Patient dead when anesthesiology not present at induction, only crna

[calvnandhobbs68]

This is one example of serious problems with people that are exclusively outpatient in offices.
This CRNA hadn't intubated a patient in 5 years. 5 years! In an emergency they were, quite predictably, useless.
There was a case I saw recently where a pediatric NP was responsible for covering a hospital at night without in house peds physician back up. There was an urgent C/S and they were called to resuscitate the baby. They couldn't intubate the baby and the CRNA was unwilling and/or unable to leave their patient (the mother). The anesthesiologist was called and arrived to a bloody mess of an airway 10 minutes after delivery and about 5 minutes after being called. They took several minutes to intubate the baby which ended up with a severe anoxic brain injury.
The plaintiff sued the hospital, NP and peds group. The "experienced" peds NP had not intubated anyone in 5 or 6 years, had less than 10 or 15 intubations ever, and had never intubated anyone at birth.
We as educated patients need to ask hard questions about who is taking care of us for routine outpatient procedures and if we don't like the answers, we need to opt for a different location, surgeon, etc.
Would you deliver your baby at a location that has an NP working alone and unafraid who has NEVER intubate a newborn. Sad, predictable, and avoidable.
They will all get appropriately crushed.

Just as an example of how graduate medical training is superior...any pediatrician (not even talking about NICU docs here) would have intubated a newborn at least several times over and would have basic experience in newborn resuscitation given that basically all pediatrics residents in the country do a significant amount of NICU time. Thus, you would never run into this situation if you just had a pediatrician in house, instead of trying to cut costs by hiring a rando "peds" NP who took a few online pediatrics classes.

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[TooMuchResearch]

it may very well be safe in your hands - i don't know.

however, i have been called to various ER's more than once to rescue an airway after propofol "sedations" gone awry - aspiration, obstruction, desaturation, etc... usually when the procedure takes longer than anticipated, small therapeutic window, ignorance of context-sensitive half time, poor airway evaluation, poor plan B/C setup etc...

propofol should remain the domain of anesthesiologists.

non-anesthesia folks should stick with ketamine, versed, and fentanyl. (no respiratory depression, flumazenil, narcan)

if those drugs don't work you need an anesthetic delivered by an anesthesiologist - we are happy to help.

BTW what FiO2 do you think you are achieving with a nasal cannula on "full blast"?

You know that meant 15 lpm, and you choose to phrase your question in a condescending manner. Apneic O2 is pretty standard EM practice.

There is a robust body of EM literature on the safety and efficacy of propofol in the ED.

I'll call you if I need an induction with inhalational anesthetic.

 

[TooMuchResearch]

you are naive - i would wager >98% of the propofol volume delivered in this country is by anesthesia providers.

this is the situation i caution against. a doctor with non-anesthetic training both doing a procedure and supervising the anesthetic ie ordering an RN to push the drug. vast majority of the time it goes fine. but we're not talking bout a rash or pruritis if things go wrong - we're talking about anoxic brain injury.

as i've said, ER docs (and other non-anesthesia personnel) should stick to ketamine, fentanyl, and versed. if that doesn't work, you need an anesthesiologist.

this opinion is echoed by most every other board certified anesthesiologist i have spoken to on the subject.

Well if the anesthesiologists want to tell emergency physicians how to do their jobs, they must be right!

 

[nap$ter]

I'm sure you're right, but I've never seen one present in the ED for any procedure. I just wasn't aware that this was uncommon.

i meant in the OR. the total amount of propofol delivered in ER's is tiny compared to the volumes delivered in the OR - we use propofol for virtually every case.

 

[PikminOC]

Well if the anesthesiologists want to tell emergency physicians how to do their jobs, they must be right!

Stop it.
This is what always keeps docs down.
We fight amongst ourselves.

Nurses do NOT.

 

[TooMuchResearch]

We have a sedation service and they are prohibited from using propofol. I don't know what the ED uses and don't care. They call for difficult airways and L1 traumas, that's enough. They also have airway skills if they get into trouble that GI, etc. does not.

*like*

 

[PikminOC]

Just as an example of how graduate medical training is superior...any pediatrician (not even talking about NICU docs here) would have intubated a newborn at least several times over and would have basic experience in newborn resuscitation given that basically all pediatrics residents in the country do a significant amount of NICU time. Thus, you would never run into this situation if you just had a pediatrician in house, instead of trying to cut costs by hiring a rando "peds" NP who took a few online pediatrics classes.

