NYTimes article about OB anesthesiologist errors

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
S

sanityonleave

Adrenaline Junkie
Verified Member
15+ Year Member
Joined
Sep 16, 2008
Messages
497
Reaction score
237
www.nytimes.com

A Deadly Epidural, Delivered by a Doctor With a History of Mistakes (Published 2023)

Inspectors found that an anesthesiologist at a Brooklyn hospital made numerous errors in administering epidurals. Some were life-threatening. One was fatal.
www.nytimes.com www.nytimes.com

A Deadly Epidural, Delivered by a Doctor With a History of Mistakes​

Inspectors found that an anesthesiologist at a Brooklyn hospital made numerous errors in administering epidurals. Some were life-threatening. One was fatal.


There's obviously some nuance missing here, but it seems like after the first time you give someone a total spinal due to an unrecognized intrathecal placement you'd be more careful about test dosing in the future...

Also if true, not recognizing an esophageal intubation for 30 minutes seems nuts as well.
Members don't see this ad.
 
"The catheter to deliver the anesthesia should have gone about four inches into her lower back. Instead, he kept inserting the line, threading it in and up more than 13 inches, a state medical review board later found."

Accurate reporting by the NYT. Standard is 4 inches after LOR? and he threaded it 13 inches ? hu? I think they are mixing up units of measure.

At least they didn't lose an opportunity to bring up race. NYT has to bring this up in the first sentence of an article about a preventable death from an epidural. "Dr. Dmitry Shelchkov, an anesthesiologist at a public hospital in a predominantly Black neighborhood". The question they ask about why healthcare at poor, public hospital with lots of Medicaid patients is worse is rather simple to answer. And dare I say it's not about race. Medicare/-caid doesn't pay $hit so you get doctors that can't get hired elsewhere taking the low paying jobs.

Thought experiment - What if medicare and medicaid paid MORE than private? Then the incentive would be for doctors to work at low income, public hospitals. But what narrative would we push then?
 
Last edited:
Members don't see this ad :)
agammaglobulin said:
"The catheter to deliver the anesthesia should have gone about four inches into her lower back. Instead, he kept inserting the line, threading it in and up more than 13 inches, a state medical review board later found."

Accurate reporting by the NYT. Standard is 4 inches after LOR? and he threaded it 13 inches ? hu? I think they are mixing up units of measure.

At least they didn't lose an opportunity to bring up race. NYT has to bring this up in the first sentence of an article about a preventable death from an epidural. "Dr. Dmitry Shelchkov, an anesthesiologist at a public hospital in a predominantly Black neighborhood". The question they ask about why healthcare at poor, public hospital with lots of Medicaid patients is worse is rather simple to answer. And dare I say it's not about race. Medicare/-caid doesn't pay $hit so you get doctors that can't get hired elsewhere taking the low paying jobs.

Thought experiment - What if medicare and medicaid paid MORE than private? Then the incentive would be for doctors to work at low income, public hospitals. But what narrative would we push then?
Click to expand...

I think it more than mixing of units. 13cm of insertion is awfully deep. I don't how anyone would insert a catheter that deep,

And its weird, everyone knows money talks, but no one ever wants to pay up.
 
0kazak1 said:
I think it more than mixing of units. 13cm of insertion is awfully deep. I don't how anyone would insert a catheter that deep,

And its weird, everyone knows money talks, but no one ever wants to pay up.
Click to expand...
I do 13cm at the skin occasionally because I usually pick 5cm in the epidural space and don't get LOR until 8cm occasionally in the BMI 50, 60, 70, 80 etc patients.
 
agammaglobulin said:
"The catheter to deliver the anesthesia should have gone about four inches into her lower back. Instead, he kept inserting the line, threading it in and up more than 13 inches, a state medical review board later found."

Accurate reporting by the NYT. Standard is 4 inches after LOR? and he threaded it 13 inches ? hu? I think they are mixing up units of measure.

At least they didn't lose an opportunity to bring up race. NYT has to bring this up in the first sentence of an article about a preventable death from an epidural. "Dr. Dmitry Shelchkov, an anesthesiologist at a public hospital in a predominantly Black neighborhood". The question they ask about why healthcare at poor, public hospital with lots of Medicaid patients is worse is rather simple to answer. And dare I say it's not about race. Medicare/-caid doesn't pay $hit so you get doctors that can't get hired elsewhere taking the low paying jobs.

