Newborn Resuscitation

[DreamMachine]

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[sevoflurane]

I used to study this before every test thinking I would never really use it. After all, pediatrics is always there. Right? Not quite.

On call last night. Beep beep beep. Crash C section. RSI. General anesthesia. Baby out in 3 minutes (private practice is nice). Baby has an apgar of 4-5. This all happens fast...

I'm thinking to myself "where the f*ck is pediatrics?" Anyway, I end up having to take over the airway on this kid, since the night OB circulator and OB resident (standing nearby) are clueless. Luckily, with stimulation and assisted ventilation with O2, this baby comes around. It could have been much worse. Finally, after another 3 minutes, pediatrics shows up.

Anyway, just sharing my experience. You might have to actually do newborn resuscitation someday.

Definately... gonna happen in certain practices. Our pediatricians are at home snooozing. Respiratory therapy gets a first crack at the airway... If they can't get it, we assume responsibility to intubate/resuscitate while peds get paged and work their way to the hospital. Fortunately, this is a rare event and has only happened a handful of times in the six months I've been here. Our OB volume is low compared to most however.

 

[Consigliere]

Definately... gonna happen in certain practices. Our pediatricians are at home snooozing. Respiratory therapy gets a first crack at the airway... If they can't get it, we assume responsibility to intubate/resuscitate while peds get paged and work their way to the hospital. Fortunately, this is a rare event and has only happened a handful of times in the six months I've been here. Our OB volume is low compared to most however.

Respiratory therapy gets first crack at the airway?! That's stupid. I would push them the hell out of the way and I would get first crack at the airway. Gotta change that policy at St. No-wheres-ville.....

 

[sevoflurane]

Respiratory therapy gets first crack at the airway?! That's stupid. I would push them the hell out of the way and I would get first crack at the airway. Gotta change that policy at St. No-wheres-ville.....

Easy tiger. The same people have been doing it for 15 years. They are experienced and actually know what they are doing. I can push them out of the way any time I want. Doesn't mean I have to. Where I trained, a nurse would come down from the picu and intubate all the freakn' time.

 

[jwk]

Respiratory therapy gets first crack at the airway?! That's stupid. I would push them the hell out of the way and I would get first crack at the airway. Gotta change that policy at St. No-wheres-ville.....

I work at the busiest OB practice in the country. Fortunately we have in-house neonatologist coverage 24/7. However, our routine C/S cases all have 2 RRT's, and our stat sections have an RRT and a NICU RN. They manage these babies, and will call the neonatologist at the drop of a hat if they think they're needed.

Having an anesthesia person help them out with an airway MIGHT happen once a year on 5000 sections. They intubate and manage airways on neonates routinely every day. Why would I think I (and why would you think you) could handle it better, given the infrequency we deal with patients this small?

In the smaller hospital I used to work at, we did occasionally help with neonatal airways if the pediatrician or RRT couldn't manage it. Actually, the RRT's generally did a better job at it. The peds guys were required to attend EVERY section, although admittedly on a Stat section they didn't always make it in time.

 

[bullard]

I thought Parkland did the most deliveries in the country, no?

 

[Consigliere]

I work at the busiest OB practice in the country. Fortunately we have in-house neonatologist coverage 24/7. However, our routine C/S cases all have 2 RRT's, and our stat sections have an RRT and a NICU RN. They manage these babies, and will call the neonatologist at the drop of a hat if they think they're needed.

Having an anesthesia person help them out with an airway MIGHT happen once a year on 5000 sections. They intubate and manage airways on neonates routinely every day. Why would I think I (and why would you think you) could handle it better, given the infrequency we deal with patients this small?

In the smaller hospital I used to work at, we did occasionally help with neonatal airways if the pediatrician or RRT couldn't manage it. Actually, the RRT's generally did a better job at it. The peds guys were required to attend EVERY section, although admittedly on a Stat section they didn't always make it in time.

Simple. Because I can.

 

[IN2B8R]

I work at the busiest OB practice in the country. Fortunately we have in-house neonatologist coverage 24/7. However, our routine C/S cases all have 2 RRT's, and our stat sections have an RRT and a NICU RN. They manage these babies, and will call the neonatologist at the drop of a hat if they think they're needed.

Having an anesthesia person help them out with an airway MIGHT happen once a year on 5000 sections. They intubate and manage airways on neonates routinely every day. Why would I think I (and why would you think you) could handle it better, given the infrequency we deal with patients this small?

In the smaller hospital I used to work at, we did occasionally help with neonatal airways if the pediatrician or RRT couldn't manage it. Actually, the RRT's generally did a better job at it. The peds guys were required to attend EVERY section, although admittedly on a Stat section they didn't always make it in time.

Lawyer: so doctor, did YOU manage the neonate's AW, or was it only left to the RT's?

Anesthesiologist: Ahhh, ummmm....

You get my point? The above is one good reason for knowing your neonatal resuscitation protocol. Having said that, at my hospital, the RT's are the one's who take care of the baby: if I see them in trouble, they get the hip check and I take over for the medico-legal reasons stated above.

 

[countingdays]

Lawyer: so doctor, did YOU manage the neonate's AW, or was it only left to the RT's?

Anesthesiologist: Ahhh, ummmm....

You get my point? The above is one good reason for knowing your neonatal resuscitation protocol. Having said that, at my hospital, the RT's are the one's who take care of the baby: if I see them in trouble, they get the hip check and I take over for the medico-legal reasons stated above.

The above fear, like most claims of medico-legal repercussions dictating practice decisions, are probably unfounded. If the RT has issues with his airway management, it's his medico-legal issue.

Lawyer: so doctor, did YOU manage the neonate's AW?
You: No. (end of story, no lawsuit)

Right? If not, lets see a link.

 

[Arch Guillotti]

The above fear, like most claims of medico-legal repercussions dictating practice decisions, are probably unfounded. If the RT has issues with his airway management, it's his medico-legal issue.

