Is Canada's health system overdue for an "Extreme Makeover"?


I've pointed out here on Plastic Surgery 101 that despite the dysfunction of the American health care system, the alternatives in other western nations have their own problems. In 2007 I posed the question "So You Think You Want Universal Health care?" and featured Dr. Val's review of "Sicko" which glowingly featured other countries' systems.

It was particularly interesting to me to see the "religious conversion" of one Claude Castonguay on this topic. Who is Claude Castonguay? He's the father of Canada's socialized medicine program. After four decades, he finally admitting that the system he laid out for Canada is failing to meet both the medical needs of beneficiaries as well as the budget needs of the individual Canadian provinces. Castonguay now advocates contracting out services to the private sector and American-style co-pays for patients who want to see physicians.

For an interesting overview on this, read the Investor's Business Daily editorial page article "Canadian Health Care We So Envy Lies In Ruins, Its Architect Admits". The Canadian author, David Gratzer, has written extensively on Canada's uneasy relationship with their countries health program.


Rob

Swedish Woman Marries the Berlin Wall

While we are featuring June brides, undying love, and weddings, we could not help but notice the following headline:

Swedish Woman Marries the Berlin Wall

Well, okay, you’re hearing a lot right now about June brides because, well, it’s June!

And we blog about it here because everybody who gets married or falls in love wants to look good for the object of their affection and often take advantage of rejuvenation surgery.

But love, and those ensuing nuptials, can take many forms.

Moreover, it’s not always a guy and a gal that marry. For instance, you may be reading a lot about gay and lesbian marriages becoming legal in California. And some people afflicted with a strange new obsession known as objectophilia, become fascinated over, fall in love with, and even marry inanimate objects.

Like Eija-Riitta Elkoef-Mauer, a Swedish woman who first visited the Berlin Wall in 1979. She legally changed her name to “Berliner-Mauer” (German for “Berlin Wall”) after visiting six times and then declaring herself legally wedded to the concrete and barbed wire structure. And, yes, she was just crushed (no, not literally) when the wall came tumbling down. Read more.


Berlin Wall before its (his?) nuptials.
(Stefan photo)


On her website, the bereft Eija explains: “My husband’s job was to divide East and West Berlin. He’s retired now.”

Meanwhile, a woman in Germany whom Spiegel Magazine will only identify as Sandy K., claims to have fallen in love with New York City’s World Trade Center Twin Towers when she was eight years old. (Why is it distant things are often so-o-o-o- much more attractive?) And Sandy, too, felt let down on 9-11. She didn’t even have a chance to get engaged.


The former World Trade Center in the background in New York City
(New York Tourist Authority photo)


The Canvas blogger observes a plot line about objectophilia was used in T.V’s Boston Legal when one of the lawyers mentioned he had a client who had been in love with an electricity switch box. And one blogger Storyteller mentions a woman who was so attracted to a new ‘fridge that she wanted to get intimate with it. (If you have any technical questions about that, please hesitate to ask. I can’t figure it out either.)

Despite a dearth of weddings, objectophilia is probably a real phenomenon because there is even a movie, Lars and the Real Girl, about a lonely but sensitive man who falls head over heels for a mail-order, inflatable doll.

Well, love may conquer all but it sure won’t provide plastic surgery for that love interest! Hey, she’s already plastic! Besides, she doesn’t heal well. There’s also a priest in the movie who often smiles indulgently at the 27-year-old who totes around the plastic love doll. But we won’t give away the surprise ending!


Lars and his significant, inflatable, other. A more attractive match
than with the Berlin Wall, huh?
(Amazon.com photo)


We were curious if maybe these people get their noses fixed to look better to their significant others? Then again, the ‘fridge (or wall, building or electric box) doesn’t care if your nose is long or short. As far as I can tell, those items don’t care about anything.

But hey, this obsession is really not so strange, after all. If you see the motion picture version of Sex and the City, you’ll find four seemingly sane professional women who have raised footwear to the level of passionate desire. And what about Imelda Marcos? Didn’t she have something like 97 zillion pairs of shoes?


