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.