Lawsuit: Florida surgeon removed woman’s kidney by mistake during back surgery

Pacheco, a West Palm Beach resident, was 51 years old and suffering from back pain due to a car crash when she was scheduled to undergo anterior lumbar interbody fusion surgery in April 2016, the October 2017 lawsuit said. The surgery, which took place at Wellington Regional Medical Center, is described by the American Academy of Orthopaedic Surgeons as a "welding process," in which problematic vertebrae in a person's spine are fused together into one larger bone.

The term anterior meant that doctors would go in from Pacheco's abdomen instead of her back. The academy explains on its website that an anterior procedure allows more direct access to the discs between the vertebrae, which are removed during the procedure, and offers a quicker recovery time.

Surgeons are also able to access the spine without moving nerves out of the way, but they have to move organs and blood vessels to the side to reach the spine, the website says.

Pacheco told WPTV in West Palm Beach there were no signs of what would go wrong when she prepared for the operation.

"There was no red flags or anything," Pacheco told the news station.

Pacheco’s orthopedic surgeons that day were Dr. John Britt and Dr. Jeffrey Kugler, who was the treating physician. Vazquez, a general surgeon with staff privileges at the hospital, was assigned with opening the patient up and providing access to the surgical site so the other doctors could perform the fusion.

An administrative complaint against Vazquez filed with the state medical board by Florida Department of Health officials -- the outcome of which is still pending -- described what happened next.

"During the surgical procedure, (Vazquez) noted a pelvic mass and provided a presumptive diagnosis of a gynecologic malignancy, lymphoma and/or other metastatic disease," the December 2017 complaint stated. "The pelvic mass was clipped, transected and removed in its entirety."

A few days later, a hospital pathologist discovered that the mass was not cancer -- it was Pacheco’s left kidney.

It turned out that Pacheco had a “pelvic kidney,” which occurs when a person’s kidney does not ascend like it should as the organs develop in utero. The kidney remains in the pelvis instead of settling in the flank.

Read the administrative complaint against Dr. Ramon Vazquez below.

Pacheco’s lawyers argued in the lawsuit that Vazquez was provided with MRI images taken of their client’s spine in February 2015 and February 2016. The images showed that Pacheco had a pelvic kidney.

The MRIs also showed that the kidney was functional, the document said.

"If he would have looked at the MRIs that were given to him, he would've realized it," Pacheco told WPTV.

Vazquez never confirmed what was on the images or discussed the images with Kugler and Britt before removing Pacheco's kidney, according to the lawsuit. He also failed to biopsy the "mass" before deciding to remove it, the health department complaint stated.

Pacheco was not consulted about the removal or given options for treatment of what Vazquez thought he found, the lawsuit said.

The lawsuit stated that Kugler and Britt were negligent because they failed to exhaust all “conservative pain management options” before recommending surgery, and that they should have confirmed that Vazquez consulted with Pacheco and looked at the MRIs before opening her up.

The doctors also failed to ensure that Vazquez knew she had a pelvic kidney prior to surgery, the lawsuit said.

The Palm Beach Post reported that the medical malpractice insurers for Kugler and Britt settled the case for $250,000 per doctor.

Wellington Regional revoked Vazquez's privileges following the incident. Hospital officials told WPTV that all necessary and appropriate steps were taken to ensure it did not happen again.

"In the 30-year history of Wellington Regional Medical Center, an incident of his nature has never occurred, before or since," a hospital statement read.

Vazquez's attorney, Mike Mittelmark, told the Post his client did not admit wrongdoing in settling with Pacheco.

"The case was settled on his behalf for a nominal amount due to the uncertainty of litigation and in no way did Dr. Vazquez admit liability by agreeing to this settlement," Mittelmark told the newspaper.

Read the entire lawsuit filed by Maureen Pacheco below.

Florida law subjects a doctor to discipline for performing or trying to perform a procedure on the wrong patient, a procedure at the wrong site, a wrong procedure or an unauthorized procedure that is medically unnecessary or otherwise unrelated to the patient's diagnosis or condition. That includes while preparing the patient, the health department's complaint stated.

“Respondent performed a medically unnecessary procedure on (Pacheco) by removing a pelvic kidney during a lumbar fusion,” the complaint said.

The recommendation of Florida Surgeon General Celeste Philip was for Vazquez to suffer permanent revocation or suspension of his license, restriction of practice, imposition of a fine, a reprimand, probation, corrective action, refund of fees collected, remedial education "and/or any other relief the board deems appropriate."

Pacheco’s attorney, Donald Ward III, said he didn’t expect Vazquez to lose his medical license over what happened.

"It's unlikely that he would lose his license over something like this," Ward told WPTV. "What is most likely is that he would face a fine and possibly be required to do some continuing medical education so that he could learn not to make the same mistake in the future."

There were some oddities about the case, however, on top of Pacheco losing a healthy kidney.

"What is not common is for you to meet that general surgeon the morning of (surgery) and be told that if something were to happen to you, that general surgeon doesn't carry any health insurance whatsoever," Ward said.

Vazquez did not have malpractice insurance, which means if he is fined by the state, the fine will have to be paid out of the doctor’s own pocket, the lawyer said.

Pacheco said she harbors “no ill will” against Vazquez.

"Everyone is entitled to their livelihood, but you should have consequences when gross mistakes and negligence are made," she told the news station. "I just wish that he learns a lesson from the consequences. It's always in the back of my mind -- lifelong kidney transplant or dialysis.

“Now I’m always fearful.”