Correct. Medical education is accredited and standardized. Many midlevel training programs are not. So you really don't know the product you are getting.

 

[nap$ter]

You know that meant 15 lpm, and you choose to phrase your question in a condescending manner. Apneic O2 is pretty standard EM practice.

There is a robust body of EM literature on the safety and efficacy of propofol in the ED.

I'll call you if I need an induction with inhalational anesthetic.

believe me - we really don't want to tell ER docs how to do their jobs - the ER is their domain.

however, I also don't want to be asked by ER docs to come down to the ER to bail them out when things go wrong - and this has happened to me a few times with attempted propofol sedations.

lost airways (or other major complications) with propofol are rare events with catastrophic consequences not captured by EM literature especially when anesthesia fire depts prevent the end result of serious code-able morbidity and mortality that would otherwise ensue.

your implication that you can do anything in anesthesia except inhalational inductions illustrates my point that ER docs don't know what they don't know about anesthesia. what they do know they know well.

my question about hi-flo nasal cannula was genuine - we don't use that technique in the OR. do you set up genuine hi-flo nasal cannula with humidifier and what is your flow rate and believed fio2? i am not much familiar with the technique outside of the PICU - they used flows from 15-60!! L/min and i got varying answers about fio2 - many variables seemed to potentially play a role. or do you mean that you just use a regular nasal cannula jacked to 15L/min? if so why? why not a regular old facemask? in the OR we rarely need more than a cheap ol' facemask - if the pt is maintained with adequate spontaneous ventilation not much supplemental fio2 is needed - usually...

and believe me, i have often been called to witness the standard of care ER attempts at apneic oxygenation (NOW i know what that is!) - usually in the setting of unanticipated difficult airways and a call to us for help... i kid, i kid!!

 

[Iso4ane]

believe me - we really don't want to tell ER docs how to do their jobs - the ER is their domain.

however, I also don't want to be asked by ER docs to come down to the ER to bail them out when things go wrong - and this has happened to me a few times with attempted propofol sedations.

lost airways (or other major complications) with propofol are rare events with catastrophic consequences not captured by EM literature especially when anesthesia fire depts prevent the end result of serious code-able morbidity and mortality that would otherwise ensue.

your implication that you can do anything in anesthesia except inhalational inductions illustrates my point that ER docs don't know what they don't know about anesthesia. what they do know they know well.

my question about hi-flo nasal cannula was genuine - we don't use that technique in the OR. do you set up genuine hi-flo nasal cannula with humidifier and what is your flow rate and believed fio2? i am not much familiar with the technique outside of the PICU - they used flows from 15-60!! L/min and i got varying answers about fio2 - many variables seemed to potentially play a role. or do you mean that you just use a regular nasal cannula jacked to 15L/min? if so why? why not a regular old facemask? in the OR we rarely need more than a cheap ol' facemask - if the pt is maintained with adequate spontaneous ventilation not much supplemental fio2 is needed - usually...

and believe me, i have often been called to witness the standard of care ER attempts at apneic oxygenation (NOW i know what that is!) - usually in the setting of unanticipated difficult airways and a call to us for help... i kid, i kid!!

If you had normal nasal cannula running at 15LPM, I get a feeling that you patient is going to hate you, otherwise you have bigger problems on your hands.

 

[Doctor Bob]

There is always a turf war with ED and Anesthesia over propofol. I'm not entirely sure why. I have seen far more sedation misadventures with versed/fentanyl than with propofol.
Versed/fentanyl for sedation in the ED is a less than optimal sedation plan; the sedation onset for the combination is slower and variable and often people oversedate in order to get the person to the desired level of sedation in the desired amount of time.
Propofol on the other hand is rapid on, rapid off; which makes it ideal for the ED.

I can kill someone with any drug if I don't know how to use it. I've seen nephrologists nearly kill someone with lasix; that doesn't mean they shouldn't be allowed to use it.
I disagree with the idea that any drug should be restricted to any specific field.
Imagine if the plastic surgeons said "we are the only ones who can use a #15 scalpel because the rest of you surgeons occasionally have bad post-op scars that we have to fix". Ridiculous. The rest of the surgeons wouldn't stand for it. There's so much tension between the ED and Anesthesia over propofol because while the rest of the medicine docs are content with having that drug restricted from them, the ED is pretty aggressive with pushing back.

