Learn from the mistakes of others--Use CRNAs and you will pay up the ...

http://www.philly.com/dailynews/local/20080524_A__20_5M_AWARD_IN_LIPO_DEATH.html


Make sure you have a physician working with you either to help you diagnose a problem and take care of the patient or to split the liability with you. Don't be fooled by the CRNAs. You are majorly liable when you work with a nurse and this veredict proves it. They are using you as protective shields.

"The jury of nine women and three men deliberated for 14 hours over three days before awarding the Fleddermans $20.5 million in compensatory and punitive damages, finding that Glunk and his nurse anesthetist were responsible for Amy's death. The jury found yesterday that Glunk and his nurse anesthetist, Edward DeStefano, were negligent. It awarded $5.5 million in compensatory damages. The liability is split 75 percent for Glunk and 25 percent for DeStefano. Glunk is on the hook for an additional $15 million in punitive damages."

 

And where did I say it was his fault? My point is the lawyers will always go after you since you are assumed to be supervising the nurse as you are the only physician in the room. Get it?

 

Yeah, CRNAs suck, but your field created them, your field continues to employ them, and your field puts them on the chairs at the head of the bed. Don't use a CRNA? Good luck finding an anesthesia group that doesn't use them for you.

I agree 100%.

Here's a thought: why don't you try to distinguish yourselves from these nurses, and explain what it is you provide to us that the CRNAs don't (aside from the liability issues)? So when a PA does a knee or a hip or a lap chole or an appy, what is it exactly that you are providing that a PA can't besides being liable for a bad outcome?

You know what I see right now? We see some dude induce the patient, intubate, drop some lines, read the newspaper, and transport the patient to the PACU. Not only do I usually have no idea if it's an MD or a CRNA, it makes absolutely no difference to me.

When things go well, I am sure it does not matter to you. It's when problems arise that you will care.

Hell, one of the senior attendings on your own forum recently made the point that there is nothing the MD anes guys do that the CRNAs can't/don't in the OR.

The same thing can be said of a surgical PA whom I have seen do more than surgery residents. Seen Ortho PAs do entire cases and they do it better than the ortho residents. I am sure you know they use them in CT surgery and they usually have their own clinics doing pre and postop checks. So what do surgeons have to offer in terms of technical skills that a PA cannot provide?


Maybe you should spend a little time marketing your own field. That is, if you actually have anything to offer that the nurses don't . .

Taking care of surgical patients in the SICU is something anesthesiologists do everyday. If you didn't know that then you are missing the big picture. Who is it that you call all the time to take care of your patients pain via epidural, blocks, and other type of pain management modalities?

 

We don't know whether he just stood there and failed to recognize the problem. I am giving him the benefit of the doubt but I would not be surprised if he was not smart enough to figure it out.

Your comment is not surprising since you are a CRNA.

 

This is something I would love to have surgeons support. I think it is an incredible opportunity and it would allow, as you correctly state, surgeons to operate more and have more time for their other tasks.

 

So this is your argument? "CRNAs are just as good as anesthesiologists, but you should go with the -ologist because PAs do surgery better than surgical residents." Wow. Very moving.

What I want to convey to you is that the technical aspect of any medical specialty does not define your role as a physician. Hell, cardiologists can teach a PA/NP to put stents and they can learn to do it better than the cardiologist. But does that mean they should be allowed to take over the cardiologist role? By the same token, just because an ortho PA can do a knee or a hip does that mean he should take the role of the orthopedic surgeon? Of COURSE NOT! We should not devalue the role of a physician regardless. I am not sure how that is so difficult to understand.

So that's my point, that we should always ensure the highest level of expertise possible provided they are cost-efficient. As you know the anesthesia bill is the same regardless of who provides the anesthestic so the cost-effectiveness issue does not apply.


Presumably you posted here because you recognize that surgeons have some measure of control over who they use for anesthesia. What I'm trying to get across to you is that right now the surgeons I work under see no difference between an MD anes and a CRNA.

Where I am training, the surgeon does not control who they get as anesthesia. The anesthesia control desk assigns who they want to provide the anesthestic so many times you have no control especially in large centers where the anesthesia dept are large.

In the OR, CRNAs do everything you are training to do, and they learn it in like 25% of the time you do.

Again, the same can be said of a PA who goes to PA school and learns to do the surgeries in less time than a surgical resident. So why are you spending so much time training to be a surgeon when you could have gone to PA school?

I know that the conclusion you draw from this is "They are inadequately trained." But there is nothing intuitive about that conclusion, and you have yet to discredit the counter-conclusion of "It doesn't take that much training."

