Spring Allergies: How a Nose Specialist Deals with His - and His Patients'

Photo Credit: SpooSpa

Ah, springtime. Trees, grasses and other plants return. The world looks green and better. Except for those of us with inhalant allergies. The lining tissues of the nasal passages swell, the nose becomes stuffy. This gives rise to the pressure sensation, headache, difficulty breathing, itching, sneezing, post-nasal drip, coughing and sometimes even loss of taste, due to temporary loss of smell.

While allergies are rarely "cured" (they represent a mismatch with the environment), relief of symptoms is the goal. And, while some people have long-standing breathing problems because of a deviated nasal septum or nasal fracture, even they can obtain relief when further burdened by an allergic attack.

The following treatment plan has been effective, for me and my patients, to relieve the burdensome nasal symptoms.

I use two nasal spray medications. First, Afrin, or Otrivin, well-known, non-prescription spray-mists, which shrink the lining of the nose and provide almost instantaneous relief from the blockage and pressure sensations. This drug, a cousin of adrenaline, shrinks the internal nose's blood vessels, which are dilated maximally as part of the body's reaction to the inhaled allergens. Typically, I will spray four sprays into each nasal passage, wait four minutes, and then again install four sprays into each nasal passage. It is important to allow that four-minute waiting period, since the initial sprays will shrink only the swollen front portion of the nasal interior. Following the pause, the second round of sprays will then gain access to the back portion of the nasal passages.

While it is easy to fall in love with the effectiveness of these sprays, the user is reminded that after five to seven days, there comes the "rebound effect", whereby the internal nose becomes intolerant to the spray that now does less and less. Some unfortunates become habituated to its use. I once had a physician-patient who had become so hooked, he sported an Afrin-containing holster on his belt!

The second medication is a prescription cortisone nasal spray. Brand-names include Flonase, Nasalide, Nasacort, Vancenase, Beconase, Nasonex. The mission of these sprays is to blunt the biochemical reaction that the offending invisible allergic particle has incited, causing the swelling of the tissues. These sprays are designed for long-term use; there is no tolerance developed. However, there is a several day "ramp-up" before the medicine reaches peak effect, hence the wisdom of utilizing, temporarily, the immediate-action oxymetrazolamine to provide relief until the steroid spray kicks in.

Non-prescription decongestant nasal sprays last eight to twelve hours; the prescription cortisone nasal sprays typically last twelve hours. For the first week of treatment while waiting for the cortisone to take effect, as both sprays are being used, I use the decongestant first. One half-hour later, the steroid spray, now entering an unblocked nose has room to work its magic.

Incidentally, the same program works for the common cold. In that case, the nasal tissues become swollen because of the reaction to the cold-causing virus.

Related Topics:

• 100 Worst Spring Allergy Cities
• Treating Nasal Allergies: Your Day-to-Day Game Plan

Technorati Tags: spring allergies, nasal allergies, nose sprays

Mommy Makeover Book Misses the Mark

People have been asking about some new book that apparently advises high-anxiety mothers planning a Mommy Makeover cosmetic surgery. The book purports how Mom should explain and justify the surgical experience -- including the immediate and not glamorous post-operative appearance -- to her ostensibly worried 4-7 year old youngsters.

Frankly, I see this as an inane book in search of a need. Of the six billion people on earth, the book's potential readership might fit into the local school auditorium. Do parents really require scripting to explain their decision and then the temporary bruising and swelling? Cannot the average parent, in their own words, better allay any anxiety or answer questions posed by the little ones?

Is a how-to book necessary for every occurrence in life?

Has there ever been a book-for-kiddies delivering scripts on how to explain the also-temporary bloating and swollen ankles of pregnancy? Or, spoon-feeding advice on handling an irritable Mommy during menopause? Or, why Mom can't trampoline with the kiddies one day after her bunionectomy?

Have we no confidence in the innate common sense and sensibility of today's parents? Are we all thought to be that stupid and lacking adequate communication skills?

