[danachow]

From my reading of that story what was interesting was that shit hit the fan with a post-op infection after the hernia repair. A reducible hernia isn't an automatic indication for surgery these days - and post-op risks outweighing benefits is one of the reasons why. It's also weird why the "time left untreated" would have any bearing on the repair and risk of complications - people go through life with uncomplicated hernias for years - if they're complicated they declare themselves pretty rapidly. There are many other reasons I can think of that would increase risk though. When I hear a story like this it is very hard for me to believe the entire pertinent medical history is being conveyed.

[haldujai]

I concur. I often work as a radiologist in the ED setting, while this is anecdotal I can’t imagine that anyone with history of recent hernia repair, purulent discharge, and chills would not get a CT scan at an academic centre in the US (OP stated residents were present.

I can only speak to the centre I’ve worked/rotated at but this seems inconceivable based on the requisitions I get in my career. We do a lot more for a lot less.

The only point I would disagree on is that “time left untreated” can increase complication rate. If this a partially strangulated hernia and there was a microperforation (quite common and often missed) or bacterial translocation in the hernia sac mesh would almost certainly get infected. Even if not strangulated/perforated at time of surgery, if there are dense adhesions from recurrent/intermittent obstructions that may also increase operative complexity and a lysis of adhesions may contaminate the field. That said you could also just not use mesh.

[throwaway742]

In my experience US EDs tend to be very liberal with testing. At times it seems excessive. I have heard complaints from technicians who say they feel like sometimes the doctors just tick every box on their tablet. I think this might have to do with malpractice insurance. Perhaps, and I say this as a proponent single payer, the NHS prefers cost savings to risk reduction.

[vo2maxer]

Remember that in the chronology, the infection occurs after the second surgery, the hernia repair. The mass develops after the first surgery. I agree with you otherwise. Internal Medicine here.

[haldujai]

Yes exactly, perhaps I was unclear.

In my description, it is conceivable that due to chronicity the field was contaminated at the time of second OR and/or a lysis of adhesions resulted in a contaminated field.

If the surgeon implanted mesh in a contaminated field this would be seeded and inevitably get infected.

This is not uncommon and why surgeons often don’t implant mesh in complex LOA or possibly dirty fields.

I’m not saying this is what happened, but delayed diagnosis of a complicated hernia can increase the risk of complications from repair.

[cameronh90]

It's not clear to me exactly why the wound got infected, as currently all the parties involved are blaming each other.

The surgeon who performed the mesh repair did clearly state it was a possibility, but the hernia wasn't suitable for non-mesh repair, which would have been his preference.

There was no indication of infection or contamination at the time of the hernia repair, and the surgeon who performed the mesh believes the infection was most likely caused by poor aftercare, which was handled by the local hospital due to covid travel difficulties. Of course, he could just be saying that to cover his ass.

[haldujai]

This isn’t necessarily covering his ass.

Mesh infection is a known risk, by your description you were appropriately consented for this.

It will be impossible to definitively identify the source of infection (I.e. was there an inadvertent enterotomy intraoperatively? Was it an inguinal hernia repair which is a relatively “dirty” region close to genitalia and a common location for surgical site infection? Did your mom develop a bacteremia for another reason and seed the implant?).

At the end of the day none of this really matters though because you were appropriately consented.

The only apparent angle for malpractice here would be if a reasonable and competent surgeon would disagree with the use of mesh and would have done a primary or two-stage repair (I.e. reduce the hernia under laparoscopy +/- small bowel resection. Bring the patient back several months later to repair the abdominal wall defect.)

If you saw a physician specializing in hernia care, I would assume that they follow best practices and this type of case was not amenable to the options I described.

If this is the case, it is incredibly unfortunate what happened to your mother. However, bad things happen and this is why we consent for complications (especially ones as devastating as mesh infection).

I wish everything I did worked and I never had complications but the only way to have no complications is to never see patients.

[cameronh90]

We aren't particularly bothered by the mesh infection. Complications happen.

We are bothered by the hospital not diagnosing the hernia despite it being painfully obvious there was a hernia, which led to complications, and then ignoring the signs of infection until it got to the point where it nearly killed her.

[vo2maxer]

Well, the history is not clear. All we know is that post-first surgery, an abdominal mass develops which becomes painful over time. I assume the “hernia expert”, which is just another name for a general surgeon, followed a simple algorithm: Protruding painful abdominal mass -> Hernia? Incarcerated? With possible increasing risk of vascular compromise to bowels > CT Scan. Go from there. Period.

[haldujai]

To be fair and in defense of OP, I’m not sure why you are putting quotes around hernia expert.

