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Dying patient left alone for 30 minutes

Court documents detail death of realtor; college had concerns about risks at cosmetic clinic

Hamilton Spectator
July 19, 2008

The young real-estate agent who died last year after a liposuction procedure at a Toronto doctor's office was lying in a recovery room for 30 minutes with no vital signs before anyone called 911, according to allegations filed in court.

Documents detailing the death of realtor Krista Stryland also show that the College of Physicians and Surgeons of Ontario had concerns about risks to patients being treated at Dr. Behnaz Yazdanfar's busy cosmetic clinic as far back as 2002.

And just over two months before Stryland's death, another patient had serious complications after five litres of fat were liposuctioned from three body parts in a single session, according to court documents. The college alleges that Yazdanfar previously told the college that she only removes under two litres of fat at a time, and only performs liposuction on one body area per procedure. That patient survived and her family has complained to the college as well.

Stryland, 32, died on Sept. 20, 2007. The young mother had gone to the Toronto Cosmetic Clinic for liposuction. Both the hospital doctor who later tried to revive her and the coroner suggest the delay could have contributed to her death.

The college is seeking a court order to compel Yazdanfar's co-operation in its investigation of her medical practice. The court hearing is Tuesday. In support of the application, the college has filed hundreds of pages of documents. Some remain subject to a publication ban or have portions blacked out. This story is based on documents in the public domain.

Yazdanfar is not accredited as a plastic surgeon and holds no surgical designation. A Star investigation last fall documented the college's dithering around regulation of the rapidly expanding field of cosmetic surgery.

Today, hundreds of MDs without recognized surgical training continue to perform cosmetic procedures in private offices over which the college has limited oversight.

The court documents reveal a lengthy history of college involvement in Yazdanfar's practice.

Tracey Tremayne-Lloyd, a Toronto lawyer representing Yazdanfar, said each of the issues raised by the college over the past six years was "addressed and rectified."

"(Stryland) suffered her unfortunate complication in the recovery room. The surgery went perfectly fine. It was in recovery that something happened to the patient. The patient took a very sudden downturn that had to be dealt with as an emergency," Tremayne-Lloyd said.

Back in 2002, the college looked into a complaint about her lack of formal training. Yazdanfar told investigators she had taken "a course in liposuction in Colorado the previous spring and had been performing the procedure since then," court records show. Because the college had no specific standards for cosmetic surgery, the investigator concluded the doctor's training was "adequate but not extensive."

The next year, a college-appointed plastic surgeon was asked to assess Yazdanfar's practice. He concluded she had the "skill, knowledge and judgment to safely practice liposuction," but found several areas where her practice fell "below an acceptable standard of care."

For example, the assessment report said Yazdanfar's assistant, an Iranian nurse, "is not actually a registered nurse in Ontario and has not taken the College of Nurses Licensing exams." The report called Yazdanfar's practice of delegating duties such as infusions (giving fluids by intravenous) to the nurse "an unacceptable standard of practice."

Documents filed in court by Yazdanfar indicate those problems were subsequently remedied.

Other documents in the file raise alarm bells about patient safety in the years leading up to Stryland's death.

A college letter to Yazdanfar in April, 2004, stated the college was "quite troubled by the lengthy list of deficiencies at your facility, relating to sterilization and infection control practices, lack of appropriate equipment and room allocation."

A follow-up assessment last year found the cleanliness issues had been dealt with.

Throughout the documents, the college raises issues common to its general concern about unregulated surgeries.

For example, in 2006, a college-appointed assessor raised concerns about the use of anesthesia in a private clinic where the normal "protective envelope" of a hospital is missing.

"Dr. Yazdanfar does not have hospital privileges," the assessment report says. "She should therefore have at the very least, a standing relationship with the surgical department of a hospital that would guarantee the efficient, speedy and safe transportation of her patient to that hospital for ongoing surgical care in the event that it would be necessary. Instead, Dr. Yazdanfar would refer her patients to the Emergency department and depend on the medical personnel in that department to make appropriate decisions about the management of her surgical patients. When surgical complications arise requiring transfer and admission the process should be as seamless and efficient as possible."