(Squidonius photo)

Next: Top 10 Weird Uses for Botox

Dr. Zenn flamed in Freakonomics plastic surgery Q & A session


Little did Duke University plastic surgeon, Dr. Michael Zenn, know what he was in for in a recent Q&A guest appearance in the Freakonomics Blog column in the New York Times. Out of about 20 questions on a range of subjects he responded to, he made the "mistake" of accurately discussing a single innocuous question about breast implants.
Q: Would you endorse cohesive gel instead of silicone due to the concern over safety issues of silicone? Or do you believe that was all just hoopla? Is it true that breast implants should be redone every 5 to 10 years?

A: Today’s breast implant options are saline or silicone. Saline implants are a silicone shell filled with salt water, silicone implants are a silicone shell filled with cohesive gel. Both implants are equally safe, both have the same safety profile.
The Institute of Medicine found that much of the concerns were hoopla — except for the problems that they both have: rupture, scarring, and infection. Most plastic surgeons and patients will tell you silicone just feels better. Implants are replaced when one of the above problems occurs


Skip down to the comments section and you'd think he was advocating beating your wife as nearly 5 out of every 6 comments are by breast implant "survivors" wailing alternately on his intelligence, character, and ethics. Ah, the wonders of the Internet to organize like-minded partisans into rapid response teams!

Much like the autism vaccine conspiracy theorists, the breast implant siliconistas come off looking out of touch with such reflexive outrage on command, particularly when you recognize the kind of heavy duty microsurgical and reconstructive surgery practice that Dr. Zenn is known for at Duke. He's one of the good guys for Pete's sake!

There's intelligent reasons to object to breast augmentation surgery, but claiming it caused symptom or disease "X,Y,Z...." is a dead horse that's been buried several times over! For a refresher see here and here to recap the comprehensive 2007 landmark review.

Rob

Follow up to a question on breast cancer

I got a question about some of the ideas I was talking about in my last post on how I think about breast cancer. A breast cancer patient wrote me and asked about the difference in how her oncologist explains things
"They quote an 80% recurrence free 10 year survival rate for stage IIA and 75% for stage IIB. I'm stage IIA and my onc says I am probably cured (after surgery, chemo, etc.).

Do you really think all node positive younger women are destined to recur?

Another question: how do you compare positive nodes with lympho vascular invasion? My onc says that there is no data that LVI is as negative an indicator as nodes."


I think it's important to understand that not all breast cancers of stage "x" are created equal, and the biologic "aggressiveness" of a tumor can really skew your personal risks. I talked about 3 of the more important factors (node status, estrogen receptor status, and tumor size), but you've also got histologic characteristics (like tumor grade) and other genetic markers (like HER2/neu) in the mix. Some % of these patients also identified or unidentified inherited genes or mutations which increase their risk substantially for breast and other cancers.

There were two competing worldviews of breast cancer in the classic "Halsted Model" (breast cancer progresses from local->regional->systemic disease) and the "Systemic Model" (breast cancer is already systemic at the time of most diagnosis). I found a nice summary of these ideas on this old newsgroup post for those interested. Personally, I split the difference in my head in that I think that if you're node negative with favorable histology the Halsted model is still true, and that a true absence of residual cancer is possible. If you have nodes involved I'm inclined to believe the Systemic Model in that you have already likely have had some cancer burden establish elsewhere. This is supported by the fact that metastatic breast cancers still show up decades after mastectomy on occasion with no local or regional recurrence of the original cancer preceding it.

Younger breast cancer patients are particularly worrisome in that you have some many decades left of potential exposure for recurrence or new primary breast cancers. It makes absolutely no sense to me to push breast conservation (lumpectomy and radiation) for all but the most favorable invasive cancers in women in their 20's or early 30's. I think maximum risk reduction should be advised for many of these women with bilateral prophylactic mastectomy.

For stage II/III breast cancers (those without systemic mets) the data's a pretty slippery slope where 10 year survival curves run from 70-78% in the more favorable patients to 20-40% depending on grade, size, and # of nodes. This data is laid out nicely at this British Cancer site. Keep in mind that all 3 of those factors are subject to sampling error, and that some of the stage II patients are actually stage III.


