Three days later, he fell and fractured the implanted substitute. … The rod was replaced the following morning without incident.’ This belies the statement that redoing the surgery was a greater risk.”

    Hmmm. Have you ever played poker? Do you know the odds of drawing a flush or a straight? If you were a poker player, these are things you would need to know. They are, of course, much more calculable than what we are speaking of, but it can be used as an analogy. Now suppose you had calculated that your odds of sticking with your two pair was better than your odds of drawing a flush. You would probably stick with the two pair, then, based on simple mathematics. Dr. Ricketson stuck with the two pair.

    Now, along comes the next card – wow, if you had gone for the flush – you would have won the game! (This is like you looking at the situation after the fact, and surmising that the other option was better). There is a difference between attempting to calculate what will happen in the future – and surmising AFTER AN EVENT – what really did happen. If we always knew what would happen, then we wouldn’t need the science of statistics, insurance, the gambling industry would be done for, etc., etc.

    I’ll give you the opportunity for the last comment – unless you say something too outrageous and draw me in again!

  • Anon

    How do you settle claims or payout on judgements when no insurance is involved? Are these kind of judgements not detrimental to physician’s family financial stability? Dr. Ricketson did not have a lawyer so can we assume that he did not have insurance to cover that particular claim so that all financial judgements were out of his pocket?

  • Robert Ricketson

    I did wonder when someone would get around to asking that particular question. That would indeed be true unless there existed some pretrial understanding between plaintiff and defendant counsels. You see, the intention of this post was not to discuss decision making in surgery but rather to clear up misinformation that has been presented in the media. The plaintiffs attorney was well aware I had no financial means to pay a judgment. It was well known to the plaintiff by way of depositions, medical records, and other legal documents that my patient was discharged from the hospital in Hilo in good condition and without any evidence any complications other than to replace the rod. That is indisputable fact. It wasn’t until his next surgery, at another hospital, and under the care of another surgeon when he became paralyzed as a result of a failure to timely diagnose an epidural hematoma. That event was what was directly responsible for his multiple medical complications leading ultimately to his death 2 years later. As you may know, I was not the only party named in the complaint. As a direct result of the sensational publicity and my past misgivings, it was a foregone conclusion that I would be found liable. After all, it only takes a preponderance of the evidence. As I was unable to afford an expert witness, I was unable to admit significant supportive evidence due to lack of foundation. So, you might ask, why even bother to sue someone, use up three years of legal time and a 5 week trial against someone who had no means to pay even if there was a judgment? I was simply a conduit to a potentially greater end. There were other defendants who did possess an ability to pay large amounts of damages, if they were found liable. My role in this was to limit damages, not against myself necessarily, but to the other defendants.

  • Anon

    Now this begs the question, what happened to the other defendants? What were the damages awarded? And if you say confidential…

  • Robert Ricketson

    According to published, public documents the outcome was: “Plaintiff’s verdict for $5.6 million including $3.4 in punitive damages” with my portion being 65% and HMC 35%. The medical supply company was found to have 0% liability. What has transpired is that the appeal was denied due to lack of jurisdiction. I am unaware as to HMC’s final disposition.

  • Tucker

    My first foray into the blogosphere and my first comment. Its very difficult to come to a conclusion that is based on incomplete facts. So, I have no conclusion. Based on my limited information, I have some general thoughts and futher questions. In malpractice we know there are certain elements that need to be established in order for liability to be found. Among them, duty, negligence, injury, damages and, causation between the negligent conduct and the injury. Importantly, the defendant’s negligence must be shown to be the proximate cause of the plaintiff’s injury. What is “proximate”? This is not only dependent upon time, but other factors that establish a legitimate link between the inciting action and ultimate result. The jury determines whether this requirement is satisfied.

    So, I guess in this case the jury found that Dr. R’s actions were to some extent the proximate cause of the plaintiff’s injuries.

    But what actions? Starting the operation without confirming the presence of all required medical devices? Improvising once that absence was discovered? I don’t know. Maybe it was based on the outcome of the second case he performed. Dr R states that after the pt fell 5 times in one day, it was later discovered that the rods were “displaced.” Maybe the jury concluded that he had never properly placed them, and that is what caused the pt to eventually have problems that led to him falling 5 times in one day. Dr R seems to belive that the falls caused the displacement. I don’t know.

