Harriet Corbett Programme Director on behalf of the CORESS Advisory Board

Delayed diagnosis of testicular torsion 

A 16-year-old man complained of testicular pain at around 9.30pm but then went to bed as the pain was not severe. He was woken at 2am by severe pain and his mother drove him to the local emergency department. He vomited several times on the way. The emergency department did not have surgical services onsite, so an emergency transfer was arranged because he was suspected of having testicular torsion. The young man arrived at the hospital at 6am and was assessed by the on-call trainee surgeon at 6.30am. The pain had eased somewhat and a diagnosis of epididymitis was made because the epididymal tissue was very swollen. The trainee recommended an ultrasound scan ‘in hours’ and at handover they told the day team of the plan. The ultrasound scan was performed at 11.30am and, although testicular torsion was identified, the surgical team were not notified. The on-call consultant reviewed the patient at 1.30pm and arranged emergency scrotal exploration within 30 minutes. The testis was torted and of doubtful viability but retained as there was some bleeding when the capsule was incised. However, atrophy followed over the next three-four months and the patient subsequently requested insertion of a testicular prosthesis. 

Reporter’s comments 

The trainee had already undertaken a scrotal exploration for torsion that night. During the subsequent case review they noted that had influenced their decision making as they thought it was so unlikely to have ‘two in a night’. The patient was not discussed with the on-call consultant at presentation. Morning handover was very busy and handover was inadequate: the patient’s history (high risk in view of age, severity of pain and vomiting) was not discussed nor was the working diagnosis questioned, both of which were missed opportunities. There were further missed opportunities since the post-take ward round was delayed because of another emergency and the radiologist did not flag the abnormal scan. The patient made a successful claim. 

CORESS comments 

This young man presented at a typical age with a history of severe testicular pain and vomiting – these red flag symptoms made testicular torsion highly likely. Prompt exploration was required and could have been achieved within the ideal six-hour window (assuming significant interruption of blood flow at 2am) despite the interhospital transfer. While some units would request an urgent out-of-hours pre-operative ultrasound, in a case like this, the history was sufficiently concerning that immediate exploration to detort the testis was the right course of action. Even an urgent ultrasound (to diagnose torsion) would almost certainly cause undue delay so is not recommended. If in doubt, discussion with the on-call consultant is advised, whatever the time of day. An adequate handover is also critical.

Spinal drain issues

Ischaemic spinal cord injury (SCI) is a significant complication of thoracoabdominal aortic surgery, especially in older patients, patients who have had previous aortic surgery and those requiring emergency surgery. Neurological deficit usually presents immediately after surgery. Lumbar cerebrospinal fluid (CSF) drainage with a spinal drain has been shown to reduce the risk of ischaemic SCI following aortic surgery by optimising spinal cord perfusion. 

Following an emergency aortic aneurysm repair, a patient developed paraplegia. The spinal drainage was 0-3ml/hr and the pressure was 1-2 for some hours before the problem becoming evident. During spinal drain safety checks at 10pm, it was noticed that a filter was connected between the spinal drain tubing and a three-way tap. This filter should have been connected to the injection port for intrathecal medication, not within the drainage tubing. After correcting the position of the filter, the spinal drain pressure increased to 35 and drainage was 10ml in 15 minutes. Total drainage from 8am to 10pm (before the filter was moved) was just 17ml. Following removal of the filter, drainage was 47ml in three hours. Lower limb sensation improved but limb movement did not recover.  

This case was reported to the National Reporting and Learning System and has subsequently been discussed by the CORESS Advisory Board. 

CORESS comments 

Spinal drains may be sited for different reasons. Drains sited for the purpose of giving medication, such as intrathecal chemotherapy, should have a filter through which the medication passes before reaching the CSF. However, when sited following aortic surgery the purpose is to drain the CSF, which a filter will impede. Education regarding the critical difference in the two indications for a lumbar drain is vital. Considering the natural turnover of critical care staff, there should be regular training sessions that familiarise staff with all aspects of spinal drain indications and management. The World Federation of Societies of Anaesthesiologists has an online tutorial, which is a valuable educational resource (visit resources.wfsahq.org).

Consent issues and failure to treat low parathyroid hormone post-thyroidectomy

This case, which has been discussed by the CORESS Advisory Board, is based on a case vignette from Best practice for Thyroidectomy Documentation – guidance produced by GIRFT in partnership with the Royal College of Surgeons of England and British Association of Endocrine and Thyroid Surgeons. 

A patient with a family history of thyroid cancer was referred to hospital for investigation of a lump in her throat. Ultrasound and fine-needle aspiration cytology suggested a benign cyst. A CT scan showed some early narrowing of the trachea on the left and the left thyroid lobe appeared larger. The possibility of surgery (left hemi-thyroidectomy or total thyroidectomy) was discussed and the patient elected to proceed with a total thyroidectomy. 

The consent form stated that the intended benefits were to relieve compressive symptoms and the risks were noted as scarring, bleeding, infection, hypocalcaemia, necessity for hormone supplements, hoarse voice, loss of voice, airway compromise and tracheostomy. A total thyroidectomy was performed. Postoperatively, while in hospital, the patient developed respiratory problems and carpopedal spasm, which was not recognised promptly. 

Allegations were raised that there was a failure to obtain informed consent, that a partial thyroidectomy should have been performed and that there was a failure to monitor for hypoparathyroidism postoperatively. The patient claimed that had she been consented properly she would have opted for a partial thyroidectomy and, if her condition had been monitored appropriately, she would have avoided severe hypocalcaemia and tetanic muscular spasms. Eventually, the Trust settled a claim for damages. 

Reporter’s comments 

Permanent hypoparathyroidism is a recognised risk in thyroidectomy, although there was no definite evidence that the patient had permanent hypoparathyroidism. However, areas of vulnerability identified for the Trust were in relation to bruising of the parathyroid glands during the thyroidectomy, and that the low parathyroid hormone was not treated promptly postoperatively with calcium supplementation and repeat monitoring before any discharge. The case highlights the importance of documenting inpatient PTH and calcium levels after thyroidectomy, before discharge. 

CORESS comments 

While a formal consent form is helpful in documenting risks discussed with the patient, a record of the consent discussions undertaken in the outpatients department and patient involvement in the clinical decisions, copied to both patient and general practitioner, might have been useful in this case.

We are grateful to those who have provided the material for these reports. 

The online reporting form is on our website, coress.org.uk, which also includes previous feedback reports. 

CORESS is an independent charity supported by AXA Health.

Published cases will be acknowledged by a Certificate of Contribution, which may be included in the contributor’s record of continuing professional development.