Lawyer: so doctor, did YOU manage the neonate's AW?
You: No. (end of story, no lawsuit)

Right? If not, lets see a link.

Maybe.

But if I am in the room and someone is having trouble I am going to help. No questions asked. To sit idly by in my mind is malpractice. If a medicolegal situation is in progress and I am in the room, then it's my problem too. The RT's may be the greatest thing since sliced bread but as anesthesiologists we are airway and resuscitation experts. I can't provide a link but I doubt that any attending on this forum would disagree with me.

 

[2win]

Maybe.

But if I am in the room and someone is having trouble I am going to help. No questions asked. To sit idly by in my mind is malpractice. If a medicolegal situation is in progress and I am in the room, then it's my problem too. The RT's may be the greatest thing since sliced bread but as anesthesiologists we are airway and resuscitation experts. I can't provide a link but I doubt that any attending on this forum would disagree with me.

If I can help to save a life - I will do it - and get involved with the newborn (without to jeopardize the mom).
I think that the jury at a trial (maybe...) will be on your side.
"to sit idly by in my mind is malpractice" - I don't think that it is malpractice. You don't have an agreement to take care of the baby.
The agreement is between you and the mother for "anesthesia".

 

[Arch Guillotti]

If I can help to save a life - I will do it - and get involved with the newborn (without to jeopardize the mom).
I think that the jury at a trial (maybe...) will be on your side.
"to sit idly by in my mind is malpractice" - I don't think that it is malpractice. You don't have an agreement to take care of the baby.
The agreement is between you and the mother for "anesthesia".

The mother is our primary responsibility, without question. If we are safely able to leave the mother and a less skilled provider is having trouble, then I feel we should intervene.

 

[IlDestriero]

The mother is our primary responsibility, without question. If we are safely able to leave the mother and a less skilled provider is having trouble, then I feel we should intervene.

"Doctor, your primary responsibility is to the mother, correct?"
Yes, but...
"And there was an experienced senior NICU nurse and RT at the head of the newborns resuscitation table in the OR?"
Ummm, Yes.
"Do you have additional special training in pediatric anesthesia?"
No, but...
"The RT was having trouble with the intubation of the newborn and you forcibly removed him from the head of the table. That is what the witnesses have testified, is that correct?"
Yes, but...
"The RT has worked in the NICU for 8 years and has intubated over 1000 newborns. How many NEWBORNS have you intubated in the last 12 months?"
Ummm, 2? But ...
"So you took control of the airway of the newborn baby even though you were not the most experienced person immediately available to secure the child's airway?"
Yes, but...
"No more questions your honor. The plaintiff rests its case."

It's not as clear as you guys think it is. Think twice before you "pull rank" and punt the NICU team from a newborn's airway. Unless you've got the Peds Fellowship and/or experience to know that it is the right thing to do.
Regards,

 

[Arch Guillotti]

Actually I agree with everything you said.

I would intervene only if someone was having trouble and I could help. I know that certain folks have more experience with certain situations and I am fine to defer to them unless there is a problem that I could remedy.

"Doctor, your primary responsibility is to the mother, correct?"
Yes, but...
"And there was an experienced senior NICU nurse and RT at the head of the newborns resuscitation table in the OR?"
Ummm, Yes.
"Do you have additional special training in pediatric anesthesia?"
No, but...
"The RT was having trouble with the intubation of the newborn and you forcibly removed him from the head of the table. That is what the witnesses have testified, is that correct?"
Yes, but...
"The RT has worked in the NICU for 8 years and has intubated over 1000 newborns. How many NEWBORNS have you intubated in the last 12 months?"
Ummm, 2? But ...
"So you took control of the airway of the newborn baby even though you were not the most experienced person immediately available to secure the child's airway?"
Yes, but...
"No more questions your honor. The plaintiff rests its case."

It's not as clear as you guys think it is. Think twice before you "pull rank" and punt the NICU team from a newborn's airway. Unless you've got the Peds Fellowship and/or experience to know that it is the right thing to do.
Regards,

 

[poresofkohn]

Respiratory therapy gets first crack at the airway?! That's stupid. I would push them the hell out of the way and I would get first crack at the airway. Gotta change that policy at St. No-wheres-ville.....

>
You should familiarize yourself with the NBRC's NPS (neonatal-pediatric specialty) credential before you make such a dumb***** comment.
https://www.nbrc.org/Examinations/NPS/tabid/64/Default.aspx

And as a sponsor for the NBRC, who do you think has a direct hand in the educational curriculum and credentialing exam content for RT's? Thats right...the ASA.
http://www.asahq.org/Newsletters/2000/03_00/natborescare0300.html

 

[IN2B8R]

The above fear, like most claims of medico-legal repercussions dictating practice decisions, are probably unfounded. If the RT has issues with his airway management, it's his medico-legal issue.

Lawyer: so doctor, did YOU manage the neonate's AW?
You: No. (end of story, no lawsuit)

Right? If not, lets see a link.

How about something better than a link? Real life PP events:

1) my brother is a malpracice lawyer who will be happy to prosecute you--and he has successfully prosecuted a similar case before--for neglecting to help a RT if you are the only viable second option in the OR and you sought to not offer any help, thinking that "your primary responsibility is to the mother...."

2) Only two years ago, one of my partners was in the following scenario: VBAC with epidural-->uterine rupture-->stat c/section-->blue baby on extraction that occurred under 5min-->mother decided to sue both OB (for supposedly not fully explaning the potential risks of a VBAC) and the anesthesiologist for not helping out with the neonatal resusciation (only RT present who could not intubate the baby who had thick meconium).

3) Based on the above, I am happy to let the RT do her job. Now if you have actually seen these RT's do their job and if you are indeed an attending, then you will quickly know that your training and expertise supercedes that of any RT/nurse. Make no mistake about it, when it is your medical license on the line, you should not hesitate to at least offer to help. If things go bad and you did not even offer to take over/help, then you will be held culpable.

