A tale that should make you lose sleep

Discussion in 'Anesthesiology' started by BuzzPhreed, 05.16.14.

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  1. BuzzPhreed

    BuzzPhreed

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    This is a story that those of you who practice in a high ratio and multiple handoff practice should think about. I was briefly "that guy" in a practice. I left that situation because I questioned the ethics of it. Because I was so swamped I simply couldn't know all the details of every case including the cases dumped on me in the afternoon by the lazy fatcat grayhairs trying to make their tee time. "They" always told me I should simply trust our CRNA "colleagues" to do the right thing. Doing the right thing means actually directing the care you're involved in and having the time to do it properly, if that's what you're getting paid for, as well as making sound clinical decisions.

    Issue 1: Talk to the surgeon.

    Issue 2: Know who you are working with.

    Issue 3: Know what's going on.

    Issue 4: Know what you're handing off and, more importantly, know what you are getting.

    Issue 5: Actually have a sound plan in advance of executing that plan. You are violating TEFRA if you don't.

    Issue 6: Don't assume that (a) the CRNA you're working with knows what is going on (b) that they are going to communicate that with you and (c) if they don't that everything is going along okay. This point also reiterates issue 1, 3 & 5.

    Conclusion: If you direct CRNAs, your job is to make sure this is true.

    http://www.arbd.com/vicarious-liabi...-for-the-malpractice-of-its-independent-anest
     
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  3. ProwlerturnGas

    ProwlerturnGas Junior Member 10+ Year Member

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    Ok…..I admit to not having done a ton of plastics cases. Why are the lips sewn together? I don't think I have ever met a CRNA who wouldn't think this was a problem? Are we missing some facts here?
     
  4. BuzzPhreed

    BuzzPhreed

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    Don't miss the forest for the trees.

    The point is not that the lips were sewn together, the point is that neither of them talked to the surgeon before the case and didn't develop a plan. That plan was then not relayed properly to the anesthesiologist who took over. Neither of them appreciated how green this CRNA was and how much direction she needed.

    The result? Ka-ching $$$. That's all you need to know about this case.

    If you want to discuss sewing lips together or how to do a plastics case in general, start another thread. Don't derail this one. Please. Pretty please.
     
  5. chmd

    chmd ASA Member 2+ Year Member

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    It seems that this patient entered a persistent vegatative. I doubt that she or her 2 year old daughter thinks that the result is "Ka-ching $$$."
     
  6. ProwlerturnGas

    ProwlerturnGas Junior Member 10+ Year Member

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    I agree. This sounds like very bad management. Didn't mean to try to derail :(
     
  7. BuzzPhreed

    BuzzPhreed

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    Yeah, well tell that to the plaintiffs attorneys who get up to 40% of the settlement. Or, maybe like John Edwards they just take these cases for the good of humanity.

    As far as the anesthesiologists who let this happen? The chickens have come home to roost. You practice in this lazy bull**** manner, it's eventually going to catch up to you.
     
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  8. urge

    urge 7+ Year Member

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    The story was fine until the lips "sewn together." What kind of plastics case gets that? Plus she had a nose job? How was she supposed to breathe afterwards?

    Sounds like the veracity of the whole story is questionable.
     
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  9. urge

    urge 7+ Year Member

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    I would venture and say the case was a cleft lip/palate. Seems like she got hypoxic in pacu. Too much narcotic? Too much muscle relaxant? It doesnt seem to me to be the deep extubation.

    Regardless, assuming a surgeon were to sew someone's lips, shouldn't it be his responsibility to tell the team, rather than expecting people to know? Is that common practice? Of course not.
     
  10. BuzzPhreed

    BuzzPhreed

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    Oh, good lord. :rolleyes:

    The original dissertation says the lips were sewn together at the midline. This was an Asian lady who, for whatever reason, had this surgery and probably had a significant congenital defect that was delayed in its repair.

    You guys are getting hung up on a technical aspect of the surgery. Which is okay. Because the point is that you are asking questions that underscores exactly what the anesthesiologist in question didn't do! Who knows why? He had a very unseasoned CRNA working with him and he handed off the case. That's the point.
     
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  11. BuzzPhreed

    BuzzPhreed

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    READ THE WHOLE REPORT! I linked it.
     
  12. urge

    urge 7+ Year Member

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    So, are you saying that an inconsistent story is still adequate to make a point?

