After Death in the GI Suite, Patient's Family Sues CRNA

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Taurus

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As I firmly believe, physicians must use the law to their full advantage. It only takes a few cases like this to create a powerful deterrence.

After Death in the GI Suite, Patient's Family Sues CRNA
Family says CRNA should have been supervised while administering anesthesia to patient with sleep apnea.

The family of a man with sleep apnea who died during a routine colonoscopy is suing the nurse anesthetist who cared for the patient.

The plaintiffs allege that before his May 2009 colonoscopy at Parkway Regional Hospital in Fulton, Ky., Charles Harold Curtis Jr. told his anesthesia provider, Leonard Hohlbein, CRNA, that he had sleep apnea and needed to use a continuous positive airway pressure machine while sleeping. Mr. Hohlbein allegedly looked at Mr. Curtis' neck, said it looked normal and administered a reduced dose of propofol with a nasal cannula. When the patient's condition "deteriorated," the anesthesia provider tried to intubate the patient but couldn't manage, according to court documents filed in April in the U.S. District Court for the Western District of Kentucky.

Although Mr. Hohlbein opened the airway with a cricothyroidotomy and performed CPR for 45 minutes, Mr. Curtis died about an hour after the colonoscopy had begun. The biopsy results of the polyps found during the procedure were not malignant, according to court documents.

In the complaint, Mr. Curtis' family says that because of his sleep apnea and history of difficult intubations during other surgeries, Mr. Hohlbein should have been supervised by an anesthesiologist and should not have used propofol. "Hohlbein should have considered and used alternative methods for Mr. Curtis' sedation," says the complaint. The family is suing for an undisclosed amount.

In court documents filed this week, Mr. Hohlbein and the hospital deny that they were negligent in caring for Mr. Curtis. Mr. Hohlbein's attorney did not return a request for comment. The family's attorney was out of the country and not available to comment.

The Curtis family has asked the court for a jury trial. No date has been set.​

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As I firmly believe, physicians must use the law to their full advantage. It only takes a few cases like this to create a powerful deterrence.

After Death in the GI Suite, Patient's Family Sues CRNA
Family says CRNA should have been supervised while administering anesthesia to patient with sleep apnea.

The family of a man with sleep apnea who died during a routine colonoscopy is suing the nurse anesthetist who cared for the patient.

The plaintiffs allege that before his May 2009 colonoscopy at Parkway Regional Hospital in Fulton, Ky., Charles Harold Curtis Jr. told his anesthesia provider, Leonard Hohlbein, CRNA, that he had sleep apnea and needed to use a continuous positive airway pressure machine while sleeping. Mr. Hohlbein allegedly looked at Mr. Curtis' neck, said it looked normal and administered a reduced dose of propofol with a nasal cannula. When the patient's condition "deteriorated," the anesthesia provider tried to intubate the patient but couldn't manage, according to court documents filed in April in the U.S. District Court for the Western District of Kentucky.

Although Mr. Hohlbein opened the airway with a cricothyroidotomy and performed CPR for 45 minutes, Mr. Curtis died about an hour after the colonoscopy had begun. The biopsy results of the polyps found during the procedure were not malignant, according to court documents.

In the complaint, Mr. Curtis' family says that because of his sleep apnea and history of difficult intubations during other surgeries, Mr. Hohlbein should have been supervised by an anesthesiologist and should not have used propofol. "Hohlbein should have considered and used alternative methods for Mr. Curtis' sedation," says the complaint. The family is suing for an undisclosed amount.

In court documents filed this week, Mr. Hohlbein and the hospital deny that they were negligent in caring for Mr. Curtis. Mr. Hohlbein's attorney did not return a request for comment. The family's attorney was out of the country and not available to comment.

The Curtis family has asked the court for a jury trial. No date has been set.​

I would not mind being an expert witness for this case. I actually would cherrish that role.
 
So... for educational purposes... What should the anesthetic have been? General w/ LMA? The article said that the patient's family said that he "should not have received propofol" What else are you going to do for a colonoscopy that wouldn't cause obstruction? Ketamine? All that seems like overkill for a 10 minute procedure.
 
