chocomorsel

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This reminds me of our recurrent discussions with EM docs about NPO guidelines.
You can only recommend to other docs what to do and not do.
If a complication occurs due to them using too much and not communicating with you or listening to your advice, then that should be on them and easily provable if documented correctly I would think.
But you still may initially get dragged in the lawsuit.
Personally, if the surgeon is comfy w all that local in their tumescent, then that is on them. And it seems like the papers out there allow much, much higher doses injected in the fat from my brief review. Not the same as IM or IV dose ranges which is what we are used to in our field.
 
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Ronin786

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Thank you for your recommendation. It is self evident that the lowest effective dose should be used. My population of patients is in the 80kg.+ range. While recommended doses are valuable, an alternative view is that maximum weight based doses does not necessarily correlate to the resulting blood level and does not take into account relevant patient factors, the site of injection or the dilution (tumescent lidocaine solutions up to 55mg/kg are used). BTW you may want to recalculate your analysis .....according to my math 5Oml of .25 bupivicaine is 125mg not 175 mg ...and my injection is 30mg per side initially and only at the end if ok with anesthesia...The point of my post was not to tout the value of local anesthetics in breast augmentation but to point out the need for the surgeon and anesthesiologist to communicate effectively before and during the case... before I use any local anesthetic or epinephrine containing solution I let the anesthesiologist know.
In all seriousness, what do you expect your anesthesiologist to let you know? I know of nothing outside of math that can help predict whether or not LAST is going to occur. Especially in a sedated individual.
 

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Was the anesthesiologist unaware that 600mg of lidocaine plain and 300mg of bupivicaine plain were on the field and/or injected?
They were vaguely aware but the attendings who staff the ASC are, shall we say, mostly hands off. Also generally try to stay out of the way of surgeons. Those facts also did not escape the M&M.

Everything is fine, until it isn't. The question is, when something bad happens (which is unavoidable, regardless of how careful you are), how will history judge you? Obviously, you can find an expert witness to support or destroy whatever decision you make, but for me, personally, I'd want to know what the majority of my colleagues find reasonable. The case I mentioned was probably like 98:2 against that decision. Your example is still lower, maybe like 85:15, but still pushing it.

The risk:benefit for healthy patients having elective procedures is obviously way skewed compared to sick patients w/ sick procedures. If you end up with LAST because you're pushing the limits of LA toxicity to avoid a GA on a cardiopulmonary cripple, that's obviously a very different story than an 18yo having plastic surgery.
 

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They were vaguely aware but the attendings who staff the ASC are, shall we say, mostly hands off. Also generally try to stay out of the way of surgeons. Those facts also did not escape the M&M.

Everything is fine, until it isn't. The question is, when something bad happens (which is unavoidable, regardless of how careful you are), how will history judge you? Obviously, you can find an expert witness to support or destroy whatever decision you make, but for me, personally, I'd want to know what the majority of my colleagues find reasonable. The case I mentioned was probably like 98:2 against that decision. Your example is still lower, maybe like 85:15, but still pushing it.

The risk:benefit for healthy patients having elective procedures is obviously way skewed compared to sick patients w/ sick procedures. If you end up with LAST because you're pushing the limits of LA toxicity to avoid a GA on a cardiopulmonary cripple, that's obviously a very different story than an 18yo having plastic surgery.
Vaguely aware? Wow!! Where i practice all meds injected by the surgeon or on the back table are written on the crayon board at the start of the case. Whenever I inject anything, e.g. 1 ml of lidocaine with epi in a medial fat pad, methylene blue, or epi irrigation ..I let the anesthesiologist know...lidocaine went on sale in the USA in 1948, that year the FDA made its recommended dosage based on epidural injections.....evidence shows that up to 55mg/kg can be injected depending on concentration and location ..... the amount of lidocaine in the dilution I described in my patient population is "not pushing it"....
 

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In all seriousness, what do you expect your anesthesiologist to let you know? I know of nothing outside of math that can help predict whether or not LAST is going to occur. Especially in a sedated individual.
I agree with you....my expectation is that if I were doing something to harm the patient, like overdosing a patient, i would want my anesthesiologist to say so....
 

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I agree with you....my expectation is that if I were doing something to harm the patient, like overdosing a patient, i would want my anesthesiologist to say so....
I think what he's saying is that if you are checking if it's OK, there isn't anything we can look at and let you know they aren't about to go into cardiac arrest. I mean I guess I could note that they do not appear to be seizing yet. When patients do get local toxicity, it pretty much just happens all at once for the most part.
 
