This case also taught me the value of understanding the standards of care and not being afraid to take a deep dive into complex medical procedures.
This Parkinson’s Case Taught Me to Think Outside the Box
by Leanne Sells, RN, BSN, CLNC
My most Memorable CLNC® Case involved a patient with a 25-year history of Parkinson’s disease who experienced optimal results from bilateral deep brain stimulators. After the first set of stimulators had reached the life of the medical device, the patient opted to have new stimulators placed for continued parkinson’s management. Since the patient had relocated to a different state, he was seeing a different neurosurgeon for this procedure. The end of life medical devices were removed by the second neurosurgeon and new temporary leads were placed. After a successful trial, the patient was scheduled for new, permanent deep brain stimulator placement. The patient suffered post operative wound complications following the second implantation, requiring the stimulators to be prematurely removed due to the ongoing infection. Eventually, a retained foreign object was identified and had to be surgically removed.
Since Set #1 and Set #2 of the deep brain stimulators were implanted by two different neurosurgeons, it was essential to establish which neurosurgeon was responsible for the retained foreign object. The pathology report identified the retained foreign object as a plastic cylinder with four electrical conduit connections. The pathology report also included photos of the retained foreign object. I could immediately tell it was not a deep brain stimulator lead or the battery generator pack, but I had no idea what the object could be. The good news was that my attorney did not know either and said, “That’s what I hired you to find out.”
In my initial review of the medical records there were no obvious deviations from the standards of care in either of the two procedure operative notes. Since I only had superficial knowledge of the deep brain stimulator procedure, I started with researching the standard of care for the implant and removal procedures. Next, I obtained the serial numbers of the medical device implants from the circulating nurse documentation on the intraoperative summaries. Since the two implant procedures were 10 years apart, I expected the technology to be different.
I was able to locate the manufacturer product information booklets for all of the medical devices. The information included diagrams of the deep brain stimulator system. The system included the leads, the generator battery pack and a connector that joined the two together. The picture of the connector used in Set #1 showed 3 conduit points, and the connector used for Set #2 showed 4 conduit points. Not only were we able to identify the foreign object, but the upgrade in technology and locating the product information allowed us to determine the appropriate implant procedure. The neurosurgeon’s office records also noted that the battery pack was left in place, as the patient did want new stimulators placed once the infection resolved. After reviewing that information, I went back to the operative note for the Set #2 removal, and my eyes were immediately drawn to the removal portion of the operative report, “The lead wire was cut cephalad to the connector. The proximal cranial incision was then opened, and the lead itself was removed as was the locking cap. The subgaleal space was dissected to free the wire of the lead. This was then removed in one piece.” Since the surgeon had documented cutting the lead wire cephalad to the connector, the system was no longer in one piece. The cut wire created two pieces, and there was no documentation that the connector was removed, only the lead wire.
Ultimately, the case was settled in favor of the plaintiff for an undisclosed amount. My attorney-client was the third attorney to review the case. The first two attorneys had decided the case was too complicated and there was no way to prove which physician was responsible for the retained foreign object. The patient had multiple evaluations, required additional surgeries and had long term antibiotic therapy for sepsis treatment.
This case taught me the importance of thinking outside of the box. I remembered from my initial training, the Institute said “You are a nurse, you can do anything.” It took me awhile to obtain the confidence to consult on cases outside of my clinical specialty. Effective patient education was always a strength for me. My ability to research complicated processes and translate them to lay terms is a huge asset to attorneys and is a marketing advantage in promoting my legal nurse consulting business. This case also taught me the value of understanding the standards of care and not being afraid to take a deep dive into complex medical procedures. In my earlier RN practice days, I would always dive into the medical records. Now I obtain the base facts, do the appropriate research to ensure my knowledge is up to date on recommended best practices and then complete the review. When I conducted root cause analyses in the hospital setting, we always began with what should have happened and then reviewed what actually happened. I have found adopting this same principle in my legal nursing consulting business has been a valuable tool.
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