This story is a part of my complaint to the College of Surgeons and Physicians of Ontario (CSPO)
I was referred to Dr. West in 2007 by my family physician, Dr. Oleg Livshin, for a bunion operation on my feet. The first and the only pre-operation appointment with Dr West. He recommended a joint replacement surgery. He said that it was a routine operation and that he had done hundreds of them. This included a full recovery, over six weeks, and a painless life after. Not a word about surgical risks and complications.
1. March 28th 2008. Dr West performed a joint replacement surgery on my left foot in North York General Hospital. It turned out that during the surgery my fourth toe bone was fractured and Dr. West didn’t notice. Two weeks in cast were not enough to heal the fracture but I didn’t feel any pain.
2. April 9th 2008. I had a follow-up appointment with Dr. West at the Hospital Orthopedic Centre. I waited for 3.5 hours. He removed a bandage, did several X-rays, didn’t notice the fracture and then said that he was very pleased with the result. I asked him why my big toe looked 1.5 cm separated from other toes and he answered that he straightened it out and suggested to exercise my foot as much as I could.
3. As soon as I started walking, my foot started swelling in my fourth toe area. It became bluish and painful. I called Dr. West's office several times but his voicemail wouldn’t accept messages. When I finally reached his secretary she said that Dr. West was not available and recommended that I go to ER, walk-in or family doctor.
4. April 21st 2008. My foot was getting worse. I don’t drive and that’s why I limped to the closest walk-in clinic Solutions and they suggested I to go to the ER
5. April 23rd 2008. Went to the closest ER (Western Hospital) and waited for 5 hours to see a doctor (Dr. Arnold Paul F.) The triage nurse was annoyed that I came to them and not to my surgeon. They made several X-rays, prescribed pain killers and recommended that I see my surgeon as soon as possible.
6. I had to wait a week until the next follow-up appointment with Dr. West on April 30th.
7. April 30th 2008. I complained about swelling, pain and that my big toe is sticking out. Dr. West made several X-rays, did not answer my questions then explained that it sometimes takes 3 month to heal. His comment was not relevant to my questions. He prescribed Tylenol 3 and recommended more exercise.
8. My foot is not getting better and Dr. West is not available.
9. May 12th 2008. Made it to my family doctor Dr. Oleg Livshin. He made two X-rays, found a fracture, recommended stop exercising and sent me for a nuclear bone exam.
10. May 15th 2008. Nuclear bone exam at Branson Site showed two hot spots on the big toe and fourth toe.
11. May16th 2008. Dr. Livshin prescribed taking APO-METRONIZOLE and APO – CEPHALEX and ARTHROTEC for 10 days and referred me to Gallium exam. Swelling started to decrease; on two separate occasions there was a green matter excreting from the operation scar. Walking is still painful.
12. June 5th 2008, At St. Paul’s Hospital, Vancouver, the next nuclear exam (white blood cells exam) shows no evidence of active infection.
13. July 9th 2008. The next appointment with Dr. West at the Center. After several X-rays, that he didn't show me, he said, "now I see that the fracture is healed, but the joint is displaced. I honestly don't know why it happened.“ I asked for a second opinion. Dr. West said, â€I am going to get the second opinion and consult the main specialist in this medical area, Dr. Johnny Lau in Toronto Western. It takes a year to get an appointment with him but I will try to get it as soon as possible. Call my office in one week. Meanwhile, try to exercise your foot and not to be discouraged." I handed him this history and he put it in my file without reading.
14. July 16th 2008. Spent a half of the day trying to reach Dr. West's office until I finally found out that an appointment was set on August 14th and then reset on July 31st at 11:30 AM as an emergency. Dr. West promised to send my medical history and all X-rays to Dr. Lau's office. His secretary gave me a number to confirm the appointment 3 days prior.
15. July 17th 2008. Family Dr. O. Livshin prescribed anti-depressant Ratio-Paraxetine
16. July 22nd 2008. My big toe is swollen and there is some discharge around the nail. I called Dr. West's office but he is not available.
