MD gets blamed for aspiration death/not being in room for induction

[aneftp]

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Yep, another aspiration death lawsuit on front page of the Orlando newspaper yesterday.

http://articles.orlandosentinel.com...cf-20110807_1_barbara-hicks-wurm-harold-hicks

They blamed the MD for not being present during induction when the patient aspirated during an emergency ex lap for SBO. The CRNA started the case.

Also blames the MD for not "ordering an NG tube" to suck out gastric consents prior to induction.

Apparently the insurance company already settle for 1 million but I think the patients are trying to go after the MD for more than the max policy.

There are a couple of things to point out here.

1. MD should have been present during induction, especially during emergency cases. I can't blame the patient for suing in this case. But I work in Florida and it's the wild wild west sometimes when you supervise 4 rooms and many things are going at the same time.

I do think MD needed to be in the room "for induction". Always mark present for induction especially for emergency cases.

2. The NG argument is a load of crap. We all know the NG tube was most likely ordered during the ER admission but nursing always "passes" the buck to anesthesia if they know patient is going to the OR. I am surprised the patients didn't sue the hospital for this.

 

[btbam]

Article doesn't mention anything about RSI, but if one was done properly then I don't think having the attending in the room would've made much if any difference.

 

[Narcotized]

.

 

[nycitygas]

Even if it wouldnt have made a difference, he should have been in the room.

 

[pgg]

I was 2nd call behind a 1st call CRNA two weekends ago. Ex-lap for free air comes in through the ER, he does the case (surgeon placed the central line for him). Patient was in DKA at the time they went to the OR. I think the patient ultimately did fine.

My role: none.

Say what you will about opt-out states, I don't have 4 nurses of widely varying skill/experience/intelligence to "supervise" and keep in line while I'm really the one on the hook. They do their cases (with a heavy scheduling bias for the elective list) and I do mine. It's nights and weekends when the hospital places its bets and takes its chances.

(I'm not saying I support opt-out independent practice, just that I'll never get sued for their shenanigans under this system.)

 

[RT2MD]

(I'm not saying I support opt-out independent practice, just that I'll never get sued for their shenanigans under this system.)

pgg - I was wondering about this last bit. Haven't there been cases of litigation in a "true" independent practice where the physician was expected to step in and put out fires? In your practice, what happens in the following scenario?
1) A CRNA in another room has problems and calls for help
2) A physician responds
3) The patient expires (or has some horrible outcome) due to the CRNAs initial action/inaction.

Is it possible the physician gets sued b/c they are the physician and have the deepest pockets (or can be held to a higher standard of care, or whatever)?

I'm only a 2nd year student, but the supervising aspect of anesthesia scares me... I can be a bit OCD about how things are done. It might drive me crazy knowing that there is stuff going on in an OR that I have no knowledge of, and yet I could be held responsible/liable.

Thank you for any replies,
-RT2MD

 

[sevoflurane]

Is it possible the physician gets sued b/c they are the physician and have the deepest pockets (or can be held to a higher standard of care, or whatever)?

You becha!

 

[pgg]

pgg - I was wondering about this last bit. Haven't there been cases of litigation in a "true" independent practice where the physician was expected to step in and put out fires? In your practice, what happens in the following scenario?
1) A CRNA in another room has problems and calls for help
2) A physician responds
3) The patient expires (or has some horrible outcome) due to the CRNAs initial action/inaction.

Is it possible the physician gets sued b/c they are the physician and have the deepest pockets (or can be held to a higher standard of care, or whatever)?

Sure, life's not fair.

But even in an unfair world, there's some difference between

• an uninvolved anesthesiologist with no prior duty to the patient, who comes to help out a CRNA in trouble
• the anesthesiologist who preops the patient and directs/supervises the CRNA

 

[RT2MD]

Sure, life's not fair.

