In Doctors We Trust -- A Cautionary Tale

"I would express to doctors how I would feel, and they would write in the report that it's just fine."

"I paid attention that when I came out from the surgery the other patients that were with me in the room for recovery were able to stand up, to walk around, to move, and to eventually go home with the help of their family members."

"I could not move. Something was very heavy and pulling wherever the surgery was on the right upper abdominal side."

"This is when we felt betrayed, confused, and very bitter, because we did not know where to go for help."
"We felt relieved, we felt validated. At the same time we felt very puzzled how nobody would even click that something so simple can cause so much trouble, and such a deteriorating state of existence where I would be just outsourced to go home and to live on morphine."
"It’s obvious, mistakes happen in the medical community. My expectation as a patient is that you don’t run away, that as a doctor you come back and you help me to get better instead of closing yourself in your own insecurity shell."
Kapka Petrov, 40, Toronto

FAMILY PHOTO    Kapka Petrov, the Toronto woman who suffered excruciating pain after a metal clip was left inside her stomach during gall bladder surgery.

Surgeons are focused, certainly they must be, since much depends on it. A wrong move on the operating table and they could be the cause of a death. In the case of Toronto mother Kapka Petrov, there was no death, but her experience most certainly did alter the chronic state of her health and with it her life. In 2009 she required gall bladder surgery. As the old saying goes, the surgery was successful, but the patient will remain forevermore a patient.

Post-surgery she was assailed with excruciating stomach pains. She required help to shower, to dress, even to eat. But that help was not forthcoming from the medical community; her husband lost his job needing to focus on his wife. The medical team looking after her seemed unmoved by her condition, much less her complaints. Finally she did get some attention; it must have occurred to someone in the medical community that eight hospitalizations in the course of a single year indicated something awry.

But no, it didn't. She left Canada at her parents' concerned behest, to travel back to Bulgaria where she had emigrated from, to look for medical care there. And there, in Bulgaria, with a health-care system that Westerners sneer must surely be inferior to what pertains in North America, doctors discovered a metal clip left unharvested after her surgery. The clip held together the main nerve of her liver and an artery and had abnormally crimped her liver.

In Toronto, Ms. Kapka's surgeon described the removal of her gallbladder teeming with stones, so inflamed that a minor hemorrhage of the liver resulted, but everything would be fine, just stay home and take the prescribed painkillers. But nothing was fine; she experienced rising discomfort accompanied by vomiting, so she had returned to the hospital where a second surgeon met with her and her husband, concerned about a possible lawsuit.

Another surgery ensued, an ERCP liver procedure along with a sphincterotomy in case remaining stones were responsible for her pain. Once again she was discharged from hospital and a jar of morphine accompanied her home. As the months went on, the pain did too, along with gastro problems. To this, her original doctor denied there was a surgical issue involved, and she was not to bother them again.

She was convinced she was about to die. But she underwent surgery in Sofia, Bulgaria, after which she recalled her father comforting her: "I just remember his face coming to me and saying, ‘You made it. They saved you. They discovered horrible things, but you’ll make it. You’re alive and you’ll keep living’." Horror story over. But not so fast; two years later, as she continued to recover from her original ordeal, she fell ill again, requiring an emergency hysterectomy.

After this surgery she was once more subject to severe pain, in the pelvic and rectal regions, and the solution once again was the prescription of painkillers and anti-depressants. She experienced partial paralysis on her left side when six months later a surgeon diagnosed damage to the pudendal nerve, giving her a nerve block injection. It was all too, too familiar. 

Back she went to Bulgaria where surgeons discovered a huge endometrial nest in her left ovary and severe burns to the sigmoid colon and urinary tract resulting from the laparoscopic hysterectomy. Her ordeal has been listed in a recently published report by Health Quality Ontario and the Canadian Patient Safety Institute which examined international cases, did a survey of Canadian nurses, doctors and other health-care professionals and held an online public consultation.

A 2004 study the last time it was done, indicates that 7.25 percent of patients, amounting to one in 13 people, had undergone unintended harm through admissions at Canadian hospitals. Topping the list of errors are surgeries that were unsuccessful when doctors have operated on the incorrect body part or even the wrong patient; carrying through the wrong surgery; and overlooking medical equipment left in a patient's body. 

Toxic gas wrongly administered is also on the list. The report speaks also of unsterilized equipment, the placing of incorrect biological material, inclusive of wrong blood type, incompatible organs and wrong donor sperm into a patient as well as giving patients drugs they have a listed allergy to and burns and failure to prevent attempts at suicide. Infant abductions and baby swaps also made the list.

On a personal note and hardly applicable as being in the same serious category as these is a recent experience of a 78 year-old woman who fell down a full flight of stairs, slammed her cranium against the marble floor at the bottom of the stairs, sustaining half-face bruising and a closed left eye with the eyelid swelling and drooping over the eye. She decided not to see her family doctor. A month went by and the swelling reduced but the bruising remained, albeit fainter.

She went to see her family physician over another matter, an inflamed cyst that had appeared on her outer stomach wall, that was becoming infected. Her doctor is a pleasant, personable younger man, trained in eastern Europe, and practising in Canada. She had been concerned that he would ask whether she was a victim of familial abuse. No worry. The doctor, though examining her and speaking with her congenially, never seemed to notice her bruised face.