A case of alleged intraop recall in the news

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TheLoneWolf

TheLoneWolf

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UCSD, plantiff lawyer alleges the anesthesia record was falsified. Is this a trend in the legal world to readily assert a bad outcome ? I don't work there but would be surprised if they aren't using an EMR. CRNA denies changes to the medical record and little incentive to do so. There could be other reasons for this case of alleged intraop recall. Light on gas, chronic Etoh or stimulant use?
 
I’m usually cynical about these cases. But it looks like he has a good case. Especially if he was seeing a therapist before he found out the anesthesiologist was diverting.

I would guess the anesthesia record wasn’t falsified. Just that not as much fentanyl was given by the crna as she thought. I guess that would still be falsifying by Hayes.
 
With a MAC of 0.8 or above, recall should be pretty rare even without anything else on board. I’m not sure the diversion of fentanyl had much to do with the recall aspect of it.

However, I have personally experienced multiple CRNAs forgetting to turn on the gas after intubating. Probably more likely than falsifying records or underdosing opioids, IMO.
 
Unless the drug addicted anesthesiologist drew up the meds and gave it to the CRNA to administer. It’s highly unlikely drug switching occurred. I mean it could happen if the doc gave the CRNA a break in the case. I former drug addicted colleague of mine did that to me (MD only case). Turns out he switched esmolol for fentanyl. So I thought I was giving fentanyl when he actually gave me esmolol.

He was found shooting up in the bathroom later that day. Promptly asked to give a drug test. He declined. Turned his badge in and bolted.

But I’m surprised the hospitals would let this doc continue clinical medicine. I believe in second chances. But that’s it. If u mess up the second time. U are gone. He could have been in charge of pat clinic for a paycut to avoid narcotics temptation. Or given some other non clinical position.
 
anaesthetic said:
With a MAC of 0.8 or above, recall should be pretty rare even without anything else on board. I’m not sure the diversion of fentanyl had much to do with the recall aspect of it.

However, I have personally experienced multiple CRNAs forgetting to turn on the gas after intubating. Probably more likely than falsifying records or underdosing opioids, IMO.
Click to expand...

Isn’t is essentially pretty rare even with a MAC of 0.5 and above?
 
Opioid free anesthesia. It’s super popular. Sometimes I give none til the end since they don’t “feel” pain.
Sounds like a bull**** case capitalizing on the doctors tragedy.
 
Fentanyl lowers MAC enough to matter. It is the difference between having 0.8 MAC and 1.3 MAC during a case. Especially in middle aged man. Throw in the fact that the anesthesiologist “passed out” in the bathroom I t sounds like the day of the surgery. And again, if the patient had therapist documenting these dreams and stress before it became public. It all seems like a convincing case beyond coincidence.
 
He saw a few hazy figures over him during what sounds like an ACDF. The drapes were not yet up and gas likely not dialed in. No other evidence of instances of recall. Ridiculous if you need therapy for that. Maybe we should refer all sedation cases to therapy.
 
BobLoblaw78 said:
Fentanyl lowers MAC enough to matter. It is the difference between having 0.8 MAC and 1.3 MAC during a case. Especially in middle aged man. Throw in the fact that the anesthesiologist “passed out” in the bathroom I t sounds like the day of the surgery. And again, if the patient had therapist documenting these dreams and stress before it became public. It all seems like a convincing case beyond coincidence.
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That seems like a big difference in mac just due to fentanyl. What are you basing this on?
 
TheLoneWolf said:

UCSD, plantiff lawyer alleges the anesthesia record was falsified. Is this a trend in the legal world to readily assert a bad outcome ? I don't work there but would be surprised if they aren't using an EMR. CRNA denies changes to the medical record and little incentive to do so. There could be other reasons for this case of alleged intraop recall. Light on gas, chronic Etoh or stimulant use?
Click to expand...
Would be interesting to see the timeline if they had an EMR. Most can be expanded out to 1 min increments. If it shows ET gas concentration that should be pretty telling. Sounds like this was perhaps pre-incision since his recollection is about people standing over him. Would also be interesting to know if the claimant admits to marijuana use and whether that might contribute to the issue.