There's a great article in the Atlantic magazine "Good News and Bad News About Breast Cancer" from a decade ago which is much more eloquent then I am trying to be reluctant about telling people they're "cured" from breast cancer. It features some of the work by one of my professors, the late Dr. John Spratt from the University of Louisville, who was really visionary in describing tumor's behavior and growth clinically

Breast cancer, unfortunately, is not among this select group (of tumors we can eradicate). As far as we know, a woman found to have invasive breast cancer is always at higher risk of dying prematurely than women without breast cancer. Even thirty years after her diagnosis she is up to sixteen times as likely to die of the disease as a woman in the general population. That is why responsible researchers in this field avoid the word "cure." Even as they report advances, they must acknowledge the reality: Postsurgical chemotherapy and antihormonal therapy do buy time—an important advance. The slowed progress of the disease can give a woman additional years of life and even allow her to die of other, less traumatic, causes. But breast cancer is every bit as incurable as it was in Halsted's day.


Rob

Breast Cancer primer and a new wrinkle in breast cancer treatment


There was a good article for the lay public a week ago in the New York Times "With a Tiny Bit of Cancer, Debate on How to Proceed" about the phenomena and controversy over breast cancer "micrometastasis" to lymph nodes. I do a lot of breast cancer related surgery and have this kind of discussion frequently with patients. I've tried over the years to come up with simple concepts for these women who often feel overwhelmed with ideas and terms that have been poorly explained to them.

If you're trying to keep things simple for patients with invasive breast cancer (meaning it has acquired characteristics on microscopic exam suggesting it has the potential to spread elsewhere), it's important to come up with a simple way to explain what their diagnosis really means. There's 3 things that really affect whether or not you're likely to do well when you're diagnosed with invasive breast cancer.


  1. the size of your tumor

  2. the presence or absence of cancer in your lymph nodes

  3. the presence of Estrogen hormone receptors on the cancer cells


Tumor size and nodal status are proxies for metastatic potential. A larger tumor is more likely to have spread to the lymph nodes at the time of diagnosis. A tumor present in the lymph nodes is in turn more likely to have spread elsewhere and show up again down the road as systemic terminal disease. Breast cancer, like most solid tumors that spread via lymphatic tissue, is conceptually really only "cured" if you remove it surgically before it gets to lymph nodes. This basic fact is essentially unchanged despite steady refinement in radiation (XRT) and chemotherapy (CRT) treatments for 60 years. XRT or CRT do not cure anything, but rather decrease/delay recurrence or palliate symptoms. (I'm simplifying this greatly, but that's the skinny in a nutshell).

Estrogen receptors (ER) are conceptually an "on/off" switch for normal breast tissue cells. A breast cancer cell that still maintains this normal regulatory switch offers a target for hormone manipulation. This "killswitch" provides the basis for medicines like Tamoxifen or Arimidex to show improvements in local recurrence after surgery by blocking these receptors or interrupting estrogen metabolism by essentially "starving" the tumor. We're increasingly seeing how important having this receptor is, particularly in post-menopausal women. It's looking more and more from tumor databases that many older women with ER+ tumors may be able to avoid chemotherapy altogether after surgery, and this observation is currently being tested in prospective trials. A breast cancer that's ER- (missing the receptor) suggests a more "primitive" tumor that's lost some of it's normal regulatory mechanisms and implies a worse prognosis. I found a really nice primer on this for people over at "Cancer Geeks"


BACK TO THE TIMES ON "MICROMETS"
Complicating treatment options now is our increasing ability to detect infinitesimal amounts of cancer cells (micrometastasis) in some lymph nodes that would have been labeled normal just a few years ago. Do we treat this the way we traditionally did positive nodes or are we over treating? We just don't know. It has played a little havoc with interpreting some breast cancer data that was suggesting we were doing better with our treatment.

Why? Well if you suddenly take these micromet positive patients and up the stage of their diagnosis like you would normally with positive nodes, you make both the node - and node + groups look like things are getting better. Nothings really changed except you're removing people who do worse from one group and putting them into a group of node + cancer patients where they will do better then their peers. (I cannot for the life of me think of the name for this statistical phenomena....)

Anyway, read the article (click here) as it's interesting.

Rob

Rob

June Weddings: Plastic Surgery’s Time to Shine

Liposuction and Breast Augmentation for Brides!
Facial Plastic Surgery for Mothers of the Brides!




