Failure to ensure appropriate postoperative care
A 48-year-old man came to Plastic Surgeon A to discuss treatment for excess fat and skin following a 71-pound weight loss. The patient was 6’4” and weighed 258 pounds.
Failure to ensure appropriate postoperative care
A 48-year-old man came to Plastic Surgeon A to discuss treatment for excess fat and skin following a 71-pound weight loss. The patient was 6’4” and weighed 258 pounds.
Presentation
A 48-year-old man came to Plastic Surgeon A to discuss treatment for excess fat and skin following a 71-pound weight loss. The patient was 6’4” and weighed 258 pounds.
Physician action
Plastic Surgeon A examined the patient and found that he had excess abdominal skin circumferentially, diastasis, and some lipodystrophy. He determined the patient would be a good candidate for SAFELipo.
The patient was scheduled for an abdominoplasty and liposuction of the chest, back, and flank. The patient’s measurements were taken for postoperative compression garments, and he was given preoperative instructions.
As an alternative to going home after the surgery, the patient was told he had the option to stay at a private postoperative recovery center for an additional cost. The patient chose to stay at the recovery center and paid the fee. (While not a medical facility, the recovery center was set up to provide a “luxury level of comfort” for patients recovering after cosmetic surgery.)
The patient came to the outpatient surgery center as scheduled on April 30. The preoperative anesthesia evaluation was positive for tobacco (chewing tobacco daily for 20 years); positive for snoring; and positive for alcohol use. Plastic Surgeon A performed the abdominoplasty and liposuction, in a procedure that began at 8:03 a.m. and ended at 12:40 p.m. The patient received 2,000 ml of IV fluid during the surgery and his urine output was 500 ml.
Plastic Surgeon A documented that the surgery went well, and that he removed more than five pounds of skin and fat. At 1:20 p.m., Plastic Surgeon A discharged the patient to the recovery center for two days and then to home.
While at the recovery center, the patient’s blood pressure dropped to 96/60 mm Hg at 9 p.m. He was diaphoretic and pale. Plastic Surgeon A was contacted via text and responded that the patient had plenty of urine during surgery, but they could insert a catheter to help the patient urinate if needed. If the patient did not have urine output with a catheter or if there were any other problems, the patient should be sent to the ED.
At 11:20 p.m., Plastic Surgeon A was told that the patient had voided 200 cc of dark amber urine. Plastic Surgeon A responded that he would be at the recovery center at 8 a.m. The patient tried to urinate at 4 a.m. and 7 a.m., but was unsuccessful. A catheter placed at 7:20 a.m. yielded 30 ml of urine. The patient’s blood pressure was 110/86 mm Hg with a heart rate at 120. The patient reported feeling faint and was pale and clammy.
Plastic Surgeon A arrived at the recovery center at 8 a.m. He placed a foley catheter, examined the patient’s abdomen and found bloody fluid leaking from the surgical site near the naval. Plastic Surgeon A decided to admit the patient to Hospital A. EMS arrived at 9:18 a.m., and started the patient on IV fluids and oxygen. This raised his Sp02 from the 80s to the 90s.
When he arrived at Hospital A, the patient’s blood pressure was 111/61 mm Hg; heart rate was 110 bpm; and temperature was 97.5 degrees. He had scrotal swelling and bruising. Lab work revealed WBC of 24.99; hemoglobin 10.6; hematocrit 31.5; lactic acid 5.7; creatinine 2.9; albumin 2.8; glucose 130; and BUN 25.
Emergency Medicine Physician A diagnosed acute renal failure with oliguria, lactic acidosis, leukocytosis, and hypokalemia. The patient was given fluids and blood and was admitted under the care of Hospitalist A. Plastic Surgeon A continued to monitor him.
On May 9, Plastic Surgeon A took the patient to the OR to evacuate an abdominal hematoma. He also performed debridement procedures on May 10, 13, and 14. Fluid cultures were negative, though the patient had fever and a high white blood cell count. On May 13, the patient was given 3 units of red blood cells. A wound vac was placed during the final debridement procedure.