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I use 50cc lidocaine 1% in 250cc NS, and 50cc .025 marcaine with epi in 100cc NS. This allows a "light" anesthesia. I don't usually care whether its IV sedation, ET, or LMA as long as the patient wakes up........while dressing is going on. One of the few rules i have is, no toradol. If there's an interest i'd be happy to offer some suggestions how anesthesiologists and plastic surgeons can work together for the benefit of the patient.
The idea that the increased amount of local allowing "lighter" anesthesia and therefore increasing your efficiency is only in your mind. You could use half the amount of local and still do the same thing for anesthesia. Behind the drapes these patients are really under GA with no airway, combined with an unnecessary and dangerous level of local that you have managed to get away with. Half the local and do an LMA as plan A. With an anesthesiologist who knows what they are doing, wake up times will still be the same and safety will be much increased.

you dont want to operate at the bare minimum of safety. have a couple of levels of protection. a protected airway, a local dose definitely below toxic, a competent, dilligent anesthesia provider. thats what i would take away from this article - dont run right on the line of safe because "youve never had a problem"
 
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I agree with you....my expectation is that if I were doing something to harm the patient, like overdosing a patient, i would want my anesthesiologist to say so....
I think there is some expectation that you as a physician should know what you are doing. You did go to medical school right?? You inject, you should know what and how much and how safe. Why are you asking anyone else? If you "have been doing this for years" you should understand the literature in terms of what is a safe dose and what isnt. The ASA and your plastic surgery society has clear guidelines on this. If you deviate from established norms you better have a damn good reason because there is little defense if you **** up. No one will back u up. U will be crucified in court.

If LAST happens it happens very quickly and often with little warning in an anesthetized patient.
 
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The idea that the increased amount of local allowing "lighter" anesthesia and therefore increasing your efficiency is only in your mind. You could use half the amount of local and still do the same thing for anesthesia. Behind the drapes these patients are really under GA with no airway, combined with an unnecessary and dangerous level of local that you have managed to get away with. Half the local and do an LMA as plan A. With an anesthesiologist who knows what they are doing, wake up times will still be the same and safety will be much increased.

you dont want to operate at the bare minimum of safety. have a couple of levels of protection. a protected airway, a local dose definitely below toxic, a competent, dilligent anesthesia provider. thats what i would take away from this article - dont run right on the line of safe because "youve never had a problem"
I hate the argument "Ive never had a problem" so it must be safe."


I've always driven drunk and never had a problem. must be safe
Ive always run red lights and never had a problem, must be safe.
I always extubate in stage 2 and never had a problem, must be safe.
I never preoxygenate and never had a problem, must be safe.
I never abide by npo guidelines and never had a problem, must be safe.


What do the above have in common.
THey are all idiotic statements.
THey are all bad long term strategies.
 

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I hate the argument "Ive never had a problem" so it must be safe."


I've always driven drunk and never had a problem. must be safe
Ive always run red lights and never had a problem, must be safe.
I always extubate in stage 2 and never had a problem, must be safe.
I never preoxygenate and never had a problem, must be safe.
I never abide by npo guidelines and never had a problem, must be safe.


What do the above have in common.
THey are all idiotic statements.
THey are all bad long term strategies.

These are examples of the behavioral economics of rare events- You diminish the risk in your mind until you have an event.
 
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Mman

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There are risks to any procedure but the real fault here is that they waited so long to call 911
while that is something that is just wrong, calling 911 wasn't going to change the outcome. A hypoperfusion/hypoxic event that kills an otherwise young healthy person wasn't going to be prevented by picking up the phone and calling 911 and having EMS arrive in 15 or 20 minutes. That's the sort of thing that needs to be treated as it is happening or the outcome is irreversible.
 
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eikenhein

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while that is something that is just wrong, calling 911 wasn't going to change the outcome. A hypoperfusion/hypoxic event that kills an otherwise young healthy person wasn't going to be prevented by picking up the phone and calling 911 and having EMS arrive in 15 or 20 minutes. That's the sort of thing that needs to be treated as it is happening or the outcome is irreversible.
Maybe. Maybe not.

No idea what kind of monitoring this patient had post arrest. Intubated? BP monitoring? Temperature? I seriously doubt Meeker was sitting next to the patient for 5 hours running an office based ICU before he decided to call 911.

What's undeniable is this. He ****ed up and the optics of holding an unconscious post arrest patient in an office setting without calling for help makes him look shady as fu k and trying to hide something. Completely outside the standard of care. Meeker is ****ed.
 

