Man dies during cataract surgery as "Music Bingo" played

[IVdoc]

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Recently published article in Denver area, a healthy 56yo man went in for cataract surgery at an eye surgery center in Feb 2023 and went into cardiac arrest and died. From the online articles and new clips, the surgeon and the anesthesiologists were playing a game of "Music Bingo", the anesthesiologist had turned off the machine alarms, the patient was draped and no one was paying attention to his vitals as the alarms were turned off. For anyone who has done anesthesia for cataract surgeries, the surgeons usually don't ask for much, maybe like 1-2mg of Versed, a touch of fentanyl as they patients already had local anesthetics via eye drops in preop holding. The surgeons usually want the patient to be able to talk to them. It is quite annoying when the music in the OR is blasting so loud mostly from the surgeon's playlist. I tell them to turn down the music or I turn off the music especially during induction and emergence. The surgeon blamed the anesthesiologist, the anesthesiologist denied wrongdoing, the wife and son are without a husband/dad, the anesthesiologist now works in Oregon as an anesthesiologist. The wife was tipped off by another physician not in the case that the anesthesiologist and surgeon were playing "Music Bingo". CRNAs commenting on FB saying it's an anesthesiologist not CRNA as CRNAs who be paying attention to alarms. Sad story. Vigilance is the ASA motto but apparently it didn't apply in this case

 

[aneftp]

For once. This is 100% on anesthesia. No way around this.

Notice I didn’t say anesthesiologist fault. This is anesthesia fault. Crna or md

If crnas want to blame the MD on this one. They are 100% correct.

But we can blame the rex crna in the Denver plastics death of the 18 year old having a boob job when he didn’t pay attention to her as well.

 

[UscGhost]

Were they playing "Another one bites the dust"?

Or maybe Dead Mans party?

 

[Toffifay]

I Can See Clearly Now followed by Pixies track 6 on their album Doolittle.

 

[Aether2000]

Loud music is the bane of anesthesia.

 

[Lab Lover]

Anybody know what exactly the patient received for meds and the cause of the arrest?

 

[Gern Blansten]

I would guess a vagal response issue that went unrecognized in a person whose cardiac disease was much worse than was known.

 

[coffeebythelake]

I would guess a vagal response issue that went unrecognized in a person whose cardiac disease was much worse than was known.

Perhaps? Or maybe got slammed with a ton of versed and opioids. it is bad enough that it happened.. but the circumstances of unrecognized due to alarms off and the story of unprofessional ism playing musical bingo while things going down make this much much worse.

 

[IVdoc]

There is a local news report video on this on YouTube that was just released last week. The news report obtained the medical records and autopsy report. It appears that it was 28 minutes after anesthesia started (12:48p) that someone in the OR noticed that the patient had "abnormal vitals" (1:16p). The autopsy report says that the patient suffered from global hypoxemia during intraoperative cataract surgery with Versed and fentanyl. Other new articles say that the surgeon and the anesthesiologist had done 8,000 cataract surgeries together and one posting has this anesthesiologist listed as the medical director of this eye surgery center. So the surgeon and anesthesiologist probably felt comfortable working together and thought this is "routine" cataract surgery and had played this "Music Bingo" for many surgeries in the past. "Routine" is usually when things go bad because people let their guard down and think "healthy patient; I've done this thousands of times and everything has always gone fine". Loud music, playing games in the OR is the same as distracted driving but in this case the other person (patient) doesn't even have a chance at reacting since they are sedated.

 

[Agast]

There is a local news report video on this on YouTube that was just released last week. The news report obtained the medical records and autopsy report. It appears that it was 28 minutes after anesthesia started (12:48p) that someone in the OR noticed that the patient had "abnormal vitals" (1:16p). The autopsy report says that the patient suffered from global hypoxemia during intraoperative cataract surgery with Versed and fentanyl. Other new articles say that the surgeon and the anesthesiologist had done 8,000 cataract surgeries together and one posting has this anesthesiologist listed as the medical director of this eye surgery center. So the surgeon and anesthesiologist probably felt comfortable working together and thought this is "routine" cataract surgery and had played this "Music Bingo" for many surgeries in the past. "Routine" is usually when things go bad because people let their guard down and think "healthy patient; I've done this thousands of times and everything has always gone fine". Loud music, playing games in the OR is the same as distracted driving but in this case the other person (patient) doesn't even have a chance at reacting since they are sedated.

“Someone in the OR noticed the patient had “abnormal vital signs””

Since they didn’t specify a role, I’m imagining some poor college pre-med student trying to get in their shadowing hours asking timidly what the flat lines mean

 

[Aether2000]

Most of our cataract surgeries are about 10 minutes. In my world, 28 minutes of anesthesia would mean the surgeon either had trouble in the prior case and was still in that OR attending to the patient, the surgeon is abysmally slow, or the surgeon was taking a lot of time between cases. That being said, here is where you can order Music Bingo to try in your OR: Musical Bingo - Musical Bingo

 

[PpfSuxTube]

I dont know anything about the case but there is no "healthy" 56 yo with cataracts bad enough to need to be done...
This guy was likely a diabetic wreck underneath the hood and obviously had clowns looking after him... am I wrong?

 

[deleted87051]

I dont know anything about the case but there is no "healthy" 56 yo with cataracts bad enough to need to be done...
This guy was likely a diabetic wreck underneath the hood and obviously had clowns looking after him... am I wrong?

One of my friends had a cataract done when he was 50. He was running 50k trail races at the time. The news coverage said this patient was skiing every weekend.

