Duty of the Ontario Minister of Heath

Subject: Minister of Health

I am formally requesting a meeting with you ASAP. Please speak with MPP Steve Clark with regard to my concerns.

*** NOTE: B. Bybrick was the head of the CPSO at the time involved in the third decision, which clearly indicates the top priority of bringing my complaint to a final conclusion regardless of the medical facts and contradictory statements by the College and I suspect HPARB colluded with the CPSO as proven by HPARB's third decision and denial of my two requests to review it's decisions.

The Ontario Health Minister MUST investigate or risk losing all credibility as an elected member of the Legislature, as a member of the Conservative Cabinet and as Ontario's Minister of Health!

Over the past numerous years, I have asked the Minister of Health to address my concerns with regard to the CPSO and HPARB

Mr Hoskin's response was basically to say he had no authority to intervene or question the process and decisions by both the CPSO and HPARB.

-----COMPLETE BULLSHIT OF A RESPONSE

This was and is a lie as you will see. but I will shorten it

The following excerpt comes from Mr Hoskins' letter to the College Presidents and Registrars/Executive Directors as seen below:

What a lovely motherhood statement with no authoritative action taken!

"My hope is that we can work collaboratively to implement these steps as we work together to maintain the public’s trust in our health care system. However, as Ontario's Minister of Health and Long-Term Care, my ultimate responsibility is to the people of Ontario. I reserve the right to take any and all necessary measures to ensure that the public interest remains paramount, including exercising the powers reserved to me under subsection 5(1) of the RHA including the ability to require Councils to do anything that, in my opinion, is necessary or advisable to carry out the intent of the RHPA and the health profession Acts."

HE FAILED ALL ONTARIO CITIZENS BY NOT ACTING!

You, as our new Conservative Health Minister, do have the authority to investigate holding both the CPSO and HPARB accountable for an inept, dishonest investigation into my complaints and enacting appropriate legislation in the Legislature to ensure this never happens again. You should also involve the Minister of Correction to do the same with regard to the Chief Coroner's Office and the DIOC, as both institutions are complicit in the cover up of medical negligence and covering up their own role in such.

According to Regulated Health Professions Act you do have the authority to look into the CPSO either personally or through the Advisory Council. You may erroneously consider this as possible interference but it is your responsibility to do so, and you are mandated to do so!

--matters concerning the quality assurance programs undertaken by Colleges;

-- each College’s patient relations program and its effectiveness;

-- require the Council to do anything that, in the opinion of the Minister, is necessary or advisable to carry out the intent of this Act, the health profession Act

AND question

--whether regulated professions should no longer be regulated;

Duty of Minister

3. It is the duty of the Minister to ensure that the health professions are regulated and coordinated in the public interest, that appropriate standards of practice are developed and maintained and that individuals have access to services provided by the health professions of their choice and that they are treated with sensitivity and respect in their dealings with health professionals, the Colleges and the Board. 1991, c. 18, s. 3.

Powers of Minister --“Council” means the Council of a College;

5. (1) The Minister may:

(a) inquire into or require a Council to inquire into the state of practice of a health profession in a locality or institution

(b) review a Council’s activities and require the Council to provide reports and information;

(c) require a Council to make, amend or revoke a regulation under a health profession Act, the Drug and Pharmacies Regulation Act or the Drug Interchangeability and Dispensing Fee Act;

(d) require a Council to do anything that, in the opinion of the Minister, is necessary or advisable to carry out the intent of this Act, the health profession Acts, the Drug and Pharmacies Regulation Act or the Drug Interchangeability and Dispensing Fee Act. 1991, c. 18, s. 5 (1); 2009, c. 26, s. 24 (1)

A great injustice has taken place. This case exemplifies the very reason why Bill 29 should have been passed but was not, and the importance of the Minister of Health acting on my concerns. Just imagine if this happened to me, what other citizens have gone through??

--They are not placing patients and patient safety first therefor they are completely ineffective when it comes to investigating complaints

My daughter went through a colon resection and a tumor removed without the mandatory antibiotic prophylaxis, she also did not receive any antibiotics for the abdominal infection of the incision whereby all staples were removed. As well, she did not receive any antibiotics for the presence of "many gram negative bacilli". NO ANTIBIOTICS WHATSOEVER DURING HER TIME IN THE HOSPITAL. SHE BLED TO DEATH 12 HOURS AFTER DISCHARGE.

IS THE COLLEGE MAINTAINING THE APPROPRIATE STANDARDS?

OR, ARE THEY ACTIVELY COVERING UP SURGEON NEGLIGENCE!

Medical Opinion

NOW WITH RESPECT TO ALL THE MEDICAL FACTS LISTED BELOW, LET US LOOK AT THE EXPERT OPINIONS PROVIDED AND BY OTHER QUALIFIED SURGEONS OUTSIDE OF ONTARIO AND CANADA:

WHY SHOULD AN ONTARIO CITIZEN HAVE TO GO OUTSIDE OF ONTARIO AND THE COUNTRY TO GET THE TRUTH AND WHY SHOULD THE FATHER OF THE DECEASED HAVE TO CONDUCT HIS OWN DEATH INVESTIGATION OF HIS DAUGHTER???

A. Dear Mr Kilby: I have read the sad account of your daughter's illness and the medical society's review and find the review flawed and inadequate. I cannot be an expert witness since I am no longer a practicing surgeon. However, I formerly served on our San Francisco Medical Society's Review Panel. Your daughter's surgeon was wrong and failed to observe your daughter's presenting laboratory and physical findings of intra-abdominal sepsis and wound infection. The surgeon's "slap on the wrist" and review submitted by the Society must have been upsetting to him as a caring surgeon. This may be the only consolation you can ever see for your daughter's death. Hopefully he will have learned from this experience and it will help him provide better care for future patients.

James P. Geiger, MD, FACS COL. MC US ARMY, Retired *********************************************************************

B. Mr. Kilby,  Again, I am sorry about the delay in my response and, more importantly, very sorry about your daughter's death and the difficulty that you are having in trying to get the system to recognize the errors that seem to have been made in her tragic death. To preface my comments, as you know, I am a pediatric surgeon and do not operate on adults. That being said, I did complete an adult general surgery residency prior to my peds surgery fellowship and am Boarded in adult general surgery in addition to pediatric surgery by the American Board of Surgery. 

As I review the file that you attached, there are several concerns that come to mind. You indicated that she did not receive appropriate bowel preparation prior to surgery. Even though there is some controversy re: bowel preps and performing surgery on the right colon, I think most surgeons would proceed with a mechanical bowel prep prior to an operation where possible right hemicolectomy was possible.However, there is very good evidence that mandates that patients receive broad spectrum IV antibiotics prior to having colon surgery, especially if they haven't received a bowel prep. If this wasn't done this is not in line with the standard of care in the US. 

Also, I have concerns that the nurses documented for Terra's abdominal exam that her abdomen was "large" for the last several days of her stay in the hospital. More importantly, they document for a number of days prior to her discharge that there was a foul smelling odor and that the wound was "oozing copious amount of purulent discharge" during this entire time as well is very concerning. This doesn't happen with a superficial wound infection. These things happen when there is an anastomotic breakdown and leakage through the wound and possibly into the peritoneal cavity. If I recall, you indicated that a physician didn't even see Terra or examine her for the last couple of days while she was in the hospital? I would be very curious to read their last few notes in the chart and if they didn't document anything b/c they didn't see her, that is inexcusable. 

In regards to colon anastomoses breaking down and causing an acute hemorrhagic event to where someone would bleed out within 12 hours, I have a hard time believing that and have never heard of this happening before, especially over a week out from surgery. She clearly should have been tolerating a diet fairly well before she was released.Again, all of my comments have to be considered in light of the fact that I don't practice on adults and may not be absolutely up to date on everything re: colon surgery in adults.

However, I doubt that any of my above concerns are too far off base, if at all. Ideally, you would be able to find a surgeon that practices on adults, is credentialed by the ABS if in the US or one in Canada that co- corroborate my concerns. I hope my comments help and wish you the best in your efforts to correct the system that appears to be failing you and your family.

All the best, David David A Lanning, MD, PhD Surgeon-in-Chief, Children's Hospital of Richmond Virginia Commonwealth University Medical Center PO Box 980015 Richmond, VA 23298-0015 

*****

Mr. Kilby, I have reviewed the document and stand by the comments and concerns that I have sent to you through various emails. In addition to those, my only other comments are:

1. It is very concerning that the nurses repeatedly documented in the chart that her abdomen was large and there was foul odor coming from the wound. Since there was no documentation from the surgeon re: an exam on multiple days, then one can only infer that no surgeon examined her on those days. 

2. Gram-negative bacteria on the cultures from a wound with foul drainage suggest an intestinal injury or anastomotic leak. 

3. Preoperative antibiotic prophylaxis is the standard of care in the US and, I would imagine, the same in Canada. 

4. I can't believe that any physician or surgeon would release a patient from the hospital without seeing the patient or, at least, speaking with the nurses caring for the patient by phone. 

Hope these comments, as well as those that I have made in the past, help your cause. All the best, David David A Lanning, MD, PhD Surgeon-in-Chief, Children's Hospital of Richmond Virginia Commonwealth University Medical Center PO Box 980015 Richmond, VA 23298-0015

While complications can happen with any operation, I think the key thing with your daughter's care is that it appears to me that there was evidence that there was a problem before she left the hospital that was not picked up by the doctors, either because they ignored the evidence or didn't see / examine her. How long was she at home after her discharge from the hospital before she returned to hospital

/ ED D. Lanning MD

It is also concerning that she had not passed stool and was quite distended.” D. Lanning **********************************************************************

C. I have reviewed the data you supplied and the data from the colorectal surgeon (acting as an independent peer review). I am at a loss to understand the opinion he offered given the abdominal incision was leaking foul discharge which would mandate re-exploration, or at the very least, a CT scan of the abdomen which would likely have shown significant intra-abdominal fluid, suspicious for anastamotic issues. I have four children and my only prayer is to be in the ground before any of them……Short of not agreeing with the expert opinion offered by the independent physician I don’t know how I can help. Your daughter’s loss was tragic and it would appear to me preventable.

Good luck with your appeal if that is the direction you chose….Moe Lyons MD FACS

I am very sorry for your loss. I am sure the wounds are still very painful 4 years later. The short answer to your question is that, yes, antibiotics should be given prior to colon surgery (and most other surgeries for that matter). 