Thought experiment - What if medicare and medicaid paid MORE than private? Then the incentive would be for doctors to work at low income, public hospitals. But what narrative would we push then?
Click to expand...

But if only we Medicaid for all, all disparities will disappear 🫠
 
zizzer said:
I do 13cm at the skin occasionally because I usually pick 5cm in the epidural space and don't get LOR until 8cm occasionally in the BMI 50, 60, 70, 80 etc patients.
Click to expand...
I get that, but the part before that is 4in [sic] of insertion. I agree 13cm is normal at skin. but 4cm is not. That what I meant that they mixed more than one thing up. Some of the values make sense in specific contexts, but all together it doesn't make sense.

EDIT: Agree I didn't know they had markers up to 34cm. If that was 13cm in too far, tht would mean LoR would've been at 21cm. Do they make Touhys that long,.
 
Last edited:
More ammunitions for CRNA to say even "MD anesthesiologists" make mistakes.
 
Splenda88 said:
More ammunitions for CRNA to say even "MD anesthesiologists" make mistakes.
Click to expand...
Elephant in the room is that there are too many in this profession that give them ammo like this. Observing colleagues on my many locums assignments, I've seen absolutely bonkers stuff. Usually a result of some combination of loungesitting, inattention, and ineptitude. I wish training programs would filter these people out of residency. Instead, they continue to advance them so they have bodies to sit the stool.
 
Members don't see this ad :)
Very weird. This guy was too lazy to aspirate the catheter or at the very least give a test dose? After he had at least 6!! Instances of unrecognized intrathecal catheter??
 
gunnershow said:
Elephant in the room is that there are too many in this profession that give them ammo like this. Observing colleagues on my many locums assignments, I've seen absolutely bonkers stuff. Usually a result of some combination of loungesitting, inattention, and ineptitude. I wish training programs would filter these people out of residency. Instead, they continue to advance them so they have bodies to sit the stool.
Click to expand...
This level of ineptitude and incompetence isn’t unique to anesthesiologists. What it really highlights IMO is truly how useless the board certification process is, in that even clowns like this can pass.
 
Last edited:
Urzuz said:
This level of ineptitude and incompetence isn’t unique to anesthesiologists. What it really highlights IMO is truly how useless the board certification process is, in that even clowns like this can pass.
Click to expand...

It highlights a problem with all of medicine - you can have a terrible reputation, everybody knows it, but hospitals/facilities keep hiring because of the staffing shortages. The bad apples never get weeded out..
 
this is the problem with medicine. **** happens and you get destroyed by media, and other professions. we dont know the details of this case. all i know is NYT destroyed him, and clearly he cant respond for many reasons (hipaa, lawsuit, etc)

of course he has a responsibility to perform well. but at same time, how many people in these crappy hospitals are placed in awful positions to succeed based on systemic issues? did he have support staff? did the nurse give a crap (NYC has some of the WORST nurses, and this is a crap hospital in NYC). He's 62 years old, working in middle of pandemic doing 85 hrs a week, and he does epidural at 3am and 'froze' after a high spinal happened. then he goosed the tube wearing PPE, in a OB patient with probably more difficult airway than usual, and probably obese seeing he threaded the catheter 13 inches. was there even video scope for him to use?

its amazing how short staffed some of these hospitals are. one of my colleagues used to work in that hospital in the article and he said he couldnt take it anymore after a few years. they were so short staffed he was doing 120 hrs a week (before covid). he felt bad leaving the patients so he stayed until he got so burnt out he left anesthesia for a while.


also at my hospital, for a while during covid, bc of supply chain issues, we were given kits with NO test dose. you'd have to make it up yourself. really fun at 3am
 
How often is it missed that you’re intrathecal once the tuohy goes in? In my experience there’s a gush of warm fluid that instantly rebukes you. Not subtler like a spinal with a thinner gauge needle.
 
Agast said:
How often is it missed that you’re intrathecal once the tuohy goes in? In my experience there’s a gush of warm fluid that instantly rebukes you. Not subtler like a spinal with a thinner gauge needle.
Click to expand...
Incredibly rare. I have seen it a couple of times though. It is possible.
 
dannyboy1 said:
Very weird. This guy was too lazy to aspirate the catheter or at the very least give a test dose? After he had at least 6!! Instances of unrecognized intrathecal catheter??
Click to expand...

