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XXX Law Firm Attorneys at Law xxxxxxxx Street, Suite xxx XXXX, Florida 33333
[PATIENT NAME]
1. XXXand XX,
Plastic Surgery of XXXX : April 2, 2002 through August 6, 2002
ALL PATIENT AND HEALTHCARE PROVIDER NAMES, FACILITIES AND ADDRESSES HAVE BEEN BLOCKED OUT TO MAINTAIN CONFIDENTIALITY.
CASE REVIEW XXXXX is a 54-year-old white female, born January 17, 1948 who works as a hairdresser. The patient originally saw Dr. XX on April 2, 2002. At that time, the patient informed Dr. XX that she would like to eliminate the protrusion of her abdomen and would also like to improve her breasts and get as much lift as possible. At the time of the initial consultation, the patient had a previous history of asthma, mitral valve prolapse, and Scarlet fever. She had hepatitis B at the age of 18. She also had a history of a breast reduction, laparoscopy, tubal ligation and bunionectomy. She was allergic to codeine and erythromycin. The patient is 5 feet 3 inches tall, and weighed over 200 pounds. She smoked one-half pack of cigarettes per day for the past 25 years. Her exam revealed that she had bilateral breast ptosis and had a panniculus of the abdomen, with an increased amount of fat in the abdomen. It was Dr. XX' recommendation that the patient undergo bilateral breast lift, with augmentation with 425 cc implants. He also recommended an abdominoplasty. He stated to her that after three months, she could have a liposuction of her abdomen as well to make it flatter. According to the initial consultation, Dr. XX discussed the postoperative course, as well as possible complications. On June 27, 2002, the patient underwent a screening mammogram, which was negative and on June 24, 2002, the patient signed multiple documents in Dr. XX' office with regard to the risks, benefits and complications involved with the surgery, including anesthesia risks and surgical risks such as capsular contraction, hematoma, infection, loss of sensation to the skin or nipples, exposure or extrusion of implants, wrinkling and other risks of seroma formation, pulmonary emboli, fat emboli, blood clots, fluid accumulation, asymmetry and indentation of excess fat removal. These documents were signed by [patient]. There is also a notation that a prescription for Levaquin (antibiotic) was given to the patient for 7 days, Lorcet for pain relief and Zofran one tablet PO b.i.d for nausea to be taken after the surgery. On July 1, 2002, the patient underwent surgery at the xxx Surgery Center, xxxxxxxxx Avenue, XXXX, XX xxxxx. The operative report indicates that the patient underwent an extended abdominoplasty, liposuction of the lateral chest wall, breast augmentation and mastopexy through the bilateral inframammary folds. Dr. Xxx was the surgeon, assistants included Xxxx, M.D., and Xxxxxx was the certified surgical technician. Anesthesia was general with endotracheal intubation. There are no notes to review with regard to the postoperative nursing records at the XXX Surgery Center or an anesthesia record. The first postoperative visit was on July 2, 2002. There is no signature on the visit, but it states that the dressing was changed. There is a note from July 3, 2002, indicating a follow-up visit . There were no signs or symptoms of infection were noted. The Jackson-Pratt drains were patent, and drained approximately 75 cc of serosanguineous fluid. Minimal to moderate swelling was noted. The sites were cleansed with normal saline. Bacitracin was applied with Xeroform and wet-to-dry 4 X 4 abdominal pads were placed. The patient was to follow-up with Dr. Xxx on September 9, 2002. Note from July 9, 2002 states the patient was doing okay. Note from July 16, 2002 states no show. Note from July 17, 2002 is difficult to read, but it appears that it states that there is a 5 x 2-cm open wound and that a debridement took place by Dr. XX. Cipro samples were given. On July 18, 2002, the note states that the patient is in for a wound check one day status post debridement and flap closure, necrotic tissue is noted. The patient states that at approximately 4 AM, she had uncontrollable drainage from her abdomen. She states it soaked her clothes and her bed. Upon examination by the medical assistant, the patient was noted to have very minimal drainage through her clothes. The right side was wet. Attempt to aspirate fluid from the abdomen was unsuccessful. She was told to follow-up on Monday. Another note on July 22, 2002, from the medical assistant indicates that both revision sites were dehisced. Wounds were cleansed and packed with wet-to-dry dressings. She was to follow-up the next day. On July 23, 2002, the note indicates that the patient called stating that she could handle doing the dressing changes herself. She was informed of the importance of wound care and she was