The discharge of somebody with abdominal distention who had undergone a wound packing for infection also seems well below acceptable standards here in the US. Usually if abdominal distention arises post op the etiology of that distention needs to be sought prior to discharge.Having said all of that it the lawyers for the doctors are correct; medicine is an art (sometimes performed very poorly) not a science. See the SCIP initiatives available online (Google SCIP initiatives) to better understand when, and what type of antibiotics are recommended prior to colon surgery. Good luck with your inquiry and again I'm sorry for your loss......................

Moe Lyons,

Maurice Lyons,  **********************************************************************

D. Dear Mr. Kilby, I just read through the attachment, and I recall reading your prior email.

My personal opinion is that your daughter died of septic shock related to dehiscence of her bowel anastomosis complicated by acute hemorrhage.

Apparent lapses in care are:

1) Lack of peri-operative antibiotics (I am not a general surgeon and do not know if this fails to meet standard care for right colon surgery).

2) Discharging your daughter with ongoing diarrhea of unexplained etiology,

3) Prolonged period of inadequate nutrition,

4) Nursing records that appear to be at odds with the physician record of the abdominal exam,

5) Failure to distinguish the intra-abdominal catastrophe from the wound infection.

It is self-evident that she was discharged prematurely or she would not have died outside the hospital of a devastating post-operative complication.

The big questions are: would a reasonable general surgeon have acted differently, and did her surgeon practice according to the standard of care – I seriously doubt that he did and I think a good surgeon would have done a more thorough investigation prior to discharge.

Things to consider:

1. The low hematocrit prior to discharge is not evidence of malpractice as this is common with acute illness such as what your daughter exhibited.

2. It would be interesting to see if there was a platelet count prior to discharge.

3. The temperature curves and the reported abdominal fullness are concerns that seem discounted by the College assessment.

As I told you previously, I am a father of an almost 3 year old girl and I now have a 6 month old son and a 4 year old son. I cannot imagine losing any of them particularly in such circumstances. Only you can decide if your quest for justice is worth further fight. I do not understand the Canadian system, so I cannot judge. Your case would be helped if you could find a Colorectal surgeon to review it. Unfortunately, most surgeons would not take interest and I do not personally know anyone who can help you. I do wish you the best and I hope that at some phase you can find peace.

Max Mitchell MD FACS

***************************************************************

E. It sounds like your daughter did not receive the appropriate standard of care. Patients undergoing colon resection (if not an emergency), should receive colonic cleansing pre-op. Additionally, all patients undergoing surgery should receive pre-operative antibiotics. “It does not seem that her nutritional supplementation was adequate. Finally, it seems that she was discharged while still infected.” I'm sorry to hear about the death of your daughter. A parent should never lose a child.

Allan Stewart MD ***********************************************************

F. Dear Mr. Kirby: From what I remember and my review of the information you sent me my opinion is that your daughter received suboptimal care approaching malpractice-at least by US standards. I would have to assume that Canadian standards are equivalent to US standards but from the response I read perhaps they are not.

Best wishes, Steven J. Phillips, MD FACS

*******************************************************************

H. GET A BETTER LAWYER. RRG SWCVTS

******************************************************************

I. Hello Mr. Kilby, It is very difficult to comment sufficiently on your question. There are just so many issues that I may not be aware of and questions that would need to be answered to give you an adequate answer to your question. I can say that for many years I have encouraged patients to build themselves up prior to surgery and to begin using amino acids as soon as possible after surgery. And I have given amino acids to patients so they can begin using them as soon as possible since I do not agree with the often followed practice of near fasting for patients after surgery - the body needs the amino acids to begin the healing process.

I am really sorry to hear of your daughter's case and I am so sorry for your loss. I do hope that someday physicians will be more proactive about improving their patient's nutritional status before and after surgery. I am not optimistic given the general disregard for nutrition that exists anyway.

God bless you, Roger Roger Trubey Dr PH, MPH, ND

You are welcome, Arnold. All I can say is that here in the States you would have a solid case for litigation. I don't encourage frivolous lawsuits or ambulance chasing but some cases can be so egregious that the only way hospitals and physicians will learn is to pay for their mistakes with the hope that the pain is such that it will save others from your daughter's fate.

God bless you, Roger *********************************************************************

J. The nutritional aspect is contributory in that with a prolonged postoperative ileus, supplemental nutrition should reasonably have been considered.

Matthew M. Cooper, MD FACs

Mr. Kilby: I looked over the materials you sent. I am once again sincerely sorry for your loss and trust that your daughter will live on in your hearts and thoughts. There are several items here that in combination raise concern. Individually, they may have been overlooked as insignificant. Further, hindsight may allow piecing together a potential pattern that may not have been detected as they occurred. 

Were peri-operative prophylactic antibiotics administered? There is a suggestion that they may not have been.

1. It is standard of care to do so for a limited time around the time of operation. 

2. I am concerned about the description of the abdominal examination progressing from "rounded" to "large" in the context of no clear normalization of bowel function. Is that to be interpreted as a distended abdomen? Were there normal bowel sounds? Was flatus present indicative of returning function? Or was there a postoperative ileus? If function was not returning normally in the presence of a progressively distending abdomen, that should raise concerns that might require imaging of the abdomen but certainly resolution prior to discharge. 

3. The nutritional aspect is contributory in that with a prolonged postoperative ileus, supplemental nutrition should reasonably have been considered. 

4. Such a bleeding complication after such surgery is certainly a possibility but should be exceedingly rare. If, as you suggest, your daughter's complications were part of a series of such problems then, indeed, a system or operator issue is suggested which satisfies the stated requirement for a complete investigation. 

If I were in your place, I would do the following: 

1. Contact the American Board of Surgery to see if they have an Expert Review Panel to which you could send this case for review. 

2. Canada must have a physician licensing board to whom the above questions could be raised - particular to your daughter's care as well as the potential system issues. 

3. If you have not already, you may address these questions to your daughter's surgeon. Keep a paper trail of the questions, and the response. 

Matthew M. Cooper, MD FACs  *********************************************************

K. “The discharge of somebody with abdominal distention who had undergone a wound packing for infection also seems well below acceptable standards here in the US. Usually if abdominal distention arises post op the etiology of that distention needs to be sought prior to discharge.”

Paul Kirshbom, MD Emory University School of Medicine **********************************************************************

L. “If there is a documented infection it is mandatory to treat it with antibiotics” Wendel Smith, M.D *********************************************************

M. “Your daughter needed pre-op antibiotics, post-op antibiotics, and antibiotics when a wound infection occurred. I think that she needed to have a bowel movement prior to discharge. We do this for our cardiac patients and they have not had any bowel procedures. Bleeding from a stapled anastomosis that leads to hemorrhage shock and death seems a little unusual. I see negligence in this case”

Ron Hill, MD, FACS

*************************************************************

N. What troubles me from the material you sent is the expert's/ coroner's opinions as to the cause of death. Patients do not die from bleeding at the staple line of an intestinal anastomosis. When such bleeding occurs, it is manifested by significant BLEEDING PER RECTUM, which to my knowledge your daughter did NOT demonstrate. If she died of "intraperitoneal bleeding", that could have come from either a disrupted anastomosis or from larger blood vessels ligated during the resection of the mesenteric cyst and her right colon.

If indeed her abdomen was distending, and her pulse rate rising over an observable period of time, then the really important issue was why was she not rushed back into the operating room when it was clear that an intra-abdominal catastrophe was occurring?I would agree that CAT scans are not necessary to establish an emergency situation, so what was the time delay between what her condition was upon discharge until she was brought back to the hospital? I think it more likely you would get more useful information from the dictated operative report from her original surgery, from personal review of her medical records to see what her condition was when leading up to her discharge, and from the coroner's report of the autopsy findings. 

Anastomotic disruption following a RIGHT colon resection is quite rare actually, and the range stated in the expert's report probably reflects the overall leakage rate from ALL colon anastomoses. Such leakage/disruption is much more common in lower (or "distal") anastomoses, closer to the rectum. If her anastomosis did "disrupt", as alluded to, then it is usually a TECHNICAL ERROR on the part of the operating surgeon, especially because of the young age and apparently excellent former health of the patient. If there is sufficient proof of the above, then an investigation of the surgeon's performance both in this case and others might lead to "systemic" issues which deserve correction. 

The main thrust of such investigations should be prevention of similar outcomes, with a willingness to confront all the causative factors, including surgeons' performances. I hope the above clarifies your thinking, from an insider's perspective. Please let me know your thoughts.

yours sincerely, Mark Helbraun, MD, FASCRS 

Hello again Mr. Kilby: Now you are getting to the important issues in this case! If indeed she died 12 hours after discharge, then the emphasis in your investigation should focus on what was happening to your daughter in the 24 hours prior to discharge from the hospital.It is inconceivable to me that the autopsy report would not contain more detail than what you have given me regarding the status of her ileal-to-colonic anastomosis, since that would be the area that would demonstrate what (if any) disruption of the bowel occurred. 

Since there was "no rectal bleeding" prior to discharge, what bleeding she was having would have been intra-abdominal, and if those counts were falling in the hours prior to discharge, that also should have sent up red flags of warning to anyone who was paying attention. The time plot becomes critical to reconstructing events in a fair and honest way. Again, look carefully at the autopsy results, the operative note, and the version of events leading up to discharge that you have been given. I suspect you would agree that there is a more fitting memorial to your daughter than a garden, and that memorial would be a living, breathing accountability system which would ensure that events like what occurred to Terra would never happen again. These are sometimes called "never events" in our system here, and they are investigated to the maximum. Keep me posted.....

Mark Helbraun MD, FASCRS Mark Helbraun, MD, FASCRS Member of the 2010-2011 International Council of Coloproctology 35 years experience Academic Colon & Rectal Spec Hackensack, NJ Hackensack University Medical Holy Name Hospital Holy Name Hospital, Teaneck, NJ Hackensack University Medical Center, Hackensack 

****************************************************************

O. Dear Mr. Kilby, Based only on the information you have provided I find it difficult to justify what appears to be a "whitewash" of the patient's cause of death. The points you have raised are--in my opinion--legitimate reasons to question the validity of classifying her death as "natural" and would support your complaint of inadequate investigation. She unmistakably died of surgical complications that were arguably survivable with less flawed management. Under ordinary circumstances I would be willing to consider testifying on your behalf after undertaking an appropriate first-hand examination of the records. Please accept my regrets and best wishes. 

Benson B.Roe, MD,FACS, Professor Emeritus. Department of Surgery, University of California at San Francisco Medical Center

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The following was sent first to HPARB requesting a reconsideration of the Third HPARB decision in which they denied my request. I then contacted the Ombudsman’s Office asking them to get involved. This was pointless waste of my time as well. The Current Health Minister duty must delve into the CPSO and HPARB, as it is quite evident that both have abused their position to cover up negligence by a surgeon resulting in the death of my daughter and have thus failed all citizens in Ontario.