But even in an unfair world, there's some difference between

• an uninvolved anesthesiologist with no prior duty to the patient, who comes to help out a CRNA in trouble
• the anesthesiologist who preops the patient and directs/supervises the CRNA

Very true and valid points... I suppose that your attorney could *hopefully* successfully argue this. I would imagine that the prosecutor would completely pick apart every intervention that you did - trying to link the outcome in anyway to your actions as well. I'm sorry, Dr. pgg - it took you 6.2 seconds to perform this intervention... the standard of care is 5.1 seconds. Pay up, sucka!

I'm in the basic science years of medical school, am married to an attorney (who does not do litigation) and am already sick of/scared/dreading the medico-legal world awaiting me in practice.

Sorry for the hijack, aneftp... and now back to our regularly scheduled programming...

 

[imfrankie]

I was 2nd call behind a 1st call CRNA two weekends ago. Ex-lap for free air comes in through the ER, he does the case (surgeon placed the central line for him). Patient was in DKA at the time they went to the OR. I think the patient ultimately did fine.

My role: none.

Say what you will about opt-out states, I don't have 4 nurses of widely varying skill/experience/intelligence to "supervise" and keep in line while I'm really the one on the hook. They do their cases (with a heavy scheduling bias for the elective list) and I do mine. It's nights and weekends when the hospital places its bets and takes its chances.

(I'm not saying I support opt-out independent practice, just that I'll never get sued for their shenanigans under this system.)

Interesting approach. Never thought about that. If I get back to a mixed practice, I'll consider your way.

 

[pgg]

I would imagine that the prosecutor would completely pick apart every intervention that you did

It is astonishing the kinds of things the plaintiffs claim in malpratice suits. Whether it's no pre-induction NG tube, or an "emergency" 50 mcg dose of fentanyl, or something else that only highlights their illiteracy and ignorance.

All any of us can do is be diligent, document well, pay our malpractice premiums on time ... and be nice to patients so they'll like you. Being sued is sometimes more about angry patients and families than actual errors.

 

[imfrankie]

Very true and valid points... I suppose that your attorney could *hopefully* successfully argue this. I would imagine that the prosecutor would completely pick apart every intervention that you did - trying to link the outcome in anyway to your actions as well. I'm sorry, Dr. pgg - it took you 6.2 seconds to perform this intervention... the standard of care is 5.1 seconds. Pay up, sucka!

I'm in the basic science years of medical school, am married to an attorney (who does not do litigation) and am already sick of/scared/dreading the medico-legal world awaiting me in practice.

Sorry for the hijack, aneftp... and now back to our regularly scheduled programming...

Best prevention is good relationship with patient preop.

 

[RT2MD]

... and be nice to patients so they'll like you. Being sued is sometimes more about angry patients and families than actual errors.

Best prevention is good relationship with patient preop.

Hope this holds true. I believe that this will be one of my strong suits... I can strike up a pretty good rapport with patients in a very short time. 👍

 

[dhb]

It is astonishing

be nice to patients so they'll like you. Being sued is sometimes more about angry patients and families than actual errors.

👍

 

[jwk]

I was 2nd call behind a 1st call CRNA two weekends ago. Ex-lap for free air comes in through the ER, he does the case (surgeon placed the central line for him). Patient was in DKA at the time they went to the OR. I think the patient ultimately did fine.

My role: none.

Say what you will about opt-out states, I don't have 4 nurses of widely varying skill/experience/intelligence to "supervise" and keep in line while I'm really the one on the hook. They do their cases (with a heavy scheduling bias for the elective list) and I do mine. It's nights and weekends when the hospital places its bets and takes its chances.

(I'm not saying I support opt-out independent practice, just that I'll never get sued for their shenanigans under this system.)

