Posted on 03/27/2008 8:43:35 PM PDT by neverdem
Stephanie Kuleba's motto on her MySpace page was "live your life."
But hers was cut tragically short after something went terribly wrong Friday in a doctor's office where she was undergoing breast surgery. The West Boca High School cheerleader, 18, died Saturday from complications during surgery to correct asymmetrical breasts and inverted nipples, after being rushed to Delray Medical Center Friday morning.
According to her family's attorney, a rare and silent condition called malignant hyperthermia could have killed the popular teen, who was looking forward to her senior prom and heading to the University of Florida.
The condition is triggered by anesthesia. Symptoms include rapid heart rate, muscles that become rigid, and a fever of 110 degrees or higher. The condition is reversible if recognized and acted upon - usually within 30 minutes of onset - with Dantrolene, the only known antidote, said Dr. Henry Rosenberg, president of the Malignant Hyperthermia Association, whose organization fielded a call to its hot line about Kuleba's case.
Although he could not talk specifically about Kuleba, Rosenberg said the association generally helps callers assess the situation, see what's been done, and answer any questions.
"This isn't a common event, so when you are dealing with this unusual problem it's nice to have someone who has expertise," he said.
Malignant hyperthermia is an inherited disorder and generally those who have it don't know they do until they are exposed to certain anesthetics.
There is no simple, straightforward test to diagnose the condition, said Rosenberg.
Response slow, lawyer says
Prior to the discovery of the antidote, about 80 percent of those who suffered from malignant hyperthermia died. But today it's more like 5 percent.
"There have been patients who have survived because people were well-prepared," Rosenberg said.
The surgery was performed by Dr. Steven Schuster, a board-certified plastic surgeon, in his Boca Raton medical office.
"I am devastated by the loss and I feel for the family," he said Tuesday in a statement.
It's unknown whether Schuster's practice had Dantrolene on hand. The drug, which has a shelf life of about three years, isn't cheap. It costs about $2,200 for 36 vials, the dosage needed for a single treatment, Rosenberg said.
"It's like an insurance policy. You hope you never need it, but when you do, you do," he said.
As Kuleba fought for her life Saturday, West Boca High cheerleading coach Victoria Briggs said, her team gathered at Delray Medical Center. Since her death, they have spent every moment together in order to comfort and support one another.
Every person who has ever cheered at the school is wearing a team jacket this week to honor Kuleba.
"I called her sunshine, because that's what she was," Briggs said. "We're missing her. She was the captain. She was our leader. She was my right hand.
"It's like our sunshine has faded away," she said.
Doctors won't know for sure the exact cause Kuleba's death until the results of an autopsy are in, but the Kulebas' attorney, Roberto Stanziale, told reporters Tuesday that he believed the fatal complication could have been prevented.
According to Stanziale, Kuleba's surgery began at 8:05 a.m., and paramedics were not called until 9:45 a.m.
"If in fact the medical examiner does come back and indicates to us that the cause of death was malignant hypethermia, the questions are now going to be: 'Why wasn't she diagnosed quickly? Why wasn't she administered Dantrolene? And if she was administered Dantrolene, was it done at the appropriate times and in the appropriate dosages?' " Stanziale asked.
The American Society of Plastic Surgeons has a database of 1.4 million plastic surgery procedures performed in accredited outpatient surgery centers and it has never seen a case of malignant hyperthermia, said Dr. Michael McGuire, a spokesman for the society and an associate professor at UCLA.
Rosenberg, of the Malignant Hyperthermia Association, said statistics are hard to come by and range from one in 5,000 to one in 60,000.
"We just don't have good data on this," he said.
Cosmetic surgery has risks
Records show Schuster has never been disciplined by the Florida Board of Medicine.
A formal complaint would have to be filed against either him or the anesthesiologist, who is said to have been present during surgery, before the board would initiate an investigation in this case, said Eulinda Jackson, deputy press secretary for the Florida Board of Health.
Experts note that Kuleba's death also serves as a reminder that any surgery, no matter how commonplace, has its risks.
"We have become sanguine about this, it's just a lift, a tuck, an implant. But at the end of the day you are still cutting someone open and doing something that's ordinary only after it's a success," said Kenneth Goodman, director of the University of Miami's bioethics program.
Despite the risks, the number of cosmetic procedures has skyrocketed in recent years, particularly among those 18 and younger.
