Anesthesiologist sued for penis amputation!

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Yangkower

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Penis amputation trial opens in Miami

[email protected] (Jose Lambiet) 05/13/2012 10:35
An unusual medical malpractice trial opens in a Miami court Monday, one in which a jury will have to decide whether an anesthesiologist can be held liable for a patient losing his penis.

The plaintiff, former Miami resident Enrique Milla, will be testifying at the trial via Skype because American authorities deported him and his family back to Peru last year.

“Mr. Milla lived in Miami for 40 years and worked in the medical supply business and paid taxes,” said Spencer Aronfeld, Milla’s Coral Gables attorney. “It shouldn’t make a difference that he was deported.

“At the end of the day, he has to sit down to pee through a tube.”

In 2007, according to records, Milla, then 60, chose to have elective surgery for an implant (a plastic straw) because of erectile dysfunction caused by diverse ailments.

“He didn’t do this to have a bigger penis,” Aronfeld said. “This was because of medical reasons: He just wanted to have relations with his wife.”

Two weeks after the surgery, however, a small infection turned into gangrene, and life-saving amputation became necessary.

Aronfeld’s contention is that anesthesiologist Dr. Laurentiu Boeru should have known that Milla wasn’t in top physical shape at the time of the surgery and would have a hard time recovering.

“Mr. Milla had high diabetes and high blood pressure when they cleared him for surgery,” Aronfeld said. “They should postpone the surgery until he got better.”

Milla originally filed the lawsuit in 2009, naming Boeru and urologist Dr. Paul Perito, the penile implant expert who performed the surgery.

Court records show Perito settled with Milla last year, although the details of the deal aren’t publicly available.

“What happened to Mr. Milla was just bad luck,” said Boeru’s attorney, Jay Chimpoulis. “But filing frivolous lawsuits won’t change his bad luck.”
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That is one crazy lawsuit. That lawyer should be disbarred,
 
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NPO said:
... seriously?
Click to expand...

I bet the plaintiff's attorney introduces the blood glucose level and HgbA1C as evidence the patient wasn't fit for penile prosthesis. I always thought it would be a total joint or CABG patient who might sue over a bad outcome holding the PERIOPERATIVE Physician responsible along with the surgeon for the bad outcome. But, penile prosthesis??
 
Conclusions

Use of glycosylated hemoglobin A1C values to identify and exclude surgical candidates with increased risk of infections is not proved by this study. Elevation of fasting sugar or insulin dependence also does not increase risk of infection in diabetics undergoing prosthesis implantation.



http://www.sciencedirect.com/science/article/pii/S0022534701634128
 
J Urol. 1992 Feb;147(2):386-8.
Use of glycosylated hemoglobin to identify diabetics at high risk for penile periprosthetic infections.

Bishop JR, Moul JW, Sihelnik SA, Peppas DS, Gormley TS, McLeod DG.
Source

Urology Service, Walter Reed Army Medical Center, Washington, D. C. 20307-5001.

Abstract

We report an 18-month prospective study of 90 patients undergoing penile prosthesis implantation to evaluate a possible cause-and-effect relationship between degree of diabetic control and the risk of infection complicating the operation. Long-term diabetic control was objectively evaluated by measurement of the glycosylated hemoglobin of the patient, which is known to provide an objective value for degree of control for the preceding 60 to 90 days. Of 90 patients 5 (5.5%) had a periprosthetic infection requiring explantation and all infections occurred in the 32 diabetics (36%) in the population (p less than 0.009). Of the 32 diabetics 13 (41.1%) were poorly controlled with time as demonstrated by a glycosylated hemoglobin level of greater than 11.5% and 4 of the infections occurred in this group. Of the 19 remaining controlled diabetics (glycosylated hemoglobin level less than 11.5%) only 1 infection occurred. Therefore, infection occurred in 31% of the poorly controlled versus 5% of the adequately controlled patients (p less than 0.0003). Measurement of glycosylated hemoglobin values appears to be a useful tool to evaluate diabetic patients before implantation of a penile prosthesis. Patients with a glycosylated hemoglobin level of 11.5% or greater should be more optimally controlled before undergoing implantation in an effort to avoid infectious complications.
 