 

[Iso4ane]

Sounds cool and all but I bet if you asked a rando pediatrician years out from training how comfortable they are tubing a baby...those few intubations as an intern aren't going to cut it.

But, would you have someone who as least one point in time tubed a infant in the past vs someone who has never tubed an infant before.

 

[Brigade4Radiant]

Just as an example of how graduate medical training is superior...any pediatrician (not even talking about NICU docs here) would have intubated a newborn at least several times over and would have basic experience in newborn resuscitation given that basically all pediatrics residents in the country do a significant amount of NICU time. Thus, you would never run into this situation if you just had a pediatrician in house, instead of trying to cut costs by hiring a rando "peds" NP who took a few online pediatrics classes.

I'm not sure a pediatrician would have been able to get that case. Most pediatrician don't get a lot of intubations in residency and a lot of intubations got to the NICU fellow. The NP has intubated before and a lot of pediatric residents don't intubate a baby at birth. They do all intubate though.

 

[calvnandhobbs68]

But, would you have someone who as least one point in time tubed a infant in the past vs someone who has never tubed an infant before.

That's the point. If I had to choose between someone who's never intubated an infant before vs someone who has...I'm going with the person who has. I'm not saying most pediatricians routinely intubate infants but they've likely done it at some point along the line. Should they have someone who's comfortable doing newborn intubations routinely around? Sure that would be ideal, but most hospitals can't staff a NNP or NICU doc 24/7.

I probably shouldn't have said you would "never" run into this situation, but would it be preferable to having someone who has literally never done the thing they are now attempting to do it in a life threatening situation? I'd say yes.

Also, a point I didn't make earlier. This situation where the NP didn't call the anesthesiologist until 5 minutes of unsuccessful intubations is ridiculous and another great example of them not calling for backup until they're so far in the crap they can't step out. Any reasonable person in that situation who knows they might have to intubate and hasn't done it in this situation EVER should be calling the anesthesiologist as they're walking down the hallway to let him/her know what's going down. I would hope that the rando pediatrician would have the sense to do that.

 

[Iso4ane]

That's the point. If I had to choose between someone who's never intubated an infant before vs someone who has...I'm going with the person who has. I'm not saying most pediatricians routinely intubate infants but they've likely done it at some point along the line. Should they have someone who's comfortable doing newborn intubations routinely around? Sure that would be ideal, but most hospitals can't staff a NNP or NICU doc 24/7.

I probably shouldn't have said you would "never" run into this situation, but would it be preferable to having someone who has literally never done the thing they are now attempting to do it in a life threatening situation? I'd say yes.

Also, a point I didn't make earlier. This situation where the NP didn't call the anesthesiologist until 5 minutes of unsuccessful intubations is ridiculous and another great example of them not calling for backup until they're so far in the crap they can't step out. Any reasonable person in that situation who knows they might have to intubate and hasn't done it in this situation EVER should be calling the anesthesiologist as they're walking down the hallway to let him/her know what's going down. I would hope that the rando pediatrician would have the sense to do that.

I don't know a lot about coding for payments, but how is anesthesia reimbursed in cases like this,

 

[acceptmeplease]

For your viewing pleasure.
http://emcrit.org/wee/real-surgical-airway/

Why did I like this so much?

 

[IlDestriero]

I don't know a lot about coding for payments, but how is anesthesia reimbursed in cases like this,

When we are called to the ICU, etc. for an airway we write a procedure note and that goes to billing. However, a very important however btw, if you submit a bill you may no longer be viewed as an uninvolved Good Samaritan coming to help your colleague in an emergency.
In a case like this, a bad trauma intubation in the ED after failed intubation attempts, a coding a lost airway in the unit, etc. where I was concerned there may be litigation, I wouldn't write a procedure note and would write a progress note instead. They don't get automatically billed. In the old days I just wouldn't submit the billing sheet. I don't want any part of the liability for something I'm not involved with.
I'm sure the hospital, NP and peds group in this case would have loved to pass some of the liability on to the anesthesiologist or CRNA, and would have in a heartbeat if they could have. They can try to sue you anyway of course, but part of the proof that you didn't have a doctor patient relationship with the patient is that you didn't get paid for your services. And this isn't exactly going to make the Porsche payment, if you know what I mean. I rarely bill for these kind of things.