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if in that particular state CRNA's have autonomy ( it would seem so from the article as no MDA is mentioned) or if the supervising physician was the GI doc. Also it would be interesting to see how the consent was given that is , if the patient was informed that his anesthetic would be administered by a nurse, unsupervised, and he had no issue with it. Finally, and I know there is probably no way to know given the limited data in the article, I would like to know if this was just s hitty luck or if the difference in training if the CRNA vs the MDA would have made a difference in this case?
 
if in that particular state CRNA's have autonomy ( it would seem so from the article as no MDA is mentioned) or if the supervising physician was the GI doc. Also it would be interesting to see how the consent was given that is , if the patient was informed that his anesthetic would be administered by a nurse, unsupervised, and he had no issue with it. Finally, and I know there is probably no way to know given the limited data in the article, I would like to know if this was just s hitty luck or if the difference in training if the CRNA vs the MDA would have made a difference in this case?

KY is not an opt-out state, so technically the GI doc must have been "supervising."
 
So... for educational purposes... What should the anesthetic have been? General w/ LMA? The article said that the patient's family said that he "should not have received propofol" What else are you going to do for a colonoscopy that wouldn't cause obstruction? Ketamine? All that seems like overkill for a 10 minute procedure.
A 10 minute procedure in an almost certainly morbidly obese, severe sleep apneic, known difficult airway patient is anything but routine. Something that the CRNA learned the hard way. He's also not a good candidate for the GI suite, an argument that the CRNA will almost never win, if he even thought to bring it up.
I have done surgical cricothyroidotomies on patients, BUT I had the advantage of actual training on the procedure, practice on pig tracheas and an A in anatomy in medical school. I would love to see the dude's neck after he was done. I would also be willing to bet that by the time he said "betadyne splash and a scalpel!" it was too late. Items that they may not even have in the GI Suite. So, an alcohol wipe and his rusty, dull pocket knife?
 
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he had sleep apnea and needed to use a continuous positive airway pressure machine while sleeping. Mr. Hohlbein allegedly looked at Mr. Curtis' neck, said it looked normal and administered a reduced dose of propofol with a nasal cannula.


Question for residents/attendings:

Is it not totally inappropriate to use a nasal cannula in a patient with obstructive sleep apnea severe enough to warrant CPAP?
Would any of you have opted for an NPA that could sufficiently clear the genioglossus?
 
Question for residents/attendings:

Is it not totally inappropriate to use a nasal cannula in a patient with obstructive sleep apnea severe enough to warrant CPAP?
Would any of you have opted for an NPA that could sufficiently clear the genioglossus?

Nasal negative pressure application? Clear the genioglossus?

It CAN be appropriate to use a nasal cannula in a patient with OSA on CPAP.

It IS appropriate to use propofol for a colonoscopy in a patient with OSA on CPAP; The question is what dose/rate of infusion is appropriate.

Finally, it is HIGHLY appropriate that the CRNA be sued by the family, although the reasons they specifically base their complaint upon could use some tweaking.
 
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Seriously, this news should be sent to CNN and other major news networks. We need to get on the offensive, we need to take our profession back.
 
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So... for educational purposes... What should the anesthetic have been? General w/ LMA? The article said that the patient's family said that he "should not have received propofol" What else are you going to do for a colonoscopy that wouldn't cause obstruction? Ketamine? All that seems like overkill for a 10 minute procedure.

Without knowing the full history and physical of the patient, the patient's expectations of the anesthetic, or the full extent of what the GI doc wanted to accomplish (time frame), this is a question with myriad answers. There's many ways to safely anesthetize this patient and manage his airway. The statement by the patient's family "should not have received propofol" is (understandably) uneducated and wrong; It's all about the dosing and what other medications you have administered prior/along with the propofol.
 
So... for educational purposes... What should the anesthetic have been? General w/ LMA? The article said that the patient's family said that he "should not have received propofol" What else are you going to do for a colonoscopy that wouldn't cause obstruction? Ketamine? All that seems like overkill for a 10 minute procedure.


