Man dies after anesthesiologist and CRNA take breaks during procedure

[Random Anesthesiologist]

http://www.foxnews.com/health/2012/09/07/man-dies-after-doctor-goes-on-lunch-break-during-surgery/

A Swedish man undergoing surgery died on the operating table after the anesthesiologist and a nurse went to lunch during the procedure, The Local reported.
The 72-year-old man was having a tumor removed at a hospital in Lidköping, Sweden, and had gone under anesthesia at 10:45 a.m. According to The Local, the head anesthesiologist then left at noon for lunch, followed by the head nurse anesthesiologist fifteen minutes later.

Oh my. I read this article this morning, noticed this was Sweden. How on earth could this happen? I'm not very familiar with Sweden's heath care system, except that I know it's of the socialized variety... I'm not sure either if they call nurse anesthetists CRNAs, but just used the title as we know it.

---

Members don't see this ad.

 

[Idiopathic]

well, im sure it happened exactly as that 200 word foxnews article describes it

 

[Random Anesthesiologist]

well, im sure it happened exactly as that 200 word foxnews article describes it

Yes, I've read the literal portion. My question is, how does someone get to the point professionally where they take a lunch break, in the middle of the case, without appropriate backup?

I'm wondering if this was an apathetic situation or a miscommunication. Maybe I'm just being naive?

 

[chessknt]

Yes, I've read the literal portion. My question is, how does someone get to the point professionally where they take a lunch break, in the middle of the case, without appropriate backup?

I'm wondering if this was an apathetic situation or a miscommunication. Maybe I'm just being naive?

From what I read it looks like there was a CRNA-equivalent in the room, she just had no idea what she was doing, which lead to a late call and the pt's death.

 

[urge]

I don't think we are being fair with CRNA's. I don't know what kind of training nurse anesthetist they have in Sweden, or whether they can stay in the room by themselves.

 

[Planktonmd]

This guy was not Swedish was he?

 

[cincincyreds]

This guy was not Swedish was he?

Ha Ha, I like the picture of the infamous Dr. Murry. It is really sad that this thing could happen anywhere. I hope justice is served in this case, like in Dr. Murry's case.

 

[BLADEMDA]

From what I read it looks like there was a CRNA-equivalent in the room, she just had no idea what she was doing, which lead to a late call and the pt's death.

In my career here in the USA on more than one occasion I have gotten that "late call" from an Operating room staffed by a CRNA; if I had delayed by more than 60 seconds in my response to the calls the patients would both be dead.

Both times the CRNAs failed to recognize impending cardiac arrest and both times they didn't even call me stat to the room.

 

[cincincyreds]

In my career here in the USA on more than one occasion I have gotten that "late call" from an Operating room staffed by a CRNA; if I had delayed by more than 60 seconds in my response to the calls the patients would both be dead.

Both times the CRNAs failed to recognize impending cardiac arrest and both times they didn't even call me stat to the room.

This is why I have done all my own cases since day one out of residency. Because I have zero trust in anyone else but myself, especially a cRNA, I know things get done correctly.

 

[Surfer]

Ha Ha, I like the picture of the infamous Dr. Murry. It is really sad that this thing could happen anywhere. I hope justice is served in this case, like in Dr. Murry's case.

Oh please. Murray was a total scape goat. What he did was medical malpractice, not criminal homicide. It's pretty clear Michael was self medicating...spare me the feigned outrage.

 

[Planktonmd]

Oh please. Murray was a total scape goat. What he did was medical malpractice, not criminal homicide. It's pretty clear Michael was self medicating...spare me the feigned outrage.

The problem though our legal system does not agree with you and he was found guilty of a criminal charge.
He certainly provided a precedence that will be used in the future to criminally prosecute physicians who contribute to a bad outcome.
He actually hurt all of us with his stupidity.

 

[Random Anesthesiologist]

This guy was not Swedish was he?