 

[cbrons]

When we are called to the ICU, etc. for an airway we write a procedure note and that goes to billing. However, a very important however btw, if you submit a bill you may no longer be viewed as an uninvolved Good Samaritan coming to help your colleague in an emergency.
In a case like this, a bad trauma intubation in the ED after failed intubation attempts, a coding a lost airway in the unit, etc. where I was concerned there may be litigation, I wouldn't write a procedure note and would write a progress note instead. They don't get automatically billed. In the old days I just wouldn't submit the billing sheet. I don't want any part of the liability for something I'm not involved with.
I'm sure the hospital, NP and peds group in this case would have loved to pass some of the liability on to the anesthesiologist or CRNA, and would have in a heartbeat if they could have. They can try to sue you anyway of course, but part of the proof that you didn't have a doctor patient relationship with the patient is that you didn't get paid for your services. And this isn't exactly going to make the Porsche payment, if you know what I mean. I rarely bill for these kind of things.

Is this a common thing?

 

[tiedyeddog]

When we are called to the ICU, etc. for an airway we write a procedure note and that goes to billing. However, a very important however btw, if you submit a bill you may no longer be viewed as an uninvolved Good Samaritan coming to help your colleague in an emergency.
In a case like this, a bad trauma intubation in the ED after failed intubation attempts, a coding a lost airway in the unit, etc. where I was concerned there may be litigation, I wouldn't write a procedure note and would write a progress note instead. They don't get automatically billed. In the old days I just wouldn't submit the billing sheet. I don't want any part of the liability for something I'm not involved with.
I'm sure the hospital, NP and peds group in this case would have loved to pass some of the liability on to the anesthesiologist or CRNA, and would have in a heartbeat if they could have. They can try to sue you anyway of course, but part of the proof that you didn't have a doctor patient relationship with the patient is that you didn't get paid for your services. And this isn't exactly going to make the Porsche payment, if you know what I mean. I rarely bill for these kind of things.

Wow. Thanks for the post, I always wondered how this worked.

 

[IlDestriero]

Is this a common thing?

Anesthesia is the airway expert. Others can intubate, but we have the most experience. We go to all L1 traumas if we are available to go down, and may intubate if they have not already and they are busy with lines, resuscitation etc., we get called for all known or suspected difficult airway patients that need intubation, and we are occasionally called to help out when the sedation service is having problems. The problems are usually airway related and often mid procedure, so we secure the airway and take over the case. That situation I always bill for, but the sedation service is very conservative about who they will sedate, so it is uncommon. There is also a policy that we are called after the 3rd unsuccessful intubation attempt. That keeps us from being expected to rescue an airway that has been cut, bruised, bloodied by 6 failed attempts from every person in the room. Of course, at night and on the weekend, depending on what's going on, we may not be able to come to help.

 

[Psai]

Anesthesia is the airway expert. Others can intubate, but we have the most experience. We go to all L1 traumas if we are available to go down, and may intubate if they have not already and they are busy with lines, resuscitation etc., we get called for all known or suspected difficult airway patients that need intubation, and we are occasionally called to help out when the sedation service is having problems. The problems are usually airway related and often mid procedure, so we secure the airway and take over the case. That situation I always bill for, but the sedation service is very conservative about who they will sedate, so it is uncommon. There is also a policy that we are called after the 3rd unsuccessful intubation attempt. That keeps us from being expected to rescue an airway that has been cut, bruised, bloodied by 6 failed attempts from every person in the room. Of course, at night and on the weekend, depending on what's going on, we may not be able to come to help.

yeah but you're anesthesia, you're obviously responsible for cleaning up the mess after someone butchered the intubation and now there's a ton of edema and bleeding from all the trauma

 

[Iso4ane]

When we are called to the ICU, etc. for an airway we write a procedure note and that goes to billing. However, a very important however btw, if you submit a bill you may no longer be viewed as an uninvolved Good Samaritan coming to help your colleague in an emergency.
In a case like this, a bad trauma intubation in the ED after failed intubation attempts, a coding a lost airway in the unit, etc. where I was concerned there may be litigation, I wouldn't write a procedure note and would write a progress note instead. They don't get automatically billed. In the old days I just wouldn't submit the billing sheet. I don't want any part of the liability for something I'm not involved with.
I'm sure the hospital, NP and peds group in this case would have loved to pass some of the liability on to the anesthesiologist or CRNA, and would have in a heartbeat if they could have. They can try to sue you anyway of course, but part of the proof that you didn't have a doctor patient relationship with the patient is that you didn't get paid for your services. And this isn't exactly going to make the Porsche payment, if you know what I mean. I rarely bill for these kind of things.

