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Anesthesiologist blamed in Lap Band death
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there's the meat of the article. interesting.
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Sad story!
The message must get out there that anesthetics for any procedure (ASA 1 OR ASA 3+ as in this case) are not benign, and should be managed by a physician throughout the PERIOPERATIVE period.
If this obese individual with multiple co-morbidities (including sleep apnea) was seen pre-operatively be me, I may have recommended the procedure to have been done at the hospital for 23 hour admission. But I imagine there may have been pressures to do this procedure at the ASC to keep churning out cases. I'm only a CA1 but really an eye opener as to the risks with GA (MAC cases can also be difficult in this patient population also).
To the attendings in PP out there, how would you guys proceed with these types of patients where outpatient procedures in the ASC are better served at a hospital?
The message must get out there that anesthetics for any procedure (ASA 1 OR ASA 3+ as in this case) are not benign, and should be managed by a physician throughout the PERIOPERATIVE period.
If this obese individual with multiple co-morbidities (including sleep apnea) was seen pre-operatively be me, I may have recommended the procedure to have been done at the hospital for 23 hour admission. But I imagine there may have been pressures to do this procedure at the ASC to keep churning out cases. I'm only a CA1 but really an eye opener as to the risks with GA (MAC cases can also be difficult in this patient population also).
To the attendings in PP out there, how would you guys proceed with these types of patients where outpatient procedures in the ASC are better served at a hospital?
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I guess the crux of it is, would a "reasonable physician" ever do GA on a patient with OSA at an ASC and not admit them overnight to the hospital?
My hunch is probably yes.
I don't really get this part about "leaving the patient under the care of a nurse." I mean, was the anesthesiologist doing another case in the OR and the patient was in the PACU?
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see the problem is the surgeons probably employ the anesthesiologist and if he cancelled too many cases.... they woul dfire him and get another one. and in this tight job market he was trying to keep his job and went ahead and did the case.. almost all the time everything would go ok.. This time it didnt. SO now everyone is asking questions.
Other troubling issues that come to mind is that Surgeons can operate at hospitals where it is much safer.. have many more skilled people to help but the hopsitals try to control the doctors sooo much they get fed up and open up all these shops and they wanna do it without the hospitals. And they refuse to send any patients to the hospital despite being asa 4s. something needs to change otherwise more and more of these cases will continue to happen.
Other troubling issues that come to mind is that Surgeons can operate at hospitals where it is much safer.. have many more skilled people to help but the hopsitals try to control the doctors sooo much they get fed up and open up all these shops and they wanna do it without the hospitals. And they refuse to send any patients to the hospital despite being asa 4s. something needs to change otherwise more and more of these cases will continue to happen.
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Sounds to me his history is what's put him under.
The surgeons at that center have history of poor outcomes, it appears.
The surgeons at that center have history of poor outcomes, it appears.
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This setup to me looked like a disaster waiting to happen when you try to do these high risk patients at a same day surgery center. I can understand the incentives for surgeons to take their business away from the hospital and into the ASCs (where they may have a financial stake in the practice) but you have to draw the line somewhere, right? Morbid Obesity, OSA....If that wasn't a candidate to be admitted to a hospital for some observation post-op I don't know what is. I agree with hivoltage that there needs to be some oversight so that not every decision that the surgeon (and anesthesiologist) makes is driven by how they can maximize their profit margin.
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I am confident that there are some pretty shady outpatient surgery centers who practice dangerously and will eventually result in greater regulations for all.
But to say you shouldn't be able to perform a GA on a patient with OSA at an outpatient surgery center is a little extreme in my opinion.
But to say you shouldn't be able to perform a GA on a patient with OSA at an outpatient surgery center is a little extreme in my opinion.
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yeah but if you do enough lap bands at an OSC, you will eventually have one like this. im not sure what happened with management, but if you get the wrong nurse on the wrong day... (not blaming nurses, just they are the bedside provider in this case)
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Nobody is saying that. BUt i think judgement is in order when you start dealing with taking obese patients and putting them to sleep at an outpatient center. Just make a judgement call. Dont just post all of your cases at the surgery center without any regard to the patients status.