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The idea that the increased amount of local allowing "lighter" anesthesia and therefore increasing your efficiency is only in your mind. You could use half the amount of local and still do the same thing for anesthesia. Behind the drapes these patients are really under GA with no airway, combined with an unnecessary and dangerous level of local that you have managed to get away with. Half the local and do an LMA as plan A. With an anesthesiologist who knows what they are doing, wake up times will still be the same and safety will be much increased.

you dont want to operate at the bare minimum of safety. have a couple of levels of protection. a protected airway, a local dose definitely below toxic, a competent, dilligent anesthesia provider. thats what i would take away from this article - dont run right on the line of safe because "youve never had a problem"
thanks for your comments.. in the office operating room (quad A approved),the anesthesiologist i've been using for for the past 9 years places an
endotracheal tube...
 

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I think there is some expectation that you as a physician should know what you are doing. You did go to medical school right?? You inject, you should know what and how much and how safe. Why are you asking anyone else? If you "have been doing this for years" you should understand the literature in terms of what is a safe dose and what isnt. The ASA and your plastic surgery society has clear guidelines on this. If you deviate from established norms you better have a damn good reason because there is little defense if you **** up. No one will back u up. U will be crucified in court.

If LAST happens it happens very quickly and often with little warning in an anesthetized patient.
thanks for your comment, I agree with you...the doses i described are within the plastic surgery guidelines...I was referring to the orthopedic case where 60 cc of 1% plain lidocaine and a toxic dose of marcaine where injected apparently intra-articular (another contraindication).....while the orthopedist has the greatest amount of malpractice exposure...the anesthesiologist and hospital stall will share liability
 

nofliesonme

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I hate the argument "Ive never had a problem" so it must be safe."


I've always driven drunk and never had a problem. must be safe
Ive always run red lights and never had a problem, must be safe.
I always extubate in stage 2 and never had a problem, must be safe.
I never preoxygenate and never had a problem, must be safe.
I never abide by npo guidelines and never had a problem, must be safe.


What do the above have in common.
THey are all idiotic statements.
THey are all bad long term strategies.
The doses and manner of injections i described follow current guidelines practiced by specialty boards.....as I previously stated lidocaine was developed by a Swedish anesthiologist in the 1940's, it went on sale in the USA in 1948, the anesthesiologist who "discovered" it felt 1 gram was acceptable....
the FDA's recommendation in 1948 was based on epidural injection case reports....in the last 70 years there has been a plethora of information regarding blood serum levels, dilutions and injection sites.....this info is not my opinion (in fact i practice well below the guidelines), guidelines of specialty boards and surgical organizations recognize injections of up to 55mg/kg... you may want to reflect that this is not based on thousands of cases, but millions (over 250,000 liposuction cases are performed yearly just in the USA) .
 

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It all depends on what one considers “acceptable risk”. Sadly plastic and “cosmetic” surgeons offices seem to be one of the settings where ASA1 patients getting minor/superficial procedures end up dead.
 
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nimbus

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The 6 heuristic traps outlined in this article are relevant to this thread. I am sometimes guilty of these.


“In class, Ryan identified McCammon’s six decision-making or “heuristic” traps. (Per McCammon: “Most of the time, the consistency heuristic is reliable, but it becomes a trap when our desire to be consistent overrules critical new information about an impending hazard.”) The traps that interested me most, because they were traps against which I was typically guarded — and so was happy to have them validated as specieswide frailties rather than personal quirks — were Familiarity (failing to remain vigilant when faced with the known), Social Facilitation (everybody’s doing it, so it must be O.K.) and Expert Halo (the experts must know what they’re doing, and so it’s safe to unquestioningly follow them).

The others are Consistency (or “commitment” — every moment you don’t turn around for home, it becomes harder to do so), Scarcity (powder fever) and Acceptance (peer pressure). The broad solution, Ryan said, to avoiding all heuristic traps is group decision-making, constant communication and the regular practice of emotional vulnerability.“


 
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eikenhein

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It all depends on what one considers “acceptable risk”. Sadly plastic and “cosmetic” surgeons offices seem to be one of the settings where ASA1 patients getting minor/superficial procedures end up dead.
Tbh I'm not sure what the data is on outpatient asa1 patients dying from LAST vs other causes such as oversedation, hypoxemia, airway obstruction and failed airways
 

WholeLottaGame7

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The doses and manner of injections i described follow current guidelines practiced by specialty boards.....as I previously stated lidocaine was developed by a Swedish anesthiologist in the 1940's, it went on sale in the USA in 1948, the anesthesiologist who "discovered" it felt 1 gram was acceptable....
the FDA's recommendation in 1948 was based on epidural injection case reports....in the last 70 years there has been a plethora of information regarding blood serum levels, dilutions and injection sites.....this info is not my opinion (in fact i practice well below the guidelines), guidelines of specialty boards and surgical organizations recognize injections of up to 55mg/kg... you may want to reflect that this is not based on thousands of cases, but millions (over 250,000 liposuction cases are performed yearly just in the USA) .
The fact that you're using the dose for tumescent liposuction as the toxic dose for subcutaneous injection only reinforces how lucky you've been.

