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California – Internal Medicine – Smart-Lipo Planned For Seven Regions Of An Obese Woman’s Body

On 4/30/2013, a 54-year-old female (5’6” tall weighing approximately 210 pounds) went to a clinic for a consultation with an internist. The patient was interested in Smart-Lipo to her chin/neck/jowls, front and back bra rolls, upper arms, inner and outer thighs, hips, waist/abdomen, knees, and pubic regions. The patient indicated that she had previously undergone a “tummy tuck with liposuction.” The medical record did not indicate when she underwent this procedure. The patient also indicated that she suffered from diabetes and took aspirin regularly. Smart-Lipo surgery was scheduled for 5/31/2013, and the patient paid for the surgery to be performed on the 7 areas initially requested.

That same day, the patient underwent her pre-operative procedures and testing, which included blood work, an incomplete history, and an extremely limited physical examination conducted by a Licensed Vocational Nurse (LVN). The patient completed a two page “Medical Intake” form, a one page medication list, and a written consent form specifically for patients with a high body mass index. The LVN also completed a 2 page “Pre-Procedural Evaluation for Smart-Lipo” form that involved checking boxes and filling in blanks for vital signs and what areas would benefit from Smart-Lipo procedure. The patient did not meet with the internist until the day of surgery.

On 5/31/2013, the internist only performed Smart-Lipo on the patient’s chin/neck, upper and lower abdomen, and pubic areas, rather than all 7 areas scheduled. The medical records did not clearly indicate what areas the internist operated on as all seven areas were circled on a “Body Regions” form. According to the patient, when the internist first came into the surgery room, she asked the patient what procedures she was having done. The patient told the internist “it says in the file.” The internist and her assistant then had to locate the medical file. The patient’s medical records did not include an operative report or summary written by the internist about the procedure. The records did not indicate why only 5 of the 7 areas scheduled were operated on.

The patient complained that she was in severe pain throughout the entire procedure and requested multiple times that the internist stop. According to the patient, the internist told her this was the price of beauty and continued with the procedure. During the internist’s interview with the Medical Board on 12/9/2014, the internist did not remember if the patient complained about being in pain during the procedure, but the “Physician Charting” form indicated that the patient’s pain level was between a 6 and a 10 out of 10. There was also a notation in the chart that when the patient complained about the 10 out of 10 pain, she was laughing. The internist said she would have stopped the procedure if the patient asked for it to be stopped and if “I thought that she was actually in pain.”

On 6/3/2013, the patient returned to the internist’s clinic for post-surgical follow-up. During this appointment, the patient indicated that she was not sure whether she was happy with the results, that she was in pain, she was dizzy, and that she had “light bruising” to her abdomen. The patient also noted that she had a lot of post-surgery drainage requiring her to change the bandages several times.

On 9/16/2013, the internist conducted a follow-up on the patient’s upper arms, upper abdomen, and pubic region. The “Six-Month Follow-Up Report” indicated that the patient was still suffering from pain and was not happy with the results. The patient wanted the internist to fix the areas that she was unhappy with, but the report did not specify if those were all the regions where the Smart-Lipo was performed or just on some of the areas.

On 11/16/2013, the patient saw the internist for the last follow-up. During this appointment, the medical note indicated that the patient refused to allow any measurements or her weight to be taken and remained unhappy with the results. According to the note, the patient wanted her arms to “look like [the internist’s]” and was promised that another doctor could do that. The note further stated “it is impossible to make her arms look absolutely perfect.”

During the internist’s interview with the Medical Board, she indicated that she offered to do a revision on the patient’s arms, but could not promise to make her arms look perfect. The internist claimed that the patient rejected the revision surgery. There was no notation in the file that the internist offered the patient a revision surgery to try to correct the problems that the patient noted. The internist refunded the patient for 2 of the 7 regions paid for that were not operated on.

The Medical Board of California judged that the internist’s conduct departed from the standard of care because she failed to maintain adequate and accurate medical records and lacked sufficient skills and knowledge to perform Smart-Lipo safely.