More than 333,000 adolescents 18 years or younger underwent plastic surgery and cosmetic procedures in 2005, according to the American Society of Plastic Surgeons. Breast augmentation was one of the most popular.
In 2007, there were 10,505 breast augmentation procedures performed on 18- and 19-year-olds; up from, 9,104 the year before. Another 1,700 teens between 13 and 19 underwent breast lift surgery.
And it's not just teenage girls undergoing breast surgery. Close to 14,000 males between the ages of 13 and 19 underwent gynecomastia, or breast reduction surgery, in 2006.
Asymmetrical breasts is a not uncommon problem for many women, McGuire said.
"For the individual, it can be a real social issue, especially in the teen years," said McGuire, who has performed plastic surgery on teenagers.
"There are procedures that are very appropriate in the teenage range, but it depends on the individual," he said. "The vast majority of these people are suffering and want to be able to wear normal clothing, to wear a bathing suit and interact with their peers."
My wife was a La Leche League member and helped many women breast feed who had inverted nipples and as far as being symmetrical, I would rather be asymmetrical and alive than any other option. I guess what I am saying is that surgery certainly was not the best option in this situation.
I cant believe people are so vain, and my guess is there probably was only 1/2 a cup size difference.
My daughter had the worst breast asymmetry that anyone including the doctor who did the surgery had ever seen. She had surgery to correct it when she was 20. Tragic that this girl did not survive.
Those facts put this case in a very different light. This wasn't just some girl getting bigger breasts, there was more to it than that.
Very sad.
It sounds like a very good surgeon was simply not prepared for this rare condition, and screwed up the management of this surgery gone wrong.
And you know that how?
you would think with inverted nipples you would have less embarrassing moments when it gets chilly.
I would not have surgery anywhere but a full service hospital.
teenage girls are vain
My take: one should NEVER undergo elective general anesthesia outside of a name medical center. That means Stanford, Chicago, MGH/BethIsrael/Brigham, Hopkins, Cleveland Clinic, Texas Heart, and, under certain circumstances, a few others. Why any adult (the victim in this case barely qualifying, since she was only 18, after all) would voluntarily let themselves be knocked out in some private office or second rate medical center is beyond me.
Not having Dantrolene on hand at a site doing general anesthetics with volatile anesthetic agents and probably Succinylcholine is unthinkable, and most likely an automatic judgement against all involved.
Oh yeah, and another thing. There’s this line:
“The American Society of Plastic Surgeons has a database of 1.4 million plastic surgery procedures performed in accredited outpatient surgery centers and it has never seen a case of malignant hyperthermia.”
Just to drive the significance of that home, the article also includes this helpful bit of information:
“statistics [on the number of malignant hyperthermia cases] range from one in 5,000 to one in 60,000.”
Inescapable conclusion? There’s something wrong with the American Society of Plastic Surgeons data. I don’t know what the problem is, though I would bet that the data consists purely of voluntary submissions from plastic surgeons, who simply haven’t been mentioning untoward events. If that’s so, then the ASPS data is likely useless for any application, other than figuring out what the ASPS members want you to think.
MH is not the easiest thing in the world to diagnose...if you are not paying colose attention AND have a heightened sense of awareness that a la, you can get behind the 8 ball very quickly. It is an exceedingly rare condition.
Couple that with the fact that they were in a Doctor's office where staff was probably 'short' (treating a MH crisis is an 'all hands on deck' situation, and requires manpower and assets that an 'office-based' center might not have available), and that compounds the problem. Anyone that has ever treated a case or potential case of MH knows of what I speak.
It sounds like a very good surgeon was simply not prepared for this rare condition, and screwed up the management of this surgery gone wrong.
Most surgeons wouldn't know MH if it hit them upside the head with a 2X4...this was the Anesthesiologists call/responsibility to diagnose and initiate treatment, but in all likelihood, it was a no win situation from the onset.
That is ridiculous! Do you realize that medical care would come to a standstill under your criteria? Most of the time these clinics are completely safe. The condition (if indeed that was the problem) is rare.
No, it’s not an inescapble (?) conclusion, and there is not anything necessarily wrong with the plastic surgeon societies data.
Asking about family history of MH, which is an inherited disorder, can catch a lot of potential susceptible patients who then get sent to a hospital for their care before even undergoing surgery at a smaller clinic/center.
