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An intoxicated 30-year -old male heavy equipment operator was involved in a severe one-vehicle rollover accident with multiple injuries --- including a severe head injury. After arrival by ambulance to the hospital, he was treated in the Emergency Room(ER) where an ER Physician noted on the Patient's chart: " 3-cm stellate laceration to the right scalp with a Glasgow coma scale (sensory perception measure) of 3 --- indicating a serious head injury. The ER Physician ordered chest x-rays and a CT (Computer Tomography Scan) of the Patient.
The Radiologist read the CT to show " a left hematoma with a right shift" without evidence of skull fracture, and also noted " a small subarachnoid hemorrhage."
The Neurosurgeon was provided both the CT and the related Radiologist report but noted her reason for consult as " right thin subdural hematoma, mass effect and midline shift", but in her patient history noted " CT scan of the brain demonstrated cerebral edema with left-to-right midline shift and a 7 millimeter subdural hematoma, predominantly in the left temporal lobe."
The Neurosurgeon then performed what she described in her notes as an "unintended right craniotomy " (right-side skull opening) before performing the needed left craniotomy for the left
subdural hematoma.
Eight days later the Neurosurgeon had to do a re-approximation of bone flap and insertion of an
addition plate in the Patient's skull. Fortunately, the second craniotomy was successful and the patient recovered "fairly well" from his injuries.
EXPERT OPINIONS :
The three neurosurgery experts agree that this case of wrong-side surgery was a definite breach in the standard of care for this type of operation, but also for both neurosurgery and surgery protocols in general.
[See, www.medQuestltd.com/craniotomy-performed-on-the-wrong-side]
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