to return on July 24, 2002. On July 24, 2002, the patient was brought in for a wound check and dressing change. The patient requested to see Dr. XX. According to the note, the area was débrided of necrotic tissue and the wound was packed with gauze by the medical assistant. On July 25, 2002, there is a note stating that there was a no show. On July 26, 2002, there is a note stating that full instructions were given to her concerning wound care and that she was to be followed by Dr. XX on Friday July 31, 2002. There is a note from the Medical Assistant on July 30, 2002 indicating the patient had called very upset, stating that no one had called her to check on her and that she had a staphylococcus infection (staph) since the surgery. She stated to the Medical Assistant that her umbilicus smelled and it was open through to the full abdomen. A note from August 2, 2003 indicates an open wound. Cultures were taken on July 31, 2002, which showed light staph and they were waiting for sensitivities and she was on Keflex. Further note from August 3, 2002 states that the Medical Assistant changed the dressing. The patient was complaining of discomfort. A note by Dr. XX on August 6, 2002 at 9 AM states that "patient is not compliant. We have called constantly." Report on sensitivity shows light methicillin-resistant staphylococcus aureus (MRSA) and skin flora and an infectious disease (ID) consult is to be obtained. August 6, 2002 at 10 AM, a second note from Dr. XX states that he had called the patient and she was not compliant and that he informed her that she necessitated further debridement and an ID consultation. A third note on August 6, 2002 by Dr. XX states that he had spoken to Dr. Xx and that Dr. Xx had told the patient that this type of complication can occur and that Dr. Xx agreed with Dr. XX, in that an ID consult was necessary. Dr. XX further states that the patient was noncompliant during his care. There are no other records from Dr. XX's office after the August 6th note. Copies of prescriptions indicate that the patient was given Demerol 50 mg tablets on July 9, 2002; Lorcet tablets for pain on July 22, 2002; Levaquin prescription on July 22, 2002 for 7 days of antibiotics; Diflucan 150 mg tablets on July 31, 2002 and Xanax for anxiety on July 31, 2002. Culture from July 31, 2002 indicates light growth of staphylococcus aureus and methicillin resistant staph aureus. Records from Dr. Xx's office state that on August 6, 2002, the patient visited Dr. Xx for the first time. According to his note, the patient had an abdominoplasty by Dr. XX on July 1, 2002. She had partial dehiscence which necessitated debridement and closure on July 17, 2002. Unfortunately, according to Dr. Xx's note, the patient had a second recurrent dehiscence and she was left with open wounds and poorly granulating tissue with a significant infection. The notes also further indicate that Dr. Xx spoke with Dr. XX about the case, and according to Dr. Xx's note, Dr. XX's associates were seeing the patient daily and that she had been on antibiotics from the time of the surgery. The most recent cultures indicated a MRSA infection. The patient was febrile. Dr. Xx took digital pictures, which showed a large open area around the umbilical stalk and two large areas in the lower abdomen where the fascia appeared to be intact, but where there was poor granulation tissue. Dr. Xx was concerned that on the day of admission the patient had an outbreak of psoriasis and there was a potential for infection of her breast implants. He recommended admission to the hospital and consultation with an infectious disease physician, Dr. XXXXX at XXXX Hospital. XXXX XX Medical Center medical records indicate the patient was admitted on August 6, 2002. On August 7, 2002, Dr. XXXXX from Dr. xxxx's office evaluated the patient and felt that the patient had a MRSA infection and started her on vancomycin intravenously. The patient was also started on hydrotherapy twice per day in the physical therapy department. On August 8, 2002, the patient had been running a fever, and was kept on vancomycin intravenously. August 9, 2002 progress notes indicate that the patient was doing better with no fever, and no erythema, or purulence around the wound. Wound packing was done on a daily basis. She was discharged home on August 10, 2002 on I.V. antibiotics using vancomycin and she was to be followed by an outpatient by Dr. Xx, and Dr. X's. She was to have wound care done on a daily basis with dressing changes and home I.V. antibiotics from an outpatient nursing company. It should be noted that the patient's admitting blood work on August 6, 2002 indicated a white blood count of 12.4, hemoglobin 9.7 and hematocrit of 30.3. She had a fever on August 6 and August 7, 2002, but on August 8 she had no fever and was sent home afebrile.