The patient's safety is of utmost importance here, my friend. Always make that your priority. With that said, the least that should have occurred here is a thorough eval of the patient's airway, trying to elicit details from the patient as to his prior intubations and have airway equipment ready to go (LMA, glidescope, etc). I know in this business is very easy to feel overconfident of one's abilities and undermine simple details. The moment you start to think that way, you'll get burned.
 
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This is a colonoscopy. Minimal sedation in this type of individual.
 
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I just went on the Parkway Hospital website-looks like they have one anesthesiologist on staff-seems to be mainly a CRNA run hospital
 
Seriously, this news should be sent to CNN and other major news networks. We need to get on the offensive, we need to take our profession back.

I sent this article to CNN and a little blurb about how the public should understand who is giving their anesthetic - often times a nurse with little or no supervision - and how this can often have serious and even deadly consequences.
 
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I sent this article to CNN and a little blurb about how the public should understand who is giving their anesthetic - often times a nurse with little or no supervision - and how this can often have serious and even deadly consequences.

Good man.
 
I sent this article to CNN and a little blurb about how the public should understand who is giving their anesthetic - often times a nurse with little or no supervision - and how this can often have serious and even deadly consequences.

You assume they're interested in actual facts - that is frequently not the case, as evidenced by their near-orgasmic reporting of all things related to Obama.
 
So... for educational purposes... What should the anesthetic have been? General w/ LMA? The article said that the patient's family said that he "should not have received propofol" What else are you going to do for a colonoscopy that wouldn't cause obstruction? Ketamine? All that seems like overkill for a 10 minute procedure.

The patient died during a routine procedure. Hard to call anything overkill when there is a good chance this could have been prevented.

Reminds me of the world's worst anesthetist I had to work with who would continually argue with me... IN THE OR... AS THE PATIENT IS BEING INDUCED... that preoygenation of patients wasn't necessary. We "probably won't have any problems" is a really bad rationale for terrible patient care.
 
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You assume they're interested in actual facts - that is frequently not the case, as evidenced by their near-orgasmic reporting of all things related to Obama.

:laugh::laugh: What, you haven't had your dose of koolaide that Obama is "brilliant" and that he "saved our economy from depression"??
 
I can already see the number of anesthesiologists willing to be expert witnesses..

Who's the plaintiff's attorney?

To those that want to learn how to do COLONOSCOPIES and anesthesia on patients with severe OSA and difficult a/w history..here's a suggestion...go to MEDICAL SCHOOL and then do an anesthesiology residency.

You are not going to learn how to do it by asking questions on a forum (maybe the private forum).
 
Just contacted Dr. Keith Ablow at Fox News. With his now infamous Nurses-Masquerading -As-Doctors article, perhaps he can get his producers to back a televised segment regarding this lawsuit.

As much as I deplore Fox, if anybody can convey this story to the public (Do YOU know who is supervising your Anesthesia? Secrets of the OR) it's them.
 
what happened was he was given a dose of propofol... he obstructed.. desatted precipitously crna panicked tried to ventilate him .. couldnt do it. the guy turned all shades of blue.(which the morbidly obese do which is why preoxygenation is a good idea) tried to intubate.. this proved hard.(based on skill level)... have any sux..????. no we dont carry it.. heart rate went down.. precipitously.. panic panic panic panic.. call 911 call 911.. dont call 911.. dont call yet.. call 911.. dont you know what you are doing.. spo2 reading 20s... now flatline. ekg... im gonna cuit his neck... do you have a scalpel.. this is a gi center.. hey use this.. kitchen knife to neck.. ett tube in.. blood everywhere. cant ventilate because guy dies...

complete conjecture on my part.. but this is how it usually happens.. all could have been avoided by... careful titration of propofol.. inserting both a nasal and oral airway if necessary and asking the gi doc to abort and continute at the hospital if it cant be done at the center. if you think it will be difficult.. say.. i aint do ing it.. and go home.. may cost you your job.. but guess what... the guy is still alive and you dont have to deal with a dieing patient.
moral of the story.. Dont f*** around with someone's life.. this is serious ****ing business

i heard of 2 patients die unexpected during anesthesia and both were during endoscopies/
 
Just contacted Dr. Keith Ablow at Fox News. With his now infamous Nurses-Masquerading -As-Doctors article, perhaps he can get his producers to back a televised segment regarding this lawsuit.