CONCLUSIONS:

Paraplegie, non-controlled diabetes mellitus, secondary implantation and surgeon's inexperience appear to be the risk factors for penile prosthesis infection. In secondary implantation, longer operation time is detected as a factor increasing the risk of penile prosthesis infection. For these patients, careful preoperative preparation, more attention to perioperative antisepsis and postoperative follow-up are required. Since it has been determined that surgical experiences decrease the complication rate, these patients should be operated by experienced surgeons.


http://www.ncbi.nlm.nih.gov/pubmed/15072498
 
This is a typical south Florida med mal lawyer trying to make a few bucks.
The surgeon settled so the only one left standing is the anesthesiologist.
I wonder if the hospital or the ASC settled as well.
 
Planktonmd said:
This is a typical south Florida med mal lawyer trying to make a few bucks.
The surgeon settled so the only one left standing is the anesthesiologist.
I wonder if the hospital or the ASC settled as well.
Click to expand...


Plankton,

I agree this is typical South Florida malpractice crap. Still, looking at the evidence the Plaintiff does indeed have a case. A weak case but a case nonetheless.
 
Since this is an ongoing trial against an anesthesiologist you might want to avoid volunteering your expert opinion and copied and pasted studies on the internet to facilitate the job of the plaintiff's lawyer.
Just a suggestion!

BLADEMDA said:
CONCLUSIONS:

Paraplegie, non-controlled diabetes mellitus, secondary implantation and surgeon's inexperience appear to be the risk factors for penile prosthesis infection. In secondary implantation, longer operation time is detected as a factor increasing the risk of penile prosthesis infection. For these patients, careful preoperative preparation, more attention to perioperative antisepsis and postoperative follow-up are required. Since it has been determined that surgical experiences decrease the complication rate, these patients should be operated by experienced surgeons.


http://www.ncbi.nlm.nih.gov/pubmed/15072498
Click to expand...
 
Planktonmd said:
Since this is an ongoing trial against an anesthesiologist you might want to avoid volunteering your expert opinion and copied and pasted studies on the internet to facilitate the job of the plaintiff's lawyer.
Just a suggestion!
Click to expand...

If I was the defendant I'd get the Urologists from the first study to be my experts.


J Urol. 1998 May;159(5):1537-9; discussion 1539-40.
Quantifying risk of penile prosthesis infection with elevated glycosylated hemoglobin.

Wilson SK, Carson CC, Cleves MA, Delk JR 2nd.
Source

Southwest Impotency Center, Van Buren, Arkansas, USA

CONCLUSIONS:

Use of glycosylated hemoglobin A1C values to identify and exclude surgical candidates with increased risk of infections is not proved by this study. Elevation of fasting sugar or insulin dependence also does not increase risk of infection in diabetics undergoing prosthesis implantation.
 
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I am going to offer a new service for these type of cases. For 20 grand, I can make the defendant vanish from the face of the earth.

Seriously, this is disgusting. No one is protecting the physicians. I hope the judge that accepted this case gets pancreatic cancer. The judge is a piece of garbage also.

I'm only doing cases now with hgba1c less than 6 unless it is an emergency.
 
cincincyreds said:
I am going to offer a new service for these type of cases. For 20 grand, I can make the defendant vanish from the face of the earth.

Seriously, this is disgusting. No one is protecting the physicians. I hope the judge that accepted this case gets pancreatic cancer. The judge is a piece of garbage also.

I'm only doing cases now with hgba1c less than 6 unless it is an emergency.
Click to expand...

The evidence shows HgbA1c of 6.9 is good enough. I use 8.5 myself. Remember, this is poorly controlled Diabetes and MAJOR operations. There is no evidence you can't safely proceed with a ESWL, Cataract, Minor Othro surgery, etc. in this group with high HgA1C
 
Last edited:
J Urol. 1993 Jul;150(1):190-1; discussion 191-2.
Gangrene of the penis after implantation of penile prosthesis: case reports, treatment recommendations and review of the literature.

Bejany DE, Perito PE, Lustgarten M, Rhamy RK.
Source

Department of Urology, University of Miami School of Medicine, Florida.

