malpractice case @ UT Houston

[Noyac]

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GI docs are super greedy themselves. But they own their own path labs. So many of these patients get multiple biopsies. And get the stigma of having a "history of a benign colon polyp" when it was really nothing at all. GI docs just happened to bx multiple sites cause they collect $$$$ from each bx.

This is the dirty business of GI anesthesia (no pun intended)

GI docs have positioned themselves at the bottom of the medicine chain when it comes to conscientious patient centered practice. And at the top of the money grab chain.

 

[aneftp]

To add. The reason I mentioned is if this was medical direction or medical supervision again involves greed.

Many commercial/private insurance (not all) will grant the anesthesia company/group/biller an "extra unit" if it's medical direction. Plus give them a few dollars extra per unit as well

So what?

Right?

Well it's a lot of money considering the volume of GI anesthesia.

Say x insurer gives you $100/unit. You bill 7 units. That's $700 dollars for a GI procedure for anesthesia. Not bad. But add "medical direction". The insurer will give you not only an additional one unit for medical direction (approx $70). But instead of giving you $100/unit. They will give you say $105/unit.

So with medical direction. That adds up to around $800 for the case. That's $100/more per case.

This all adds up. Your group say provides 60 GI anesthesia cases a week. Say it's 50% commercial insurance ratio. That's 20 or so extra $100/case for medical direction per week. That's $2000 extra per week. So an extra $100k a year for the group billing GI anesthesia as medical direction.

But the issue is if this is a general anesthetic and group is billing as medical direction and patient is dead. Was anesthesiologist involves for "all critical aspects" of GI procedure? To me. If Crna is giving a 100-150mg bolus of propofol at beginnings for an EGD. That's an induction dose. MD HAS TO BE IN THE ROOM for it to be considered medical direction.

Lawyers will have a field day if they find out group is billing as medical direction. Either group has committed fraud by billing illegally (trying to gain that extra$100/case). If group is billing as medical supervision they can fight this case better.

My bet is group or hospital or whoever is running the anesthesia contract is billing it as medical direction.

 

[aneftp]

GI docs have positioned themselves at the bottom of the medicine chain when it comes to conscientious patient centered practice. And at the top of the money grab chain.

And amsurg corporation (the same corporation which purchased Sheridan) is at the top of these GI practices. Since they own the most endo centers in the USA in a "joint venture" with GI docs. Now win Sheridan purchase. Amsurg is more than agressively getting into the anesthesia business.

 

[Mman]

I've said this before. EGD on obese sleep apnea patients is one of the most dangerous procedures we do. I've maintained this way before the joan rivers death. This is no case for the inexperienced. I am surprised we get minimal training for this because "Its so easy". Its only after training did i do one thousand of them to realize the real risks.

I don't find it dangerous because I put a tube in all of them. If I have any question about your health or your airway, you get an ETT when somebody is messing around in your airway. If the GI doc doesn't like it they can do the anesthesia themselves. If I'm involved, I'm opting for safety.

 

[criticalelement]

I don't find it dangerous because I put a tube in all of them. If I have any question about your health or your airway, you get an ETT when somebody is messing around in your airway. If the GI doc doesn't like it they can do the anesthesia themselves. If I'm involved, I'm opting for safety.

LOL. Dude you would last half of a morning at the local freestanding GI clinic.

 

[CrazyJake]

Me too, I tube any Pt I'm worried about. GI docs don't like it b/c it 'slows them down.'

As I told one today, stop bringing me ASA 3 and 4s and I'll put the ETT back in draw #3

 

[chmd]

LOL. Dude you would last half of a morning at the local freestanding GI clinic.

So obviously don't work for scumbag GI docs who employ you and compromise patient safety.

Maybe just don't work for other physicians or hedge fund managers.

 

[Noyac]

There is no reason an ETT should slow things down any.

My technique is to induce with whatever, DL and spray the **** out of the cords and trachea with atomized LTA. Wait a second or two then pass the tube. Pt breathes the entire time. Turn off whatever you are using early and use small bumps of propofol if the GI turd keeps dicking around. Pt will be awake as the scope is coming out and we are off to phase 2.

 

[Mman]

LOL. Dude you would last half of a morning at the local freestanding GI clinic.

and why the hell would I care what they do at their clinic? I'm not the one getting sued for an airway complication. If morbidly obese OSA patients are having GAs with uncontrolled airways and there is a bad outcome, there isn't much of a legal defense and you better just open the wallet.

So yes, LOL

 

[criticalelement]

and why the hell would I care what they do at their clinic? I'm not the one getting sued for an airway complication. If morbidly obese OSA patients are having GAs with uncontrolled airways and there is a bad outcome, there isn't much of a legal defense and you better just open the wallet.

So yes, LOL

You are not getting sued, but you also are looking for another job. Pick your poison.
Doornumber 1: EGD without ETT with judicious use of propofol Tight sphincter
DOornumber 2: Look for another job.

 

[Planktonmd]

They listen to the patients concerns and hold their hand while they're circling the drain. The closed minded doctors jump to conclusions, rapidly doing invasive procedures like intubations and cricothyrotomies without taking a holistic approach to the desaturation.

