malpractice case @ UT Houston

[qwerty89]

http://www.painterfirm.com/a/170/Me...opofol-causing-death-of-45yearold-woman#tab-1

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[yancantcook]

Wow, just a reminder how the words of lawyer distort reality and reaffirms their status as the scum of the earth.

 

[OB1🤙]

Cringeworthy.

Sux overdose?

C'mon, man.

 

[Planktonmd]

There are some helpful points in this article, it states clearly that a nurse should not administer anesthesia unsupervised.

 

[SitraAchra]

Memorial Hermann Southeast is not UT Houston as the title of this thread implies, just as a correction.

 

[risnwb]

As ridiculous as the article is, the lawyers recognition of the importance of an anesthesiologist being present was a pleasant surprise.

 

[btbam]

This article reads like it was written by a 7th grader.

 

[Phyzicz]

"resuscitation effort lasted for nearly an hour, but they were not able to bring Michelle back until the drug overdoses wore off, our expert witness has told us..."
This is obviously incorrect metabolism information from the expert witness, unless the patient had pseudocholinesterase deficiency...

 

[deleted126335]

As ridiculous as the article is, the lawyers recognition of the importance of an anesthesiologist being present was a pleasant surprise.

Before we all go jumping into bed together, never forget that the medmal plaintiff's bar are parasites that feed on pain and misery and lie as easily as they speak. The fact that some of their speech and behavior is occasionally useful in our conflict with AANA and local state societies should not be thought of as anything more than one of our adversaries taking a bite out of another of our adversaries for their own benefit, not ours.

 

[risnwb]

Before we all go jumping into bed together, never forget that the medmal plaintiff's bar are parasites that feed on pain and misery and lie as easily as they speak. The fact that some of their speech and behavior is occasionally useful in our conflict with AANA and local state societies should not be thought of as anything more than one of our adversaries taking a bite out of another of our adversaries for their own benefit, not ours.

Point taken.

Still, this line surprised me:

"In fact, in our experience, we have seen these tragic deaths occur when a certified registered nurse anesthetist gives a patient Propofol, and something goes wrong while an anesthesiologist is not in the operating room."

 

[criticalelement]

Wow, just a reminder how the words of lawyer distort reality and reaffirms their status as the scum of the earth.

what distortion of reality? The lady is dead after an egd and received propofol. That is what happened isn't it?

 

[criticalelement]

Point taken.

Still, this line surprised me:

"In fact, in our experience, we have seen these tragic deaths occur when a certified registered nurse anesthetist gives a patient Propofol, and something goes wrong while an anesthesiologist is not in the operating room."

The only reason we are still in business is because of the lawyers(medical liability) otherwise there would be a stable of crnas in hospitals doing things without us. The lawyers insist on our names being on the chart.

 

[criticalelement]

I've said this before. EGD on obese sleep apnea patients is one of the most dangerous procedures we do. I've maintained this way before the joan rivers death. This is no case for the inexperienced. I am surprised we get minimal training for this because "Its so easy". Its only after training did i do one thousand of them to realize the real risks.

 

[nimbus]

I've said this before. EGD on obese sleep apnea patients is one of the most dangerous procedures we do. I've maintained this way before the joan rivers death. This is no case for the inexperienced. I am surprised we get minimal training for this because "Its so easy". Its only after training did i do one thousand of them to realize the real risks.

It's not really a dangerous procedure. It's only potentially dangerous because it has become routine to compromise technique for the sake of efficiency. If you did geta instead of GA with a shared compromised airway, it is a no brainer.

That said, I have noticed shoving an endoscope down the esophagus often improves airway obstruction, acting as an oral airway.

 

[Consigliere]

It's not really a dangerous procedure. It's only potentially dangerous because it has become routine to compromise technique for the sake of efficiency. If you did geta instead of GA with a shared compromised airway, it is a no brainer.

That said, I have noticed shoving an endoscope down the esophagus often improves airway obstruction, acting as an oral airway.

And if you even suggested this at a busy endo center, you would soon be UNEMPLOYED.

 

[CrazyJake]

We do a lot of these cases, quick EGD...in and out. I fear these cases more than almost any other (outside of bleeding tonsil maybe). Our GI docs literally have no clue.

These People laryngospasm, buck, cough, desat...it's purely 5-10 mins of hell. We do mostly Propofol gtts and typically only ETT if seriously worried about the airway. What are you all doing?

Limited details in the case, but I'm guessing this patient was larger given planned bariatric surgery.

