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:
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:
Technorati Tags: Donda West, heart disease, hypertension, surgery risk factors, obesity, autopsy
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:
- The surgeon
- The anesthesiologist
- The patient's personal physician
- An outside, independent family practitioner/internal medicine specialist, who is recruited specifically to perform the examination.
- 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:
Technorati Tags: Donda West, heart disease, hypertension, surgery risk factors, obesity, autopsy