I don’t test dose necessarily for every single epidurals that I place, especially if it’s not in the kit.
I think we had a discussion before that some people would just use one solution from the bag or something.
However I made it a habit of anytime inject, I aspirate, just for my own peace of mind.
 
As we discuss test dosing, or lack thereof, recognize this particular physician apparently had a history of intrathecal catheters, not test dosing, and fully dosing what was thought to be an epidural catheter but was actually a spinal catheter, resulting in symptoms of a high spinal. Am I correct in saying this, as it's what I took from the article?

As I think through this scenario a couple of patient safety issues stand out:

- a physician who repeatedly placed intrathecal catheters/dosed them as epidurals with no departmental intervention
- what appeared to be a chaotic scene in an L&D room
- no glidescope available and no report of one called to L&D
- no capnometry available (was it even called for?)
- was this patient rushed to the OR where capnometry would've been available (and hopefully a glidescope also?) for the C-section
- odd tendencies with placing epidural catheters (thread 4in? 13in?) with no report of departmental intervention

everyone is aware of the swiss cheese model for lapses in patient safety resulting in patient harm. None of us should be above the following scenario: intrathecal catheter with inadvertent dosing resulting in a high spinal, respiratory depression/failure, intubation occuring in an L&D room, esophageal intubation.

However, it is what we do between and after all of these points that determines positive or negative outcome with the patient. A lot occured in this situation that led to the unfortunate outcome.
 
Last edited:
zizzer said:
On the medicine subreddit, they're saying there's actually no unit mix up and the linked disciplinary report documents that he threaded the catheter to 34cm. I didn't even know they were that long.
Click to expand...
If he did thread the catheter to that depth then only a small section of a few cm would be sticking out. How is that even possible? I still don’t buy it. Guy may be incompetent but you would have to be a complete !diot to do that.
 
0kazak1 said:
I think it more than mixing of units. 13cm of insertion is awfully deep. I don't how anyone would insert a catheter that deep,

And its weird, everyone knows money talks, but no one ever wants to pay up.
Click to expand...

zizzer said:
I do 13cm at the skin occasionally because I usually pick 5cm in the epidural space and don't get LOR until 8cm occasionally in the BMI 50, 60, 70, 80 etc patients.
Click to expand...


Where do you guys practice? Is your patient population made up of waif super models having kids? My average patient is a 35 BMI prior to pregnancy. I would say if I place 6-12 epidurals in a shift then 1/3 will have LOR at 8+cm. 8cm plus 5cm in the space isn’t even close to unusual. Now, I am not defending this guy by any means just pointing out that a 13cm depth isn’t uncommon.
 
PainDrain said:
Where do you guys practice? Is your patient population made up of waif super models having kids? My average patient is a 35 BMI prior to pregnancy. I would say if I place 6-12 epidurals in a shift then 1/3 will have LOR at 8+cm. 8cm plus 5cm in the space isn’t even close to unusual. Now, I am not defending this guy by any means just pointing out that a 13cm depth isn’t uncommon.
Click to expand...
Agreed and I'm working with a primarily "healthy" military population.
 
Agast said:
How often is it missed that you’re intrathecal once the tuohy goes in? In my experience there’s a gush of warm fluid that instantly rebukes you. Not subtler like a spinal with a thinner gauge needle.
Click to expand...
Even when the touhy is in the epidural space, the catheter itself can puncture the dura. If you aspirate you will get a syringe full of CSF. I’ve had this happen multiple times. Much more common with the old “hard” catheters, but can happen with the soft catheters as well. No excuse. That’s why we aspirate and give test dose.
 
dannyboy1 said:
Even when the touhy is in the epidural space, the catheter itself can puncture the dura. If you aspirate you will get a syringe full of CSF. I’ve had this happen multiple times. Much more common with the old “hard” catheters, but can happen with the soft catheters as well. No excuse. That’s why we aspirate and give test dose.
Click to expand...
To puncture into the subarachnoid you have to push the catheter extremely hard. This has never happened to me because I never force the catheter in like that, it should slide in smooth a large majority of the time. If it doesn't you're not in the right place or not completely midline and should re-adjust your position. This can also mean the needle bevel is barely past the dura (enough to inject saline but not enough to thread) and the catheter is getting stuck on the fibers. When I get loss with continuous I insert another 0.5cm while flushing. This is using the braun non-soft tip catheters btw.
 
