Patient's Agony Ignored During Colonoscopy After Doctor Leaves Hearing Aids Behind
In a recent, dramatic case, an 84-year-old doctor failed to hear a patient's cries of pain during a routine colonoscopy, sparking a disciplinary response from the Florida Department of Health. The situation unraveled because the physician, Dr. Ishwari Prasad, was not wearing his hearing aid during the procedure, an oversight that had devastating consequences. As more details surface, the question remains: How could such a severe mishap occur?
Procedure Gone Wrong
On June 5, 2023, Dr. Ishwari Prasad, a gastroenterologist, performed two colonoscopies at the Ambulatory Surgery Center Tampa. Unfortunately, these procedures did not go as planned. According to reports from the Florida Department of Health, Prasad did not wear his hearing aid during at least one of the procedures, impairing his ability to hear vital communications from both his staff and the patient. The patient, identified as R.F., was reportedly not fully sedated before Dr. Prasad inserted the scope, causing the patient to scream in pain.
Despite the patient's apparent distress, Prasad did not stop the procedure, leading the medical board to conclude that he had fallen below the minimum standard of care.
A Pattern of Oversight
The medical board found more problems. During both procedures, Dr. Prasad improperly delegated medical tasks to a surgical technician who was not licensed to perform them. Such tasks, which may have included scope manipulation or removal of polyps, should have been completed by a trained physician. The Board's findings highlight that this breach of medical protocol further compromised patient safety, exacerbating the fallout from the initial sedation issue.
The patient's IV line failure during the second procedure made matters worse. Instead of addressing the problem when the patient expressed pain and when a hospital administrator in the room told him he had to wait, Dr. Prasad shouted, "I know," and continued manipulating the colonoscope, according to a report by the NY Post. This behavior raised concerns not only about his hearing impairment, but also about his clinical judgment during the incident.
Medical Board's Response
The Florida Board of Medicine responded decisively. In an order finalized on Aug. 7, 2023, Dr. Prasad was placed on probation and fined $7,500. In addition to financial penalties, he must reimburse the Department of Health $6,301 to cover the investigation costs. To continue practicing medicine, Dr. Prasad must undergo an evaluation of his clinical competency and have another physician supervise any future gastroenterology procedures.
The Broader Implications
This case underscores the importance of patient safety, especially regarding surgical procedures involving sedation. Dr. Prasad's inability to hear the patient's cries due to a missing hearing aid reveals how seemingly minor oversights can lead to significant patient harm. The combination of miscommunication, inappropriate delegation of tasks, and failure to stop when necessary paints a troubling picture of neglect and malpractice.
With Prasad facing ongoing scrutiny, the medical community may need to reassess how physicians with physical impairments are supported in the workplace to avoid similar incidents. The Florida Board of Medicine's swift action shows how seriously the institution takes the potential consequences of medical errors, mainly when they result in unnecessary patient suffering.
References: 84-year-old doctor doesn't notice colonoscopy patient screaming in pain because he wasn’t wearing hearing aid, medical board says | Florida doc, 84, couldn't hear colonoscopy patient screaming in agony because he wasn't wearing his hearing aids: complaint