Nor was he an anesthesiologist.

 

[matthi]

I love how this thread has become a "let's blame CRNA's" thread. Childish.

 

[Bertelman]

I love how this thread has become a "let's blame CRNA's" thread. Childish.

What thread are you reading? There was exactly one post commenting negatively on CRNAs, and it seemed to be well-founded. Insert "resident" in there, and it would be just as relevant.

 

[BLADEMDA]

I love how this thread has become a "let's blame CRNA's" thread. Childish.

Not knowing how to run an operating Ventilator is gross malpractice in the USA for a CRNA or an Anesthesiologist.

All this talk about "Solo" CRNA is just crap. These days the quality has NEVER been lower while the quantity has never been higher. Some schools are producing CRNAs who can't even function competently in a rigid ACT model.

The CRNA being discussed here was clearly incompetent while the Attending was stupid, foolish or lazy (or all 3).

 

[fakin' the funk]

http://www.foxnews.com/health/2012/09/07/man-dies-after-doctor-goes-on-lunch-break-during-surgery/

Oh my. I read this article this morning, noticed this was Sweden. How on earth could this happen? I'm not very familiar with Sweden's heath care system, except that I know it's of the socialized variety... I'm not sure either if they call nurse anesthetists CRNAs, but just used the title as we know it.

Well, that story was as clear as mud.

I stopped reading when I decided that the "nurse anesthesiologist" was clearly to blame.

 

[Teillard]

In my career here in the USA on more than one occasion I have gotten that "late call" from an Operating room staffed by a CRNA; if I had delayed by more than 60 seconds in my response to the calls the patients would both be dead.

Both times the CRNAs failed to recognize impending cardiac arrest and both times they didn't even call me stat to the room.

Hmmm...That's bad. I relieved an anesthesiologist who let his forane run dry. He was trying to figure out where the hypertension and tachycardia were coming from. Walked in on another one pre- oxygenating his patient with the black straps and mask with the APL valve closed. The bag was basketball sized and the patient was whipping her head from side to side.

Both times the physicians didn't even realize there was a problem.

Tit for tat anecdotes...everyone's got 'em

 

[cincincyreds]

Not knowing how to run an operating Ventilator is gross malpractice in the USA for a CRNA or an Anesthesiologist.

All this talk about "Solo" CRNA is just crap. These days the quality has NEVER been lower while the quantity has never been higher. Some schools are producing CRNAs who can't even function competently in a rigid ACT model.

The CRNA being discussed here was clearly incompetent while the Attending was stupid, foolish or lazy (or all 3).

I've never met a cRNA. I didn't have them in training, and they are not at the hospital I am at right now. But after hearing these stories, I think it is best for someone out of residency to just do their own cases. I've done all my own cases since residency and I think it has been for the better.

 

[WholeLottaGame7]

Hmmm...That's bad. I relieved an anesthesiologist who let his forane run dry. He was trying to figure out where the hypertension and tachycardia were coming from. Walked in on another one pre- oxygenating his patient with the black straps and mask with the APL valve closed. The bag was basketball sized and the patient was whipping her head from side to side.

Both times the physicians didn't even realize there was a problem.

Tit for tat anecdotes...everyone's got 'em

Of course. I don't think anybody's denying that there are bad anesthesiologists and great CRNAs out there. The question is, what is it like across the spectrum of each provider? In my (obviously) limited experience at one institution, there is a lot more variation in CRNA quality. The standard deviation is much wider, so to speak.

 

[pgg]

Tit for tat anecdotes...everyone's got 'em

For every 'dumb anesthesiologist left the APL closed' anecdote you could relate (or fabricate), I could spot you a dozen 'dumb nurse rearranged ECG lead stickers to make ST depression go away' anecdotes.