Outpatient records from Dr. Xx indicate that the patient was seen on August 12, 2002 and she stated she was doing much better and had no fever. She was to continue on vancomycin. She was seen on August 20, 2002, and according to the note, the patient showed much improvement. Her psoriasis had completely gone into remission. There was no mucopurulent discharge. There appeared to be granulation tissue forming around the wound. It was Dr. Xx's suggestion that within a few weeks, the patient would necessitate further debridement, the umbilicus would need to be reset and the wounds would need to be closed. On August 27, 2002, the patient was again seen by Dr. Xx and the wound appeared to be clean. She had completed a course of I.V. vancomycin as of that date. Dr. Xx, suggested she be admitted to XXXX Hospital the following week for debridement and flap closure. XXXX Hospital records from September 4, 2002 as an outpatient, indicate that the patient had a debridement and closure of her wounds. The surgery started at 12:30 and was finished by 13:50. According to the operative note, the patient underwent a closure of an open wound and debridement. Further notes from Dr. Xx's office indicate that the patient was doing well postoperatively and that she was getting daily wound care three times per day. Dr. Xx saw her on an every other day basis, until approximately September 10, 2002. She was then seen again on September 17, 2002, and at that point developed copious amounts of yellowish-drainage. She was seen by the infectious disease doctor and was kept on Flagyl, Levaquin and Diflucan. The patient was seen again on September 24, 2002. At this visit, her sutures were removed, the wound was closed and there was no sign of infection. She was followed up again on October 9, 2002 and at that time, she stated she had some fluid drainage, and there was a concern that she may have developed a small seroma pocket and a CT scan was ordered. The patient returned on October 18, 2002 and at that time she was having a re-exacerbation of her eczema. She had no fever, but she was feeling depressed about the outcome of her surgeries. According to Dr. Xx's note, the patient had some minimal erythema around the gluteal area, but there were no signs of any gross infection. She was left on Flagyl and Levaquin. She was told to call Dr. Xx if there were any further problems. Further notes from November 6 and November 7, 2002, state that phone calls were made to [patient] with regard to checking up on her, but there was no office visits after the October 18th note. Nurses XX notes concerning home visits indicate similar findings to Dr. Xx's notes. Notes were made of routine wound dressing changes and the infusion of vancomycin intravenously every 12 hours. The last visit on October 8, 2002 indicated that the patient had been doing well, intravenous antibiotics had been discontinued and she was to follow-up with Dr. Xx.
CASE SUMMARY
CASE SUMMARY:
Mrs. XXX is a 54-year-old obese female who underwent extensive
abdominoplasty as well as breast augmentation on July 7, 2002, by Dr.
XX, M.D. According to Dr. Xx's notes the patient was immediately hospitalized at XXXX Medical Center. An infectious disease consultation was performed. Indications on the date of admission showed that the patient had a fever, as well as an elevated white count indicative of an ongoing infection. The patient was hospitalized for four days and was discharged on home dressing changes, and intravenous antibiotics utilizing vancomycin for coverage of her staph infection. After one month of dressing changes and intravenous antibiotics through home care, the patient was admitted as an outpatient to XXXX Medical Center by Dr. Xx on September 4, 2002 to have revision closures of the abdominoplasty. Postoperatively, the patient continued to necessitate care for six weeks and was left with significant scarring in the lower abdomen from the infection and subsequent treatment.