And, I have more problem with the MHAUS data of 1:5000 to 1:60000...I’ve been doing anesthesia for 19 years, and have initiated MH treatment on ONE patient (who in the end probably didn’t have the disorder but I do not know for certain since they refused testing post-op).
apparently there is a non-surgical method for correcting inverted nipples.
http://www.aventamerica.com/products/breastfeeding/breastfeeding_niplette.asp
It sounds like a very good surgeon was simply not prepared for this rare condition, and screwed up the management of this surgery gone wrong.
"A formal complaint would have to be filed against either him or the anesthesiologist, who is said to have been present during surgery, before the board would initiate an investigation in this case, said Eulinda Jackson, deputy press secretary for the Florida Board of Health."
That implies an anesthesiologist was there or on call with a nurse anesthetist present. Something isn't kosher. Patient undergoing general anesthesia have vital signs monitored in real time including temperature. If malignant hyperthermia is the final diagnosis, then it better be something like an electronics malfunction in the thermometer or its temperature printout.
hmmm...looks like one shouldn’t have surgery requiring anesthesia in an office setting.
Insist on having it done in the hospital - certainly the hospitals will have this antidote in stock.
Thanks for the link.
“Those facts put this case in a very different light. This wasn’t just some girl getting bigger breasts, there was more to it than that.”
And you know that how?
Answer: Because an interested party told you this, as though this removes the frivolous reasoning for the surgery. Was her newborn having difficulty maintaining weight due to inadequate lactation?
You sound like good fodder for a plaintiff-chosen juror. Please tell me it is not so.
Then again, she could have died in a car wreck on her way to school, or from any of a number of causes. Things happen in life. Given the choice I’m sure she would choose the same as you did. Unfortunately, she didn’t know that was the choice she was making. It’s a sensational news story, but really, it’s just another tragedy among many that happen every day.
Read the article: she was looking forward to her senior prom. Gotta have PERFECT breasts for that.
[donning flame-proof suit]
Rosenberg, of the Malignant Hyperthermia Association, said statistics are hard to come by and range from one in 5,000 to one in 60,000."
Sounds like way too much discrepancy here. "
I personally think that to attempt to make jokes about a dead woman's deformities indicates a totally sick, perverted mentality at work.
Is there some VS that triggers you to react. A certain HR or temperature, muscle rigidity or some combination of the three? The treatment is 36 vials? How is that administered or is it case sensitive?
What’s sad is that I guess she felt she needed this surgery to be normal.
It’s a myriad of things...but the earliest signs are usually unexplained tachycardia (which can be mistaken for ‘light anesthesia’), and an unexpected increase in expired (end-tidal) CO2 (indicative of increased metabolic rate) which usually cannot be remedied with increased minute ventilation. Somewhere along the course the patient will usually also develop mottling of the skin, muscle rigidity, cardiac arrhythmias and profound acidosis...the temperature increase is usually a relatively late sign.
Each vial of Dantrolene contains 20 mg in powder form which must be re-constituted to an injectable solution with water...and it needs to be shaken for quite awhile to get it dissolved as it is ‘relatively’ insoluble...for an average size person at a dose of say 2.5 mg/kg that means that you might need to dissolve say 7-10 vials of the stuff...hence why it takes a LOT of manpower to assist..and this is only a ‘starting dose’, as you basically give the stuff to the patient until the symptoms subside. It can take a number of people doing nothing but reconstituting the drug for the anesthesiologist to administer.
It’s kind of involved to go through the whole thing here, but that’ll get you started...
Please, don't make assumptions about things you obviously know little about.
If you wait for the rise in temperature to make the diagnosis of MH, the horse has already left the barn...in all likelihood the patient will die if not acutely then a bit later from associated end organ damage which will already have occurred.
apparently there is a non-surgical method for correcting inverted nipples.
______________________
A determined baby can work wonders.
When I was a young woman I didn’t even realize I had inverted nipples until I was pregnant and a doctor pointed it out - I didn’t have to compare myself to other women in that way. Now they get surgery on intimate parts just to “date.”
A young woman I know told me that her boyfriend told her that men don’t like to “date” girls who haven’t had the full wax job down below. More porn-level competition that we didn’t have to worry about 20 years ago, just to win a boyfriend, not even the commitment of marriage.
