Underlying Facts
On January 18, 2018, the 57-year-old patient had coronary artery bypass graft surgery at Jackson Memorial Hospital for treatment of triple vessel coronary disease. While the procedure was performed without complications, the patient’s ventilation machine was disconnected from the circuit while he was being transferred from the operating room table to the bed. The Board found that the surgeon failed to ensure that the patient was properly ventilated by failing to ventilate the patient; by failing to timely recognize a prolonged lack of ventilation; by failing to timely recognize a ventilation failure and ventilate the patient; and, by failing to prevent transient inadvertent disconnect from the anesthesia circuit.
The Board found that the patient was not well ventilated for a total of two to nine minutes. The patient developed severe bradycardia followed by a full ventricular fibrillation cardiac arrest. Despite CPR, the patient failed to have return of spontaneous circulation and had his sternotomy reopened and underwent open cardiac massage during which the right ventricle was punctured and the patient was placed on a cardio pulmonary pump.
The patient was taken to the ICU on Extracorporeal Membrane Oxygenation. The patent was found to be brain dead and was pronounced dead on January 23, 2018.
The Department of Health requested that the Board impose one or more of the following penalties: permanent revocation or suspension of the doctor’s medical license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, placement of the doctor on probation, corrective action, refund of fees billed or collected, remedial education, and/or any other relief the Board deemed appropriate.
In deciding to impose lesser disciplinary sanctions, the Board cited that not all of the events surrounding the circumstances were within the doctor’s control; the patient’s death was at least in part caused by a system error; and, the doctor willingly and voluntarily participated in a root cause analysis subsequent to the event.
The doctor has been licensed in Florida since 1997 and maintains his office in Miami, Florida.
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