Allow me to introduce you to the "bell curve" concept as it applies to physician vs nurse anesthesia:

I work with some really outstanding CRNAs. I also get to see some of the ones who came from strip-mall CRNA mills, usually they're temporary locums fill-ins at my moonlighting job. The #1 insurmountable problem with independent CRNA practice is the ridiculous lack of quality control from CRNA diploma mills. The CRNA bell curve extends faaaaaaar to the left. That there's some overlap on the right side with the anesthesiologists is not a defense for the really, really poor CRNAs who are allowed to graduate and practice.

But go ahead and keep claiming that the difference is just 'tit for tat anecdotes' ...

 

[BLADEMDA]

For every 'dumb anesthesiologist left the APL closed' anecdote you could relate (or fabricate), I could spot you a dozen 'dumb nurse rearranged ECG lead stickers to make ST depression go away' anecdotes.

Allow me to introduce you to the "bell curve" concept as it applies to physician vs nurse anesthesia:

I work with some really outstanding CRNAs. I also get to see some of the ones who came from strip-mall CRNA mills, usually they're temporary locums fill-ins at my moonlighting job. The #1 insurmountable problem with independent CRNA practice is the ridiculous lack of quality control from CRNA diploma mills. The CRNA bell curve extends faaaaaaar to the left. That there's some overlap on the right side with the anesthesiologists is not a defense for the really, really poor CRNAs who are allowed to graduate and practice.

But go ahead and keep claiming that the difference is just 'tit for tat anecdotes' ...

Awesome post. You know I love that graph. But in all fairness the overlap is a little larger than that shown in the graph.

 

[pgg]

Awesome post. You know I love that graph. But in all fairness the overlap is a little larger than that shown in the graph.

You're right, there's more overlap. 10 minutes with Excel, 9 of which was reading Wikipedia for the normal distribution formula

to plug into Excel was all the effort I could muster. No one should take the graph at face value.

 

[Mr Wizard]

Yes, I've read the literal portion. My question is, how does someone get to the point professionally where they take a lunch break, in the middle of the case, without appropriate backup?

I'm wondering if this was an apathetic situation or a miscommunication. Maybe I'm just being naive?

You would be surprised at the frequency where anesthesiologists in Europe leave the operating room during a case without signing out to an another.

Spent a couple months in France during residency working the trauma/ortho rooms. It was commonplace to go block your next patient in an attached anteroom while your current case is finishing up. It was also not rare to see an anesthesiologist sipping on some espresso in the break room or smoking a cigarette outside during a case. (5-6 years ago, the smoking was still being done in the breakroom between the ORs).

 

[dhb]

You would be surprised at the frequency where anesthesiologists in Europe leave the operating room during a case without signing out to an another.

Spent a couple months in France during residency working the trauma/ortho rooms. It was commonplace to go block your next patient in an attached anteroom while your current case is finishing up. It was also not rare to see an anesthesiologist sipping on some espresso in the break room or smoking a cigarette outside during a case. (5-6 years ago, the smoking was still being done in the breakroom between the ORs).

True... and then some...

 

[TrojanGopher]

Many of my attendings practiced in Europe (namely Germany and Switzerland) before they came to the USA to take faculty positions. While neither of these countries is Sweden, their experience may shed some light on the discussion. As far as I understand, CRNA's (in the American sense) do not exist in Europe. Rather, these "Anesthesia Nurses" more like PACU/pre-op nurses with a bit more knowledge of anesthesia. They are able to give anesthesiologists breaks, but legally are not allowed to change the patient's care (ie give drugs). I'm told they basically watch/chart vital signs and if something change, are expected to call the anesthesiologist immediately. But, I've also been told the more experienced nurses are given a bit more leeway than the aforementioned "chart-vitals-and-call-for help" setup while giving breaks.

That being said, I'm not quite sure what a "head nurse anesthesiologist" is?

 

[dhb]

Not true for all countries: in France it's a 2 year degree and they perform significant parts of anesthesia care often with remote supervision.