For this case and others, the Medical Board of California placed the internist on probation for 4 years and ordered the internist to complete a professionalism program (ethics course), a medical record keeping course, an education course (at least 25 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine. The internist was assigned a monitor for practice and billing, and she was prohibited from practicing or attempting to perform liposuction or laser skin treatments. The internist was also prohibited from supervising physician assistants.

State: California

Date: April 2017

Specialty: Internal Medicine, Plastic Surgery

Symptom: Dizziness, Pain, Wound Drainage

Diagnosis: N/A

Medical Error: Lack of proper documentation

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

California – Internal Medicine – Excessive Wound Drainage, Weakness, And Dizziness After Smart-Lipo On 32-Year-Old Obese Patient

On 9/18/2014, a 32-year-old female had a Smart-Lipo consultation with an internist. On the patient registration form, the patient indicated that she was interested in Smart-Lipo to her upper and lower abdomen, hips, waist/flank area, back bra rolls, outer thighs, and upper arms. She indicated that she had a history of anemia, cold sores, keloid scarring, irregular periods, and depression. On the “Smart-Lipo History Intake” form, the patient indicated that she was 5’0.5” tall and weighed 178 pounds. Under a list of possible medical conditions that the patient had, the patient circled chest pain, recent weight loss or gain, cold sores, back pain, difficulty swallowing, depression, heart murmur, Lap-Band surgery in 2008, removal of Lap-Band in 2011, gastric sleeve in 2013, and removal of her gallbladder in 2014. The patient indicated that she took Latuda for depression and has an ultrasound of her heart done every 5 years.

On 12/9/2014, the patient completed a second “Smart-Lipo History Intake” form. On this form, the patient now indicated that she was suffering from anemia and “microvalve prolapse.” She also listed her height as 5’1” with a weight of 190 pounds. On the “Pre-Operative Screening” form, the patient stated that she was taking Adderall, lansoprazole, and Latuda. The patient’s weight was noted as 193.5 pounds with a BMI of 36.6. Measurements were also taken of the areas where surgery was to be performed. Blood was also collected for standard blood testing as well as an EKG. The patient also completed a Smart Lipo “Pre-Operative Screening” form/High BMI consent form. The form explained what a high BMI is, what obesity is, and why an obese patient should have Smart-Lipo performed.

Also, the form stated that the patient must obtain medical clearance from her primary care provider before the internist performed the procedure. The internist admitted during the interview with investigators on behalf of the Board that she never obtained medical clearance from any of the patient’s medical provides, despite the notation on the form. The informed consent forms were completed by the patient and an LVN. The internist never went through the informed consent forms or discussed the risks and benefits of the surgery with the patient before the day or surgery. The records also did not contain any documentation that the internist even discussed the risks and benefits of the surgery with the patient at any time.

On 12/16/2014, the internist performed Smart-Lipo on the patient’s hips, upper arm, upper and lower abdomen, and waist/flanks. On the pre-printed Smart-Lipo OR Package form, it was noted that the patient “had a light meal before coming.” The NP checking in the patient did not document exactly what the “light meal” consisted of or when it was consumed. The internist wrote that the patient had keloid scarring, but the location of the scarring was not legible. She also wrote that the patient was planning on having a tummy tuck in the future and had excessive skin laxity on her abdomen. The internist listed the patient as ASA Category I. Prior to surgery, the pictures were taken of the patient showing “bat wing” deformity of the arms (hanging skin), truncal obesity, and smooth abdominal skin contour with small keloids.

According to the progress note, the procedure started at 1:00 p.m. and finished at 3:25 p.m. About 30 minutes into the procedure, the patient complained of 8 out of 10 pain, and the comment portion of the note read ‘VV (2-3 sec).” Then about an hour and twenty minutes into the procedure, the patient reported pain on a scale of 4 out of 10. During the two-hour and 15-minute surgery, the patient’s vital signs were not continuously monitored.

During the internist’s subject interview on 3/15/2016, the internist initially did not know what “VV (2-3 sec)” meant, but she eventually stated that she believed it meant the patient had a vasovagal episode, meaning she passed out during the procedure. This is generally caused by sudden drops of blood pressure and heart rate.