Would the same hold true, for a GI endoscopy that went south?

 

[IlDestriero]

I'm not responsible for someone else's train wreck and mismanagement. We are not available to assist someone 24/7 and when the airway pager goes off and I'm doing my own disaster, maybe a NICU preemie washout or unstable level 1 trauma, we are not going to come. You might get the fellow if they are available, but I'm not leaving an unstable patient, and we are not expected to.

 

[ACSurgeon]

When we are called to the ICU, etc. for an airway we write a procedure note and that goes to billing. However, a very important however btw, if you submit a bill you may no longer be viewed as an uninvolved Good Samaritan coming to help your colleague in an emergency.
In a case like this, a bad trauma intubation in the ED after failed intubation attempts, a coding a lost airway in the unit, etc. where I was concerned there may be litigation, I wouldn't write a procedure note and would write a progress note instead. They don't get automatically billed. In the old days I just wouldn't submit the billing sheet. I don't want any part of the liability for something I'm not involved with.
I'm sure the hospital, NP and peds group in this case would have loved to pass some of the liability on to the anesthesiologist or CRNA, and would have in a heartbeat if they could have. They can try to sue you anyway of course, but part of the proof that you didn't have a doctor patient relationship with the patient is that you didn't get paid for your services. And this isn't exactly going to make the Porsche payment, if you know what I mean. I rarely bill for these kind of things.

Interesting view point. Our anesthesia team always writes a procedure note if they come and intubate in the or icu or trauma bay.

I'm curious about the not billing= no obligation part. Do you have a reference that I can go back to or is this based on opinion?

 

[IlDestriero]

Would the same hold true, for a GI endoscopy that went south?

I'm not sure what you're asking. If the sedation team loses an airway and the patient arrests or has near arrest, the scope is over. If we get called to help the sedation team in the middle of a tunneled central line that the patient needs, we would probably secure the airway and take over the case. If we take over, I'd bill it as a case, if we were there for a code/pre code on a procedure that can stop, I would not. We would help wake the patient up or send them to the ICU, or call a code and let the code team manage the resuscitation. Once in a blue moon we get called to IR, etc. And what they really want is the code team, they just don't know it yet.

 

[IlDestriero]

Interesting view point. Our anesthesia team always writes a procedure note if they come and intubate in the or icu or trauma bay.

I'm curious about the not billing= no obligation part. Do you have a reference that I can go back to or is this based on opinion?

There is definitely case law supporting it. I have seen it for surgery when they call in another surgeon to help and it all goes sideways, and I was told is true for anesthesia in residency. We would never bill for the disaster assists. I have not personally seen case law for anesthesia, but definitely surgery. I don't see why it would be different.
Your liability and role in the disaster is not black and white and would depend on the situation. I'll try to expand more later.

 

[username456789]

I'm not responsible for someone else's train wreck and mismanagement. We are not available to assist someone 24/7 and when the airway pager goes off and I'm doing my own disaster, maybe a NICU preemie washout or unstable level 1 trauma, we are not going to come. You might get the fellow if they are available, but I'm not leaving an unstable patient, and we are not expected to.

If this was in response to Psai, I believe he was being sarcastic.

 

[PikminOC]

There is definitely case law supporting it. I have seen it for surgery when they call in another surgeon to help and it all goes sideways, and I was told is true for anesthesia in residency. We would never bill for the disaster assists. I have not personally seen case law for anesthesia, but definitely surgery. I don't see why it would be different.
Your liability and role in the disaster is not black and white and would depend on the situation. I'll try to expand more later.

so u do work wo pay?

