CRNA horror stories

[lordbob]

Current anesthesia resident with very little exposure to CRNA's at my program. I'm a long time lurker on these forums and constantly read about dangerous CRNA's and how the "CRNA almost killed my young healthy patient" , but people offer very little details about he specifics of the incident. Anyone care to share specifics, because it does take some effort to hurt a young and healthy patient. Thanks

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[criticalelement]

Current anesthesia resident with very little exposure to CRNA's at my program. I'm a long time lurker on these forums and constantly read about dangerous CRNA's and how the "CRNA almost killed my young healthy patient" , but people offer very little details about he specifics of the incident. Anyone care to share specifics, because it does take some effort to hurt a young and healthy patient. Thanks

For me it is always they choose sux when they should use a non depolarizer and a non depolarizer when they should use sux
They use too much narcotic inappropriately
They give neo when they should give volume and give volume when they should give neo.
universally they almost always extubate too early. and they are too slow to wake up patients.
they talk too much, they say stupid things to patients that are un warranted.
goes on and on and on and on...

 

[Chloroform4Life]

Some don't seem to understand how ventilation works. I've walked in on a case where the patient has an lma and the etco2 reading was in the 80s and the crna was just playing on her phone like it was a normal smooth case.

 

[lordbob]

Some don't seem to understand how ventilation works. I've walked in on a case where the patient has an lma and the etco2 reading was in the 80s and the crna was just playing on her phone like it was a normal smooth case.

lol. someone probobly once told her "never give PPV through an LMA"

 

[criticalelement]

Some don't seem to understand how ventilation works. I've walked in on a case where the patient has an lma and the etco2 reading was in the 80s and the crna was just playing on her phone like it was a normal smooth case.

The reason etco2 was in the 80s is because they have a "MUST GIVE NARCOTIC" mentality. SO they titrate the REsp rate to 6-8 when 18 is fine.

 

[GravelRider]

To be honest, anesthesia is not hard "to do." You can teach a monkey to push the blue one then the white one then the red one and the purple one if that number on the screen is low. However, understanding anesthesia and the interplay with increasingly complex patients is the difference. While most of my gripes with crna's have to do with things already mentioned here like inappropriate titration of narcotics, delayed emergences, and overaggressive ventilation (TVs close to 1L and etco2 at 20), none of these will kill the patient. It's just less than ideal because they don't think through the whole situation. Most CRNAs also have well-defined hours, so they go home at 3pm whether or not their emergence took 1 minute or 20 minutes after drapes come down. On the other hand, I have worked with some very thoughtful and skilled CRNAs who I would rather give me my anesthetic than some fat, old, lazy partner who collects a check and hasn't put his hand on a bag in 10 years.

 

[soorg]

Too much narcs!

 

[PainDrain]

How about giving 11 liters during a 5 hour neck dissection with less than 200 EBL. The patient could not be extubated at the end of the case, was grossly volume overloaded, and required 24 hours of diuresis before we even considered extubating. Or the one time a pedi bronchospasm wasn't recognized and the kid was bradycardic before the attending was called to intervene.

 

[NightNight]

How about giving 11 liters during a 5 hour neck dissection with less than 200 EBL. The patient could not be extubated at the end of the case, was grossly volume overloaded, and required 24 hours of diuresis before we even considered extubating. Or the one time a pedi bronchospasm wasn't recognized and the kid was bradycardic before the attending was called to intervene.

Last point here is the most important. The most dangerous CRNAs (ie the ones most likely to actually hurt a patient) are the ones who think they don't need to call for help such that by the time they do significant sequelae have already occured.

 

[twoliter]

How about giving 11 liters during a 5 hour neck dissection with less than 200 EBL. The patient could not be extubated at the end of the case, was grossly volume overloaded, and required 24 hours of diuresis before we even considered extubating. Or the one time a pedi bronchospasm wasn't recognized and the kid was bradycardic before the attending was called to intervene.