    I think the real point behind the story is that no matter what really goes on, if the patient has an unexpected bad outcome you are screwed. But that doesn't have anything to do with new crnas, sewn lips, gauzed up noses or 3 different attendings.
     
  13. WholeLottaGame7

    WholeLottaGame7 10+ Year Member

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    The scary part for me is that it is very easy to see how this scenario develop. Especially in those long or end-of-day cases, we'll have cases with 3 or more different attendings and 3 or more residents/CRNAs, and those always make me nervous.

    We've had various initiatives to try to standardize signouts, using handover sheets, etc, with mixed results. I think nothing replaces you as an individual doing your due diligence in understanding the patient and potential issues that may arise, but it seems hard when your colleagues are in a hurry to get home and just dump off their room to you. One of the things I'm not looking forward to as an attending.
     
  14. BuzzPhreed

    BuzzPhreed

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    Did you click the link and read the full report? My guess is "no". The story is not inconsistent. But like what what happens in the media, it only matters what you say in a deposition and how that is then twisted by the lawyers.

    The point is there was a green CRNA who wasn't adequately supervised. For whatever reason. My guess is that the attending anesthesiologist was either too busy doing other things or didn't care. Maybe both. That's the real point behind the story: pay attention. Or you might end up like these guys.
     
  15. risnwb

    risnwb Member 10+ Year Member

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    At my place there's a rule that a max of three attendings can ever sign in on a case. Most of the time they still have no idea what I'm doing with the patient and rarely do they actually get signout from the previous attending. In fact after 5 pm they probably only step foot in the room 50% of the time.


    Posted using SDN Mobile
     
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  16. BuzzPhreed

    BuzzPhreed

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    There are two things at play here. Laziness and complacency. The fact is that most of the time things go well and there isn't a problem. So people get complacent. The laziness occurs when the fact that the attending anesthesiologist didn't go in the room for a full two hours and all manner of stupid sh*t was being done by this very green nurse anesthetist that he had no clue was going on. THEN he signs out the room to some other schmo.

    Again this is the precise reason I left a practice recently. This kind of modus operandi was standard practice there. It is a ticking time bomb. And sooner or later they are going to be dealing with a multimillion dollar lawsuit.

    Recognize it. Fix it. If you can't fix it, leave. That's what I did. Sometimes it's a culture in a practice that you alone won't change. If that's the case you have no other option but to quit. Or tolerate it.
     
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  17. Ronin786

    Ronin786 ASA Member 5+ Year Member

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    Why isn't their more emphasis on this green CRNA and how they screwed things up in the first place? That's just as big of a problem as the anesthesiologist's complacency.
     
  18. BuzzPhreed

    BuzzPhreed

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    It is the attending anesthesiologist's responsibility to direct the care and to make certain that the green CRNA (who should be recognized as such) is reined in and actually directed. From the way this story is relayed, it's pretty clear this didn't happen.

    It'd be kind of like blaming the baby for knocking his bottle of milk off the highchair and spilling it all over the floor when it's actually the parent's fault for putting it there in the first place.
     
  19. epidural man

    epidural man ASA Member 7+ Year Member

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    Hold on!

    If a CRNA graduates a program, the CRNA community is arguing that they are absolutely and unequivically equal and as competant as any anesthesiologist. So, ABSOULTELY they should look at the CRNA. This line really irks me "When our client presented to this hospital for her surgery, she reasonably presumed that the personnel providing her medical services were competent, trained medical personnel that would provide her with the services necessary to perform her surgery." Where is the CRNA community to defend the anesthesiologist? They should be screaming at the top of their lungs on this case - THE ANESTHIOLOGIST IS NOT TO BLAME. CRNA's are JUST AS GOOD!
    And consequently they need to bare the burdon of that claim.

    And it is why my solution fixes everything. The MD community should give full carblanche to CRNA's let them practice equal - but we need to REFUSE to work side by side with them. We will REFUSE to work in the same hospital. And patients can decide where to get surgery done - at an all CRNA hospital, or a hospital with physicians doing the anesthesia.

    Luckily, at my hospital, this would never happen. CRNA's are completely indepedant. If they screw up, it's on them.
     
  20. BuzzPhreed

    BuzzPhreed

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    I agree with you, epidural man. Until we have that system, the directing anesthesiologist is on the hook.
     