Mrs VS
I had a friend, an athlete, who was to undergo knee surgery for a meniscus problem. He was young and healthy, but after the anesthesia, he experienced malignant hyperthermia. He nearly died, and was in intensive care for a day or so while recovering. Luckily he was in a traditional hospital, they recognized what was happening and he received immediate intervention. Interesting thing was he later found out there was a “genetic” component to this condition and years ago his mother had had a similar reaction to anesthetic, but hadn’t realized it could be genetic, so they hadn’t communicated that to the physician.
Between me and my family we have had three different procedures at this site. All have been satisfactory. This was a terrible, terrible tragedy resulting from a rare situation.
Hopefully measures will be taken in the future to avoid a repeat of this incident.
"I would not have surgery anywhere but a full service hospital."
My thoughts exactly! There just too many things that can go wrong and I can't imagine that a doctor's office, no matter how well equipped, could be prepared for any and all eventualities.
Thanks a lot for the info. :)
And any surgery is more risky if conducted in a "clinic" which often is not much more than a doctor's office with a full sized operating table.
I had one friend die and another who was saved after his heart stopped during minor operations in these "clinics." As mentioned in the article these facilities have to rely on 911 for medical emergencies since they have no emergency equipment or procedures in place.
Weren't there lots of comments regarding the idea that high school girls are now getting boob jobs?
This does not sound like a Pamela Anderson kind of surgery.
A set of braces probably costs nearly as much from your local dentist. Lots of 'vain' people get those also.
How crooked to somebody's teeth need to be before you will judge them for being too vain?
Wow, Sherlock. Great detective work.
She was looking forward to prom! Great observation. How strange of this girl.
She deserves our scorn.
/s
There are those of us who do feel we need surgery to look “normal”. I can’t tell you the embarassment I felt as a competitive swimmer wearing a skintight lycra suit when I was young and it carried over to my adult life. At age 36 I finally decided to do something about it and visited a plastic surgeon. Best thing I’ve ever done for myself. Dr. explained that there were actually medical terms for my condition and performed surgery.
It may not be for everyone but I don’t regret it for a moment.
I have malignate Hypothermia as well. I almost died once from it. That is how they discovered it. This is so sad.
No, the surgery isn't 'more risky' if conducted in a clinic or surgery center. What changes is the odds of recovery from a serious event may be less...this is why these centers conduct screening for appropriate patients and appropriate proceddures, and refer patients who do not meet outpatient criteria or who are having more involved surgery to larger hospital centers.
I had one friend die and another who was saved after his heart stopped during minor operations in these "clinics." As mentioned in the article these facilities have to rely on 911 for medical emergencies since they have no emergency equipment or procedures in place.
The sad thing is that people die every day...they die in their sleep, they die cooking dinner, they die driving home from work...sometimes they die in a medical clinic too, and then something is always assumed 'wrong' with the clinic. You may be correct, and the clinic/provider may be at fault, but that is not necessarily so. I've seen people's 'heart stop' having as mundane and routine a procedure as having an IV placed or blood drawn due to a profound vasovagal response. For most, this would be a relatively innocuous stimulus ...so what? That is an inherent PATIENT problem, not the fault of the person performing the procedure for the most part...I've seen it in hospitals, surgery centers and outpatient clinics.
And as to the last part, that these facilities have to 'rely on 911 for medical emergencies', well....DUH. They aren't hospitals and aren't staffed or equipped as such...it's why they can offer services for less money in most cases. They are held to different standards by different government/regulatory agencies which function to ensure that certain minimum standards are met to deal with MOST eventualites...but nothing is perfect. Local hospitals also rely on 'emergency services' to medevac cases that they cannot handle to major teaching centers...do you want to avoid them too in case you are the 1:100,000 patient that develops some problem they cannot deal with?
Further, I can almost guar-an-damn-tee you that the clinic/surgery center had emergency equipment AND procedures in place...all of these health care facilities that do surgery are closely regulated by local/state/federal authorities and inspected on a regular basis. This however does not guarantee outcomes from all possible medical disasters.
So many on this thread are far too quick to jump to conclusions that make no sense whatsoever based on the presented facts, but I guess that's human nature. If this precious child had been killed driving to school or work, no one would bat an eye because, well, that's just a risk of living life...I doubt many would be making life changing decisions regarding their driving habits, and up until she entered that facility to have her procedure, her odds of dying in a car crash were probably greater than the odds of her dying from an MH episode.