All due respect, I don't get this - but my perspective is different because I've always worked in a true ACT practice. I'm assuming that the CRNA's do not work for you and work for the hospital, and there is no co-mingling of cases. Does an anesthesiologist at your facility participate in any cases where care is provided by the CRNA or is everything separate e.g. you do yours and they do theirs? It just seems strange to me that an anesthesiologist doesn't have primary responsibility in a hospital that has anesthesiologists on staff (although I know my CRNA friends on "the other board" would point out that it's a common arrangement). It seems like a good trial lawyer might have a field day knowing an anesthesiologist was around but not utilized, and that the hospital would be at some risk because of that.

 

[deleted126335]

From the AANA code of ethics:

3. Responsibilities as a Professional
CRNAs are responsible and accountable for the services they render and the actions they take.
3.1 The CRNA, as an independently licensed professional, is responsible and accountable for judgments made and actions taken in his or her professional practice. Neither physician orders nor institutional policies relieve the CRNA of responsibility for his or her judgments made or actions taken.
3.2 The CRNA practices in accordance with the professional practice standards established by the profession.
3.3 The CRNA participates in activities that contribute to the ongoing development of the profession and its body of knowledge.
3.4 The CRNA is responsible and accountable for his or her conduct in maintaining the dignity and integrity of the profession.
3.5 The CRNA collaborates and cooperates with other healthcare providers involved in a patient's care.
3.6 The CRNA respects the expertise and responsibility of all healthcare providers involved in providing services to patients.
3.7 The CRNA is responsible and accountable for his or her actions, including self- awareness and assessment of fitness for duty.


I promise you that the Plaintiff's attorney, and defense attorney were fully aware of this. They were also fully aware of state law, Local medical staff bylaws, Department policy and procedure manual, ASA position statement on the Anesthesia care team, How the case was billed and the billing requirements. The CRNA's and Anesthesiologist's employment agreement and if a private group their contract with the hospital. They were also aware that depending on the judge and what he had for breakfast, the jury may only hear some of the above.

What six out of eight people with different level's of grey matter and political beliefs and personal experiences might think about all of the above, and what they choose to care about is anybody's guess.

That is really the way that trials work.

 

[chocomorsel]

I quit a job because I was basically never expected to be in the OR for induction, emergence, or anything else. Yes he should have been in there. Yes there should have been an NG. Yes we are broke and the treasury is insolvent (oh sorry, wrong thread on the last point).

Thanks Narc. This made me laugh out loud.

 

[chocomorsel]

I was 2nd call behind a 1st call CRNA two weekends ago. Ex-lap for free air comes in through the ER, he does the case (surgeon placed the central line for him). Patient was in DKA at the time they went to the OR. I think the patient ultimately did fine.

My role: none.

Say what you will about opt-out states, I don't have 4 nurses of widely varying skill/experience/intelligence to "supervise" and keep in line while I'm really the one on the hook. They do their cases (with a heavy scheduling bias for the elective list) and I do mine. It's nights and weekends when the hospital places its bets and takes its chances.

(I'm not saying I support opt-out independent practice, just that I'll never get sued for their shenanigans under this system.)

Good for you. And this is why I am looking for MD only practice. I may have to settle for MD mostly though, but I don't want to supervise others and be held ultimately responsible. I want to take responsibility for my own screw ups.

 

[B-Bone]

maybe it's just me, but I'm pretty sure the MD in this case is 100% liable for anything that goes on in his ORs with his pts. I supervise most of the time, and I make it my business to get my ass to every induction and every emergence, and always know what's going on in my rooms. I do this by actually going in the rooms, looking at the monitors, checking (and rechecking throughout the case) positioning, evaluating the fluids/EBL/UOP, talking to the surgeons to see how it's going, etc (basically what I'd be doing if I were sitting the room). This is what you are legally required to be doing if you are supervising. Anything less, and you're committing insurance fraud by billing for services you didn't render. I let the CRNAs know that we're doing my MY PLAN, MY WAY, and it's not up for discussion. It's my signature on the bottom of the chart, so I make the calls.