Where was the attending anesthesiologist during this five hours? Or was it an 11-liter bolus?

 

[Noyac]

It's been a long time since I've worked with a crna. But I can remember two things from my past gig that will never forget. The first was when I was a new grad and I was supervising a bowel case on a respiratory cripple. I placed a pre-op thoracic epidural and dosed it up as I always did prior to the case when I had the time in order to minimize the anesthetic requirements and to determine the effectiveness and accuracy of the placement. The crna (which I was told was one of the good ones) freaked out that I had dosed it and refused to do the case stating that she would have to resuscitate the pt after induction and throughout the case. The pt did great. And I quickly learned the limits of their education and understanding of anesthesia physiology.
The second was when I was called emergently into a pedi case when the crna was having issues. The it was a long time ago so I don't recall all the details but in a nutshell the child was hypotension and bradycardic. The crna gave atropine in a large dose and was checking tube placement when I ran into the room. The first thing I noticed was that the Sevo was cranked at 8%. The child was later admitted to the PICU for central anticholinergic syndrome secondary to the large dose of atropine.

Good times.

 

[IlDestriero]

How about giving 11 liters during a 5 hour neck dissection with less than 200 EBL. The patient could not be extubated at the end of the case, was grossly volume overloaded, and required 24 hours of diuresis before we even considered extubating. Or the one time a pedi bronchospasm wasn't recognized and the kid was bradycardic before the attending was called to intervene.

This would get us both fired where I work. The CRNA for gross malpractice and me for not supervising them. Ok it might not get us fired, but we'd be on some supervision list to QA months of anesthetics and I'd take a bonus hit in the thousands.

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Il Destriero

 

[urge]

but we'd be on some supervision list to QA months of anesthetics and I'd take a bonus hit in the thousands.

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Il Destriero

At your place, when you screw up, they put you on QA surveillance for a few months?

 

[IlDestriero]

If you did something that stupid, absolutely. And they would pull old records and look for a pattern of incompetence. In the situation above, they would probably talk to the senior CRNAs and see if we are actually supervising them or just coming in for intubation and extubation.
Double secret probation absolutely exists here, and your bonus does depend on clinical competence. In fact in the non academic track, they might give you the soft firing if they think you're clinically weak. As opposed to giving you a clinical mentor to man up. That can be a problem in academics when you're out of the OR 1/2 the time and the schedulers coddle you. Some wicked call **** goes down and, surprise, you suck.


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Il Destriero

 

[Random Anesthesiologist]

 

[pgg]

This would get us both fired where I work. The CRNA for gross malpractice and me for not supervising them. Ok it might not get us fired, but we'd be on some supervision list to QA months of anesthetics and I'd take a bonus hit in the thousands.

How does that work? Is there a scale for the amount of docked pay for a sentinel event, vs unplanned admission, vs some other complication?

 

[Chip N Sawbones]

I overheard a CRNA say this:

"If your doctor puts you on antibiotics, don't take all of them. You should stop taking them as soon as you feel better; that way your immune system gets a better workout. It's like bodybuilding for your immune system and it'll help it grow stronger."

 

[IlDestriero]

How does that work? Is there a scale for the amount of docked pay for a sentinel event, vs unplanned admission, vs some other complication?

Everyone gets quarterly QA data. From signing charts on time to competence concerns. It's not all transparent. Clinical competence is on a scale to 15. I'm always a 12 or 13. I'm told that's good, when I've asked before. You probably have to walk on water and use sevoflurane for mouthwash to get a 15. Fall below the required minimums and you're not getting 100% of your bonus.
All CQI stuff gets evaluated and judged avoidable or not. We've all had bad **** go down, but I've never been on the wrong side of that eval, so I can't say what the boss does with a single event. Though I'm sure it involves a sit down. I think they mostly look for patterns. Again clinical faculty are certainly expected to be clinically superior and need higher teaching scores. That's all a factor.