Abstract

We report 3 cases of gangrene of the penis seen at our institution after penile prosthesis implantation. All 3 patients had insulin-dependent diabetes mellitus. Amputation was required in 2 patients. Aggressive debridement in conjunction with hyperbaric oxygen prevented amputation in the third patient
 
Perito performs approximately 500 penile implant surgeries per year.
PaulPeritoMD.jpg
Dr. Paul E. Perito As Chairman of Urology at his primary hospital, Coral Gables Hospital, Dr. Perito has completed well over 3,000 penile implants, establishing Perito Urology as one of the top centers in the world for the treatment of erectile dysfunction. During this time, Dr. Perito developed a technique for penile implantation regarded as one of the most expedient and efficacious available.


http://peritourology.com/about-perito-urology/
 
BLADEMDA said:
J Urol. 1993 Jul;150(1):190-1; discussion 191-2.
Gangrene of the penis after implantation of penile prosthesis: case reports, treatment recommendations and review of the literature.

Bejany DE, Perito PE, Lustgarten M, Rhamy RK.
Source

Department of Urology, University of Miami School of Medicine, Florida.

Abstract

We report 3 cases of gangrene of the penis seen at our institution after penile prosthesis implantation. All 3 patients had insulin-dependent diabetes mellitus. Amputation was required in 2 patients. Aggressive debridement in conjunction with hyperbaric oxygen prevented amputation in the third patient
Click to expand...


The Urologist who did the amputation was a resident at Univ of Miami/Jackson when these 3 cases of gangrene occurred. Please note his name in the middle of the three authors listed.

He seems like a top notch penile implant surgeon in the USA.
 
Yangkower said:
Aronfeld’s contention is that anesthesiologist Dr. Laurentiu Boeru should have known that Milla wasn’t in top physical shape at the time of the surgery and would have a hard time recovering.
Click to expand...

As a perioperative physician and a prospective diplomate of the American Board of Anesthesiology, I would want to know if this patient could achieve 4 METs with his pathetic limp Mr. Softy d*ck.
 
fakin' the funk said:
As a perioperative physician and a prospective diplomate of the American Board of Anesthesiology, I would want to know if this patient could achieve 4 METs with his pathetic limp Mr. Softy d*ck.
Click to expand...

For a low-risk surgery why would he need to?

As suggested above, this type of litigation could become an unintended consequence of the ASA's attempt at billing us as perioperative specialists in the "surgical home" model. I think all the deep pockets will continue to get sued, but plaintiffs could start actually winning cases because of it.
 
So Blade, how do you deal with the surgeons who want to operate on a patient (say, hip revision, fem-pop, or the like), otherwise optimized, but an A1C of 8.6? Do you show them the paper? Do they agree? Do you advise and document, but then do the case? I can envision myself writing a note along the lines of "d/w surgeon elevated risks of poorly controlled DM, including infection, major adverse cardiovascular events, death, and s/he elects to proceed." Do you include the patient in such a discussion?
 
Association with increased MI is hardly evidence of modifiable risk with temporary improvement in glucose control.

The patient should sue himself for his failure to control his blood sugars.
 
I guess it is a little difficult in retrospect to justify going ahead with a clearly elective surgery in a patient with an AIC of 8.6 (especially since he lost his penis), but we don't know what conversations were had with the patient and surgeon?

I wonder what most attending would have done with this patient? Does this case change anyone's practice? Before reading this case I probably would have considered the patient low risk and gone forward with the case. If anesthesiologists are going to be sued for post op infections in elective surgeries related to high AIC then I think we have to consider sending these patient's back to their PCP for tighter managment even if it pisses off the surgeon (and the patient). I bet this surgeon won't do it again.
 
Suing the perioperative physician? wtf? Who recognizes the anesthesiologist as the ultimate decision maker any more. For all we know, the Urologist might have insisted the surgery go through, and in this roll-over-and-die environment anesthesiologists have created for ourselves, dude probably went along with it as would a lot of anesthesiologists.
 