As much as I deplore Fox, if anybody can convey this story to the public (Do YOU know who is supervising your Anesthesia? Secrets of the OR) it's them.

The only media which might not censor the truth you still deplore because of .. WHAT?
:laugh:


When I was younger and more naive I thought brainwashing is characteristic only for totalitarian states :D
 
Interestingly, the one Anesthesiologist on staff at the hospital, Dr. Harbans Malik is not named as a defendant.

"Parkway Anesthesia and Pain Management" is listed as a defendant, though. Can't find any info about the company on a quick Google search to see who owns it.
 
The only media which might not censor the truth you still deplore because of .. WHAT?

Infotainment.

Didn't say only Fox though. All televised networks are guilty, but Fox (and CNN) just seem to take the cake. Come to think of it, I deplore most televised anything...
 
What CRNA's reading this thread need to understand is that this is not an issue about "this case is worthless because this could have happened to an anesthesiologist too". This is about when it comes to medicine the physician is the "gold standard". In this case, the anesthesiologist is the gold standard. Anything less than that means you're a "higher risk" from an insurance perspective and hospital privileges point of view. We need more cases like this to drive up the premiums for independent CRNA's and NP's and restrict their hospital privileges. Anybody who has worked in a hospital knows that they are extremely risk adverse and it only takes one bad case to change policies.

Therefore, do not cover up the mistakes of CRNA's. I think physicians too often don't report the mistakes of CRNA's and NP's and instead just quietly fix them. As a resident, I see it all the time. Talk to any physician and they will tell you their horror stories about CRNA's and NP's, especially independent ones. Physicians should not be hiding these stories. Let the public and lawyers know full well what's really happening in healthcare today. That should be our ethical duty to public safety.
 
Is it (preoxygenating) necessary?

- pod

Nah, they'll "probably be ok." :D
But it's nice to buy you a little extra time when you wish you had it.

An airway expert once told us as residents that an important key to airway management is to "anticipate the unanticipated difficult airway."
 
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Maceo:
I totally agree with your posting-most of these endo suites couldn't find emergency airway stuff in a pinch (ie cric kits). In addition, there have been several cases where equipment/supplies have been of insufficient supply/quality (ie patient died of MH at ASC with TWO vials of dantrolene). I hate to say it but I truly believe that you are a product of your environment.
 
what happened was he was given a dose of propofol... he obstructed.. desatted precipitously crna panicked tried to ventilate him .. couldnt do it. the guy turned all shades of blue.(which the morbidly obese do which is why preoxygenation is a good idea) tried to intubate.. this proved hard.(based on skill level)... have any sux..????. no we dont carry it.. heart rate went down.. precipitously.. panic panic panic panic.. call 911 call 911.. dont call 911.. dont call yet.. call 911.. dont you know what you are doing.. spo2 reading 20s... now flatline. ekg... im gonna cuit his neck... do you have a scalpel.. this is a gi center.. hey use this.. kitchen knife to neck.. ett tube in.. blood everywhere. cant ventilate because guy dies...

complete conjecture on my part.. but this is how it usually happens.. all could have been avoided by... careful titration of propofol.. inserting both a nasal and oral airway if necessary and asking the gi doc to abort and continute at the hospital if it cant be done at the center. if you think it will be difficult.. say.. i aint do ing it.. and go home.. may cost you your job.. but guess what... the guy is still alive and you dont have to deal with a dieing patient.
moral of the story.. Dont f*** around with someone's life.. this is serious ****ing business

i heard of 2 patients die unexpected during anesthesia and both were during endoscopies/


Endoscopies are bad business. Alot of times I feel like the GI guys don't seem to take into account whether or not the patients really needs the exam. Does that ASA 4.5 patient with a BMI of 55, AICD, ef of 25%, really need to be worked up for vague abdominal pain or gerd symptoms. But that is a different issue.