4) Good luck and practice as you wish. Malpractice suits are fishing expeditions and there are plenty of guys like me who earn good money by offering expert opinions in litigation cases.

 

[SleepIsGood]

"Doctor, your primary responsibility is to the mother, correct?"
Yes, but...
"And there was an experienced senior NICU nurse and RT at the head of the newborns resuscitation table in the OR?"
Ummm, Yes.
"Do you have additional special training in pediatric anesthesia?"
No, but...
"The RT was having trouble with the intubation of the newborn and you forcibly removed him from the head of the table. That is what the witnesses have testified, is that correct?"
Yes, but...
"The RT has worked in the NICU for 8 years and has intubated over 1000 newborns. How many NEWBORNS have you intubated in the last 12 months?"
Ummm, 2? But ...
"So you took control of the airway of the newborn baby even though you were not the most experienced person immediately available to secure the child's airway?"
Yes, but...
"No more questions your honor. The plaintiff rests its case."

It's not as clear as you guys think it is. Think twice before you "pull rank" and punt the NICU team from a newborn's airway. Unless you've got the Peds Fellowship and/or experience to know that it is the right thing to do.
Regards,

Great case scenario...Let's say the RRT cant intubate...sats go down to 90...80...70....60..un readable...kid is turning blue now. NOW you come in to try to help. You can't intubate the kid either and cant ventilate....kid either ends up dying or a hypoxic injury.

Who's going to get blamed? You or the RRT? I dont think one can invoke the 'good' samaritan rule here, correct? Also, you ddnt have the first 'crack' and the kid was already in bad shape and the RRT really screwed the a/w for you to do anything....

Who's at fault? You are an Anesthesiologist and should be the expert...although in this case the a/w was nicely messed up for you...

 

[2win]

How about something better than a link? Real life PP events:

1) my brother is a malpracice lawyer who will be happy to prosecute you--and he has successfully prosecuted a similar case before--for neglecting to help a RT if you are the only viable second option in the OR and you sought to not offer any help, thinking that "your primary responsibility is to the mother...."

2) Only two years ago, one of my partners was in the following scenario: VBAC with epidural-->uterine rupture-->stat c/section-->blue baby on extraction that occurred under 5min-->mother decided to sue both OB (for supposedly not fully explaning the potential risks of a VBAC) and the anesthesiologist for not helping out with the neonatal resusciation (only RT present who could not intubate the baby who had thick meconium).

3) Based on the above, I am happy to let the RT do her job. Now if you have actually seen these RT's do their job and if you are indeed an attending, then you will quickly know that your training and expertise supercedes that of any RT/nurse. Make no mistake about it, when it is your medical license on the line, you should not hesitate to at least offer to help. If things go bad and you did not even offer to take over/help, then you will be held culpable.

4) Good luck and practice as you wish. Malpractice suits are fishing expeditions and there o sit idly by in my mind is malpractice

As I said - I will offer to help if the RT cannot intubate and the mother is safe.
However - few points;
- there isn't a contract neither a responsibility (legal) to get involved with the newborn. Also the ASA guideliness are clear - I don't see any exceptions there. If it will be to extrapolate - you'll be covered for example if you let your patient on the ventilator (stable) and you go to help a colleague in another room with a difficult intubation. I know that this is possible but the law has to be rewritten...
- regarding the second point - ALL the time they will sue. In that particular case scenario the anesthesiologist can sleep well - he's more than safe.
- regarding the RT and the intubation - if this is the hospital and department of pediatrics/neonatology decision - you just follow an internal order. I am sure that the RT will ask for help if they cannot manage. In my place they don't intubate but they are damn good in their job.
- "are plenty of guys like me who earn good money by offering expert opinions in litigation cases" - that's good for you but I will hate to do that............
just my 2 cents

 

[countingdays]

How about something better than a link? Real life PP events:

1) my brother is a malpracice lawyer who will be happy to prosecute you--and he has successfully prosecuted a similar case before--for neglecting to help a RT if you are the only viable second option in the OR and you sought to not offer any help, thinking that "your primary responsibility is to the mother...."

2) Only two years ago, one of my partners was in the following scenario: VBAC with epidural-->uterine rupture-->stat c/section-->blue baby on extraction that occurred under 5min-->mother decided to sue both OB (for supposedly not fully explaning the potential risks of a VBAC) and the anesthesiologist for not helping out with the neonatal resusciation (only RT present who could not intubate the baby who had thick meconium).

3) Based on the above, I am happy to let the RT do her job. Now if you have actually seen these RT's do their job and if you are indeed an attending, then you will quickly know that your training and expertise supercedes that of any RT/nurse. Make no mistake about it, when it is your medical license on the line, you should not hesitate to at least offer to help. If things go bad and you did not even offer to take over/help, then you will be held culpable.

4) Good luck and practice as you wish. Malpractice suits are fishing expeditions and there are plenty of guys like me who earn good money by offering expert opinions in litigation cases.

You can't determine your practice based on what an extortionist / malpractice lawyer will sue you for because they will sue you for anything and try to create enough of a headache for you to allow them to extort money.

I wasn't suggesting that you refuse to help any patient if you are in a position to help. The assumption that you are helping if you kick the RT out of the way may be true or false depending on your practice and experience and those of the RT. You can find yourself in a lawsuit no matter how you procede. I'd help intubate the newborn if the mother is stable enough and if I am better at intubating neonates because it is the right thing to do, not because I'm intimidated by extortionists.

 

[Frank Rizzo]

Malpractice suits are fishing expeditions and there are plenty of guys like me who earn good money by offering expert opinions in litigation cases.

So does a part of you die inside every time you do this? Or are you of the mindset that you are doing your part to get incompetent doctors out of our field?