 

[IlDestriero]

How much do you think I'm giving up by not billing for an intubation?
There's a big difference between getting called to the ED or NICU for a code and securing the airway in a patient unconscious, dead, or near death as an extended part of the code team and then leaving, and if they call early when the patient is having respiratory failure and we take over the airway, push drugs, etc.
In situation one, the failed airway in the ED for example, we're coming in to assist in an emergency and shouldn't really be part of the wreck when all was said and done, assuming that you did the intubation correctly. You don't sue the code team that comes to resuscitate the patient appropriately and transport to the unit.
However, if we take over a somewhat stable situation, like an unstable Cspine in the trauma bay, impending respiratory failure in the unit, and push drugs, manage the airway, etc. and fail to secure the airway in a timely manner, etc., or completely drop the ball and do something like tube the esophagus and not recognize it, I would absolutely expect to be subject to liability for my mistake. That's different than coming to assist in an emergency. I would bill for the 2nd example and probably not for the first. My partners may bill for everything, I really don't know.
I do know that if you want to hide behind being a Good Samaritan, and there is litigation later, you better have not send a bill. It's not like this happens every day. We are not leaving hundreds of thousands of dollars on the table. I would guess an intubation is worth 4 units, so that would be ~$100-400, assuming they have some kind of coverage. I'm not risking liability in a courtesy save of someone's mismanagement for $100.

 

[PikminOC]

Can you use good Samaritan in these situations? Show me one case.

 

[IlDestriero]

I'm not a lawyer, I don't collect case law, but I have read med mal stuff from the state and a newsletter that a partner forwards to me for the last 10 years or so. There is case law where surgeons who help other surgeons in an emergency, like a urologist helping with a cut ureter, have gotten sued for helping. I've read it.
They claim they were a Good Samaritan helping in an emergency, the court/jury disagreed because they billed the patient. Good Samaritans don't submit bills for their assistance, just as an ER doctor wouldn't submit a bill for roadside triage in a bad accident they witnessed on the highway.
The case law exists. This was absolutely discussed in one of the med mal newsletters, but I don't know when and don't save them.
Of course, as I said, it would be different if I mismanaged the airway and that was attributed to the morbidity or mortality. I'm not in the best malpractice area, and I do what I can to limit my liability, and if that means leaving a few hundred dollars a year unclaimed, I'm fine with that. We do fine. I've participated in many many traumas and codes, emergency assisted with challenging cases that went bad, etc. over almost 20 years. I'm sure some went to litigation, and I've not been named in a suit. Which of course may be completely unrelated to billing, but when you work at a big hospital and take care of complex patients regularly, bad things happen, and sometimes they look for people to blame. If I can limit my exposure to risk, I will try to do it.
In the case above, in the c section, the anesthesiologist was not sued when the NP couldn't secure the airway. He/she had no commitment to the baby, his responsibility, and that of the CRNA, was to the mother. A variation of this scenario is a common oral board question.
I don't even think I can try to bill for some things we may help with, like placing an IV in an ICU patient, or an Aline, etc. I probably can bill for a central line or a picc line if I placed them, but they don't call for that.

 

[Winged Scapula]

In agreement with @IlDestriero here, as I've been told the same thing by a malpractice attorney: if you are assisting in surgery, even a non-emergency, and something goes horribly wrong in the OR, don't bill for your assist fee. It won't protect you from being sued but it makes it easier to claim no physician-patient relationship/Good Sam if you haven't.

 

[PikminOC]

interesting. can I do this in outpt solo pp?

 

[PikminOC]

I'm not a lawyer, I don't collect case law, but I have read med mal stuff from the state and a newsletter that a partner forwards to me for the last 10 years or so. There is case law where surgeons who help other surgeons in an emergency, like a urologist helping with a cut ureter, have gotten sued for helping. I've read it.
They claim they were a Good Samaritan helping in an emergency, the court/jury disagreed because they billed the patient. Good Samaritans don't submit bills for their assistance, just as an ER doctor wouldn't submit a bill for roadside triage in a bad accident they witnessed on the highway.
The case law exists. This was absolutely discussed in one of the med mal newsletters, but I don't know when and don't save them.
Of course, as I said, it would be different if I mismanaged the airway and that was attributed to the morbidity or mortality. I'm not in the best malpractice area, and I do what I can to limit my liability, and if that means leaving a few hundred dollars a year unclaimed, I'm fine with that. We do fine. I've participated in many many traumas and codes, emergency assisted with challenging cases that went bad, etc. over almost 20 years. I'm sure some went to litigation, and I've not been named in a suit. Which of course may be completely unrelated to billing, but when you work at a big hospital and take care of complex patients regularly, bad things happen, and sometimes they look for people to blame. If I can limit my exposure to risk, I will try to do it.
In the case above, in the c section, the anesthesiologist was not sued when the NP couldn't secure the airway. He/she had no commitment to the baby, his responsibility, and that of the CRNA, was to the mother. A variation of this scenario is a common oral board question.
I don't even think I can try to bill for some things we may help with, like placing an IV in an ICU patient, or an Aline, etc. I probably can bill for a central line or a picc line if I placed them, but they don't call for that.