The thing about all malpractice cases and comments about them is that people need to have the whole story before making a judgement. I agree with the folks on here that say the the CRNA should have been supervised because I feel that all anesthetics should be medically directed. What happened? We don't know. But I'll be honest, this case could happen to anybody that does a fair number of endos. I know of an endo case where 25mcg of fentanyl and 30mg of propofol was given and the patient died. It wasn't my case but could have been. Everything was done properly, as soon as the sats dropped appropriate measures were taken, but at the end of the day the patient still died.

I don't think we know what happened in this CRNA case. But if you do endoscopies, you will do this same patient at least once a day if you are lucky. The above was an airway issue. We have all seen airways go bad. I am not saying this CRNA managed things appropriately, but I am saying that even when things are managed appropriately bad outcomes still happen.

Also, I have to ask this question. How many of you have done a cric on a morbidly obese patient in an emergency? I haven't and don't want to.
 
We "probably won't have any problems" is a really bad rationale for terrible patient care.

Oh, brother, you are so on point here, right on target with this.

I tell patients this in the ED: "You probably aren't having {X}. I probably won't get hit by a bus while going home. I probably won't win the lottery today. I probably won't die falling out of bed (because I don't own one). But they all could happen. That's why we want to do {Y}. Not likely, but possible."

"Failing to prepare is preparing to fail."
 
Just contacted Dr. Keith Ablow at Fox News. With his now infamous Nurses-Masquerading -As-Doctors article, perhaps he can get his producers to back a televised segment regarding this lawsuit.

As much as I deplore Fox, if anybody can convey this story to the public (Do YOU know who is supervising your Anesthesia? Secrets of the OR) it's them.

:thumbup:
 
The bigger issue (besides CRNAs doing own cases without supervision) is OSA. To get a successful malpractice verdict, one must meet all 4 elements of malpractice. I am just typing off the top of my head but if the CRNA did everything right, there's no malpractice case here. You must meet all 4 elements. And the only element so far that's been met, is the outcome, breach of duty (death of patient).

So many non-anesthesia physicians don't realize how dangerous anesthesia for sleep apnea patients can be, especially in a non-OR setting (GI suites being the prime example).

As for what happened in this case: I actually think the fat OSA patient had pre existing reflux. The GI doctor puts a lot of air into th colon. The patient was somewhat sedated. Than with combination of air in the colon pushing up, along with the GI doc manually putting pressure (or his assistant in the room) on the patient's belly=bad reflux=larygospasm in a lightly sedated OSA patient and the patient can go downhill very quickly from there.

As for GI anesthesia being bad business. It's not. It's actually big profitable business. A buddy of mine by up in the Washington DC area does 80% GI anesthesia, 20% eye balls. He's pulling in over $500K a year working 4-5 days a week, no calls, no weekends. Just do the math: $200-500 per case (10-20 minute cases) X 10-15 procedures a day. That's a lot of money. But he does screen all his patients. BMI's over 40 are a no-no with him.
 
Hola, Friends,

What should the anesthetic have been? General w/ LMA?
Possibly, or even endotracheal. I have never regretted intubating a patient, even for one minute procedures. The converse is true, too, I have many times wished I had intubated a patient I didn't intubate.

All that seems like overkill for a 10 minute procedure.
Do you see the irony in your statement? I think you didn't intend it that way. It seems to be a bona fide assertion. The fact is that not intubating him and not giving him a full fledged general anesthetic was the over-kill.

Obstructive sleep apnea is just incidental. According to closed claims analysis, this is a common case scenario even in the absence of obstructive sleep apnea. That is why most cardiac arrests during the oral boards are presented during a local or sedation case.

If there is one message to take home from this case is this: Please take anesthesia seriously, take endoscopies seriously, and take sedation seriously.

Greetings
 
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Endoscopies are bad business. Alot of times I feel like the GI guys don't seem to take into account whether or not the patients really needs the exam. Does that ASA 4.5 patient with a BMI of 55, AICD, ef of 25%, really need to be worked up for vague abdominal pain or gerd symptoms. But that is a different issue.