If some jagoff is out there signing charts and letting nurses run wild, he deserves to get his pants sued off when the s*&t hits the fan. That's the deal. You can't have it both ways, i.e. claim CRNAs shouldn't practice independently and then NOT EVEN SUPERVISE THEM WHEN YOU WORK IN A "SUPERVISORY" PRACTICE. Sounds like this is just some lazy POS sipping coffee in the lounge billing for anesthesia he didn't provide while a nurse killed somebody. Kudos,bro.

 

[Idiopathic]

+1

edit: amazingly it seems he was there and then left the room. i wonder if there was something more pressing? i sure do appreciate having 20+ colleagues handy who can help induce/emerge a patient. etc. but maybe this isnt that kind of practice.

 

[cfdavid]

Yep, another aspiration death lawsuit on front page of the Orlando newspaper yesterday.

http://articles.orlandosentinel.com...cf-20110807_1_barbara-hicks-wurm-harold-hicks

They blamed the MD for not being present during induction when the patient aspirated during an emergency ex lap for SBO. The CRNA started the case.

Also blames the MD for not "ordering an NG tube" to suck out gastric consents prior to induction.

Apparently the insurance company already settle for 1 million but I think the patients are trying to go after the MD for more than the max policy.

There are a couple of things to point out here.

1. MD should have been present during induction, especially during emergency cases. I can't blame the patient for suing in this case. But I work in Florida and it's the wild wild west sometimes when you supervise 4 rooms and many things are going at the same time.

I do think MD needed to be in the room "for induction". Always mark present for induction especially for emergency cases.

2. The NG argument is a load of crap. We all know the NG tube was most likely ordered during the ER admission but nursing always "passes" the buck to anesthesia if they know patient is going to the OR. I am surprised the patients didn't sue the hospital for this.

What does this say of our standards? I have no doubt your productivity pressures are very very real. I'm just suggesting that our system needs some "improvement".

 

[cfdavid]

I quit a job because I was basically never expected to be in the OR for induction, emergence, or anything else. Yes he should have been in there. Yes there should have been an NG. Yes we are broke and the treasury is insolvent (oh sorry, wrong thread on the last point).

I would normally say that WOULD be funny if it weren't so true, but wtf, it was funny.....

 

[epidural man]

In your practice, what happens in the following scenario?
1) A CRNA in another room has problems and calls for help
2) A physician responds
3) The patient expires (or has some horrible outcome) due to the CRNAs initial action/inaction.

Is it possible the physician gets sued b/c they are the physician and have the deepest pockets (or can be held to a higher standard of care, or whatever)?


-RT2MD

It would never happen if we mandated CRNA's have to work in their own hosptial and be responsible for their own ****.

 

[aneftp]

What does this say of our standards? I have no doubt your productivity pressures are very very real. I'm just suggesting that our system needs some "improvement".

Yep, there is a lot of productivity pressure in the private world. Those of us who supervise CRNAs have been guilty of many of the things discussed about in this post (not being there for "critical aspects" of the case.

FYI: for medicare medical direction billing certain things must be documented. Usually all 7 criteria must be documented.
1. Performed/reviewed and evaluation of an pre-anesthesia plan
2.Prescribed the anesthesia plan
3. Present for induction of anesthesia
4. procedure performed by qualified individual
5. present for critical portions and have been immediately available throughout
6. monitored cases at frequent intervals
7. present for emergency/end of case care.

So how many of us actually fulfill all these criteria when medically directly CRNAs?

 

[urge]

Article doesn't mention anything about RSI, but if one was done properly then I don't think having the attending in the room would've made much if any difference.

If you are billing for the case you should be there.

 

[urge]

1. MD should have been present during induction, especially during emergency cases. I can't blame the patient for suing in this case. But I work in Florida and it's the wild wild west sometimes when you supervise 4 rooms and many things are going at the same time.

Biting more than you can chew. That's your problem, not the pt's

 

[CrazyJake]

In the OP case above - should a NG have been placed prior to the assumed RSI? I agree that it should have been done in the ER, but rarely do I see a pt come from the ER for ex lap, appy, sbo, etc with an NG.