Ms Boucher,

RE: my complaint submitted to the Ombudsman's Office with regard to HPARB:

"was not carried out in accordance with the principals of natural justice and lacked procedural fairness."

Appearances:

The Applicant: Arnold Kilby

Support for the Applicant: Murray Kilby

Support for the Applicant: Hilda LeBlanc

Support for the Applicant: Maie Liiv

For the Respondent: Katherine Booth, Counsel

For the College of Physicians and Surgeons of Ontario: Angela Bates (by teleconference) for the the consecutive time

The selection below also indicates how the procedure during my third appeal was not fair as I was cut short and not allowed the opportunity to complete my oral presentation, so I could comment on the matters related to (a) and (b) below:

And since this was third time I have appealed the College's decision, the Board should have 2(b) required the College to send a representative instead of allowing them for the third time to take part via telephone conference call-- it is a fifteen minute walk from the CPSO to HPARB

Regulated Health Professions Act, 1991

S.O. 1991, CHAPTER 18

Consolidation Period: From December 3, 2015 to the e-Laws currency date.

Last amendment: 2015, c. 30, s. 28.

Conduct of review

33. (1) In a review, the Board shall consider either or both of,

(a) the adequacy of the investigation conducted; or

(b) the reasonableness of the decision.

Procedure

(2) In conducting a review, the Board,

(a) shall give the party requesting the review an opportunity to comment on the matters set out in clauses (1) (a) and (b) and the other party an opportunity to respond to those comments;

(b) may require the College to send a representative;

(c) may question the parties and the representative of the College;

(d) may permit the parties to make representations with respect to issues raised by any questions asked under clause (c); and

(e) shall not allow the parties or the representative of the College to question each other. 1991, c. 18, Sched. 2, s. 33.

******************************************************************************

NOW WITH REGARD TO PROCEDURAL FAIRNESS AND PRINCIPALS OF NATURAL JUSTICE:

THE BASIS FOR RECONSIDERATION IS CLEARLY STATED BELOW:

#1 Having the Chair for the third appeal, who pretty much control the entire proceedings from London, Ontario (Forest City Lawyers - London) as is the College's Independent Opinion Provider, Dr. Brian Taylor.

No problem perhaps, but it certainly explains how this HPARB panel completely came up with their incredible decision and prevented me from giving my oral presentation. Both are highly notable men in London and I am confident they may have met many times at public, political and social events.
I would have thought the Chair would have excused himself from this panel!

This was extremely unfair and the procedural process was definitely affected negatively.

#2 The contradictory CPSO's opinion with their own expert as well as the factual documentation within Terra's medical records!

This was extremely unfair and the procedural process was definitely affected negatively.

In response to a request for further information from the College, the IO provider also set out the following information:

The standard of practice for open bowel resections is to provide antibiotic prophylaxis.
However, such administration would not reduce the risk of anastomotic leak.

The standard of practice would be to administer prophylactic antibiotics in connection with laparoscopic procedures if the bowel were involved; however, in this case, Dr. Klein believed he would be dealing with a cyst only and not opening the bowel, so the standard would not require administration of prophylactic antibiotics for the laparoscopic procedure.

AWKILBY’s Response: The above is pure BS. He knew before he converted to a laparotomy!!

Note the following: This proves that Dr. Klein was going to attempt laparoscopically a colon resection for a mesenteric mass. This was before he converted to a laparotomy!!!

Note the Procedure Desc. In the chart I submitted for the third appeal.

Note the Procedure Desc. In the following chart:

“Laparoscopic Colon Resection Attempted For Mesenteric Mass”

The second Procedure Desc. indicates the laparotomy.


And from Dr. Taylors’ (the College’s I.O) letter to Angela Bates May 8th, 2011,

During the surgery on July 11 2006, Dr. Klein realized that the mass was not separable from the colon or retroperitoneum and obtained consultation with a colleague and went ahead with an open right colectomy. This is well documented in the operative note on page 48.”

From Dr Klein’s own notes:

At the time of laparoscopy, a large cyst could be seen in the mesentery of the right colon. It was densely adherent to the bowel as well as densely adherent to the lateral abdominal wall. It felt very solid and not at all in keeping with a simple mesenteric cyst. We therefore made the decision to convert to an open procedure.

The fascia was divided. The peritoneal cavity was entered under direct vision. A 10 mm trocar was inserted. Pneumoperitoneum was obtained. A 5 mm subxiphoid and 5 mm suprapubic port were placed under direct vision. We immediately could see the large mass in the right upper quadrant and the findings were as above. We did not feel that this was at all easily accessible laparoscopically and could not separate the plane from the lateral abdominal wall as well as from the colon. At this point, we made a decision to convert to a laparotomy

Issue before the Committee

HPARB directed the Committee to reconsider this matter in light of the question of whether Dr. Klein met the standard of practice concerning the use of preoperative antibiotics.

Addendum Report from the IO Provider

The IO provider set out the following information in an addendum to the IO report:

The issue of antibiotic administration at the time of conversion to an open procedure is really not relevant to the outcome for this patient.

AWKILBY’s Response: The outcome is not part of the complaint!

Most general and colorectal surgeons administer antibiotics preoperatively prior to laparoscopic or open colorectal surgery, as they have been shown to reduce the incidence of wound infection. Antibiotics, however, have not been shown to decrease the incidence of anastomotic leak.

AWKILBY’s Response: Temporarily forget the anastomotic leak which was not in my complaint.. The above statement indicates the Standard of Care that was not followed by Dr. Klein.

#3 The complaint was about the Standard of Care not my daughter’s death. Interesting to note the College always mentions the tragic outcome. Stick to the Standards of Care not the Death. HPARB got sidetracked away from Standard of Care and somehow interpreted the Standard of Care not resulting in the death. This was not the complaint.

How can HPARB not focus on the actual wording from the Independent Opinion Provider and the College with respect to their statement contained within the Second and Third Decisions?

· "The routine use of antibiotics prior to bowel surgery is an important aspect of care that was neglected by Dr. Klein in this case. The Committee would suggest that Dr. Klein consider the routine use of antibiotics in such circumstances. Having said that, we do not consider this oversight to have contributed to the unfortunate outcome in this case."


Neglected equals Negligence


Notice how the College brings into the discussion my daughter's death from these example below: reason to deflect away from the standards of care to the Terra's death

"The routine use of antibiotics prior to bowel surgery is an important aspect of care that was neglected by Dr. Klein in this case. The Committee would suggest that Dr. Klein consider the routine use of antibiotics in such circumstances. Having said that, we do not consider this oversight to have contributed to the unfortunate outcome in this case."


"The issue of antibiotic administration at the time of conversion to an open procedure is really not relevant to the outcome for this patient."


"He agrees with the IO provider that: The issue of antibiotic administration had no bearing on the outcome of this case,”

“The only benefit of pre-operative prophylactic antibiotics is to prevent a postoperative wound infection, Preoperative antibiotics have no preventative or beneficial effect for an anastomotic leak."

"Further to this clarification, the Committee notes that, as supported by the IO, the lack of antibiotics in this case did not influence the unfortunate outcome, given there was no evidence of sepsis at the time of the discharge from the hospital."

THE STANDARD OF CARE IS THE ADMINISTERING OF THE MANDATORY ANTIBIOTIC PROPHYLAXIS NOT THE OUTCOME!

This was extremely unfair and the procedural process was definitely affected negatively.

#4 It appears this decision was made in record time: less than two months from the meeting in June my receiving the decision by mail on Aug. 1st.

This was extremely unfair and the procedural process was definitely affected negatively.

It makes one wonder whether HPARB had already decided well before, especially considering the following:

--HPARB appears to substantiate the College's opinion that Dr. Klein did not know that a colon resection was to take place until after he converted to an open abdominal surgery. The HPARB panel totally disregarded the operation record that clearly stated that the first procedure attempted was: "laprascopic surgery for colon resection." This clearly indicates that he knew that a colon resection was to be performed before he opened her up.

--No antibiotics what so ever, even after an abdominal incision infection and the presence of "many gram negative bacilli". Again, found in the hospital records. Also, they ignored the letter from then Eastern Ontario Coroner which stated reasons for death also included "complicated by an infection

--Totally ignored my expert's opinions.

--Again, common sense. Not an emergency situation, this was elective surgery supposedly well planned. --- A surgeon is going to make an 9 inch incision in the abdomen, move around some internal organs, remove a tumor and perform a colon resection.----- without the mandatory antibiotic prophylaxis.

#5 The Third HPARB appeal panel had my submission on their laptops but they could not locate the sections I was referring to during my oral presentation. They became so frustrated, the Chair, Thomas Kelly interrupted me and stated that I need not continue as they had read the submission. BUT, I had my presentation prepared to highlight and point out the inconsistencies with regard to the College’s opinion and the medical facts contained within the hospital records and supporting documents. This was extremely unfair and the procedural process was definitely affected negatively.

# 6 How could HPARB be sidetracked away from the "Standards Of Care" issues and be concentrating whether these issues to led to my daughter's death? HPARB should have been dealing with whether the Standards of Care were held up to, or not!

This was extremely unfair and the procedural process was definitely affected negatively.

# 7 And Dr. Klein merely laughs off the College decision: And this was in with the package the CPSO sent to HPARB.


From letter sent to the College by Dr. Klein

July 13, 2011

Ms. Angela Bates Manager,

Committee Support Area Investigations and Resolutions

College of Physicians and Surgeons of Ontario 80 College St. Toronto ON M5G2E2

RE: Ms. Terra Dawn Kilbv - Your File #77429

Antibiotics

The independent assessor is correct that Ms. Kilby did not receive preoperative antibiotics. I agree with the independent assessor's opinion in response to your subsequent letter that preoperative antibiotics would not have been a contributing factor to the anastomotic leak. Antibiotics are used to prevent or treat an infection. They have no preventative or beneficial effect for an

anastomotic leak. Furthermore, it is not my practice to prescribe antibiotics for a planned laparoscopic surgery with possibility of conversion to an open procedure As I have explained in my initial response, Ms. Kilby did develop a superficial wound infection postoperatively that was treated appropriately. I do not feel that the wound infection 'was in any way related to the outcome of this case.

L. Klein

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AGAIN, WE ARE TALKING ABOUT STANDARD OF CARE NOT THE OUTCOME.

Oh, my God!!!! Dr. Klein has not learned a thing from Terra's death and is obviously going to continue as he did!

This is detrimental to the safety of patients that are under his care!!!!!!