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Il Destriero

 

[Orin]

You probably have to walk on water and use sevoflurane for mouthwash to get a 15.

Would've thought the ivory towers prefered Iso for the cost savings?

 

[PainDrain]

Where was the attending anesthesiologist during this five hours? Or was it an 11-liter bolus?

I wasnt personally I nvolved in the case and only heard about the massive amount of fluids because it had a lot of people saying "wtf"? I have no idea how it slipped past the attending but it did.

 

[Pooh & Annie]

Everyone gets quarterly QA data. From signing charts on time to competence concerns. It's not all transparent. Clinical competence is on a scale to 15. I'm always a 12 or 13. I'm told that's good, when I've asked before. You probably have to walk on water and use sevoflurane for mouthwash to get a 15. Fall below the required minimums and you're not getting 100% of your bonus.
All CQI stuff gets evaluated and judged avoidable or not. We've all had bad **** go down, but I've never been on the wrong side of that eval, so I can't say what the boss does with a single event. Though I'm sure it involves a sit down. I think they mostly look for patterns. Again clinical faculty are certainly expected to be clinically superior and need higher teaching scores. That's all a factor.


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Il Destriero

I LOVE that idea! Pay for performance! But does the data include resource use? Someone could waste a LOT of department/hospital money trying to get the best outcomes on every case.

 

[deleted171991]

My main story (which apparently prompted this thread) was unrecognized OSA in a young male with BMI of 35.

The CRNA overdosed him with propofol during endoscopy,
then failed to recognize the obstruction,
then failed to recognize agitation as a sign of hypoxia (and gave him even more propofol for that),
then failed to believe the pulse oxymeter which was showing 50%,
then failed to call for help (despite being asked by room nurse and me being less than 30 feet away),
then I walked in just because of gut feeling,
then s/he tried to ventilate the patient with poor technique (after s/he was told that the hypoxia was real),
then s/he tried to waste time drawing up sux and was told this was OSA not laryngospasm,
then s/he did not recognize that sudden bradycardia to 20s was due to profound hypoxia and needed better oxygenation not wasting more time with drawing up atropine (sats were very low),
then s/he was pushed over while I did the two-hand masking and s/he squeezed the bag,
then the patient recovered in 30 seconds to 100% and normocardia,
then the patient was allowed to breathe on his own with obvious rocking motion and upper airway obstruction,
then s/he did not recognize that it was OSA and said that he could be left to breathe on his own,
then s/he was told it was OSA and needed airway support until more awake,
then s/he was asked if ok to do the next case after near miss,
then s/he asked what near miss and told me not to even suggest that (the patient had woken up unharmed),
then s/he was reported for not being good enough for the endoscopy suite,
then the chief CRNA informed all of them that I was a CRNA hater to teach me a lesson,
then nothing happened to that CRNA.

Overnarcotizing patients, pushing 50 mg of Roc on zero twitches one hour before wake up, keeping elderly patients hypotensive at more than 2% of sevo, letting the patient breathe spontaneously at etCO2 of 70, running des at 2L/min, not following attending instructions etc. are piece of cake. And if you report those, you must be a hater, too.

Am I allowed now to be very afraid of working with them?

 

[ambiturner]

I wasnt personally I nvolved in the case and only heard about the massive amount of fluids because it had a lot of people saying "wtf"? I have no idea how it slipped past the attending but it did.

I'll bet the surgeons did some flap work and said under no circumstances could pressors be used, so the response was to slam fluids in to maintain a high pressure. I've been put in that situation and it sucks but I'd like to believe I was more judicious than that...

 

[deleted171991]

I wasnt personally I nvolved in the case and only heard about the massive amount of fluids because it had a lot of people saying "wtf"? I have no idea how it slipped past the attending but it did.

I had bowel ischemia patients arriving to the ICU on vaso, was told by attending that a patient had been septic (tachycardic and hypotensive) intraop and needed ICU just to discover that CRNA had been running patient on 2.8% sevo and no opiates the entire case, regularly have patients bolused with 50 of roc before transport to ICU etc.