 

[IVdoc]

An article said that the surgeon knew the patient for many years as the patient had congenital retinopathy and cataracts. So it is possible to be healthy in the rest of the body but not have healthy eyes.

 

[Arch Guillotti]

I dont know anything about the case but there is no "healthy" 56 yo with cataracts bad enough to need to be done...
This guy was likely a diabetic wreck underneath the hood and obviously had clowns looking after him... am I wrong?

Yes.

 

[PpfSuxTube]

Yes.

Fair enough. I never do eyes, hate that list. But when I did the average age was 90+

 

[eyeeye_captain]

Weird. If he really did have a retinal dystrophy, they can have some association with cataracts and cardiac issues. The genetics involved are often poorly understood and categorized, and most people haven’t gotten tested.

I have music on during my retina cases, which are longer than cataracts. Since I’m 95+% MAC, the patients like the distraction. It doesn’t get turned on until after the monitors are on and the block is done, and it goes off as soon as the drapes come off. Quiet enough that the whole team can use normal speaking voices.

I have a friend in that market, I’ll have to ask what the word is around town.

 

[GassYous]

Most of our cataract surgeries are about 10 minutes. In my world, 28 minutes of anesthesia would mean the surgeon either had trouble in the prior case and was still in that OR attending to the patient, the surgeon is abysmally slow, or the surgeon was taking a lot of time between cases. That being said, here is where you can order Music Bingo to try in your OR: Musical Bingo - Musical Bingo

yeah..28 mins after anesthesia was induced?
It should be 15 minutes in the room to out of the room.

 

[Lab Lover]

I would still love to know what meds he received and whether they did a block in the room or other possible causes of the arrest?

 

[dozitgetchahi]

There is a local news report video on this on YouTube that was just released last week. The news report obtained the medical records and autopsy report. It appears that it was 28 minutes after anesthesia started (12:48p) that someone in the OR noticed that the patient had "abnormal vitals" (1:16p). The autopsy report says that the patient suffered from global hypoxemia during intraoperative cataract surgery with Versed and fentanyl. Other new articles say that the surgeon and the anesthesiologist had done 8,000 cataract surgeries together and one posting has this anesthesiologist listed as the medical director of this eye surgery center. So the surgeon and anesthesiologist probably felt comfortable working together and thought this is "routine" cataract surgery and had played this "Music Bingo" for many surgeries in the past. "Routine" is usually when things go bad because people let their guard down and think "healthy patient; I've done this thousands of times and everything has always gone fine". Loud music, playing games in the OR is the same as distracted driving but in this case the other person (patient) doesn't even have a chance at reacting since they are sedated.

Back when I was a med student rotating on surgery, I can remember getting stuck with this resident/attending that was very much like this. My surgical knowledge was barely assessed, but rest assured my knowledge of classic rock was intensely evaluated. Thankfully, I’m a big classic rock fan, and my knowledge carried me through obscure questions about Beatles live performances, deep tracks from Queen, Stones and Who albums, T. Rex, how exactly Kurt Cobain died, etc etc. Combined with the blaring nonstop music, this intense line of questioning made me wonder just how much anyone was focusing on the surgeries at hand…

 

[eyeeye_captain]

I would still love to know what meds he received and whether they did a block in the room or other possible causes of the arrest?

Doubt there was a block. Most cataract surgeons these days would probably only do a subtenons instead of a retrobulbar, so a much lower risk for systemic issues, and even then only if they had a complicated case (which this might have been given the operative time with an experienced surgeon). Even the oldest school anesthesiologists I work with turn green when I ask if they still know how to do a RBB, so I’m guessing he wouldn’t have done one.

 

[Lab Lover]

Doubt there was a block. Most cataract surgeons these days would probably only do a subtenons instead of a retrobulbar, so a much lower risk for systemic issues, and even then only if they had a complicated case (which this might have been given the operative time with an experienced surgeon). Even the oldest school anesthesiologists I work with turn green when I ask if they still know how to do a RBB, so I’m guessing he wouldn’t have done one.

Agree, but the unlikely is not impossible and there are still some gomer docs out there.

 

[ak_ps]

only thing that is worse in the ortho ORs besides the freezing cold is the nonstop insistence on blasting their dog**** music

 

[aneftp]

Has to be sleep apnea and versed Most of us have given 2 mg of versed to some patient who quickly desaturated

Guy is healthy but look at his picture and jaw

 

[PpfSuxTube]

One of my friends had a cataract done when he was 50. He was running 50k trail races at the time. The news coverage said this patient was skiing every weekend.

Maybe but skiing can be a wide variety of things... I know guys one fart away from a coronary that can ski better than me cause they've done it since since they were 2 yr old

 

[aneftp]

Autopsy would have shown cad/pe whatever

This looks like clear case of versed or whatever he was given induced hypoxia due to sleep apnea.

 

[deleted87051]

Maybe but skiing can be a wide variety of things... I know guys one fart away from a coronary that can ski better than me cause they've done it since since they were 2 yr old

Lugging skis is >4mets.

 

[Fpg1245]

only thing that is worse in the ortho ORs besides the freezing cold is the nonstop insistence on blasting their dog**** music

I will never forget politely asking to turn the music down only to be told to increase the volume on the monitors.

Absolute frat house in the ortho room

 

[PainDrain]

Who takes >20 minutes for a cataract outside of academics?

 

[cchoukal]

I will never forget politely asking to turn the music down only to be told to increase the volume on the monitors.

Absolute frat house in the ortho room

Down or off. They're not going to scrub out to turn it back on, I promise.

 

[CopaceticOne]

Down or off. They're not going to scrub out to turn it back on, I promise.

Yep, I just walk over and turn in down when it is really too loud.