More Medical Experts

The Medical Community: some answer the specific questions, some provide emotional support, some comment on other issues


Apparently, only in Ontario is it not the standard to administer antibiotic prophylaxis for open abdominal surgery to remove a tumor and perform a colon resection. Take a good look at all the surgeons below who have a conflicting assessment to that of the CPSO? Now seriously, as Ontario's Health Minister, should you not question this in order to maintain the standards and protect Ontario citizens? Of course, you should!

“Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?”

1. Yes Kumar (B. Sivakumar MD)


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2. Dear Mr. Kilby,
I am very sorry for your daughter.
Just one question, how did you get my contact?
By the way you are telling things happened it seems to me that bowel cleansing is not mandatory
although antibiotics are!
Call me if you need any help. Best Dr Schraibman MD

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3. In general, bowel prep or bowel cleansing is somewhat controversial and is not absolutely considered standard-of-care and is clearly not related to bleeding. Now not giving antibiotic prophylaxis is a bit different - I think it is standard to receive antibiotics for a planned colon resection, at least in an adult. Still that would relate to a higher infection rate and is not related to bleeding. Bleeding happens during and after surgery. I hope this helped but I really do not know anything about the details. I have a daughter myself and I hope things worked out.

Douglas Iddings MD

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4. Antibiotic prophylaxis is important and can reduce postoperative infection. Bowel cleansing has not been shown to have a positive or negative effect on outcome.

Dale D Burleson, MD

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5.  Mr. Kilby,
First, I am very sorry for your loss.  
To answer your questions in general. Bowel cleansing is a matter of surgeon's preference prior to colon resection. There is evidence to show that the outcomes are not significantly different with or without a bowel preparation for colon surgery.
Antibiotics are recommended for colon surgery 
just prior to the start of the operation but
should be stopped within 24 hours unless
there are clinical indications to
continue
beyond the 24 hour period.

These are the guidelines in the US and the
goal of perioperative antibiotics is to prevent
wound infections from surgery.
Sincerely,    Daniel H. Hunt  MD

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6.  If the situation played out as you said above, then I would have given her
anti-biotic prophylaxis.
I would like to know the diagnosis before the operation
to be able to say if I would have had your daughter have bowel clean sing.
W Mourad  MD

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7.  Dear Sir/Madam
I am sorry to hear about your daughter's outcome. To answer your question, the 
colon bowel prep has been in debate for few years. Some surgeons do not feel it is
necessary while others still use it.
The antibiotic prophylaxis is
used to prevent infection during and after
surgery.
As I am aware, both practices may not increase or decrease the
incidence of postoperative bleeding
I hope this will answer your question and help you deal with the event. Please feel
free to ask more questions. I hope that your daughter is recovering well.
Sincerely;   Niazy M. Selim, MD, PhD, FACS
Associate Professor of Gastrointestinal/Laparoscopic,
Endoscopic and Robotic Surgery
Medical Director of Bariatric Program. Department of Surgery

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8.  I am sorry for your loss   Usually antibiotic are given iv 
prior to colon surgery

I hope you will find peace in your future
Amelia Grover, MD

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 9.  YES     Willie Melvin  MD

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10. The antibiotic bowel prep the day before surgery has become controversial, but the antibiotic dose within one hour of surgery that can be continued for up to 24hrs after surgery is standard of care.

Your Welcome, Dr. DeNoto MD

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11. yes, one dose at the beginning of operation Victor Tomulescu MD

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12. Yes, that would be the standard of care.

Helen Chan MD

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13. Antibiotic prophylactic cover is essential to colonic resection while bowel prep is controversial Michael LI K.W. MD

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14. Without knowing the details, I believe that most surgeons would perform some type of bowel prep and give preoperative antibiotics for elective colon surgery. Elective colon surgery without a bowel prep has been reported.

Michael H. Wood, MD, FACS

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15. Both are standard practice for whoever undergoing elective colorectal surgery unless your daughter received an emergency surgery without time for formal bowel preparation. Once again the colonic surgery is a clean contaminated operation, routine antibiotics prophylaxis should have been given
Thanks

C N TANG Dr, HKEC CSD(Accreditation & Standard) / PYNSUR Cons

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16. Hi Mr. Kirby,

First of all, I am sorry for your tragic loss. The use of antibiotics in colon rectal surgery is currently a very hotly debated topic.
While most surgeons agree that IV antibiotics should be routinely used at the time of surgery, there is a widely emerging body of data that has brought the use of preoperative bowel preparation and oral antibiotics under question. Currently the evidence is supporting the use of no oral antibiotic or mechanical bowel preparation.

Gregory Gallina MD

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17. I am sorry to hear about your daughter. I hope she came through this OK. I do not have the details of the case, and clearly this opinion is not based on the details of this case. The importance of bowel prep is currently being debated. In general IV prophylactic antibiotics given preop is indicated in colon surgery. Despite this, I doubt that the absence of bowel prep or antibiotics contributed to the bleeding episode. I hope this is helpful.

Harold Kennedy MD

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18. Yes I would Michael LI K.W. MD

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19. Hi Mr Kilby-

I am sorry for your loss. Clearly you are describing a difficult situation and it sounds like there are significant legal issues. I will only say that in the US it is considered standard of care to administer IV prophylactic antibiotics within one hour of skin incision for a clean-contaminated surgical case. Colon resection is considered a clean contaminated case. I do not know have any knowledge of the particulars involving your daughters case, nor would it be appropriate for me to be involved so these comments are in no way intended to be related to the case you are describing. I am only making a statement about what you asked with regard to prophylactic antibiotics and colon surgery. Best of luck

Elliot Newman MD

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20. Good Morning,
Yes, antibiotics prophylaxis is in case of open abdominal surgery (colon resection) a routine procedure.

Best Regards Dr.Tvaruzek MD

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21. Yes C N TANG Dr, HKEC CSD(Accreditation & Standard) / PYNSUR Cons

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22. The simple and accepted answer is yes. I am sorry for your loss Charles Anderson MD

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23. I was able to catch Dr. Parra-Davila between cases to see if he could answer your question below. Dr. Parra-Davila said yes to your question below and said it is a US guideline to follow for this procedure. Hope this helps.

Penny Griggs Advanced Minimally Invasive & Bariatric Surgery ConsultantsAdministrative Assistant to Drs. Keith Kim and Eduardo Parra-Davila

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24. Mr. Kilby: The answer is yes. I would recommend an antibiotic that is effective against the common colonic flora. Perhaps for 24-48 hours starting at the time the abdominal incision is made. I wish you good luck with your crusade.

hugo gomez-engler

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25. Mr. Kilby, I I am sorry for your loss and obvious anguish over your daughter’s death. In answer to your question, antibiotics are routinely given prior to colorectal operations, whether open or laparoscopic – but this does not prevent infections from occurring (still occur 10-20% of the time regardless of antibiotic use). There are rare circumstances where they are not advised (allergies, etc.). Best of luck, and thank you for your interest in our program. Hopefully your legal counsel will provide the support you need to get the answers you are seeking.

PW Paul E. Wise, M.D., FACS Assistant Professor of Surgery Director, Vanderbilt Hereditary Colorectal Cancer Registry Vanderbilt University Medical Center

D5248 MCN Nashville, TN 37232-2543 Office: (615) 343-4612 Fax: (615) 343-4615www.vanderbiltcolorectal.com

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26. Yes Malcolm Steel MD

*********************************************************************** 27. I see, well I certainly am very sorry to hear about such a tragedy and nothing could possibly replace her in you heart. I am a cardiac surgeon and thus general surgery is out of my expertise. However all patients having surgery are required to have antibiotic preoperative and if there is a documented infection it is mandatory to treat it with antibiotics. I would retain an attorney and have it investigated and seek damages if your attorney deems it just.
Sincerely Wendel Smith, M.D.

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28. We always used to give a bowel prep including antibiotics, but recent studies suggest a bowel prep is not necessary and results are better without a bowel prep. I doubt she died because she did not receive antibiotics. Something else must have been going on. I cannot understand why the coroner would make that statement without explaining the circumstances to you.

Adrian Greenstein, MD

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29. Mr. Kilby,
I am sorry for your loss.
Yes of course a patient should receive antibiotics prior to colon resection.

Sanjeev Sharma MD FACS

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30. Yes Sent from my iPhone

Cohen, Robbin MD

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31. Arnold.

I am sorry hear about your daughter. What a loss. Regarding the antibiotics; I have not done colon surgery for some time but I used to give antibiotics prior.

Go to the American colorectal website and see if they have an official policy.

Matt Slater, MD

Associate Professor

Clinical Director, Adult Cardiac Surgery OHSU Sent from my iPhone

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32. YES todd grehl MD

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33. Just this one... yes

Anthony P Furnary MD

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34. Yes, he should J.S. Smetana Josef MD

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35. Dear Arnold,

The answer to your question is YES. Usually a broad spectrum antibiotics administered at the time of induction of anaesthesia.

Kind regards,

David Jayne MD Senior Lecturer in Surgery Leeds

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36.
Yes Demeester, Steven MD

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37. The answer is yes. I'm sorry for your loss.

FF. fernando Fleischman M D

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38. Yes, she should have received "preoperative" antibiotics within

One Hour if beginning operation. Whether this would have prevented her death is unclear, but infection rates are known to be significantly reduced with routine antibiotic use. I am sorry to hear about your daughter’s loss.

Luis Castro. MD

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39. Mr Kilby,

I am sorry for your loss. It seems that there's more to it than just the lack of prophylactic antibiotics that was involved. Unfortunately with every procedure, there are potential risks. I don't know the circumstances around the death of your daughter but I can most certainly feel your pain. My condolences

Alex Ky MD,FACS,FASCRS Division of Colon and Rectal Surgery 212-241-3547

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40. Dear Mr. Kilby,

I am sorry for your loss, having children myself of similar age I can only imagine how difficult it has been for you. In answer to your question, bowel preparation and
administration of antibiotics for prophylaxis prior to surgery have been a standard of care in surgery for at least 25 years. In my opinion you have every reason to deserve frank answers about what happened to your daughter. Cases involving perioperative death are always reviewed by hospital morbidity/mortality committees, as well.

Regards, Douglas Boyd Professor of Surgery University of California Davis

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41. Yes the colon should be cleaned and antibiotic started prophilactically

Sent from my iPhone HOMAYOON Ganji

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42. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Definitely yes. Usually the day of surgery, and at least an hour before surgery.

Long, William :LPH Dir. Tra

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43. It is the standard in the United States to give prophylactic antibiotics within one hour of surgery.

