Cases like that of Donda West are exactly why we started this column. When an unusual medical case enters the purview of the public forum , details are often murky at best and we are here to sort through the vague press releases and nonspecific symptomology to provide you with as accurate a medical assessment as possible. Please understand that we are not the physicians or caregivers in this scenario and are sort of akin to color commentators watching the evolution of an interesting, but sad, medical mystery i.e. please refrain from chastising us for being irresponsible.
While potentially a bit morbid, we mean no offense by our medical curiosity and only wish to begin a dialogue about something that is already quite prevalent in the lay press.
Here's what we know:
- Donda West died Saturday night at age 58 at Centinela Freeman Regional Medical Center in Marina del Rey after she stopped breathing at her home, according to Deborah Ettinger, a hospital vice president; she was taken to the hospital by paramedics in response to a 9-1-1 call.
- Dr. Jan Adams, the surgeon, told celebrity gossip site TMZ.com that he performed a tummy tuck (abdominoplasty) and breast reduction (mammoplasty) on Donda West, but that she might have died from a heart attack, pulmonary embolism, or massive vomiting.
- Lt. Fred Corral, a county coroner spokesman said preliminary information suggested Donda West died from "complications of surgery".
- A plastic surgeon, Dr. Andre Aboolian of Beverly Hills, said Monday that West had approached him months ago about having cosmetic surgery. He said he never performed the procedure, telling her he was worried about a pre-existing condition she had.
OK, this should be enough info to at least start the discussion. So we know that Ms. West had some type of elective cosmetic surgery and that she made it home to her house. It would be nice to know exactly what day post-operative she was as that would greatly influence our list of possible diagnoses. We will assume then that she had an uneventful recovery from surgery and went home on the 3rd or 4th day after surgery.
Post-operative bleeding becomes much less likely since any bleeding that is likely to be significant would be picked up on the days (or hours) immediately following surgery. Unless the surgical complication is frank wound dehiscence, it is hard to imagine such an acute decompensation related to a plastic surgical procedure occurring more than 3 days post-op.
Furthermore, we can safely rule out complications associated with anesthesia since it is several days following the surgical procedure. Organ failure, usually liver, is not a rapid demise and would not likely present with an emergent call to EMS.
So what is most likely? In a non-cardiac surgery, one of the most common and likely culprits is pulmonary thromboembolism, or pulmonary embolus (PE). This is caused by the migration of a clot, usually sitting in the large veins of the pelvis, to the lungs thus causing obstruction of blood flow to the lungs and then to the heart. Some of the risk factors for PE include prolonged periods of immobility (like that which occurs post-surgery), pregnancy, malignancy, hereditary clotting abnormalities and surgical procedures, particularly orthopedic. The clinical picture of a patient going home healthy post-operatively and presenting with sudden death so classic it sounds like a test question.
Less likely but also in the differential are cardiac problems to which the press-loving Dr. Aboolian alluded. Unless Ms. West had a very significant cardiac history, like an intracoronary stent or recent heart attack, it is very unlikely that her death was secondary to a cardiac etiology. As far as Aboolian's claim that he turned down the case because he demanded that she undergo pre-op screening is absurd. Internists and cardiologists are often called to evaluate patients prior to surgery to evaluate the likelihood that the stress of the surgery will cause a cardiac event. Nowadays this is more of a courtesy to the referring physicians than anything else. The result of pre-operative screening rarely changes the management and the most recent American College of Cardiology guidelines for pre-op screening suggested that unless the patient is experiencing active chest pain or very recently had an MI, the patient can proceed with the vast majority of elective surgeries.
At StopPagingMe.com, we like to remind our readers of those jaded clichés thrown around by the older attendings because more often than not, they are true. You can choose any one you lie because they all teach the same lesson:
"Common things occur commonly."
"If it walks like a duck and looks like a duck, it's probably..."
" Go where the money is."
In this case, our money is on PE.