The thing about all malpractice cases and comments about them is that people need to have the whole story before making a judgement. I agree with the folks on here that say the the CRNA should have been supervised because I feel that all anesthetics should be medically directed. What happened? We don't know. But I'll be honest, this case could happen to anybody that does a fair number of endos. I know of an endo case where 25mcg of fentanyl and 30mg of propofol was given and the patient died. It wasn't my case but could have been. Everything was done properly, as soon as the sats dropped appropriate measures were taken, but at the end of the day the patient still died.

I don't think we know what happened in this CRNA case. But if you do endoscopies, you will do this same patient at least once a day if you are lucky. The above was an airway issue. We have all seen airways go bad. I am not saying this CRNA managed things appropriately, but I am saying that even when things are managed appropriately bad outcomes still happen.

Also, I have to ask this question. How many of you have done a cric on a morbidly obese patient in an emergency? I haven't and don't want to.

:thumbup::thumbup:

Done a few endos in your day I see :)

It's true that the GI docs will give the anesthesiologist a hard time if he/she wants to cancel a case. If you cancel "too many" cases, even if you are 100% justified, the GI doc will find someone else who won't. Maybe that person is another MD, maybe its a CRNA. I have seen MD's bullied into doing cases they were not comfortable with because the GI docs made a big stink about it. They seem to care more about the fact that the person spent a whole day prepping than whether or not they will make it through the procedure alive. Medical clearance is not required in most cases, so nobody knows what they are going to be dealing with once they sedate the patient.

I agree that we don't know the whole story. I have seen patients go bad under the care of very experienced attendings, and even with minimal meds. This type of thing can happen to anyone.
 
Hola, Friends,

Possibly, or even endotracheal. I have never regretted intubating a patient, even for one minute procedures. The converse is true, too, I have many times wished I had intubated a patient I didn't intubate.

Do you see the irony in your statement? I think you didn't intend it that way. It seems to be a bona fide assertion. The fact is that not intubating him and not giving him a full fledged general anesthetic was the over-kill.

Obstructive sleep apnea is just incidental. According to closed claims analysis, this is a common case scenario even in the absence of obstructive sleep apnea. That is why most cardiac arrests during the oral boards are presented during a local or sedation case.

If there is one message to take home from this case is this: Please take anesthesia seriously, take endoscopies seriously, and take sedation seriously.

Greetings

I'm in agreement with your post about intubation. If I'm thinking about it, I generally do it.

To word your last paragraph another way, my chairman used to say "While a surgery or a procedure can be minor, there is no such thing as minor anesthesia."
 
To get a successful malpractice verdict, one must meet all 4 elements of malpractice. I am just typing off the top of my head but if the CRNA did everything right, there's no malpractice case here. You must meet all 4 elements. And the only element so far that's been met, is the outcome, breach of duty (death of patient).

Not really.

1) The CRNA obviously had a duty to the patient
2) If anesthesiologist supervising is the standard of care, that has been violated
3) Did lack of #2 cause the damage? Maybe. Depends on expert testimony and details of the case.
4) Death obviously counts as a damage.

IMHO the case easily meets 3 of the 4 criteria and it's not hard to argue the 4th.
 
:Medical clearance is not required in most cases, so nobody knows what they are going to be dealing with once they sedate the patient.
QUOTE]

OK, I am not sure what type of health student you are, but I would assume every anesthesiologist on this board understands that "medical clearance" is generally BS. A preop eval by an anesthesiologist yields much more useful information about a patient and the likely hood of anest. complications. But apparently in this case, there was no anesthesiologist to eval the pt and weigh risk and benefits to determine the best approach to this case.
 
