Inadequate anticoagulation plays role in misconduct ruling against cardiologist

Failure to provide adequate anticoagulation during a fatal angioplasty procedure was a factor in a professional misconduct finding delivered against a high profile cardiologist.

Former AMA president Dr Keith Woollard has been involved in a long-running legal battle with the Medical Board of Australia over the 2005 death of journalist John Brown, who suffered occlusion of the left main coronary artery following angioplasty at Mount Hospital in Perth in 2005.

In August, the State Administrative Tribunal in Western Australia found five of six allegations brought against Dr Woollard by the board proven, including his failure to use a high enough dose of heparin before the procedure in the patient who was at high risk of occlusion due to a complex lesion in the left coronary artery.

The tribunal was told Dr Woollard lacked the training and experience needed to perform angioplasties without supervision, but had made false representations to hospital bosses in order to gain the accreditation to do so.

Ahead of surgery, Dr Woollard ordered the patient have 5000 units of heparin, with a repeated dose 30 minutes later.

This was lower than the weight-based dose of 5250 units recommended in guidelines at the time. The tribunal was told that the low dose of heparin used might have been justified if adequate anticoagulation had been confirmed by testing of the activated clotting time (ACT), something Dr Woollard failed to perform.

In his evidence, Dr Woollard claimed that a hospital protocol at the time advised a standard dose of 5000 units of heparin for every patient, administered twice without measuring clotting time.

But this protocol – which was not tendered in evidence – “would be dangerous” according to one interventional cardiologist who said it would be extraordinary as no one had ever suggested giving heparin irrespective of patient body weight.

Dr Woollard further claimed that the machine used to test ACT was not working on the day of the procedure.

But the test could have been performed in the hospital’s lab, and Dr Woollard’s failure to do the test before surgery “reflects a somewhat cavalier attitude” and lack of judgment, one expert witness told the tribunal.

“To be using a borderline dose of heparin in such a high-risk scenario is ­to me, is pushing the envelope unnecessarily,” US-based interventional cardiologist Dr Jonathon Marmur said in evidence.

All three cardiologists agreed that if there was no way to test ACT, an operator should administer an initial bolus dose of heparin “at the higher end of the range”.

The trio disagreed over the cause of Mr Brown’s death – two believed the occlusion was likely caused by guide catheter dissection or wire dissection, with inadequate anticoagulation playing a role, while the third blamed trauma from the guidewire and thrombosis, but not dissection.

In his finding on August 10, Justice Jeremy Curthoys said Dr Woollard’s failure to have regard to a patient’s weight and simply using a standard anticoagulant dose “shows a basic lack of understanding of heparin” and his performance of the angioplasty without administering sufficient heparin or an ACT machine or arrangements with the on­site pathology laboratory amounted to conduct “substantially below the standard reasonably expected of a registered medical practitioner of an equivalent level of training and experience”.

“It was not simply an error of judgment. Dr Woollard engaged in professional misconduct.”

Justice Curthoys also found Dr Woollard was not adequately trained or experienced in angioplasty to perform it unsupervised, and deliberately made false representations to gain accreditation so he could do so. He also failed to inform his patient about the risks of occlusion or offer referral to a cardiothoracic surgeon for consideration of a coronary artery bypass grafting procedure.

The tribunal concluded that five of the six allegations against Dr Woollard made by the Medical Board of Australia were made out, and that he was guilty of professional misconduct.

A decision on Dr Woollard’s penalty is pending.

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