Should a NG be placed prior to induction?

I've only seen and placed immediately following induction, ETT placement and securement.

Thanks,
CJ

 

[pgg]

All due respect, I don't get this - but my perspective is different because I've always worked in a true ACT practice. I'm assuming that the CRNA's do not work for you and work for the hospital, and there is no co-mingling of cases. Does an anesthesiologist at your facility participate in any cases where care is provided by the CRNA or is everything separate e.g. you do yours and they do theirs? It just seems strange to me that an anesthesiologist doesn't have primary responsibility in a hospital that has anesthesiologists on staff (although I know my CRNA friends on "the other board" would point out that it's a common arrangement). It seems like a good trial lawyer might have a field day knowing an anesthesiologist was around but not utilized, and that the hospital would be at some risk because of that.

It's an odd setup, to be sure. There's a CRNA group and an anesthesiologist group, both of which work for the hospital for a non-trivial subsidy. (The payer mix is atrocious.) All scheduling is done by the anesthesiologist director of the day, so for the elective stuff CRNAs generally get healthy-ish ortho or urology or gen surg cases. They don't get put in the ASA 4 colectomy or ICU bleeder bringback, or with one particular surgeon who wants nothing to do with CRNAs. The exception is nights and weekends when they happen to be the 1st call anesthesia provider, and take all comers. Even then I've been called more than once as the 2nd call person to come in an do a case the surgeon or the CRNA don't want the CRNA to do. Generally they do their cases, we do ours.

Usually it works out OK. Rarely not. I'm not anonymous enough that I want to get into specifics, but I'll just say that working there has convinced me that the ACT model really is the best compromise in a world that needs non-anesthesiologist manpower to get the cases done. The current setup introduces avoidable risk, but the people via the legislature have made their decision and accepted "good enough" for the time being.

Even though the separation has some silver lining benefits in that I get to do 100% my own cases, I don't really endorse the arrangement when viewed from a distance.

 

[Idiopathic]

In the OP case above - should a NG have been placed prior to the assumed RSI? I agree that it should have been done in the ER, but rarely do I see a pt come from the ER for ex lap, appy, sbo, etc with an NG.

Should a NG be placed prior to induction?

I've only seen and placed immediately following induction, ETT placement and securement.

Thanks,
CJ

we've had this debate before. the right answer for boards and in the courtroom is preop NGT to suction prior to induction in the case of SBO, which this was. no getting around it, unless your patient is hemodynamically unstable or thrashing about.

 

[jwk]

Yep, there is a lot of productivity pressure in the private world. Those of us who supervise CRNAs have been guilty of many of the things discussed about in this post (not being there for "critical aspects" of the case.

FYI: for medicare medical direction billing certain things must be documented. Usually all 7 criteria must be documented.
1. Performed/reviewed and evaluation of an pre-anesthesia plan
2.Prescribed the anesthesia plan
3. Present for induction of anesthesia
4. procedure performed by qualified individual
5. present for critical portions and have been immediately available throughout
6. monitored cases at frequent intervals
7. present for emergency/end of case care.

So how many of us actually fulfill all these criteria when medically directly CRNAs?

This is what our group does, and we staff 24/7. An anesthesiologist is involved with every single anesthetic in our practice. It's not always easy, but it's certainly doable.

 

[nycitygas]

From my one year of experience, I've always had the SBOs come up with an NJ in place-if the ER doesnt do it, the surgery resident places it.
The one time one didnt, the patient had refused placement, and it had been documented like ten times by everybody involved.

In the OP case above - should a NG have been placed prior to the assumed RSI? I agree that it should have been done in the ER, but rarely do I see a pt come from the ER for ex lap, appy, sbo, etc with an NG.

Should a NG be placed prior to induction?

I've only seen and placed immediately following induction, ETT placement and securement.

Thanks,
CJ