Florida Liposuction Death?

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.


I was going to wait until the autopsy came back to comment on this news article, but there are points to be made even now.
First, it isn’t known if the death was due to liposuction. 
This December 30th Palm Beach Post article gives the basics and that is all:   South Florida woman, 35, dies getting plastic surgery (bold highlights are mine).

Lidvian Zelaya's New Year's resolution for 2011 was to "look good," so she went to Strax Rejuvenation Center in Lauderhill on Monday to have fat liposuctioned from her waist and added to her buttocks, her husband, Osvaldo Vargas, said.

Three hours later, Vargas said, his wife was rushed to emergency facilities at a nearby medical center. When he arrived there, he was told she had died. She was 35. 

Vargas and his attorney, Spencer Aronfeld of Coral Gables, said they were not sure what doctor performed the procedure nor whether the procedure had started when the medical problems began.

It troubles me that the husband isn’t sure who performed the procedure.  It wasn’t a training hospital, but a private clinic (Strax Rejuvenation Center).  Perhaps it is reports like this one  and this one which has caused a loss of trust in physician integrity.

It troubles me that the husband wasn’t sure the procedure had even started when the medical problems began.  As difficult as it would have been, didn’t Lidvian’s surgeon (reported elsewhere to have seen Dr. Roger L. Gordon in consultation)  sit down and talk with the family?

He may not have done anything wrong.  It may turn out she had an allergic reaction to a medication or malignant hyperthermia or ….

Or perhaps Dr. Gordon did talk to the family, but the grief stricken husband didn’t hear or process it.

This also troubles me, as I know it will Dino Doc who has written on clearing patients for surgery.

From the ABC News article on January 3, 2011:  Did Florida Woman's New Year's Resolution Costs Her Life?  Cosmetic Surgery Gone Wrong Has Family Wondering What Happened 

According to the family, Zelaya was in perfect medical condition, and the clinic cleared her through a pre-operative screening. Now, the family is urging anyone considering cosmetic surgery to undergo a second, pre-surgical health evaluation by an independent primary care physician.

"I think it's an inherent conflict of interest if you are getting screened by the surgeon who wants to do the procedure," said Aronfeld.

Dino Doc that says a lot about why you are increasing asked to do pre-surgery clearances.


Related posts:
Know Your Surgeon (November 3, 2010)
Liposuction – Shaping not Weight-loss  (February 8, 2010)
Liposuction Overview  (October 6, 2010)
Major and Lethal Complications of Liposuction -- An Article Review  (July 16, 2008)

Shout Outs

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Dr. Rob,  Musings of a Distractible Mind, is this week's host of Grand Rounds.   It is the Groundhog Day edition. You can read this week’s edition here (photo credit).

It happens every year.

I try to get a little shut-eye, but then these guys in hats come around and yank me out of bed.  They proceed to parade me around a huge throng of people (most of whom are not wearing hats), obsessing about the presence or absence of stratus clouds.

What a strange group of people.  I seem to be the center of attention for the day, though, and that’s not all bad.  It’s my day on February 2nd, and nobody has ever taken that from me.

Until this year.

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Have you seen the National Library of Medicine’s exhibit “Changing Faces of Medicine”?  One of the physician’s mentioned on the site as a “local legend” is Dr Betty Lowe (photo credit) who was head of the department of pediatrics at Arkansas Children’s Hospital when I was a medical student.

“I like science; the idea of doing something that isn't always the same. And life as a pediatrician is definitely unpredictable!”

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From Peter Lipson, White Coat Underground:   Why you should read The Immortal Life of Henrietta Lacks (photo credit)

This is a special shout out to the doctors and scientists out there. Everything we do in our fields has repercussions, often unexpected ones. Because of this, we strive to practice ethically to help prevent or minimize negative repercussions.

This discussion comes up specifically as an epiphenomenon of the release of The Immortal Life of Henrietta Lacks (my full review can be found here.) How one reacts to this book would, I suppose, depend on your perspective. A neighbor of the Lacks's might react quite differently than a 22 year old doctoral student. And that's really the point.