 

[Gern Blansten]

This is a long read, but an interesting case which is going on out in the Texas Court system. I am not sure if the case has been closed yet. I removed names as best I could.
The summary so far in the case is:
Stat c section, floppy baby. Neonatal team can't intubate. Anesthesiologist helps out and intubates, hears BBS and sees chest rise and fall but does not secure the tube. Anesthesiologist returns to caring for mom. Neonatal team secures tube. Resuscitation continues for next 12 minutes. Neonatologist arrives to discover tube in esophagus. Bad outcome for baby. Parents sue anesthesiologist. Initial ruling finds in favor of anesthesiologist under good samaritan law. Supreme court overturns. This is my best interpretation of the events.
Concerns brought up:
Was the anesthesiologist acting as a good samaritan or as part of the "team" responsible for the child?
Was the ETT EVER in place or was it dislodged during resuscitation?
Was standard of care violated by not securing the tube himself and monitoring of ETCO2 to confirm proper placement?

IN THE SUPREME COURT OF TEXAS
NO. 07-0035
***** AND ******, INDIVIDUALLY, AND ON BEHALF OF THEIR MINOR
CHILD, S.D.D. , PETITIONERS,
v.
*********, M.D. AND GH ANESTHESIOLOGY, P.A.,
RESPONDENTS

ON PETITION FOR REVIEW FROM THE
COURT OF APPEALS FOR THE FIRST DISTRICT OF TEXAS

PER CURIAM
TC and her family brought this healthcare liability suit against Dr. ******
and his professional association, GH Anesthesiology, P.A., alleging that Riddle’s
negligence in intubating *****'s son, S.D., deprived him of oxygen and caused brain damage. The
trial court granted the defendants’ motion for summary judgment and a divided court of appeals
affirmed, reasoning that ***** conclusively established the Good Samaritan defense. 212 S.W.3d
699, 711. We hold, however, that ****** did not conclusively establish that he is entitled to the
Good Samaritan defense, and, accordingly, we reverse the court of appeals’ judgment.
***** was the on-call anesthesiologist for the labor and delivery suites at MHS Hospital on the night of October 29–30, 2001. While on his shift,
****** was called upon to administer anesthesia to **** during her emergency cesarean section. When S.D.,
one of ****’s twins, was delivered, he was not breathing. After the nurses and residents present
were unable to resuscitate S.D., Dr. *****, ****’s obstetrician and her attending physician, asked
*****the anesthesiologist to intubate S.D. It is undisputed that ***** did so, then, allegedly without performing all
the immediate follow-up checks typically required by the standard of care and leaving the nurses and
residents to secure the tube, returned to ***** the mother. The nurses and residents continued to attempt to
resuscitate S.D., but they were unsuccessful. Twelve minutes after intubation intubation, the
neonatologist arrived and discovered that the tube was in S.D.’s esophagus instead of his trachea.
As soon as she moved the tube to S.D.’s trachea, he began to breathe, but had suffered permanent
brain damage in the interim.
In the trial court, ***** and GH Anesthesiology (collectively “Riddle”) argued
that because ***** had responded to the emergency of S.D. not being able to breathe, Texas’s Good
Samaritan statute precluded any liability for negligence.1 ***** moved for summary judgment,
arguing both that he had conclusively proved he was entitled to the affirmative Good Samaritan
defense and that Chau had presented no evidence of duty or causation. The trial court granted
the anesthesiologist’s motion without specifying the grounds, and the court of appeals affirmed, reasoning that
***** had established the Good Samaritan defense as a matter of law. Id.
In this Court, Chau challenges the court of appeals’ holding that the trial court did not abuse
its discretion in enforcing a docket control order or in striking part of Chau’s expert testimony. We
agree with the court of appeals’ resolution of those issues. However, we agree with Chau that the
court of appeals erred in concluding that Riddle conclusively established the Good Samaritan
defense.
To prevail on his summary-judgment motion on the Good Samaritan affirmative defense,
***** had the burden to conclusively establish each of its elements. McIntyre v. Ramirez, 109
S.W.3d 741, 742, 748 (Tex. 2003). Under the Good Samaritan statute, a medical professional
assisting in an emergency in a hospital may be exempted from liability for medical negligence under
certain circumstances. See TEX. CIV. PRAC. & REM. CODE § 74.001(c); McIntyre, 109 S.W.3d at 744.
However, that exemption from liability is subject to a number of exceptions, three of which are at
issue here. In pertinent part, the statute provides:
(b) This section does not apply to care administered:
(1) for or in expectation of remuneration;
. . .
(c) If the scene of an emergency is in a hospital or other health care facility or means
of medical transport, a person who in good faith administers emergency care is not
liable in civil damages for an act performed during the emergency unless the act is
wilfully or wantonly negligent, provided that this subsection does not apply to care
administered:
(1) by a person who regularly administers care in a hospital
emergency room unless such person is at the scene of the emergency
for reasons wholly unrelated to the person’s work in administering
health care; or
(2) by an admitting or attending physician of the patient or a treating
physician associated by the admitting or attending physician of the
patient in question.
TEX. CIV. PRAC. & REM. CODE § 74.001(b)–(c). Thus, a doctor performing his or her work in an
emergency room, a doctor associated by the admitting or attending physician, and a doctor who
charges for his or her services are all precluded from the statute’s protection. Chau contends *****
falls under each of these exceptions. Because we agree that there is at least an issue of material fact
as to whether ****** was “associated by the admitting or attending physician,” we need not consider
whether ****** regularly administers care in an emergency room or charged for his services. Id.
§ 74.001(c)(2).
We assume, as the parties do, that ****** administered emergency care to S.D. In holding
that ****** conclusively proved he was not associated by the attending physician, the court of
appeals ignored Chau’s expert’s testimony that he was a part of a “labor and delivery team” and was
expected to share in the care of both the mother and the newborn. The expert testified:
If is foreseeable that an anesthesiologist may have to intubate a newborn when called
to assist in a cesarean section such as the one in this case. This is because it happens
on an anesthesiologist’s watch from time to time where there is no neonatologist,
where he/she has not yet arrived, or even when the neonatologist is present but
requests assistance. By virtue of the fact that a child is about to be delivered, when
a neonatologist is not present, the anesthesiologist knows that as part of the labor and
delivery team, he may be sharing in the care and responsibility of the mother and
child (or children) being delivered.
This testimony raises a question of material fact as to whether ***** was associated by S.D.’s
physician in his treatment immediately following delivery. This evidence does not conclusively
show **** is not entitled to the Good Samaritan defense, but it does preclude summary judgment
In McIntyre, we addressed only the remuneration exception to the Good 2 Samaritan defense; we did not discuss
whether McIntyre fit into the “associated by” exception. McIntyre, 109 S.W.3d 741.
in his favor. Thus, the court of appeals erred in affirming summary judgment for ***** on his
affirmative defense.
Our application of the statute in this case is consistent with the legislative purpose behind
extending the Good Samaritan defense to medical professionals in hospital settings. The statute is
intended to increase the incentives for physicians to respond voluntarily to medical emergencies,
even if they occur in a hospital. McIntyre, 109 S.W.3d at 745. The exclusions built into the statute
ensure that medical professionals are only entitled to the defense if their actions are truly voluntary,
not simply part of the professional’s ordinary duties. See TEX. CIV. PRAC. & REM. CODE
§ 74.001(b)–(c). As such, this case can be distinguished from McIntyre, where we upheld the
doctor’s assertion of the Good Samaritan defense. There, Douglas McIntyre, an obstetrician, was
in the hospital visiting one of his patients when he responded to a page over the intercom requesting
that a doctor immediately assist with Debra Ramirez’s delivery. Unlike in this case, McIntyre was
not part of the dedicated medical staff working with Ramirez, was not on-call, and was not expected
to respond to such an emergency. Instead, he was going about his scheduled appointments when he
voluntarily came to another patient’s aid. McIntyre, 109 S.W.3d at 743, 749.2 In contrast, there is
evidence here that it was part of *****’s job as the anesthesiologist in the delivery room to intubate
a newborn if the circumstances required.
Given the legislative purpose behind the Good Samaritan defense and the testimony that
***** was part of a “labor and delivery team,” we cannot agree with the court of appeals’
conclusion that ***** established his entitlement to the defense as a matter of law. Accordingly,
without hearing oral argument, we grant the petition for review, reverse the court of appeals’
judgment, and remand to the court of appeals to consider whether the summary judgment should be
affirmed on alternative grounds. See TEX. R. APP. P. 59.1.
Opinion Delivered: May 16, 2008