 

[Blunder]

Thought I would just fill in a couple of blanks for you guys:

The swedish "nurse anesthetist" has a basic nursing degree (bachelor), plus one year of anesthesia studies.

We (I'm a swedish nurse anesthetist) work with anesthesiologists in something that (I guess) resembles the Anesthesia Care Team model. The anesthesiologists are responsible for the patient evaluation and anesthesia plan. They are also to be available at all times, for consultation or to adjust the plan when unexpected situations arise. In the end, the nurse anesthetist is expected to call for the anesthesiologist when bad things (are about to) happen.

About the case discussed here:

The anesthesiologist responsible for the patient made him/herself unavailable by leaving the department for lunch. He/she did not report the case to another anesthesiologist, or tell the nurse anesthetist. Then the nurse anesthetist was relieved, by another nurse anesthetist, for a lunch break.

After a while the patient started bleeding profoundly and the nurse anesthetist in the OR called the anesthesiologist, who was unreachable. So the nurse anesthetist did what he/she could to try and salvage the situation without any help. At some point the nurse anesthetist switched the ventilator from automatic to manual - probably because the patient was light - and then administered muscle relaxants. After some time the anesthesia delivery unit gives off an apnea-alarm, which the nurse anesthetist silences. Then the ADU never gives off another apnea-alarm. The nurse anesthetist then forgets all about "Airway-Breathing-Circulation..." in this dire situation and the patient isn't ventilated for 8 minutes, as the nurse anesthetist is reading the situation wrongly.

The nurse anesthetist should have done better, and the fact that the apnea-alarm only goes off once if temporarily silenced, is no excuse for what transpired. It is, however, something that can be changed to possibly help prevent future mistakes/catastrophes. [Edit:] Other issues are, of course, the fact that the nurse anesthetist was left without any kind of backup immediately available. For example the anesthesiologist and the first nurse anesthetist should never have left the department at the same time.

Hopefully that sheds some light on what happened.

 

[BLADEMDA]

Thought I would just fill in a couple of blanks for you guys:

The swedish "nurse anesthetist" has a basic nursing degree (bachelor), plus one year of anesthesia studies.

We (I'm a swedish nurse anesthetist) work with anesthesiologists in something that (I guess) resembles the Anesthesia Care Team model. The anesthesiologists are responsible for the patient evaluation and anesthesia plan. They are also to be available at all times, for consultation or to adjust the plan when unexpected situations arise. In the end, the nurse anesthetist is expected to call for the anesthesiologist when bad things (are about to) happen.

About the case discussed here:

The anesthesiologist responsible for the patient made him/herself unavailable by leaving the department for lunch. He/she did not report the case to another anesthesiologist, or tell the nurse anesthetist. Then the nurse anesthetist was relieved, by another nurse anesthetist, for a lunch break.

After a while the patient started bleeding profoundly and the nurse anesthetist in the OR called the anesthesiologist, who was unreachable. So the nurse anesthetist did what he/she could to try and salvage the situation without any help. At some point the nurse anesthetist switched the ventilator from automatic to manual - probably because the patient was light - and then administered muscle relaxants. After some time the anesthesia delivery unit gives off an apnea-alarm, which the nurse anesthetist silences. Then the ADU never gives off another apnea-alarm. The nurse anesthetist then forgets all about "Airway-Breathing-Circulation..." in this dire situation and the patient isn't ventilated for 8 minutes, as the nurse anesthetist is reading the situation wrongly.

The nurse anesthetist should have done better, and the fact that the apnea-alarm only goes off once if temporarily silenced, is no excuse for what transpired. It is, however, something that can be changed to possibly help prevent future mistakes/catastrophes. [Edit:] Other issues are, of course, the fact that the nurse anesthetist was left without any kind of backup immediately available. For example the anesthesiologist and the first nurse anesthetist should never have left the department at the same time.

Hopefully that sheds some light on what happened.

Pathetic. Gross malpractice all around.