- Joined
- Jan 9, 2014
- Messages
- 1,224
- Reaction score
- 648
When you are on-call your weekend is pretty much blown. So what better way to use it than to go over some cases that landed people in hot water. In this case the old 2:00 AM urgent (but apparently not emergent) c-section in a failure to progress. The solo CRNA at the helm and let's take the transcript from there...
(Case transcript can be found here.)
The incident occurred in 1994. This was well before Kansas opted-out of CMS requirements which happened in 2003. We should assume (and the entire legal proceeding mentioned is based in part on this assumption) that Dr. Costello is the 'supervising' physician in this instance. Nonetheless spinal anesthesia would be the correct choice if an epidural was not already in place. So far so good.
Uh-oh. Already differing accounts of what happened next.
I tend to believe the OB/Gyn here. After all the husband is not going to look over the drape at this point and watch the surgery. At least that is not common practice nor what I allow when the babydaddy is in the surgical delivery suite. Even if he were able to look over the drape the point where the Pfannenstiel incision is made on a gravid abdomen would not be easily visible from his perspective unless he happened to see a reflection in an overhead surgical light, etc. (which most dads I've found aren't swift enough to figure out).
Let's assume that the OB/Gyn is correct. He nicked the skin. He may even have only Allis tested it at this point. Who knows for sure except the people in the room. I'm giving the benefit of the doubt to the surgeon. He says he nicked the skin, he nicked the skin.
Okay. Stop here. It is clear that the block has failed in this patient or at least is inadequate to proceed with the surgery. There is some dispute as to whether or not there is a small skin incision (likely) or a larger skin incision. It is also unclear whether this represented truly a failed spinal, or if the transcript is wrong and she had been laboring with an epidural that failed. Again the facts reported may be different than actually what happened.
Nonetheless you know have a prepped and draped anxious woman with a failure to progress imminently undergoing c-section with a failed neuraxial anesthestic who has had the procedure started. Things that are not clear: was the baby in distress? What was the exact timing of the events? Where there other mitigating factors in this delivery (mother's health, etc.)? This information is not available. Let's assume that the mother is otherwise healthy, the baby is not in imminent distress (hence no need to "crash" the section in the first place), and that the timing of the case proceeded in such a way that CRNA Mahoney was able to adequately prep for every contingency. But put yourself in his shoes. It is early in the morning and you are now stuck in this situation.
What would you have done next?
(The link will take you to the case but don't cheat. We'll get there eventually.)
(Case transcript can be found here.)
Dr. Costello [the on-call obstetrician] ordered anesthesia services and Certified Registered Nurse Anesthetist (CRNA) Greg Mahoney was assigned to administer the anesthesia to Cathy [Glassman]. Mahoney discussed the options available with Cathy and her husband, Jerome Glassman. Dr. Costello was not a part of this discussion. A spinal rather than a general anesthetic was chosen and administered by Mahoney.
The incident occurred in 1994. This was well before Kansas opted-out of CMS requirements which happened in 2003. We should assume (and the entire legal proceeding mentioned is based in part on this assumption) that Dr. Costello is the 'supervising' physician in this instance. Nonetheless spinal anesthesia would be the correct choice if an epidural was not already in place. So far so good.
As the surgery began, the testimony of what happened became inconsistent.
Uh-oh. Already differing accounts of what happened next.
Dr. Costello claimed he only nicked the skin with the first incision. Jerome testified the first incision was 4 to 6 inches in length and Cathy said: “I can feel that, you'll have to stop, its not deadened.”
I tend to believe the OB/Gyn here. After all the husband is not going to look over the drape at this point and watch the surgery. At least that is not common practice nor what I allow when the babydaddy is in the surgical delivery suite. Even if he were able to look over the drape the point where the Pfannenstiel incision is made on a gravid abdomen would not be easily visible from his perspective unless he happened to see a reflection in an overhead surgical light, etc. (which most dads I've found aren't swift enough to figure out).
Let's assume that the OB/Gyn is correct. He nicked the skin. He may even have only Allis tested it at this point. Who knows for sure except the people in the room. I'm giving the benefit of the doubt to the surgeon. He says he nicked the skin, he nicked the skin.
Jerome stated a mask was placed over Cathy's face, CRNA Mahoney said “go ahead,” and Dr. Costello deepened the original incision. At this point, Jerome was excluded from the operating room.
Okay. Stop here. It is clear that the block has failed in this patient or at least is inadequate to proceed with the surgery. There is some dispute as to whether or not there is a small skin incision (likely) or a larger skin incision. It is also unclear whether this represented truly a failed spinal, or if the transcript is wrong and she had been laboring with an epidural that failed. Again the facts reported may be different than actually what happened.
Nonetheless you know have a prepped and draped anxious woman with a failure to progress imminently undergoing c-section with a failed neuraxial anesthestic who has had the procedure started. Things that are not clear: was the baby in distress? What was the exact timing of the events? Where there other mitigating factors in this delivery (mother's health, etc.)? This information is not available. Let's assume that the mother is otherwise healthy, the baby is not in imminent distress (hence no need to "crash" the section in the first place), and that the timing of the case proceeded in such a way that CRNA Mahoney was able to adequately prep for every contingency. But put yourself in his shoes. It is early in the morning and you are now stuck in this situation.
What would you have done next?
(The link will take you to the case but don't cheat. We'll get there eventually.)