Don't think because your anesthesiologist is OK with it means that it's safe. Half of my M&M example (the injections were subQ, btw) was to show you that anesthesiologists, like all physicians, are susceptible to motivations other than patient safety.

Fortunately, after 30 years, assuming you're not on Wife #5 and Boat #3, you're probably close to walking away. Congratulations, you won the game. I'd probably quit playing if I were you.
 

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The fact that you're using the dose for tumescent liposuction as the toxic dose for subcutaneous injection only reinforces how lucky you've been.

Don't think because your anesthesiologist is OK with it means that it's safe. Half of my M&M example (the injections were subQ, btw) was to show you that anesthesiologists, like all physicians, are susceptible to motivations other than patient safety.

Fortunately, after 30 years, assuming you're not on Wife #5 and Boat #3, you're probably close to walking away. Congratulations, you won the game. I'd probably quit playing if I were you.
Won't be taking retirement advice from you.....any competent anesthesiologist knows that plastic surgeons are judged by how many mistresses they have not wives....and boats?...like row boats or pedal boats?.....its yachts and ships for the plastic surgery fleet.
 

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So the plastic surgeon Dr Kim has his license suspended

while Meeker CRNA has a "non-disciplinary interim cessation" as a CRNA but is still able to practice as a nurse. Meeker also signed his voluntary cessation agreement on 12/31/19 which means he was likely practicing and putting more patients at risk from 8/19 until then. This is so ****ed up.

Where is the AANA jumping in to protect the plastic surgeon?
 
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So the plastic surgeon Dr Kim has his license suspended

while Meeker CRNA has a "non-disciplinary interim cessation" as a CRNA but is still able to practice as a nurse. Meeker also signed his voluntary cessation agreement on 12/31/19 which means he was likely practicing and putting more patients at risk from 8/19 until then. This is so ****ed up.

Where is the AANA jumping in to protect the plastic surgeon?
I wonder if this will make private practice surgeons pause in hiring CRNAs
 
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Truly can't believe the surgeon is deemed exclusively responsible for the negligence and damage of the CRNA. Blows my mind.
He's not exclusively responsible. The CRNA is being sued also and can't practice as a CRNA. The plastic surgeon is a physician and should be treated as such. He has a duty to do right by the patient. They collectively kept a patient in an office setting despite, per the evidence presented so far, it being CLEARLY in her best interest to be transferred to a facility that could provide a higher level of care. He also abandoned the patient, along with the nurse(s), by leaving her alone, under anesthesia apparently, being either unmonitored or poorly monitored.

Put another way, what did you expect would occur?
 

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What’s the malpractice situation like in Colorado? This could be a huge sum of money especially at that age.
 
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dr doze

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if you are the surgeon and there is no anesthesiologist around, you are definitely "the captain of the ship" and are going down with that ship when things go south.
Sometimes. It depends on state law, the institutional bylaws, the contracts, etc.


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if you are the surgeon and there is no anesthesiologist around, you are definitely "the captain of the ship" and are going down with that ship when things go south.
This is debatable depending on the situation.
 

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there is a 100% chance of the surgeon being primarily in the lawsuit
And depending on state law, the contracts, and the bylaws there is an excellent chance the case against the surgeon will be dismissed as a matter of law by the judge.
 
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nimbus

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What’s the malpractice situation like in Colorado? This could be a huge sum of money especially at that age.
Doesn’t matter. Since there are huge economic damages, even in tort reform states this could be an 8 figure case.
 
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And depending on state law, the contracts, and the bylaws there is an excellent chance the case against the surgeon will be dismissed as a matter of law by the judge.
which state specifically because it isn't happening in any of the ones I am familiar with
 

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And depending on state law, the contracts, and the bylaws there is an excellent chance the case against the surgeon will be dismissed as a matter of law by the judge.
I am going to be “that guy”.

This is the case we need to publicize. CRNA independent practice, not only bad for the patient, also ****ty for surgeons.

#****tyallaround
This absolutely should be THE case (once it works it's way through the system which could take a while) that says surgeons will also be on the hook with the CRNAs they claim they don't supervise and the CRNAs claim they're "independent" (And please don't quote any opt-out crap - it doesn't apply).
 