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Voting continues at MedGadget for the medical blog awards. Polls will close 12 midnight on Sunday, February 14, 2010 (EST).  Vote here. 

The categories for this year's awards are:

-- Best Medical Weblog
-- Best New Medical Weblog (established in 2009)
-- Best Literary Medical Weblog
-- Best Clinical Sciences Weblog
-- Best Health Policies/Ethics Weblog
-- Best Medical Technologies/Informatics Weblog
-- Best Patient's Blog

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The need for help to Haiti continues. Anyone wishing to donate or provide assistance in Haiti is asked to contact the Center for International Disaster Information. Here is a list of organizations who need your help in providing care to Haiti:

• Clinton Foundation -- Donate online or Text "HAITI" to 20222 and $10 will be donated to relief efforts, charged to your cell phone bill.
• American Red Cross International Response Fund – Donate
• Doctors Without Borders
• The International Rescue Committee
• International Medical Corps
• Mercy Corps Haiti Earthquake Fund (1-888-256-1900)
• Partners in Health
• UNICEF (1-800-4UNICEF)
• UN World Food Program
• National Disaster Search Dog Foundation (SDF)
• The International Fund for Animal Welfare (IFAW)

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If you are a physician and would like to do volunteer work in Haiti, then check this out:  Help Haiti: AMA registers physician volunteers

The registry -- launched Jan. 26 -- is open to all licensed doctors and requests information such as specialty, language skills, availability and previous disaster medicine experience.

The registry is available online (www.ama-assn.org/go/haiti-volunteer).

An in-depth Webinar on how medical responders can prepare for working in Haiti is available, along with other resources, at the AMA Web site (www.ama-assn.org/go/haiti-earthquake).

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H/T to @NHPCO_news  Noted researcher Joan Teno MD shares her family's hospice experience on public radio's "This I Believe" http://www.wrni.org/content/hospice.  It is an interesting listen.

Death.  It's not a pleasant subject, of course, yet all of us know of its inevitability, in our own lives and those of the people we love.  Sadly, for many the end of life is filled with a toxic mix of pain, suffering, and an agonizing loss of control.  But, as Dr. Joan Teno notes, life does not have to end this way.  Indeed, we know better.

Dr. Joan Teno is the daughter of Doris Teno, who died on October 15, 2008.  She is professor of community health at The Warren Alpert School of Medicine of Brown University and Associate Medical Director of Home and Hospice Care of Rhode Island.

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From Threads comes this article, Create Intricate Fabric With Pin Weaving, which gives clear instructions on the technique.  I’ll be adding it to my list of things to try someday, especially now that I have more leftover yarns as I am knitting more.

Pin weaving doesn’t require much equipment; you only need a padded board for a base that will act as your “loom.” The pin-woven fabric is formed over a piece of fusible interfacing. Once you are happy with your design, iron it to the fusible interfacing to hold everything together.  The result is a soft, pliable and beautifully textured fabric.
…….Pin weaving is the perfect on-the-go craft for sewers looking to use up scraps from their stashes.

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Dr Anonymous is back this week with Dean Brandon from Pediatric Dentistry blog.  Come join us.

Upcoming Dr. A Shows (9pm ET)
2/11 : Drew Griffin from Wound Care Education Institute
2/18 : Rhett and John from FireFighter Netcast

When Does Death Start?

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

H/T to @ctsinclair and @doclake  for the link to this December 16th NY Times article.  If you haven’t read it, it is worth the time, especially if you have any interest in this topic.

When does death start? from NYT http://bit.ly/8xGXjL

The article, "When does death start?",  was written by Darshak Sanghavi, the chief of pediatric cardiology at the University of Massachusetts Medical School, is Slate’s health care columnist and the author of “A Map of the Child: A Pediatrician’s Tour of the Body.”

The article uses the story of Amanda to discuss “brain death” and “death after cardiac arrest”  in conjunction with organ procurement.   No organs can be procured until a person has been declared dead (the so-called dead-donor rule). 

The question of “when does death start?” comes from the 5 minute of no heart activity after cardiac arrest.