The patient was transferred to Hospital B for a higher level of care on May 15. His admitting diagnoses were cellulitis/surgical site infection, severe protein malnutrition, complex abdominal wall infection, and penoscrotal edema with cellulitis. There was concern that the patient had Fournier’s gangrene.
During the patient’s stay at Hospital B, Plastic Surgeon B performed three debridement procedures. On June 1, the patient was discharged to a long-term acute care hospital for treatment of necrotizing fasciitis and Fournier’s gangrene.
Allegations
A lawsuit was filed against Plastic Surgeon A and the recovery center. The allegations against Plastic Surgeon A were failure to ensure the patient was discharged to a facility with trained staff who could recognize and treat hypovolemic shock and failure to evaluate the patient the evening of April 30.
Legal implications
According to the plaintiff’s plastic surgery expert, Plastic Surgeon A fell below the standard of care when he sent the patient to a recovery center whose staff were not trained, experienced, or equipped to treat the patient for hypovolemic shock. This expert claimed that by the time the patient was administered fluids at Hospital A it was too late to reverse the tissue death around the surgical site. The tissue became infected, which led to the development of necrotizing fasciitis and Fournier’s gangrene.
The plaintiff’s expert further criticized Plastic Surgeon A for not evaluating the patient in person when he was told about the patient’s symptoms at 9 p.m. on April 30. According to this expert, if the patient had received IV fluids at 9:30 p.m., the hypovolemic shock would have been reversed and the patient would not have experienced kidney failure, hyperkalemia, hematoma, and tissue death in his abdomen.
Plastic surgeons who reviewed this case for the defense were not supportive of the defendant’s actions. Plastic Surgeon A performed an extensive procedure on the patient — removing more than five pounds of tissue and fat — in an outpatient facility followed by transfer to a non-medical facility. The recovery center did not have the ability to give IV fluids or to closely follow the patient’s urine output.
Two reviewers stated that the abdominal binder likely contributed to the complications that arose after surgery. Because the binder was tight around the patient’s abdomen, it allowed the bleeding, swelling, and hematoma to go unnoticed. If the patient had been at a facility with a higher level of care, these issues might have been evaluated and addressed sooner.
Disposition
This case was settled on behalf of Plastic Surgeon A. The case against the recovery center was also settled.
Risk management for plastic surgeons
Disclaimer
Presentation
A 48-year-old man came to Plastic Surgeon A to discuss treatment for excess fat and skin following a 71-pound weight loss. The patient was 6’4” and weighed 258 pounds.
Physician action
Plastic Surgeon A examined the patient and found that he had excess abdominal skin circumferentially, diastasis, and some lipodystrophy. He determined the patient would be a good candidate for SAFELipo.
The patient was scheduled for an abdominoplasty and liposuction of the chest, back, and flank. The patient’s measurements were taken for postoperative compression garments, and he was given preoperative instructions.
As an alternative to going home after the surgery, the patient was told he had the option to stay at a private postoperative recovery center for an additional cost. The patient chose to stay at the recovery center and paid the fee. (While not a medical facility, the recovery center was set up to provide a “luxury level of comfort” for patients recovering after cosmetic surgery.)
The patient came to the outpatient surgery center as scheduled on April 30. The preoperative anesthesia evaluation was positive for tobacco (chewing tobacco daily for 20 years); positive for snoring; and positive for alcohol use. Plastic Surgeon A performed the abdominoplasty and liposuction, in a procedure that began at 8:03 a.m. and ended at 12:40 p.m. The patient received 2,000 ml of IV fluid during the surgery and his urine output was 500 ml.
Plastic Surgeon A documented that the surgery went well, and that he removed more than five pounds of skin and fat. At 1:20 p.m., Plastic Surgeon A discharged the patient to the recovery center for two days and then to home.
While at the recovery center, the patient’s blood pressure dropped to 96/60 mm Hg at 9 p.m. He was diaphoretic and pale. Plastic Surgeon A was contacted via text and responded that the patient had plenty of urine during surgery, but they could insert a catheter to help the patient urinate if needed. If the patient did not have urine output with a catheter or if there were any other problems, the patient should be sent to the ED.
