Interesting case of CRNA malpractice

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Taurus

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KEVIN BERRY v. ORA PATTEN AS NEXT FRIEND OF BIANCA PATTEN SHADARRYL HARDNETT AND MARIAH PATTEN

Interesting case.

CRNA screws up.
Family sues.
CRNA tries to hide behind anesthesiologist.
Verdict against both anesthesiologist and the CRNA.
Supreme Court of Mississippi reverses decision and says that only CRNA should be considered.

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KEVIN BERRY v. ORA PATTEN AS NEXT FRIEND OF BIANCA PATTEN SHADARRYL HARDNETT AND MARIAH PATTEN

Interesting case.

CRNA screws up.
Family sues.
CRNA tries to hide behind anesthesiologist.
Verdict against both anesthesiologist and the CRNA.
Supreme Court of Mississippi reverses decision and says that only CRNA should be considered.

Are you sure that's what the link shows?

I saw a fat patient who came back with an SBO, likely difficult tube, and aspirated. Stuff like this can't really be prevented..and you don't place an NG down pre-induction, and you wouldn't in this lady immediately post-op bypass, so what's the real beef of this lawsuit?

The CRNA did induce without the anesthesiologist. That's the real problem.
 
I only scanned through the article.

SBO poses an extremely high risk for aspiration. I have never had one aspirate but I know other very prudent safe anesthesiologists that have had SBO patients aspirate despite their best efforts. Sometimes **** happens. I am not sure if I would have wanted to pass an NG tube on this patient. A serious discussion with the surgeon is warranted.

I agree 100% that the anesthesiologist should have been present for induction.
 
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Interesting case.

A couple of questions or topics to talk about:

Is placing an NGT in high-risk patients (NOT those who've just had a gastric bypass) pre-induction the "standard of care?" Should it be?

Is placing the pt in Trendelenburg immediately after a witnessed regurgitation event, and then suctioning, to prevent aspiration, the "standard of care?" Should it be?

If a pt aspirates, is placing the ETT, and then a tracheal suction catheter through it, prior to ventilating, the "standard of care?" Should it be?

Also -- it did not appear that cricoid pressure (or attempted cricoid pressure) worked in this situation.
 
I am not sure if anyone will agree on what is "standard of care".

Aspiration might have happened despite best efforts.

Head down is a prudent maneuver pre-induction (especially if there is no NG).

If you have put the tube in the trachea, then suctioning first is absolutely the right thing to do unless the pt. is so hypoxic that they are about to code.


Interesting case.

A couple of questions or topics to talk about:

Is placing an NGT in high-risk patients (NOT those who've just had a gastric bypass) pre-induction the "standard of care?" Should it be?

Is placing the pt in Trendelenburg immediately after a witnessed regurgitation event, and then suctioning, to prevent aspiration, the "standard of care?" Should it be?

If a pt aspirates, is placing the ETT, and then a tracheal suction catheter through it, prior to ventilating, the "standard of care?" Should it be?

Also -- it did not appear that cricoid pressure (or attempted cricoid pressure) worked in this situation.
 
CRNA tries to hide behind anesthesiologist.
Verdict against both anesthesiologist and the CRNA.
Supreme Court of Mississippi reverses decision and says that only CRNA should be considered

From what I was able to glean it seems that the jury in the initial malpractice suit returned a verdict only against the CRNA and returned a verdict in favor of the anesthesiologist. The Supreme Court reversed the trial court's decision stating the plaintiff failed to prove the CRNA had breached the "standard of care". If anything, the Supreme Court suggested it was the anesthesiologist and the surgeon involved in the case that breached the "standard of care" as explained by the plaintiff's expert witness (an anesthesiologist). Fortunately for them, the jury did not see it that way.
 