Who is this woman and why is she pictured here?

Okay, we have joked around a lot, pulled your leg a little and brought you a ton of off-the-wall items about plastic and cosmetic surgery.

But now we bring you something that remains very much on-the-wall, as well as a serious matter to the 2.2 million* weddings that will take place in 2008: it is the…hold for trumpets sounding in the background... June wedding!

Plastic Surgery

Many wedding planners are recommending adding into the already astronomical budget for the nuptials an allowance for plastic surgery procedures, even if it’s only a vial or two of Botox. The average U.S. wedding now costs $28,000* and that’s before any surgical rejuvenations.

But don’t take my word for it. Read more about how plastic surgery has become as huge of an issue as…the wedding dress?

Back to the woman pictured above. She is Lynn Plante. Official title: Mother of the Bride. She and thousands like her are so feared and respected that even tough Mafia dons quake in their patent leathers. Woe betide he or she who crosses the Mother of the Bride and the planning of The Wedding!

Lynn is actually a brave, brave woman because she is undergoing four plastic surgery procedures so that she can look her best in her daughter’s wedding pictures which will be taken on July 18, 2008. Providing everything goes according to plan, that is. (READ: Nobody gets cold feet!)

Like General Eisenhower, who planned and oversaw the D-Day invasion, any Mother of the Bride oversees and plans an operation equally as complex. No wonder she looks worried!

The Cost of Plastic Surgery

Here’s another tidbit that tells you what a remarkable woman Lynn is: Over many years, Lynn has saved just a little from each paycheck to put toward the cost of plastic surgery, just so she can look her best at the wedding. After all, wedding pictures are handed down for generations, you know.

Anyhow, we’ll follow Lynn and the approaching Big Day while bringing you up to date on her continually improving appearance. Lynn only admits to being “in her late 50s,” so we will see how her appearance improves. Will she look 40ish in the wedding pictures? Refreshed? Rested? Younger than the Bride, maybe?


Emily Cannon on The Big Day
(Photo, Courtesy of Emily Cannon)


Read how a plastic surgeon saved the day when Emily Cannon’s breast augmentation came undone – resulting in a condition often referred to as a “uniboob” – just before her wedding.

Meanwhile: here’s my favorite wedding toast from the last (and I do mean last!) time I got married:

“Here’s to the Bride, Here’s to the Groom, Here’s to the Mother-in-law!
Let’s just hope there’s never a need for an attorney-at-law!”

--Old Irish Wedding Toast

And my favorite advice about weddings comes from actor Mickey Rooney, who walked down the aisle eight times:

“Always get married early in the morning. That way, if it doesn’t work out, you haven’t wasted the whole day!”


*Statistics, courtesy of The Wedding Report, Inc.

Conan the Barbarian's wants his breasts back.


Computer game publisher Funcom had to do some fixing of their popular online mulitplayer game when apparently a recent update of the game's software code left the female characters suddenly "breast deficient".

The MMORPG Age of Conan: Hyborian Adventures features partially nude female character models. Based on the original stories by Robert E. Howard and brought to the big screen in 1982 by Gov. Arnold Schwarzenegger, the game takes place in the fantasy world of Hyboria, which combines fantasy elements with strong sexuality.

This issue has caused controversy all over nerd-dom with hundreds of messages left by players demanding Funcom bring their boobs back. Seen below is a pair of images whose player felt like they'd had a mastectomy.






"Funcom can confirm that some of the female models in the game have had the size of their breasts changed. This is due to an unintended change in data that was introduced in an earlier patch, data which controls the so-called morph values associated with character models and the size of their respective body parts. We are working on a fix for this and your breasts should be back to normal soon. The plastic surgeons of Hyboria apologize for the inconvenience."


Well at least they have a sense of humor about it!


Rob

Top 10 Most Outrageous Plastic Surgery Items

In any new industry, many novelty items are developed early, and quickly put into use by adoring fans and then go the way of the Dodo bird.

For instance, cars once had little ovens attached to their exhaust manifolds for cooking while you travel. When steam powered cars were popular, just after the turn of the 19th century, one thoughtful auto maker installed a steam-powered organ as a pricey option in the backseat.