Ive seen surgeons push the limit especially at gi centers, they take morbidly obese patients and want to do egd/colon on them with propofol an dwhen the anesthesiologist says NO way.. the anesthesiologist is the *******. WTF.
There was a time when mortality from anesthesia was very high. ITs not that way anymore but it still happens. More and more of these cases happen... people are going to start to wake up and understand that anesthesia is dangerous.
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This article is too vague to form an opinion. However, PACU is still part of our responsibility. I imagine that's why he is being blamed.
PACU care becomes a problem when your are working solo. I imagine he was probably doing another case and couldn't come out. In the meantime the patient was going south. Be careful with the kind of job you sign up for.
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How long are you guys keeping your OSA patients who have undergone GA at your ASC before discharge?
6 hours form their last hypoxic event (sats < 90%)? 3 hours from last dose of pain meds? Once they look like they are ready?
http://www.ascassociation.org/resources/sleepapnea.pdf
http://ether.stanford.edu/asc/documents/osa.pdf
6 hours form their last hypoxic event (sats < 90%)? 3 hours from last dose of pain meds? Once they look like they are ready?
http://www.ascassociation.org/resources/sleepapnea.pdf
http://ether.stanford.edu/asc/documents/osa.pdf
how many pts for lap bands DONT have OSA? And if they dont they have just not been diagnosed.. so I guess the ? is should we be doing bariatric surgeries at ASCs? I think we all know these cases can get hairy unpredictably.. i say make all the fatties go to a real hospital, i mean we are rerouting there guts, intubating potential difficult airways, dealing with potentially full stomachs, lower pulm reserves... send them all to the hosp
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Actually, I am hoping people will wake up and realize their comorbidities are dangerous, and will lead to a shortened life span despite medicine's ability to prolong the inevitable.
I like to think anesthesia is pretty safe, but if you're tempting Death or circling the drain, anesthesia will gladly push you over the cliff in the wrong hands.
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Bariatric surgery should not be done in ASC's, and if I remember right, designation as a "Bariatric Center of Excellence", for whatever that's worth, is only available to hospitals.
We do a fair number of OSA patients for non-OSA surgery in our ASC's, but they spend extra time in the PACU and/or observation area for at least four hours post-op. The attending anesthesiologist makes the determination as to whether or not an individual patient is suitable for a procedure in the ASC. Morbid obesity, questionable airways, home CPAP, etc., all tend to push patients towards the hospital. We also do not to sleep apnea procedures in our ASC's.
We as anesthesiologist need to start setting BMI limits for stand a lone outpatient facilities.
I know the ASA had a special talk on this matter a few years ago at their conference but nothing solid was ever decided.
In Europe, I think the only study done on obesity stated that BMI's over 35 had a higher morbidity rate in outpatient centers.
Obviously refusing to do patients BMI's of 35 in a USA facility will decrease a surgery center's revenue by at least 30 percent.
There needs to be a middle ground on BMI regardless of the type of surgery.
At a university outpatient center I covered, the BMI was arbitrary set at 40. Anything above 40 required a face to face exam with the anesthesiology. Because there some patients with BMI's over 45 who don't have sleep apnea and there are patients with normal BMI's who do have sleep apnea. Although the majority of sleep apnea patients are overweight.
So I feel this discussion shouldn't just be about lap band procedures in outpatient settings. It shold be about obesity in general in the outpatient center.
I know the ASA had a special talk on this matter a few years ago at their conference but nothing solid was ever decided.
In Europe, I think the only study done on obesity stated that BMI's over 35 had a higher morbidity rate in outpatient centers.
Obviously refusing to do patients BMI's of 35 in a USA facility will decrease a surgery center's revenue by at least 30 percent.
There needs to be a middle ground on BMI regardless of the type of surgery.
At a university outpatient center I covered, the BMI was arbitrary set at 40. Anything above 40 required a face to face exam with the anesthesiology. Because there some patients with BMI's over 45 who don't have sleep apnea and there are patients with normal BMI's who do have sleep apnea. Although the majority of sleep apnea patients are overweight.