If you question what they do, before they do it, they will label you as micromanager and hate you. If you don't, it's supposedly your mistake for not supervising them well. It's never their fault, and administrators will protect them because they are cheaper and more difficult to replace than you.

 

[Planktonmd]

My main story (which apparently prompted this thread) was unrecognized OSA in a young male with BMI of 35.

The CRNA overdosed him with propofol during endoscopy,
then failed to recognize the obstruction,
then failed to recognize agitation as a sign of hypoxia (and gave him even more propofol for that),
then failed to believe the pulse oxymeter which was showing 50%,
then failed to call for help (despite being asked by room nurse and me being less than 30 feet away),
then I walked in just because of gut feeling,
then s/he tried to ventilate the patient with poor technique (after s/he was told that the hypoxia was real),
then s/he tried to waste time drawing up sux and was told this was OSA not laryngospasm,
then s/he did not recognize that sudden bradycardia to 20s was due to profound hypoxia and needed better oxygenation not wasting more time with drawing up atropine (sats were very low),
then s/he was pushed over while I did the two-hand masking and s/he squeezed the bag,
then the patient recovered in 30 seconds to 100% and normocardia,
then the patient was allowed to breathe on his own with obvious rocking motion and upper airway obstruction,
then s/he did not recognize that it was OSA and said that he could be left to breathe on his own,
then s/he was told it was OSA and needed airway support until more awake,
then s/he was asked if ok to do the next case after near miss,
then s/he asked what near miss and told me not to even suggest that (the patient had woken up unharmed),
then s/he was reported for not being good enough for the endoscopy suite,
then the chief CRNA informed all of them that I was a CRNA hater to teach me a lesson,
then nothing happened to that CRNA.

Overnarcotizing patients, pushing 50 mg of Roc on zero twitches one hour before wake up, keeping elderly patients hypotensive at more than 2% of sevo, letting the patient breathe spontaneously at etCO2 of 70, running des at 2L/min, not following attending instructions etc. are piece of cake. And if you report those, you must be a hater, too.

Am I allowed now to be very afraid of working with them?

You are lucky you didn't get fired for causing a toxic work environment!

 

[urge]

I have no idea how it slipped past the attending but it did.

Didn't we conclude recently that pager/phone malfunction is common?

 

[urge]

Would've thought the ivory towers prefered Iso for the cost savings?

He works at a peds hospital.

 

[urge]

Again clinical faculty are certainly expected to be clinically superior and need higher teaching scores.


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Il Destriero

Am I supposed to understand that research faculty can suck clinically as long as they put papers out?

 

[IlDestriero]

Am I supposed to understand that research faculty can suck clinically as long as they put papers out?

Their promotion doesn't depend on superior clinical skills and teaching scores, ours does. If you really suck, you have to go, but the productive but weak are definitely coddled, given mentors, etc. Look at certain faculty assignments over a week or 2 and you'll see some patterns. If I was clinically weak, I'd be on double secret probation and told to look for another job. Having said that, many of the academic track faculty are great, though certainly not all.


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Il Destriero

 

[deleted171991]

I think the solution is daily reviews, as with residents. I could not convince my department to do that, of course. Otherwise, things just get fixed by different attendings every day, and there is no way to prove that a CRNA is weak. Which is exactly how they want it, so they can fly under the radar and argue how good they are.

 

[deleted171991]

Am I supposed to understand that research faculty can suck clinically as long as they put papers out?

Yes.

 

[pgg]

They use too much narcotic inappropriately

Too much narcs!

Common theme. I can count on one hand the number of days it's been since the last time I was called to the PACU to handle the consequences of a ridiculous intraop opiate overdose ...

I went in to take over a case one day, asked about the ST segment depression on the monitor, and after initially saying it was baseline (until I pulled up the preop 12-lead), he ultimately "fixed" it by moving the ECG leads on the patient.