The technical aspects of any medical specialty do not take long to learn. It is not about the technical aspects. If it was, you are wasting your time doing a surgical residency.

(1) I have heard that anes does critical care. But I have never seen it, so I can't comment on it. And doesn't that take a fellowship?
Yes, you must be in a small program. We have a large sicu with over 70 beds and it's anesthesia-run.

(2) I don't see, or particularly care about, pain patients. That's a great argument to use with the Primary Care guys, but for the surgeons it carries zero weight. So post op pain is not an issue for surgeons? Interesting. You sure you are a surgical resident?

(3) CRNAs routinely do regional in my facility. Another area you let slip away.

Pain management is not only doing blocks or epidurals.

 

Let me guess, you are another CRNA. Why am I not surprised of your response? Are you afraid the surgeons will find out the game you are trying to play by demanding independent practice rights and putting the surgeons at increased liability?

You can claim all the laws you want but all that matters is what the jury thinks and what they see is a surgeon with deeper pockets supervising a NURSE. The nurse will claim she/he was working under the surgeon supervision.


Let's use this case as an example:

http://www.bakercityherald.com/news/story.cfm?story_no=5967

Why is the orthopod also being sued when it was the CRNA who clearly caused and failed to recognize the problem which led to the patient's death?

"The second claim for relief against Sandefur (The orthopod) and the hospital alleges that Sandefur:

Knew or should have known that Loper (the CRNA) "had shown a pattern of unsafe and substandard medical care."

Failed to inform Meinzinger (the patient) about Loper's alleged pattern of substandard care, "thereby giving (Meinzinger) the option of refusing defendant Loper as his anesthesia provider or having surgery at a different facility."

Failed to adequately observe Meinzinger's condition during surgery. "

How the hell is the surgeon supposed to know and do all of this while he is performing surgery?

 

Anesthesiologist who did not have a clear, defined supervisory rule takes the wrap for a CRNA mistake. Now just change the word supervising anesthesiologist to "supervising surgeon" and the surgeon will be dragged to court and get eaten alive on the stand by the trial lawyers.

MH was a 38-year-old, 5′0″, 250-pound Licensed Practical Nurse who worked in the delivery room at Hospital. MH slipped in the delivery room and injured her knee, requiring arthroscopic surgery. MH was admitted by surgeon Dr. B to Hospital.

Hospital had contracted with Anesthesia Group ("Group"), a partnership composed of Dr. H and Dr. M, to "provide full-time Anesthesiology services and assume general responsibility for the conduct and operation of Hospital's Anesthesiology Department, subject to approval of Hospital." The contract provided that services under it would be performed as scheduled by the Hospital and that Group was required to provide an anesthesiologist from 7:00 am to 3:30 pm Monday through Friday and as required by Hospital. Emergency services could be provided by a CRNA with an anesthesiologist available for supervision.

Group contracted with five CRNAs who worked under the partnership at Hospital. One of these CRNAs, CRNA S, visited MH the evening before surgery. CNRA S introduced himself as being from the "anesthesia department." CRNA S did the preoperative workup on MH and wrote for preoperative medication. CRNA S signed Dr. H's name to the orders. Dr. H did not see MH, nor did CRNA S consult with Dr. H on MH's case.

On October 5, after having been given morphine at 6 am for the surgery, MH was taken to the preoperative holding area. MH was visited by CRNA J, who was scheduled to administer anesthesia. Dr. M was the floating anesthesiologist responsible for surgeries that day. Dr. M reviewed MH's records in the preoperative holding area, approved the preoperative medications after they had been given, discussed for a minute or two the anesthesia plan with CRNA J, and spoke briefly with MH.

Dr. M was not present in the operating room when anesthesia was induced nor during the surgery. MH was "put to sleep" and then given 100 mg of Anectine at 7:05 am and intubated. The surgery was uneventful and was completed at 7:46 am. At 7:48 am, the endotracheal tube was suctioned out and removed. MH was suctioned again and as preparations were being made to roll her onto a gurney, a laryngospasm was observed by CRNA J. CRNA J administered 20 mg of Anectine at 7:51 am in an effort to break the spasm. It broke for approximately three breaths but then recurred. At approximately the same time, surgeon Dr. B noticed MH's toes and toenails becoming cyanotic. Dr. B notified CRNA J, who responded that he was "administering medicine." A second 20 mg dose of Anectine was given at 7:56 am; however, it had no effect on the ability of CRNA J to ventilate MH. At 8 am, circulating nurse D left the OR and told the nurse at the desk to find Dr. M. D then returned to the OR with the code cart. After this, Dr. M arrived and began to assist CRNA J to resuscitate MH. At 8:02 am, CRNA J gave a 100 mg dose of Anectine, reintubated the patient, and started an intravenous (IV) drip of Anectine.