But, alas, roadside restaurants came into vogue, eliminating the need for cooking while driving and car radios made any type of traveling musical instrument unneeded.

You can find the same trend taking place in rejuvenation surgery worldwide.

So, if you don’t look quick, these top 10 plastic surgery novelty items may be gone before you know it:

1. Breast Massage Robot


(Inventorspot.com illustration.)

Its purpose doesn’t seem real clear, but this machine from China purports to automatically massage the breasts of the person sitting in it. One of its supposed uses is to relieve the post-op pain associated with breast augmentation.

2.Cool Mask


(Aqueduct Medical photo)

Sure, you could do the job with a bag of frozen peas flopped on rejuvenated eyelids or a freshly lifted mid-face, but it’s much cooler -- both stylistically and thermally -- to circulate cold water through a high-tech device to remove any surgical sting. Besides that, what’s wrong with going incognito? Do you want everybody to know about your surgery? The incognito thing apparently worked well for Zorro and the “Phantom of the Opera”; let’s just hope bank robbers don’t start using them!

3.Patented Baldness Technique


(Inventorspot.com illustration)

Another invention registered in the U.S. Patent and Trademark Office lays claim to the technique we now know as the “combover” to conceal baldness. Sure, you could call it The Donald Trump, but that name is also trademarked and copyright protected. And woe betide he or she who misuses that moniker! The Donald would hire you just for the pleasure of firing you!

4.Traveling Hair Scrap Book


(Academy of Natural Sciences photo)

While we’re on the topic of hair, one thing every school child has always wanted to see: 200-year-old locks of hair from the first 12 U.S. presidents. Those snippets were taken long before anybody ever thought of hair restoration or, apparently, hair dye. For instance, George Washington’s sample is brown-gray, while Thomas Jefferson’s locks are reddish-gray. Titles weren’t exactly nailed down yet either. The second U.S. president was known as “His Excellency, John Adams.” Monroe, John Quincy Adams, and Jackson were also “His Excellencies.”

5.Roll CIT device


(Des Fernandes, M.D. photo)

If you perceive this to be a shrunken model of the lawn device that rolls across your grass to create drainage holes, you’ve got the concept. But this gizmo is approved for home use; you just roll this across your face as it is slathered with some vitamin A and other minerals. The Roll CIT (“Collagen Induction Therapy”) apparently replaces the need for chemical peels, dermabrasion or laser ablation. The device makes hundreds of tiny needle holes to allow fresh collagen to flow to the surface, thereby removing sun damages, fine lines, wrinkles, acne scars, and other facial marring.

6.Vacuum Pump Breast Augmentation


(Daily Mirror photo)

Above, notice we’ve carefully airbrushed the model’s actual, ah, mammary glands to make this fit for family viewing. The vacuum device -- basically two plastic domes connected to a suction machine --- claims it can replace surgical breast enlargement. But you had better have some time on your hands. Apparently, all m’lady has to do is wear it for 10 hours a day for 10 weeks. Presto! A/B cups morph into C/D cups, sans knife, surgeon, recovery period, or great expense. And not to worry! It’s all connected to a micro computer that won’t make you too large. The system is advertised in Britain at 790 pounds, which amounts to $1,539 U.S. smackers. Read more.

7.Lip Pumper



Not only Hans and Franz from the old Saturday Night Live “vanted to pump you up.” Yet another plastic surgery device -- pictured above -- claims it can pump up your actual kissers. And you don’t have to use it for 10 hours a day to get lip augmentation!

8.Breast Implants for Tattoos



(Remember, we are not making this up.) But the leading technique of getting real curves for his tattoo of a woman, turned out to be -- no pun intended -- a bust. Seems a non-surgeon put the tiny implants under the tattoo but left behind some nasty superbugs that created a raging infection. Plus, one of the implants, not having much wiggle room, broke under the skin. Result? More infection! Kinda makes you think Dodo birds have not really gone away.

9.The Plastic Surgery Freeway


The Beverly Hills Freeway has been built to ease and speed the flow of traffic in and through Beverly Hills (the world Mecca of Plastic Surgery.) So, while you’re zipping along at 70 mph, you can easily see the names of some of the city’s favorite off-ramps, like “Tummy Tuck Drive” and “Liposuction Place.” Most people just call it the Plastic Surgery Freeway.