Yes... it's all in the holistic approach

 

[Mman]

You are not getting sued, but you also are looking for another job. Pick your poison.
Doornumber 1: EGD without ETT with judicious use of propofol Tight sphincter
DOornumber 2: Look for another job.

Door 3: don't start working at such a crappy job in the first place

 

[jwk]

LOL. Dude you would last half of a morning at the local freestanding GI clinic.

We do a number of freestanding GI clinics - and we do NOT and will not do bariatric sleep apnea patients at any of them, period. We insist they be done in the hospital GI lab. Somebody has to have the balls to say NO. That would be us.

 

[jwk]

...

 

[Guy Caballero]

You must not understand the difference between MAC and GA. 99% of the time when using propofol, it's a general anesthetic. There are a million ways you can accomplish this, and I prefer to use a combination of drugs that maintains or at least avoids suppressing their spontaneous ventilations too much.

Everyone responds differently to drugs, as is evident by the recent disastrous outcomes. If people used their heads instead of cookie cutter anesthesia and giving high doses of propofol to everyone, we'd have a lot better outcomes. Most of the time you get away with it, but that doesn't make it optimal.

I typically bring those patients in and start with an intraosseous line, then sedate with clonidine, promethazine, and scopolamine. I then let them breathe nitrous oxide until they are drowsy, give intranasal fentanyl and rectal tylenol (in hopes that it will be fully dissolved by the time the procedure is done). Everyone gets 50 mg IM ketamine. Then, just before the GI doc is ready to insert the colonoscope, I thread a retrograde wire and leave it in place just in case I need it (I usually don't, thankfully). Hit them with a little demerol and haloperidol for the wake up and out the door with a prescription for methadone. Pretty standard day.

 

[jwk]

You must not understand the difference between MAC and GA. 99% of the time when using propofol, it's a general anesthetic. There are a million ways you can accomplish this, and I prefer to use a combination of drugs that maintains or at least avoids suppressing their spontaneous ventilations too much.

Everyone responds differently to drugs, as is evident by the recent disastrous outcomes. If people used their heads instead of cookie cutter anesthesia and giving high doses of propofol to everyone, we'd have a lot better outcomes. Most of the time you get away with it, but that doesn't make it optimal.

Of course I do.

Polypharmacy in the bariatric patient is a recipe for disaster - simple is better. Besides lots of GI, we do plenty of bariatric and sleep apnea surgery. Our ENT surgeons demand no versed on any OSA patient, and with good reason. I had an EGD/colon a few years ago and got versed/fent/propofol and was in PACU almost an hour waking up and I'm not of the bariatric persuasion. Last year, I did the same thing but insisted on no versed/fent and was awake before I left the procedure room.

How much propofol do I use? Enough - but not too much. Not sure about your outcomes, but I have zero morbidity/mortality on my GI cases over a long career. I abandoned using versed/fent in GI years ago - it complicates things unnecessarily. That's not cookie cutter - that's a lot of experience.

 

[jwk]

...

 

[Planktonmd]

I typically bring those patients in and start with an intraosseous line, then sedate with clonidine, promethazine, and scopolamine. I then let them breathe nitrous oxide until they are drowsy, give intranasal fentanyl and rectal tylenol (in hopes that it will be fully dissolved by the time the procedure is done). Everyone gets 50 mg IM ketamine. Then, just before the GI doc is ready to insert the colonoscope, I thread a retrograde wire and leave it in place just in case I need it (I usually don't, thankfully). Hit them with a little demerol and haloperidol for the wake up and out the door with a prescription for methadone. Pretty standard day.

Excellent technique
Have you considered adding nitric oxide through face mask to cover potential pulmonary hypertension?

 

[deleted682700]

Less is more, versed if they are younger than 60. Double dilute the propofool when they are over 70 and take control. Gi doctors and cardiologists are scared of the airway. And I love cardiologists because when SHTF they can take care of the cardiac part and I am confident of the airway, touch wood

 

[caligas]

I typically bring those patients in and start with an intraosseous line, then sedate with clonidine, promethazine, and scopolamine. I then let them breathe nitrous oxide until they are drowsy, give intranasal fentanyl and rectal tylenol (in hopes that it will be fully dissolved by the time the procedure is done). Everyone gets 50 mg IM ketamine. Then, just before the GI doc is ready to insert the colonoscope, I thread a retrograde wire and leave it in place just in case I need it (I usually don't, thankfully). Hit them with a little demerol and haloperidol for the wake up and out the door with a prescription for methadone. Pretty standard day.

No precedex? Malpractice.

 

[Psai]

Less is more, versed if they are younger than 60. Double dilute the propofool when they are over 70 and take control. Gi doctors and cardiologists are scared of the airway. And I love cardiologists because when SHTF they can take care of the cardiac part and I am confident of the airway, touch wood

hopefully not the patient's

 

[polar403]

Less is more. Rarely need anything more than propofol. Don't even need close to an induction dose to get them deep enough to slip a nasal trumpet in if you're concerned about superfluous pharyngeal tissue and let GI put a scope in. Careful titration afterwards. General.. MAC.. MACeral.. call it whatever you want. They're ready to go home or back to the floor by the time you get them in to recovery if you do it right.