At this point, CRNA J saw no improvement in his ability to ventilate MH. Both CRNA J and Dr. M listened to MH's chest, but MH's obesity made chest sounds "less clear." Both believed MH had developed a bronchospasm in addition to the laryngospasm. During this period, MH became bradycardic, and experienced at least two incidents of asystole. Cardiac massage was performed. Efforts to medically treat both the cardiac problem and suspected bronchospasm were ineffective; at 8:07 am, due to continuing difficulty, Dr. M removed the endotracheal tube and replaced it with another. At 8:10 am, improvements in respiration began to be clinically noted. MH was then stabilized and taken to the intensive care unit (ICU).

Upon arrival at the ICU, nurses noted that MH's abdomen was "distended and tympanic sounding." In the ICU, MH never regained consciousness and remained on a respirator until she was declared brain dead and life support was removed on October 11.

MH, through her estate, sued Group for medical malpractice, claiming Group was responsible for falling below the standard of care for anesthesia care and supervision and for the actions of CRNA J. Group argued that it followed all applicable standards of care and could not be held negligent for the activities of CRNA J, because CRNA J was not its employee and it did not direct the actions of CRNA J. Group also indicated that even if it were responsible for supervising CRNA J, Group did so appropriately when Dr. M arrived during intubation of MH.

At trial, Dr. H admitted the contractual relationship between Group and CRNA J did not reduce Dr. H's ability to control the CRNAs and to direct their activities in anesthesia. But Dr. H indicated there had been no instructions given to CRNAs as to when they should call an anesthesiologist to the OR. Dr. H believed the understanding of the CRNAs was that they should call when they needed the doctor for "consultation." Further, Dr. M stated he was unaware of any written or verbal guidelines that delineated when the CRNA should request assistance from the anesthesiologist.

Two anesthesiologists testified as experts. Dr. J, for Dr. H, opined that CRNA J's actions were deficient in several respects and that the degree of supervision and direction exercised by Dr. M was not commensurate with that required in the practice of anesthesiology at that time. In Dr. J's opinion, the CRNA should immediately initiate treatment and call the doctor as soon as any respiratory problems arise. Instead, CRNA J continued to try to correct the problem alone and Dr. M was finally summoned by the circulating nurse. Dr. J also believed that MH's size made a 20-mg dose of Anectine useless and that the 100-mg dose should have been given initially. It was also Dr. J's opinion that CRNA J's intubation at 8:02 am was into the esophagus, not the trachea, which would have resulted in distention of her abdomen if allowed to continue for five minutes or more. Dr. J indicated such intubations can occur but felt that failure to recognize that the tube was in the wrong place and failure to correct it for over five minutes caused the damage resulting in MH's death, most likely due to cardiac arrest.

Dr. B, Dr. M's expert, initially testified that calling Dr. M after the second laryngospasm was appropriate; but then added that the anesthesiologist should be called immediately when cyanosis is present. Dr. B also agreed that the 20-mg dose was insufficient for a woman of MH's size and that the second dose should have been a full 100 or 120 mg to break the spasm.

The jury at trial found for MH. Group appealed, indicating that since the actions were taken by CRNA J, Group nor Dr. M or Dr. H could be liable, and that Dr. M properly supervised CRNA J. MH indicated that no legal error was committed, and the jury verdict should stand.

Legal analysis

The appellate court first noted that "'By statute, the physician is the only one empowered to practice medicine.' … [but] an exception [is in] the specialty of anesthesiology and allows a nurse who meets the qualifications of the statute to administer anesthesia under particular supervision." The court noted that the statute establishes the standard of conduct constituting ordinary care for use of CRNAs and that its violation can amount to negligence per se—negligence by definition. Further, the court quoted the Hospital's guidelines for anesthesia:


The anesthetist responsible for the anesthesia decisions required during anesthesia management [must] be already identified [before induction] to the patient and to any technician who may assist in such care and management, and his availability for supervision and direction be established if he is not administering the anesthesia personally.


The appellate court first concluded that in the case of MH, there was sufficient evidence from which a jury could find that there was no clear understanding between Drs. M and H and the CRNAs, and in particular Dr. M and CRNA J, as to when a physician should be summoned whenever difficulties were encountered. This was a failure of the legally mandated degree of direction and responsibility in supervision as evidenced by the delay in Dr. M's entry into the OR, which resulted in inadequate treatment of the laryngospasm for over five minutes before Dr. M was called to the OR.

