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fakin' the funk

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More concerned about the 911 call that apparently happened HOURS after the initial cardiac arrests.

Pure conjecture: young female, high vagal tone, predisposed to bradycardia, has profound hypotension leading to pulselessness at some point during anesthesia/surgery, CPR/ACLS is done, still minimally responsive, after hours they decide to call 911 from the surgicenter. Open them pockets fellas.
 

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Plastic surgery office procedure with inadequate monitoring and an unsupervised CRNA to cut costs? I'm surprised it hadn't happened before. Oh, wait, the article says it did.
 
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They probably didn't call 911 for help, they probably called 911 to transport the brain-dead patient somewhere else so they could close up shop for the evening.

"What are we going to do with her?"

"We can't keep her here forever."

"Let's just wait a few more minutes and see if she'll wake up."

[2 hours later]

"PACU wants to go home, what should we do? We can't wait forever."

"Let's call 911 and have her taken to a hospital."

----------


I feel sorry for everyone involved. This should have never happened.
 
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More concerned about the 911 call that apparently happened HOURS after the initial cardiac arrests.

Pure conjecture: young female, high vagal tone, predisposed to bradycardia, has profound hypotension leading to pulselessness at some point during anesthesia/surgery, CPR/ACLS is done, still minimally responsive, after hours they decide to call 911 from the surgicenter. Open them pockets fellas.
No way.

2pm, last case of day.

Prop, roc, tube, antibiotics.

Breakroom.

Come back after 15 minutes.

Patient prepped.
BP ???/???
HR 0

CPR/ACLS.

ROSC.

PEA.

CPR/ACLS.

ROSC.

3pm.

4pm.

5 pm.

6pm.

7:35pm.

"PACU nurses want to go home."

"Ok. Fine. Let's transfer her to the hospital."
 
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Why would a nurse anesthetist leave a patient immediately after induction?

He's done it every other time, the patient is always "fine".

She's young and healthy.

The circulating nurse and surgeon were always fine with it.

Except this time was different.
 

dr doze

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No way.

2pm, last case of day.

Prop, roc, tube, antibiotics.

Breakroom.

Come back after 15 minutes.

Patient prepped.
BP ???/???
HR 0

CPR/ACLS.

ROSC.

PEA.

CPR/ACLS.

ROSC.

3pm.

4pm.

5 pm.

6pm.

7:35pm.

"PACU nurses want to go home."

"Ok. Fine. Let's transfer her to the hospital."
I find it impossible to believe that they transferred her because they wanted to go home. Far more likely the staff was in a state of denial.


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Surgeon probably left the building after he decided not to proceed with surgery, after the second arrest.

The CRNA was left alone with the other room nurses for five and a half hours, playing M.D. without a license.

"Just need a few more minutes, she'll wake up."

5.5 hours later............
 
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I find it impossible to believe that they transferred her because they wanted to go home. Far more likely the staff was in a state of denial.


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I think the CRNA was by himself, no surgeon present, stringing the staff along.

He was thinking to himself: [This can't be happening. Not this again!]
 

IMGASMD

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More concerned about the 911 call that apparently happened HOURS after the initial cardiac arrests.

Pure conjecture: young female, high vagal tone, predisposed to bradycardia, has profound hypotension leading to pulselessness at some point during anesthesia/surgery, CPR/ACLS is done, still minimally responsive, after hours they decide to call 911 from the surgicenter. Open them pockets fellas.
Most concerning is the cRNa DID IT AGAIN! He had another case before, resulted in brain death, then death.
 
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I find it impossible to believe that they transferred her because they wanted to go home. Far more likely the staff was in a state of denial.


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Surgery center at 7:35pm, the PACU nurses were definitely not in denial.

The CRNA would have waited for 3 more hours.
 

dr doze

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Surgery center at 7:35pm, the PACU nurses were definitely not in denial.

The CRNA would have waited for 3 more hours.
That I could buy. I was referring as to why I suspect they didn’t call EMS immediately.


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dannyboy1

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More concerned about the 911 call that apparently happened HOURS after the initial cardiac arrests.

Pure conjecture: young female, high vagal tone, predisposed to bradycardia, has profound hypotension leading to pulselessness at some point during anesthesia/surgery, CPR/ACLS is done, still minimally responsive, after hours they decide to call 911 from the surgicenter. Open them pockets fellas.
Most likely airway/respiratory. It’s always that. Probably “sedation” and CRNA left the room and patient obstructed. That being said it never hurts to give a young patient some glyco before incision .....
 
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Most likely airway/respiratory. It’s always that. Probably “sedation” and CRNA left the room and patient obstructed. That being said it never hurts to give a young patient some glyco before incision .....
Sedation?

This was a breast augmentation, I've only done them under general anesthesia.

Glyco at skin incision? Why? To reverse secretions or to counteract vagal bradycardia? This isn't an intraabdominal procedure.

And I doubt he'd leave the room for 15 minutes with an unsecured airway. Nobody is that stupid.

And the article makes no mention of airway problems.
 

