Tragic events have a way of stimulating bad legislation.

Co-conspirator in Plastic Surgery blogging, "Dr. 48307", Tony Youn had a very insightful retort a few weeks backto a bill ("the Donde West law") introduced in the California legislature (read here) to mandate medical clearance on all patients undergoing cosmetic surgery. Something similar is now being mentioned in Illinois. Dr Youn writes:

This is a very interesting bill, considering less than a year ago the California legislature passed a law permitting oral surgeons (DDS dentists) to perform all forms of facial plastic surgery. Instead of forcing surgeons to make their patients undergo preoperative testing (some young, healthy patients may not need it), maybe they should instead make sure that anyone performing plastic surgery is a real, board-certified plastic surgeon?

Keep in mind that California is also the state where a judge ruled in 2006 that a certificate from a non-recognized cosmetic surgery "board" organization was equivalent (or better!) to the American Board of Plastic Surgery for accreditation proposes over the objections of the state medical board for California, the American Medical Association (AMA), the American Society of Plastic Surgeons (ASPS), the American Board of Facial Plastic Surgery, the American Board of Medical Specialties (ABMS), and others. This ruling ignored the existing state law that allowed physicians to advertise board certification only if the certifying board or association is recognized by ABMS or deemed equivalent by the state medical board.

BACK TO THE "DONDE WEST" LAW

Broad non-directed medical screening by 3rd parties would be an extremely inefficient and unnecessarily expensive way to clear patients for surgery. Besides, this process already takes part as part of a patients' surgery evaluation. Now your doctor can be a tool, and adopt the blanket position that "I send all my patients for medical clearance before surgery", but that's just punting the ball and practicing defensive medicine to the extreme.

The scale we commonly use to characterize surgery patients' anesthesia risk, called the ASA system, is a pretty good screening tool. The overwhelming amount of patients undergoing cosmetic surgery are low risk, and ASA class I or II patients should not need "medical clearance". In addition, many primary care doctors have absolutely no idea what "medical clearance" means anyway, and get a little peeved when patients show up for non-reimbursable office visits.

When we talk about medical clearance, it's usually in the context of chronic medical issues or asking whether the patient needs provocative testing for coronary artery disease. Patients who may need to be "tuned up" prior to surgery are those with:

• diabetes - Are there blood sugars under control?


• significant hypertension


• morbid obesity


• sleep apnea


• symptoms of (or strong risk factors for) coronary disease

Many of those conditions might be exclusionary for elective cosmetic surgery in the first place, particularly when combined. Keep in mind that the patient involved in the event triggering this reactionary bill, Donde West's, had undergone coronary testing earlier in the year (which was reportedly normal) and died over 24 hours postop from what sounds like a probable aspiration event. No amount of screening would prevent something like that.

"Smart Laws" relating to cosmetic surgery seem to be a little more difficult to implement. A more practical way to address the whole issue of office based surgery procedures would be to standardize the accreditation of facilities and remove the loopholes in some states that still exist. My state, Alabama, for instance has set a timetable for requiring accreditation for office an ambulatory surgery centers (ASC) over the next 18 months. The ASPS already makes it a requirement for membership that you will pledge to only operate in accredited (or planned accredited) office facilities. A common sense regulatory step would be to require hospital privileges for any surgery you'd propose to do in your office requiring sedation or general anesthesia, which would have the de facto effect of an additional level of credentialing applied by hospital medical staff offices. It's so common sense that it will be violently opposed by many "cosmetic surgeons" who would see their ability to practice cut off at the knees. Something to think about!

Thanks again Tony for your wonderfully entertaining blog!

Rob

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The autopsy report on Ms. Donde West, mother of hip-hop star, Kayne West has been released. You can read it here. On November 9th, 2007 Ms. West underwent breast augmentation/mastopexy, belt-lipectomy ("around the world" tummy tuck), and liposuction of her trunk.

Her autopsy report noted that West had moderate coronary artery disease (CAD), with blockage between 50 to 70 percent in her right coronary and left circumflex arteries. The 5-foot-2-inch, 188-pound woman also was moderately overweight and had developed several complications after surgery, including fluid in her lung. The investigation found nothing unusually high in the level of her narcotics and no signs of internal bleeding, infection, or pulmonary emboli.

According to West's autopsy report, she underwent cosmetic surgery on Nov. 9 and went home that day, "even though she was advised that she receive postoperative care at another facility." (That advice in her record may become very important for Dr. Adams defense when this is investigated)

Her first day home she was walking around and appeared fine according to the interviews with some of her care takers . She did complain of pain as you'd expect from such a huge series of procedures. The next day she developed mild trouble breathing and was found in full arrest when left alone for a short period of time.

A separate report by a coroner's investigator said it couldn't be determined whether West underwent any type of pre-surgical screening before her plastic surgery. She apparently had a stress test in January 2007 after experiencing vague chest and shoulder pain, but those symptoms apparently never returned and she seemed to be on only modest medications.

I'm 100% convinced after reading her full autopsy report that the explanation is pretty simple. It is very likely that she vomited and aspirated and then went into respiratory arrest. You see this frequently in hospitals and nursing homes in older and younger patients. I'm not sure why her pathologist was obtuse in his language about this. I take that back.... I know exactly why he is so guarded! He knew this case was going to be scrutinized and probably later litigated. This is defensive medical language 101 to me in all honesty.

To me, Dr. Jan Adams comes off a little better with this information in hand. This wasn't a surgical complication at all per se, and she apparently did not have any evidence of a heart attack (read the autopsy description of the heart itself - it was normal). Even if he'd kept her overnight in the hospital (which I think most people might do for this), it still would not have prevented this as it happened well after 24 hours post op. You can argue the wisdom of such a complex set of procedures as an outpatient surgery on a nearly 60 year old overweight woman with borderline hypertension, but I'm not sure that she would have been medically excluded from surgery all together by her internist. (Remember, she apparently had a fairly unremarkable cardiac stress test earlier in the year that did not trigger further work-up with a cardiac cath study.)

It will be interesting how this plays out. I will be surprised if the logic I'm outlining is not exactly how this plays out in front of the California Medial Board review of this episode.

Rob

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