Osteoimperfecta said:
Suing the perioperative physician? wtf? Who recognizes the anesthesiologist as the ultimate decision maker any more. For all we know, the Urologist might have insisted the surgery go through, and in this roll-over-and-die environment anesthesiologists have created for ourselves, dude probably went along with it as would a lot of anesthesiologists.
Click to expand...

Well, "going along with it" means you share the responsibility if anything goes wrong.
If the HgbA1c was indeed over 11 in the patient then strong consideration should have been given to CANCELLATION for better glucose control.

If you won't assume any responsibility for evaluating patients for surgery then why are you needed over a Nurse at all?
 
BLADEMDA said:
Well, "going along with it" means you share the responsibility if anything goes wrong.
If the HgbA1c was indeed over 11 in the patient then strong consideration should have been given to CANCELLATION for better glucose control.

If you won't assume any responsibility for evaluating patients for surgery then why are you needed over a Nurse at all?
Click to expand...

What he described is the reality in many places, the anesthesiologist sees the patient only 5 minutes before surgery and the pre-op evaluation and optimization is entirely handled by the surgeon and the primary care physician.
In this type of very common situation the anesthesiologist can not be seen as the only peri-op physician, and he/she will have to rely on the judgement of these other physicians.
The anesthesiologist remains the gate keeper and should be able to say no to cases where proceeding with surgery could cause unjustified risk, but if the anesthesiologist starts canceling cases based on things like elevated A1C that anesthesiologist will not be very popular and might have a job security issue.
 
BLADEMDA said:
Well, "going along with it" means you share the responsibility if anything goes wrong.
If the HgbA1c was indeed over 11 in the patient then strong consideration should have been given to CANCELLATION for better glucose control.

If you won't assume any responsibility for evaluating patients for surgery then why are you needed over a Nurse at all?
Click to expand...

Which is my point exact. We surrendered our role and responsibilities for survival reasons. Trying to please the surgeons and hospitals at any cost has indeed cost us control in the OR, and maybe our position in the system.
 
Yangkower said:
I guess it is a little difficult in retrospect to justify going ahead with a clearly elective surgery in a patient with an AIC of 8.6 (especially since he lost his penis), but we don't know what conversations were had with the patient and surgeon?

I wonder what most attending would have done with this patient? Does this case change anyone's practice? Before reading this case I probably would have considered the patient low risk and gone forward with the case. If anesthesiologists are going to be sued for post op infections in elective surgeries related to high AIC then I think we have to consider sending these patient's back to their PCP for tighter managment even if it pisses off the surgeon (and the patient). I bet this surgeon won't do it again.
Click to expand...

Then after the case is cancelled, you will be looking for a new job as the urologist who owns the outpatient center won't want you as you just caused him to miss his bmw payment for the month by canceling the case.
 
Osteoimperfecta said:
Which is my point exact. We surrendered our role and responsibilities for survival reasons. Trying to please the surgeons and hospitals at any cost has indeed cost us control in the OR, and maybe our position in the system.
Click to expand...

Maybe there should be more "pre-op" evaluation...maybe anesthesiologists should have more clinic "pre-op evals" weeks before the OR, not just 5 minutes before.

Peri-op must be more than 5 minutes before and 30 minutes after, no?

HH
 
Hamhock said:
Maybe there should be more "pre-op" evaluation...maybe anesthesiologists should have more clinic "pre-op evals" weeks before the OR, not just 5 minutes before.

Peri-op must be more than 5 minutes before and 30 minutes after, no?

HH
Click to expand...

This aspect has come up before, and certainly many academic centers have started doing this. It's hard, though not impossible, to bill for a lot of the care, but at least at some places, they've been able to justify their cost/staff by demonstrating reduced cancellation rates, which increases revenue.
 
Hamhock said:
Maybe there should be more "pre-op" evaluation...maybe anesthesiologists should have more clinic "pre-op evals" weeks before the OR, not just 5 minutes before.

Peri-op must be more than 5 minutes before and 30 minutes after, no?

HH
Click to expand...