 

[nimbus]

And if you even suggested this at a busy endo center, you would soon be UNEMPLOYED.

Absolutely! No disagreement at all. I'm just sayin' we compromise safety for the sake of efficiency.

 

[chocomorsel]

All the time nimbus. I bet most of us give GA without securing the airway in these cases. You gotta be vigilant with the fatties.
Thankfully I no longer work with CRNA's and at the hospital where we do our endo procedures, the suites are right next to the OR suites and are set up exactly as an OR is. If **** hits the fan I know where everything is, have knowledgeable people around and I have a working anesthesia machine. Makes a world of difference not to be two flights and a mile down the corridor in the Endo Suite.

 

[k12balla]

The old, sick, and super obese in a fast paced Endo suite, really force you to use your wits and earn your money. Yes, ideally intubated or done in the main OR with a full cardiac work up, etc but we all know this is not a reality. It helps to have a fast GI doc so you can get it get out. But when you perform these cases in the real world, what are some of your cocktails/techniques?

For fatties I load em with versed, Demerol, touch of prop, nasal airway once sedated, if it's a colon I'll throw in an oral airway, optimize their head positioning and jaw thrust if need be. At times Ill use precedex or ketamine, all this with a thorough discussion beforehand that I'm not guaranteeing a full anesthetic, and that they may temporarily awaken or have recall, but that this is done with their safety in mind. Communicating this to the GI team also helps as well, so that their expectations are more realistic.

 

[criticalelement]

The old, sick, and super obese in a fast paced Endo suite, really force you to use your wits and earn your money. Yes, ideally intubated or done in the main OR with a full cardiac work up, etc but we all know this is not a reality. It helps to have a fast GI doc so you can get it get out. But when you perform these cases in the real world, what are some of your cocktails/techniques?

For fatties I load em with versed, Demerol, touch of prop, nasal airway once sedated, if it's a colon I'll throw in an oral airway, optimize their head positioning and jaw thrust if need be. At times Ill use precedex or ketamine, all this with a thorough discussion beforehand that I'm not guaranteeing a full anesthetic, and that they may temporarily awaken or have recall, but that this is done with their safety in mind. Communicating this to the GI team also helps as well, so that their expectations are more realistic.

Multiple ways one can attack the anesthetic and an endotracheal tube at 1015 am with 10 more scopes to go for the day is not one of them. As consigliere pointed out, that will be your last day at the center.

 

[Noyac]

"Ask what role the anesthesiologist will have, as opposed to the roles of a certified registered nurse anesthetist or anesthesia assistant, both of whom have much less training that an anesthesiologist."

Wait a minute. I thought they had the same amount of training. I could swear I read something from AANA stating that the training was equal to an anesthsiologists.

 

[CrazyJake]

Noyac I saw the same thing....same books, same training, same skills but even better.

 

[CrazyJake]

I know zero details about this case and whole-heatedly believe the lawyer is the way bigger scumbag (vs anesthesia providers) evidenced by this garbage write-up.

But here's what my simple doctor teaching (as the AANA would want most to believe) did teach me...if you need bariatric surgery you probably need a secure airway. At the very least you probably need an extra set of hands. I do a ton of these cases and its impossible to hold jaw lift, get a tight mask, maybe vent and draw up Succ while managing everything else going on, especially in a crisis.

 

[IlDestriero]

"Ask what role the anesthesiologist will have, as opposed to the roles of a certified registered nurse anesthetist or anesthesia assistant, both of whom have much less training that an anesthesiologist."

Wait a minute. I thought they had the same amount of training. I could swear I read something from AANA stating that the training was equal to an anesthsiologists.

Better actually because of all their ICU experience and nursing background.

 

[IlDestriero]

They listen to the patients concerns and hold their hand while they're circling the drain. The closed minded doctors jump to conclusions, rapidly doing invasive procedures like intubations and cricothyrotomies without taking a holistic approach to the desaturation.

 

[Noyac]

They listen to the patients concerns and hold their hand while they're circling the drain. The closed minded doctors jump to conclusions, rapidly doing invasive procedures like intubations and cricothyrotomies without taking a holistic approach to the desaturation.

LMAO!!!

 

[jwk]

For fatties I load em with versed, Demerol, touch of prop, nasal airway once sedated, if it's a colon I'll throw in an oral airway, optimize their head positioning and jaw thrust if need be. At times Ill use precedex or ketamine, all this with a thorough discussion beforehand that I'm not guaranteeing a full anesthetic, and that they may temporarily awaken or have recall, but that this is done with their safety in mind. Communicating this to the GI team also helps as well, so that their expectations are more realistic.