Deliberate hypotension in a sitting shoulder in a chronic hypertensive patient because that's what we do to improve viewing conditions for the surgeon.


But I have to say, the most egregious thing I've ever seen was a successful assassination by an anesthesiologist. The case was a trach. Intubated patient. He somehow lost the airway before the surgeon even got to the trachea, had a hypoxic arrest. I was pulled into the room by the circ RN and arrived to find the patient reintubated, chest compressions underway, being hand ventilated with the sevo dial at 8%. Patient in v-fib. He hadn't even started ACLS. No shocks, no drugs. I turned the sevo off and started running the code. Asked him about the sevo and he said it was just up for a moment because the patient was moving a little. Eventually we called it. And what does he do? Says words to the effect of "sometimes you lose them" and leaves. Left it to me and the surgeon to go talk to the family.

 

[Planktonmd]

Common theme. I can count on one hand the number of days it's been since the last time I was called to the PACU to handle the consequences of a ridiculous intraop opiate overdose ...

I went in to take over a case one day, asked about the ST segment depression on the monitor, and after initially saying it was baseline (until I pulled up the preop 12-lead), he ultimately "fixed" it by moving the ECG leads on the patient.

Deliberate hypotension in a sitting shoulder in a chronic hypertensive patient because that's what we do to improve viewing conditions for the surgeon.


But I have to say, the most egregious thing I've ever seen was a successful assassination by an anesthesiologist. The case was a trach. Intubated patient. He somehow lost the airway before the surgeon even got to the trachea, had a hypoxic arrest. I was pulled into the room by the circ RN and arrived to find the patient reintubated, chest compressions underway, being hand ventilated with the sevo dial at 8%. Patient in v-fib. He hadn't even started ACLS. No shocks, no drugs. I turned the sevo off and started running the code. Asked him about the sevo and he said it was just up for a moment because the patient was moving a little. Eventually we called it. And what does he do? Says words to the effect of "sometimes you lose them" and leaves. Left it to me and the surgeon to go talk to the family.

There are a lot of people out there who don't have the simple reflex of turning off the vapor when a patient is severely hypotensive.
I have seen this frustrating behavior in both CRNAs and Anesthesiologists but way more frequently in CRNAs.
It is more common in people who did not have any meaningful trauma training, they just keep worrying about awareness or movement when they obviously need to be worrying about the patient not dying!

 

[kazuma]

At my residency program we had a well seasoned nurse (easily 20+ years experience) treat what they thought was refractory HTN and tachycardia with frequent doses of esmolol and labetolol only for the attending to discover the volatile agent was never turned on and the patient was paralyzed. The patient recalled the entire procedure and they offered an immediate uncontested settlement as it was indefensible.

Also agree with nurses often being heavy handed with opioids. I've had many nurses pontificate on the vast benefits of high dose opioids. It's actually the exact opposite of my practice which usually involves narcotic sparing approaches, multimodal (ketamine, magnesium, decadron, precedex, NSAIDS, tylenol etc) and regional techniques.

I find it very satisfying to have awake and comfortable patients w no N/V in PACU despite having painful procedures with minimal or no opioids. I routinely give as little as 25-50mcg Fent for multilevel spines or abdominal cases. It's pretty rare for me to give more than 100 mcg for most cases and I rarely use dilaudid.

 

[Doctor4Life1769]

There are a lot of people out there who don't have the simple reflex of turning off the vapor when a patient is severely hypotensive.
I have seen this frustrating behavior in both CRNAs and Anesthesiologists but way more frequently in CRNAs.
It is more common in people who did not have any meaningful trauma training, they just keep worrying about awareness or movement when they obviously need to be worrying about the patient not dying!

Don't even get me started on a few of my former attendings.