Okay, thanks for bearing with us but you’ve been had! (It’s really a picture of a refrigerator magnet.) While everything else here is 100 percent true, we did make this one up. However, do you think it’s possible that someday we might build a Plastic Surgery Freeways in other hot spots like Miami, Manhattan, Brazil, Korea, Nashville, and Columbus, Ohio?

10.Plastic Surgery Glue



Why go see a plastic surgeon when you can just pick up some droopy or wrinkled skin and glue it in back in place? (Is this for real?) And, hey, don’t you just love that it works to the last drop? I always get so miffed when that final drop of anything lets go!

Beverly Hills Rhinoplasty Blog


I'd like to direct some traffic to the really good Beverly Hills Rhinoplasty Blog. Excellent original and insightful articles without the up front promotion that plagues many Plastic Surgery/Cosmetic Surgery blogs run by surgeons.
I've enjoyed their particular focused writing on rhinoplasty and facial aging!

Rob

Something else that belongs on bull#%@*.com


I was pleased (snark!) to find out via the mail today that I am now officially one of "America's Top Surgeons" as recognized by the "Consumers' Research Council of America" (CRCA). Ever heard of it? Me neither.

What do you have to do to be recognized? Have a medical licence and a credit card to buy their over-priced cheezy swag plaques and knick-knacks to impress patients with as far as I can tell.

The sad thing is that some meaningless promotional thing like this is just as likely to get someone's attention for my skill as any of my academic awards, real diplomas, or multiple board-certification certificates.

Rob

www.bull#%@*.com - the wild,wild world of hospital rankings




US News and World Reports' (USNWR) annual hospital ranking, akin to their notorious college rankings, is kind of the king of the block for these types of rankings. Keep in mind though, there are hospitals on some of those lists that patients in some of those cities (and even some doctors who work in those hospitals) won't take their dog to, particularly in some urban teaching hospitals. (And No, I'm not naming names!)

The "leapfrog study" indexed by USNWR for rankings reviewed available data from nearly 1300 hospitals and ranked hospitals largely (as I understand it)on 4 endpoints

1. Having intensive care units staffed by specially trained doctors

2. Having computerized order-entry systems for medications and other orders with error-prevention measures

3. Performing procedures such as cardiac catheterization and caring for certain high-risk neonatal conditions

4. Having practices such as those designed to control hospital-related infections and cut down on medication and treatment errors.

It's hard to argue in theory that these are bad goals, but are these the things that patients need/want and is the information we're using to assess it accurate. A number of high profile institutions are typically included on these list which can make some doctors chuckle.


I saw an interesting editorial in the journal, Contemporary Surgery,a commentary on how confusing or misleading it is to try and figure out which hospitals, programs, or physicians are "the best". A quick review of a number of consumer oriented web sites provide significant inconsistencies -- for example, with colon resections for cancer, one hospital was ranked best by two sites but worst by the other site, and the hospital ranked best on that site was ranked worst on another, in a study reported in the journal, Archives of Surgery. Why is this so? There is no standard way of calculating quality differences, thus different sources (despite good intentions)come up with different results for the same hospitals

"What makes the 2007 Toyota Camry Motor Trend’s Car of the Year? Who decides who should be ranked number 1 in college football? Which tastes better: Coke or Pepsi? More importantly, is your hospital any good, and are you any good?...Ask patients to weigh in on their surgical experience or hospital care and you might be surprised to find out what they want (free parking). Or, what they don’t care about (board certification)."

Sites like Healthgrade, purport to offer patients some objective criteria for making comparisons between hospitals. This site ranks hospitals, surgery centers, and nursing homes based on data generated from Medicare records. Hospital rankings are based on 13 AHRQ (Agency for Healthcare Research and Quality) categories that include: decubitus ulcers, death in low mortality DRGs, postoperative hip fracture, and postoperative PE or DVT among others. The rankings are “calculated” by 100 employees in Golden, CO, using Medicare data that hospitals supply. Repeat: your very own hospital supplies the data!