According to the progress note, 10,720 ml of tumescent fluid was infused into the patient’s body, which contained 3,090 mg of lidocaine (the safe dose of lidocaine should never exceed 3,076.5 mg), and 4,240 ml of fluid was removed from the patient’s arms and abdomen, of which 1,900 ml was fat, which left 6,470 ml of tumescent fluid remaining in the patient. The medical record failed to indicate where and how much fat was removed from each region the internist performed Smart-Lipo surgery on.

There was no indication in the medical record that the internist warmed the tumescent fluid to body temperature before infusing it into the patient. There was also no indication in the medical record that the patient utilized compression boots during the surgery. The patient was discharged from the facility at 3:40 p.m. following a 30-minute observation period.

On 12/17/2014, the patient returned for her follow-up appointment. She indicated that she was weak, her pain over the night was a 6 out of 10, approximately 2 cups of fluid drained from the surgical sites, and she was light headed. It was difficult to determine from the medical record whether the internist ever saw the patient, but it did not appear that she did.

On 1/16/2015, the patient returned for her one-month follow-up appointment. The measurements were taken, along with a height and weight. The patient still weighed 193 pounds with a BMI of 36.5. In response to the question “How do you feel about your results”, the patient answered ‘good.”

On 6/8/2015, the patient returned for her 6-month follow-up appointment. The patient reported that while she had seen improvements, she was not happy with the results of the Smart-Lipo surgery. Measurements were taken along with the patient’s weight, showing a 7 pound weight gain. The internist wrote “skin laxity is an issue, will pursue tummy tuck.” the internist did not recommend a revision surgery, and the patient never returned. According to the patient, the internist told her “she wasn’t a good candidate [for Smart-Lipo] to being with.” She also complained that at the 6-month post-procedure mark, she gained 7 pounds, but her arms looked the same, and her stomach was deformed and protruded from her abdomen. Pictures were taken of the patient at several visits, but none of the photographs were dated making it impossible to determine the progress of the patient’s recovery.

The Medical Board of California judged that the internist’s conduct departed from the standard of care because she failed to maintain adequate and accurate medical records and warm the tumescent fluid to body temperature to avoid life-threatening arrhythmias and left an unsafe amount of fluid remaining in the patient. The patient was not an appropriate candidate for the procedure, the internist lacked knowledge or understanding of the risks posed by infusing large amounts of tumescent fluid containing lidocaine while the patient was also taking Latuda and Adderall, a potentially fatal drug interaction. Also, the internist failed to meet with the patient before the day of surgery to discuss the risks and benefits of the surgery with the patient and allowed an LVN to go through the informed consent process.

State: California

Date: April 2017

Specialty: Internal Medicine, Plastic Surgery

Symptom: Weakness/Fatigue, Dermatological Abnormality, Dizziness, Chest Pain, Wound Drainage

Diagnosis: Post-operative/Operative Complication

Medical Error: Unnecessary or excessive treatment or surgery, Failure of communication with patient or patient relations, Failure to properly monitor patient, Improper medication management, Lack of proper documentation, Procedural error

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

California – Obstetrics – Twin Gestation With Premature Spontaneous Rupture Of Membranes Complicated By Infection And Numerous Drug Allergies

On 6/23/2013, a 30-year-old G2P1 with twin gestation, due date 9/3/2013, and allergies to antibiotics, experienced preterm premature spontaneous rupture of membranes during her 29th-30th week of pregnancy. She was admitted by Obstetrician A, who was covering for Obstetrician B.

At 8:59 p.m. on 6/24/2013, Obstetrician B dictated the patient’s admission history and physical. The patient was given tocolytics (nifedipine) to inhibit uterine contractions. Clindamycin was also given (presumably for group B streptococcus chemoprophylaxis) along with azithromycin. Vaginal cultures for group B streptococcus, mycoplasma, and ureaplasma were ordered. On 6/25/2013, the cultures came back positive for group B streptococcus and yeast.