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And depending on state law, the contracts, and the bylaws there is an excellent chance the case against the surgeon will be dismissed as a matter of law by the judge.
Where does anesthesia end and medical/physician care begin? In this case the plastic surgeon was the physician and bears responsibility for the outcome of the patient. The CRNA is solely responsible for the airway and the anesthesia drugs. But, would another physician have done something different to save this girl’s life? Again, the practice of medicine is the plastic surgeon’s sole responsibility. The CRNA is the anesthesia nurse and only responsible for the anesthetic.

I doubt a judge will just Toss out this plastic surgeon. He will let the jury decide his fate.
 
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Where does anesthesia end and medical/physician care begin? In this case the plastic surgeon was the physician and bears responsibility for the outcome of the patient. The CRNA is solely responsible for the airway and the anesthesia drugs. But, would another physician have done something different to save this girl’s life? Again, the practice of medicine is the plastic surgeon’s sole responsibility. The CRNA is the anesthesia nurse and only responsible for the anesthetic.

I doubt a judge will just Toss out this plastic surgeon. He will let the jury decide his fate.
I tend to agree with this. If the surgeon really abandoned the non responsive patient leaving everyone behind for his McLaren Club ride or whatever he will be crucified. Any remotely competent physician should recognize that the patient was in dire trouble and needed to be sent to a full service hospital immediately. Would the outcome be any different? Who knows. Probably not. But they clearly would have done more than stare at her in the pacu for hours and hours hoping for a miracle. Any return of function at all is better than what they have now. Though if it was me, I’d hope I was just sick enough to be unresuscitable.
 

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Where does anesthesia end and medical/physician care begin? In this case the plastic surgeon was the physician and bears responsibility for the outcome of the patient. The CRNA is solely responsible for the airway and the anesthesia drugs. But, would another physician have done something different to save this girl’s life? Again, the practice of medicine is the plastic surgeon’s sole responsibility. The CRNA is the anesthesia nurse and only responsible for the anesthetic.

I doubt a judge will just Toss out this plastic surgeon. He will let the jury decide his fate.
I never said this surgeon was off the hook for this case. He will likely get torched. Colorado is an independent CRNA practice state, I am not an attorney and have no training in law, but, the Surgeon was probably the employer of the CRNA, It was his office, the surgeon also had a duty to transfer the patient after CPR, Probably had a duty to be skilled in resuscitation, etc.

The types of things that surgeons do get to skate on are independent practice states in a rural hospital, a purely anesthetic complication, where the surgeons have no requirement to supervise or collaborate with the CRNA, per state law and the bylaws and no privileges in anesthesia, no contractual duty either.
 

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Remember some people here used to say ASA 1 patients could theoretically be handled by CRNAs independently?


Class action would be better fit for this, at the national level, against the AANA. Get all the patients ever injured in the care of a nurse anesthetist. Sue the AANA for false advertising, misrepresentation.
Nah they'll just hide behind the doc
 

TikiTorches

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"Malpractice" cases should go before a qualified review panel and not a jury of ignorant civilians. This panel would review and decide cases based on facts and the rule of law. The panel's decision would be binding but each side could appeal the decision in a court of law but the panel's recommendations and review of facts would be admissible in a court room.

Our current system favors lawyers looking to sue to collect money based on outcome and sympathy for the defendant; the facts have little to do with many lawsuits. There are hired guns (MDs) online who make their living giving testimony at trial and at depositions. These hired guns can be a very unscrupulous bunch contributing to the problem in this country.

This young woman clearly deserves compensation for her lifelong injuries due to negligence. I simply disagree with how the current system works and promotes numerous lawsuits without merit.
But the proposal Medicare for all doesn't address tort reform at all
 
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Probation For Plastic Surgeon In Controversial Breast Implant Case

"In addition to having his medical license on probation for three years, Kim also agreed to complete a medical education program, only perform surgical procedures with a licensed anesthesiologist onsite, and complete an ethics program."

Maybe always have an anesthesiologist on site instead of an imposter.
 
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Probation For Plastic Surgeon In Controversial Breast Implant Case

"In addition to having his medical license on probation for three years, Kim also agreed to complete a medical education program, only perform surgical procedures with a licensed anesthesiologist onsite, and complete an ethics program."

Maybe always have an anesthesiologist on site instead of an imposter.

How much would they have to pay you to work with this guy? IMO no anesthesiologist should take this job. He should be functionally castrated from surgery for the rest of his life for his roll in this disaster.
 

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