After a complete review regarding abdominoplasties and the complications from abdominoplasties, it is very clear that there are specific preoperative factors that affect the overall outcome in this patient population. In numerous articles, the overall complication rate ranges between 30 to 40% with major complications in the range of 2 to 4%. The revision rate is approximately 40% and is usually related to fine-tuning of the aesthetic appearance of the abdominoplasty. Numerous articles indicate that there is a significantly higher rate of major complications including dehiscence of wounds in obese patients. In an article from Annals of Plastic Surgery in 1999 written by Bastin and Morgan, the overall complication rate was 80% in obese patients as compared to a complication rate of 33% in those who were non-obese. Other articles indicate that there is a significant increase in the complication rate of those who smoke versus those who are nonsmokers. Further review of the literature indicates that when a dehiscence occurs, it is imperative that cultures are taken, antibiotics are given, and that the wounds need to be thoroughly débrided. Recent articles discuss the use of a foam suction dressing combination with a rapid serial wound closure, which appears to have allowed acceptable anesthetic results, which did not occur when delayed closures were performed. Articles in the British Journal of Plastic Surgery in 2001 by C. H. Fen, and a further article by C. Cedidi and A. Berger in September 2002, indicate that utilizing polyurethane foam combined with vacuum-assisted wound closure devices for secondary wound closures, provides the best aesthetic results. Although this is a relatively new procedure, it is well-documented in the literature. Further review of the literature indicates that it is important that immobilization of the wounds at the time of the abdominoplasty is essential for better aesthetic results. Further review of the literature indicates that it is paramount to attempt to decrease the possibilities of major complications after abdominoplasty with regard to thromboembolic complications which could be life-threatening, and which occur at a higher rate in morbidly obese patients. The incidence of these complications are minimized with preventive measures such as early immobilization of the patient, perioperative treatment with low molecular-weight heparin, the wearing of antithrombotic stockings. Based on the above discussion, there a few areas in question with regard to Dr. XX's medical care in this patient. This patient was morbidly obese at 5 feet 3 inches and weighing well over 200 pounds. Although there was a consent form signed by the patient with regard to the numerous complications that can occur during the procedure, the initial record by Dr. XX does not indicate that he discussed the high incidence of complications due to the patient's morbid obesity, and the fact that she was not a good candidate for the abdominoplasty due to her excessive weight. Furthermore, although there was a consent signed by the patient with regard to lack of cessation of smoking, it still warrants education by the plastic surgeon and/or his staff with regard to the understanding that there is a higher rate of skin and necrotic problems in smokers. The doctor fell below the standard of care with regard to the perioperative period when there was no indication that any type of type of antithrombotic preventative treatment was given. Furthermore, the patient, according to the records, did not have any significant postoperative compression applied to the abdominal wall to decrease the possibility of hematoma and/or seroma.
Eight days after the initial surgery, when the patient began having necrotic tissue and a wound dehiscence occurred, there were no indications that wound cultures were taken to determine the appropriate antibiotic coverage for the patient, nor was there any indication that the patient received antibiotic coverage between the time in which Levaquin was given for 7 days, and Cipro was then given approximately 17 days after the surgery. The first cultures that noted were after the patient had high fevers and was seen on July 31st, which is well after the second wound dehiscence occurred. In conclusion, it is my opinion that the physician in question fell below the standard of care, both with regard to his preoperative selection of this patient for the type of procedure that was performed, as well as the perioperative treatment of the patient to attempt to prevent complications. Furthermore, treatment of the complication was below the standard of care, due to the lack of obtaining an appropriate culture, as well as appropriate antibiotic coverage and receiving a consultation in a timely basis from an infectious disease specialist, in order to aggressively treat the patient's infection. I would be happy to supply you with the appropriate plastic surgery expert for an affidavit. It may also be necessary to obtain an infectious disease expert for this case as well. Sincerely,
PMS:las
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