thanks. I like learning the med mal.
in Illinois good sam doesn't protect much in this litigious state

 

[ACSurgeon]

In agreement with @IlDestriero here, as I've been told the same thing by a malpractice attorney: if you are assisting in surgery, even a non-emergency, and something goes horribly wrong in the OR, don't bill for your assist fee. It won't protect you from being sued but it makes it easier to claim no physician-patient relationship/Good Sam if you haven't.

And that's what I was wondering about. I guess billing= obligation but not billing does not equal no obligation.

I live in a low malpractice state, and my attendings rarely do things explicitly because of malpractice concern...

 

[cbrons]

This is important to remember. Not billing does absolutely nothing to protect you. However, if you don't bill in the situations this anesthesia bro is talking about, you may avoid having your name lumped in the lawsuit. If you are named but not at fault, it will be a serious headache but nothing more. If you F up the airway and cause harm, not billing won't do $hit. If there's a suit, you'll be on it. Even if a consultant gives advice over the phone without ever seeing a patient, but there is evidence that the case was discussed and they have advice, they could be named in a suit.

Of course this a problem because if you are automatically liable if you are called for help and respond (no matter what happens), there is an incentive NOT to respond. Except that many feel it is unethical not to respond (perhaps even illegal?)

No legal expert at all but seems like an impossible situation.

 

[PikminOC]

How many cases have you all been named in?

 

[PikminOC]

Yes but can be sued for anything. I'd be curious to see your thought on this when you are an attending

 

[colbgw02]

It's easy to minimize medical malpractice based on theoretical concerns, but, practically, even being named in a suit is a huge deal. No matter how frivilous, it requires you to report said suit to every relevant medical board, your insurance, and your hospitals. So, in that sense, it is an impossible situation. That's why we spend so much effort and energy avoiding lawsuits in the first place.

And the idea that any telephone conversation with a consultatnt equals liability is incomplete. To commit malpractice, one must establish a doctor patient relationship. If someone asks a consultant, in general terms, how to handle diagnosis X, and then documents as much in the medical record, it does not necessarily follow that said consultant has established a doctor-patient relationship. The consultant may have, but the details are critical.

 

[PikminOC]

Were their practices conservative before the suits?

 

[PikminOC]

It's easy to minimize medical malpractice based on theoretical concerns, but, practically, even being named in a suit is a huge deal. No matter how frivilous, it requires you to report said suit to every relevant medical board, your insurance, and your hospitals. So, in that sense, it is an impossible situation. That's why we spend so much effort and energy avoiding lawsuits in the first place.

And the idea that any telephone conversation with a consultatnt equals liability is incomplete. To commit malpractice, one must establish a doctor patient relationship. If someone asks a consultant, in general terms, how to handle diagnosis X, and then documents as much in the medical record, it does not necessarily follow that said consultant has established a doctor-patient relationship. The consultant may have, but the details are critical.

But as you said you dont even want to be named as part of the call. Lawyers shotgun everyone

 

[PikminOC]

Hard to say from my position, honestly. But I doubt it's a coincidence.

Have you looked up their cases? Were they cowboys?

 

[colbgw02]

When you call a consultant, you are not speaking in general terms. You give a specific history, describe imaging/diagnostic test results, and potential treatment plan for a certain patient. If I call a consultant who is on call, describe a case, and receive recommendations with the consultant not seeing the patient, they are just as liable as if they saw the patient. There are obviously different scenarios that you can play out. But in general, if this happens and the chart reflects such a conversation took place, yeah, the consultant is involved.

