July 2007, first and the only one pre operation appointment with physician. He recommended a joint replacement surgery, said that it was a routine operation, he had done hundreds of them, six weeks full recovery, pain free life after. Not a word about surgical risks and complications.
- March 28th 2008, my specialist performed a joint replacement surgery on my left foot in a Toronto hospital. It turned out that during the surgery my fourth toe bone was fractured and my specialist didn’t notice it. Two weeks in cast were not enough to heal the fracture but I didn’t feel any pain.
- April 9th 2008, follow up appointment with the specialist at the Hospital's Orthopaedic Centre. Waited for 3.5 hours. He removed a bandage, did several X-rays, didn’t notice the fracture and said that he was very pleased with the result. I asked him why my big toe looked 1.5 cm separated from other toes and he answered that he straightened it out and suggested to exercise my foot as much as I could.
- As soon as I started walking, my foot started swelling in fourth toe area and became bluish and painful. I called my specialist office several times, his machine wouldn’t accept messages and when I finally reached his secretary she said that he was not available and recommended to go to ER, walk-in or family doctor.
- April 21st 2008, my foot was getting worse. I don’t drive and that’s why I limped to the closest walk-in clinic and they suggested to go to ER
- April 23rd 2008, I went to the closest ER, waited for 5 hours to see a doctor, the triage nurse was annoyed by me as I came to them and not to my surgeon. They made several X-rays, prescribed pain killers and recommended to see my surgeon as soon as possible.
- I had to wait a week till the next follow-up appointment with the specialist on April 30th.
- April 30th 2008, I complained on swelling, pain and my big toe sticking more and more out. The specialist made several X-rays, did not answer my questions just said that sometimes it takes 3 month to heal. It was not relevant to my questions. He prescribed Tylenol 3 and recommended to exercise more.
- My foot is not getting better. The specialist is not available.
- May 12th 2008, made it to my family doctor. He made two X-rays, found a fracture, recommended stop exercising and sent me to nuclear bone exam.
- May 15th 2008, nuclear bone exam showed two hot spots on the big and fourth toe.
- May16th 2008, my family doctor prescribed taking APO-METRONIZOLE and APO – CEPHALEX and ARTHROTEC for 10 days and referred me to Gallium exam. Swelling started going down; two times there was a green matter coming out from the operation scar. Walking is still painful.
- June 5th 2008, at a Vancouver hospital the next nuclear exam (white blood cells exam) shows no evidence of active infection.
- July 9th 2008, the next appointment with the specialist at the hospital. After several X-rays, that he didn't show me, he said "now I see that the fracture is healed, but the joint got displaced. I honestly don't know why it happened,“ I asked for a second opinion. The specialist said: ”I am going to get the second opinion and consult the main specialist in this medical area in Toronto downtown hospital. It takes a year to get an appointment with their specialist but I will try to get it as soon as possible. Call my office in a week. Meanwhile, try to exercise your foot and not to be discouraged." I handed out this history to him; he put it in my file without reading.
- July 16th 2008, spent a half of the day trying to reach my specialist's office and finally I found out that an appointment was set on Aug 14th and then reset on July 31st at 11.30am as an emergency. The specialist promised to send my medical history and all X-rays to the other specialist's office. His secretary gave me a number to confirm the appointment 3 days prior.
- July 17th 2008, family doctor prescribed antidepressant Ratio- Paraxetine.
- July 22nd 2008, my big toe is crocked and swollen and some pus is coming out of from around the nail. Call my specialist's office, but he is not available.
- July 28th 2008, trying to call the given number to confirm the appointment with the other specialist, the number is not in order. Call my specialist's office – there is a message that the office is closed till August 5th and the machine is not taking messages. I have to go to the hospital on foot and it turns out that the time of the appointment was wrong too – it was 10.45 am.