As an adult, I can understand it, but this was a young girl, not really even finished growing. There are so many prosthetics available these days, for women who have had cancer, and don’t want reconstructive surgery. It’s too bad someone couldn’t convince her to wait just a few more years.
And they never tell you whether or not the OR is equipped with a BIS monitor. Using that sort of monitor enables the anesthesiologist to give the right amounts of medicine and will also determine whether or not the patient is actually awake during surgery. If memory serves me right, people with red hair are more apt to be the ones who can be awake during surgery. I saw a story about this monitor about 10 yrs. ago, so it’s nothing new.
http://www.google.com/search?hl=en&q=%22bis%22+%22surgery%22
"These centers" obviously fell short of your expectations in at least two cases. One person died because the "screening" didn't show potential problems. The other had to be resurrected because, after the procedure, the anesthesiologist gave him a shot which stopped his heart. If the clinic had had a defibrillator and someone who knew how to use it there may have been a lot less trauma for the patient as well as the anesthesiologist.
Yes, people die all every day. When they die as the result of a "minor" procedure there is always a question as to whether they were given all of the care and treatment they should have expected. I doubt that many doctors explain that the procedure can be done cheaper in a clinic at a higher risk the the patients life. On the other hand that "explanation" may be buried in the dozens of papers one signs at admittance and at various other times during the journey through the system. In fact I remember signing a form recently that explained the possible "side effects" of the operation. They went something like "headaches, soreness, dizziness, ...., death." Pretty comprehensive.
I'm not in academics, so on a typical workday for me I would bet I average 7-8 cases/day....and that's for the days I'm in the OR.
60-70% of the time, I am providing 'medical oversight' to as many as 5 CRNA's doing their own cases, so on those days I might have exposure to 30-40 cases/day.
Personally, I would put the estimate of MH incidence at the 1:60000 number or even somewhat higher...but what Dr. Rosenburg and I are referring to as 'MH' incidents may be different. What I mean is that the range of clinical symptoms exhibited for an MH patient can range from isolated masseter mucle spasm or trismus to full blown MH as seen in this case. I'm referring to incidents of MH that require Dantrolene treatment. If you include patients that develop masseter muscle spasm from succinylcholine as all being 'susceptible' to MH, as some academic anesthesiologists contend (but this is not universally accepted), you will increase the number of people classified as MH susceptible and the number of reported 'MH' cases (not all reported cases require treatment).
And, IIRC, the ASPS said that they never had a documented case of MH in the 1.4 million cases done at accredited outpatient surgery centers. As I tried to mention earlier, since MH is an inherited disorder, careful questioning of patients and families regarding anesthetic problems or complications can identify a significant number of 'potential' MH patients ahead of time allowing either referral to a hospital setting or the use of a non-triggering anesthetic....this will reduce the number of cases of MH seen in the outpatient surgery centers.
It's a bit complicated, and I'm not sure I'm doing a good job explaining it either...but I for one do not find the ASPS claim to be particularly unbelievable.
Ahh...the BIS monitor....
This monitor was brought out purporting to decrease the incidence of awareness under anesthesia....which was a crock....this monitor has NEVER EVER been shown to decrease the incidence of intraoperative recall in 'low risk for intraoperative recall patients' (which would include probably greater than 95% of all surgical procedures). As a matter of fact, there were some studies that suggested that using the BIS increased the incidence of recall in low risk patients, because anesthesia providers were using this monitor to tailor the delivery of anesthetic agents even though no one ever has shown a correlation between BIS analysis and memory supression.
What is really somewhat comical is that since the BIS monitor has been shown not to be effective for preventing intraoperative recall, now they are marketing it as a device that can save money by allowing the use of less anesthetic agents...but there's one big problem...I can do a general anesthetic for less than $20 of agents, and the BIS probes cost about $17 a piece (last I checked when they visited us about a year or so ago to sell us the monitors). So, unless they allow me to cut the cost of my anesthetic agents by 85%, they aren't being very cost effective for routine use. We have two BIS units, which are used for high-risk for intraoperative recall patients such as stat/crash OB patients and open heart/trauma etc patients...it might have a role in those instances. Go ahead and Google BIS monitor increased awareness and do some reading.
I’m not heaping scorn on anyone, merely making an observation from the available facts. Girls used to buy a new dress for the prom, not new breasts.
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