In all fairness, I have not had a chance to read the entire book because, right now, it lives only in its pre-publication promotion and PR phase. So, currently, we must rely on the news media to deliver the book's message and purported wisdom. Perhaps there will be a better book than the press releases suggest; I hope so.

However, given limited budgets and bookshelf space, perhaps parents should think first of books that teach universal life lessons, broaden awareness, stimulate imagination, expand vocabulary and teach tolerance and respect. Think the Dr. Seuss series. Or, for old-fashioned, real-life practicality, Everyone Poops (My Body Science). After all, the pool of 4-7 year olds -- nervously grappling with how to understand their Mommy's makeover sojourn -- is rather miniscule. But, every kid needs a running start in mastering the essential basic life skills.

Related Topics:

• Body Image and Your Kids
• The Mother-Daughter Weight Connection

Technorati Tags: cosmetic surgery, parenting, mommy makeover, books

Priscilla Presley and Silicone

"Priscilla Presley is the victim of botched cosmetic procedures."

From (TMZ):

Priscilla, whose face looks ... strange on "Dancing with the Stars," went to Dr. Daniel Serrano around 2003. Serrano was a good-looking doc from Argentina who hooked into Hollywood's social A-list and started giving them what he claimed were miracle injections that worked better than Botox.

In fact, Serrano was injecting industrial, low-grade silicone similar to what's used to lubricate auto parts in Argentina into the faces of these women.

Another celebrity falls into the hands of the wrong doctor for cosmetic surgery. So much for fame and fortune immunizing against bad selection of professionals.

If these people - presumably with savvy connections - and living in the world's epicenter of cosmetic surgery, Beverly Hills, can't pick the right doctor, or at least one with a CA medical license, what about the less sophisticated of America?

My latest book, The Essential Cosmetic Surgery Companion, a unique workbook, really makes it easy to avoid doing dumb things. It even has links to the Federation of State Medical Boards to facilitate checking that the doctor working out of his patients' homes (a huge RED FLAG) has a valid medical license.

It's sad that the great accomplishments of modern cosmetic surgery are tainted by crooks, charlatans and grifters. But, in this world, medical or otherwise, it is "Buyer Beware!"

Related Topics:

• Get Savvy Before Cosmetic Surgery
• Cosmetic Procedures: Botox

Technorati Tags: priscilla presley, botox, silicone, cosmetic surgery

Florida Teen's Cosmetic Surgery Death Explained

Since yesterday, there have been many reports and comments about the Florida teenager who died during  breast augmentation surgery.  Some report highlights:

• Malignant hyperthermia, the cause of death, is hereditary and thus any patient undergoing GENERAL anesthesia should be asked: "Family history of problems with anesthesia?" If so, there is a diagnostic test available


• MH, very rare, but reversible if detected early and treated aggressively. Every anesthesia specialist and surgeon should know the management.


• An accredited, licensed or certified surgical facility, whether hospital, outpatient surgery center or office facility is required to have the specific antidote, a drug called Dantrolene, on the premises for emergency use.

What we know, so far, is that the 18-year old Florida patient developed the very rare complication of general anesthesia, malignant hyperthermia, literally "dangerous elevated temperature". But the temperature, per se, is not the only, nor typically the first, sign of this acute erroneous error of muscle metabolism. It is merely the most striking sign because few other elements of surgery or anesthesia will generate a high temperature in the middle of an operation.

While the patient's pre-disposition is hereditary, because of the condition's rarity, few patients can report a family history. Therefore, unless suspected, the condition arises without warning during surgery.

Here are the classical signs of malignant hyperthermia:

1. Sudden and otherwise unexplainable RAPID and STEEP rise in the pulse rate, e.g from 80 to 150 within minutes.


2. Rapid rise in breathing rate.


3. Major temperature elevation, which usually follows the above. Can rise to 106 F or more.

Think in terms of a marathon runner. The muscles are working overtime and the body attempts to self- regulate by automatically increasing heart and breathing rate and the temperature rises to "cool down" the body.

In malignant hyperthermia, the muscles are working overtime but not carrying the patient anywhere.

