Posted by Bill Sandweg on 22 May 2023.
Over and over again, I have recommended that people considering surgery take a close look at the credentials of the surgeon, who is being considered for the operation. This is especially true in the case of plastic surgery. Any licensed doctor can hold himself or herself out as a plastic surgeon. Patients need to make sure their “plastic surgeon” has received training in plastic surgery and is not just claiming to be one. As I also point out, however, while making sure the doctor is properly trained and credentialed cannot guarantee that the patient won’t be the victim of medical malpractice, it does give the patient the best chance for a good outcome. Today’s case in point shows that even well-trained and properly credentialed doctors can harm patients when they get greedy and cut corners.
The patient was a healthy, 36 year old mother of two, who wanted a breast augmentation. She found the San Diego area surgeon on line. He was well-trained. He had gone to a good medical school and had participated in a general surgery residency before switching over to a plastic surgery residency at a very good hospital. He claimed to be board certified in plastic surgery. So far, so good. These are just the kind of credentials you want, if you are planning plastic surgery, although it later developed that he was lying about being board certified.
Plastic surgery is like the wild west. Anyone can claim to be a plastic surgeon and there is stiff competition for patients. Based on what happened, it appears the surgeon was trying to keep costs down so he could offer competitive prices while at the same time taking home a big paycheck.
There are a lot of risks associated with breast augmentation. It is usually performed under general anesthesia administered by an anesthesiologist or a certified nurse anesthetist (CRNA). While it is occasionally performed under what is called “conscious sedation,” administered by a Registered Nurse (RN), the nurse must be properly trained for the job. Proper training includes training on the medications to be used to sedate the patient, the risks associated with those medications, how to properly monitor the patient, and how to respond in the event of an emergency.
The surgeon performed the procedure at the surgery center he owned. He planned to perform the procedure under conscious sedation. He did not have either an anesthesiologist or a CRNA to administer the sedation. Instead, he used an RN nurse employee, who, despite being an RN, had not had the training needed to safely administer the sedation, which involved the administration of some very powerful drugs, including fentanyl. It is cheaper this way, but it increases the risk of a problem developing and, if it does, the RN is not well-equipped to either recognize it or deal with it.
Everything went well at first, but a little over an hour into the procedure, the patient’s oxygen saturations began to drop to dangerous levels and her heart rate rose as her body attempted to compensate for the low levels of oxygen in her blood. Her blood pressure dropped and her heart stopped. In the face of this emergency, the proper procedures are clear. First and foremost, before doing anything else, have someone call 911. There are a number of possible explanations for what is happening to the patient. Some the surgeon may be able to address at the surgery center but some may require the services only a hospital can provide. The patient needs to be taken as quickly as possible to a place where she can be fully evaluated and her problems addressed.
The surgeon did not call 911 and directed that no one else call either. He began CPR and got the automated external defibrillator (AED) that he kept in the building to try and shock the patient’s heart back into normal rhythm. He was finally able to get her heart going again and she began to breathe on her own but was not able to keep her oxygen saturations at acceptable levels. The surgeon and his staff had to keep pushing oxygen into her lungs to keep her saturations up. Unbeknownst to the surgeon, the patient had suffered a tension pneumothorax, a recognized risk of breast augmentation. A tension pneumothorax occurs when blood or fluid in the lung space prevents the lungs from fully inflating. The tension pneumothorax was the probable root cause of the low oxygen levels and the cardiac arrest. The patient needed more care than the surgeon and his staff could provide, but they did not know that.
Three hours passed before the surgeon finally called 911. During that time he called two anesthesiologists to discuss how to treat the patient. One offered to come over to help but the surgeon declined the offer. In neither case did he tell the anesthesiologists what was actually happening with the patient. When he finally called 911, he misrepresented the condition of the patient.
The patient was taken to a nearby hospital, where she died a little over a month later due to the effects of the brain injury she suffered during the surgery when her oxygen levels were too low for too long. The surgeon is facing criminal charges arising out of the death and the California Medical Board has restricted his license.
A well-trained doctor cut corners by having unqualified people deliver anesthesia and then panicked when the patient crashed. His panic was undoubtedly increased by his knowledge that the patient’s cardiac arrest was likely due to the unqualified people he was using to deliver anesthesia. You can check and double check a doctor’s credentials, but, sadly, you can never check their greed levels.