If you have put the tube in the trachea, then suctioning first is absolutely the right thing to do unless the pt. is so hypoxic that they are about to code.

absolutely right, in my opinion (non-subpoenable).

i think you could also make the case that awake FOI should be considered in these patients, even though we never do it.

also, cricoid pressure gets a good rap because it usually "works" (i.e. people get intubated before their stomach contents come up, most of the time), but its really not effective, especially when performed by someone who has no training (circulating nurse??).

and yeah, why wasnt our 2-on-1 MD present for this induction? i would imagine that this patient had to be more acute than his other patient
 
I think that inducing these bariatric patients head down is far from optimal.

What little FRC you have is compromised in this position, which is a big deal for these pts. Also, you're begging for regurgitation, which will compromise your view, even if those contents won't then head into the lungs. Why make it hard on yourself?

Induce head up, about 30-40 degrees, I say. Maximize FRC! Preox. RSI. I like lots of roc, so you don't have to worry about a fasciculation-induced increase in intragastric pressure. Glidescope in the room, but you probably won't need it.

Gastric contents obey the laws of physics and of gravity. They cannot passively rise up the esophagus of a head-up patient who is paralyzed. So get the height of the pharynx above the height of the stomach and take away the patient's ability to increase their own intragastric pressure with muscle relaxants.

Misapplied cricoid pressure likely does more harm than good; it relaxes LES tone. Properly applied cricoid pressure (which almost nobody does in my experience, it takes more force than most people use to be effective) is probably helpful in flat or T-Berg pts, but is a waste of energy IMO if someone is head-up and completely paralyzed.

My 2 cents, which I expect to be controversial.
 
also, cricoid pressure gets a good rap because it usually "works" (i.e. people get intubated before their stomach contents come up, most of the time), but its really not effective, especially when performed by someone who has no training (circulating nurse??).

I remember reading a study somewhere (anesthesia? a&a?) that suggested circulating RNs were the most consistent in appropriately applying cricoid pressure in the OR. MDs and CRNAs were not as consistently good. I think it's probably because the circulating nurse won't get distracted trying to do something else like help hold the mask or some other task unrelated to holding cricoid.
 
I think that inducing these bariatric patients head down is far from optimal.

What little FRC you have is compromised in this position, which is a big deal for these pts. Also, you're begging for regurgitation, which will compromise your view, even if those contents won't then head into the lungs. Why make it hard on yourself?

Induce head up, about 30-40 degrees, I say. Maximize FRC! Preox. RSI. I like lots of roc, so you don't have to worry about a fasciculation-induced increase in intragastric pressure. Glidescope in the room, but you probably won't need it.

Gastric contents obey the laws of physics and of gravity. They cannot passively rise up the esophagus of a head-up patient who is paralyzed. So get the height of the pharynx above the height of the stomach and take away the patient's ability to increase their own intragastric pressure with muscle relaxants.

Misapplied cricoid pressure likely does more harm than good; it relaxes LES tone. Properly applied cricoid pressure (which almost nobody does in my experience, it takes more force than most people use to be effective) is probably helpful in flat or T-Berg pts, but is a waste of energy IMO if someone is head-up and completely paralyzed.

My 2 cents, which I expect to be controversial.

Re: bold comments. If you have a patient who has been proven to be an easy intubation, it's one thing. If I thought a patient might be difficult, I'd rather hedge my bets with Sux. I'd rather be trying to oxygenate for 8 minutes than an hour. If you have a difficult airway cart/trach set in the room, then maybe I'd be more flexible. But if you are that prepared, you may want to consider an awake fiberoptic (controversial in itself). I'm more referring to the rare patients that seem intubatable but you get surprised despite a thorough preop assessment.

I love the Glidescope but it isn't always available. Are you going to necessarily delay a case for one piece of equipment? Sometimes it's justified, but usually not.

In my experience Sux doesn't increase intragastric pressure all that much. I did dozens of patients with gastric tumors in residency who filled my suction canister with their gastric secretions after I placed the OG tube, but I had no problems with visible regurgitation.
 
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Unless I am reading this incorrectly, the CRNA got off scott free.