So I feel this discussion shouldn't just be about lap band procedures in outpatient settings. It shold be about obesity in general in the outpatient center.
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We are doing thyroids at our asc now. Thoughts on that? We check a calcium 6 hours post op and send them home if normal. Not sure how I feel about it.
Our group also has a BMI policy, all pts over the limit go to the hospital. This is a hard and fast rule....except when it comes to bariatrics, they can be whatever BMI...seriously. I don't do those cases on purpose.
Our group also has a BMI policy, all pts over the limit go to the hospital. This is a hard and fast rule....except when it comes to bariatrics, they can be whatever BMI...seriously. I don't do those cases on purpose.
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we had this come up recently re: thyroids at ASC. i looked at the literature and there is a good review of a few thousand cases detailing issues and only like three patients who had a complication, only one of whom came to the ER. No life threatening issues, so I decided it would be okay to do them at ASC, based on who the surgeon is
Desflurane, what's your group's BMI policy? 40? 45? before you bounce them to the hospital.
Because there are some airways in those 5 foot 8 280 males that alarms me more than the 5 foot 4 300 pound women.
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At the present, I agree with jwk's opinion that bariatric surgery should not be done in stand-alone ASC's. We perform ours in hospitals which have attained "Bariatric Center of Excellence" status; I think that designation does guarantee a certain level of care and safeguards that deal with complications unique to the bariatric patient.
Our group also has a BMI cutoff for stand-alone ASC's - currently I think it's 40. Honestly I don't know how hard a cutoff point it is for those in our group though.
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It's a reasonable comment... that patient population has plenty of comorbidities that complicate anesthesia. If you're concerned about the wording, this is an informal discussion between colleagues.
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There's nothing offensive about calling some hospitals "real hospitals"
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You've got to understand the business situation that exists for these lap-band centers.
Youll see a billboard, hear a jingle, come across a commercial for 1-800- whatever (avoiding directly naming a specific group to keep it simple).
They're not a medical group at all. They're the advertiser. They own the name, the jingle, the commercial.
You're the surgical center and you want the patient flow, so you pay them, they refer patients to you, and off you go.
These places are generally an equation: surgery cost x patients/month - (overhead costs: nursing, anesthesia, OR time) = profit.
That's it. You want to increase profit, then decrease the amount you're paying the other staff, increase the number of patients, or all of the above.
This is the reality of a lot of private practice settings where (especially for he anesthesiologists) you preform and provide or you find another job.
We all (hopefully), when asked, would always say we'd put the patient's care above the profit of the procedure, but the reality isn't so pretty, especially if you're burdened with debt, struggling to find work in a competitive marketplace, or simply not a very marketable anesthesiologist.
I've seen some sketchy, SKETCHY things happen at a number of hospitals and surgical centers over the past few years, and very little of it was because of the provider being poorly educated or unaware of the risks.
Here's the ASA guidelines on these situations:
http://www.asahq.org/publicationsAn...PracticeParameters/ObstructiveSleepApnea.ashx
again, they're GUIDELINES, and NOT hard and fast rules, so you're got to interpret and apply them on your own, but they do state a fairly strong recommendation to have patients deemed concerning for post-op respiratory depression be monitored and NOT done on an outpatient basis.
Again, it's not a rule, but a guideline.
Youll see a billboard, hear a jingle, come across a commercial for 1-800- whatever (avoiding directly naming a specific group to keep it simple).
They're not a medical group at all. They're the advertiser. They own the name, the jingle, the commercial.
You're the surgical center and you want the patient flow, so you pay them, they refer patients to you, and off you go.
These places are generally an equation: surgery cost x patients/month - (overhead costs: nursing, anesthesia, OR time) = profit.
That's it. You want to increase profit, then decrease the amount you're paying the other staff, increase the number of patients, or all of the above.
This is the reality of a lot of private practice settings where (especially for he anesthesiologists) you preform and provide or you find another job.
We all (hopefully), when asked, would always say we'd put the patient's care above the profit of the procedure, but the reality isn't so pretty, especially if you're burdened with debt, struggling to find work in a competitive marketplace, or simply not a very marketable anesthesiologist.