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Most likely airway/respiratory. It’s always that. Probably “sedation” and CRNA left the room and patient obstructed. That being said it never hurts to give a young patient some glyco before incision .....
Agree with Mikkel, definitely not a “sedation” case and it never hurts to give glyco before incision?? Saayy wwhhaaatttt?
 

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Agree with Mikkel, definitely not a “sedation” case and it never hurts to give glyco before incision?? Saayy wwhhaaatttt?

I have done breast augmentation under MAC and it isn’t rocket science. You need a few basic things: a great surgeon, a surgeon who can perform adequate intercostal blocks, and a combination of midaz/prop/ketamine (note: no opiates). I have worked with a guy who can do four of these and finish by 1pm.
 
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I have done breast augmentation under MAC and it isn’t rocket science. You need a few basic things: a great surgeon, a surgeon who can perform adequate intercostal blocks, and a combination of midaz/prop/ketamine (note: no opiates). I have worked with a guy who can do four of these and finish by 1pm.
No thanks.
 

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Agree with Mikkel, definitely not a “sedation” case and it never hurts to give glyco before incision?? Saayy wwhhaaatttt?
If the thought is unexpected high vagal tone give some glyco to counteract it. It doesn’t bother me if a teen has a relatively high heart rate. We’re not talking about an old AS patient here. FWIW I’ve seen a Brady arrest from skin incision alone....
 

dannyboy1

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Sedation?

This was a breast augmentation, I've only done them under general anesthesia.

Glyco at skin incision? Why? To reverse secretions or to counteract vagal bradycardia? This isn't an intraabdominal procedure.

And I doubt he'd leave the room for 15 minutes with an unsecured airway. Nobody is that stupid.

And the article makes no mention of airway problems.
I mean what the surgeon thinks is sedation. Prop gtt at GA doses with an unsecured airway. Personally I hate sedation in young people and prefer to tube/LMA them every time...
 
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I mean what the surgeon thinks is sedation. Prop gtt at GA doses with an unsecured airway. Personally I hate sedation in young people and prefer to tube/LMA them every time...
What's the point of propofol gtt for 2 hours with an unsecured airway? What's your goal? To have an extremely slow wakeup? To constantly be on the patient maintaining an airway? I have never heard of doing a breast augmentation under sedation. That makes no sense.
 

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What's the point of propofol gtt for 2 hours with an unsecured airway? What's your goal? To have an extremely slow wakeup? To constantly be on the patient maintaining an airway? I have never heard of doing a breast augmentation under sedation. That makes no sense.
Completely agree. But you know how some plastic surgeon are a$$holes and want everything done “their” way. Maybe they promise the patients “it will just be sedation”. Could be one of those private plastic surgery offices that don’t have an anesthesia machine ( they still exist!!) There is a lot of less then ideal anesthesia techniques out in the same day surgery world that are dictated by surgeon/recovery room preferences, and unfortunately a lot of anesthesia personnel who will accommodate against their better judgement......
 
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dr doze

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The lawyer can’t be that good. The surgeon is being sued for failing to properly supervise the conduct of a solo CRNA. Colorado is also an opt out state. Perhaps the AANA could inform him that he is making a terrible mistake.



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Opt out refers only to CRNAs ability to bill MediCare without physician oversight. Has nothing to do with malpractice/independent practice especially in the setting of cash pay plastics.

Beyond that it’s gonna be whatever CO state malpractice laws are.
 

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Bradycardia and arrest. Has to be an unrecognized esophageal intubation unless proven otherwise. Dime a dozen in these surgicenter cases with **** supervision. Patient codes, airway secured and 10 hours of hoping it's not anoxia.
 
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The lawyer can’t be that good. The surgeon is being sued for failing to properly supervise the conduct of a solo CRNA. Colorado is also an opt out state. Perhaps the AANA could inform him that he is making a terrible mistake.



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Line 45-54 is pretty damaging.

It seems like they induce anesthesia without monitor? Then everyone left the room? the RN comes back to notice pt is blue then they start putting monitors on.

The RN was the one to notice the pt turns blue, not the CRNA. Do they not have etco2 monitor? Or even pulse ox? Or they just not bother to put them on
 
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eikenhein

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This is so ****ing horrible. The negligence here is so outside the scope that i would argue CRNA should be held personally financially responsible
 
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Didn’t read whole thread. There ARE documented instances of overinflated LMA’s occluding the carotids...
 
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eikenhein

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Didn’t read whole thread. There ARE documented instances of overinflated LMA’s occluding the carotids...
Not really relevant to this case.

But Can u link some case reports regarding this?
 

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Didn’t read whole thread. There ARE documented instances of overinflated LMA’s occluding the carotids...
Read the whole thread
 

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This is so ****ing horrible. The negligence here is so outside the scope that i would argue CRNA should be held personally financially responsible
I’ll bet you an internet dollar that the local DA is still sniffing around this one for manslaughter if she dies. I suspect the fact that she is alive is the only reason why nobody was indicted - yet. The 5 hour delay in calling 911 is a big problem.
 

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You don't need to pretreat with glyco.