17. July 28th 2008. Trying to call the given number to confirm the appointment with Dr. Lau but the number is not in order. Call Dr. West's office – there is a message that the office is closed until August 5th and the machine is not recording messages. I have to go to the hospital on foot and it turns out that the time of the appointment was also wrong – it was 10:45 AM.
18. July 31st 2008. Dr. Lau's office at Western Hospital. Dr. West didn’t send my file and X-rays to Dr. Lau. He had to make five X-rays again.
Dr. Lau verdict: I need a more complicated second operation to fix my foot. It will involve the removal of all the stuff that Dr. West is responsible for. Then they will take a part of my pelvic bone and fuse it into big toe joint. Dr. Lau ordered some blood work done and asked that I bring him my file with my bone. That same day, I went to the Hospital to get a CD with my post-operation exams, free of charge.
19. August 5th 2008. Called Dr. West's office and asked why they didn’t send my file to Dr. Lau. The secretary answered that I have to come tomorrow after 9 AM to pick it up and pay $50!
20. August 6th 2008. I asked my daughter to get my X-rays from Dr. West's office. Imaging clinic staff did not find the X-rays and suggested that either I or the doctor’s office signed them out. The doctor’s assistant, Sandra, did not find the file at the office. I am concerned that my X-rays are misplaced as an evidence of malpractice.
Summary: As a result of the unsuccessful surgery and Dr. West's subsequent negligence, the complications of this surgery (fractured bone, inflammation, implant dislocation) have caused a poor quality of life and an inability to walk in shoes. I consumed a large amount of high-impact antibiotics and painkillers, yet my problem is still not resolved. I became depressed and I now live on anti-depressants.
My toe is swollen, big (bigger than it was before my operation) and curved and there is a 2 cm gap between it and the other toes. It hurts when I squeeze them together to put a shoe on and I can’t walk.
I’ve taken more than twenty X-rays, two nuclear exams and plenty of heavy drugs in a short period of time. I’ve lost wages because I have to do a lot of walking in my job in shoes that cause great pain. I can only limp barefoot. I’ve lost quality of life because I cannot do things that I used to do like walking, hiking, skiing, etc. Many of my shoes don’t fit and I'm forced to order custom shoes which I cannot afford.
I’ve suffered a lot and I am still suffering. I used to be a very active and cheerful person and now I cry every day. I am even more depressed because I am facing a new surgery that might also have unfortunate outcome at my age. It was my first serious experience with the Canadian Health System and I found it stiff, indifferent and, in my case, hostile. It allows doctors like Dr. West to treat their post-operation patients the way he treated me. Every time I saw him or talked to him he didn’t answer my questions and left my symptoms untreated. I had three major surgeries in Russia, all successful, and all my surgeons provided excellent post-surgical care.
I want Dr. West to be accountable for what he did to me, and I don’t want other people to suffer the same way. That’s why I am writing this complaint.
Sent to CSPO in September, 2008. When my medical history became available to me I discovered that Dr West was not truthful about the state of my health from the first post operation appointment. Looking at my X-Rays that suggested “Standing view …demonstrates displacement of the proximal phalanx of the left 1st digit to the prosthesis of the head of the 1st metatarsal†“Alignment is not congruent†hi said that he was pleased with the results. The toe was sticking out; he obviously overdid the straightening of the toe and did not have the courage to acknowledge that and to take measures to fix it.
He claimed to the College that during our first meeting before the surgery he warned me orally about surgical risks and it was not true. The College took his word over mine.
The College also did not find enough evidence that my fourth toe was fractured during the surgery. It took the CSPO almost a year of investigation to come to the conclusion that Dr. West did everything right. The only action the CSPO took was counseling Dr. West with respect, post-surgical access, follow-up, and regarding the importance of documenting his discussions with patients.
My next step was to send a request for review the College decision to the Health Professions Appeal and Review Board. I sent it in July 2009. There was a teleconference held on June 2010, which Dr. West did not attend.
The review was conducted on September 30th 2010. Dr. West showed up along with his lawyer from Medical Protection Association. I was with my daughter. The Board stated that it is very rare for a surgeon to attend such a case. He let his lawyer talk for him. At the end he said, “I am sorry, Ms. Krakovna, the SYSTEM failed you.†The system, not him.
I am still waiting for the Board decision.
To be continued…