Group argued to the appellate court that the only ineffective care was the esophageal intubation, but this was done in the presence of Dr. M, and as a matter of law was under Dr. M's "direction and responsibility," and thus supervision was legally adequate. However, the court rejected this contention, indicating "[p]retermitting the issue of whether his walking in the door during the reintubation was sufficient supervision, [MH's] theories were broader than this. They included the lack of understanding between doctor and CRNA as to when the doctor should be called and the failure to have the doctor available sooner." The court noted that the level of supervision by an anesthesiologist working with a CRNA was a subject for expert testimony as to the standard of care; the resolution of conflicting perspectives regarding the relevant standard was for the jury to decide. The jury's decision against the anesthesiologists was thus legally appropriate as a matter of law and Group's claim of adequate supervision could not be sustained.

The court concluded that because the anesthesiologists did not have an appropriate understanding with the CRNAs as to when anesthesiologist presence was necessary, and because testimony elicited at trial indicated there was a violation of the standard of supervisory care in anesthesia, the trial court's conclusion that the anesthesiologists had been negligent was not reversible. It then affirmed the judgment.

--------------------------------------------------------------------------------

 

You hit the nail on the bed. There's a lot of lazy, apathetic anesthesia attendings who are there to just collect the paycheck and don't care one way or the other. These are the people who are selling out the specialty for extra money. I have absolutely no respect for those scumbags and I hope they either retire or die soon so those of us who want to actually work (and don't mind working hard) can take over.

The other problem too is that there's a lot of greedy hospital administrators who want to cash in by hiring CRNAs, paying them less money and pocketing the difference since the bill is the same regardless of who does the anesthesia.

The nurses are also fighting tooth and nail to get independence practice rights so they can work "under collaboration" with the surgeon, podiatrist, dentist, plastic surgeon, etc. What these unsuspecting folks don't know is that when the shizznit hits the fan, despite what the nurses may say, they will likely be dragged into court and since the physician has deeper pockets than the nurses, they will become the target. I am sure you know how ambulance-chasing lawyers are.

I will leave you with a story of yet another physician who was caught in the middle of a mess caused by a CRNA. http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=379590&pageID=1&sk=&date=

Here's the story

The day Joy died

When my patient died needlessly, part of me died, too.

Oct 20, 2006
By: Gary P. Brandeland, MD
Medical Economics


It'll soon be the anniversary of my OB patient's death. Twenty years ago, I stood in the ICU, holding her limp hand. Her name, in stark contrast to her present condition, was Joy. Her mother was the only other person in the room.

The patient was brain dead, the result of an anesthesia catastrophe. In preparing her for her C-section, the nurse anesthetist had accidentally intubated the esophagus and failed to put a pulse oximeter alarm on her. She became severely anoxic during the operation, went into V fib, and was shocked back to sinus rhythm. The airway was corrected by an anesthesiologist who responded to the code, but it was far too late.

The patient was a beautiful, healthy 21-year old. She was well known locally as a singer. She and her husband had family all over the area. She came to me for her OB care because her mother had told her, "Go to Dr. Brandeland, he's always been so kind and polite when he gets his messages." Her mom worked at the telephone answering service I used.


So, I saw her and her husband at every visit. I was 18 months into my career after finishing my family practice residency in the same town. The practice was thriving. I couldn't have dreamed of something this bad happening to a patient, a family, and my life. I thought I might someday miss a diagnosis and have a malpractice suit, but this was like getting hit with a telephone pole.

Facing the family without any help

Everyone who'd been involved left the hospital. I looked out the window, and saw nurses who had been in the OR literally running to their cars to escape the horror of what had just happened. The senior OB who had performed the C-section disappeared. I was just the first assistant.

The family had been expecting to hear happy news. Instead, I had to tell them there'd been an accident. I answered some preliminary questions and agreed to meet with the family in a few hours so that all of them could be present.

Not surprisingly, no one from the hospital administration, the nursing staff, or the medical staff including the operating OB, wanted to join me. I was told by several people, "You're the family doctor, it's best if you speak to them." I walked in alone.

It was a regular-size conference room, standing room only, holding about 35 relatives. I gave a complete description using the chalkboard to illustrate. Without oxygen for that long, I could predict a grim outcome for the patient and her baby, who was now on the way to a hospital that specialized in neonatal care. I assumed my career was over and I thought that her five older brothers would probably kill me or at least beat me severely. I wasn't afraid. I was too numb to care and, subconsciously, probably hoped they would.