The immediate treatment is well-established. The general anesthestic agent, is "turned off"; 100% oxygen is driven into the lungs. To stop the muscles' hyper-metabolism, a drug, Dantrolene -- specifically used for malignant hyperthermia -- is given intravenously. The body is cooled by packing in ice and the patient is transported to a hospital intensive care unit.

The key to successful treatment and saving the patient's life is early recognition by the surgeon and anesthesia specialist. Because most anesthesiologists have not seen a case in their careers, they must carry a high index of suspicion when the computerized monitors' warning lights and bells suddenly go off for no apparent reason.

Appreciation to Kevin Tehrani, MD, Chief of Anesthesia at the Summit Surgery Center, Beverly Hills, CA., for his input. In preparing this, I consulted with Dr. Tehrani whom I recalled had successfully treated a case of malignant hyperthermia at the USC-LA County Hospital.

Related Topics:

• Guide to Breast Enlargement Surgery
  
• Breast Implant Safety
  

Technorati Tags: florida, teenager, breast enlargement, augmentation, death, malignant hyperthermia

Peels, Lasers and Microdermabrasion? Which is Best?

What is the difference between the non-surgical skin treatments: peels, lasers and microdermabrasion? How do you select the best one for aging skin?

With over 100 treatments now available, it is daunting to know what is best for your skin.

"Light" Chemical Peeling Agents

Alpha-hydroxy Acids: These mild peeling agents act as a deep exfoliant removing the dead cells from the skin surface and accelerating the maturation of the remaining cells. The aim is to make the skin smoother to the touch and more lustrous in appearance. The most commonly used alpha-hydroxy acids are lactic acid, glycolic acid and citric acid. Alpha-hydroxy acids (in concentrations of less than 10 percent) are used in cosmetic preparations; in concentrations of 10-70 percent, as skin peeling agents. In antiquity, women bathed themselves in sour milk in the hope of softening and smoothing the skin. Perhaps they understood intuitively that sour milk contains lactic acid, now used for, the same purpose.

Medium Strength Chemical Peels

The most common medium strength agent is trichloroacetic acid ("TCA"). Typically used in concentrations between 20 percent and 50 percent, TCA, a strong acid, destroys the epidermis (the outer layer of skin) and penetrates into the dermis (deeper skin). As a result, it stimulates the formation of new, fresh skin that is richer in collagen and elastic fibers, and is more taut with fewer wrinkles. Trichloroacetic acid has been used by experienced practitioners for many years. Because of the strength of this chemical and the possibility of complications, TCA skin peels should be performed only by experienced dermatologists and cosmetic surgeons. Anesthesia may be required for patient comfort and safety. This process of skin rejuvenation may take five to seven days of "down time" after which the skin is red. Cosmetics are required until the red color fades. When red, the skin is extremely sensitive to the effects of the sun and, therefore, a comprehensive skin program emphasizing sun protection is mandatory.

The "Heavy Hitters"

Deep Phenol Peels

"Phenol peels," the so-called "heavy weights" of skin rejuvenation, have a long and successful history. They have been performed in the U.S. as a mainstream procedure since the early 1960's.

Phenol is an acid-like chemical that, when mixed with other agents, becomes a potent prescription, resurfacing the skin by removing wrinkles, crow's feet, age spots and other superficial skin imperfections. Experienced practitioners regard phenol formulations as the standard against which all other skin resurfacing procedures must be measured.

Because of its ability to penetrate to the deeper layers, there may be some permanent lightening of the skin.

Laser Peels

• Nd:YAG (Neodynium) laser: penetrates below the outer layer of skin, stimulating fresh collagen without causing a destruction of the outer-most layers. This translates into a shorter healing time. But this procedure, because it is less intense, requires maintenance treatments and has not lasted as long as the other laser treatments, and may not last as long as other laser treatments.
• Carbon Dioxide (CO2) laser: The first widely utilized skin laser, introduced in 1995. Strongest, most invasive laser. Less popular today because of high percentage of over treatments (think complications) and undertreats (think disappointed patients).
• Fraxel Laser: Less invasive, faster healing. Good for improving sun damaged skin, spider veins, age spots and some acne scars.