PainDrain said:
Where do you guys practice? Is your patient population made up of waif super models having kids? My average patient is a 35 BMI prior to pregnancy. I would say if I place 6-12 epidurals in a shift then 1/3 will have LOR at 8+cm. 8cm plus 5cm in the space isn’t even close to unusual. Now, I am not defending this guy by any means just pointing out that a 13cm depth isn’t uncommon.
Click to expand...

BMI 55. We call it spearing the whale.
 

dont know if you can see it but thats the docuemnt from the medical board.

he documented leaving catheter at 10cm. on autopsy they found it at 34cm. the question is... did he leave it at 34cm and feel like that is okay, or did something happen causing catheter to migrate IN (never heard of this before), but ive also never done CPR for patient after high spinal from epidural.. both sounds ridiculous
 
according to above document. NYT's article about 29 min to discover esophageal intubation is inaccurate. Patient was extubated a few min later, and another airway wasnt successfully obtained until 29 min. Unclear if they have videoscope . The another physician tried multiple times before securing airway.

also during those times, his hospital was hit heavily by covid. PACU was used as a covid ICU. and OR patients had to be recovered in the OR. (unrelated to OB patient death, but related to another case they mentioned of his)
 
Last edited:
Agast said:
How often is it missed that you’re intrathecal once the tuohy goes in? In my experience there’s a gush of warm fluid that instantly rebukes you. Not subtler like a spinal with a thinner gauge needle.
Click to expand...
Oh it happens! I’ve personally done one in a 20 year career. Totally easy/normal everything than positive test dose. Cath positive for CSF aspiration only after test dose. Old stiff catheter that I stopped using years ago. Can’t explain any more, but that’s why we do the test.
 
caligas said:
Oh it happens! I’ve personally done one in a 20 year career. Totally easy/normal everything than positive test dose. Cath positive for CSF aspiration only after test dose. Old stiff catheter that I stopped using years ago. Can’t explain any more, but that’s why we do the test.
Click to expand...

saw one in residency. test dose negative. aspiration negative. loaded her with bolus from pump (10ml). it didnt even finish all 10 and patient became profoundly hypotensive and vomiting. immediately stopped infusion bolus. we guessed since the catheter is multiorificed, it may be partially in intrathecal space and partially not. we ended up using it as a intrathecal catheter since it was a challenging epidural.

but can definitely say we dont routinely wait there for 10-15 minutes after to see what happens... we rely on nurse to monitor the patient after epidural goes in and infusion is started.
 
anbuitachi said:

dont know if you can see it but thats the docuemnt from the medical board.

he documented leaving catheter at 10cm. on autopsy they found it at 34cm. the question is... did he leave it at 34cm and feel like that is okay, or did something happen causing catheter to migrate IN (never heard of this before), but ive also never done CPR for patient after high spinal from epidural.. both sounds ridiculous
Click to expand...
Kind of a sobering document. They really hammered him about documentation. Not defending his care at all but they can hang all of us on “documentation”. Especially those still using paper records….
 
anbuitachi said:
according to above document. NYT's article about 29 min to discover esophageal intubation is inaccurate. Patient was extubated a few min later, and another airway wasnt successfully obtained until 29 min. Unclear if they have videoscope . The another physician tried multiple times before securing airway.

also during those times, his hospital was hit heavily by covid. PACU was used as a covid ICU. and OR patients had to be recovered in the OR. (unrelated to OB patient death, but related to another case they mentioned of his)
Click to expand...
extubated and successfully intubated is code for (unrecognized) esophageal intubation. The end.
 
dabears505 said:
It says during covid he was clocking in over a 100 hrs a week. At one point intubated 27 people in one day.
Click to expand...
This is insane. Doesn’t add up, not someone that could not recognize an esophageal intubation, maybe patient was profoundly hypotension and in PEA and they thought no etCO2 as a result?
 
IMGASMD said:
I don’t test dose necessarily for every single epidurals that I place, especially if it’s not in the kit.
I think we had a discussion before that some people would just use one solution from the bag or something.
However I made it a habit of anytime inject, I aspirate, just for my own peace of mind.
Click to expand...
No excuse not to aspirate a catheter. I aspirate an epidural any time I dose it, also make sure to double check the vial of medicine a second or third time before injecting an epidural.
 