I've seen some sketchy, SKETCHY things happen at a number of hospitals and surgical centers over the past few years, and very little of it was because of the provider being poorly educated or unaware of the risks.
Here's the ASA guidelines on these situations:
http://www.asahq.org/publicationsAn...PracticeParameters/ObstructiveSleepApnea.ashx
again, they're GUIDELINES, and NOT hard and fast rules, so you're got to interpret and apply them on your own, but they do state a fairly strong recommendation to have patients deemed concerning for post-op respiratory depression be monitored and NOT done on an outpatient basis.
Again, it's not a rule, but a guideline.
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No. 😡
An informal discussion between colleagues is polite. This is insulting. But apparently, being insulting to "fatties" is OK. I mean, this is one of the last groups of people that we can be disparaging to, and it's acceptable, right?
I am well aware that people who are morbidly obese have plenty of comorbidities that complicate their anesthesia, and in fact agree that the hospital is the safest place for them to go under GA.
An informal discussion between colleagues does not happen on a public board. NotAMD made it a public issue by putting his comments out for everyone to read.
So, no, this is not an informal discussion between colleagues. It was a public lash out at people who are overweight. And I'm calling him out on it, because I find it insulting and offensive.
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Maybe you would feel more comfortable in the pre-medical forums?
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Maybe I'll browse whatever forums I feel like, and respond to people that I feel are being derogatory in their posts.
I'm not the problem here. I think it's a crappy attitude, and don't appreciate having to read his name calling, just so he can feel good about himself, because he's obviously better that "the fatties".
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Dude, relax. It's just a generic term. I have a bit of a belly, although my BMI is still in the normal range. My skinny sister harasses me about it all the time. So do my parents, including my dad who has a bigger one than me. While it gets annoying after a while because I already know about my problem (and don't need it pointed out), I do not find it offensive. If you want to call me a fattie, go right ahead.
Would saying, "Send the morbidly obese to the hospital" really make you feel better? It's the same message but with different wording.
If you don't want to read someone's posts you can skip over them. If you want to take the human factor out of the equation, click on the poster's name and a menu pops up. On the list is an option to add the person to your ignore list.
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oh good we havent had this debate in a while
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Sure it does. We have them here every day, in between the tax, politics, gun, alcohol, watch, car, snowboarding, and weightlifting[1] threads. The essence of SDN and a big reason it's so popular and busy is its informality.
Yes, the term "fattie" is vaguely derogatory, but so is "drunk" or "high" or "chainsmoking COPD'er" or "tooth-to-tattoo-ratio" or any of a dozen other imprecise nonmedical terms we sometimes use to describe patients with self-inflicted diseases that influence (always in a bad way) our anesthetics.
If you want heavily moderated and politically correct, you've come to the wrong place.
[1] now that our resident HUGE guy Jet's back I'm guessing it won't be long 🙂
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...and the components of the guideline have never been formally tested to see if the recommendations made by the panel are in fact valid. A preliminary study of the major novel recommendation of the guidelines (the OSA-scoring system) suggested that the scoring system was not helpful.
Last month, there was an observational cohort study from Toronto looking at the rates of complications for obese ambulatory patients with high risk for OSA following laparoscopic gastric banding. It would have been more interesting if they had compared these rates to the rates of the 1,624 obese individuals at low risk for OSA who underwent laparoscopic gastric banding at the same institution, but
Last spring, there was a good study from Ontario, Canada which looked retrospectively at 1,641 patients who underwent ambulatory laparoscopic banding at a specific surgery center.
A British study in 2008 compared complication rates of ambulatory surgery in individuals with a BMI >35 (n=258) to complication rates in individuals with a BMI < 35 (n=10,522) and found no difference in the rates of unplanned admissions, or in rates of postop complications.