In procuring organs from patients like Amanda, doctors have created a new class of potential organ donors who are not dead but dying. By arbitrarily drawing a line between death and life — five minutes after the heart stops — they have raised difficult ethical questions. Are they merely acknowledging death or hastening it in their zeal to save others’ lives?

The article takes the reader through the history of transplantation and the need to define “when death starts.”

Henry Beecher, a Harvard anesthesiologist and medical ethicist, convened a 13-member committee to write a definition of “irreversible coma,” or brain death, for The Journal of the American Medical Association.

President Jimmy Carter asked a blue-ribbon commission to examine the issue. The commission culminated in the Uniform Determination of Death Act in 1981, which defined death as “irreversible cessation of all functions of the entire brain, including the brainstem.”

The 1981 Uniform Determination of Death Act also defines death as the “irreversible cessation of circulatory and respiratory functions,” which left an opening for another source of donors.

In 1987, the nation’s pediatrics authorities tried to standardize the diagnosis, listing 14 different criteria to confirm brain death, like the absence of reflexes, and requiring, under certain conditions, additional X-rays and tests for brain-wave activity.

In 1997, the federal government asked the Institute of Medicine, an independent advisory body, to gather experts to determine how a dying donor might be treated. The experts ended up endorsing the procedure for donation after cardiac death, in which death occurs through a process of withdrawing life support and allowing the heart to develop “irreversible cessation.”

In 2004, pediatric cardiologist Mark Boucek at Denver Children’s Hospital, financed by a federal grant,  wrote a far more aggressive D.C.D. protocol that would save the heart, which was adopted after going through the hospital’s review process. His version …..most controversially, rejected the five-minute rule imposed by the Institute of Medicine and initially picked three minutes instead.

David Campbell, the pediatric cardiac surgeon at Denver who procured the first heart using the (Boucek) protocol, realized that even three minutes was too long. ….. In reviewing the medical literature, Boucek found the longest recorded time that a heart had ever stopped and then spontaneously restarted without medical intervention was 65 seconds.

The article goes on to discuss the current needs for organ donation.  It is estimated that at least 18 people on the transplantation list die each day before the needed organ becomes available.  This need makes the need for an answer to the question of “when does death start?’ extremely important.  The answer could increase the availability of viable organs.

The Institute of Medicine created a new class of potential organ donors: living patients with little hope of recovery who could be declared dead soon after life-support removal. Within a decade, the number of such donors increased tenfold; they now account for 8 percent of organ transplants nationwide, up to 20 percent in certain areas. Still, many hospitals were slow to adopt the practice.

Suicides and Our Soldiers

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

This topic has become more real for my family. My first cousin’s son-in-law committed suicide this past weekend. He had had difficulty adjusting since his return from Iraq, but the family was still caught off-guard. If you can make it any worse, he chose his wife’s birthday to take his life. Fortunately, neither she nor their toddler son was home at the time.

The issue of soldier suicide concerns many. Maj. Gen. William D. Wofford, Arkansas' National Guard Adjutant General, recently made a public plea for help asking family members, friends and employers of the state's 10,000 Guardsmen to watch for personality changes or signs of stress overwhelming his soldiers and airmen. There has been four suicides in Arkansas Guardsmen since January.

As Dr Chad Morrow points out the suicide risk for active duty males is now higher than for the general population.

This is particularly noteworthy considering that the military entrance process screens out serious mental illness prior to entry onto active duty, and that the rate of suicide in military males has historically been significantly lower than comparable civilian populations.

Morrow goes on to touch on “the three-way interaction between burdensomeness, belongingness, and acquired capability.” He suggests that “belongingness is less robustly related to suicidal desire than burdensomeness.”

I don’t know if my young cousin-in-law’s suicide could have been prevented. He came back from Iraq physically intact. I’m not sure how much help he sought or took advantage of. I do know he has left loved ones who now have to face their grief, the loss of his presence, and many questions.

Here are some of my random thoughts on suicide prevention in our troops:

They need to feel connected. We know that text messages have been helpful in getting patients to do better with their chronic diseases or take their meds. Is there anyway to use text messages to help them feel more connected?

