An orthopedic surgeon at UW Health has been ordered into training after a patient died during surgery from receiving too much adrenaline, which is used to control blood loss.
Last month the Wisconsin Medical Examination Board ordered Dr. Molly Day to undergo six hours of training in communication and root cause analysis following her October 11, 2021 operation, in which the patient died shortly after start of shoulder surgery.
Per the medical board’s order, a nurse asked Day whether he would prefer a single-use vial containing 1 milliliter of epinephrine or a large reusable vial containing 30 milliliters of epinephrine. Day said “one of two” and pointed to the larger vial, thinking the small amount of adrenaline needed could be withdrawn from it and mixed with an anesthetic used to control pain, the order said.
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The nurse took the 30 mL vial to a lavatory technician, who drew it all up into a 30 cubic centimeter syringe and made the syringe available to Day. After Day returned from washing up for the procedure, he injected the syringe into the patient, who quickly developed an abnormal health rhythm and died. The man was born in 1962.
According to the order, the scrub technician said he labeled the syringe “Epi,” but Day said there was no label on the syringe. Day provided affidavits from two other orthopedic surgeons at UW Health, saying the syringes were inconsistently labeled.
Day is pursuing the education required by the medical board and the nurse and scrub technician are still employed at UW Health, UW Health spokeswoman Sara Benzel said.
“Dr. Day remains a valued member of our faculty, and we are confident in the treatment he provides for our patients,” said Tamara Scerpella, interim chair of the Department of Orthopedics and Rehabilitation at the UW School of Medicine and Public Health.
The state Department of Occupational Safety and Services has an “unfinished business” involving the nurse, said Jennifer Garrett, the department’s assistant assistant secretary. Garrett said the state does not license laundering technicians and the only technicians on the list of licensed professions are chiropractic technicians.
The medical commission issued a usually large number of disciplinary orders at its monthly meeting on December 21. Among others:
Dr. David Eckerle’s license was limited based on a deal he reached with the United States Drug Enforcement Agency to reduce his prescribing of controlled substances and pain treatment, per his order. Eckerle, who worked at the Group Health Cooperative of South Central Wisconsin in Madison, agreed to pay $110,000 in 2021 to settle federal civil charges
- who wrote prescriptions for opioids and other controlled substances for no legitimate medical purpose.
- Dr. Scott Stillwell’s license was suspended for 30 days and he was required to undergo three hours of professional ethics education after falsely reporting in the Wisconsin vaccination record that he, his wife and their children had received the COVID-19 vaccination ,
. Stillwell, of Green Bay, used a physician assistant’s credentials without authorization to access the registry, the order said. After admitting the false report, he resigned from a De Pere clinic. In the month of July,
opened Stillwell Family Medicine
direct primary care practice
- Dr Steven Meress, of Fond du Lac, was reprimanded and ordered to take three hours of patient documentation training after treating a patient for persistent Lyme disease without proper informed consent,
. In 2015, the board regulated Meress, with Fox Valley Wellness Center, for
treating Lyme disease patients with excessive antibiotics
- and inadequate informed consent, requiring him to use a specific form for informed consent. In 2018, he provided such assistance without using the form, the order said.
- Dr Shawn Laibly’s license was suspended for 30 days and he was ordered to undergo eight hours of training in cervical procedures after a patient he operated on died of septic shock two days later.
- . Laibly, an Oshkosh obstetrician-gynecologist whose LinkedIn page says he worked at Aurora Health Care, performed a procedure in March 2021 to obtain a sample for testing from a woman born in 1954 who complained of excessive vaginal bleeding. During the procedure, the woman’s uterine wall and rectum were injured, leading to septic shock, or widespread infection, the order said.
- Dr. Michael Kim, an Oshkosh colon and rectal surgeon who still works at the Aurora, was reprimanded for the same incident, during which he was on call,
- . After discussing the patient’s situation with a doctor over the phone, Kim recommended antibiotics and medical stabilization. He failed to see the patient in person or recommend further surgery at that time, the order said.
“We immediately conducted a thorough internal investigation and took appropriate action,” Krissy Lillie, a spokeswoman for Aurora’s attorney, said in a statement for Aurora Medical Center – Oshkosh in response to an inquiry into Laibly and Kim.
Eckerle’s attorney, Stillwell, and Stillwell’s attorney did not respond to a request for comment, and an attorney for Meress declined to comment.
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