CALGARY — Suffering from abdominal pain, Andres Martinez was admitted to Rockyview Hospital for an urgent, overnight appendix surgery.
Within hours, after bleeding profusely from an artery damaged during the operation, the 24-year-old Calgary man died.
In a fatality inquiry report released Tuesday, provincial court judge Michael Dinkel said an “improper” surgical technique led to Martinez’s March 29, 2010, death.
The judge, however, offered no recommendations to prevent similar deaths, noting several improvements have already been made.
“It is clear to me that the tragic death of Andres Martinez was as a result of the improper use of a surgical instrument called a disposable trocar. The initial entry into the patient’s abdominal cavity should have been undertaken with a blunt reusable trocar,” Dinkel wrote in his report.
The surgeon who performed the operation, Samer Elkassem, “was a highly skilled surgeon at the time of this incident and he experienced a momentary lapse in judgment that caused him to believe that he could use the bladed trocar safely,” wrote Dinkel.
Elkassem couldn’t be reached Tuesday.
An Alberta Health Services spokesman declined to comment on the matter, “as this is before the courts.”
According to the fatality inquiry report, the fatal injury took place soon after Martinez’s laparoscopic appendectomy surgery began.
Much of the inquiry testimony revolved around the type of trocar — a cylindrical surgical device — Elkassem used during Martinez’s operation. According to the report, the surgeon “blindly” inserted the device into Martinez’s abdomen and unexpectedly cut a major vessel.
Elkassem, who’d performed at least 74 appendectomies before operating on Martinez, testified he generally used a reusable trocar with a blunt end, but the device wasn’t available that night. That’s why he used a disposable trocar, which had a blade that remained shielded unless it encountered resistance, the inquiry heard.
However, a scrub nurse who also took the stand at the inquiry testified she specifically recalled having both types of trocars available in the operating room that day.
The city’s head of surgery, meanwhile, Dr. John Kortbeek, testified that “the use of a sharp trocar inserted blindly is incorrect,” the report stated.
Dinkel noted that administrative and safety reviews since Martinez died have led to a formal surgery safety checklist that “addresses many of the concerns regarding the availability of instruments, equipment and blood products prior to a surgery.”
While the judge didn’t make formal recommendations, he crafted 10 “suggestions,” including standardizing the names of the various trocars and making sure the province’s surgeons understand the dangers of using the bladed instrument for initial entry into the abdomen.
“It is impossible to create requirements or protocols that would eliminate the human error that led to the patient’s death in this case. Still it is important to look at how the operating room functions and determine if any recommendations can be made to improve upon the existing protocols,” Dinkel wrote.
Further, Dinkel suggested that a new family support protocol be named in honour of Martinez, and his father, Eugenio Martinez, who pushed for the inquiry to find answers about his son’s death.
The new protocol gives families 24-hour access to social workers, and led to dedicated waiting areas set up near operating rooms.