Clearly we don't have the full story on the case or Dr. Calmes analysis of it. I seriously doubt that she criticized him for the standard practice of transferring care to a PACU nurse while he went to do another case. Or else she has no business commenting on this or any other case. Perhaps he went to another ASC or it was at the end of the day and he went home (neither of which are outside routine practice in many places). If the report is correct, then the criticism on this count is invalid. However, if there was a delay in the provision of appropriate care or a delay in the decision to transport that was the result of the unavailability of the anesthesiologist or one of his partners (if he has partners) in a timely fashion, then the criticism is valid.
More concerning is her criticism of the decision to treat a morbidly obese patient with OSA in a ASC. I do not believe it is a valid criticism as we really don't know if there is an increased risk or not. Would the patient have been safer in a hospital setting? We really don't know and to say otherwise and assign blame in a coroners report borders on unethical testimony and behavior.
Like the defense lawyer, Mr. Silverman, I have numerous questions and concerns about the testimony of Dr. Calmes, and I agree with his statement that.
But then again all we have to go on is the writing of a non-medically educated non-legally trained reporter who may not be able to present the nuance of Dr. Calmes report or the legal arguments.
- pod
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really great post. blade could learn a thing or two from that one.
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I get smarter but feel dumber every time pod posts something.
Yes you are. You come out from nowhere of the premedical existence and feel offended that fat people are being called fat people which they are.
Grow up and loose weight.
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[U said:
Let's take this to the next level. I'm gonna make a public lash out at group I find appalling.
That's right, I can't stand farmers.
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Feel free to head back to the kiddy forum.
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I don't actually disagree that patients undergoing Lap Banding procedures (or other surgeries) can be done on an outpatient basis.
What I think is important to reiterate, and especially important to understand, is the different risks associated with the morbidly obese and post-operative respiratory depression.
It's this appreciation of their fragility that was obviously underestimated in this case.
A patient's dead, and they're dead because they were mismanaged in the post-operative period.
How this got pinned on the meat cleaver wielding anesthesiologist is beyond me, without getting some more information on what the PACU set up was for this patient.
Which also makes it hard for me to coment on whether Dr. Calmes' assessment was either fair, accurate, or clinically sound.
Not to nitpick, but since at least one other person will likely read this post.
These two studies:
don't evaluate respiratory depression, they're looking more at complicatoins like PONV, retained surgical equipment, infections, etc.
. . . and while I agree with you that:
It's not a unique problem with this guidline. Most of many guidlines suffer the same problem. That's why they're guidelines.
Even the NPO guidelines that we clutch onto so strongly have also never been formally proven (in fact they're oversimplified and incorrect), and are essentially just dogma, based on practitioner consensus (it even states this in the guidelines. . . which were updated in march of this year if anyone's bored and really wants to read them again).
Because they haven't been formally proven isn't a reason not to follow them, or the ASA guidelines on OSA patients for that matter, but you've got to read into them to understand how they came to their conclusions so you can interpret and apply them yourself.
It's one of the inherent dangers I find with guidelines. People will often dissect the methodology of an esoteric RCT publication, but not look into the details of a broad reaching guideline.
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My take-home lesson from this thread is to refrain from answering the door when I'm wielding a meat cleaver... irrespective of how much I enjoy walking around the house wielding a meat cleaver... or two... sometimes... naked...
It could result in censure from the state medical board and being placed on probation.
[Gotta remember to put that cleaver down first... then put on some pants... then open door... ]
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Reread the studies. They were looking for ANY complications, but only found relatively minor complications like PONV, pain, bleeding, infection etc. It wasn't that they weren't looking for respiratory problems, it is just that no significant respiratory problems occurred during the study time frame so they could not report those complications.
Of the 1,641 patients in the Couburn study,
In the Davies study,
Any respiratory problems that cropped up were transitory in nature and did not result in significant morbidity. What these studies did not evaluate specifically was any additional risk from OSA. However, given that the overall risk was so low, it is hard to imagine that a subgroup analysis of those with OSA would be significant.
However, there is a huge difference between the NPO guidelines and the OSA guidelines. No one is actively publishing data with which to challenge the NPO guidelines. There is no large group of institutions who are doing elective surgery on thousands of sub-optimally fasted patients every year. However, there is a large group of institutions doing ambulatory surgery on OSA patients and the data to begin to refute the guidelines exists and is being further developed.