Ismael N. Nuno, MD, FACS, FACC, FAHA. Chief, Cardiac Surgery Service LAC+USC Medical Center TEL: (323) 409-8666

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44. Dear Mr. Kilby,

Your anger I share, and your unresolved grief is palpable. I have tangled and lost with a family medical issue in Victoria, which still angers me. That was five years or so ago, and fortunately I have moved on to the point where it is just a bullet point in the list of reasons to keep our own medical system as it now stands. I wish truly that I could be of more help with the resolution of your problem, and also that time will allow you to move on.

Cord Cordell H. Bahn MD

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45. I am very sorry for your loss. It is generally advisable to administer antibiotics just prior to skin incision.
Tara Karamlou MD Sent from my iPhone

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46. Hi - sorry to hear about this sad case....It is tragic and nothing in life is perfect.
God willing and with some luck and fate, we will conquer.
Best to you. Ed Yee MD
PS
: pre-operative antibiotics for "clean contaminated" cases are usually recommended...

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47. The standard of care in the US is for patients undergoing any surgery is antibiotics within 1 hr of surgery, and for 24 hrs after surgery. This applies to clean and dirty procedures. Clean procedures referring to procedures where bacteria are not normally involved other than skin bacteria, and dirty procedures where bacteria are normally in-countered such as bowel surgery (colon surgery), gyn surgery, and oral surgery Your daughter should have had pre-op and peri-operative antibiotics.

Michael Wood MD

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48. Arnold

I am a retired cardiothoracic surgeon who is board certified in general surgery and thoracic surgery. I can't comment on your daughter's case without the record and autopsy report but there is no doubt she should have been given pre-operative and post operative antibiotics. Was this the cause of her death, that I can't say without more information. I am sorry for your loss.

Mike Perelman MD

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49. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Yes Diethrich, Edward MD

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50. YES, AND YES, GET A BETTER LAWYER. RRG

SWCVTS@aol.com

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51. Mr. Kilby,

My sincere condolences on the loss of your daughter. You are correct that I am not a general surgeon but I know that it is the accepted procedure to use prophylactic antibiotic coverage for colon surgery in the hospital where I work here in Denver, CO. I believe that is true throughout the US. It is disheartening to hear of the lack of transparency on the part of the medical / governmental establishment in the Canadian health care system. Unfortunately, thanks to our socialist president we in the US are probably headed for a similar fate. It sounds like your daughter died of peri-operative sepsis. Prophylactic antibiotics were indicated but that treatment does not prevent this complication in 100% of cases. In all likelihood it would have reduced the probability of such a tragic outcome. Good luck in your struggle to obtain justice for your daughter.

Stanley Carson, MD

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52. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Absolutely.

HP MD

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53. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? My answer is unequivocally YES

I have no pressures from any organization.

BBRoe Benson Roe

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54. Dear Mr. Kilby,

I am a practicing Cardiovascular and Thoracic surgeon in North Dakota. I have not done a colon resection in over 20 years, although I have maintained my general surgery credentials for purposes of covering trauma cases and teaching medical students. For legal purposes, I would not consider myself an expert witness.

I would suggest that you look up the US Medicare SQIP Protocol (Surgical Quality Improvement Project) to review the current recommendations for antibiotic prophylaxis for colon resections in this country
. Generally, it restricts antibiotic prophylaxis to a single pre-op dose, and less than 24 hours of coverage post-op. Antibiotic bowel preps have also fallen out of favor. Antibiotic use beyond 24 hours is only recommended for treatment of infections that are either suspected or known.
I do think it is fair to say that a preoperative antibiotic dose for a colon resection is the standard of care in this country. Whether or not it would have made any difference for your daughter is problematic, absent a proper record review. Even then, it may be difficult to be certain that the omission was causal in her death.
I am sorry for your loss. I help this will eventually help you gain some closure.
Sincerely, A. Michael Booth MD PhD FACS

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55. www.cochrane.org/reviews/en/ab001181.html
I hope you'll find this study helpful. Said Yassin MD

Antibiotics administered to patients prior to colorectal surgery

When people undergo surgical operations of their abdomen they are at risk of infection which will often be cured by an antibiotic. However, it might be better to give this before the operation to prevent the infection (prophylaxis or prophylactic use), rather than wait until an infection occurs before giving it. This review looks at the evidence for giving an antibiotic before surgery takes place.

The review found 260 studies which had recruited over 43 thousand people undergoing abdominal surgery. The studies had some limitations in relation to the number of people who remained in the studies and the possibility that the results were affected because some of the researchers in the studies knew which people had received antibiotics before surgery. However, when the results were analysed effect of prophylactic antibiotics was consistently beneficial meaning that these limitations were unlikely to have had a major impact on the nature of the overall results. Abdominal surgical wound infection in patients having operations on the large intestine occurs in about 40% of patients if antibiotics are not given. This risk can be greatly diminished by the administration of antibiotics prophylactically before surgery. The antibiotic(s) given usuallly needs to cover different types of bacteria some of which need oxygen (aerobic bacteria) and others which do not need oxygen (anaerobic bacteria).. They are usually given via a canula injected into a vein, though there is evidence that a combination of oral and intravenous antibiotics may provide more protection. This last finding raises a problem in that current clinical practice is to avoid mechanical cleansing of the colon because it is not thought to be necessary before surgery (and not popular with patients). Studies that found a benefit to oral antibiotics were done at a time when mechanical cleansing of the colon was routinely done. In the light of current practice regarding mechanical cleansing before surgery of the colon, the benefit of oral antibiotics is uncertain.

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56. Yes

Grantham, Nathan MD

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57. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? Yes
John Calhoon MD Professor and Head CT Surg UTHSCSA

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58. AK:

The standard of practice for prevention of wound infection in colon surgery is to use prophylactic antibiotics.

The description of your ordeal following your daughter’s death suggests that a satisfactory closure will only be achieved by thinking outside the box. You are correct in your assessment of the constraints of the legal response to malfeasance. Novelists, magazine writers, television inquiry shows and personally committed politicians are the alternative methods of casting light into sordid corners.

Who asked you to write me?

Bill Murphy MD

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59. Mr Kilby,

I have no idea how the Canadian system works and I have to preface my remarks with the comment that I obviously only have your side of this story. Also, I am a pediatric heart surgeon so your daughter's case is not within my area of expertise.

In the US this would have been settled or tried in court. I would think antibiotic prophylaxis for colorectal surgery is routine and indicated - at least 15 years ago when I last did general surgery. Without seeing the facts I cannot determine if this played an important part in the unfortunate outcome for your daughter.

I have great sympathy for you and the lack of transparency you describe is alarming. If I were in your shoes I would sue.

Max Mitchell MD

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60. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Hello Arnold, Thank you for contacting Hadassah.

The answer to your question is yes.

Best Regards, Isabelle Stroweis Hadassah External Relations Division

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61. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the

operation?

Yes- that is standard. Blackmon, Shanda, M.D.

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62. Yes antibiotic prophylaxis prior to colon surgery is standard

Whether this would have saved your daughter is unclear however.

Brinkman, William T MD


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63. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Arnold,

I am truly sorry for your loss. I believe pre-op antibiotics should have been given. I have included a link that may be helpful.

Derek Derek von Haag MD


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64. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Prophylaxis is standard of care to my knowledge

I am very sorry for your loss.

Matt Cooper MD


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65. We still adhere to the fact that patients should have a dose of antibiotics at the time of surgery for most colorectal procedures especially those involving a resection. Some hospitals give up to three doses as prophylaxis, although there is no evidence for this. Karen Nugent

Honorary Secretary

Association of Coloproctology of Great Britain & Ireland


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66. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? Likely should have received

antibiotics

Baron Hamman MD


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67. I’m sorry for your loss. I can’t imagine losing either of my boys (6 & 3).

In the United States, it is standard of care to administer appropriate antibiotics within one hour of surgical incision for any case deemed at risk for infection. We get in trouble for any case not administered and documented as such.The US is more into malpractice and I can’t speak to Canadian law. My cousins are lawyers in Duluth and Chicago and would tell you that each case has its own issues and merits. No action will return your daughter to you; that doesn’t mean you shouldn’t pursue this with the national body and perhaps your lawyers.My parents are also retired teachers/pastor and ran Luther Village for a summer in the 60’s. Ontario is one of the most beautiful provinces in the world and I’m sure your daughter was the same. AT Trachte, Aaron Dr.


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68. Mr. Kilby,

I am terribly sorry to hear about you loss. I have two children and can’t imagine the pain.As you said I am a cardiothoracic surgeon so I probably can’t help on the details of your daughter’s case. But the answer to your question on antibiotic prophylaxis is a clear yes. The Surgical Care Improvement Project (SCIP) has established clear guidelines on antibiotic prophylaxis prior to all surgery (timing, type). Here in the US our hospital is literally graded on compliance with the SCIP protocols. As a department chair I am responsible for compliance on my team and have to have appropriate procedures in place to assure compliance. When a patient “falls out” (i.e. one of the SCIP guidelines was not followed), the individual doctor receives a letter from the director of the medical staff.

Here is a link to one article showing that following SCIP guidelines decreases surgical site infections following colorectal surgery.

http://www.ingentaconnect.com/content/sesc/tas/2008/00000074/00000010/art00028

Lishan Aklog, MD Chair, The Cardiovascular Center

Chief of Cardiovascular Surgery St. Joseph’s Hospital and Medical Center

500 W. Thomas Rd, Suite 500 Phoenix, AZ 602-406-2996 (Assitant Beth)
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69. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Yes indeed. That is the standard of care

Dr. MacMillan MD


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70. Dear Mr. Kilby, Please accept my sympathy over the tragic loss of your daughter. Whether the lack of antibiotics before surgery was the essential factor that brought about her demise is still unclear and may always be so. There could have been some other problem during the colon resection which could have led to contamination. This remains unknown. Meanwhile, you are left to cope with your loss and the mental anguish associated. As one who has also lost a young daughter, I believe I can share your grief. I can also affirm that, while not easy, you must do all that you can to go forward with your life, honoring your daughter’s memory.

Yours truly, Denton A. Cooley, MD


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71. I am very sorry for your loss. I am sure the wounds are still very painful 4 years later. The short answer to your question is that, yes, antibiotics should be given prior to colon surgery (and most other surgeries for that matter). The discharge of somebody with abdominal distention who had undergone a wound packing for infection also seems well below acceptable standards here in the US. Usually if abdominal distention arises post op the etiology of that distention needs to be sought prior to discharge. Having said all of that the lawyers for the doctors are correct; medicine is an art (sometimes performed very poorly) not a science.

See the SCIP initiatives available online (Google SCIP initiatives) to better understand when, and what type of antibiotics are recommended prior to colon surgery.

Good luck with your inquiry and again I'm sorry for your loss......................