The patient was allergic to penicillin, sulfa, aspirin, and trimethoprim. Magnesium sulfate was given presumably for neuroprotection and tocolysis; betamethasone was given for fetal maturation.

Bu 9:20 p.m. on 6/24/2013, Obstetrician B appeared to be the responsible obstetrician. On that day, the patient’s uterus continued to contract despite the combination of tocolytics and an increasing magnesium sulfate infusion rate. The labor and delivery nurse was able to contact Obstetrician B during this patient’s preterm labor.

In light of the breakthrough labor and preterm twins, the plan was to perform a Cesarean section. However, while the spinal anesthetic was being administered, the first twin delivered spontaneously in the vertex presentation at 8:13 p.m. The patient then underwent a primary Cesarean section for twin B, who was in the breech presentation.

At 8:59 p.m. on 6/24/2013, Obstetrician B completed a handwritten operative note. The placental pathology confirmed chorioamnionitis (an infection around the fetuses).

On 6/28/2013, the patient was discharged home.

On 7/3/2013, the patient presented at the emergency department with a fever of 102 degrees. She had bleeding from her incision, which appeared indurated and erythematous with a mucoid-serous discharge. It was tender to palpation. The admission white blood cell count was elevated at 14,200. Her urinalysis was contaminated.

At 4:41 a.m., the patient was admitted from the emergency department by Obstetrician A. At 4:00 p.m., later in the day, Obstetrician B wrote orders.

The wound culture grew out E. coli, group B streptococcus, and diphtheroids. The urine culture also grew out group B streptococcus. The patient’s blood cultures were all negative. Due to her allergies, the patient was administered vancomycin, gentamycin, aztreonam, and clindamycin. A pelvic ultrasound demonstrated a small uterine hematoma.

On 7/5/2013, the patient was discharged by Obstetrician B.

Given this instance and several others, the Board outlined the applicable standards of care relevant to Obstetrician B. The Board noted a physician responsible for a patient on labor and delivery must remain reasonably available to respond. The physician must come in for emergency or urgent situations that require evaluation or management decisions that are beyond the scope of the labor and delivery nurse.

The Board also noted that when a vaginal delivery is anticipated for a woman in active labor with unknown group B streptococcus status, intrapartum chemoprophylaxis must be provided. Penicillin is recommended, but if the patient is allergic to penicillin, alternative agents include cefazolin or vancomycin.

The Board issued a public reprimand with stipulations for Obstetrician B to complete a medical record keeping course and an obstetrics course.

State: California

Date: October 2015

Specialty: Obstetrics

Symptom: Bleeding, Fever, Wound Drainage

Diagnosis: Post-operative/Operative Complication

Medical Error: Improper medication management

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

Washington – Plastic Surgery – Platysmaplasty And Chin Reduction With Resulting Post-Operative Infection

A 58-year-old woman sought chin reduction surgery to improve her appearance. The patient found a physician’s practice by conducting an internet search for cosmetic surgery. During the pre-operative telephone consult on 7/23/2012, the physician suggested to the patient that a platysmaplasty, or neck lift, performed with chin reduction would achieve the best results. The patient felt pressured to consent to both procedures because she wanted to confirm her already-scheduled surgery appointment. Two weeks later, the patient arrived to have the procedures done.

On 8/6/2012, the physician performed a chin reduction with neck lift procedure on the patient. Though the operative clinical note is appropriate for the procedure, it is unreliable. There are no notated deviations specific to the patient, such as vascularity of the flaps raised, tension on the closure, or difficulty of hemostasis. The physician’s operative notes on the patient appear to be templated and are identical to the operative notes on a different patient who underwent a completely different surgery.

On 8/9/2012, the patient returned for her post-operative follow-up with the physician. The patient appeared to be recovering as expected with swelling and draining from the incisions behind both ears and on the right-side of her chin. The patient continued taking prescriptive antibiotics. The physician’s chart notes on the patient stated “normal post-operative findings” with “no evidence of infection, hematoma, or abnormal findings.”