I don't disagree with the majority of the guidelines, just the portion where they list procedures that should/ should not be done in the ASC and the scoring system both of which are based on supposition and are increasingly appearing to be outdated based on actual evidence. (In fact I don't completely disagree with this portion yet, but I completely disagree with using this portion of the guidelines to condemn an anesthesiologist who went outside this part of the guidelines)
At the time of the publication of the guidelines, supposition was likely appropriate as there was no data so a conservative approach was indicated. However, if we stuck with a conservative approach despite the evidence, all ASC's would be shut down and all patients would return to being admitted to hospitals the day before their surgery, and would remain inpatient postoperatively for all surgeries. We have to move forward.
We don't know that. We have a reporter telling us this. However, if this is true, it adds further support to my contention that the outcome is tied to the management, not the fact that the patient was obese with OSA and had an upper abdominal laparoscopy in an ASC.
- pod
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I think we're both agreeing to the same point.
What I'm trying to emphasize, especially to some of the residents, is that there are guidelines published by the ASA.
You need to read into ANY guideline to understand how to interpret and apply them to your patient population.
While I completely agree that setting a hard and fast rule that OSA patients (which is not interchangable with obese) does not make any sense, is not the inherent nature of a guideline, nor in this case holds up to scientific rigor; if you're going to go against a national guidleline, and want to be able to withstand having a former departmental chair state you mismanaged a case, then you need to understand the logic and the data that is out there.
I don't think OSA patients inherently require overnight admission and observation for general anesthetics, but I do think there are going to be specific characteristics that will eventually be teased out to help identify those with degrees of OSA that merit a higher level of care for these procedures.
Which is exactly why subgroup analysis is necessary in these cases.
That was the flaw in some of the studies you mentioned. They weren't powered enough, nor did they look at, respiratory depression that could have become more problematic.
The first study you originally mentioned did look into incidences of respiratory depression, but the problem beyond that is clouded by how the patient is managed afterwards. The difference in repiratory depression leading to respiratory arrest is often how the patient is monitored, managed, and supported.
The numbers will eventually get there, but likely only after multiple large studies, and possibly a meta-analysis in the end.
The OSA scoring system they're using is a great idea, but I concur that it doesn't do its job, and people are obviously holding it up in this case without looking at the other evidence, which raises significant questions about it.
A patient's dead. We know that.
And that outcome is tied to someone's management.
And that management was not appropate for this patient who was obese and has OSA.
Whether it was inappropriate management because the patent was obese and has OSA, we may never know.
The learning point in this situation is:
OSA and obesity are co-morbidties. They are also co-morbidities with a spectrum of severity.
Like any co-morbidities there are adjustements in management that need to be made.
Saying patients who are obese and have OSA can or can not be done on an outpatient basis is too much of a generalization.
Which is why, when there are guidelines published, you need to understand them to determine when to follow them or deem your patient outside of their applicability.
The patient died, some people are using this as a rallying point to claim that obese and OSA patients shouldn't be done on an outpatient basis.
I'm saying it's more likely an example of mismanagement and reinforces the importance of vigilance in the perioperative period.
Deliniating guidelines for anesthetic management of OSA patients still has a way to go, in both understanding the risks and stratifying/classifying risk factors within OSA.
Until these are done, keep an eye on them, and don't be slow to pull the trigger if you've got concerns they may not be safe to DC home.
Inaccurate guidelines don't mean a problem isn't there, it just means we haven't figured it out yet.
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It sounds like we are pretty much in agreement on the utility and pitfalls of guidelines. If your society publishes them you need to know and understand them and their limitations, and understand that they are designed to be conservative to a fault, as they should be.
My original concern was with the use of guidelines to accuse/ condemn an anesthesiologist who had a bad outcome.