 

[Ronin786]

At my residency program we had a well seasoned nurse (easily 20+ years experience) treat what they thought was refractory HTN and tachycardia with frequent doses of esmolol and labetolol only for the attending to discover the volatile agent was never turned on and the patient was paralyzed. The patient recalled the entire procedure and they offered an immediate uncontested settlement as it was indefensible.

Also agree with nurses often being heavy handed with opioids. I've had many nurses pontificate on the vast benefits of high dose opioids. It's actually the exact opposite of my practice which usually involves narcotic sparing approaches, multimodal (ketamine, magnesium, decadron, precedex, NSAIDS, tylenol etc) and regional techniques.

I find it very satisfying to have awake and comfortable patients w no N/V in PACU despite having painful procedures with minimal or no opioids. I routinely give as little as 25-50mcg Fent for multilevel spines or abdominal cases. It's pretty rare for me to give more than 100 mcg for most cases and I rarely use dilaudid.

While I understand the benefits of opioid-sparing techniques, I think too many people take it to the other extreme. I find it just as satisfying to wake someone up smoothly having been able to run them at low-volatiles throughout the case with very stable hemodynamics and higher dose opioids.

Patient selection and the type of surgery obviously play a big role, but I don't think opioids need be demonized. They have a good role in your arsenal, especially if you're able to avoid some other things. My issue is with CRNAs who will run someone on 1 MAC+ of gas while giving 10ccs of Fentanyl for a lap chole.

 

[Ezekiel2517]

Happened during my residency. Long spine case. No art line. Episodes of hypotension during case. Record showed Pt's MAPs below 50 for one period of nearly 30 min intraop. Pt woke up at the end paralyzed permanently. Pt also happened to be one of the gastroenterologists at our hospital. Not sure if the hypotension was the definite cause but it doesn't look good

 

[deleted171991]

Happened during my residency. Long spine case. No art line. Episodes of hypotension during case. Record showed Pt's MAPs below 50 for one period of nearly 30 min intraop. Pt woke up paralyzed permanently. Pt also happened to be one of the gastroenterologists at our hospital. Not sure if the hypotension was the definite cause but it doesn't look good

It must have been the lazy supervising anesthesiologist's fault. At least that's what the lawyers will say.

 

[Doctor4Life1769]

It must have been the lazy supervising anesthesiologist's fault.

I thought you were quoting the awareness post.

Either way, must've been the pager malfunction.

 

[btbam]

How about giving 11 liters during a 5 hour neck dissection with less than 200 EBL. The patient could not be extubated at the end of the case, was grossly volume overloaded, and required 24 hours of diuresis before we even considered extubating. Or the one time a pedi bronchospasm wasn't recognized and the kid was bradycardic before the attending was called to intervene.

Not saying your 2nd point is wrong, but hypoxic neonates can brady in <30 seconds.

 

[Doctor4Life1769]

Not saying your 2nd point is wrong, but hypoxic neonates can brady in <30 seconds.

Either way, main thing is to oxygenate the neonate, fix that and the bradycardia resolves

 

[vector2]

Seconding the ridiculous amount of opioids. Also, do they not teach CRNA's about the concept of additive MAC or MAC aware in their clown colleges? Every single one of them wants the sevo 2+ or the iso 1.2+ no matter the pt's age or how much benzo, narcotic, adjunct etc they've gotten. I'll have my 80yr old whipple traintracking with 0.7 mac, dex at 0.5, ketamine and/or fentanyl boluses q1h or prn. One of them comes to give me a break and I tell them not to touch anything, but yet I come back to see my volatile doubled and the CRNA fighting the pressures with neo. I ask WTF is going on???.....response: "Had to turn up gas because awareness"

 

[Doctor4Life1769]

Seconding the ridiculous amount of opioids. Also, do they not teach CRNA's about the concept of additive MAC or MAC aware in their clown colleges? Every single one of them wants the sevo 2+ or the iso 1.2+ no matter the pt's age or how much benzo, narcotic, adjunct etc they've gotten. I'll have my 80yr old whipple traintracking with 0.7 mac, dex at 0.5, ketamine and/or fentanyl boluses q1h or prn. One of them comes to give me a break and I tell them not to touch anything, but yet I come back to see my volatile doubled and the CRNA fighting the pressures with neo. I ask WTF is going on???.....response: "Had to turn up gas because awareness"

Hahahah
Reminds me of an attending who did that. I subsequently turned it back down and no longer needing a neo gtt to keep map normal.