Unfortunately, the MD drug abuse issue will be glaring regardless of what actually happened.
 
I knew someone who was diverting drugs in residency. They always checked out and administered a little more than the typical resident. 100% they were giving the patients normal saline instead.

If they found out later that this doctor was injecting 8 times a day, he was probably doing more than that. Drugs have to come from somewhere. The record will look clean because that’s how you obtain the drug for yourself.
 
anaesthetic said:
With a MAC of 0.8 or above, recall should be pretty rare even without anything else on board. I’m not sure the diversion of fentanyl had much to do with the recall aspect of it.

However, I have personally experienced multiple CRNAs forgetting to turn on the gas after intubating. Probably more likely than falsifying records or underdosing opioids, IMO.
Click to expand...



They could have been monitoring MEPs/SSEPs using TIVA or much less than 0.8 MAC vapor. That would make opioids a more important part of the anesthetic. Would be interesting to see the end tidal sevo during the case if they used any.
 
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nimbus said:
They could have been monitoring MEPs/SSEPs using TIVA or much less than 0.8 MAC vapor. That would make opioids a more important part of the anesthetic. Would be interesting to see the end tidal sevo during the case if they used any.
Click to expand...

True. I find myself here recently using the BIS/sedline monitors a lot more often now with the recent lawsuits and bad outcomes.
 
It seems like probably the patient got adequate anesthesia but had an unfortunate outcome - as we know everyone responds a little differently and some patients for whatever need a higher MAC. But the optics with a diverting, drug addicted, passed out attending are horrible. I'd have to think they'd settle this based on optics alone, but the underlying case is debatable.
 
Arch Guillotti said:
That seems like a big difference in mac just due to fentanyl. What are you basing this on?
Click to expand...
The numbers were arbitrary to make the point bc I don’t know this patient or any patient well enough to know their exact decrease but there is a range. The reference is posted below and I generally state 40% decrease (1.3 x 60%= 0.8 MAC) . But every patient falls on the bell curve. And it is often overlooked that MAC only means that 50% of patients won’t move, etc.

Anesthesiology

pubs.asahq.org pubs.asahq.org
 
TheLoneWolf said:

UCSD, plantiff lawyer alleges the anesthesia record was falsified. Is this a trend in the legal world to readily assert a bad outcome ? I don't work there but would be surprised if they aren't using an EMR. CRNA denies changes to the medical record and little incentive to do so. There could be other reasons for this case of alleged intraop recall. Light on gas, chronic Etoh or stimulant use?
Click to expand...

Sounds made up.
CD125 said:
Isn’t is essentially pretty rare even with a MAC of 0.5 and above?
Click to expand...
Apsf says 0.7 MAC and above to prevent recall
 
nimbus said:
They could have been monitoring MEPs/SSEPs using TIVA or much less than 0.8 MAC vapor. That would make opioids a more important part of the anesthetic. Would be interesting to see the end tidal sevo during the case if they used any.
Click to expand...

And on that scenario I think a BIS monitor would be indicated
 
ERRES2288 said:
How could you see anything (even hazy figures) with eyes taped shut?
Click to expand...
Good point for sure. But maybe makes his case even more legitimate. Have you ever seen patient’s eyes slightly open with tape that had to be retaped? What do you think a patient would see if they were not fully asleep and had plastic tape over their eyes but just open a slit….hazy figures. It would’ve been less believable had he said he saw clear figures and could describe them. He even said he couldn’t talk (I think).

Now imagine that his anesthesiologist swiped his fentanyl, he was awake, he wasn’t fully paralyzed and tried opening them but couldn’t fully bc that crappy plastic tape was on them.