Two months before Stryland's death, a 66-year-old patient had complications after liposuction surgery performed by Yazdanfar, the court records allege.

In a complaint to the college filed by Francine Mendelson's daughter, she alleges her mother's "fluid loss was staggering, and the fact that she was sent home in that condition was truly unbelievable," states the complaint by daughter Dr. Stacey Mendelson, a veterinarian.

The Mendelsons allege that when Francine visited her family doctor 12 days later, he immediately sent her to emergency at North York General Hospital where staff performed an ECG that indicated serious cardiac abnormalities. She was admitted and spent five days under the care of a cardiologist. The college records allege that five litres (5,050 ml) of fat was taken from the woman's abdomen, lower back and upper back in a single session. The college alleges that Yazdanfar previously told college officials she only operates on one body area per session, and only removes one to two litres of fat at a time.

Yazdanfar lawyer Tremayne-Lloyd said the Mendelson complaint has been answered in full, including an expert report that indicates "the woman was treated entirely appropriately," and said Yazdanfar "has never breached her undertakings to the college and would never do so."

Two months after Mendelson's procedure, Krista Stryland went to the clinic for liposuction surgery. Following the birth of her only child, she wanted to lose weight. When problems emerged during her operation "the patient deteriorated in the recovery room and there was allegedly some delay in calling 911," according to a memo from a college investigator.

Based on information supplied by a doctor who attempted to resuscitate Stryland, the investigator said the doctor's understanding was that "Mrs. Stryland's vital signs were absent for 30 minutes and then an ambulance was called and Mrs. Stryland was transferred to North York General Hospital. Resuscitation efforts were ongoing for two hours."

The college investigator notes that neither Yazdanfar nor the anaesthetist accompanied Stryland in the ambulance. A nurse from the clinic did come but she was "not present during the case," the investigator's memo said.

In answer to the alleged 30 minute delay in calling 911, Tremayne-Lloyd said both her client and the anaesthetist were still at the clinic after Stryland was moved into the recovery room and "it's my understanding that (the anaesthetist) checked his patient ... I think it's highly improbable that that state of facts will be proven to be true." According to her lawyer, Yazdanfar was in the middle of another surgery, so she sent her most senior registered nurse with Stryland, who had complete knowledge of Stryland's case. "They did the best they could. There is no requirement in law that a physician accompany their patient to hospital."

At the hospital, Stryland was in cardiac arrest. Doctors tried to resuscitate her, and called in Dr. Sean Rice, a certified plastic surgeon.

Rice, in a letter to the college, describes how he called Yazdanfar at her clinic to find out what happened. Yazdanfar "stated that she was a cosmetic surgeon and had performed the operation numerous times in the past." Rice asked her if there was "the potential for a possible puncture to an internal organ" but Yazdanfar said this was not possible. "Dr. Yazdanfar then asked how the patient was doing, I stated it appeared that Mrs. Stryland was not going to survive," Rice's letter to the college says.

Another memo from a college investigator says coroner Dr. James Edwards also raised a concern about a delay in calling 911.

The college's "broad investigation" into Yazdanfar intends to determine whether she has committed "an act of professional misconduct or is incompetent," court records show.

College investigators have asked to observe her performing surgery and interview her about her "knowledge, skill and judgment in cosmetic surgery" and ask questions about "specific cases under review." The college has also requested documents from Yazdanfar including her surgical schedule and information related to two patient testimonials on her website.

Yazdanfar has declined all such requests. Her nursing staff has also declined requests from the college to be interviewed.

When the college issued the summons requiring her to meet with them and produce documents, she also refused, arguing that she is not legally obligated to co-operate with the investigation.

Tremayne-Lloyd said that while Yazdanfar has provided the college with numerous charts, appointment books and other records, she will not submit to an interview or allow a college assessor to watch her practise surgery.

"It is our position that the college wish to go way beyond their legal jurisdiction and way beyond what would be considered legally appropriate. They want to force her to allow a college inspector to stand and watch her and that expert will then become the college expert in a prosecution against her ... The whole thing strains credulity that she should be forced to do that."

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