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.
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