¶ 45. After careful review of the record, we find the trial court erroneously denied Berry's motion for directed verdict, and for judgment notwithstanding the verdict.   Plaintiffs in a medical-malpractice action must establish through expert testimony not only the relevant standard of care, but the manner in which the defendant breached it.   In this case, the plaintiffs failed to establish through expert testimony a CRNA's standard of care, or that Berry had breached it.   Accordingly, the judgment of the Circuit Court of Lafayette County is reversed and rendered.
 
Re: bold comments. If you have a patient who has been proven to be an easy intubation, it's one thing. If I thought a patient might be difficult, I'd rather hedge my bets with Sux. I'd rather be trying to oxygenate for 8 minutes than an hour. If you have a difficult airway cart/trach set in the room, then maybe I'd be more flexible. But if you are that prepared, you may want to consider an awake fiberoptic (controversial in itself). I'm more referring to the rare patients that seem intubatable but you get surprised despite a thorough preop assessment.

I love the Glidescope but it isn't always available. Are you going to necessarily delay a case for one piece of equipment? Sometimes it's justified, but usually not.

In my experience Sux doesn't increase intragastric pressure all that much.
I did dozens of patients with gastric tumors in residency who filled my suction canister with their gastric secretions after I placed the OG tube, but I had no problems with visible regurgitation.

I would have to humbly disagree, atleast for post roux-en-y patients. Last year I did an emergency take back roux-en-y for a leaking anastamosis. Pt was empty stomach except for PO contrast. With a true rapid sequence induction, gastric contents were literally pouring into the mouth on succinylcholine defasiculation. Would never have believed it if I had not seen it myself. I immediately suctioned the posterior oropharynx and left the suction in the posterior oropharynx while I intubated. After intubation, I aggressively suctioned down the tube before ventilating. Fortunately the pt did well without sequelae, but scared the hell out of me at the time.

Talking with one of the older gastric bypass surgeons, he said that he had seen this once before and thought it was due to air and GI contents in the small bowel that are force proximally with the defasiculations the the new gastric pouch cannot accommodate and is therefore forced by the lower esophageal sphincter.
 
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I agree with everything you said HB.
Inducing head down seems like a bad idea to me. Now if regurgitation occurs applying T-berg might reduce inhalation.
 
I would have to humbly disagree, atleast for post roux-en-y patients. Last year I did an emergency take back roux-en-y for a leaking anastamosis. Pt was empty stomach except for PO contrast. With a true rapid sequence induction, gastric contents were literally pouring into the mouth on succinylcholine defasiculation. Would never have believed it if I had not seen it myself. I immediately suctioned the posterior oropharynx and left the suction in the posterior oropharynx while I intubated. After intubation, I aggressively suctioned down the tube before ventilating. Fortunately the pt did well without sequelae, but scared the hell out of me at the time.

Talking with one of the older gastric bypass surgeons, he said that he had seen this once before and thought it was due to air and GI contents in the small bowel that are force proximally with the defasiculations the the new gastric pouch cannot accommodate and is therefore forced by the lower esophageal sphincter.

Thanks. I'll keep it in mind.
 
I think that inducing these bariatric patients head down is far from optimal.

What little FRC you have is compromised in this position, which is a big deal for these pts. Also, you're begging for regurgitation, which will compromise your view, even if those contents won't then head into the lungs. Why make it hard on yourself?

Induce head up, about 30-40 degrees, I say. Maximize FRC! Preox. RSI. I like lots of roc, so you don't have to worry about a fasciculation-induced increase in intragastric pressure. Glidescope in the room, but you probably won't need it.

Gastric contents obey the laws of physics and of gravity. They cannot passively rise up the esophagus of a head-up patient who is paralyzed. So get the height of the pharynx above the height of the stomach and take away the patient's ability to increase their own intragastric pressure with muscle relaxants.

