It is widely understood that there are two key background issues to the case now being heard at the College of Physicians and Surgeons of Ontario.
One is the simmering and ongoing turf war between highly trained plastic surgeons and doctors who do "cosmetic surgery" and who may not be surgeons or even have any surgical training at all.
The other is the College's lack of enthusiasm, demonstrated over years, for cracking down on the latter.
These are serious matters, but they are the responsibilities of the College, the regulatory body for Ontario doctors, or to put it another way, the collective responsibility of the province's physicians.
But what is galling in the Krista Stryland death on Sept. 20, 2007, is not any collective or societal misstep, but rather what the prosecution portrays as the stunning failures of the individuals who were charged with taking care of the young woman that day.
It appears from the prosecution view that when all is said and done, after things were clearly going south in the recovery room and Ms. Stryland was in dire straits, none of the medical team summoned the balls or the will to make in a timely way the 911 call that might have saved her life.
Ms. Stryland was a 32-year-old Toronto real estate agent who signed up for liposuction at the Toronto Cosmetic Clinic.
Her doctor was Dr. Behnaz Yazdanfar, a former general practitioner who is not a plastic surgeon and holds no surgical designation. Her anesthetist was Dr. Bruce Liberman, who regularly worked at the clinic.
Both face charges of professional misconduct and incompetence in connection with Ms. Stryland's death; both hearings, at various stages, are under way this week at the College.
There were also two nurses, at least one of whom has apparently faced prosecution by the nurses' college, and a surgical assistant.
At Dr. Yazdanfar's hearing Wednesday, College prosecutor Carolyn Silver's voice was thrumming with outrage as she delivered her closing summation.
She said that by the account most favourable to Dr. Yazdanfar - the doctor's own, naturally - it was at 3.17 that afternoon when she finally went to check on her patient.
Dr. Yazdanfar was busy, after all; she was already in the midst of another liposuction on another patient.
"At 3.17, by her account, she goes and finds [Ms. Stryland with]three IV bags, pressure bags…[Ms. Stryland's body]is oozing dark fluid, she's been re-intubated.
"She [Dr. Yazdanfar]spends 30 seconds with her and goes back and continues with the other surgery," Ms. Silver said.
"No responsible surgeon would start another surgery with a patient in extremis, in undeniable crisis. She's not a responsible surgeon…she picks up her cannula [the instrument used in liposuction]"
Here, Ms. Silver wiped her hands together, mimicking Dr. Yazdanfar's brisk getting on with business, and chirped, "I'm done!"
Again, by the doctor's own account, Ms. Silver said, she continued on for another 15 minutes or so with the other patient's surgery. "She keeps her cannula in [Patient X]" Ms. Silver said. "She doesn't bother to put it down. … Seventeen minutes later, she scrubs out. Hmmm … what does she do? Nothing."
For another 17 minutes, Ms. Silver said, Dr. Yazdanfar paced the hall in "a panicked and traumatized state" before calling 911, by the kindest light a total of "34 minutes after she sees her patient in indisputable crisis.
"It is a shocking - shocking - standard of care to go, to leave her dying patient and go do more lipo on another patient," Ms. Silver said.
As for the doctor's contention that it was Dr. Liberman's call to make, not hers, and that she was merely deferring to him, Ms. Silver snapped, "Dr. Liberman was failing in his duty, [but]Krista Stryland's dying at 3:17 and her duty was to dial three numbers! ...The most important person in the room was the patient."
The College actually alleges Dr. Yazdanfar knew well before 3.17 p.m. and perhaps as early as 1.15 that her patient was in distress, but either lacked the training to understand how serious the situation was, or was cavalier about it, or that she misunderstood her responsibilities, curiously believing that a patient was her patient only in the operating room, and the anesthetist's in recovery.
When Dr. Yazdanfar belatedly called emergency, she told the 911 operator that her patient was "bleeding a bit more than usual" when in fact, Ms. Silver said, Ms. Stryland was "bleeding so much they had to put a second binder" on her and one of the EMS personnel asked for a smock to prevent the dark fluid coming from her body from splashing him.
After Ms. Stryland died of post-operative hypovolemic shock at hospital - she was VSA, or vital signs absent when the paramedics arrived - an autopsy revealed she had had liposuction on no fewer than 23 different sites on both legs, her buttocks and back, abdomen and chest wall.
An Ontario Divisional Court decision in the case, which upheld strict restrictions on Dr. Yazdanfar's ability to practise pending the result of the disciplinary hearing, found that the doctor "vigorously resisted the investigation by the College," refused to allow the nurses who'd been on duty the day Ms. Stryland died to be interviewed and refused for more than a year herself to answer questions from the College investigator.
As Ms. Silver noted in her closing, at one point, Ms. Stryland's moans were audible from the recovery room.
Neither Dr. Yazdanfar nor Dr. Liberman went to hospital with the young woman. Later that night, the clinic team went out for dinner, to debrief.
Within two days of Ms. Stryland's death, apparently over the alleged trauma, Dr. Yazdanfar was back at work with her cannula, removing huge volumes of fat and fluids - well beyond any recognized guidelines, as the prosecution alleges - from other patients.
Dr. Yazdanfar's lawyer will present her closing arguments Thursday.
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