Monday, July 31, 2017

"Move that defibrillator paddle so I can finish the case"

A plastic surgeon in Sydney was reprimanded by the New South Wales Professional Standards Committee for continuing breast augmentation surgery after a patient had been successfully resuscitated from a cardiac arrest.

According to a report, the surgeon, Dr. Niroshan Sivathasan, defended his actions two years after the incident saying he operated for another 30 minutes after an ambulance arrived because he hadn't finished inserting the left breast prosthesis or closed both wounds, and he was concerned about infection if he aborted the case.

The committee didn't buy that excuse correctly pointing out that the patient could have had another cardiac arrest and said he "demonstrated almost no insight into the nature of his conduct or how he failed his patient."

He was also told he must undergo mentoring and submit a report documenting all of his complications every three months.

Sivathasan works at The Cosmetic Institute, Australia's largest plastic surgery center, which has had some problems in the past. In 2016, the Health Care Complaints Commission found six patients had experienced potentially life-threatening complications — tachycardia, seizures, and cardiac arrest—during breast implant surgery done over a 12 month period.

The complications were thought to have been due to the use of large amounts of local anesthesia with epinephrine. In addition, the facility was licensed for administering conscious sedation only, but some patients had undergone general anesthesia without their consent.

The 21-year-old woman who survived the cardiac arrest in 2015 was interviewed back then for an article in the Sydney Morning Herald. She described waking up in the hospital and finding she had received CPR and cardiac defibrillation. She said Sivathasan told her there was a problem with the anesthetic.

Regarding her surgeon, she said, "If it wasn't for him I wouldn't be alive. That place is so prepared for whatever. Literally, they saved my life."

I don't think they have Press Ganey scores in Australia, but if they did, no doubt the surgeon and the facility would have received 5-star ratings from this patient.

UPDATED ON AUGUST 14, 2017

Dr. Sivathasan, the surgeon involved in this case, emailed me with comments which shed some light on why he continued the operation. They are published without editing below.

I felt it important to write to you just to highlight a few things that were ‘not’ correctly reported in the press release:

1) the operation was close to being finished when the patient developed ventricular fibrillation;
2) hardly any local anaesthetic was used in this case (only 10mL of 1% ropivucaine);
3) by good fortune, there were TWO specialist anaesthetists (one being a senior cardiac anesthesiologist) who were managing the patient, and the patient responded very quickly to their efforts;
4) the ambulance service despatched two incorrectly equipped ambulances, and a THIRD ambulance was required to transfer the patient.  This entailed a delay;
5) it was UNANIMOUSLY agreed by FOUR doctors (both anaesthetists and both surgeons who were present) that we ought to use the window to give the most definitive outcome for the patient.

At the end of the day, the patient, a sizeable percentage of the public, and a considerable number of doctors supported us for our actions.  They recognized that it takes more judgement and nerve to finish a procedure under such stressful circumstances, than it does to just ‘whack in a few staples and down tools’.

Unfortunately, due to the regulatory processes in place, two doctors who were not present during the incident, were able to judge upon the actions of four doctors (all of whom were in agreement).  This is simply illogical and is, certainly, an indictment of the regulatory board’s processes.  Furthermore, neither of the two doctors that were presiding over the case is an expert in critical care – one was a retired surgeon and the other was an emergency physician.

Accordingly, what those two doctors failed to recognize, in my strong opinion, is that a patient whom has been salvaged from a nasty situation remains unstable and should not immediately be in the back of an ambulance; rather, the patient shall be better served when under the care of two anesthesiologists maintaining anaesthesia (which is relatively cardioprotective given the high catecholamine situation (which may provoke another episode of VFib)).  The VFib was ‘not’ secondary to haemorrhage or anything surgical, and therefore to capitalize on the undesirable situation by finishing an almost-finished operation appeared to be the best decision (as opposed to requiring a GA in the future, where the induction may be a lottery).  

Experienced doctors shall appreciate that medicine, and especially surgery, involves judgement calls.  This patient in question has had a positive outcome.  Unfortunately, the institution where the problem occurred has been the subject of debate due to a few suboptimal practices by the management team, and this ended-up biasing the outcome.

3 comments:

Old FoolRN said...

A good example of why higher patient satisfaction scores are associated with increased mortality.

Skeptical Scalpel said...

Old, that's debatable. A new study just found that patients who are more satisfied with their doctors and hospitals had better outcomes.

Lady Anne said...

I tend to agree with SS. If I am in a snit and have an "attitude", I'm not as apt to cooperate with the staff. I really mental status is vitally important to outcome.

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