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Licensed for Life: Pacemaker procedure gone wrong leaves patient dead

Licensed for Life: Pacemaker procedure gone wrong leaves patient dead

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The Medical Board of California granted Madhusudhan T. Gupta a license to practice on June 14, 1982. A cardiologist by training, Gupta practiced in the Los Angeles area for three decades after that.

There is no Medical Board record for Dr. Gupta prior to the 2000s, so let’s assume that he practiced uneventfully – even skillfully – for his first 20 years in medicine. But his case also illustrates how the skills a physician has earlier in their career don’t necessarily remain sharp toward the end. I have written about this phenomenon before on Antidote, and some groups have called for periodic testing of physicians after a certain age. I will break down Gupta’s case over two posts.

In October 2005, Gupta began to treat a patient identified in Medical Board documents as E.T. Over the years, E.T. was diagnosed with high blood pressure and suffered a stroke, for which she began taking Plavix, a drug that stops the blood from clotting. She also took aspirin for the same reason.

In August 2009, though, E.T., then 78, ended up in the hospital. She was weak and her heart rate was slow. The doctors at the hospital diagnosed her with bradycardia — the medical term for slow heart rate — and noted her previous medical history.

Because of her hospitalization, Gupta recommended that E.T. have a pacemaker implanted. Two days after she entered the hospital, Gupta performed a procedure to insert a pacemaker through her blood vessels, and he skipped a step. According to Medical Board documents, Gupta should have first injected contrast material into E.T.’s blood and performed an X-ray test to see how the blood was flowing. This would show him the right pathway for inserting the pacemaker or whether it could even be inserted at all.

He didn’t do that. Instead, he made “multiple failed attempts” to insert the pacemaker through a blood vessel, according to Medical Board documents. Only after that, did he perform the X-ray test, known as a venogram.

Meanwhile, E.T.’s blood pressure began to fall and she “was noticed to be pale.” Medical Board documents state:

An attempt was made to normalize her blood pressure with vasopressor, dopamine, elevation of the legs, and boluses of saline.

A cardiac surgeon was called in, identified by the Medical Board as Dr. B.N. When he arrived, Gupta had bad news for Dr. B.N. He told him that he had “punctured the subclavian artery about two to three times in his attempts to access the subclavian vein.”

Gupta should have been inserting the pacemaker guide wire into the vein all along. And had he checked the blood flow and the color of the blood, he would have known that he was trying to jam the wire into the wrong blood vessel.

Bad situation. And it was about to get worse.

At this point, the doctors could have decided to leave well enough alone and wait for E.T. to return to normal blood pressure and then consider how to proceed with implanting a pacemaker.

Instead, as the Medical Board documents state, “In spite of the patient being extremely unstable, [Gupta] decided to continue with the pacemaker insertion.” With help from Dr. B.N., Gupta inserted the pacemaker. How was E.T. doing? Not well, according to the Medical Board:

During this time, the patient was noted to have diminished breath sounds on the left side and was extremely pale and hypotensive [low blood pressure].

Dr. B.N. inserted a chest tube into E.T. to relieve pressure from any air buildup in her chest cavity, and the doctors noticed blood coming out of it, another bad sign.

They ordered a blood transfusion and fresh plasma, which E.T. received. They also ordered one unit of platelets, which would have helped E.T.’s blood clot and stop the bleeding. For some reason, E.T. was never given the platelets.

E.T. was transferred to the intensive care unit. By 5 p.m., seven hours after the pacemaker procedure began, she was dead.

Next: How the doctor tried to cover his tracks and how long the Medical Board dithered.

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Photo by Artur Bergman via Flickr.

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