So you're doing a GA and calling it a MAC? I'm confused.

Versed - totally unnecessary, especially for a 5 min case in a bariatric patient. Demerol - ????? Precedex and ketamine - for what?

We do literally thousands of GI cases a year, 99% of them with straight propofol, even with bariatric or elderly patients. We judiciously titrate the propofol dose in these patients. If they need GA, give them a GA, without question, but do a real GA with a real protected airway. If you're using an oral airway, it's a GA IMHO.

 

[Mad Jack]

As ridiculous as the article is, the lawyers recognition of the importance of an anesthesiologist being present was a pleasant surprise.

That was only put into the case to make the anesthesiologist seem negligent for not being there, so that he could set the blame 75% on the anesthesiologist and 25% on the CRNA, but still...

 

[Mad Jack]

what distortion of reality? The lady is dead after an egd and received propofol. That is what happened isn't it?

Things like calling propofol a "dangerous drug" in a way that implies it is implicitly more dangerous than other drugs and some kind of cowboy choice to use as an anesthetic. Making it sound like the anesthesiologist just left for no good reason, without mentioning that they were likely overseeing 4 CRNAs at the time and can only be in one place at a time.

 

[k12balla]

So you're doing a GA and calling it a MAC? I'm confused.

Versed - totally unnecessary, especially for a 5 min case in a bariatric patient. Demerol - ????? Precedex and ketamine - for what?

We do literally thousands of GI cases a year, 99% of them with straight propofol, even with bariatric or elderly patients. We judiciously titrate the propofol dose in these patients. If they need GA, give them a GA, without question, but do a real GA with a real protected airway. If you're using an oral airway, it's a GA IMHO.

You must not understand the difference between MAC and GA. 99% of the time when using propofol, it's a general anesthetic. There are a million ways you can accomplish this, and I prefer to use a combination of drugs that maintains or at least avoids suppressing their spontaneous ventilations too much.

Everyone responds differently to drugs, as is evident by the recent disastrous outcomes. If people used their heads instead of cookie cutter anesthesia and giving high doses of propofol to everyone, we'd have a lot better outcomes. Most of the time you get away with it, but that doesn't make it optimal.

 

[nimbus]

You must not understand the difference between MAC and GA. 99% of the time when using propofol, it's a general anesthetic. There are a million ways you can accomplish this, and I prefer to use a combination of drugs that maintains or at least avoids suppressing their spontaneous ventilations too much.

Everyone responds differently to drugs, as is evident by the recent disastrous outcomes. If people used their heads instead of cookie cutter anesthesia and giving high doses of propofol to everyone, we'd have a lot better outcomes. Most of the time you get away with it, but that doesn't make it optimal.

I have to agree with JWK on this one. I get my best outcomes without polypharmacy. Simpler better workflow, faster emergence and faster discharge with straight propofol. Who has time to draw up multiple drugs at a busy endoscopy center? And yes it's GA.

 

[k12balla]

I agree it has its merits, I'm more referring to sicker inpatients where you're not as concerned with turnover or emergence as you are patient safety

 

[risnwb]

The old, sick, and super obese in a fast paced Endo suite, really force you to use your wits and earn your money. Yes, ideally intubated or done in the main OR with a full cardiac work up, etc but we all know this is not a reality. It helps to have a fast GI doc so you can get it get out. But when you perform these cases in the real world, what are some of your cocktails/techniques?

For fatties I load em with versed, Demerol, touch of prop, nasal airway once sedated, if it's a colon I'll throw in an oral airway, optimize their head positioning and jaw thrust if need be. At times Ill use precedex or ketamine, all this with a thorough discussion beforehand that I'm not guaranteeing a full anesthetic, and that they may temporarily awaken or have recall, but that this is done with their safety in mind. Communicating this to the GI team also helps as well, so that their expectations are more realistic.

Demerol? What anesthesiologist uses Demerol when you have fentanyl at your disposal? I don't see the advantage... just disadvantages. Also, in these morbidly obese patients who most definitely have osa, I completely avoid narcotics. They just delay discharge due to pacu monitoring standards and these procedures don't hurt, they are just uncomfortable.
As for midazolam, I think it's really useful in this population to decrease total propofol dose. I used to do all my uppers and lowers with propofol alone. The. I switched to using 2mg midazolam in holding on younger patients (<70 or so) and wheeling them back to the endo suite slightly sedated. It has decreased my rate of desats, decreased my total propofol dose significantly, and smoothed out the whole anesthetic. In fact, most are discharged earlier than they would have been with just propofol as our gi docs expect complete immobility and to achieve this I was giving really high doses of prop... Maybe it's different with different gi docs, but ours are pretty rough.