This simply isn't true, but let's be plain about the language. There is a difference between "calling a consultant" and placing a consult. In the latter, then clearly the consultant is on the hook for whatever advice is offerred. However, there is a huge grey area regarding the former, which might be colloquially referred to as "curb-siding". A curb-sided consultant has not necessarily established a doctor-patient relationship.

 

[Winged Scapula]

How many cases have you all been named in?

Two.

 

[colbgw02]

Ok sure, I'm talking about a consult not a curbside. This is well established.

No, it's not, which is part of my point. A curb-sided consultant can still be liable, depending on the specifics of the conversation.

 

[PikminOC]

Not sure how to do that? Rumor is the ones I know about we're eventually settled for minor sums or dismissed.

Settlements and dismissals have to be reported.
Sometimes settlements are to avoid lengthy trials. Doesn't mean all the tenets of malpractice were violated, even basically.

 

[PikminOC]

No, it's not, which is part of my point. A curb-sided consultant can still be liable, depending on the specifics of the conversation.

Thank you. As an attending you are privy to more of these facts.

 

[PikminOC]

Two.

I knew about one from another one of your postings.
I think some docs are naïve regarding these things.
So now back to this thread. I still don't understand the if you don't bill you're less liable in a hospital situation with a group who is covering for gas.

 

[cbrons]

Two.

I've heard they name a ton of people originally but then gradually remove people as the case moves forward... I hope that was the case with you (that they removed from the suit later on). One of my classmates mother is a GI and she got sued recently - spent a personal fortune just trying to protect her reputation, didn't want to settle like her lawyer advised her.

 

[PikminOC]

I've heard they name a ton of people originally but then gradually remove people as the case moves forward... I hope that was the case with you (that they removed from the suit later on). One of my classmates mother is a GI and she got sued recently - spent a personal fortune just trying to protect her reputation, didn't want to settle like her lawyer advised her.

It's not just about protecting reputation. And it costs a great deal to defend one of these.

Remember that there are alot of lawyers out the. Alot.

Not all the malpractice tenets have to be violated...

 

[IlDestriero]

So now back to this thread. I still don't understand the if you don't bill you're less liable in a hospital situation with a group who is covering for gas.

Things are rarely black and white and the possible scenarios are endless and the details may significantly affect your risk of litigation. Nothing can protect you from liability if you botch things up yourself. Meaning making a mistake or use poor judgement that causes harm to the patient. If you f up, whether you bill or not doesn't matter, nor would it matter if you were the responsible anesthesiologist for a case and there was a bad outcome. Even if the surgeon is clearly at fault, you may be named in a suit, at least initially. Along with the hospital, radiology, the patients Family practitioner that recommended the surgeon, the janitorial staff, etc.
The situations I've referred to above assume you are not the responsible provider for the case and are just going into a bad situation to help, which usually means to secure the airway and leave, and not assuming care for the patient. The only time we would really do that is when sedation calls for help in the middle of a procedure. Fortunately they are very conservative and that is rare. I don't stick around to second guess the management of the patient after the airway is secured. I assisted the situation by performing the procedure and I'm only there long enough to secure the airway, or turn it over to RT, and write a note in the chart. In the case of an airway in the Unit or trauma bay, etc., assuming you did your procedure properly, you may try to claim that you are not liable for whatever badness happened/happens as provided by your states Good Samaritan protection. Some case law supports that if you bill for a procedure you give up Good Samaritan protection, which I'm sure varies a great deal by state, and that makes sense to me. If I bill the patient, I obviously had a physician-patient relationship with them. If I don't bill, my attorney will argue that I did not, and I was only called to do assist in an emergency with a procedure that was unrelated to the morbidity or mortality that lead to the litigation.
We are the airway experts, and line experts as well, BUT unlike our obligation to provide 24/7 coverage for trauma, we are NOT obligated or even expected to be available to assist with airways, code resuscitations etc. if we are busy with other things, like a trauma or other emergency in the OR, etc. As we are not contractually obligated to provide these services, they are provided as a courtesy to the facility, and of course are in the best interests of the patients. The attorneys can't argue that I had an obligation for all airways in the hospital, as I don't.
Someone else's contract may say other things and that may affect what services that you are required to provide, which may affect their liability for various scenarios.