Senator SPECTER. Our third panel is Judge Joseph Donahey and Dr. Ralph Specken. Judge Donahey is a Circuit Court Judge for the Sixth Judicial Circuit in Florida since 1995. He is a former crimi- nal defense attorney. He spent 38 years in the justice system as a lawyer and judge. He is a member of the Florida, American and Federal Bar Associations. The introduction says: Although a true Floridian, Judge Donahey was born in State College, Pennsylvania, where his father started a strip coal mining business.
Judge Donahey, I think that this is undue editorial license for my staff to call you a true Floridian, when I would say you are a true Pennsylvanian. The place of birth governs. You can dissent from that, but that may be the official committee view.
Judge DONAHEY. Senator, I bleed blue and white when Penn State plays.
Senator SPECTER. I am glad you made my point so effectively. Would you introduce the beautiful woman to your left? And I am looking forward to your testimony.
Judge DONAHEY. Yes, sir, this is my wife Tina, who is in fact a true Floridian.
Senator SPECTER. Okay, 50/50. That is not too bad.
Thank you very much for joining us, Judge, and we look forward to your testimony.
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Judge DONAHEY. Thank you, sir. Very simply, or as simply as I can make it. On January the 11th, 1999, I was fully sighted. I went in as a patient to Tampa General Hospital for lower back sur- gery. I had disks virtually gone between L–2–3, 3–4, 4–5, L–5 and S–1. It was major surgery. I had done quite a bit of time checking out, trying to find out where to go.
I had been referred by one of my former law partner’s husband, who was a physician in Clearwater, to a neurosurgeon with a won- derful reputation, who refused to touch me, referred me to another neurosurgeon at Tampa General Hospital with a reputation for having just magnificent hands and wonderful technique and who could solve my problem, if anybody could. I went to see him. I con- sulted with him. I was assured that he felt they could deal with the problem, that they could resolve it, and that I could get back to going back on the tennis court and doing things that I enjoyed doing physically, like chopping wood at my cabin in North Caro- lina, et cetera.
Very confident. I was very pleased. And I went into surgery again January the 11th, fully sighted. Ten hours, I came out blind. Never had I ever heard from anybody anywhere that loss of vision was a potential side effect or a potential result of such surgery.
In the informed consent that preceded the surgery I was told that I could die. I was told that I might end up a paraplegic. I was told that I might have drop-foot in my left leg or something like that. These things rarely occurred, but never, ever a mention of loss of vision.
I emphasize that because post-surgery I learned that in fact this physician had had this similar result three times prior to mine. One of those results was just within 30 to 40 days prior to my sur- gery. In fact, the day I consulted with him and he was giving me— predicting prospectively what was going to occur, I have since learned that he had a meeting with his last patient, who suffered an impairment of vision from surgery a month before.
Obviously, when the anesthesiologist and I came out of the anes- thesia were saying, how many fingers do I have up, and I could not see fingers, it was quite an experience.
Several things that I think are important to what you are doing here today. No. 1, this doctor did not inform me that he had had these results in three cases before. And by the way, my loss of vi- sion is bilateral, both eyes—his previous three cases were only loss of vision in one eye, which they seem to feel was far less signifi- cant. I was not told that they had had that result. I have since learned that risk management at Tampa General Hospital did not know that he had had these results.
Now, he is the lead neurosurgeon on that hospital staff, and yet risk management/quality assurance assures me that they have never heard of these results at their hospital before. And we know that that simply is not true.
Post-surgery I have learned some other interesting things. The first is that he did not perform my surgery. And I went to him be- cause of the buildup and the recommendation and because of the assurances he gave me personally of how he developed the tech- nique, of how he has trained other physicians around the country to do this rather unique surgery, but that he felt it could be done.
As it turns out, he did not do it. It was a resident who performed the surgery. He was supervising.
The interesting part of it is that he was not supervising just my surgery, but he was supervising surgery in an adjoining surgical suite. He was floating back and forth between the two.
In this type of surgery, with the length of the surgery—and by the way, he told me that the surgery would last from 5 to 6 hours. His physician’s assistant told me that the surgery, the actual sur- gery, would only last about 4 and a half hours. The other hour or so that he talked about was with the anesthesia, preparation and coming out of the anesthesia. The surgery actually lasted 10 hours. My suggestion would, or my suspicion would be, that the fact that he did not do it himself but had a resident do it and the fact that he was floating back and forth, supervising two suites, may well have lengthened the procedure. That is very important be- cause my loss of vision is directly attributable to their failure to maintain the oxygen and red blood cell level during the course of the surgery, depriving my optic nerves of oxygen, resulting in the neuropathy and the loss of vision.
Were there warning signals? Yes, absolutely. We have now had this situation reviewed. Warning signals, there were big flags wav- ing everywhere. I now know that when they initially administered the anesthesia that my blood pressure dropped dramatically. They did nothing. The anesthesia was not being administered by the an- esthesiologist that I was told would be doing it, but by a resident. So the anesthesiologist was floating back and forth between the same two surgical suites. It turns out that the resident surgeon and the resident anesthesiologist apparently did not know what to do. I do not know whether they were cowered by the fact that they had these sages that were supervising them, that they did not want to approach them, they did not want to tell them.
I do not know what caused them to not react as they should have, but they did not. And as a consequence, after I was strapped in, the blood pressure had recovered. When they flipped me over, the blood pressure dropped again. All during this time the red blood cell count—or when the surgery started, I started losing blood.
By the way, I had provided two pints of my own blood for them to give me the transfusions during the course of the surgery if it became necessary. I was assured that it would not, but if it became necessary. As it turned out, they did not give me the blood during the surgery even though the blood cell count went below acceptable levels. They did not give it to me until post-surgery, when they found out I was blind.
I sat here and I listened to this testimony about reporting and whether it should be reported and whether or not it should be iden- tified. Let me assure you, Senator, I have had my wife in Roch- ester, Minnesota, at Mayo for surgery. I was seeking the best place to go to get my surgery done. It was complex. I knew that. It was difficult. I would not have hesitated for a moment to go to Roch- ester or to Duke or to a number of other places—all of which were available to me. I chose this doctor and this facility because of what I was told and, as it turns out, because of what I was not told.
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And what I was not told was that this physician, this surgeon, had had three cases of vision impairment in the 18 months pre- ceding my surgery.
Senator SPECTER. Well, Judge Donahey, thank you for sharing your experience with us. It was a very poignant and unfortunate story.
Before asking any questions, I just want to turn to Dr. Specken. But I would be interested to know what your status now is with respect to your eyesight.
Judge DONAHEY. I cannot see. Senator SPECTER. You cannot see.
Judge DONAHEY. There is a bright light up here. And there is an- other one over here. I every now and then get just a bit of form of where you are. I think you are right there.
Senator SPECTER. Well, you appear to have eye contact, but that is deceptive from my view, not from yours.
Judge DONAHEY. I do that in the courtroom. I try to follow voices. Senator SPECTER. What is the prognosis?
Judge DONAHEY. This is it.