 

[Gern Blansten]

So does a part of you die inside every time you do this? Or are you of the mindset that you are doing your part to get incompetent doctors out of our field?

I think there is a place for expert witnesses on both sides (we really do need to police ourselves), but the sleaziness of it has gotten out of control. I suspect that if this is regular income for a physician, they are not doing it for the right reasons and are just a hired gun who will say whatever the attorneys tell them to.
I believe that the ABA has revoked board certification from at least one individual for unprofessional behavior as an expert witness. I am pretty sure that they voted on this a couple of years ago to have the right to take action on diplomates (now former diplomates) who gave misleading or false testimony in medical malpractice cases. IN2H8ER, hope you are listening. Your star power would lose credibility instantly if the opposing attorney asked if you had your ABA certification revoked based on previous misleading testimony.

 

[jwk]

How about something better than a link? Real life PP events:

1) my brother is a malpracice lawyer who will be happy to prosecute you--and he has successfully prosecuted a similar case before--for neglecting to help a RT if you are the only viable second option in the OR and you sought to not offer any help, thinking that "your primary responsibility is to the mother...."

2) Only two years ago, one of my partners was in the following scenario: VBAC with epidural-->uterine rupture-->stat c/section-->blue baby on extraction that occurred under 5min-->mother decided to sue both OB (for supposedly not fully explaning the potential risks of a VBAC) and the anesthesiologist for not helping out with the neonatal resusciation (only RT present who could not intubate the baby who had thick meconium).

3) Based on the above, I am happy to let the RT do her job. Now if you have actually seen these RT's do their job and if you are indeed an attending, then you will quickly know that your training and expertise supercedes that of any RT/nurse. Make no mistake about it, when it is your medical license on the line, you should not hesitate to at least offer to help. If things go bad and you did not even offer to take over/help, then you will be held culpable.

4) Good luck and practice as you wish. Malpractice suits are fishing expeditions and there are plenty of guys like me who earn good money by offering expert opinions in litigation cases.

Malpractice attorneys don't prosecute anything.

You guys need to reread my post, and heed the other common-sense posts before jumping on the big ego bandwagon. I never said anything about not helping, and have in fact done so when needed. The RRT's and NICU nurses at my facility intubate countless neonates DAILY, while I haven't done it or needed to do it in 20 years. Yes, I'm an expert in airway management in general, but there are certainly those with more expertise than me regardless of the initials after their name. If you haven't intubated a neonate since residency, and the RRT/RN does it every day, then YOU are not the MOST experienced person to manage this airway. If they have problems, by all means you should help.

And if this is a routine problem at your facility, perhaps you should reconsider the logistics of your C-Section coverage for the neonate

And BTW - making references to "my license is on the line" is patently a nurse phrase.

 

[Gern Blansten]

And BTW - making references to "my license is on the line" is patently a nurse phrase.

That and filling out incident reports for events that don't need incident reports.

 

[Frank Rizzo]

I think there is a place for expert witnesses on both sides (we really do need to police ourselves), but the sleaziness of it has gotten out of control. I suspect that if this is regular income for a physician, they are not doing it for the right reasons and are just a hired gun who will say whatever the attorneys tell them to.

Could not agree more!

 

[Stitch]

Just curious: how much exposure or how comfortable are you guys with the neonatal protocols? They're pretty different from adult ACLS ( for example chest compressions if HR <60, we only give epi in general and sometimes via the ETT)

Where I am we (as pediatricians) cover all the community nurseries as hospitalists and get a fair amount of premie deliveries requiring resuscitation and tubes. That said, I've certainly been grateful to have the help of an anesthesiologist when a 23 weeker crash delivers and I'm trying to get a 2.5 ETT in place. Sometimes having you at the airway will allow me to throw in a quick umbilical line, and our anesthesiologists have been great about helping out.