0kazak1 said:
I think it more than mixing of units. 13cm of insertion is awfully deep. I don't how anyone would insert a catheter that deep,

And its weird, everyone knows money talks, but no one ever wants to pay up.
Click to expand...

Would love to have had your OB experience, 13 cm was a normal catheter depth (at the skin) for me. Deepest was LOR 13.5 cm catheter at 19 cm
 
I have heard of some people doing this, they thread catheter as much as possible, batons the 20 cm mark, so that 10+ cm of catheter are in the epidural space. I wouldn’t think it would make much of a difference, although there’s definitely a chance of one sided block, catheter knotting, etc.
 
mdo1738 said:
Would love to have had your OB experience, 13 cm was a normal catheter depth (at the skin) for me. Deepest was LOR 13.5 cm catheter at 19 cm
Click to expand...
I was talking about threading the catheter so that 13cm is in the space. 13cm at the skin would be a birdie around here.
 
agammaglobulin said:
Thought experiment - What if medicare and medicaid paid MORE than private?
Click to expand...
if this were the case, white people would figure out a way to get on medicare/medicaid or elect officials to lower the payments by decreasing taxes or something like that. The race dynamics of poor POC getting poor healthcare would definitely rear its ugly head
 
Lashler9054 said:
if this were the case, white people would figure out a way to get on medicare/medicaid or elect officials to lower the payments by decreasing taxes or something like that. The race dynamics of poor POC getting poor healthcare would definitely rear its ugly head
Click to expand...

So your thought is if Medicare/Medicaid paid physicians more White people would actively try get on it and /or lower reimbursement because racism?

I don't follow
 
agammaglobulin said:
"The catheter to deliver the anesthesia should have gone about four inches into her lower back. Instead, he kept inserting the line, threading it in and up more than 13 inches, a state medical review board later found."

Accurate reporting by the NYT. Standard is 4 inches after LOR? and he threaded it 13 inches ? hu? I think they are mixing up units of measure.

At least they didn't lose an opportunity to bring up race. NYT has to bring this up in the first sentence of an article about a preventable death from an epidural. "Dr. Dmitry Shelchkov, an anesthesiologist at a public hospital in a predominantly Black neighborhood". The question they ask about why healthcare at poor, public hospital with lots of Medicaid patients is worse is rather simple to answer. And dare I say it's not about race. Medicare/-caid doesn't pay $hit so you get doctors that can't get hired elsewhere taking the low paying jobs.

Thought experiment - What if medicare and medicaid paid MORE than private? Then the incentive would be for doctors to work at low income, public hospitals. But what narrative would we push then?
Click to expand...

Very true.

Pay physicians more to work and you will get a higher quality physician.

It's a basic premise that the government and hospital admin refuses to entertain.

Who else is going to work in a crappy hospital with crap infrastructure unless you have no other options?

The other thing this shows is that physicians are not replaceable widgets. Most are well trained but some docs are more skilled than others. It would behoove a health system etc to hang onto these better skilled docs instead of antagonizing them and thinking you can just replace them with another warm body.
 
anonperson said:
Very true.

Pay physicians more to work and you will get a higher quality physician.

It's a basic premise that the government and hospital admin refuses to entertain.

Who else is going to work in a crappy hospital with crap infrastructure unless you have no other options?

The other thing this shows is that physicians are not replaceable widgets. Most are well trained but some docs are more skilled than others. It would behoove a health system etc to hang onto these better skilled docs instead of antagonizing them and thinking you can just replace them with another warm body.
Click to expand...
No physician thinks that every physician is the same and replaceable with another warm body,
however it seems like everyone else in the healthcare field thinks that way.
it is all about the money.
from hospital administrators to the midlevels.
 
You must log in or register to reply here.

Similar threads

Ashers
Maui anesthesiologist arrested
Replies
22
Views
3K
NumTacos
NumTacos
P
Ob staffing
Replies
9
Views
1K
ERRES2288
E
D
Anesthesiologist shortage
2 3
Replies
138
Views
15K
Dantrolene FC
D
I
VA hospital anesthesiologist pay
Replies
37
Views
5K
aneftp
A
Bobcat18
RHOBH “Nurse Anesthesiologist”
Replies
11
Views
4K
Bobcat18
Bobcat18
Top