Skin Rejuvenation Technology

• Titan®: Light flashes purportedly restructures the dermis to tighten the skin without surface changes.
• Thermage®: Radio frequency technology. Superheats the skin and claims to thereby tighten the skin by strengthening the collagen. Little down time, but reports of a very high percentage of disappointed patients.
• Plasma Energy New: Claims resurfacing of the skin to "reduce wrinkles and improve skin tone and texture". Further evaluation is needed.
• Intense Pulse Light (IPL): Flashes of light to reduce spider veins, pigmentation, also employed against acne. Has been well accepted with very low complication rate.
• Microdermabrasion: Gentle sandblasting to smooth the lines and lighten age spots and other signs of skin damage. A minimal treatment.

Note: This list is not intended to be all-inclusive. I have chosen a variety of the more popular and/or promising treatments so that one may understand the variety in procedures and technology available today.

Related Topics:

• WebMD Video: Peel Away Wrinkles
• Age-Fighting Skin Treatments for Men

Technorati Tags: cosmetic surgery, peels, lasers, microdermabrasion, aging skin

Getting a Nose Job? What Can Be Fixed -- And What Can't

PART I - ANALYSIS

The best cosmetic nasal surgeons are adept at very detailed analysis of all aspects of the nose. The outside and the inside. For some patients, the evaluation of the inside is critical if there is a breathing, allergy sinus problem or all of the above. All this is about diagnosis. The right diagnosis leads automatically to the right procedure.

THE OUTSIDE

The external nose is comprised of areas and zones. Each may have imperfections that contribute to an overall unsatisfactory look. To help patients understand what we can - and cannot - do, at consultation, I analyze each portion of the nose that is unsatisfactory to the patient and relate what changes can be performed on that portion

Here is a list of the anatomical features of the nose that we most commonly are asked to correct:

1. The bump.


2. The entire nose is too wide.


3. The nose juts out too far from the face.


4. The bulbous tip.


5. Unsightly nostrils.


6. The nose-lip angle.

THE INSIDE

Remember, I mentioned that when the specialist examines the nose, he must understand the internal structure of the nose - inside and outside. The hidden interior architecture always has a bearing on the outside appearance. That internal partition, the septum, composed of both bone and cartilage, has a major influence. A crooked nose will almost always be accompanied by a crooked or deviated internal nasal septum. As a matter of fact, it is axiomatic in the world of nasal surgeons that, "As the septum goes, so goes the nose". Even the lower (towards the lip) segment of the profile is a reflection of the height and strength of that septum.

That nasal septum runs a long course, from the front of the nose, where it sits behind the vertical partition that separates the nostrils, the columella ("little column"), to the back of the nasal cavity, where the upper throat begins.

A proper and thorough examination of the nose - breathing and sinus problems, allergies or not - should always include an evaluation of the internal septum and other key internal nasal passage structures called the turbinates. The turbinates, three in each nasal passage, are finger-like shelves attached to the lateral wall of the right and left nasal passages. Their function is to help moisturize, filter, and warm incoming air. The lower, or inferior, turbinate plays a major part in airflow volume. Enlargement of the turbinates takes up valuable nasal passage space and will diminish breathing. Typically, when turbinates are enlarged, allergy is the culprit. The doctor should also check for blockage of the openings to the sinuses, those air-filled chambers within the face bones. "Sinus sufferers" may learn that their problems begin within a blocked nose.

Had prior nasal surgery? "Inside", "outside", or both? The doctor will need to be particularly thorough with both the external and internal examination when the tissue has already been visited. Often some tissues are absent or still enlarged and misshapen, and all this has a bearing on what needs to be done.

PART II - WHAT DOES THE SURGEON DO AND HOW IS IT DONE?

Remember, no two patients require the same services. You should know - prior to surgery - what is on the surgeon's "To-Do" list.

1. The hump: The surgeon tunnels under the skin. Using delicate filing and shaving instruments, he shaves down the bump to a more satisfactory level. The "excess" skin is never removed; it naturally shrinks down to conform to the new architecture.