Could the military and/or guard set up a “facebook” system for the troops where they could interact with each other? Virtual “group sessions” that would overcome distance (living too far from a VA Clinic), like telemedicine.

Solders, like physicians, have a higher completion rate on suicides than the general public. You can’t take away the training needed to do our jobs. The focus has to be on connecting, feeling useful/needed/capable.

Each individual has to reach out and grab the lifeline that is thrown his way.

Sources

Ark. National Guard asks for help as suicides rise; AR State Wire
By Jon Gambrell, Published: Sep 18, 2009

Suicide in active duty military personnel by Chad Morrow, Psy.D; Psychotherapy Brown Bag, September 1, 2009

Army Suicide Rates Hit Record High; Huffington Report by Pauline Jelinek and Kimberly Hefling; January 29, 2009

Fort Campbell hosts suicide run: Run for Resiliency at Destiny Park features 25 information booths By JAKE LOWARY; The Leaf-Chronicle, September 20, 2009

Grieving

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

We buried my mother last Friday, May 22, 2009.  I find myself moving through each day trying to get things back to normal, but unsure I will ever accomplish that goal.  I was never very good at picking up the phone to call my mom though I did on her birthday and on holidays.  I was good at writing her notes.  Over the past several years I have written her at least one note/letter each month and an e-mail now and then.  My father died when I was only eight, so I have some experience with grief.  Still this is different, magnified.  I am now an orphan.

I do not believe I am as good a writer as Meghan O'Rourke.   She has written a series of articles dealing with the loss of her mother which I found thanks to Christian Sinclair, MD (PalliMed).  Ms O’Rourke lost her mother to cancer on Christmas day.  I know what she means when she says:

Since my mother's death, I have been in grief. I walk down the street; I answer my phone; I brush my hair; I manage, at times, to look like a normal person, but I don't feel normal.

As Christian puts it in his post:

She researches the medical literature, and thankfully finds the Yale study on Kubler-Ross stages/states from 2007. She makes many literature references including CS Lewis' A Grief Observed, Shakespeare's Hamlet, Sogyal Rinpoche's The Tibetan Book of Living and Dying, multiple poets and Joan Didion's The Year of Magical Thinking. She even talked with Holly Prigerson, the lead researcher on the Coping with Cancer study.
This series is a must read for anyone in hospice and palliative care. Use each article as a discussion point at your next team meeting. Feel free to post other ways to use these articles in the comments.

I would add that these articles might be a “must read” for any of us who are grieving for our mothers, fathers, brothers, sisters, etc on this Memorial Day or any other day.

National Healthcare Decisions Day

 Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Nathan A Kottkamp, a healthcare attorney,  is the chair and founder of the grassroots effort to promote advance care planning and healthcare decision making,  National Healthcare Decisions Day (NHDD).  This day was chosen in a nod to Benjamin Franklin and his adage “Nothing in life is certain but death and taxes."   Yesterday, April 15th, was tax day here in the United States.

More than 75 national organizations, plus 660 state and local organizations, will have teams at hospitals, nursing homes, hospices, doctor's offices and even libraries to explain the benefits of advance directives.  Those who wish will be assisted in writing / signing living wills and other medical directives. The services are free.  For a list of participants check here.

It is not only important to discuss these end of life issues, but it is important to occasionally review our decisions and make changes to them as necessary. 

Kotthamp is quoted as saying "No one likes to think about the possibility of a life-threatening injury or disease, but the simple act of creating an advance directive can turn out to be an incredible gift for loved ones in the event of an accident or severe illness.  No matter where you live, you can fill out an advance directive without hiring a lawyer. It's easy to do and is free."  

I had trouble finding any specific locations around Arkansas.  If you know of any, please, let me know and I’ll add them.
White County Medical Center (Batesville, Arkansas)
Arkansas Advance Directive; Planning for Important Healthcare Decisions (pdf file)

The National Healthcare Decisions Day website has some great resources about advance directives and how to get one.