Not saying it’s a slam dunk. But they have a better case then 99% of patients that tell me they woke up during surgery.
 
Tough to know without seeing an intraop chart. Et sevo, if adequate, is tough to argue against, despite the bad optics of the fentanyl abuse.

That being said, what prevents any patient from making such a claim?? Perhaps we should put a BIS on every patient as there seems to be more of these cases in the news. Or perhaps we should stop routinely using muscle relaxation on most cases unless it’s absolutely necessary.
 
Either he has some hazy recall from right after induction which nobody should care about or he’s full of it. I’d believe him if he said he had a hazy vision of a blue drape slapping his face repeatedly while he felt searing cutting pain. This isn’t traumatic recall, it’s just tragically bad anesthesia.
 
source.wustl.edu

Device no better than cheaper alternatives for preventing intraoperative awareness

Anesthesiology researchers have shown that a device to reduce the risk that patients will recall their surgery does not lower the risk of intraoperative awareness any more than a less expensive method. Unintended intraoperative awareness occurs when a patient becomes aware during surgery and...
source.wustl.edu source.wustl.edu

The NEJM study used 0.7% MAC Et tidal Anesthetic Vapor. For higher risk of recall patients I insist on 0.7% MAC. For the elderly and low risk of recall I insist on 0.5% MAC. You can always add 50% Nitrous Oxide if the patient can't tolerate 0.5% MAC ET Vapor.
 
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Anesthesiology

pubs.asahq.org pubs.asahq.org




RESULTS​

A total of 7 of 2861 patients (0.24%) in the BIS group, as compared with 2 of 2852 (0.07%) in the ETAC group, who were interviewed postoperatively had definite intraoperative awareness (a difference of 0.17 percentage points; 95% confidence interval [CI], −0.03 to 0.38; P=0.98). Thus, the superiority of the BIS protocol was not demonstrated. A total of 19 cases of definite or possible intraoperative awareness (0.66%) occurred in the BIS group, as compared with 8 (0.28%) in the ETAC group (a difference of 0.38 percentage points; 95% CI, 0.03 to 0.74; P=0.99), with the superiority of the BIS protocol again not demonstrated. There was no difference between the groups with respect to the amount of anesthesia administered or the rate of major postoperative adverse outcomes.
 
BLADEMDA said:

Anesthesiology

pubs.asahq.org pubs.asahq.org




RESULTS​

A total of 7 of 2861 patients (0.24%) in the BIS group, as compared with 2 of 2852 (0.07%) in the ETAC group, who were interviewed postoperatively had definite intraoperative awareness (a difference of 0.17 percentage points; 95% confidence interval [CI], −0.03 to 0.38; P=0.98). Thus, the superiority of the BIS protocol was not demonstrated. A total of 19 cases of definite or possible intraoperative awareness (0.66%) occurred in the BIS group, as compared with 8 (0.28%) in the ETAC group (a difference of 0.38 percentage points; 95% CI, 0.03 to 0.74; P=0.99), with the superiority of the BIS protocol again not demonstrated. There was no difference between the groups with respect to the amount of anesthesia administered or the rate of major postoperative adverse outcomes.
Click to expand...


I think over reliance on BIS can cause some people to run lower ET vapor concentrations than they otherwise would. We’ve all had the experience of a rising BIS that lags patient movement or vital sign changes.