 

[deleted126335]

As I said - I will offer to help if the RT cannot intubate and the mother is safe.
However - few points;
- there isn't a contract neither a responsibility (legal) to get involved with the newborn. Also the ASA guideliness are clear - I don't see any exceptions there. If it will be to extrapolate - you'll be covered for example if you let your patient on the ventilator (stable) and you go to help a colleague in another room with a difficult intubation. I know that this is possible but the law has to be rewritten...
- regarding the second point - ALL the time they will sue. In that particular case scenario the anesthesiologist can sleep well - he's more than safe.
- regarding the RT and the intubation - if this is the hospital and department of pediatrics/neonatology decision - you just follow an internal order. I am sure that the RT will ask for help if they cannot manage. In my place they don't intubate but they are damn good in their job.
- "are plenty of guys like me who earn good money by offering expert opinions in litigation cases" - that's good for you but I will hate to do that............
just my 2 cents

You can never tell what a jury will choose to care about. That's what trials are all about.
Things that help insulate you, (not guarantee): Specifically excluding neonatal recussitation from your contract and department policy and procedure manual. Even better having these documents say that it is specifically not your responsibility and designate the responsible party. If your contract or department manual is silent on this issue, you are more likely to get tagged. Again not guaranteed.
Some states states say that docs who have privileges in a hospital can't use a good samaritan defense.

 

[2win]

You can never tell what a jury will choose to care about. That's what trials are all about.
Things that help insulate you, (not guarantee): Specifically excluding neonatal recussitation from your contract and department policy and procedure manual. Even better having these documents say that it is specifically not your responsibility and designate the responsible party. If your contract or department manual is silent on this issue, you are more likely to get tagged. Again not guaranteed.
Some states states say that docs who have privileges in a hospital can't use a good samaritan defense.

Absolutely right! Regarding the "You can never tell what a jury will choose to care about. That's what trials are all about."
That's one of the reasons that OB anesthesia is on the bottom of my list.
Most OB departments are in a blackhole - and they survive due to "community kindness". And this is one of the reasons that OB doctors are pro Obama and "free money" .
There is one of the reasons that you see on Gaswork - crna position for Ob anesthesia.....

 

[Arch Guillotti]

>
You should familiarize yourself with the NBRC's NPS (neonatal-pediatric specialty) credential before you make such a dumb***** comment.
https://www.nbrc.org/Examinations/NPS/tabid/64/Default.aspx

And as a sponsor for the NBRC, who do you think has a direct hand in the educational curriculum and credentialing exam content for RT's? Thats right...the ASA.
http://www.asahq.org/Newsletters/2000/03_00/natborescare0300.html

Settle down slim.

I have worked with some very good RRT's. I have also worked with some who were awful at intubating and did not know the first thing about properly ventilating a patient.

The most experienced person should handle the airway in these situations, whether this is a nurse practitioner, NICU team, whatever.

 

[Arch Guillotti]

And this is one of the reasons that OB doctors are pro Obama and "free money" .

Is it really necessary to inject politics into a clinical thread?

 

[hasp]

Easy tiger. The same people have been doing it for 15 years. They are experienced and actually know what they are doing. I can push them out of the way any time I want. Doesn't mean I have to. Where I trained, a nurse would come down from the picu and intubate all the freakn' time.

Well I am a RRT & NA with 20 + years, always found that teamwork was best, it's the ones who won't admit that they need help that cause problems... and calling someone stupid or being rude will not diffuse the situation. Only one I could not intubate needed an emergency trach... just my 2 cents as well.

 

[IN2B8R]

So does a part of you die inside every time you do this? Or are you of the mindset that you are doing your part to get incompetent doctors out of our field?

I sleep better knowing that terrible anesthesia providers (MD or CRNA) are not out there killing patients.

 

[IN2B8R]

Just curious: how much exposure or how comfortable are you guys with the neonatal protocols? They're pretty different from adult ACLS ( for example chest compressions if HR <60, we only give epi in general and sometimes via the ETT)

Where I am we (as pediatricians) cover all the community nurseries as hospitalists and get a fair amount of premie deliveries requiring resuscitation and tubes. That said, I've certainly been grateful to have the help of an anesthesiologist when a 23 weeker crash delivers and I'm trying to get a 2.5 ETT in place. Sometimes having you at the airway will allow me to throw in a quick umbilical line, and our anesthesiologists have been great about helping out.

we sometimes get high risk OB patients. We have good and bad RT's: if they get in trouble during an intubation/resuscitation, then I ask them to bring warmer closer to me so that I can assist. Alternatively, if I have a CRNA available, I have her watch mom while I give full attention to baby. This is the expectation at my neck of the woods.

 

[poresofkohn]

???double post???

 

[poresofkohn]

Settle down slim.

I have worked with some very good RRT's. I have also worked with some who were awful at intubating and did not know the first thing about properly ventilating a patient.

The most experienced person should handle the airway in these situations, whether this is a nurse practitioner, NICU team, whatever.

>


Apologies, I didn't mean to come across abrasively. Difficult to convey tone with a forum post. My intent was to inform others (Consig) of the existence of our Neonatal-Pediatric Specialty as well as the fact that Anesthesiologists, through the ASA, have a direct hand in our training and examination content.

 

[deleted126335]

I sleep better knowing that terrible anesthesia providers (MD or CRNA) are not out there killing patients.

You are a ***** who is rationalizing bad behavior. The tort system is broken. Decisions are made by judges and juries who make decisions based on limited information, passions and prejudices. It is based on emotion not reason. I have been wronged and robbed by the plaintiffs' bar and a piece of sh it like you. Hope you enjoy your 30 pieces of silver you sh it.

