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An Overview of Obesity-Related Claims

What is the common factor in these five cases?

1. A young male, 5 feet tall, weighing 290 lbs, elected to undergo gastric bypass surgery. Multiple serious postop complications with organ failure led to his death two weeks later.
2. A woman in her late 30s and weighing more than 325 lbs with hypertension, diabetes, and a 25-year history of smoking, died after a myocardial infarction and pneumonia were missed by the surgeon.
3. A patient weighing more than 350 lbs suffered nerve damage due to positioning on a treatment table.
4. A 35-year-old patient, 5 feet 4 inches tall and weighing 260 lbs, vomited and aspirated during a manipulation under IV sedation without an endotracheal tube in place.
5. Spinal surgery on a woman, 5 feet 6 inches tall and weighing 275 lbs, created serious postop complications and paralysis.
    

The common factor in these five cases is obvious—obesity-related complications in otherwise routine clinical settings.

Mosby’s Medical, Nursing, and Allied Health Dictionary defines obesity as “an abnormal increase in the proportion of fat cells, mainly in the viscera and subcutaneous tissues of the body.” Morbid obesity is “an excess of body fat that threatens necessary body functions such as respirations.”

Our population is growing, not only in numbers, but more importantly in size. And as is evident in many articles, obesity is not restricted to adults; children are at risk as well. ABC News recently reported on a three-year-old child who weighed 120 lbs and was 42 inches tall—three times heavier than the average three-year-old.

Obesity-Related Loss Analysis

The Doctors Company has seen an alarming increase in lawsuits that involve obese patients. The following loss analysis focuses on claims from 1992–2002. The total number of patients was 287. There were 84 deaths. The ages of the patients ranged from four to 82, with a breakdown of claims by age and specialty as follows:

Types of Events Causing Litigation

Of note is the fact that more than 90 percent of these obese patients have diabetes. The profile leading to litigation includes the following:

• Sixteen patients had gastric bypass procedures.
• Fifty-eight patients used Fen-Phen.
• Three events were related to other medications (e.g., codeine dependency, intramuscular injection, wrong drug).
• Eight patients suffered dental injuries because of difficulty with intubation or extubation due to patient size.
• Anesthesia events aside from those associated with dental injuries numbered 17.
• There were eight nerve injuries not related to positioning.
• Thirty-one patients had respiratory difficulties.
• Nineteen patients had cardiac events.
• Five patients suffered strokes.
• Patient positioning problems and falls affected 15.
• Seventeen cases involved obstetrical patients.
• Twenty-four patients developed postop infections.
• Six patients required additional surgery for retained foreign objects (retractors, sponges, etc.).
• Three events were related to spine procedures.
• There were 13 other types of surgical complications.

Issues When Treating a Morbidly Obese Patient

Q.   Are preoperative medical and anesthesia consultations necessary?
A.   Yes. Good intra- and postoperative care are directly dependent on a thorough knowledge of the patient.

Q.   Should operating room and treatment tables be able to accommodate all patients?
A.   Yes. Oversized equipment is readily available and should be used in any elective procedure.

Q.   When is it safe to perform surgery in a standalone surgicenter?
A.   Patient safety should be uppermost in the mind of every health care provider. The location for surgery must be prepared to deal with airway and cardiac complications.

Q.   Excluding bariatric surgery, are different criteria used for elective and emergent or urgent surgical procedures?
A.   Yes. Elective procedures may often be deferred until weight loss is achieved. Since many of the procedures in the loss analysis were elective, adverse outcomes are harder to accept.

Q.   What should be included in the informed consent process?
A.   The informed consent process becomes even more significant on emergent or urgent procedures for an obese patient. Conveying the additional risks and complications, as appropriate to the procedure and patient’s size, are the health care provider’s responsibility. A thorough, well-documented consent may spell the difference between a plaintiff or defense verdict should trouble occur.

For Bariatric Procedures

Q.   Are bariatric procedures performed more frequently in standalone surgery centers or in hospitals?
A.   Even when performed laparoscopically, bariatric surgery is almost always undertaken in a hospital setting. It requires properly trained and experienced staff in an operating room environment specifically designed to accommodate morbidly obese patients. Claims arising from bariatric surgery performed outside a hospital setting can be difficult to defend.

Loss Prevention Measures

• Communicate: Don’t hesitate to tell it like it is—obese patients should be warned of all the hazards associated with being overweight, including the nature and frequency of possible complications.
• Document: Document any and all discussions you have with the patient related to the need for weight loss.
• Manage Closely: Provide intensive patient management. Develop criteria for preoperative management of the obese patient. Criteria are especially valuable for elective procedures.
• Delay Surgery: When the patient doesn’t meet these criteria, suggest a delay in elective surgeries, with weight loss as a goal.
• Obtain Assistance from Other Specialties: If faced with an emergent or urgent surgery, obtain as much help as possible from appropriate consultants (e.g., medicine, endocrinology, and anesthesia).
• Expand the Informed-Consent Process to Its Clearest and Fullest Potential.
• When in Doubt: Don’t perform the procedure.

Web Sites to Visit for Additional Information:

• American College of Surgeons: www.facs.org
  
• American Society for Bariatric Surgery: www.asbs.org
  
• American Medical Association: www.ama-assn.org
  
• American Obesity Association: www.obesity.org
  
• National Institutes of Health: www.nhlbi.nih.gov
  (See Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults.)
  
• For ongoing articles about obesity in the news, see dailynews.yahoo.com (search “obesity”).
  

J4243 2/05

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