Go Lean…Caribbean

Go Lean Commentary

To the family of Beverly Brignoni, according to the foregoing news article, the publishers of the book Go Lean … Caribbean, SFE Foundation, extend condolences for the loss of their dearly departed loved one. This article – as follows – shows the down-side of medical tourism, an accidental death from an apparent lax oversight in a cosmetic surgery clinic.

By: Ben Fox and Ezequiel Abiu Lopez
Beverly Brignoni was a young New Yorker seeking a less expensive way to enhance her appearance and she did what many other people are now doing: travel to the Dominican Republic for cosmetic surgery; (see undated “selfie” photo posted to her Instagram account, courtesy of the Brignoni family).

It went horribly wrong. The 28-year-old died Feb. 20 from what the doctor told her family was a massive pulmonary embolism while getting a tummy tuck and liposuction at a clinic in the Dominican capital recommended by friends. Family members want local authorities to investigate.

“We want to know exactly what happened,” said Bernadette Lamboy, Brignoni’s godmother. “We want to know if there was negligence.”

The district attorney’s office for Santo Domingo says it has not yet begun an investigation because it has not received a formal complaint from Brignoni’s relatives. Family members say they plan to make one.

Shortly after Brignoni’s death, the Health Ministry inspected the Vista del Jardin Medical Center where she was treated and ordered the operating room temporarily closed, citing the presence of bacteria and violations of bio-sanitary regulations. The doctor who performed the procedure and the clinic have not responded to requests for comment.

Brignoni’s death is unusual, but it is not isolated. Concerns about the booming cosmetic surgery business in the Dominican Republic are enough of an issue that the State Department has posted a warning on its page for travel to that country, noting that in several cases U.S. citizens have suffered serious complications or died.

The U.S. Centers for Disease Control issued an alert March 7 after health authorities in the United States reported that at least 19 women in five states had developed serious mycobacterial wound infections over the previous 12 months following cosmetic procedures in the Dominican Republic such as liposuction, tummy tucks and breast implants.

There were no reported deaths in those cases, but treatment for these types of infections, which have been caused in the past by contaminated medical equipment, tend to involve long courses of antibiotics and can require new surgery to remove infected tissue and drain fluid, said Dr. Douglas Esposito, a CDC medical officer.

“Some of these patients end up going through one or more surgeries and various travels through the medical system,” Esposito said. “They take a long time typically to get better.”

The Dominican Republic, like countries such as Mexico, Costa Rica and Thailand, has promoted itself as a destination for medical tourism, so-called because people will often tack on a few days at a resort after undergoing surgery. The main allure is much lower costs along with the promise that conditions will be on par with what a patient

would encounter at home.

In 2013, there were more than 1,000 cosmetic procedures performed in the Dominican Republic, 60 percent of them on foreigners, according to the country’s Plastic Surgery Society.

The Internet is flooded with advertisements and testimonials from people who say they have had successful procedures in the Dominican Republic, and an industry of “recovery houses” has sprung up to serve clients, along with promoters who canvass for clients in the United States. The price is often about a third of the cost in the United States.

Dr. Braun Graham, a plastic surgeon in Sarasota, Florida, says he done corrective surgery on people for what he says were inferior procedures abroad. He warns that even if a foreign doctor is talented, nurses and support staff may lack adequate training.

“Clearly, the cost savings is certainly not worth the increased risk of a fatal complication,” said Graham, past president for Florida Society of Plastic Surgeons.

Brignoni was referred to the Vista del Jardin Medical Center by several acquaintances in the New York borough of the Bronx where she lived, said Lamboy and Lenny Ulloa, the father of the 4-year-old daughter she left behind.

“Supposedly, it was a high-end clinic, one of the best in the city,” Ulloa said.

The doctor who performed Brignoni’s procedure, Guillermo Lorenzo, is certified by the Plastic Surgery Society, but there

are at least 300 surgeons performing cosmetic procedures who are not, said Dr. Severo Mercedes, the organization’s director. He said the government knows about the problem but has not taken any action. “We complain but we can’t go after anyone because we’re not law enforcement,” Mercedes said.

The number of people pursuing treatment in the Dominican Republic doesn’t seem to have been affected by negative reports, including a previous CDC warning about a cluster of 12 infections in 2003-04.

In one recent case, the Dominican government in February closed a widely advertised clinic known as “Efecto Brush,” for operating without a license. Prosecutors opened a criminal case after at least six women accused the clinic of fraud and negligence. The director, Franklin Polanco, is free while awaiting trial. He denies wrongdoing.

There was also the case of Dr. Hector Cabral. New York prosecutors accused him of conducting examinations of women in health spas and beauty parlors in that state in 2006-09 without a license, then operating on them in the Dominican Republic, leaving some disfigured. Cabral pleaded guilty to one count of unauthorized practice of medicine in October 2011 and returned to the Dominican Republic, where he still practices.

