Jacob Moalem, MD, FACS, and David L. Feldman, MD, MBA, CPE, FAAPL, FACS
A patient over 50 years of age underwent an MRI scan for the evaluation of a symptomatic neck mass and was found to have a complex bilateral nodular goiter with moderate substernal extension. A history and physical examination by a consulting surgeon documented dysphagia and difficulty breathing, and total thyroidectomy was recommended. No fine needle aspiration was performed or offered. Informed consent was obtained. During surgery, the surgeon used a nerve monitor, although no monitor records were retained.
Per the operative note, which was dictated and transcribed on the day of surgery, the middle thyroid vein and the superior and inferior thyroid vessels were divided with a harmonic scalpel and the recurrent laryngeal nerve was protected bilaterally. No mention was made of the parathyroid glands. Two blanks were noted in the operative report in the segment of the dictation pertaining to the specifics of the thyroid gland dissection.
At the patient’s 2- and 3-week postop visits with a physician assistant, the patient complained of hoarseness and persistent dysphagia, cough, and globus sensation. The patient’s benign pathology was reviewed, but no discussion of a potential recurrent laryngeal nerve palsy took place. A month later, a CT was completed to evaluate the patient’s persistent symptoms. The CT suggested left vocal cord paralysis, as well as the persistence of a large portion of thyroid tissue below the clavicle.
A laryngoscopic evaluation confirmed left vocal cord paralysis. The patient was referred to a surgical oncologist for management of the persistent thyroid mass and dysphagia. Contemporaneously, the original surgeon dictated a second operative report due to dictation errors noted in the first report. In the second report, however, the surgeon did not mention that the recurrent laryngeal nerve was identified or protected. Rather, the report indicated that although the surgeon did not see the nerve due to the patient’s obesity, the nerve monitoring probe was used to test all areas prior to dissection.
Several experts were critical that the surgeon did not identify and protect the nerve during surgery, observing that it was below the standard of care to rely solely on nerve monitoring. Another expert was supportive, noting that the complication was known in a patient with a large goiter extending below the clavicle. The claim was settled.
The “Three Ps” refer to “prevent, preclude, and prevail"—the three key elements to reduce practitioner risk related to malpractice litigation.1
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.