An 8-hour case turned into a 16-hour ordeal, a long and horribly eventful hospital stay for the patient and a lawsuit for the surgeon and hospital — all because the surgeon and anesthesia provider never documented that they discussed the patient's comorbidities that increased her risk for complications.

Case facts
In 2005, a 43-year-old Pennsylvania woman with morbid obesity (BMI 46), insulin-dependent diabetes with neuropathy, hypothyroidism, hypertension, hyperlipidemia, degenerative arthritis and asthma elected to have a prophylactic right breast mastectomy and reconstructive breast surgery. Two years earlier, she had undergone a modified radical mastectomy for intraductal carcinoma of the left breast. Because of a strong family history of breast cancer, she decided on the second mastectomy.

The woman told her primary care physician, who recommended a pre-operative evaluation. However, she didn't show up for that appointment. On the day of surgery, the surgeon determined that she was a poor candidate for breast implantation and decided instead to proceed with the mastectomy and reconstruction with a bilateral free microvascular transfer of lower abdominal tissue (TRAM) using the superficial inferior epigastric vessels (SIEV).

During surgery — after exploring both sides of the abdominal and thoracic walls — the surgeon found no usable recipient vessels in either mastectomy area. So he decided to elevate the lower abdominal tissue as pedicle flaps.

Later during the procedure, the woman received a large volume of IV fluid to maintain blood pressure and keep blood flowing to the flap tissue. But the fluid administration resulted in significant total body edema, especially in her abdominal and breast tissues.

As a result, the surgeon wasn't able to close the incisions at the site of the pedicle flaps and decided to leave the wounds open to allow circulation in the flap tissue. He planned to bring the patient back into the OR sometime during the next several days — once the tissue edema had decreased — to close the wound.

In the meantime, he closed the abdominal wall defect with polypropylene mesh and sent the patient to the ICU, where she was placed on a propofol drip. Fourteen hours later she was diagnosed with compartment syndrome in her right forearm due to propofol extravasation and had to have a fasciotomy under general anesthesia.

Things went downhill — and fast
Things got worse over the next several weeks. The patient's flaps were ischemic with areas of necrosis and she had to have debridements. A month after the operation, she developed hypotension and oliguria. Radiologic studies revealed defects in the right breast reconstruction. The patient had respiratory failure that required a tracheostomy. She became infected with MRSA and suffered renal failure and shock.

Eventually, the surgeon removed both breast flaps, suspected to be the source of the sepsis. After 2 debridement procedures, he applied maggot dressings to aid in the debridement; eventually the sepsis resolved.

The woman went from the hospital to a rehabilitation hospital, where she stayed for 6 weeks. Eight months later, her husband left her for another woman. As a result of her tribulations, she was depressed — a "shell of her former self," is how her attorney put it — and had scars on her chest that looked like "road kill."

The woman sued the surgeon and the hospital for lost wages, pain, suffering and scarring. The case was later settled out of court.

Plaintiff's case: Why the delays?
Attorneys for the plaintiff argued that, because of her comorbidities, the woman wasn't an appropriate candidate for a bilateral TRAM flap breast reconstruction. The surgeon should have consulted the plaintiff's primary care physician and the anesthesiologist should have refused to participate in the surgery, or at least insisted on medical clearance from the primary care physician.

Attorneys also argued that consent wasn't tailored to the patient. She didn't understand how her comorbidities, particularly her diabetes, increased the risk of complications. Had she been told of the significance and realities of her co-morbidities, she would have elected to wait.

The lack of documentation was circumstantial evidence that, attorneys alleged, showed how cavalier the surgeon and anesthesiologist were about a risky procedure. After all, there was no documentation that the physicians communicated before and during surgery, particularly when complications compounded. This raised 3 questions, each related to the surgical team's delays in responding appropriately.

• Why so much fluid? Why did it take so long for the surgical team to determine that the patient was "blowing up like a balloon" and being "drowned" in fluid? The left hand didn't know what the right hand was doing. Otherwise, the plaintiff's attorneys argued, the patient wouldn't have received volumes of fluid unnecessarily.
• What about the extravasation? While infiltration can be a risk to IV placement, why did it take so long for hospital staff to diagnose and treat the extravasation?
• Pedicle flap infection? The delay in identifying and treating the infection in the pedicle flaps was well below the standard of care and resulted in an extended hospital stay and increased costs.

Defendants' position: nothing unusual
Attorneys for the surgeon and hospital argued that patients with similar comorbidities often undergo this procedure, and that the surgeon had substantial training and experience.

The surgeon said he didn't believe that medical clearance was necessary and that the patient had told him that her primary care physician was aware of the plan and had no objections. The surgeon said that he personalizes each informed consent discussion to the patient and that the patient understood the risks and accepted them.

While it wasn't documented, the surgeon and the anesthesiologist said that they discussed the case before the operation and established a contingency plan for complications. When the complications occurred, they took the appropriate actions, they said. The patient received fluids to maintain adequate blood pressure and blood flow. (The surgeon also implied that the anesthesia care team is responsible for monitoring the fluid balance.) When complications arose, the surgeon said he used his best judgment in electing to defer the completion of the surgery until another day when the patient would be less edematous.

The hospital argued that, despite best practices, the propofol infiltration occurred because the patient was already edematous from the fluid overloading and the infiltration was difficult to detect. Once detected, however, it was immediately addressed. Finally, the surgeon said he didn't believe that the pedicle flaps were the source of the infection and he wanted to rule out other possibilities before committing to the removal of the flaps.

Proof that you communicated
This case highlights the importance of communication, and proof of communication, in every case, no matter how risky or banal. Regardless of whether there is no urgency or the risks are heightened because of comorbidities, you should demonstrate restraint rather than plowing ahead with an aggressive approach to treatment. At a minimum, confirm in writing that you've explained the risks — and that the patient has acknowledged them — that you have contingency plans in place and that the patient understands the significance of the more aggressive plan.

The cost of the plaintiff's care was several hundred thousand dollars. The hospital administration had no evidence to show that they knew, or even cared about, what was going on within its 4 walls. This brings up another liability: Had CMS audited this case based on federal regulations for informed consent, the hospital's administration would have been vulnerable to disciplinary action.

Documentation before, during and after surgery does more than create a paper trail. It brings everyone into the room where right and wrong decisions were made, even years later.