2. The entire nose is too wide: If the entire nose is wider than you want it, you will have to face that unfairly castigated, but really not too bad, "breaking the nose". But don't worry, you'll be asleep. You won't know it is happening and you won't feel it is happening. And it causes minimal discomfort after surgery. There is no other way to improve a wide nose. It takes the nasal surgery super-specialist only 90 seconds and "Bingo!" your nasal bones are closer friends. Less time than temporary, intricate makeup applications devised to make the nose look narrower. Plus, surgery is permanent.


3. The nose juts out too far from the face: In Part I, I described what anatomical imperfections cause the nose to over-project, to be "too far forward". It could be a combination of several factors; one or all may need correction. A prominent nasal spine is handily amputated; the owner of the nose won't miss it. A too-high nasal septum is shaved down. If the tip of the nose rides in a too-tall position, the columella, mentioned previously, that separates the nostrils can also be shortened.


4. The bulbous tip: That unattractive tip will be refined by using classic sculpture techniques to reshape and redefine the cartilage that comprises the tip, all with attention to symmetry and a natural look. Somewhat amazingly, all done "under the skin". Just as with the bridge, the excess skin that once covered large, bulky tip cartilages will contract to envelope the smaller tip.


5. The unsightly nostrils: Changing nostril size and shape is tricky. The surgical maneuvers that create a nicer tip will automatically effect the size and shape of the nostrils. For some patients, that is adequate to improve the nostril appearance; for others, it will be necessary to additionally remove a portion of the wings and/or the floor of the nostrils to achieve a satisfactory result, but that requires external incisions that could be somewhat visible.


6. The nose-lip angle: The nose that sits close to the lip and that hangs down will be improved by removing a portion of excess internal support structures, such as the front portion of the nasal septum. This allows the nose to ride up and away from and to shorten the nose. This is done essentially at the expense of the lip. The same technique is used to sharpen the angle between the nose and the tip when there is a somewhat round and unfeminine transition between the nose and the lip.


7. The nose that droops with smiling: A small but strong muscle that runs vertically from the internal upper lip to the hidden portion of the front of the nasal septum, appropriately called the "nose depressor", can be released from the nasal attachments through an invisible incision. This is done by dissecting where the nose meets the lip as a continuation of the standard internal incisions.

Click here to view a patient who needed all parts of her nose corrected. (Front view here)

All these procedures are done through hidden, inside-the-nose incisions, which are closed with dissolving stitches. External incisions, used for the "open rhinoplasty" are sometimes necessary but need not be used routinely.

A FEW WORDS ABOUT CROOKED NOSES. YOU NEED HELP BOTH INSIDE AND OUTSIDE

Whether from injury or just because Nature made you that way, your nose might be crooked. And, if it is, I'll bet that you also have a breathing problem. Because a crooked nose on the outside is almost certain to be crooked on the inside.

If you have been told that the external nose can be straightened without tackling the crooked or deviated internal nasal septum, you need a second opinion. It is nearly impossible to cure a nose that is not straight unless you tackle the internal support structures that are driving the external appearance. Please also understand that it may be impossible, at least in one operation, to get that nose perfectly straight on the outside and/or inside. Often, the tissues were so severely damaged from one or more broken noses that perfection is unlikely. However, with today's excellent filling injections --- temporary or permanent--- following surgery, as an office procedure, these fillers in minute amounts can be used to correct asymmetries that cause the crooked appearance.

Related Topics:

• Pros & Cons of Cosmetic Surgery
• WebMD Video: The Pitfalls of Cosmetic Surgery

Technorati Tags: nose job, rhinoplasty, cosmetic surgery, deviated septum

Donda West Lessons: The Pre-Op Exam

The Importance of the Pre-operative Medical Exam

Last week, when Donda West's autopsy story broke, I reviewed the post-surgery recovery location. Now there is further focus on that, plus review of recently revealed post-op findings.

Was Donda West a High-Risk Patient?

The January 11th Los Angeles Times brought forth additional information that may have significance in understanding what went wrong after Mrs. West's five and one-half hour body plastic surgery.