By 8/11/2012, the patient experienced more pain, swelling, and incision drainage. The incision areas became more blackened. The patient sent the physician text messages conveying her concerns and attached photographs of her incisions. The photographs strongly suggested the patient suffered post-operative infection with incisional necrosis.

The physician met with the patient on 8/12/2012, where he applied topical nitroglycerin paste to the patient’s chin area and instructed her to continue using the paste throughout the night. Applying nitroglycerin in incisions following cutaneous surgery is not a recognized treatment of post-operative infection. The standard of care in addressing potential post-operative infection is to take an incisional culture swab of the drainage and to start empiric antibiotics with broader coverage. If palpable fluid is collected, the wound is opened, irrigated, and packed. There is no medical documentation of the physician’s clinical treatment of the patient on 8/12/2012. The physician failed to adhere to appropriate medical record keeping, and he failed to properly identify and treat the patient’s post-operative infection despite being sent photographs the day prior. Had the physician not been able to respond or see the patient on the day she sent text messages, the expected practice is to activate his on-call coverage by another licensed practitioner who could immediately address the patient’s complaint of increased pain, swelling, and drainage.

On 8/13/2012, the patient felt weak, ill, and experienced continued drainage when she returned to the physician’s practice for her one-week post-operative follow-up appointment. The notations were identical to those of the 8/9/2012 record, stating “wounds show no significant redness, swelling, pus…normal post-operative findings,” and “wound has no evidence of infection.” The physician then contradicts these statements by noting the patient’s developing chin abscess and performing suture removal. During this office visit, the physician manually expressed fluid and irrigated the incisions. The physician directed an unregistered surgical technologist (ST) to assist in re-suturing the patient’s incision. State law prohibits unregistered STs from practicing and treating patients. The patient became frustrated with the ST’s inexperience and asked the physician to complete the suture. The physician did not re-pack the patient’s wound or broaden her antibiotic treatment even though he told the patient “the neck area is infected.” The physician instructed the patient to continue the nitroglycerin paste usage, keep her neck area wrapped, and return the next day.

By late evening on 8/13/2012, and eight days after the surgery, the patient was desperate for immediate treatment and drove to a wound care clinic for evaluation, wound cleaning, and CAT scan of the neck swelling. The patient and physician communicated through multiple phone calls for the next two days. In one of the phone calls, the physician told the patient that he was the top of his class, making him the most appropriate person to treat the patient. He also told the patient that she needed fat grafting in her neck. The physician contacted the clinic and told them to involve him in her treatment. The clinic physician documented that he was unsure the patient would agree to the physician’s involvement. He also documented the physician also failed to supply the patient’s post-operative report to the clinic.

On 8/15/2012, the patient was admitted to the hospital with complaints of swelling spreading across her jaw. The hospital surgeon performed a transcervical incision and neck abscess drainage on the patient. Hospital records indicate the patient’s recovery postoperatively showed dramatic improvement with decreased pain and swelling. During the patient’s hospitalization, the physician continued to call and send unprofessional text messages to the patient requesting step-by-step updates. After the patient’s hospitalization, the patient continued follow-up care at the wound care clinic. The patient sustained irregular scarring behind her ears and on her neck. The patient had no detectable chin reduction despite the physician’s procedure.

The physician failed to appropriately identify the patient’s worsening infection and failed to provide timely treatment after receiving photographs and observing symptoms suggestive of post-operative infection. The physician allowed an unregistered surgical technologist to assist him in treating the patient. The physician’s inaccurate and inadequate medical records were unreliable in providing sufficient information justifying his deviation from standard of care infection treatment.

For these allegations and others, the Commission ordered the following:

1) The physician’s license is to be placed on probation.

2) Any surgical procedure performed by the physician requiring general anesthesia, deep sedation, moderate sedation, or minimal sedation must be conducted with the use of a board-certified anesthesiologist or certified registered nurse anesthetist.

3) The physician is to be proctored by a plastic surgeon certified in plastic surgery or otolaryngology.