Which brings up an interesting question I thought of in the shower this morning. For the sake of argument let's say that there was a set of ASA guidelines published in 2002 that explicitly forbade giving general anesthesia to a patient with disease X. In 2006 an anesthesiologist does a general anesthetic for a patient with disease x and the patient dies. In 2007 the ASA publishes a new set of guidelines that says in effect we were wrong and in light of new evidence there is no contraindication to general anesthesia in a patient with disease X. In 2008, the patient's family sues and you are called to review the case and comment. Is it legitimate to utilize the former set of guidelines that were in effect at the time of the death? Is it legitimate to use the latter set of guidelines?
I still state unequivocally the only thing WE know about THIS case is that a patient died after undergoing surgery. Beyond that all we know is selected quotes given to us by a reporter who is looking for a sensational story that vilifyies the big bad medical establishment with quotes attributable to a med mal attorney. None of us have read the coroners report or the full criticism authored by Dr. Calmes.
Your learning points are accurate, but we do not know whether they apply to this case or not. It is no more legitimate for us to state that this was a case of mismanagement any more than it is legitimate to use it as a "rallying point to claim that obese and OSA patients shouldn't be done on an outpatient basis."
I will admit that the picture painted by the reporter/ med mal attorney looks highly suspicious for mismanagement. However, with some editorial license, the same report COULD BE written of a patient who was perfectly managed perioperatively but suffered a left main occlusion MI in PACU and died. It is actually pretty fascinating to put yourself in that mindset then go back and re-read the story. The first time through my mind convinced me this was respiratory arrest leading to cardiac arrest, but if you abandon that bias it is pretty interesting.
- pod
My original concern was with the use of guidelines to accuse/ condemn an anesthesiologist who had a bad outcome.
Which brings up an interesting question I thought of in the shower this morning. For the sake of argument let's say that there was a set of ASA guidelines published in 2002 that explicitly forbade giving general anesthesia to a patient with disease X. In 2006 an anesthesiologist does a general anesthetic for a patient with disease x and the patient dies. In 2007 the ASA publishes a new set of guidelines that says in effect we were wrong and in light of new evidence there is no contraindication to general anesthesia in a patient with disease X. In 2008, the patient's family sues and you are called to review the case and comment. Is it legitimate to utilize the former set of guidelines that were in effect at the time of the death? Is it legitimate to use the latter set of guidelines?
I still state unequivocally the only thing WE know about THIS case is that a patient died after undergoing surgery. Beyond that all we know is selected quotes given to us by a reporter who is looking for a sensational story that vilifyies the big bad medical establishment with quotes attributable to a med mal attorney. None of us have read the coroners report or the full criticism authored by Dr. Calmes.
Your learning points are accurate, but we do not know whether they apply to this case or not. It is no more legitimate for us to state that this was a case of mismanagement any more than it is legitimate to use it as a "rallying point to claim that obese and OSA patients shouldn't be done on an outpatient basis."
I will admit that the picture painted by the reporter/ med mal attorney looks highly suspicious for mismanagement. However, with some editorial license, the same report COULD BE written of a patient who was perfectly managed perioperatively but suffered a left main occlusion MI in PACU and died. It is actually pretty fascinating to put yourself in that mindset then go back and re-read the story. The first time through my mind convinced me this was respiratory arrest leading to cardiac arrest, but if you abandon that bias it is pretty interesting.
- pod
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The plaintiff's argument would probably be based on "the standard of care at the time". The doctor's defence would be that they considered the 2002 guidelines and took the view that 1) the 2002 guidelines were wrong and were no longer the standard of care (presumably for the reason they were changed in 2007) and/or 2) the 2002 guidelines did not apply in the patient's case because of reason Y.
The example can be reversed too: 2002 guidelines which say general anaethesia can be done, 2007 guidelines which say it can't, and a patient dying in 2006. In this case the doctor is arguing standard of care, and the patient's lawyers are arguing that the doctor should have taken into account the updated information which led to the guidelines being changed.
In either case there would almost inevitably be a long, technical and expensive argument in court over the contents of the guidelines themselves, with doctors as expert witnesses on both sides and lawyers coming out on top. The best hope for the doctor involved is to be aware of the current guidelines and how they apply to the patient, to take into account any other relevant factors such as more up to date information, and to make a decision they can live with, even if the patient doesn't.