Because the LA County Coroner found no specific cause of death, such as a heart attack or blood clots in the lungs, attention turned to a combination of negative factors that taken alone might not cause death but, when taken together as a constellation of predisposing conditions and post-op events, might push a 58-year-old patient over the safety edge to death.

The Deputy Medical Examiner wrote that West had "...coronary artery disease" and that the heart's main arteries were "50-75% blocked". In retrospect, this is not surprising since it has been already revealed that there was a strong family history of major heart and blood vessel disease. The Los Angeles Times article stated that "a sister died of a heart attack two years ago, and her brother had hypertension (high blood pressure). It has been reported that Donda had a history of hypertension."

The newspaper further stated: "The Coroner's office learned that she (Donda West) had been diagnosed with hypertension, which she believed had gone away. She was a borderline diabetic and obese."

Add up an unquestionably significant family history in a patient with three well-known risk factors for heart trouble--high blood pressure, obesity, and borderline diabetes--and you are seeing a patient who may not have been an acceptable candidate for an elective but long plastic surgery.
How was Donda West evaluated for surgery's risk? and, by whom?

An unbending rule of the surgery world is that every patient having any surgery under general anesthesia, from emergency to elective, should have "medical clearance". Medical clearance is a history and physical plus appropriate laboratory, x-ray, and electrocardiogram testing as a basic means of evaluating suitability for -- and the risk of -- both the operation itself and the anesthesia. In fact, sometimes, the findings of that medical exam drive the decision regarding the appropriate and safest anesthesia technique. In other words, the patient's medical status generates many decisions.

What doctor conducts this "pre-op exam" is always important and may be significant in Mrs. West's surgical sojourn. While hospital, outpatient surgery center, and office surgery suites' accreditation, or licensure, requires such an exam, there is no specification as to what specialty doctor should perform it.

There are four possibilities:

1. The surgeon


2. The anesthesiologist


3. The patient's personal physician


4. An outside, independent family practitioner/internal medicine specialist, who is recruited specifically to perform the examination.

Here is my personal read on the value and the appropriateness of each, as I discuss in my book, Secrets of a Beverly Hills Cosmetic Surgeon, The Expert's Guide to Safe, Successful Surgery.

• The surgeon The surgeon may be the least qualified. Why? Because, and pardon my syntax, a surgeon is a surgeon and not a diagnostician as are family practitioners and internists. This is about division of labor; surgeons operate, the others don't. Conversely, all day, every day, the internists and family practitioners do physical exams but don't operate. So, who is more qualified to evaluate the heart and lungs, to order and interpret the lab tests, and to interpret the all-important electrocardiogram, particularly in a 58-year-old with significant medical problems?
  
  You know the answer.
  
  The last time I felt qualified to do a top quality history and physical was the last day of my internship. After that, I began training as a surgeon. I left the world of diagnostic medicine and entered the world of surgery. You can't go back.


• The anesthesiologist: The specialty of anesthesia is defined as the practice of internal medicine exclusively in the operating room and allied environments. So anesthesiologists are internists who don't have offices open to the public but practice internal medicine in a specific location--the operating room and recovery room. Therefore, as both internists and as the administrators of anesthesia, anesthesiologists are--in my opinion--the optimal assessor of risk. But a logistic issue generally blocks their role as the director of the requisite physical examination; they don't have standard office hours and they generally don't meet the patient until the surgery day. And while they can -- and should -- speak with the patient several days prior to the surgery, the "Go or No go" decision needs to be made weeks before the surgery in deference to the patient's, doctor's, and surgery staff's schedule.


• The patient's personal physician. This doctor is most often the logical and appropriate MD to conduct the medical clearance. He or she already knows the patient's history -- including family history. And, most importantly, has invaluable records. The prior lab, x-ray and cardiogram tests allow comparison with the current recent physical exam to best evaluate the patient's current medical condition. The personal MD can be objective and impartial in his evaluation and recommendation regarding medical suitability for the procedure. He has no stake in it. And, perhaps significantly in the Donda West case, would have probably sought consultation with a cardiologist and he most likely would have known of or discovered all of these lingering questions concerning the cardiac status.
  