Misapplied cricoid pressure likely does more harm than good; it relaxes LES tone. Properly applied cricoid pressure (which almost nobody does in my experience, it takes more force than most people use to be effective) is probably helpful in flat or T-Berg pts, but is a waste of energy IMO if someone is head-up and completely paralyzed.

My 2 cents, which I expect to be controversial.

I didnt realize that neuromuscular blockers also paralyze the smooth muscle of the stomach and eliminate the possibility that an increased gastric pressure, which had until now been overcome by a high esophageal pressure, would create passive reflux. Thank goodness contents under pressure obey the laws of gravity and would never be forced upwards into a lower pressure environment.
 
I didnt realize that neuromuscular blockers also paralyze the smooth muscle of the stomach and eliminate the possibility that an increased gastric pressure, which had until now been overcome by a high esophageal pressure, would create passive reflux. Thank goodness contents under pressure obey the laws of gravity and would never be forced upwards into a lower pressure environment.

So.... you're proposing that "high esophageal pressure" has been keeping gastric contents down in a head up patient, which NMBDs have now abolished. Since the UES (cricopharyngeus muscle et al) is the only candidate site for this mechanism, you're saying that gastric contents are bubbling insidiously under pressure in the upper esophagus, and that by abolishing UES tone you'll vent that pressure and aspirate? I disagree, even if we assume an incompetent LES with low tone (which nondepolarizers obviously have zero effect on).

Yes, intragastric pressure is positive. 5mmHg or so usually, more in SBO. But still not enough to get up the esophagus of a paralyzed head up patient, who cannot generate an even higher intragastric pressure by abdominal skeletal muscle contraction. Only if intragastric pressures were VERY high would this be possible. If you suspected that, properly applied cricoid pressure would be indicated.

Re: sux and intragastric pressure, I've seen it happen firsthand to a young healthy NPO>8 hour patient. Violent fasciculations, then gastric contents noted in pharynx. Sux usually increases LES tone which is why it isn't usually a big deal, but sometimes intragastric pressure can get up higher than the LES if fasciculations cause enough rectus contraction.
 
:thumbup:


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A new Pennsylvania law aims to make it clear for patients who is taking their blood pressure, giving them an injection or preparing to operate on a loved one.

Under the law signed Nov. 23 by Gov. Edward Rendell, physicians, nurses and other health care professionals soon will be required to wear photo identification badges that state their credentials in large block letters, with descriptions such as "physician" or "registered nurse."

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Illinois adopted its Truth in Health Care Professional Services Act in July, requiring health professionals to post their license when seeing patients in their office. They also must wear a visible badge stating their license credentials during all patient encounters.
Disclosing who the doctor is

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At least 2 states require that medical ads include a health professional's title and license type.

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Dr. Brod has received inquiries from physicians across the country who are interested in supporting similar legislation. "We're hoping that this serves as a bellwether for other states," he said.​
 
Taurus, that sounds awesome. Should be a federal law.
 
So.... you're proposing that "high esophageal pressure" has been keeping gastric contents down in a head up patient, which NMBDs have now abolished. Since the UES (cricopharyngeus muscle et al) is the only candidate site for this mechanism, you're saying that gastric contents are bubbling insidiously under pressure in the upper esophagus, and that by abolishing UES tone you'll vent that pressure and aspirate? I disagree, even if we assume an incompetent LES with low tone (which nondepolarizers obviously have zero effect on).

Yes, intragastric pressure is positive. 5mmHg or so usually, more in SBO. But still not enough to get up the esophagus of a paralyzed head up patient, who cannot generate an even higher intragastric pressure by abdominal skeletal muscle contraction. Only if intragastric pressures were VERY high would this be possible. If you suspected that, properly applied cricoid pressure would be indicated.

Re: sux and intragastric pressure, I've seen it happen firsthand to a young healthy NPO>8 hour patient. Violent fasciculations, then gastric contents noted in pharynx. Sux usually increases LES tone which is why it isn't usually a big deal, but sometimes intragastric pressure can get up higher than the LES if fasciculations cause enough rectus contraction.