After a profound silence, there were questions; I stayed until the last one was answered. The meeting had started with soft-spoken voices; they gradually became heated, but to my surprise, remained nonviolent. I was so pathetically outnumbered, I think they took pity on me.

Initially, the patient still showed some brain activity on EEG. When I saw her CT scan, her brain was immensely swollen. After seven days, the consulting neurologist told me, "Take her off the ventilator." I unplugged the vent, and there weren't any spontaneous respirations. It took seven and a half minutes until she flat-lined. At that point, all I could say was, "It's over." I gave her mother a hug, asked if there was anything I could do, wrote a note in the chart, and left the hospital. I was in some kind of emotional shock.



Pilloried in the press and at the clinic

The news media had a heyday. I got calls from all over, including a major news program, but all I could say was, "No comment." The medical director of our clinic told me, "Don't say a word to anyone, not even your wife." The incident was investigated by the local district attorney's office as a possible murder, but that was quickly ruled out.

The local TV station followed the story closely. They even put the funeral procession on the 10 o'clock news. Each time it played, her death certificate was shown on the TV screen. The camera scrolled down to my easily readable signature, where it stopped for a couple of seconds. I felt the news media crucified me without knowing (or caring) what had really happened.


As I expected, the clinic was hopping with gossip. I had patients who asked me directly if she'd been my patient. When I said "Yes," they got up and walked out, leaving me barely able to speak. Clinic staff avoided me. I walked in on many conversations that ended abruptly.

The toll on the family, the toll on me

About a month after the accident, the nurse anesthetist came up to me in the cafeteria. I thought he'd apologize, but instead, he said coldly, "I'm not taking the rap for the baby."

Around the same time, the significance of the catastrophe hit me. It was the beginning of a long, long, grieving process. I was still just starting my career and this disaster was agonizing. Even though the OB was in charge of the surgery, this was my patient, and like most primary care physicians, I felt ultimately responsible. I remember telling my brother that I felt like a 60-year-old man, even though I was only 30.

For months afterward, I felt like I was being beaten with a baseball bat, physically and emotionally. Out of the 52 doctors in our clinic, only one, an ophthalmologist, asked me how I was doing. For everyone else, it was business as usual. This lack of support from colleagues was a surprise and a huge disappointment. I was treated like some kind of disease they might catch.

My practice hours decreased by half. After I delivered my patients who were already pregnant, I dropped OB from my practice.

The attorneys advised those of us who'd been involved not to talk to each other. There was a malpractice suit, but I wasn't named in it. The family specifically told their attorney not to go after me. They focused their anger on the nurse anesthetist and the hospital. Maybe it was because I was the only one who talked to the family and led them through the situation.

The baby, Rachel, spent months in a neonatal intensive care unit. I visited her every weekend. The severe injury to her brain resulted in microcephaly, severe ******ation, and spastic quadriplegia. I took care of her for five years at the clinic before I accepted a position closer to my hometown to be near my father who was dying of multiple myeloma. I was glad to leave. It was like starting a new life and a healing process. My practice became geriatrics and oncology, but it was a good change.

To this day, I'm still amazed at how other people's lives just continued as if this event never happened. Although it doesn't come close to what the family lost, the personal and professional cost to me was incalculable. It contributed significantly to my divorce. Physically, I felt like I had some sort of chronic illness, constantly overwhelmed by fatigue.

The emotional wound healed but left a huge scar. Initially, I was compulsive about how I treated patients, but that eventually leveled out. I'm proud of how well I've taken care of patients. I've caught mistakes by some less-than-attentive physicians and I think if it hadn't been for the tragedy, maybe I would have missed something. This in no way justifies what happened, but perhaps it gives it some meaning. It may sound simple and naive, but I've tried to do my best for every patient as a way of honoring my lost patient's memory.

In the years since, I've gained weight, lost hair, recovered from a life-threatening heart problem and raised two daughters. I tried my best to limit the collateral damage and I think I succeeded as well as anyone could have.

I hope a tragedy like this never happens again. The outcome was directly related to greed. The nurse anesthetists were under the control of the hospital administration and they made a lot of money for the hospital. The department of anesthesiology had been pressing the administration to get oversight of the anesthetists but the hospital wouldn't yield. In my opinion, if an anesthesiologist had been present during the induction, the accident wouldn't have happened. The day after, the hospital conceded. Maybe my story will motivate young doctors to look with a critical eye at decision-making and have the courage to speak out when something isn't right

 

And how many of the surgeons were sued along with this anesthesiologists as in the above cases?

 

Here's some food for thought, you genius.

http://www.nurseweek.com/news/Features/05-03/Malpractice.asp