In 2009, Dominican authorities charged Dr. Johan Tapia Bueno with illegally practicing plastic surgery at his apartment after several women, including a local television personality, accused him of malpractice that left them with infections. Awaiting trial, he has pleaded innocent to charges that include fraud.

Juan Linares, a lawyer hired by Brignoni’s boyfriend, said he is still awaiting an autopsy report.

Because she arrived in the country late at night on a delayed flight and was on the operating table early the next morning, a main concern is whether she received an adequate medical evaluation before the procedure. Graham, the Florida surgeon, said sitting on a plane for several hours can cause blood to stagnate in the legs and increase the risk of an embolism.

Brignoni paid the Dominican clinic $6,300 for a combination of liposuction, tummy tuck and breast surgery. Lamboy said she had decided not to have the work done on her breasts and was expecting a partial refund. The woman, who worked as a property manager, had lost about 80 pounds about a year earlier after gastric bypass surgery.

Brignoni was clearly excited about the procedure. Her final post on Facebook was a photo she took of her hands holding her passport and boarding pass for the flight from New York to Santo Domingo.

“She wanted it so bad,” her godmother said. “It felt like she was going to have a better outlook on life, getting this done.”

Associated Press writer Ben Fox reported this story from Miami and Ezequiel Abiu Lopez reported in Santo Domingo.

Source: Associated Press (AP); retrieved 03/31/2014 from: http://news.yahoo.com/low-cost-dominican-surgeries-spark-warnings-us-042418398.html

This is a very important issue for the planning and execution of the new inter-governmental agency: Caribbean Union Trade Federation (CU). First of all, someone died – life is too precious to skim over this issue with indifference. The Go Lean book serves as a roadmap to introduce and implement the CU, so as to re-boot the region’s economic engines, including avenues of medical tourism.

There are also peripheral issues associated with this news story, many of which are examined, as missions, in great details in the Go Lean book. The issues/missions are:

• Image: Confidence in the competence of service providers is sometimes based on reputation and branding. This is para-mount in medical fields. While the Caribbean is home to many excellent medical schools, facilities and practitioners, there is no regional “sentinel” role-player. The CU mandate is to zealously protect and promote the image and branding for industrial developments. So now when the media portrays “negative” depiction of Caribbean life, culture and people, there is no formal response mechanism. But with the CU’s implementation, there will be an entity to effectuate an anti-defamation response and better manage the region’s image.
• Health Administration: The Go Lean roadmap recognizes healthcare as a basic need for the people of the Caribbean. As such, there is the acknowledgement that health delivery systems generate excessive costs and risks for a community. As a planning tool, the roadmap commences with a Declaration of Interdependence, pronouncing regional integration (Page 11) as the strategy for optimized benefits:

IX.   Whereas the realities of healthcare and an aging population cannot be ignored and cannot be afforded without some advanced mitigation, the Federation must arrange for health plans to consolidate premiums of both healthy and sickly people across the wider base of the entire Caribbean population. The mitigation should extend further to disease management, wellness, obesity and smoking cessation programs. The Federation must proactively anticipate the demand and supply of organ transplantation as developing countries are often exploited by richer neighbors for illicit organ trade.
• Self-Government Entities: The foregoing news story involves a clinic regulated by a Caribbean member-state, the Dominican Republic. The Go Lean roadmap institutes an arrangement for medical/research campuses as SGE’s (Self-Governing Entities) that are only regulated by the CU federal authorities. Had this tragedy occurred on such a facility, the response would have been immediate and comprehensive, employing best-practices of trauma medicine arts and sciences, thusly requiring a post-mortem lessons-learned process that would be fully transparent and accountable.
• Lean Government: The Go Lean roadmap also extends optimizations to the member-states governments, requiring a separation-of-powers dictum to transfer oversight and administration of certain state functions to federal authorities. This includes standards, licensing and administration of healthcare facilities. The application of best-practices would most assuredly minimize the risk of medical negligence.
• US Exceptionalism: The Go Lean roadmap maintains that other countries have their own version of the American Dream. The quest for life, liberty and the pursuit of happiness is not exclusively American. Whereas there are millions of negligent deaths in the US hospitals/clinics every year, one American dying in a Caribbean facility does not constitute an exceptional event; bad things do happen to good people … everywhere, in the US, in the Caribbean and in the Dominican Republic. Having a tourism-based regional economy means we always want to extend hospitality to our American guests, but embarking on medical tourism, also means assuming some degree of risks, for the facilities, the doctors and most importantly the patients.

The foregoing article crystalizes the need for the CU Trade Federation, a super-national administration to regulate, protect, promote and foster quality delivery of the most vital public services. The publishers of the Go Lean roadmap will hereby “sit back”, observe-and-report on the manifestations of this case, hoping for the quest for justice and accountability to be fulfilled. And remembering the unconscionable loss of the beautiful 28-year-old woman, Beverly Brignoni; RIP.

Download the book Go Lean … Caribbean – now!