  Unfortunately, some patients do not have a personal physician and so the wisdom and consult of a personal physician is unavailable.


• The outside, independent internist or family practitioner. Another very good choice. In our practice, for patients without a personal "primary" physician, we offer a roster of family physicians and internists whom we know to be receptive to accepting new patients and who clearly understand the "pre-op" medical clearance issue. This doctor, to whom the patient is new and thus medically unknown, will conduct a thorough comprehensive evaluation, taking it from the top with no pre-judgment and no predispositions. He acts 100% independently and is given the authority to give us a green light ("OK" for the proposed surgery), yellow light (Can't say yet, needs to have more tests and possibly consultation with one or more specialists), red light (Surgery not advised, major risk factor, recommend cancelling).

So, who did Donda West's pre-op history and physical? Did that doctor not ask enough questions? Not order the right tests? In view of her personal and family history, should a cardiologist have been consulted?

What about the anesthesiologist? The media has reported that an anesthesiologist administered the anesthetic. What was his view? What was his appraisal of medical suitability and risk assessment?

What I have discussed regarding the requisite and so important pre-op medical evaluation is a series of gates the patient should have to pass through. Any one of the gatekeepers can close the gate to surgery if they perceive the risks are unacceptably high.

Right now, we don't yet know enough about the gatekeepers, their action, and particularly why Mrs. West's ominous family and personal history may not have been probed.

Was this a matter of the convergence of several risk factors combining to create an unsurmountable burden for the heart and lungs?

That January 11th LA Times article also revealed that "West had vomited during intubation (insertion of anesthetic air tube into the lungs)" and that "pneumonia was found in West's lung." This is very significant because while apparently the Coroner did not see a major pneumonia which would have on its own caused death, it may be that the pneumonia present was yet another burden upon Mrs. West's borderline heart function. Also significant was the speculation by a surgeon, not participating in Mrs. West's care, that "she has a tight dressing (on her chest) and then you're adding a pneumonia that decreases oxygen. That puts a further strain on the heart."

I think that's a plausible theory based on what we know to date.

Assuming that, indeed, there was a tight, or possibly overtight, compression dressing on the chest, the site of the breast surgery, then, that is another factor that might have conspired with the aforementioned unsatisfactory heart and blood vessel pathology that paved the road to a tragedy.

Let me expound on this theoretical scenario. The patient enters the operating room with underlying medical conditions that, of themselves, under non-strenuous, non-stressful daily activity are not necessarily incapacitating. While, technically, the surgery goes well, the anesthesia experience is less ideal because some vomitus is inhaled into one or both lungs. During surgery, apparently there is adequate lung function, but perhaps that was because respiration was aided by a mechanical ventilator. Without such technical supplement, the lungs may have demonstrated themselves to be functioning sub-par.

The heart and lung performance is different during recovery, however. First, the possibly pneumonia-impaired lungs may not be ventilating adequately. Additionally, lung excursions may be limited due to the tight chest binder-dressing. Then, add to the mix the possibility that the breathing is further suppressed by pain medications and sedatives. Should that be the scenario, lung function is now considerably sub-optimal and this has a bearing on how well the heart functions. Because the heart relies on a generous supply of oxygen-rich blood coming to it from the lungs, should that percentage of oxygen saturation of the blood supplying the heart itself be inadequate, the heart may fail.

Apparently and unfortunately, in the home where Mrs. West was recovering, there was no oxygen monitoring equipment. And while pulse and blood pressure are helpful parameters to gauge how patients are doing, they are relatively crude. The far more sensitive function of how well the patient's heart and lungs are functioning is an automated oxygen saturation monitor.

In summary, therefore, for the patient whose heart function is borderline, when the lung system is compromised by pneumonia plus possibly inadequate ventilation due to dressing constriction plus reduction of the rate of breathing by medications, the stage is set for a constellation of events that can lead to death.

Related Topics:

• Cosmetic Surgery: Are You a Good Candidate?
• The Pre-Op Appointment

Technorati Tags: Donda West, heart disease, hypertension, surgery risk factors, obesity, autopsy