Deaths, patient harm result in reprimands for Wisconsin doctors

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1 Deaths, patient harm result in reprimands for Wisconsin doctors host.madison.com/wsj/news/local/health-med-fit/deaths-patient-harm-result-in-reprimands-for-wisconsindoctors/article_3c8cb2a7-bb d-5afce5130dcc.html DAVID WAHLBERG January 17, 2016 From 2013 to 2015, the Wisconsin Medical Examining Board reprimanded doctors in at least 40 cases in which patients were harmed, including at least 17 in which they died. Here are five such cases: Doctor didn't order C-section In April 2008, Kellie Engen, of Mazomanie, went to Meriter Hospital to have Dr. Amy Grelle deliver her first baby. After a fetal heart monitor detected a sudden deceleration in the baby s heart rate, Grelle performed a vacuum-assisted delivery. The baby was stillborn, with the umbilical cord wrapped around his neck. 1/5

2 Grelle, a family practitioner not certified to perform Cesarean sections, should have contacted an obstetrician about doing a C-section and informed Engen and her husband of that option, experts said during a trial. A jury found Grelle negligent but said the negligence wasn t a cause of the baby s death and gave no monetary award. In 2015, the medical board reprimanded Grelle, of UW Health, and fined her $500. The fines are based on investigation costs. Grelle told the State Journal she delivered nearly 200 babies over 10 years with no problems. She stopped delivering babies in 2009, after what she called the tragedy involving Engen. Even so, the board limited her license, saying she could not do labor and delivery, except in an emergency, without an obstetrician present. Less than three months later, the board lifted the restriction. Engen, who has three children ages 1 to 5, said the board should have forced Grelle to take labor and delivery classes and restricted her license for at least five years. Grelle told the medical board, through her lawyer, that by the time the heart rate problem was detected, a vacuum-assisted delivery was better than a C-section. Chest pain treated as migraine Robin Cooley-Place, 52, of Lancaster, went to the emergency room at Grant Regional Health Center in Lancaster in October 2011 for a headache, nausea and neck pain. Her blood pressure measured high. During an evaluation by Dr. Robert J. Smith, she complained of chest pain. Smith treated her for a migraine and released her. Two days later, she died from a heart attack. Smith failed to adequately assess her chest pain and should have ordered cardiac tests, the medical board said. 2/5

3 Smith, who still works at Grant Regional, was reprimanded and fined $700 in 2014 after a lawsuit resulted in a $237,500 settlement. Cooley-Place s husband, David Place, didn t return messages seeking comment. Smith told the medical board that Cooley-Place s chest was tender, but he didn t say why he didn t order cardiac tests. Stitches led to bladder injury During a hysterectomy and ovary removal at Monroe Clinic in February 2008, Dr. James Turek injured Jacqueline Hardegree s bladder. After Turek realized the damage, he put stitches in the wrong place and failed to call a urologist for help, the medical board said. Hardegree wasn t able to urinate for many hours, requiring another emergency operation. A lawsuit, which claimed she had long-term complications, resulted in a $72,500 settlement. Hardegree, 53, told the State Journal she has needed more than 20 follow-up surgeries. In 2013, the medical board reprimanded Turek, required him to attend a urogynecologic surgery seminar and fined him $1,327. Turek, who now works in Fort Dodge, Iowa, told the medical board, through his lawyer, that the bladder injury was a known complication of the procedure. Doctor performed wrong surgery Kerry Wolfe, 62, of Fort Atkinson, went to Fort Healthcare in January 2012 to have a cyst surgically removed from her wrist. Dr. Isidoro Zambrano did a carpal tunnel surgery instead. When he realized his mistake, near the end of the procedure, Zambrano told Wolfe s husband and got permission to do the correct surgery. Wolfe told the State Journal she still has occasional sensitivity at the carpal tunnel incision. A lawsuit resulted in a $19,500 settlement. 3/5

4 In 2015, the medical board reprimanded Zambrano and fined him $300. He told the board that the hospital reviewed its pre-operation procedures and he read The Checklist Manifesto: How to Get Things Right, a book by Dr. Atul Gawande. A hospital official told the State Journal no such incidents have occurred since Stroke misdiagnosed as lung disease In April 2012, an ambulance took Lila Olson, then 72, to Moundview Hospital in Friendship for shortness of breath and difficulty speaking. Dr. Charles Pratt ordered a chest X-ray, oxygen and nebulizer treatments. Olson s daughter, Dr. Pamela Olson, who works at UW Health, talked with Pratt by phone. He told her he was treating her mother for lung disease. Dr. Olson told him another family member thought her mother was having a stroke. About two hours later, Pratt removed Lila Olson s oxygen mask. The right side of her face was drooping and her right arm and leg were weak. He diagnosed her with a stroke but said it was too late to give her a clotbusting drug. In 2013, acting on a complaint by Dr. Olson, the medical board reprimanded Pratt, made him take a class on diagnosing strokes and fined him $1,000, saying he failed to diagnose the stroke in a timely manner and give the drug. He said his treatment was reasonable. In 2015, the board reprimanded Pratt and fined him $1,457 for another incident in Brain cyst diagnosed too late Miranda Jergenson, 20, of Manitowoc, went to the Aurora Medical Center emergency room in Two Rivers that November for vomiting and a headache. Pratt treated and released her. 4/5

5 About three weeks later, after getting care elsewhere, Jergenson returned to the Aurora ER. Pratt gave her medication for a migraine but didn t order any tests. Later the same day, she went to the ER again. Another doctor ordered a CT scan, which showed a cyst had ruptured in her brain. It caused permanent damage requiring constant lifelong care. A lawsuit against Pratt resulted in a $10 million settlement in Pratt told the medical board, through his lawyer, that Jergenson s symptoms suggested nothing more serious than a migraine. 5/5