4) The physician must appear before the Commission after the proctor has evaluated and observed the physician. The Commission may modify the order if the proctor concludes the physician cannot practice with reasonable skill and safety.

5) The physician must complete a course on medical record keeping, clinician-patient communication, post-surgical infection control and management, and management of moderate sedation.

6) The physician must make provisions for an after-hours and weekend call group of other physicians.

7) The physician must complete a thorough history and physical on every patient he treats.

8) The physician will allow a Commission representative to visit his practice biannually to review patient records and interview staff.

9) The physician must report all adverse events that occur at his facility.

10) The physician must pay a fine of $25,000 to the Commission.

State: Washington

Date: October 2015

Specialty: Plastic Surgery, General Surgery

Symptom: Head/Neck Pain, Swelling, Wound Drainage

Diagnosis: Procedural Site Infection

Medical Error: Diagnostic error, Improper treatment, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

Washington – Plastic Surgery – Cheek Implant Surgery And Post-Operative Infection

On 11/16/2010, a 51-year-old man underwent a cheek implant surgery to address midface hypoplasia. Chin implant surgery is an aggressive esthetic surgery that includes intraoral incision. The physician performed incisions through the patient’s eyelids and mouth then placed six midface implants with internal titanium screw fixation. The lengthy surgery lasted 5 hours and 44 minutes, which increased the risk of infection and of potential sedation complications. Though the documented operative note as recorded is consistent with planned surgery, the note appears templated and lacks patient specific information. There is no documentation of appropriate perioperative intravenous antibiotics. The standard of care for this surgery is to administer intravenous antibiotics within one hour of surgery start time and to re-dose in six hours. The physician only documented one antibiotic dose instead of two thereby increasing the patient’s infection risk.

On 11/29/2010, the patient sent emails to the physician describing eye swelling and “foul” drainage from the left side mouth and nose. The physician told the patient to continue using compression dressings on the entire face and to continue taking prescriptive antibiotics. The following day, the patient met the physician to address possible infection. The physician’s documentation of this visit states “no significant redness, swelling, pus….normal post-operative findings… no complications are noted at this time.” However, the documentation also contains contradictory statements: “edema, swelling in the lower left eyelid pitting, and cheek,” and “redness in the lower eyelid area.” The physician failed to take a wound culture despite continued drainage through the patient’s mouth and nose, and he did not administer additional antibiotics. Given the patient’s complaint of “foul” discharge, the standard of care is to carefully probe the oral incision and document intranasal examination. Instead, the physician performed simple visualization of the oral cavity which is insufficient in identifying abscess.

For the following two weeks, email communication continued with the physician asking the patient for photographs and recommend the patient continue using a compression garment and mouth rinse. Photographs sent on 12/1/2010 demonstrate periorbital lower redness and swelling even though the physician stated that the patient “looks better.” In a 12/2/2010 email to the physician, the patient reported continued nasal discharge and fluid retention under his eye. The patient asked the physician “would [it] help to culture the infection?” The physician failed to respond to this inquiry and instead prescribed the patient an additional antibiotic even though the only diagnostic justification was the emailed photograph.

On 12/8/2010, the patient emailed the photographs of overt purulent drainage from his left eyelid incision. The physician replied, “oh, that looks significant…I would continue on the antibiotics until further notice.”

From 12/2/2010 to 12/15/2010, the patient’s emails described: continued purulent drainage and swelling; increased despondence about his recovery; and progressive deterioration of his daily life activities. The physician encouraged the patient to give the implant “the best possible chance,” and changed the prescribed antibiotic.

At no time during these two weeks did the physician arrange to physically examine the patient or refer him to another practitioner for appropriate work-up. The physician prescribed successive different antibiotics without pursuing wound culture of physical examination even though the patient’s photographs demonstrated overt drainage and infection which are absolute indications for immediate implant removal. Prolonged infection from an untreated facial abscess is not only potentially life-threatening, but it is also associated with increased scar formation and injury to soft tissue of the lower eyelid.