  21. inmyslumber

    inmyslumber ASA Member 7+ Year Member

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    The worse thing a CRNA can do is not call.

    We have had dome terrible CRNAs in our hospital. One told me he/she had xx years of experience...but no Attending ever wanted to work with him/her. This individual was over-confident in his/her abilities so I would go in every 15 minutes. If I was tied up in another OR, I would call in or ask another Attending to walk in that OR. Might have been over-cautious, but this CRNA was truly that dangerous, in my opinion. Luckily, this individual no longer works at my institution. He/she seems to not be able to hold any CRNA job for long.
     
  22. urge

    urge 7+ Year Member

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    I think the issue was that the last anesthesiologist was not very deft at deep extubations. He probably thought the patient was out of the woods and left the room when she obviously wasnt.

    A green crna didn't know any better either.

    I don't think hand off played anything here. This patient only needed oxygen to survive. Do you have to endorse that with every patient?

    The sewn lips story is ridiculous. I'm not aware of any plastics reconstruction where you have to take down the repair to intubate anyone.
     
  23. BuzzPhreed

    BuzzPhreed

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    I'm not a huge fan of deep extubations. Period. I don't routinely have patients bucking when they wake up either. That's bad anesthesia technique in my book (not enough narcotic, etc.). Likewise I'm not sure why it took '10-20 minutes' (by their account) to recognize that she wasn't breathing.

    We do a lot of ENT where the jaw is wired shut. These patients are nasotracheally intubated. There is a wire cutter at the patients bedside for this very reason. This is not plastics but then again I wasn't there. Like I said already it's like the media when they only get a part of the story correct. It doesn't matter because that is what is memorialized by being published and becomes the recorded 'truth'. Same here - it doesn't matter what actually happened only what goes on the record in court (or depositions).

    So you can continue to criticize the report or you can take the message home. That is pay attention to what goes on or you're likely to end up getting sued for someone else's actions.
     
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  24. BuzzPhreed

    BuzzPhreed

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    Here is a photo of a girl whose lips were sewn shut at the midline (as described in what I originally posted) after a plastic surgery for a dog bite. She also has nasal packing.

    [​IMG]
     
  25. dr doze

    dr doze To be able to forget means to sanity Lifetime Donor 10+ Year Member

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    FWIW, from the AANA code of ethics:

    Responsibilities as a Professional

    CRNAs are responsible and accountable for the services they render and the actions they take.

    3.1 The CRNA, as an independently licensed professional, is responsible and accountable for judgments made and actions taken in his or her professional practice. Neither physician orders nor institutional policies relieve the CRNA of responsibility for his or her judgments made or actions taken.


    Of course, this only comes into play if the doc and the CRNA are trying to throw each other under the bus. Something that defense counsel will almost never advise.
     
  26. BLADEMDA

    BLADEMDA ASA Member 7+ Year Member

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    Never Forget the "difficult" CRNA who decides to ignore your advice/plan and institute his/her own plan instead. Despite my decades of experience this continues to piss me off on a regular basis.

    In addition, the failure of CRNAS to even recognize the deep hole they have dug for themselves and their patient before calling for help remains the number one reason Anesthesiologists are needed in the operating room.

    CRNA to Blade:

    "Dr. Blade could you come to room 23 whenever it's convenient. My monitors aren't working properly and the BP Cuff isn't giving me a reading. The ETCO2 is a bit low as well. No hurry but stop in and see what you think."

    Blade rushes immediately to room 23 and informs the CRNA:

    Oh ****. We are about to code the patient. Give Epi quickly. Get ready to do chest compressions.
     
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  27. BLADEMDA

    BLADEMDA ASA Member 7+ Year Member

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    Amen to your post.
     
  28. epidural man

    epidural man ASA Member 7+ Year Member

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    Holy crap BLADEMDA, you have over 11 thousands posts. Nice!
     
  29. urge

    urge 7+ Year Member

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    Holy ****. I stand corrected. Hard to tell from the pictures, but the abc article says her top and bottom lip are sutured due to "lip switch"
     
    Last edited: 05.17.14
  30. urge

    urge 7+ Year Member

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    I still don't see how the first anesthesiologist is at fault. I think it was the surgeon's responsibility to communicate that he was going to shut the mouth at the end.

    I think the fault lies on the 2nd anesthesiologist and on the crna.
     