One thing every endo suite needs but usually does not have is etCO2 monitoring. We have loads of data that says we should use it in the OR with mac cases. I see endos as an extension of the OR. We have portable etCO2 monitors that we use with nasal canulas for endos at one of our locations, we are working on it for our other places. Those things are great. They give you a more objective view of spontaneous ventilation. I also think that every endo suite should have a difficult airway equipment immediately available. That thread a few days ago about the GI hut that basically had no sux, no difficult airway equipment, no glidescope is an example. I would refuse to work at a place that did not have the above. I don't care how much they were paying me.

As for intubating the above case, I have had cases where I have done this. It is rare. Severe gastroparesis, acchlasia, active GI bleed, supraglottic mass, a history of severe obstruction with minimal sedation, are some. If you intubate every obese mal 3 airway with OSA that you see you will not be able to function in a place that does alot of endos. That is just about every patient I take care of when I get the dreaded assignment of endo hell.

Also, I have to say that I hate endos. Doing these for a day make me want to find some way to file for disability. But the fact is I do feel like it is best that we are involved. For the ASA 1 pt that is thin and healthy it is not such a big deal. But I may see one or two of those in a day. Most patients are like the above who's staple diet is Big Mac's and french fries followed by an oreo flurry for desert so that they can wash down their 200mg am dose of oxycontin for their fibromyalgia. They have OSA, a BMI of more than 50, and are there because of dysphagia. Think about it, dysphagia and obesity, the two just don't go together.
 
:Medical clearance is not required in most cases, so nobody knows what they are going to be dealing with once they sedate the patient.
QUOTE]

OK, I am not sure what type of health student you are, but I would assume every anesthesiologist on this board understands that "medical clearance" is generally BS. A preop eval by an anesthesiologist yields much more useful information about a patient and the likely hood of anest. complications. But apparently in this case, there was no anesthesiologist to eval the pt and weigh risk and benefits to determine the best approach to this case.

Medical clearance is complete BS all of the time? They cancel cases all of the time due to lack of clearance so apparently not all of them think it's BS. I worked with docs from a large anesthesia group that do GI inhospital and in some offices and they are starting to require medical clearance from patients before the procedure. At the present time it's only ASA 3 or over a certain age, but at some point it's supposed to be. Apparently this is a trend that has been going on in order for AMD's to protect themselves from liability and is not unique to here.
The worst part to me is that the anesthesiologist often has to do cases that is against his/her better judgement or they run the risk of the GI docs not using them. That's a pretty crappy position to be in.
 
Medical clearance is complete BS all of the time? They cancel cases all of the time due to lack of clearance so apparently not all of them think it's BS.

There's no such thing as medical clearance. Patients aren't airplanes that can be blessed (I mean, cleared) for takeoff because everything checks out. We care about a patients active medical conditions, and whether or not they are optimized (as good as they could be). The word clearance implies that everything's OK, and nothing wrong will happen. It's a concept that likely originated from surgeons and internists/etc (ie not the specialists caring for the patient in the OR). Surgeons frequently use a "clearance" to attempt to bully an anesthesiologist into doing a case in a patient not optimized.

Cases are delayed because patients aren't medically optimized or there's been an inadequate evaluation to determine medical status. GI endoscopy, ophthalmology and vast majority of ambulatory cases do not require an extensive medical or laboratory evaluation.
 
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I cannot comment on those of us that will do cases that are not in the best interest of the patient. But I am not about to risk all the time I have in this gig and the life that my family is expecting on some GI doc or surgeon bullying me into a case.


I think the misunderstanding in my previous post is that "medical clearance" from an internist or FP or whomever, often does not take into account the risk/benefits of anest. techniques. "Medical clearance" may serve as a means to asses a patients baseline status concerning chronic or even acute disease states (ie CHF, DM etc.) But real clearance for an anesthetic needs to come from an Anesthesiologist. If I see a patient with clearance for local or regional only from a cardiologist--- that means crap to me.

Anesthesiologists should be the ones to clear pts for anesthetics regardless of whether or not they have "medical clearance."

I have also been on the other side of this- where a PCP deemed a patient unfit, but after my evaluation they may be sick at baseline, but as optimized as they will ever be. Point being, we all have thresholds and make decisions based on those thresholds, that's why having an anesthesiologist is necessary.
 