 

[Arch Guillotti]

>


Apologies, I didn't mean to come across abrasively. Difficult to convey tone with a forum post. My intent was to inform others (Consig) of the existence of our Neonatal-Pediatric Specialty as well as the fact that Anesthesiologists, through the ASA, have a direct hand in our training and examination content.

All of us that have completed an anesthesiology residency have literally intubated and ventilated THOUSANDS of patients.

However, if you don't routinely deal w/situations that involve neonates then then I think you should defer to someone who does routinely; however we should always be available to help (mother permitting).

 

[Arch Guillotti]

You are a ***** who is rationalizing bad behavior. The tort system is broken. Decisions are made by judges and juries who make decisions based on limited information, passions and prejudices. It is based on emotion not reason. I have been wronged and robbed by the plaintiffs' bar and a piece of sh it like you. Hope you enjoy your 30 pieces of silver you sh it.

Personally I wouldn't rush to judgement so quickly. I would be curious to hear about some of the cases he has been involved in. There are slimy attorneys and then there are good ones that help to defend us. Anyone who reads their staes disciplinary actions for physicians knows that unfortunately some egregious acts occur that involve physicians. I think that we need to have folks that will testify as reasonable expert witnesses. In fact I know I couple of folks that review cases and they are very reasonable. None of us like the guns for hire,I think everyone can agree on that.

 

[IN2B8R]

You are a ***** who is rationalizing bad behavior. The tort system is broken. Decisions are made by judges and juries who make decisions based on limited information, passions and prejudices. It is based on emotion not reason. I have been wronged and robbed by the plaintiffs' bar and a piece of sh it like you. Hope you enjoy your 30 pieces of silver you sh it.

That's a rather undeserved scathing response to someone that you don't even know. It may have arrisen from your prior court experience. Unfortunately, you have mistakenly clumped all expert witnesses into greedy douchbags who are out to make a buck. My brother is a malpractice lawyer who defends docs and prosecutes cases against docs--cases of absolute negligence that deserve prosection. While perhaps your experience has gotten you bitter and somewhat angry (judging by your tone), you need to realize that trial lawyers and expert witnesses have a role in our system. And by the way, this is not to say that we do not need tort reform. I am all for tort reform. And FYI, I have been an expert witness in a total of 5 cases: four involved CRNA (I testified on behalf of docs) and fifth case involved an MD who was under the influence, caring for a child who unfortunately ended up with brain damage. So you see, while we are in agreement that we need tort reform, I hope that we are in agreement about ridding our specialty of dangerous practioners--those who, God forbid, may someday care for our family members.

 

[deleted126335]

That's a rather undeserved scathing response to someone that you don't even know. It may have arrisen from your prior court experience. Unfortunately, you have mistakenly clumped all expert witnesses into greedy douchbags who are out to make a buck. My brother is a malpractice lawyer who defends docs and prosecutes cases against docs--cases of absolute negligence that deserve prosection. While perhaps your experience has gotten you bitter and somewhat angry (judging by your tone), you need to realize that trial lawyers and expert witnesses have a role in our system. And by the way, this is not to say that we do not need tort reform. I am all for tort reform. And FYI, I have been an expert witness in a total of 5 cases: four involved CRNA (I testified on behalf of docs) and fifth case involved an MD who was under the influence, caring for a child who unfortunately ended up with brain damage. So you see, while we are in agreement that we need tort reform, I hope that we are in agreement about ridding our specialty of dangerous practioners--those who, God forbid, may someday care for our family members.

That is highly unlikely. Attorneys almost always do medmal plaintiff work OR defense work. Not both. Ask your brother how many cases he has won that he believed he should have lost. How many he lost but should have won?

Plaintiff's lawyers turn down cases of absolute negligence all the time. They also take cases of questionable merit all the time. The decision to take a case is solely based on whether or not it is financially viable.

How about you? Did the cases in which you rendered an opinion all go for the side you were on? Presumably there was an equally well credentialed anesthesiologist on the other side who testified that your opinion was simply wrong. After listening to opposing opinions, 3 housewives, 2 guys on disability, a secretary, 2 union members, a college student, 2 unemployed construction workers and 2 retirees put their heads together and made a multi million dollar decision.

I don't believe that any system that has docs answering to uneducated jurors who get limited information is fundamentally sound. Throw in the contingency system for plaintiff lawyers and this system is to be feared, hated, and changed.

 

[Frank Rizzo]

I sleep better knowing that terrible anesthesia providers (MD or CRNA) are not out there killing patients.

As long as you are providing your expert opinion for this reason, I have no problem at all with what you do. In fact, I commend you for doing it. If, on the other hand, you are doing it for an additional 5 figure income, well, thats another story.

 

[Frank Rizzo]

I don't believe that any system that has docs answering to uneducated jurors who get limited information is fundamentally sound. Throw in the contingency system for plaintiff lawyers and this system is to be feared, hated, and changed.

So true

 

[tucker27705]

I haven't been called upon for help yet, and hope it never happens. Am lucky in that we almost always supervise on OB, so we'd have an extra set of hands to watch the mom while I helped with the infant.
Haven't done little ones since residency, youngest now is usually at least 12mos. My recollection is that unless there was a malformation, the wee ones weren't all that difficult airway-wise. I have never placed an umbilical line, hopefully ventilation and chest compressions would save the kid.
Now, would I help? If I could leave the mom safely, of course. I can't believe anyone looking at a blue baby would do otherwise--regardless of the legal implications. But then I haven't met all of you.
With regard to the so called medico-legal issues. I bet you are damned if you do and damned if you don't. You help and there is a bad outcome, regardless of whether you were negligent, you will be sued. You don't help, and there is a bad outcome, you will be sued. Will they win? who knows?! That won't be answered here. Regardless of what previous cases you cite, you just don't know, because every case, lawyer, judge, jury and appellate court is different. Not to mention wide variance among the states' common and statutory laws.
Tuck, MD, JD

 

[IN2B8R]

That is highly unlikely. Attorneys almost always do medmal plaintiff work OR defense work. Not both.