 

[aneftp]

1. You don't need "anesthesia people" present for 90% of GI procedures. We all know this.

Make GI anesthesia reimbursement the same as cataracts. You will see anesthesia companies and groups pull out of GI anesthesia business altogether.

2. Because of creative bulling, having MD "medically direct" Crna for gi procedures is a very gray area. Why? Especially when you examine the 7 criteria for Medicare reimbursement and medical direction.

Is anesthesiologist present for critical aspects of the anesthetics? For me if these creative billing companies want to bill it as medically necessary and a general anesthetic. If CRNA pushes what is an induction dose of propofol to start the EGD (I will assume Crna is pushing between 100-150mg of propofol). Folks. That's an induction dose. That's a general anesthetic. If they are billing for medical direction (which I believe they are). They will get hosed because anesthesiologist was not present for "critical aspect" of anesthetic.

Agree or disagree? General anesthesia/medical direction/anesthesiologist should be present if billing that way.

 

[IlDestriero]

Maybe they bill as supervision?
MAC or GA, no matter how you slice it, induction is certainly a critical event requiring the anesthesiologist if billing as direction.

 

[deleted162650]

Make GI anesthesia reimbursement the same as cataracts. You will see anesthesia companies and groups pull out of GI anesthesia business altogether.

Scope bills 5 units

Cataract bills 4

Time is similar for both procedures

Not seeing the big difference here that would cause groups to stop doing scopes.

 

[aneftp]

Scope bills 5 units

Cataract bills 4

Time is similar for both procedures

Not seeing the big difference here that would cause groups to stop doing scopes.

Big price differences in dollars per unit

 

[Southpaw]

Scope bills 5 units

Cataract bills 4

Time is similar for both procedures

Not seeing the big difference here that would cause groups to stop doing scopes.

Cataract - almost exclusively Medicare

Scope - not

that's the difference

 

[Southpaw]

I agree with JWK. I call it a GA and I use exclusively propofol. Polypharmacy is what the GIs use when I'm not there (fent, midaz, benadryl, promethazine, demerol, etc.). My group was asked to cover endo to speed discharge and improve patient satisfaction. To me, that=propofol. I think straight propofol is very titratable and very safe for endo (all ages, all levels of sickness). Yes, your GI docs need to be smooth and fast. And I'd never, ever want to supervise CRNAs in endoland. Very dangerous territory.

 

[Noyac]

You must not understand the difference between MAC and GA. 99% of the time when using propofol, it's a general anesthetic. There are a million ways you can accomplish this, and I prefer to use a combination of drugs that maintains or at least avoids suppressing their spontaneous ventilations too much.

Everyone responds differently to drugs, as is evident by the recent disastrous outcomes. If people used their heads instead of cookie cutter anesthesia and giving high doses of propofol to everyone, we'd have a lot better outcomes. Most of the time you get away with it, but that doesn't make it optimal.

I agree mostly. I usually start with a couple cc's of propofol followed by 5-10mg ketamine. I may give ketamine one more time during the procedure. I usually get away with less than 20cc propofol for the entire case because the ketamine just puts them in a happy breathing place. I don't start an infusion because the procedure goes from stimulating to not so much throughout the case. I just give little bumps throughout the case depending on the pt. I can usually talk to the pt during the case ( yes they will answer me). My endorsed nursing staff love the way I do these cases becaus e they are wide awake immediately after the procedure. Some of my puts even watch the last half of the procedure. This is both EGD's and Colons. Less is more.

 

[Arch Guillotti]

For fatties I load em with versed, Demerol, touch of prop, nasal airway once sedated, if it's a colon I'll throw in an oral airway, optimize their head positioning and jaw thrust if need be. At times Ill use precedex or ketamine, all this with a thorough discussion beforehand that I'm not guaranteeing a full anesthetic, and that they may temporarily awaken or have recall, but that this is done with their safety in mind. Communicating this to the GI team also helps as well, so that their expectations are more realistic.

 

[Consigliere]

Less is more.

Depends wholly on the GI doc. The ones I work with don't want the patients moving and they CERTAINLY don't want them talking.

 

[Noyac]

Depends wholly on the GI doc. The ones I work with don't want the patients moving and they CERTAINLY don't want them talking.

Then it is your job to educate them.
Mine don't move and don't talk unless you wake them and ask them something which is easy to do.