If you want to get an even more confusing way to look at healthcare, you can also check out a site like Vimo.com which purports to give consumers (err......) patients comparisons for the cost of surgical procedures. As most of those numbers represent "funny money" (ie. neither the feds, hospitals, nor insurers expect to pay these imaginary numbers).

Rob

An autopsy has confirmed that the South Florida teenager, Stephanie Kuleba, who died this Spring after corrective breast surgery (reportedly for significant asymmetry and inverted nipples) suffered from a rare genetic disease that had been speculated to have causes her death. Genetic testing at the University of Pittsburgh shows she possessed the genetic mutation RYR-1 which is responsible for most cases of the malignant hyperthermia (MH) response to certain inhaled anesthetics. However, over 80 genetic defects have now been potentially associated with MH. As these mutations are inheritable, they will vary in rates among the population and some increased clusters of MH mutation carriers have been suggested in states like Wisconsin, Nebraska, West Virginia and Michigan.

The exact incidence of Malignant hyperthermia is unknown, but the rate of occurrence has been estimated to be as frequent as one in 10,000 or as rare as one in 100,000 patients who undergo general anesthesia. (A range that big suggests they have no idea to me) There is no practical screening test to determine if a patient has the rare condition so you rely on family history or consultation questions to identify high risk patients. Again, the incidence is so rare there is no way to prevent these MH events from happening. The signs that develop are usually suble (ie. a tense jaw) before they're not (ie. 104 degree temp and cadiovasular collapse).


Despite her doctors efforts to treat the Ms. Kuleba during the event with the medication Dantrolene, her parents claim her Plastic Surgeon's office was not prepared to care for their daughter once they had figured out that she was suffering from the hidden hereditary condition and have (in the great American tradition) announced their intention to file a lawsuit.

When MH is identified or suspected, time becomes valuable for salvage treatment. As soon as the malignant hyperthermia reaction is recognized, all anesthetic agents are discontinued and the administration of 100% oxygen is recommended. Dantrolene should be administered by continuous rapid IV "push" beginning at a minimum dose of 1 mg/kg, and continuing until symptoms resolve or the maximum cumulative dose of 10 mg/kg has been reached.

Kulebas' family attorney Roberto Stanziale, has said the teenager should have received as many as seven vials of the drug as an initial dose. On medical records Stanziale obtained following her death, one doctor noted she received one vial of the antidote. The other doctor wrote she received two. It's not known at what time the drug was administered or whether there was enough Dantrolene available at Dr. Schuster's Boca Raton clinic, Schuster Plastic Surgery. Both doctors have defended their actions, saying the situation was handled appropriately and that Kuleba received the Dantrolene dose needed once they consulted with the Malignant Hyperthermia Association (MHA) hotline and called an expert at the Mayo Clinic in Minnesota.

This dosing issue and it's timing is going to be a big issue in the lawsuit. You can't really give informed consent for MH as it's so rare so that shouldn't be an issue (although that will likely be claimed by a plaintiff's attorney). According to the brochure for Dantrolene, each vial contains 20 mg of the drug. As it's suggested in her anesthesiologists notes, she received 2 vials initially (40mg) while they called the MHA hotline to confirm treatment (as again it's so rare no one really has a lot of experience with treating it). That 40mg dose is in the ballpark for the recommended range (by weight) for initial treatment for most thin teenagers.

At the end of the day, I'm not sure what's going to be achieved with this lawsuit. It sure seems like reasonable steps were initiated by her doctors after the event to try and save this girls life. There is only so much you can do when unforeseen or extremely rare complications arise and no amount of preparation can prevent some bad outcomes. Contrast the hostile posture of the Kuleba family attorney with this MH tragic event during orthopedic surgery on a 20 year old described by Dr. Henry Rosenberg, President of the Malignant Hyperthermia Association of the United States. The pain of the medical staff and their communion with the deceased's family is moving.

I hope that this event will continue to foster more discussion on oversight for office-based surgery and anesthesia. It's ironic that it's actually been Plastic Surgery that been the most progressive in regulatory oversite in ambulatory surgery. While this case was an anesthesia complication rather then a surgical one, the who's, where's , and how's of who can (or should) be doing surgery is overdue for more scrutiny.


Rob
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