  31. BuzzPhreed

    BuzzPhreed

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    This:

    They're all on the hook. Or at least they all settled out of court. Same difference.
     
  32. dr doze

    dr doze To be able to forget means to sanity Lifetime Donor 10+ Year Member

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    The much more common scenario is to trouble shoot the problem 10-20 minutes before the need to give epi. All the while getting an eye roll from the CRNA, who will never realize what was averted.
     
  33. Spinach Dip

    Spinach Dip Delicious with nachos 2+ Year Member

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    Without a physician’s order or supervision, this inexperienced CRNA began reversing our client from anesthesia halfway through the procedure. Later, she overdosed our client on lidocaine, she did not chart our client’s vital signs for at least two hours, she charted medications that she never gave and she failed to chart medications that were given.



    HOLY SH#T.
     
  34. FFP

    FFP Offline Gold Donor 7+ Year Member

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    And I guess she's still practicing anesthesia today in some overpaid rural area. ;)
     
  35. BuzzPhreed

    BuzzPhreed

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    Yeah but whose fault is that really. You're either 'directing' the anesthetic. Or you're just billing for it and you really ain't.
     
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  36. Spinach Dip

    Spinach Dip Delicious with nachos 2+ Year Member

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    How is this patient breathing post-op? I would assume a tracheostomy....?



    For arguments sake, I would assume that if the anesthesiologist is not in the room, they can't force the CRNA to record vitals or chart meds correctly.
     
  37. IlDestriero

    IlDestriero Ether Man 7+ Year Member

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    I agree. Even if you accept a bad handoff, it is now your responsibility to understand what is going on and determine if the existing plan is acceptable. Presumably he was there at extubation, so he knew the deal with the lips, etc. Blaming the physician that started the case for an error made at the end is lawyer shotgunning for more money. You took over the case and are responsible from that point on. If the original plan was faulty, it is your responsibility to recognise and correct it.

    Flaps will get your lips sewn together. Craniofacial will get you wired shut sometimes.
    That second patient probably has a trach.
     
    Last edited: 05.18.14
  38. BuzzPhreed

    BuzzPhreed

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    Maybe. But isn't that what lawyers do? Also a group of anesthesiologists may agree whats right and wrong or standard of care in a certain circumstance. But that doesn't mean a jury will. Nor does it mean that the 2nd anesthesiologist will who may be looking to mitigate his own damages.

    Keep your house in order. I think that is the bottom line point in this thread. Because if you allow someone else through carelessness to get involved in your affairs you completely lose control of the outcome.
     
  39. IlDestriero

    IlDestriero Ether Man 7+ Year Member

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    Maybe, but blaming the other guys plan, when you can still change it, and I have many times, is not an excuse for your bad outcome and/or mismanagement.
    The only way to protect yourself from this is to finish the case yourself. That would be ideal, but is not always possible for many reasons.
     
  40. BuzzPhreed

    BuzzPhreed

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    I agree with you. Keep your house in order. That's all I'm saying. Otherwise you might be saying "yes, your Honor. No, your Honor." And they are going to make the determination of who was right or wrong. No longer you or me.
     
  41. MaximusD

    MaximusD Anatomically Incorrect 10+ Year Member

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    Did this really happen or was this to illustrate a point?
     
  42. BLADEMDA

    BLADEMDA ASA Member 7+ Year Member

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    In my career it has happened TWICE to me by different CRNAs (both of whom had been practicing anesthesia for a minimum of 10 years each).
     
  43. MaximusD

    MaximusD Anatomically Incorrect 10+ Year Member

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    Pretty damn frightening. Thanks for sharing.
     
  44. anes

    anes ASA Member 2+ Year Member

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    What do they mean "reversing the client"? Did the the patient buck? Or did the CRNA administer actual reversal agents? And how can they say that the patient was overdosed on lidocaine? Did she give a massive bolus of lidocaine? Did the patient have LAST? Or are they just totalling up the cumulative dose?

    Either way, the 2nd anesthesiologist is at fault. Even if the first anesthesiologist gave a shi**y report, it's the second anesthesioligsts job to find out whats going on.
     
  45. BuzzPhreed

    BuzzPhreed

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    Again it doesn't matter what you or I (or anyone else on this forum) thinks. It matters what the court decides. That's why you should do your damnedest to stay out of court.
     

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