Bottom line is that we don't need GA for these cases. A well tailored MAC can be much safer and much more efficient.

 

[aneftp]

Then it is your job to educate them.
Mine don't move and don't talk unless you wake them and ask them something which is easy to do.

Bottom line is that we don't need GA for these cases. A well tailored MAC can be much safer and much more efficient.

Some insurance won't pay for "Mac" anesthesia unless it's clearly documented medically necessary and easiest way to do it is to document propofol usage.

It's all a scam and unfortunately big business depending on payer mix with GI "propofol sedation" aka general for 80% of the patient population.

Seriously we can talk BS talk about "efficiency, patient satisfaction etc" with propofol. But cost/benefit to the system. We all know the answer.

And worst of all half the centers have GI docs and anesthesia docs absolutely lie on their preop diagnosis. Even when patients have history of colon polyps (v12.72 diagnosis). They will document it as a "screening diagnosis". V76 diagnosis.

Why? In the age of high deductible. A polyp diagnosis means patient has to pay huge financial costs including anesthesia "propofol sedation"until they meet their $4000-10000 deductible.

But a "screening diagnosis" means it's "free to the patient" even when patients have had polyps in the distant past.

But anesthesia is still getting reimbursed 100% by insurance if it's a screening. Or else the patient if they knew they were on the hook for the $500-1000 anesthesia propofol charges would opt for the versed/fentanyl sedation route.

 

[norwood]

Wow, just a reminder how the words of lawyer distort reality and reaffirms their status as the scum of the earth.

Yep. The dangerous drug Propofol... As opposed to all the other completely harmless drugs that can cause GA...

 

[Consigliere]

Then it is your job to educate them.
Mine don't move and don't talk unless you wake them and ask them something which is easy to do.

Bottom line is that we don't need GA for these cases. A well tailored MAC can be much safer and much more efficient.

No, my job is to accomodate them, not educate them. Ain't nobody got time for dat!

 

[criticalelement]

And worst of all half the centers have GI docs and anesthesia docs absolutely lie on their preop diagnosis. Even when patients have history of colon polyps (v12.72 diagnosis). They will document it as a "screening diagnosis". V76 diagnosis.

Why? In the age of high deductible. A polyp diagnosis means patient has to pay huge financial costs including anesthesia "propofol sedation"until they meet their $4000-10000 deductible.

But a "screening diagnosis" means it's "free to the patient" even when patients have had polyps in the distant past.

But anesthesia is still getting reimbursed 100% by insurance if it's a screening. Or else the patient if they knew they were on the hook for the $500-1000 anesthesia propofol charges would opt for the versed/fentanyl sedation route.

Pretty much fraud and can get you in a federal penitentiary for a while. I would NOT be associataed with this at all.

HOw hard would it be to catch those doctors at that game? Not hard at all.

 

[criticalelement]

Then it is your job to educate them.
Mine don't move and don't talk unless you wake them and ask them something which is easy to do.

Bottom line is that we don't need GA for these cases. A well tailored MAC can be much safer and much more efficient.

these cases are all GA. no talking no moving. competely immobile. Period. Why would a mac be safer? In fact I will argue it is more dangerous.
WIth propofol it matters very little how much you give? 200- 700 theywake up the same.

 

[aneftp]

Pretty much fraud and can get you in a federal penitentiary for a while. I would NOT be associataed with this at all.

HOw hard would it be to catch those doctors at that game? Not hard at all.

A lot of them do it. Been in the business long enough.

You don't know what the coders are doing unless you got patients complaining that "they didn't get charged last time". Than you re examine the billing codes and see the coders changed the diagnostic (v12.72 with history of polyps) to a v76.51 (screening code). So that person who has a $5000 deductible never sees the bill.

That way the anesthesia company gets the guaranteed $500-1000 check from the insurance company. Vs waiting to bill the patient for that $500-1000 out of pocket expense. Who knows if the patient will pay it or not.

GI docs are super greedy themselves. But they own their own path labs. So many of these patients get multiple biopsies. And get the stigma of having a "history of a benign colon polyp" when it was really nothing at all. GI docs just happened to bx multiple sites cause they collect $$$$ from each bx.

This is the dirty business of GI anesthesia (no pun intended)

 

[Noyac]

I have no doubts that anyone here on this site can effectively perform a GA on these pts without any added risks or delays. I am not trying to change anyone's approach. Just giving my preference

In my previous group we had a policy, anytime propofol was given we called it a GA. I'm sure sure that this is the right approach but it is one way of clearing up any confusion.