Moe Lyons, Maurice Lyons,


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72. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

The short answer is “yes”. I’m truly sorry for your loss, sj

Scott B. Johnson, MD Associate Professor


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73. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

The answer is yes. What was the cause of death of your daughter? She was obviously very sick. Was she diabetic? Obviously she had a wound infection but what lead to her death is not clear at all. My advice if you are not getting anywhere is to seek a legal opinion.

John Reza Mehran, MD


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74. Dear Mr Kilby:

I have looked over some of the material about your daughter.

I am certified in surgery and thoracic and cardiac surgery. I trained at UCLA (mostly, also U of Minnesota Hospital and Johns Hopkins). I don't currently see patients, but review cases for the Arizona Medical Board.

The big problem is apparently not cleaning the colon with laxatives or enema prior to surgery. Antibiotics don't help and likely are contra indicated. I can find specific references at our medical school.

Feel free to contact me

TW Christiansen MD twc4441@aol.com

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75. Mr Kilby-

I read with great interest your email and I am very sorry for your tremendous loss.

You are right, I am a cardiothoracic surgeon, but I completed a General Surgery Residency as well.

All patients used to receive pre-operative antibiotics prior to any colonic surgery. I would be surprised if this has changed.

Unfortunately, this did not cause her death, but from what it sounds like may have contributed to it.

As I am sure you know, when we have poor outcomes, it typically stems from a series of errors/omissions/etc.

Again, a tragic story, and I hope that you may find some resolution and closure.

Kypson, Alan MD

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76. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Arnold

I am a retired cardiothoracic surgeon who is board certified in general surgery and thoracic surgery. I can't comment on your daughter's case without the record and autopsy report but there is no doubt she should have been given pre-operative and post operative antibiotics. Was this the cause of her death, that I can't say without more information. I am sorry for your loss.

Mike Perelman MD

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77. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation

Mr. Kilby,
My condolences to you and your family on the untimely death of your daughter.

It is standard of care in the United States that
all patients undergoing bowel surgery should receive pre-operative prophylactic antibiotics at least 20 min before the incision is made. As a cardiothoracic surgeon, I do a fair amount of esophageal surgery. The same rule applies in regards to this issue.

Sincerely,
MPC Michael P. Collins, MD, FACS Chief, Division of General Thoracic Surgery
Intermountain Medical Center and LDS Hospital
Clinical Professor of Surgery
Division of Cardiothoracic Surgery
University of Utah School of Medicine

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78. Mr. Kirby: My opinion to antibiotic prophylaxis is generally yes for patients undergoing open colon resection. How this relates to your daughters care remains unknown unless the entire case can be scrutinized. My sympathies for your loss.

Steven J. Phillips, MD ***********************************************************************

79. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

yes Mark S. Allen MD

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80. Optimal bowel preparation for colon surgery includes mechanical cleansing of the colon the evening prior to surgery and an intravenous dose of broad spectrum antibiotics immediately prior to beginning the operation. This dose is usually given in pre-operative holding or by the anesthesiologist during the skin preparation and draping.
Sorry for your sorrow. Robert L Replogle. MD.

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81. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Yes. Within 30 min of

incision. Jbz Zwischenberger, Jay MD

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82. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

The answer to your question is "yes". I am so sorry to hear of your heart break!
Hendrick Barner MD

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83. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

yes Walter G Wolfe MD

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84. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Yes SOC Miller, Daniel Sent from my Verizon Wireless BlackBerry

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85. It is standard that all pts receive perioperataive antibiotics with a goal of administering them within 30 minutes prior to skin incision. It is a well validated quality outcome parameter.

John V. Conte, M.D. Professor of Surgery Johns Hopkins University School of Medicine

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86. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Dear Sir
The answer to your first question is yes. Marcelo Cardarelli, MD

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87. Dear Mr. Arnold, I am very sorry for your loss, however, as you pointed out in your message, I am not the right person to review your daughter’s case. While your frustration with the system and the responses you have gotten to your questions is very clear, I find it difficult to believe that the Canadian medical system is engaged in a conspiracy of some sort involving British surgeons and everyone involved in the case. I think you are giving them far too much credit with regard to organization and cohesive intent. In my opinion, your frustrations are more likely the result of the disorganization and delays that are typical of large medical administrative units. Again, I am sorry for your loss and I hope you find the answers you are looking for.

Sincerely, Paul Kirshbom, MD Emory University School of Medicine

Dear Mr. Kilby, The short answer to your question is that, yes, antibiotics should be given prior to colon surgery (and most other surgeries for that matter). The discharge of somebody with abdominal distention who had undergone a wound packing for infection also seems well below acceptable standards here in the US. Usually if abdominal distention arises post op the etiology of that distention needs to be sought prior to discharge. In this business, patients sometimes die (and as a pediatric cardiac surgeon, when that happens, it is truly devastating for all involved). It is unavoidable sometimes, but the one thing that can be avoided is lack of communication and clarity with the family. I think that if you had received that from the beginning, you likely could have moved past this painful time in your life. I honestly hope that you get the information you seek and that you can move on. The loss of your daughter was certainly a tragedy, regardless of the circumstances. The greater tragedy would be to allow that event to rule the remainder of your own life.

I wish you the best of luck. Paul Kirshbom, MD ***********************************************************************

88. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

In answer to your question, she should have received prophylactic antibiotics and a bowel prep prior to surgery. Ron Hill, MD, FACS ***********************************************************************

89. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Absolutely yes, it is malpractice not to!

Sorry about your loss. Regards, Luca Vricella Luca A. Vricella, MD, FACS

Associate Professor of Surgery and Pediatrics Johns Hopkins University

***********************************************************************

90. I assume this was an elective (i.e. not an emergency) colon resection.

In the United States, the practice is to perform at least a mechanical bowel prep before an elective colon resection and in all circumstances perioperative antibiotics are given, usually prior to the incision. The duration of antibiotic administration depends somewhat on what is found at operation, but in most circumstances they are stopped not later than 48 hours post-op. I hope this is helpful and am sorry for your terrible loss.

Lynn H. Harrison, Jr., MD Clinical Director

***********************************************************************

91. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Yes Peter M. Scholz, MD & James W. Mackenzie Professor of Surgery

Associate Dean for Clinical and Translational Research

Department of Surgery

UMDNJ-Robert Wood Johnson Medical School

***********************************************************************

92. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Yes Sent from my Verizon Wireless BlackBerry

Joshua Sonett MD

***********************************************************************

93. It sounds like your daughter did not receive the appropriate standard of care. Patients undergoing colon resection (if not an emergency), should receive colonic cleansing pre-op. Additionally, all patients undergoing surgery should receive pre-operative antibiotics. It does not seem that her nutritional supplementation was adequate. Finally, it seems that she was discharged while still infected.

Allan Stewart MD

I'm sorry to hear about the death of your daughter. A parent should never lose a child.

***********************************************************************

94. Mr. Arnold Kilby: I feel sorry for your daughter outcome. Most of your observations and questions make sense. The legal system should be able to address them. I do not believe that anyone outside Canada can be of any help.

Sincerely R. Neirotti Rodolfo A. Neirotti, M.D., Ph.D., FETCS

***********************************************************************

95. I can only say by the description here that there must have been some kind of contamination either during or after surgery most likely coming from the bowel itself based on the gram negatives you describe.

Good luck with your search for answers, I hope you get them. God Bless. Cristy Smith MD

***********************************************************************

96. Dear Mr. Kilby,
I feel very sorry and regret what you are experiencing, and completely understand your reaction.
A patient undergoing open surgery should always have antibiotics at the time of inducing anesthesia and repeat the dose if the operation last more than 6 hours.

I hope this may help you. Good luck and best regards,

Paolo Macchiarini MD
pm pmacchiarini@thoraxeuropea.eu

***********************************************************************

97. I am indeed a CVT surgeon and not qualified in General Surgery but it is my understanding that prophylactic antibiotics are given with induction for colonic surgery. I regret your loss and hope you find answers to your questions. Goldman, Dr. Bernard Bernard.Goldman@sunnybrook.ca

*********************************************************************

98. Dear Mr Kilby,

Your questions seem utterly reasonable. As you rightly note I am a cardiothoracic surgeon, so through this reply I am asking John Black, President of the Royal College of Surgeons in England to put you in touch with someone better equipped to answer your questions.
I am sorry that the immense pain you must be feeling at the loss of your daughter is being made worse by difficulty in having some very simple questions answered.
I hope we can help you. Bruce Keogh Bruce.Keogh@dh.gsi.gov.uk
Sir Bruce Keogh NHS Medical Director

Message sent from a Blackberry handheld device. ********************************************************************

99. Mr. Kilby


I feel for your sorrow and please accept my sincere feelings. As a cardiothoracic surgeon, it is not appropriate for me to answer a question regarding abdominal surgery. However, I support using of prophylactic antibiotics before major surgery.

Sertac Cicek, MD

***********************************************************************

100. Mr Kilby-

First and foremost, I am ever so sorry for your loss and terrible tragedy. Obviously, I am in no position to legitimately comment on the adequacy of care your daughter received. But I certainly can answer your question.
Generally speaking, pts undergoing colon surgery should receive intravenous antibiotics within 60 minutes prior to their incision. The specific goal is to prevent wound infection-the antibiotics do not seem to decrease the incidence of any other surgical complication (such as a leak or abscess).

Again, my sincerest sympathies

Neil Hyman MD

***********************************************************************

101. Intravenous Antibiotic prophylaxis is standard when performing a colon resection regardless of whether it is done laparoscopically or via open methods.
Best of luck.


RL Whelan

***********************************************************************

102. Dear Arnold Kilby

Anti-biotic prophylaxis should be given at time of surgery according to practice guideline in US and in China as well while performing transabdominal colon resection based on evidence-based colorectal surgery, I think. In my opinion, your daughter may have die from postoperative infection or sepsis.