- July 31st 2008, my specialist didn’t send my file and X-rays to the other specialist. He had to make five X-rays again. Other specialist's verdict: to fix my foot I need more complicated second operation that involves taking off all stuff that my specialist put there then take my bone from pelvic and fuse it into big toe joint. The other specialist ordered some blood work to be done and asked me to bring my file with my bone scan to him. I had to go to the Hospital and there I got a CD with my post – operation exams that very day – free of charge.
- August 5th 2008, called my specialist's office and asked why they didn’t send my file to the other's office, the secretary answered that I have to come tomorrow after 9 am to pick it up and to pay $50 for it!
- August the 6th 2008, I asked my daughter to pick up my X-rays from my specialist's office. Imaging clinic staff did not find the X-rays and suggested that either Doctor’s office or me signed them out. Doctor’s assistant did not find them at the office. I am concerned that my X-rays are misplaced as an evidence of malpractice.
Summary: As a result of the unsuccessful surgery and following negligence of my specialist to the complications of this surgery (fractured bone, inflammation, implant dislocation) I have lost my quality of life, ability to walk in shoes, consumed high impact antibiotics and painkillers and my problem is still not resolved. I became depressed and now live on antidepressants. My toe is swollen, big (bigger than it was before operation) and curved and there is a 2 cm gap between it and the other toes. When I squeeze them together trying to put a shoe on, it hurts and I can’t walk. I’ve taken more than twenty X-rays and two nuclear exams and plenty of heavy drugs in a short period of time. I’ve lost wages because I have to do a lot of walking doing my job and in shoes I couldn’t walk at all, only limping barefoot. I’ve lost quality of life not able to do activities that I used to do, like walking, hiking, skiing. Any of my shoes don’t fit and I have to order custom made shoes. It is very expensive and I can’t afford it because I am a low-income person. I’ve suffered a lot and I am still suffering.
I used to be a very active and cheerful person and now I am crying every day. I am even more depressed because I am facing a new surgery that might also have unfortunate outcome at my age. It was my first serious experience with Canadian Health System and I found it stiff, indifferent and in my case hostile to people and it allows doctors like my specialist to treat their post operation patients the way he treated me. Every time I managed to see him or talk to him he didn’t answer my questions and left my symptoms untreated. I had had three major surgeries in Russia, all successful, and all my surgeons provided excellent post surgical care. I want my specialist to be accountable for what he did to me, and I don’t want other people to suffer the same way and that’s why I am writing this complaint.
When my medical history became available to me I discovered that my specialist was not truthful about the state of my health from the first post operation appointment. Looking at my X-Rays that suggested “Standing view …demonstrates displacement of the proximal phalanx of the left 1st digit to the prosthesis of the head of the 1st metatarsal” “Alignment is not congruent” hi said that he was pleased with the results. The toe was sticking out; he obviously overdid the straightening of the toe and did not have the courage to acknowledge that and to take measures to fix it. He clamed to the College that during our first meeting before the surgery he warned me orally about surgical risks and it was not true. The College took his word over mine. The College also did not find enough evidence that my fourth toe was fractured during the surgery. It took the CSPO almost a year of investigation to come to a conclusion that my specialist did everything right and the only action the CSPO took was counseling him with respect post surgical access and follow-up and regarding the importance of documenting his discussions with patients of surgical risks and benefits. My next step was to send a request for review the College decision to the Health Professions Appeal and Review Board. I sent it in July 2009. There was a teleconference held on June 2010, which my specialist did not attend. The review was conducted on September 30th 2010. My specialist showed up along with his lawyer. I was with my daughter. The Board stated that it is very rare for a surgeon to attend such a case. He let his lawyer talk for him. Just at the end he said, “I am sorry the SYSTEM failed you.” The system, not him. I am still waiting for the Board decision.
To be continued…
What we learned:
1. Patient stories should go to the College of Physicians and Surgeons.
2. Patient should contact their original surgeons
3. Patients shouldn’t go through the complaint process of the CPSO
4. Review all the complaint procedures patients must complete
5. Ombudsman should review the complaints process