Also ironic but not surprising that the case below occurred at WashU since we know a certain percentage of our patients will have intraop recall. Maybe BIS would have added another data point that could have prevented this particular case.


whdh.com

Man says he was awake but unable to speak or move during hernia surgery - Boston News, Weather, Sports | WHDH 7News

(WHDH) — A St. Louis man has filed a lawsuit after he says he was awake during hernia surgery but unable to speak or move.Matt<a class="excerpt-read-more" href="https://whdh.com/news/man-says-he-was-awake-but-unable-to-speak-or-move-during-hernia-surgery/">Read More</a>
whdh.com whdh.com
 
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I usually do end tidal 0.6 to 0.7 with some prop gtt at 30 for ponv with good results. If pt has a good block and not a sedation case then I'll do as low as 0.5 or 0.6 again with some prop in the background. Usually do 50mcg fent on induction, and redose max to 100mcg total, if I feel pt needs it. Working pretty well so far the past few years, no awareness yet *knock on wood.* I have pretty quick wake ups and less nausea. I have a couple of colleagues who go even lower than me especially at the ASCs and run them on fumes and no issues yet. I've gotta say, it seems hard to have awareness unless there's some risk factor like etoh\marijuana abuse, baseline high needs, etc. I mean even during Endo cases pt lightens up during the procedure, squirm or speak jibberish, we give more prop and they go down, yet don't have any recall.
 
2Fast2Des said:
I usually do end tidal 0.6 to 0.7 with some prop gtt at 30 for ponv with good results. If pt has a good block and not a sedation case then I'll do as low as 0.5 or 0.6 again with some prop in the background. Usually do 50mcg fent on induction, and redose max to 100mcg total, if I feel pt needs it. Working pretty well so far the past few years, no awareness yet *knock on wood.* I have pretty quick wake ups and less nausea. I have a couple of colleagues who go even lower than me especially at the ASCs and run them on fumes and no issues yet. I've gotta say, it seems hard to have awareness unless there's some risk factor like etoh\marijuana abuse, baseline high needs, etc. I mean even during Endo cases pt lightens up during the procedure, squirm or speak jibberish, we give more prop and they go down, yet don't have any recall.
Click to expand...
I thought the while low dose propofol in the background thing was voodoo as far as ponv was concerned?
 
www.blog.greatzs.com

Treat Your PONV Patients To A Propofol Sandwich

As any anesthesiologist knows, few things are more uncomfortable for a patient or time consuming for the anesthesiologist as dealing with ...
www.blog.greatzs.com www.blog.greatzs.com

"I use a propofol drip to maintain the sedation instead of giving small boluses. Giving small discreet aliquots of propofol at the end has demonstrated blood levels of the drug that is subtherapeutic and isn't adequate to prevent nausea. Running at a rate of about 100 mcg/kg/min, I can maintain good sedation during the last 20 minutes of surgery while allowing the gases to fall to zero before the patient emerges from anesthesia. The key is having as little volatile agents as possible in the patient by the time she awakens.

Why not just go with a total IV anesthetic using propofol for the entire case? Doing so runs the risk that the patient will take a long time to emerge from the anesthetic. Thanks to their insolubility, gases like desflurane and sevoflurane are expelled very quickly by the body whereas propofol can sometimes take longer than anticipated to metabolize, especially in the elderly or obese. By using a small infusion rate at the end of the case, there is less risk of the propofol accumulating in the patient causing a prolonged emergence. It is also less expensive to give a propofol sandwich than to administer TIVA."
 
Micropannus said:
Opioid free anesthesia. It’s super popular. Sometimes I give none til the end since they don’t “feel” pain.
Sounds like a bull**** case capitalizing on the doctors tragedy.
Click to expand...
100% BS.

The guy remembers waking up at the end of the case. So what? Yeah…people stand over you, tell you to open your eyes,…etc.

Or, he was fuzzy when he was drifting off to sleep. Either way, this isn’t infra-op recall.

Any CA-1 can be called to the stand and testify that opioids don’t prevent recall and aren’t used to prevent recall.

Also, I knew this guy. He was a resident when I rotated at UCSD. He was a great resident and improved my A-line skills.

What a tragedy. He suffered from addiction, got treatment and continued to work for many years, but that monkey came back. He got caught and then was fired. And then years later this class action lawsuite happens against UCSD because they didn’t disclose to all the patients that Brad took care of. They are suing the Chairman too. That is crazy.
 
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