Whats a typical pressure generated by a gastric wave? im not proposing that NMBs abolish the UES tone, but rather that sedatives do, and that nothing affects the gastric pressure, especially if the tone is high. Some of these people already have gastric contents in their lower esophagus, so is it really crazy to think that they would grossly (if passively) reflux?

Quantify for me how high you think the intragastric pressure would need to be to drive contents of a full stomach up into the esophagus, even someone at 20-30 degrees reverse T? Id argue that normal gastric peristalsis would be able to accomplish this, especially against a functionally closed distal aperture. Remember, we are not talking about a typical bariatric patient either.

Oh and another thing, cricoid pressure is absolutely standard of care in these patients. You can believe in it or not believe in it but it is indefensible to not have done it at the time of induction.
 
I would be cautious about calling Sellicks maneuver standard of care:

  • It can CAUSE active vomiting. In such circumstances, if continued, can lead to esophageal perforation, mediastinitis and death.
  • Cricoid pressure has been shown to lower LES tone.
  • Aspiration can occur despite cricoid pressure.
  • Vigorous Cricoid pressure can distort the anatomy of the larynx and actually make intubation more difficult, cause laryngeal injury and impede PPV. 30-40 newtons is a lot of force to place on the 90 y/o osteopenic 50 kilo patient with a full stomach.

How many times have you seen a slit like glottic opening with cricoid pressure that suddenly becomes the panama canal when you release it?

Cricoid pressure, IMO, most certainly has it's place in anesthesia but it is not standard of care as sometimes it can cause more harm than good.

My 2cents.

Happy Holidays SDN.
 
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I would be cautious about calling Sellicks maneuver standard of care:

  • It can CAUSE active vomiting. In such circumstances, if continued, can lead to esophageal perforation, mediastinitis and death.
  • Cricoid pressure has been shown to lower LES tone.
  • Aspiration can occur despite cricoid pressure.
  • Vigorous Cricoid pressure can distort the anatomy of the larynx and actually make intubation more difficult, cause laryngeal injury and impede PPV. 30-40 newtons is a lot of force to place on the 90 y/o osteopenic 50 kilo patient with a full stomach.

How many times have you seen a slit like glottic opening with cricoid pressure that suddenly becomes the panama canal when you release it?

Cricoid pressure, IMO, most certainly has it’s place in anesthesia but it is not standard of care as sometimes it can cause more harm than good.

My 2cents.

Happy Holidays SDN.

Im more concerned with what could be argued in court, in this instance. In a full stomach/SBO, if you are inducing general anesthesia prior to securing an airway (instead of awake FOI) then i dont see how you could fight the assertion that "you should have applied cricoid pressure"
 
...perhaps I am not understanding your reference, but if it is what I think it is, I suggest you reconsider your "couldn't help it" and take it down.

poor form

HH

I'm obviously not ProRealDoc, but you may be over reading this.

I just interpreted his graphic as a poke at how some wacko nurses seem to try to misrepresent themselves as being anyone other than what they really are --> multicolored badges.
 
I'm obviously not ProRealDoc, but you may be over reading this.

I just interpreted his graphic as a poke at how some wacko nurses seem to try to misrepresent themselves as being anyone other than what they really are --> multicolored badges.

Come on. He means murses are gay. Hence Hamhocks response about it beiing not being a very nice post or whatever.
 
I'm obviously not ProRealDoc, but you may be over reading this.

Hamhock made an error in the attribution; the image was not posted by ProRealDoc.

I just interpreted his graphic as a poke at how some wacko nurses seem to try to misrepresent themselves as being anyone other than what they really are --> multicolored badges.

That's perhaps a too-generous interpretation; I think the intended implication was pretty clear.
 
Hamhock made an error in the attribution; the image was not posted by ProRealDoc.