Plastic Surgery Posthumous

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

The recent article referenced below (HT to Kevin MD who HT’d Dr Tony Youn) reminded me of a conversation I had with a patient early in my career. She was a young widow. She was back in my office for a follow up visit after surgery. We got off on her grieving, her husband's illness, and other topics. He had died from a tumor in his lower face /upper neck that was inoperable due to the way it was connected and invading the structures nearby (think carotid and inferior jugular). It had left him very disfigured. She told me she regretted not being able to have an open casket funeral for him.

“I hope you don’t find this strange, but I wish the tumor could have been removed after he died. Then we could have had an open casket funeral.”

I blurted out "I would have removed for you."

"Really, you would?" she said.

"Yes, I would have."

"Thank you, Dr Bates. That would have meant the world to me."


Thinking back, I'm not sure why I blurted it out other than the connection we had at the moment. I don't regret saying it. I meant what I said to her. Inoperable tumors become operable after death because you don't have to worry about the blood supply to the brain anymore. You no longer have to worry about whether they might stroke out if you disrupt that supply. So debulking a tumor so the deceased looks "more normal" would be feasible. It would also be good practice for a young surgeon doing the dissection without worry of harming the person.

I don't think I would ever want to be part of doing a posthumous face lift or blepharoplasty or other cosmetic procedure, but I would be willing to debulk tumors if it would help families or individuals say "goodbye" more easily.

REFERENCE
Final Touch: A Cosmetic Lift for Your Funeral? by Diane Mapes; MSNBC, Dec 9, 2008
Hat Tip to Kevin MD: Do you want to look better dead than alive? who Hat Tipped Dr Tony Youn: Plastic Surgery by Morticians? Not Really....

Comfort

My friend's dad died this past Thursday. His death was not unexpected, as he had severe Parkinson's Disease (previous post). I have known this family for nearly 40 years now. My friend and I have been friends since we both moved to Vilonia in the fourth grade. Her mother taught business classes there. We took her typing class.

My friend lives in Rowlett, TX and was due to arrive at her parent's home Saturday afternoon. So I drove up to visit with her and her family. I beat my friend by a few hours. I ended up spending several hours there, watching people come and go. Mrs. R and I were the only two there for an hour or so. Her words "I'm going to go to the back room and make some more calls. I don't feel bad about leaving you in here alone, because you're family. You know what I mean?" She left me to make some calls for her to local hotels asking about rates for out-of-town family and friends.

I was struck by all the food that visitors brought. I was enlisted to help put some of it into zip-lock bags or other containers so that it could be frozen. We cleared the kitchen counter of pies, cakes, rolls, and casseroles that would freeze. They told me they had already done this once. And yet with the next wave of folks, more food came. The counters quickly filled up again.

I didn't take food. I had read somewhere about 5 years ago (Hints for Heloise or Ann Landers) that families with illness or deaths in the family often needed supplies/staples. It listed items like toilet paper, paper towels, paper plates/utensils, Kleenexes, coffee/creamer, note cards with stamps, etc. So that is what I have begun to do.

Mrs R encouraged all her visitors (would-be-comforters) to eat. Then she would try to get them to fix themselves a plate or two of food to take home. Part of this was simply her good nature of caring for folks. Even in this time of her grief, she was trying to take care of others. Part of it was as she explained, the need to reduce the food in the house. The family was feeling overwhelmed by the food and didn't want it to be wasted or go bad before they could eat it. Yet they were running out of freezer space. Mrs R at one point asked "Why do they all feel they need to bring us food?"

Here in the south, that seems to be the way we are raised. Funerals and the family visitations seem to be a time of feeding and by extension eating. Food is very much associated with comfort. We don't seem to be able to just go and sit and listen and tell stories and share photos/memories without taking something to the family. We want to "feed" them as a way of trying to ease "this difficult time". I would have felt "guilty" or as if I had let my own mother down if I had not taken something. But I think for my friends, they would have been happy for me just to have come as I did and spent time.

It felt funny to me to leave with a plate of food, but it made Mrs R feel better. She wanted me to take two or three plates.