On or about 12/14/2010, the patient sought a second opinion about his infection and self-referred to a facial plastic surgeon. The surgeon identified infection with impending necrosis in the cheek area, stated the need for immediate implant removal and reconstructive eyelid surgery. The surgeon recommended that the patient be evaluated by two experienced oculaplasty specialists. He discouraged the patient from returning to the physician for any reconstructive procedures.

On 12/17/2010, the physician surgically removed the patient’s cheek implants. The physician failed to culture the wound so that an appropriate post-operative antibiotic could be tailored for the patient’s recovery. Despite the patient’s subsequent complaints of a retracting eyelid and continued “discharge through nose and the taste of infection through mouth,” the physician maintained the prescribed antibiotic and compression dressing be continued. The physician failed to examine the patient for persistent infection and to assess a possible facial distortion.

On 12/27/2010, the patient became increasingly despondent about his appearance and sought an exam by an oculaplasty specialist referred by the plastic surgeon. The specialist changed the patient’s antibiotic to treat the cheek area “which may be a residual abscess.” The patient also sought opinions from other specialists about eyelid reconstruction. These specialists recommended the patient wait at least three months before proceeding with any reconstructive surgery. The patient continued to email the physician about infection symptoms and facial distortions.

On 12/29/2010, the physician emailed the patient recommending fat grafting to address eyelid deformities and stated it needs to wait “at least 2-3 months.” However, on 1/3/2011, the physician’s email to the patient referred to a fat graft procedure planned for in two weeks.

The physician’s assessment notes for 1/13/2011, one month after implant removal, states “normal post-operative findings, no complications are noted at this time. Would plan fat injections.” However, the patient had retained fluid in his eyelid with pain in the left cheek. The oculaplasty specialists that examined the patient discouraged early surgical interventions particularly during his inflammatory phase of healing. The physician disagreed with the specialists, calling their opinions “old school thought.” The physician claimed to be “thinking outside of the box” in his clinical plan for the patient’s fat grafting. The physician also asserted his expertise by asking the patient “how many of [the specialists] came up with the theory of facial beauty?” The physician appears to be referring to a research paper he co-authored while in residency training. The physician’s research paper had no relevance to the patient’s post-operative situation. Additionally, there is very limited medical evidence supporting fat grafting for eyelid retraction, and no reports supporting fat injection during the inflammatory phase of healing. The physician claimed that the patient’s eyes “can be improved drastically with very simple fat grafting procedures that can reverse things in a few hours.” This claim is unsupported by the medical literature. The patient did not pursue any further treatment with the physician.

On 2/15/2011, the patient established care with another facial plastic surgeon. The surgeon’s medical documentation indicated that the patient had severe ectropion and scleral show, synkinesis of his lower eyelids, and facial nerve paralysis. The patient required very complicated oculaplasty reconstruction. As a result of the cheek implant surgery, the patient is unable to work and suffers from depression and suicidal ideation.

In an attempt to get information from the patient, the physician sent an email on 4/27/2011 asking the patient for pictures. The physician revealed this self-interest by also telling the patient “that I’m the only one that can truly help you. I have to say that if the lawyers get involved, it may make it difficult for me to help you…”

The physician’s treatment of the patient failed to meet the standard of care by not providing perioperative antibiotic coverage; not properly and diagnosing and treating early post-operative infection; not conducting appropriate diagnostics or referring to other resources to treat facial abscess symptoms; not arranging for timely cheek implant removal; and not establishing an appropriate treatment plan. The physician’s substandard care and inappropriate communications resulted in the patient’s delayed infection treatment. The physician’s failed cheek implant surgery and removal resulted in the patient incurring additional expenses in seeking proper care by other providers.

For these allegations and others, the Commission ordered the following:

1) The physician’s license is to be placed on probation.

2) Any surgical procedure performed by the physician requiring general anesthesia, deep sedation, moderate sedation, or minimal sedation must be conducted with the use of a board certified anesthesiologist or certified registered nurse anesthetist.

3) The physician is to be proctored by a plastic surgeon certified in plastic surgery or otolaryngology.

5) The physician must complete a course on medical record keeping, clinician-patient communication, post-surgical infection control and management, and management of moderate sedation.