But you do need to actually be in the room if the patient suddenly needs it, which this CRNA was not.

I doubt the root cause was absence of glyco.
is it documented he left the room after induction?
 

XRanger

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is it documented he left the room after induction?
Line 45 says he wasn’t present in the first 15 min she’s under GA. I take it as he induced and then left the room.

Line 52-53 says the nurse reenter the room 15 min later and found pt was blue. Then they start monitoring the pt

So..no one was in the room and no monitor the first 15 min she’s under GA
 

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Most likely airway/respiratory. It’s always that. Probably “sedation” and CRNA left the room and patient obstructed. That being said it never hurts to give a young patient some glyco before incision .....
Or he can just actually be in the room watching the patient's vitals and responding as appropriate?
 

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Opt out refers only to CRNAs ability to bill MediCare without physician oversight. Has nothing to do with malpractice/independent practice especially in the setting of cash pay plastics.

Beyond that it’s gonna be whatever CO state malpractice laws are.
In Colorado the Nursing Board has claimed that crnas are practicing independently when at offices and ASC’s. This is an opportunity to address this claim. Also, I think the plastics doc is culpable if the monitoring was inadequate. I don’t know if it was actually inadequate or just not used.

i think this was an anoxic event. Not bradycardia. I’m kinda surprised at the amount of attention bradycardia is getting here. In a young healthy kid like this they can tolerate a HR of 20 for 15 min If they are ventilating well.
 
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Not really relevant to this case.

But Can u link some case reports regarding this?
Not a case, but a review of some studies that have been done (animal and human). Have to scroll down a ways... (subsection 3)

 
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sidefx

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- Plastic surgery office wants to save money on anesthesia care, hires a CRNA.
- In pursuit of maximal profits, no supervising anesthesiologist, no second provider to relieve for breaks and no breaks between cases which would delay room turnover
- CRNA gets the bright idea he can just take breaks during cases. Surgeon is ok with it because "we've $$ done it $ before and it $$ was fine $$$"
- CRNA induces general anesthesia, leaves the room for 15 minutes.
- Unclear if no monitors were attached or more likely they were and nobody was paying attention to them
- At some point OR staff notice the patient is in cardiac arrest (probably after 4 different alarms start going off and the surgeon got irritated his K-pop music was being drowned out by the air raid sirens so told his nurse to hit the silence button and that's when she looked at the monitor and freaked)
- Surgeon begins performing CPR
- CRNA gets called back into the room, dick in his hand and jaw agape like a deer in the headlights as if he never saw this coming despite having had the exact same thing happen to him previously under the same circumstances
- ROSC is achieved, but patient codes again several minutes later
- Again ROSC is achieved, patient is sent to PACU "I'm sure she'll wake up eventually and be fine, lets just watch her for 5 hours and see what happens"
- Oops, patient is brain dead
- Salivating lawyers jump on the case faster than a pack of wolves on Bambi
- Everyone involved is mince meat
 
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- Plastic surgery office wants to save money on anesthesia care, hires a CRNA.
- In pursuit of maximal profits, no supervising anesthesiologist, no second provider to relieve for breaks and no breaks between cases which would delay room turnover
- CRNA gets the bright idea he can just take breaks during cases. Surgeon is ok with it because it "we've $$ done it $ before and it $$ was fine $$$"
- CRNA induces general anesthesia, leaves the room for 15 minutes.
- Unclear if no monitors were attached or more likely they were and nobody was paying attention to them
- At some point OR staff notice the patient is in cardiac arrest (probably after 4 different alarms start going off and the surgeon got irritated his K-pop music was being drowned out by the air raid sirens so told his nurse to hit the silence button and that's when she looked at the monitor and freaked)
- Surgeon begins performing CPR
- CRNA gets called back into the room, dick in his hand and jaw agape like a deer in the headlights as if he never saw this coming despite having had the exact same thing happen to him previously under the same circumstances
- ROSC is achieved, but patient codes again several minutes later
- Again ROSC is achieved, patient is sent to PACU "I'm sure she'll wake up eventually and be fine, lets just watch her for 5 hours and see what happens"
- Oops, patient is brain dead
- Salivating lawyers jump on the case faster than a pack of wolves on Bambi
- Everyone involved is mince meat
This is strange, because typically (as someone who admittedly has gotten plastic surgery), the patient pays for the anesthesia and certainly one can ask for an anesthesiologist - they tried this switch and bait on me. I specifically asked for an anesthesiologist, was told yep. then on day of procedure the anesthesiologist comes and tells me "Ms so and so will be at the procedure." I was like ummm no. I specifically said and demand and anesthesiologist. He tells me - is there something I can tell you to change your mind? I was thinking - while he doesn't know I am a physician, I won't feel bad when so many of you are out of work as you are doing this to yourselves. I obviously said no - anesthesiologist or I go home. They surely got me an anesthesiologist within about 10 minutes.
So it's not to save money. The plastic surgeon does not eat the costs - the patient pays. Typically a lot of these procedures are an hour to a few hours long- so it typically increases the bill a few thousand which the patient pays.
 
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