Regards

Wan-Jin Shao

Chief Consultant Colorectal Surgeon,

Clinical Professor American Society of Colorectal Surgeons(ASCRS )member

Department of Colorectal Surgery Nanjing University of Chinese Medicine Hospital ***********************************************************************

103. Receiving ATBs preoperatively before an abdominal surgery is a standard of care. Regards feza Feza H. Remzi, M.D. | Chairman | Department of Colorectal Surgery

Cleveland Clinic | 9500 Euclid Ave.-A30 | Cleveland, OH 44195 | (216) 445-5020

***********************************************************************

104. Dear Mr. Kilby:

As a father of a twenty-something daughter, and a long-time practioner of colorectal surgery for over 30 years, I can relate to your circumstances and your grief. The short answer is obviously YES, your daughter should have been prepared for elective colon surgery with both a mechanical (purgation) and an antibiotic bowel preparation. These have been the standard for at least the last 30 years, spanning to the time before I began training as a surgeon in 1972. Extensive clinical research had provided data as to the efficacy and safety of that approach, so it was completely standard to do both preps prior to elective colon surgery. Having said that, and believe me when I say it, I STILL use both preps for my own operative cases and am rewarded with very low sepsis and very low overall complication rates. However, some less-than-brilliant surgeons have in the last 5 or so years begun to advocate for colon surgery without mechanical preparation beforehand! I believe both the data and the conceptual rationale for this approach to be very flimsy indeed. They claim that bowel prep is "expensive" (pure B.S., to use the American vernacular), is "intolerable" to the patient (we do it all the time for colonoscopy, for example), and that purgation interferes with the "microcirculation" of the colon. That latter "factoid" is trotted out as the reason for why those publishing surgeons claim to have LOWER complication rates when the bowel is left unprepped before surgery. They claim that interfering with the microcirculation impairs colon healing, leading to higher rates of anastomotic leakage and postoperative sepsis. In American jurisprudence, you would have no trouble finding dozens of surgeons who would be happy to testify that bowel preparation is still mandatory ("standard of care") for elective, safe colon surgery. I do not know the consensus of opinion on this topic in Canada.

Suffice it to say, on the basis of the few facts of your daughter's case presented in your short email to me, I would conclude that she was poorly, even negligently served by the surgeon entrusted with her care.

Unfortunately, I have seen in the American system, that if we did not have strong legal sanctions against negligence, many doctors would literally get away with murder. There will always be failures of judgment which lead to patient harm, as long as physicians remain fallible human beings. But my belief is that the surgeons who are promulgating colon surgery without suitable bowel preps are willfully ignoring decades of safety experience. They are trying to "reinvent the wheel", when bowel prep has an established safety record over many decades. One might reasonably ask the question "why" they would tamper with success, and that is a long, fruitless discussion from your standpoint. In brief, I believe it boils down to a question of surgical ego, where some surgeons are hell-bent to prove that they are so good they can evade the norms established by mere mortal surgeons such as myself.

Again, my condolences to you and your family. You are experiencing tragedy of the first order, and it always pains me especially when such stories come at the hands of intelligent, well-motivated surgeons who are charged above all to "do no harm" (primum non nocere).


Sincerely yours, Mark Helbraun, MD, FASCRS

***********************************************************************

105. Dear Sir:

I am so sorry for the loss of your daughter. The clinical picture that you describe is that she died from infectious complications related to a peritonitis and sepsis from post operative complications. The causes are multiple, but after colonic surgery a usually fatal complication is an anastomotic suture leak (breakdown).

Most colo-rectal surgeons will prepare the colon and give pre operative antibiotics. But this will not prevent a technical suture problem. The autopsy report should have those details. The operative report should help.

*********************************************************************

106. Taken from article entitled When is Primary Anastomosis Safe in the Colon?

2005 Surgery in Africa Monthly Reviews and 2010 update

Antibiotics with activity against aerobic and anaerobic bacteria need to be given parenterally in the peri-operative period alone. Their post-operative use should be restricted to cases with established infection. Pre-operative oral antibiotics may have an added value.

In elective colon operations there appears to be no value to mechanical bowel preparation. Even as I write this, my surgical prejudices rebel against such a notion.

Brian Ostrow MD, FRCS(C) Guelph, Ontario Canada

Adjunct Lecturer Office of International Surgery
University of Toronto Canada

***********************************************************************

107. Dear Mr. Kilby I'm very sorry to hear of your loss.

The short answer to your question is yes, giving an antibiotic prior to an elective colon resection is the standard of care in the US. In the US the sequence of events that you describe would usually generate a lawsuit.

You may find the following websites helpful http://www.qualitymeasures.ahrq.gov/search/search.aspx?term=Colorectal+Surgery+Specialty&umls=1 (the website for the national guidelines regarding standard surgical practices)

www.fascrs.org (website of the American Society of Colon and Rectal Surgeons)

www.facs.org (website for the American College of Surgeons)

www.facs.org
The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.

http://www.cags-accg.ca/ (the Canadian Association of general Surgeons)

Sincerely Tonia Young-Fadok MD

Tonia M. Young-Fadok, MD, MS, FACS, FASCRS
Professor of Surgery, Mayo Clinic College of Medicine
Chair, Division of Colon and Rectal Surgery
Mayo Clinic, AZ
5777 E Mayo Blvd Phoenix, AZ 85054 Phone: 480-342-2697 Fax: 480-342-2866
youngfadok.tonia@mayo.edu

**********************************************************************

108. Hello

I have reviewed the material. My opinion is you should try to hire an attorney to proceed with this case. I have done a lot of expert work in the field of cardiothoracic surgery which is what I do daily. I have always worked with a lawyer. I think there are a lot of problems with this case and you have a strong case to proceed. There are lawyers who could guide you with proceeding with this case. I am not familiar with the Canadian procedures for medico-legal cases. Your daughter needed pre-op antibiotics, post-op antibiotics, and antibiotics when a wound infection occurred. I think that she needed to have a bowel movement prior to discharge. We do this for our cardiac patients and they have not had any bowel procedures. Bleeding from a stapled anastomosis that leads to hemorrhage shock and death seems a little unusual. I see negligence in this case

Thanks Ron Hill, MD, FACS

************************************************************************

109.  There is very good evidence that mandates
that patients receive broad spectrum IV antibiotics
prior to having colon surgery, especially if they
haven't received a bowel prep.
If this wasn't done
this is not in line with the standard of care in the US.
David A Lanning, MD, PhD
Surgeon-in-Chief, Children's Hospital of Richmond
Virginia Commonwealth University Medical Center
PO Box 980015
Richmond, VA 23298-0015
Office (804) 828-3500
*****************************************************************************************
 110.  Mr. Kilby:                                                                                                                         
Were peri-operative prophylactic antibiotics administered? 
There is a suggestion that they may not have been
. It is standard of
care
to do so for a limited time around the time
of operation.
Matthew M. Cooper, MD FACs    
*******************************************

Medical Facts--Terra's Hospital Records


THE MEDICAL FACTS!

A)--have open abdominal surgery without the mandatory antibiotic prophylaxis

--having not had the above, accepted that there was no need for antibiotics when the abdominal incision was oozing purulent liquid and was so infected that all staples were removed--when test results showed "many gram negative bacilli", still it was quite acceptable to provide no antibiotics

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

NOW IS THERE AN HONEST SURGEON/DOCTOR/MEDICAL EXPERT WITHIN ONTARIO OR DO THEY ONLY EXIST OUTSIDE OF ONTARIO AND NOT A MEMBER OF THE CPSO AND CMPA? OBVIOUSLY, NOT! THE PROVINCIAL GOVERNMENT MUST CHANGE THIS IMMEDIATELY.

B)**-- ABDOMEN GOING FROM FLAT TO ROUNDED TO ENLARGE

--the enlarged abdomen?---That is a sign of something wrong.

Abdominal Distension may occasionally result from the accumulation of fluid in the abdomen, which can be a sign of a very serious medical problem. In the peritoneal cavity, distention may reflect acute bleeding, accumulation of ascitic fluid (Ascites is an accumulation of fluid in the abdominal cavity.), or air

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

C) Abdomen and Resting Pulse Rates Nursing Records

Description of Terra’s Abdomen

high pulse rate? 34/38 above 90

1.July 11th

1133 hrs 105

1143 105

1630 flat 106

1709 98

1730 101

2000 flat 104

2.July 12th

0000 flat 104

0400 flat 105

0800 flat 116

1300 flat 194???? This is not a typo from me. It is in the record!

1605 flat 101

2000 103

3.July 13th

0820 rounded 110

1130 rounded 105

1615 rounded 102

2100 rounded

2015 rounded 107

4.July 14th

0500 rounded 126

0815 rounded 97

1200 rounded 95

1500 rounded 117

1600 rounded

1857 rounded

2000 rounded 110

5.July 15th

0530 rounded 94

0910 rounded 97

1300 rounded

1800 rounded 108

2107 rounded

6.July 16th

0530 rounded 98

1130 rounded 105

1310 rounded 96

2000 large 102

7.July 17th

0700 large 93

0951 large 104

1437 98

2200 large 108

8.July 18th

0517 large

0600 large

1000 large 86

1510 large

1600 large 90

2000 large 85

9July 19th

0925 large 93

1957 large 96

10.July 20th

0039 large

0800 large 88 Terra was released


D)**HCT Hematocrit Count Ref. 0.36 to 0.48

July 18 0.35

Day 6 0.35

Day 4 0.32 All 5 tests are below normal

Day 3 0.32 range

Day 2 0.34

Decreased hematocrit indicates anemia, such as that caused by iron deficiency or other deficiencies. Further testing may be necessary to determine the exact cause of the anemia.

Other conditions that can result in a low hematocrit include vitamin or mineral deficiencies, recent bleeding etc

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

E)*RBC Red Blood Count Ref. 4.20-5.40

July 18 4.20

Day 6 4.16

Day 4 3.80 1 test at well low of normal range &

Day 3 3.78 other 4 below normal range

Day 2 3.95

Red Blood Cells, sometimes referred to as erythrocytes, are responsible for delivering oxygen throughout the body.

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

F)**ABS LYMPH# Absolute Lymphocytes Count Ref. 1.5 - 4.0

July 18 0.9

Day 6 0.7

Day 4 0.5 All 5 tests are well below

Day 3 0.8 normal range

Day 2 1.0

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

G)**many PMN’s (polymorphonuclear Neutrophils) –? hall mark of acute inflammatory process. The presence of many PMN’s implies an inflammatory process.

PMN’s are the hallmark of acute inflammation

PMN’s are rapidly recruited to tissues upon injury or infection

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

H)**low Absolute Lymphocyte (type of white cells to fight infection)? B cells, a type of lymphocyte (white blood cells), have an important role in the body's immune system. are responsible for making antibodies

T cells, a type of lymphocyte (white blood cells), have an important role in the body's immune system. enhance the production of antibodies by B cell

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

I)**HB Hemoglobin Ref. 120-160

July 18 119

Day 6 117

Day 4 107

Day 3 106

Day 2 111 ALL BELOW THE STANDARD

The vital role of hemoglobin in transporting oxygen from the lungs to the rest of the body is derived from its unique ability to acquire oxygen rapidly during the short time it spends in contact with the lungs and to release oxygen as needed during its circulation through the tissue

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

***********************

Individually, perhaps the test scores may be dismissed but collectively there is an indication of something going wrong and required further investigation!

J)** seriousness of the oozing, infected abdominal incision. Excessive or prolonged serosanguineous drainage could indicate increased inflammation and the possibility of infection, which could in turn lead to wound dehiscence. This is what happened to Terra, her resection broke down.