1000% agree, because what you describe puts the anesthesiologist in the drivers sit of the peri-op management of patients. If pts flow through a preop clinic before the OR, the anesthesiologist can make a CLINICAL decision based on proper evaluation of the patient with less pressure. As it stands, the patient shows up in the OR, the anesthesiologist sees the pt for 5 minutes(if that), while the surgeon is standing off to the side hands crossed ready to whine about case delay or cancelation. Hospital is counting OR minutes, ready to whine if case is delayed or cancelled due to anesthesia. Now the anesthesiologist has to tamper his/her clinical judgment with survival/financial/occasional risky factors. Often negotiating from a position of complete lack of power, which btw is one of the recipes for extinction in the dog-eat-dog world we find ourselves today.

Even from a pure survival point of view, those clinics would legitimise the anesthesiologist role as one of the physicians approving and facilitating the surgery, and not just some "service" provider who must always provide service regardless of circumstance. Much better position to negotiate from IMO. More importantly, patients like the one posted by OP are protected. Btw, this is a standard of care the ASA can and should redefine, and would probably do more for our job security and role definition, than some of the lobbying efforts we have going on.
 
Do anesthesia pre op clinics exist in private practice? Is there any reimbursement for them? Sounds like a nice retirement gig. At least in my program, pre op clinic is like a vacation. And we do prevent some bad eggs from going to the OR. I've noticed in the few private practice rotations I've done that surgeons routinely send their patients to PCP or cards for "clearance" which is generally worthless in all but healthy patients for low risk surgery.
 
BLADEMDA said:
Well, "going along with it" means you share the responsibility if anything goes wrong.
If the HgbA1c was indeed over 11 in the patient then strong consideration should have been given to CANCELLATION for better glucose control.

If you won't assume any responsibility for evaluating patients for surgery then why are you needed over a Nurse at all?
Click to expand...

Document a discussion with the patient that their poor glucose control puts them at higher risk for perioperative complications. Tell them. Let them make an informed decision. If the patient is in as good a shape as they will ever be in, it's their decision whether or not to proceed with surgery.

But you gotta at least mention to them that not taking care of their sugar means they are higher risk for bad stuff happening. And I guess with a penile prosthesis, you can now mentioning higher risk of their junk falling off afterwards. That might get their attention.
 
Why does everyone think we have to discuss the patient's surgical risk factors with them? This is the surgeon's job. When they ask me how to take care of their wound or how long it will take to heal, I don't give them detailed advice - I tell them to discuss it with the surgeon.

If they have CAD that needs to be medically optimized to minimize anesthetic risk, that makes sense. But surgeons are much better aware of all the potential surgical risks and what increases them than we are. This is a huge body of literature about which we are unaware. It extends well beyond the generalities of diabetes and wound complications.

Sounds like a slippery slope to me.
 
I don't disagree but if patients and lawyers are going to include us in lawsuits we can't bury our head in the sand. Much of what we do seems to be based on medical legal considerations not common sense or good medicine.
 
Keep in mind, a colada takes 20 packs of sugar to make and the patient population here drinks it like water.

Anyway...

hah.HAH.HAHAHAHAHAHAHA
 
Yangkower said:
I don't disagree but if patients and lawyers are going to include us in lawsuits we can't bury our head in the sand. Much of what we do seems to be based on medical legal considerations not common sense or good medicine.
Click to expand...

[YOUTUBE]http://www.youtube.com/watch?v=8X_Ot0k4XJc[/YOUTUBE]
 
Agreed. We should rise to the occasion, and lend our full-throated support for the surgical home model.
 
leviathan said:
Cases like this prove anesthesiologists can no longer take a half-cocked approach to pre-op evaluation, doing it 5 mins before the case.
Click to expand...


Even if insurance reimburses you guys for pre-op clinic visits well in advance of surgery, you guys wont do it.

The reason? $$$$$

Gas docs make a LOT more money by keeping the OR running with subadequate 5 minute pre-op "clinical consults" rather than having clinic appointments.

Furthermore, my impression is that most gas docs hate clinic anyway and thats part of the reason they chose their field.
 
You could have 5000 studies showing that its OK for patients to have surgery with A1C levels of 15% or higher....

and yet it would make zero difference in court cases.

You can ALWAYS find an 'expert' who says you screwed up, regardless of what the evidence based literature says.
 
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