At 11:20 p.m., Plastic Surgeon A was told that the patient had voided 200 cc of dark amber urine. Plastic Surgeon A responded that he would be at the recovery center at 8 a.m. The patient tried to urinate at 4 a.m. and 7 a.m., but was unsuccessful. A catheter placed at 7:20 a.m. yielded 30 ml of urine. The patient’s blood pressure was 110/86 mm Hg with a heart rate at 120. The patient reported feeling faint and was pale and clammy.
Plastic Surgeon A arrived at the recovery center at 8 a.m. He placed a foley catheter, examined the patient’s abdomen and found bloody fluid leaking from the surgical site near the naval. Plastic Surgeon A decided to admit the patient to Hospital A. EMS arrived at 9:18 a.m., and started the patient on IV fluids and oxygen. This raised his Sp02 from the 80s to the 90s.
When he arrived at Hospital A, the patient’s blood pressure was 111/61 mm Hg; heart rate was 110 bpm; and temperature was 97.5 degrees. He had scrotal swelling and bruising. Lab work revealed WBC of 24.99; hemoglobin 10.6; hematocrit 31.5; lactic acid 5.7; creatinine 2.9; albumin 2.8; glucose 130; and BUN 25.
Emergency Medicine Physician A diagnosed acute renal failure with oliguria, lactic acidosis, leukocytosis, and hypokalemia. The patient was given fluids and blood and was admitted under the care of Hospitalist A. Plastic Surgeon A continued to monitor him.
On May 9, Plastic Surgeon A took the patient to the OR to evacuate an abdominal hematoma. He also performed debridement procedures on May 10, 13, and 14. Fluid cultures were negative, though the patient had fever and a high white blood cell count. On May 13, the patient was given 3 units of red blood cells. A wound vac was placed during the final debridement procedure.
The patient was transferred to Hospital B for a higher level of care on May 15. His admitting diagnoses were cellulitis/surgical site infection, severe protein malnutrition, complex abdominal wall infection, and penoscrotal edema with cellulitis. There was concern that the patient had Fournier’s gangrene.
During the patient’s stay at Hospital B, Plastic Surgeon B performed three debridement procedures. On June 1, the patient was discharged to a long-term acute care hospital for treatment of necrotizing fasciitis and Fournier’s gangrene.
Allegations
A lawsuit was filed against Plastic Surgeon A and the recovery center. The allegations against Plastic Surgeon A were failure to ensure the patient was discharged to a facility with trained staff who could recognize and treat hypovolemic shock and failure to evaluate the patient the evening of April 30.
Legal implications
According to the plaintiff’s plastic surgery expert, Plastic Surgeon A fell below the standard of care when he sent the patient to a recovery center whose staff were not trained, experienced, or equipped to treat the patient for hypovolemic shock. This expert claimed that by the time the patient was administered fluids at Hospital A it was too late to reverse the tissue death around the surgical site. The tissue became infected, which led to the development of necrotizing fasciitis and Fournier’s gangrene.
The plaintiff’s expert further criticized Plastic Surgeon A for not evaluating the patient in person when he was told about the patient’s symptoms at 9 p.m. on April 30. According to this expert, if the patient had received IV fluids at 9:30 p.m., the hypovolemic shock would have been reversed and the patient would not have experienced kidney failure, hyperkalemia, hematoma, and tissue death in his abdomen.
Plastic surgeons who reviewed this case for the defense were not supportive of the defendant’s actions. Plastic Surgeon A performed an extensive procedure on the patient — removing more than five pounds of tissue and fat — in an outpatient facility followed by transfer to a non-medical facility. The recovery center did not have the ability to give IV fluids or to closely follow the patient’s urine output.
Two reviewers stated that the abdominal binder likely contributed to the complications that arose after surgery. Because the binder was tight around the patient’s abdomen, it allowed the bleeding, swelling, and hematoma to go unnoticed. If the patient had been at a facility with a higher level of care, these issues might have been evaluated and addressed sooner.
Disposition
This case was settled on behalf of Plastic Surgeon A. The case against the recovery center was also settled.
Risk management for plastic surgeons
Disclaimer
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