NY RN,
My take on medical clearance. A consult is rarely useful to us unless it is obtained for a specific reason and that reason is communicated to the consultant. Internists and cardiologists have no real idea what we do, how our meds work, or what is involved in an anesthetic. Some know better than others. But, most of the time an internist or cardiologist will "clear" somebody for an endo no matter how sick they are. "It's just an endo" right? Also, the term implies that we need permission from another physician to do a case. That is part of the reason why so many people on this board do not like the term. Personally, it paints me into a corner when somebody shows up and they are "cleared" but they have modifiable risk factors that did not get addressed and I still cancel the case. As far as the liability issue, it does not really help, if something bad happens we still get sued whether or not they were cleared prior to the anesthetic.
 
Thank you to the last few posters for clearing that up. It should be your judgement that ultimatly decides whether a case is done or not regardless of clearance, bit for some reason, they are asking for clearance more and more. As we all know patients are getting sicker and sicker, and there should be an anesthesiologist involved with all of these cases. My original point to those who aren't familiar with endo is that any patient can go bad, and I think we need to really hear the whole story before we blame it on the CRNA just because he is not an MD.

My issues are with anesthesiologist being bullied into doing cases. Sometimes the heat comes from the GI guys, sometimes it's your own bosses. I also thought it was against standard of care for the proceduralist to also be in control of sedation, but we know that still goes on, and in my experiences, has the worst outcomes. I know several patients would have died if anesthesia didn't step in and take over a patient that GI sedated.

I have much respect for anesthesiologists.
 
Not really.

1) The CRNA obviously had a duty to the patient
2) If anesthesiologist supervising is the standard of care, that has been violated
3) Did lack of #2 cause the damage? Maybe. Depends on expert testimony and details of the case.
4) Death obviously counts as a damage.

IMHO the case easily meets 3 of the 4 criteria and it's not hard to argue the 4th.

2. If you've worked in these rural/southern states like Kentucky, Tenn, Miss, Alabama etc, you know that some CRNAs routinely practice independently, depending on state laws. Or the GI doc could have been the supervising medical provider. It's crazy in some of these states. And it also depends on what hospital's by-laws about the scope of practice. Whether it needs to be the anesthesiologists supervising, the medical practitioner signing off, or independent practice. We don't have much details about the case. It's a horrible outcome.

My buddy was doing locums and the OBGYN (yes the OB) was doing his own epidurals in Mississippi! If it went to a C/S, my buddy would have to be involved in the C/S (who knows if the epidural was working). Suffice to say, he left that locums job very quickly. And the fact that all the medical providers were insured by the state (in other words, being a state employee makes it very hard to sue), while he was linked to the private malpractice insurance, which is easier to sue).

As for medical clearance, I believe the current literature that came out for "low risk" outpatient procedures do not even recommend routine labs/EKGs even for ASA 3 patient. Low risk procedures include routine colonscopies/cataracts. So it's you are dammed if you do, dammed if you don't.

Medical clearance is basically hog wash if it doesn't give you the answer you need to know. As the attending anesthesiologist, I've canceled procedures even with medical clearance because I've felt the patient was experiencing symptoms and the clearance came from another provider who just wrote "moderate risk" and didn't do any further workup. Patient's lie (or forget) to tell certain doctors. So those doctors take the patients at face value and elect not to do any further studies. Had this sleep apnea patient who had "clearance" for routine breast bx (yes a male patient for breast bx). Guy was 300 plus pounds, heavy smoker, DM. He had clearance without any workup. He told me he was feeling short of breath DOS. I sent him back to his PMD. Received word the guy died of massive MI the next week before he was to have testing done. Crap like this happens all the time. You, as the anesthesiologist are ultimately responsible for proceeding with elective cases.
 
Are CRNA's really trained to perform cricothryotomy????

My understanding from talking to a few is that they are. Certainly the military ones are. It would make sense, in my opinion, as it can be a vital life saving skill. Also, paramedics are trained to do this, and they have a lot less schooling than a CRNA (2 yrs minimum to medic, vs. 7 yrs minimum to CRNA).
 
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