    I think it is wrong to start a case without verifying that all the necessary equipment is in the OR. I don’t think that this error proximately caused the plaintiff’s paralysis and death.

    Based on what he told us here, I think the vast majority of the fault in this case rests with the physicians who sat on an epidural hematoma. And I further believe that if the facts are as represented here, that if Dr. R had a good attorney, he would have, and should have, prevailed.

    One other question I have; Is Anon, Dr. R?

  • Marie

    The whole time I was reading the initial article and the responses, this statement was echoing in the back of my mind:

    “…the scrub nurse, who had at the beginning of the procedure had told the circulating nurse, recorded on deposition, that she had everything, now announced that she could not locate the rods.”

    WHAT?!?!

    To me (I am a nurse), everything that happened subsequently hinges on this statement. Did she lose them?!?! Did they get thrown away? Was any attempt made to look for them? Did she think she had them but didn’t? Or had she simply lied at the beginning of the procedure?

    Was she asked generally if she had ‘everything’ or was there a checklist specifying the rods? Who was responsible for getting the rods into the OR in the first place?

    How could a surgery to insert rods not have rods?

    That is the moment when things had already gone wrong and I think that was the moment that everything should have stopped. There was clearly a major disconnect somewhere in the facility. Something as elementary as the equipment that was to be implanted, the sole reason for the operation, could not be successfully accomplished. To me that would have been a major red flag that the patient, indeed, every patient in the facility, was already in danger.

    I can sympathize with your reasoning, Dr. Ricketson. But it is not as though you were in the jungle or the patient would have perished if you didn’t improvise.

    Hindsight is 20/20, but the most prudent thing to do would have been to close the patient up, get him stabilized re. his co-morbidities, initiate an internal review to investigate the protocol failure for the rods and establish a rigorous policy and procedure to ensure it never happened again.

    And then, only then, reschedule.

    I am very sorry for everyone involved here. Dr. Ricketson, I hope you find satisfaction and happiness as you move forward in your life.

  • Robert Ricketson

    This might be a bit long.
    I had no intention of being “Anon”. That would defeat the purpose of this discussion. All the information presented here was offered as evidence at trial. As to why the jury was unwilling to look the proximate cause of the patients morbidity and mortality (epidural hematoma), the answer was my past. No going around that issue. It was easier to blame someone with past disciplinary issues than the alternative, regardless of the facts presented.
    The other issue was simply a matter of law and Rules of Evidence. As you know, learned treatises are considered hearsay and therefore inadmissible as evidence (publications, journals,etc) unless you are able to lay foundation. That information can only be presented if you have a well primed expert witness that will verify its accuracy and relevance. I could not afford an expert witness. So, yes, I was unable to introduce any learned treatise or learned opinion on neurologic injury followiing an epidural hematoma. Yes, the jury heard the medical records. I couldn’t get around the plaintiff’s hired guns.
    As fo the issue of who’s responsible for assuring the equipment is present, I agree the surgeon is always responsible. Ultimately, that’s the way it is. At trial, the circulating nurse (also the “whistleblower) testified that she had asked the scrub three times before the case started if she had everything. She said yes. That is also what she told me before it started.
    You mentioned the outcome of my second procedure. Nothing happened adversely. The patient went to Honolulu to revise the dislodged rods (third procedure). That’s where the hematoma and paralysis occured. Very clear in the medical records. Unfortunately, I didn’t have access to those records at mediation.

  • http://billposer.org Bill Poser

    On the facts presented here, a real miscarriage of justice seems to have taken place. That a creative response to a problem which appears to have caused no harm and was intended to avoid the problems that might well have been engendered by sustained general anaesthesia has been treated as malpractice is outrageous.

  • Robert Ricketson

    To Marie
    To address your question as to “where were the rods”, well quitefrankly that was literally the million dollar question. that issue was never resolved despite an extensive search and inquiry as you suggested. This next part nows begs some discussion. You need to understand the patient had no adverse medical complications. You see, he would have required an another operation regardless. I hate to kep repeating myself but the patient sufferd no ill consequeces other than a reoperation. As “Tucker” pointed out in an earlier entry, the proximate couse of the patients paralysis and subsequent medical complications was the epidural hematoma he developed in Honolulu, under the care of another surgeon.