 

[criticalelement]

There are a lot of people out there who don't have the simple reflex of turning off the vapor when a patient is severely hypotensive.
I have seen this frustrating behavior in both CRNAs and Anesthesiologists but way more frequently in CRNAs.
It is more common in people who did not have any meaningful trauma training, they just keep wzi orrying about awareness or movement when they obviously need to be worrying about the patient not dying!

i used to tell residents NEver turn the dial above MAC. under any circumstances. Nobody really needs more than mac. If you do, use a balanced technique and give more propofol fentanyl etc etc... obviously a mask induction is a totally different story

 

[criticalelement]

Seconding the ridiculous amount of opioids. Also, do they not teach CRNA's about the concept of additive MAC or MAC aware in their clown colleges? Every single one of them wants the sevo 2+ or the iso 1.2+ no matter the pt's age or how much benzo, narcotic, adjunct etc they've gotten. I'll have my 80yr old whipple traintracking with 0.7 mac, dex at 0.5, ketamine and/or fentanyl boluses q1h or prn. One of them comes to give me a break and I tell them not to touch anything, but yet I come back to see my volatile doubled and the CRNA fighting the pressures with neo. I ask WTF is going on???.....response: "Had to turn up gas because awareness"

Happens to me all of the time.
You cant tell em anything.

IF you tell them Mac is additive, if you have one twitch, 10cc of fentanyl on board really no need for 1 mac of gas. In residency and to this day i do my cases with .6 % of iso

 

[Consigliere]

Happens to me all of the time.
You cant tell em anything.

IF you tell them Mac is additive, if you have one twitch, 10cc of fentanyl on board really no need for 1 mac of gas. In residency and to this day i do my cases with .6 % of iso

Well then I've got one bit of advice for you friend: turn down the iso, assho

 

[deleted162650]

Question for those of you in ACT practices (I consider myself one of the lucky ones who has never supervised midlevels): Do you guys document a detailed written anesthetic plan in the chart/EMR? Something beyond the typical "routine monitors/GA"? Just wondering if including things like "Maintain MAP > 65, etc., etc." would provide any insulation in the event of a case like this one:

Long spine case. No art line. Episodes of hypotension during case. Record showed Pt's MAPs below 50 for one period of nearly 30 min intraop. Pt woke up at the end paralyzed permanently.

At least in that case you could show/prove that your specific plan was not followed and you were not notified.

 

[IlDestriero]

You can delegate the authority, but not the responsibility.


--
Il Destriero

 

[Chloroform4Life]

Question for those of you in ACT practices (I consider myself one of the lucky ones who has never supervised midlevels): Do you guys document a detailed written anesthetic plan in the chart/EMR? Something beyond the typical "routine monitors/GA"? Just wondering if including things like "Maintain MAP > 65, etc., etc." would provide any insulation in the event of a case like this one:

Yeah. If I see someone at high risk of end organ damage from hypotension (cad, CKD, CVA, pad, back surgery, chronic HTN, sitting position, etc) I try to write keep MAP greater than something. I don't know if it changes anything, but it makes me feel a little better.

 

[soorg]

Reversing with zero twitches!

Extubating without reversing!

Not hooking up the circuit and actually administering anesthesia after LMA/intubation.

Overdosing propofol on EGD pt's who have terrible pulmonary status. Bc, you know, so they don't move during the 2 minute procedure.

And it's NEVER their fault. Never a "Crap, I won't do that ever again," or a "Sorry, I was wrong for doing that." They have a serious humility allergy. Pisses me off.