I’m not sure what setting you practice in, I am personally in a ~1500 bed academic health sciences center.

At my institution, we have 3 general surgeons who are hernia experts (literally on their letter head). This is to say that their non ACS practice is heavily on hernia repair and they get the referrals for all complex hernia repairs from other general surgeons in the catchment area.

If you’re in a smaller setting you may not have a similar degree of sub-specialization amongst your general surgeons but hernia experts are definitely a real thing.

I appreciate your overall point and frustration, but I think you’re being a bit too dismissive here.

[vo2maxer]

That’s a fair criticism. I apologize if I came across as dismissive but it was not towards the OP. My adding quotes around hernia expert was more to show my indignation that any number of other physicians according to the OP failed to make a correct diagnosis thus requiring the “expert” to step in. My comment was poorly worded and difficult to decipher my intention with it.

I also come from a large academic based health center.

[cameronh90]

The reason for the "expert" is rather complicated.

Essentially my mum lives on an island nation where there is only a singular local hospital with a fairly poor reputation.

In order to get it looked at, we had to find a hospital in the UK, as that's where the private insurance covered treatment. The local hospital refused to even write a referral for further diagnosis as they considered it unnecessary as it "definitely isn't a hernia", so we had to find a surgeon that takes self-referrals. That rules out the normal NHS routes, even if attending privately.

So ultimately we found a team that specialise in treating hernias, who agreed to have my mum in after they saw a photo of her abdomen.

I think one thing to understand here is that a local hospital with a poor reputation isn't going to have the same standards as a large academic health centre. The reputation is such that good clinicians will avoid the local hospital, as they don't want to be seen to be associated with it.

Unfortunately, when you live there, you don't really have the same luxury.

[haldujai]

You’re absolutely correct.

I like to think I’m a good physician. At the very least I’m a highly trained subspecialty physician.

I could never work in a small community hospital with poor standards because it drives me insane to work with apathetic clinicians (100% a real thing). Additionally, given how much I trained I need to practice in a centre that can provide complexity (largely academic centres or major metropolitan non-academic sites)

This unfortunately does result in the bottom of the barrel staffing the “crappy local hospital”, but someone has to do it.

It’s unrealistic to expect high quality physicians to work on a small island nation. By choosing to live on a remote island you honestly have to accept that you’re not getting the same access to healthcare as someone in a larger city.

I’m not sure of any way to improve that.

Edit: I wanted to add that with the additional information cameronh90 has provided, in my professional opinion I can absolutely believe that his mother may have been misdiagnosed in such a practice setting.

Not uncommonly (forgive me for using this favourite word of doctors), I see egregious medical errors referred to my centre from very remote locations.

The issue in this story is not that the medical profession is apathetic, careless, negligent.

This is rather a good example of the issues in delivering quality care in remote locations. We can’t force people to move to islands and presumably an undesirable location for someone to migrate to so you end up with a higher percentage of incompetent physicians who can’t find jobs in better locations.

Most often the only times these types of practices get a recently trained physician are if the individual originally comes from there and wants to go back, a rare occurrence in my experience.

[cameronh90]

Just to add, while it is an island nation, it's not remote. It's also quite wealthy, but with a relatively small and elderly population.

While I'm not a doctor, I'd imagine that if I was a good doctor, I'd rather work somewhere that I'm likely to get exposure to interesting cases, or hospital known for producing quality research, or a teaching hospital, or at least want to live somewhere that I could go to conferences and otherwise work with other smart people. Indeed, I moved to London for similar reasons in my career.

The way the local hospital tries to maintain some level of competence is by flying doctors over for a day or two a week, but even with that it's an uphill battle trying to attract anyone in the prime of their career. It's more of a place you go for an easy retirement, earning relatively good money but for boring work in poor facilities. Even then, the money isn't comparable to what a late stage career doctor could get working privately in Harley Street for example. We do know a few doctors (and nurses) working over there, and even if they start out enthusiastic, the system ultimately grinds them down until they're apathetic. Some leave, some just give into it.

I appreciate that you obviously can't have excellent doctors everywhere, but at the same time, I bet most individuals' interactions with healthcare are those local community hospitals and pre-retirement GPs with little enthusiasm for the job. I suppose that in healthcare, reaching the best physicians is usually a bad sign regarding your prognosis (or a very good sign regarding your bank balance).

[cameronh90]

According to the surgeon who ultimately repaired the hernia, it was not an uncomplicated hernia. He said it was incarcerated and that there was an adhesion.

Ultimately, it could well have been the case that treating the hernia was not recommended, and that could have been discussed. But simply denying that there was even a hernia and refusing to perform any further investigation is clearly a failure.