FROM NURSES’ CHARTS

July 15th

Page 109 853 hrs incision oozing

910 no odour, no oozing

Page 105 1300 no odour but dressing soaked with purulent foul smelling fluid

Page 103 1430 foul odour

Page 98 2000 site #1 leaking

Page 94 2152 foul odour


July 16th

Page 86 1030 foul odour

Page 83 1310 no odour, but larger purulent foul drainage from the umbilicus

Page 78 2000 no odour, but larger purulent foul drainage from the umbilicus

Page 76 2200 foul odour


July 17th

Page 74 0445 foul odour

Page 73 0630 foul odour

Page 71 0700 no odour but large purulent foul drainage from umbilicus

Page 66 1400 large amount of drainage from umbilicus

Page 65 1700 foul odour


July 18th

Page 62 0045 foul odour

Page 60 0900 foul odour

Page 58 1300 foul odour

Page 56 1560 7 staples removed — wound gaping wound oozing copious amount of purulent fluid

Page 55 1600 oozing incision


July 19th

Page 51 0815 foul odour

Page 49 0925 wound oozing copious amount of purulent fluid

Page 48 1500 foul odour

Page 45 1957 oozing incision

Page 44 2100 foul odour


July 20th

Page 43 0039 oozing incision

Page 41 0800 oozing incision

1000 foul odour

Terra was released.

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

K)**no nutritional supplementation to ensure her nutritional needs were met. Terra was on a liquid diet of juice, jello, brothe and tea for 8 ½ days. (last two meals were regular) This diet should not be used for a long period of time unless vitamins, iron, or liquid nutritional supplements are added. Terra received no nutritional supplements. She was receiving only 687 calories per day that equates to a starvation diet. With no nutritional supplementation!!!!!

The full liquid diet is low in iron, vitamin B12, vitamin A, and thiamine. It should not be used for a long period of time unless vitamins, iron, or liquid nutritional supplements are added. The full liquid diet does not provide enough energy, protein and many other nutrients. This diet is temporary and should not be used for more than 5 days

TAKEN FROM USDA National Nutrient Database for Standard References 2004

1. LACKING 83.2% OF TOTAL DAILY IRON INTAKE! Iron is required for the formation of haemoglobin in red blood cells, which transport oxygen around the body. Iron is also required for normal energy metabolism

1. Iron Deficiency = The recommended dietary allowance required by an adult female for Iron is 18 mg/day

Terra’s diet contained: Jello .01 mg Tea .02 mg Broth .06 mg Juice .92 mg

 Terra would have received 3.03 (16.8%) mg per day in the course of her 3 daily meals. This means she was lacking 14.97 mg per day!

2.LACKING 99.6% OF TOTAL DAILY VITAMIN K INTAKE! Vitamin K is not readily stored within the body, thus the importance of the daily requirement. The over riding effect of nutritional Vitamin K deficiency is to tip the balance in coagulation toward a bleeding tendency.

2. Potassium Deficiency =The recommended dietary allowance required by an adult female is 90 micrograms of Vitamin K per day.

Terra’s diet contained: Jello 0 mcg Tea 0 mcg Broth 0.2 mcg Juice 0 mcg

 Terra would have received .6 (point 6) (.7%) mcg in the course of her 3 daily meals. This means she was lacking 89.4 mcg daily!

3.LACKING 75% OF TOTAL DAILY MAGNESIUM INTAKE! Supports a healthy immune system, energy metabolism and protein synthesis

3. Magnesium Deficiency =The recommended dietary allowance required by an adult female is 255 mg/day (milligrams) of Magnesium per day.

Terra’s diet contained: Jello 1 mg Tea 5 mg Broth 0 – 3 mg Juice 12 mg

 Terra would have received 63 (25%) mg in the course of her 3 daily meals. This means she was lacking 192 mg daily!

4. LACKING 99.7% OF TOTAL DAILY VITAMIN E INTAKE! Vitamin E is the major lipid-soluble antioxidant in the cell antioxidant defence system and is exclusively obtained from the diet.

Vitamin E significantly strengthens the immune system; supplies oxygen to the blood, which is then carried to the heart and other organs.

4. Vitamin E Deficiency =The recommended dietary allowance required by an adult female is 15 mg (milligrams) of Vitamin E per day.

Terra’s diet contained: Jello 0 mg Tea 0 mg Broth .13 mg Juice .02 mg

Terra would have received .45 (.03%) mg in the course of her 3 daily meals. This means she was lacking 14.55 mg daily!

5. LACKING 99.27% OF TOTAL DAILY CALCIUM INTAKE! Blood coagulation is dependant on calcium.

5. Calcium Deficiency =The recommended dietary allowance required by an adult female is 1000 mg/day (milligrams) of Calcium per day.

Terra’s diet contained: Jello 4 mg Tea 0 mg Broth 4 mg Juice 20 mg

 Terra would have received 73 (.73%) mg in the course of her 3 daily meals. This means she was lacking 927 mg daily!

6.LACKING 99.99% OF TOTAL DAILY VITAMIN A INTAKE! It is also required for cell differentiation and therefore for normal growth and development, and for normal vision and for the immune system.

6. Vitamin A Deficiency =The recommended dietary allowance required by an adult female is 700 mg/day (milligrams) of Vitamin A per day.

Terra’s diet contained: Jello 0 mg  Tea 0 mg  Broth 0 mg  Juice 2.5 mg

 Terra would have received 7.5 (.01%) mg in the course of her 3 daily meals. This means she was lacking 682.5 mg daily!

7.LACKING 91% OF TOTAL DAILY VITAMIN C INTAKE! assists the body in the production of collagen, a basic component of connective tissues. Collagen is an important structural element in blood vessel walls, gums, and bones, making it particularly important to those recovering from wounds and surgery.

IMPORTANT: Inflammation in the tissues causes the breakdown and destruction of collagen fibers. Sutures will pull away from damaged tissues whether the tissues are damaged by disease or medical negligence. Any infected tissue which is separated by surgery will be slow to heal, or may fail to heal.

7. Vitamin C Deficiency =The recommended dietary allowance required by an adult female is 75 mg/day (milligrams) of Vitamin C per day.

Terra’s diet contained: Jello 0 mg Tea 0 mg Broth 0 mg Juice 2.2 mg

Terra would have received 6.6 (9%) mg in the course of her 3 daily meals. This means she was lacking 68.4 mg daily!

8.LACKING 93% OF TOTAL DAILY FIBRE INTAKE!

8. Dietary Fibre Deficiency =The recommended dietary allowance required by an adult female is 25 mg/day (milligrams) of Dietary Fibre per day.

Terra’s diet contained: Jello 0 mg Tea 0 mg Broth 0 mg Juice .5 mg

 Terra would have received 1.5 (6%)mg in the course of her 3 daily meals. This means she was lacking 23.5 mg daily!

9.LACKING 70.9% OF TOTAL DAILY PHOSPHORUS INTAKE! protects against infection, and enhances the immune system;

9. Phosphorus Deficiency =The recommended dietary allowance required by an adult female is 700 mg/day (milligrams) of Phosphorus per day.

Terra’s diet contained: Jello 30 mg Tea 2 mg Broth 19 mg Juice 17 mg

 Terra would have received 204 (29.1%) mg in the course of her 3 daily meals. This means she was lacking 496 mg daily!

10. LACKING 82.7% OF TOTAL DAILY ZINC INTAKE! protects against infection, and enhances the immune system; Zinc is also required in wound healing.

10. Zinc =The recommended dietary allowance required by an adult female is 8 mg/day (milligrams) of Zinc per day.

Terra’s diet contained: Jello .01 mg Tea .04 mg Broth .36 mg Juice .05 mg

 Terra would have received 1.38 (17.3%) mg in the course of her 3 daily meals. This means she was lacking 6.62 mg daily!

11. LACKING 99.9% OF TOTAL DAILY COPPER INTAKE! Needed for the formation of red blood cells and body needs copper to be able to use iron properly.

11. Copper =The recommended dietary allowance required by an adult female is 900 µg/day (microgram mcg) of Copper per day.

Terra’s diet contained: Jello .032 µg Tea .018 µg Broth .246 µg Juice .030 µg

 Terra would have received .978 µg (microgram) in the course of her 3 daily meals. This means she was lacking 899.022 µg daily!

12.LACKING 81.5% OF TOTAL DAILY SELENIUM INTAKE! In immune function and infection prevention, and selenium deficiency has been reported in patients after intestinal surgery

12. Selenium =The recommended dietary allowance required by an adult female is 55 mg/day (milligrams) of Selenium per day.

Terra’s diet contained: Jello 1.5 mg Tea 0 mg Broth 1.7 mg Juice .2 mg

 Terra would have received 10.2 (18.5%) mg in the course of her 3 daily meals. This means she was lacking 44.8 mg daily!

13.LACKING 84.7% OF TOTAL DAILY THIAMIN INTAKE! Because of its constant demand and limited storage thiamine is required daily. enhances circulation, assists in blood formation, carbohydrate metabolism and digestion; plays a key role in generating energy acts as an anti-oxidant, protecting the body from degenerative effects

13. Thiamin =The recommended dietary allowance required by an adult female is 1.1 mg/day (milligrams) of Thiamin per day.

Terra’s diet contained: Jello 0 mg Tea 0 mg Broth .004 mg Juice .052 mg

 Terra would have received .168 (15.3%) mg in the course of her 3 daily meals. This means she was lacking .932 mg daily!

Thiamine is an essential coenzyme in carbohydrate metabolism. Because of its constant demand and limited storage thiamine is required daily.

14. LACKING 91.8% OF TOTAL DAILY RIBOFLAVIN INTAKE! Necessary for red blood cell formation, anti-body production, cell respiration, and growth

14. Riboflavin =The recommended dietary allowance required by an adult female is 1.1 mg/day (milligrams) of Riboflavin per day.

Terra’s diet contained: Jello .008 mg Tea .025 mg Broth .015 mg. Juice .042 mg

 Terra would have received .09 (8.2%) mg in the course of her 3 daily meals.

 This means she was lacking 1.01 mg daily!

15. LACKING 80.9% OF TOTAL DAILY NIACIN INTAKE! the maintenance of the gastrointestinal tract. It is required for the release of energy from food

15. Niacin =The recommended dietary allowance required by an adult female is 14 mg/day (milligrams) of Niacin per day.

Terra’s diet contained: Jello .001 mg Tea 0 mg Broth .711 mg Juice .181 mg

 Terra would have received 2.679 (19.1%) mg in the course of her 3 daily meals. This means she was lacking 11.321 mg daily!