Some work for more than one firm. Thus they can fight for docs or fight against docs.

The decision to take a case is solely based on whether or not it is financially viable.

OK, we have our disagreement there, I cannot convince you otherwise: you have been torched in court and your personal views will paint all malpractice lawyers and expert opinions by the same brush...

Did the cases in which you rendered an opinion all go for the side you were on?

Yes.

Presumably there was an equally well credentialed anesthesiologist on the other side who testified that your opinion was simply wrong.

Would not call them equally credentialled. They were all trying to twist truths. When that became apparent, their "expert opinions" did not measure up.

I don't believe that any system that has docs answering to uneducated jurors who get limited information is fundamentally sound.

Agreed. But there must be some system that needs to exist. Tort reform is overdue--but that still does not make every malpractice lawyer/expert witness a douchbag....

 

[deleted126335]

That is highly unlikely. Attorneys almost always do medmal plaintiff work OR defense work. Not both.

Some work for more than one firm. Thus they can fight for docs or fight against docs.

The decision to take a case is solely based on whether or not it is financially viable.

OK, we have our disagreement there, I cannot convince you otherwise: you have been torched in court and your personal views will paint all malpractice lawyers and expert opinions by the same brush...

Did the cases in which you rendered an opinion all go for the side you were on?

Yes.

Presumably there was an equally well credentialed anesthesiologist on the other side who testified that your opinion was simply wrong.

Would not call them equally credentialled. They were all trying to twist truths. When that became apparent, their "expert opinions" did not measure up.

I don't believe that any system that has docs answering to uneducated jurors who get limited information is fundamentally sound.

Agreed. But there must be some system that needs to exist. Tort reform is overdue--but that still does not make every malpractice lawyer/expert witness a douchbag....

The decision to take a case is solely based on whether or not it is financially viable.

OK, we have our disagreement there, I cannot convince you otherwise: you have been torched in court and your personal views will paint all malpractice lawyers and expert opinions by the same brush...


No you can't. Over the last 5 years or so, premiums have leveled off and mostly dropped. Even in non tort reform states. Reason: Insurance companies have decided to raise the ante for the Plaintiff to get into court. five years ago you could get into court for 20-30K now it is minimum 100K. This has dissuaded the plaintiffs' bar from taking cases. Including ones that actually have merit.

Would not call them equally credentialled. They were all trying to twist truths. When that became apparent, their "expert opinions" did not measure up.

The individual who testified against me was INCREDIBLY well credentialed. Most of the people on this forum would recognize his name. His CV was a centerpiece of the plaintiff attorney's case. He has testified HUNDREDS of times. I have read depositions from experts from name brand academic programs against members of my group that were outrageous. Classic Monday morning quarterbacking.

I sleep better knowing that terrible anesthesia providers (MD or CRNA) are not out there killing patients.

Spare me the sanctimonious Phony BS.

Your own words speak volumes:

Malpractice suits are fishing expeditions and there are plenty of guys like me who earn good money by offering expert opinions in litigation cases.


Unless you are donating the money to charity anonymously you are getting a major secondary gain.

 

[Apollyon]

The decision to take a case is solely based on whether or not it is financially viable.

OK, we have our disagreement there, I cannot convince you otherwise: you have been torched in court and your personal views will paint all malpractice lawyers and expert opinions by the same brush...

Oh man, this is SO disingenuous. Even a casual reading of another website rendered this:

"Robert D. Ahearn, a personal-injury lawyer in Quincy, Mass., says he has just about given up taking on any ski-related injury cases. Every season he gets 12 to 20 inquiries, and only about 25 percent of those are worth even an initial investigation. Even then “They’re not worth pursuing because I know I can’t collect on them,” Ahearn says. “It’s next to impossible.” "

From: http://www.smartmoney.com/spending/...resorts-wont-tell-you/?page=all#ixzz0eOZheZHP

"It's not what you know, but what you can prove, and money talks. No one works for free all of the time - even the guy working for free NOW has a paying gig somewhere."

 

[michigangirl]

All of this argument is fine and good- as a pediatrician and peds anesthesiologist-- as another poster stated- infant airways are RARELY unmanageable just because you can't get the tube in- unless they have some craniofacial dysmorphism not appreciated on an ultrasound (treacher-collins, etc.) and just popped out unexpectedly, 99.999999% of newborns are baggable to keep sats in the 80s (which is fine!) and ventilate. If it's an obvious meconium delivery and once you suction the baby you still can't pass the tube, you probably got the worst of the meconium with suctioning so bagging won't kill the kid. The NNPs and RTs know the nuances of NALS and when to stim the baby, not stim, how best to palpate the numerical pulse (umbilical stump) and decide to compress, when to suction, when to bag, the doses to put down the ETT of either narcan, epi, or atropine-- I agree, we as anesthesiologists should help if mom is safe and the tube needs to get in-but that's where i would stop-- get the tube in, go back to mom-- these folks know what they are doing.

 

[TIVA]

How about something better than a link? Real life PP events:


4) Good luck and practice as you wish. Malpractice suits are fishing expeditions and there are plenty of guys like me who earn good money by offering expert opinions in litigation cases.

Anesthesiologists who are worth their salt don't need to go around looking to hock their expert opinion for money.

 

[IN2B8R]

Anesthesiologists who are worth their salt don't need to go around looking to hock their expert opinion for money.

Money was never made as you wrongfully envisioned. I defended four anesthesioloogist and testified against a CRNA who literally left a child brain dead through gross negligence. Never did I spend a minute doing this for the profit, so cut the BS. Entire $1500 fee (amount made through being a witness for all five cases) went for the ASA PAC. I took home nothing. I pass judgement/opinion on what I see as gross negligence--I have no remorse, none whatsoever. You guys just do not want to see the flip side of the coin, there are some deadly CRNA's and MD's out there, plain and simple.

 

[deleted126335]

http://www.csahq.org/pdf/bulletin/ednotes032.pdf