That's perhaps a too-generous interpretation; I think the intended implication was pretty clear.

I just thought Taurus meant that they often wear Tommy Hilfiger clothes.:)
 
Come on. He means murses are gay. Hence Hamhocks response about it beiing not being a very nice post or whatever.

agree with Hamhocks about the offensive intent. and it's a lame joke, so minus two points.
 
More importantly regarding the badges, will the have room for nurses level of education, as is the intent.

Jill Nurse, CNA, LVN, RN, BA, BSN, CCRN, MA, MSN, CRNA

vs

Jack Doctor, MD

They might have to make a special larger version
 
Or they could just get rid of the degrees following the names and just write out: NURSE.

I've seen a few places just write out people's job on the ID badge. At my new hospital next year as CA-1, it'll just say my name and "Resident."
 
I think a "Mr." before the name would really stick it to 'em. As in:

Mr. Joe Murse
Male-Nurse Anesthetist/Male Prostitute
 
At my hospital, nurses have an ID card with their name and degree(s) as well as another card that says "NURSE" in big block red letters. This other card protrudes from under the ID card and is clearly visible. Seems to work well.
 
So.... you're proposing that "high esophageal pressure" has been keeping gastric contents down in a head up patient, which NMBDs have now abolished. Since the UES (cricopharyngeus muscle et al) is the only candidate site for this mechanism, you're saying that gastric contents are bubbling insidiously under pressure in the upper esophagus, and that by abolishing UES tone you'll vent that pressure and aspirate? I disagree, even if we assume an incompetent LES with low tone (which nondepolarizers obviously have zero effect on).

Yes, intragastric pressure is positive. 5mmHg or so usually, more in SBO. But still not enough to get up the esophagus of a paralyzed head up patient, who cannot generate an even higher intragastric pressure by abdominal skeletal muscle contraction. Only if intragastric pressures were VERY high would this be possible. If you suspected that, properly applied cricoid pressure would be indicated.

Re: sux and intragastric pressure, I've seen it happen firsthand to a young healthy NPO>8 hour patient. Violent fasciculations, then gastric contents noted in pharynx. Sux usually increases LES tone which is why it isn't usually a big deal, but sometimes intragastric pressure can get up higher than the LES if fasciculations cause enough rectus contraction.


Sorry if this is a dumb question, I'm just a lowly CA-1... No one mentioned the idea of using a priming dose of roc prior to sux (if you are worried about not being able to get an easy tube and having to ventilate for an hour after inducing with roc). Has that ever been shown to limit sux's effects on increased gastric pressure?
 
I fail to see where the CRNA was held liable in the original case?

The ID tags are awesome. I especially like the use of the term Physician, as opposed to Doctor. At my hospital we have the "Doctor" tags on the physicians. Doctor of what!? :mad: Physician tag is awesome.

The homophobic jokes are sub par. I hope I never work with you.
 
I fail to see where the CRNA was held liable in the original case?

The ID tags are awesome. I especially like the use of the term Physician, as opposed to Doctor. At my hospital we have the "Doctor" tags on the physicians. Doctor of what!? :mad: Physician tag is awesome.

The homophobic jokes are sub par. I hope I never work with you.

I think the point of the oversized labels is to clarify roles for patients, not titles. So, while a PharmD might hold a doctorate, they would have "pharmacist" on their name tag. Those who have a doctorate in "doctoring" would have "doctor" on their name tag.

On the actual name tag it can list all your titles so everyone can brag about how awesome they are.
 
I think the point of the oversized labels is to clarify roles for patients, not titles. So, while a PharmD might hold a doctorate, they would have "pharmacist" on their name tag. Those who have a doctorate in "doctoring" would have "doctor" on their name tag.

On the actual name tag it can list all your titles so everyone can brag about how awesome they are.

Oh I totally agree. What I was saying is that the term "Physician" is clear cut on the name tag. Doctor is becoming ambiguous in the public lexicon.
 
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