6) The physician must make provisions for an after-hours and weekend call group of other physicians.

7) The physician must complete a thorough history and physical on every patient he treats.

8) The physician will allow a Commission representative to visit his practice biannually to review patient records and interview staff.

9) The physician must report all adverse events that occur at his facility.

10) The physician must pay a fine of $25,000 to the Commission.

State: Washington

Date: October 2015

Specialty: Plastic Surgery, General Surgery

Symptom: Wound Drainage, Swelling

Diagnosis: Procedural Site Infection

Medical Error: Diagnostic error, Improper treatment, Lack of proper documentation

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 2

Link to Original Case File: Download PDF

Washington – Plastic Surgery – Lip Augmentation, Face Lift, Neck Lift, Chin Reduction, Chin Implant, And Cheek Implantation Complicated By Persistent Facial Swelling

A 47-year-old professional musician underwent cosmetic surgery in an attempt to improve his appearance so he could pursue his career goals of live performance. On 10/28/2010, a physician performed a lip augmentation, face lift, neck lift, chin reduction, chin implant, and cheek implants. The patient was given intravenous sedation during the 10 hour surgery. The physician fixated six implants with titanium screws into the patient’s midface even though there was no record documenting the patient’s awareness or consent about the number of implants to be used. There was no documented administration of antibiotics, which is necessary before and every six hours during surgery when an intraoral procedure is performed. The physician’s sub-standard antibiotic coverage increased the risk of post-operative infection particularly for a long surgical procedure. The patient spent less than an hour in the recovery room before being discharged with instructions to apply Vaseline to the incisions and to use a compression.

On 10/29/2010, the patient returned for a post-operative exam with the physician. The medical notes state “normal post-operative findings” with a plan to “follow-up in 6 days for suture removal.” There was no record indicating the patient returned six days later or had his sutures removed.

On 11/8/2010 and 11/21/2010, the physician’s staff documented additional antibiotics prescribed to the patient. The medical notes lacked any information indicating the need for administering more antibiotics. The patient stated he suffered from facial swelling for three weeks following surgery, which suggests why the physician would prescribe additional antibiotics. However, the physician failed to document the patient’s complaints of facial swelling, and he failed to arrange for a physical exam to address possible post-operative infection.

On 12/3/2010, the physician documented the patient’s assessment as “normal post-operative findings,” with “no evidence of infection, hematoma, or abnormal findings.” The physician’s evaluation stated the patient would continue antibiotics and return for “follow-up in 1-3 months.” Again, the physician’s substandard medical charting omitted information related to antibiotic treatment. The patient’s statement indicated he experienced pus “oozing” from his eyelid in addition to increased facial swelling.

Between 12/30/2010 and 1/22/2011, the patient communicated with the physician multiple times using email. The patient reported continued episodic facial swelling to which the physician told the patient to continue the antibiotics until told to stop. The patient complained that adhesions around his eyes were “tight and pull strangely” when he smiled and that the cheek implants were “very high and protruding oddly.” He was also concerned about continuing antibiotics three months after surgery and asked the physician about the possibility of infection from the implants. The physician never addressed the patient’s infection inquiry. Instead, the physician suggested fat grafting to address the patient’s appearance. The physician failed to document in the medical records his communications with the patient.

The patient consulted another plastic surgeon because of concerns about his appearance caused by the physician’s procedures. The surgeon’s opinion strongly suggested revision surgery to correct eyelid retraction and to address possible implant misplacement. After three months of antibiotic treatment and no follow-up exam by the physician, the patient still complained of facial distortion with discomfort, inability to pursue his career, and treatment for depression.

In treating the patient, the physician failed to meet the standard of care by not appropriately administering perioperative antibiotics before and during the lengthy surgery; not maintaining accurate medical and treatment notes; not arranging for a physical exam upon reporting signs of post-operative infection; not culturing the eyelid drainage before starting antibiotic treatment, and not timely addressing facial swelling and considering implant irrigation despite the patient’s continued antibiotic treatment.