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Published: Sunday, 8/26/2012 - Updated: 2 years ago

UT chief apologizes for botched surgery

BY IGNAZIO MESSINA
BLADE STAFF WRITER
UTMC president Dr. Lloyd Jacobs believes the transplant program will be reinstated. UTMC president Dr. Lloyd Jacobs believes the transplant program will be reinstated.
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As a doctor, Lloyd Jacobs knows medicine is not perfect and that mistakes can be made. At the same time, he is personally anguished over an error that led to a botched kidney surgery earlier this month.

The University of Toledo Medical Center president said he believes the hospital's kidney transplant program, which was voluntarily suspended, will eventually be reinstated after a deep look at the Aug. 10 accident that led to a viable kidney in the trash instead of the donor's sister.

"I share the sentiment expressed by others that this causes great anguish," Dr. Jacobs told The Blade. "I am deeply apologetic. I am anguished. When mistakes are made, the best thing is to acknowledge them and say I am deeply sorry about this."

The university president was hesitant to assign blame for the incident in which a nurse apparently discarded a kidney after it was removed from a Toledo man before it could be transplanted into his sister.

Two nurses involved in the surgery, Melanie Lemay and Judith Moore, were suspended, but Dr. Michael Rees, the UTMC transplant surgeon who removed the kidney before it was ruined, has not faced any discipline, Dr. Jacobs said. The hospital would not say which nurse handled the kidney before it was accidently discarded or why a second nurse was suspended.

"What we need to try to ascertain is where in that chain of command the responsibility is best focused, but at this point, and we are doing that, at this point no action has been taken with Dr. Rees. His status with the institution is unchanged," Dr. Jacobs said. "Somehow, some way, an inexplicable human error made someone think that the kidney apparently was already in the recipient body when it was not. It is just not clear."

Dr. Jacobs said he had no doubt the live kidney donation program would be restarted after reviews by the Ohio Department of Health, the Centers for Medicare and Medicaid Services, and a panel of kidney experts hired by UTMC, the former Medical College of Ohio Hospital. He also doesn't think UTMC is besmirched by the incident.

"It is an excellent program," he said. "I have no doubt that after careful study and careful assessment the program will be reinstated. Bad things happen in life but they don't extinguish life."

Dr. Rees, who has not returned telephone calls seeking comment, was accused of having a confrontation with a surgical technician during a kidney surgery in June, 2009, during which Ms. Lemay was involved, court documents show.

The same court document claims Dr. Rees stated he did not think Ms. Lemay was as experienced or as well-suited to assist in the surgery as Kelly Haas, the surgical technician who filed the lawsuit.

Ms. Haas of Oregon alleged in the suit, first filed in Lucas County Common Pleas Court and later in the Court of Claims of Ohio, that Dr. Rees kicked her during a surgery at UTMC. The suit was to determine if Dr. Rees would be immune from any action. No further court case was filed in the Court of Claims.

In the filing, court records say Ms. Haas was assisting Dr. Rees with a kidney transplant surgery beginning at 1 a.m. on June 6, 2009, and she was scheduled to take a break about midway through the surgery. That is when Ms. Lemay was scheduled to relieve her during the break.

"Plaintiff stated that Lemay arrived in the operating room to relieve her at the appointed time, and that after she briefed Lemay on the status of the operation, Lemay took her place at the operating table," the court record said. "Plaintiff stated that she then walked away from the table and toward the door, where nurse Rosalyn Gregory began to assist her in removing her surgical gown. According to plaintiff, she then felt a strong kick on the back of her left leg that caused her leg to give out, she fell forward toward Gregory, and Gregory reached out and caught her. Plaintiff stated that when she turned around, Dr. Rees stood before her, appearing frustrated and angry, and demanded to know where she was going and how long she would be gone."

The record said Dr. Rees apologized to Ms. Haas upon her return to the operating room.

"Plaintiff testified that she then replaced Lemay at the operating table and that the rest of the surgery proceeded without further incident," the record said.

The record also stated: "Melanie Lemay testified that she has worked as a registered nurse for [Dr. Rees] for 29 years, with the past six or seven years being in the operating department. Lemay related, though, that she does not regularly assist in surgeries and that she had only assisted in two or three kidney transplants prior to the incident."

It further said, "Concerning the incident, Dr. Rees testified that he was focused on the operation and did not realize that plaintiff had left the table until two successive instruments were improperly handed to him, causing him to look up and see that Lemay had relieved [Ms. Haas]. According to Dr. Rees, he believed that [Ms. Haas] was more experienced and better suited for this procedure, so he decided to either discourage plaintiff from taking a break or ask her to keep her break short."

Dr. Jacobs said he recalled the case but that it did not affect Dr. Rees' standing at UTMC in any way.

Meanwhile, news of the botched surgery circulated through the transplant community for a third day after UTMC officials revealed the incident early last week.

Donna Luebke, a registered nurse and transplant patient advocate in Cleveland and former board member of the United Network for Organ Sharing, questioned why the surgeon had not been held as responsible as the nurses.

"Why not the surgeon who took his eye off the kidney?" she wrote in an email Friday to The Blade. "Where in the recovery, flushing, and prep of a kidney, and transport to the other [operating] room is a nurse involved? Whoever was the primary surgeon should be held accountable. … I am saddened both as a nurse and live donor that nurses were blamed.

"Says a lot about the surgeon that he let the nurses take the fall."

Contact Ignazio Messina at: imessina@theblade.com or 419-724-6171.



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