Patient Nearly Dies After CRNA Mishap

[zizzer]

For anybody short on time, the patient had a hip replacement under general anesthesia in a Phoenix outpatient surgery center, and experiences respiratory arrest progressing to cardiac arrest in PACU. The case was covered by an unsupervised CRNA, but an anesthesiologist from another group helped with resuscitation in PACU. The patient woke up in the emergency department at the university hospital. Apparently, the patient didn't know that there was no anesthesiologist, and the surgeon was fired from the surgicenter for allegedly refusing to accept anesthesia responsibility.

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[Planktonmd]

This patient is so lucky to be alive. It just wasn't his time.
Typical scenario: CRNA works for the surgicenter/surgeons and wants to look slick and cool to impress his employers. So... he/she tries to have the patients wake up "smoothly" by giving some extra opiates (which is what slick and cool people do). Unfortunately people with sleep apnea can make you look less of a rock star and more of an idiot when they obstruct, quit breathing, and try to die on you. They just don't always cooperate and help you look like the stellar nurse "anesthesiologist" you are meant to be.
If they only made all patients skinny and healthy that would not have happened.

 

[vector2]

If ASA / ASAPAC was worth a **** this would be a national news story and not buried on some obscure podcast

 

[Dr. Rude]

If ASA / ASAPAC was worth a **** this would be a national news story and not buried on some obscure podcast

 

[Dr. Rude]

View attachment 362615

Are you listening ASA? I know leadership is aware of this board and posts.

 

[Ashers]

This patient is so lucky to be alive. It just wasn't his time.
Typical scenario: CRNA works for the surgicenter/surgeons and wants to look slick and cool to impress his employers. So... he/she tries to have the patients wake up "smoothly" by giving some extra opiates (which is what slick and cool people do). Unfortunately people with sleep apnea can make you look less of a rock star and more of an idiot when they obstruct, quit breathing, and try to die on you. They just don't always cooperate and help you look like the stellar nurse "anesthesiologist" you are meant to be.
If they only made all patients skinny and healthy that would not have happened.

I haven't listened to this yet, but I will. This is how Phoenix works. Phoenix is the weirdest place I've ever worked... I do locums now and live and Phoenix. The surgeons I worked with often didn't know that someone was a CRNA and responsible for them. I brought it to their attention, and they're like "really? I thought everyone here was an anesthesiologist." I tried to get the AZ society to do more, but they weren't much help.

Edit: yeah. I know this exact place.

 

[DrOwnage]

I mean I know patients usually have no idea if its a CRNA or Anesthesiologist, but for the surgeon not to know is pretty shady. Are they just working with random people they've never met before?

 

[deleted1147063]

I mean I know patients usually have no idea if its a CRNA or Anesthesiologist, but for the surgeon not to know is pretty shady. Are they just working with random people they've never met before?

Correct spelling for anybody and any body: anebody.

 

[Ashers]

I mean I know patients usually have no idea if its a CRNA or Anesthesiologist, but for the surgeon not to know is pretty shady. Are they just working with random people they've never met before?

No. They aren't. They've met them. There's usually one anesthesiologist, sometimes 2, around, but they are in their own rooms during the day. Not all the surgeons know necessarily know who is an MD and who is a CRNA, a lot of the surgeons do know. I've heard the CRNAs introduce themselves as "nurse anesthesiologist" to the patients at this place. I talked to some of the surgeons with whom I am good friends and said, "Do you realized you're technically supervising the CRNA when they're in your room?" They didn't. When I introduced myself as "Dr. Ashers" I got so many relieved, "You're a real doctor?" and I told patients they could always request a physician.

This scenario happens at more than just this location in Phoenix. Big reason why I do locums and don't work in Phoenix.

 

[IMGASMD]

No. They aren't. They've met them. There's usually one anesthesiologist, sometimes 2, around, but they are in their own rooms during the day. Not all the surgeons know necessarily know who is an MD and who is a CRNA, a lot of the surgeons do know. I've heard the CRNAs introduce themselves as "nurse anesthesiologist" to the patients at this place. I talked to some of the surgeons with whom I am good friends and said, "Do you realized you're technically supervising the CRNA when they're in your room?" They didn't. When I introduced myself as "Dr. Ashers" I got so many relieved, "You're a real doctor?" and I told patients they could always request a physician.

This scenario happens at more than just this location in Phoenix. Big reason why I do locums and don't work in Phoenix.

Is this collaborative model? So anesthesiologists in their own room have no responsibilities other than their own room?

 

[Ashers]

Is this collaborative model? So anesthesiologists in their own room have no responsibilities other than their own room?

Not collaborative. Two different groups that aren't associated. If there is a problem, an RN might call a doc into a room saying a CRNA is having problems. That happened to me I got called in for "desats and hypotension" when I was in between cases. CRNA said it was a PE, it was a mainstem with a tiny ETT too small for the patient.

 

[jwk]

Is this collaborative model? So anesthesiologists in their own room have no responsibilities other than their own room?

"Collaborative model" is a CRNA creation to give the illusion that a physician anesthesiologist is involved with a case. It's meaningless and has no legal definition that I'm aware of.

 

[Ashers]

"Collaborative model" is a CRNA creation to give the illusion that a physician anesthesiologist is involved with a case. It's meaningless and has no legal definition that I'm aware of.

Yeah. We had nothing to do with the CRNA patients unless there were room changes. Some of the docs would block for the crnas because those are billed separately. I wouldn't. If there were a room change, I'd repeat the entire preop exam.

 

[Ashers]

Are you listening ASA? I know leadership is aware of this board and posts.

I'm sending this to my friends in different states involved in the ASA. I got no help from the AZSA when I brought up concerns with the CRNAs at this place and another surgery center in February.

 

[LivetoTell]

When I listened, it sounded like the CRNA was not involved or around in the respiratory arrest/ "code" situation. Like the pt obstructed while in PACU, with subsequent arrest after the CRNA had given report and moved on ( maybe to do the next case)? Was the PACU monitoring SP02? They never mention it.

 

[Ashers]

When I listened, it sounded like the CRNA was not involved or around in the respiratory arrest/ "code" situation. Like the pt obstructed while in PACU, with subsequent arrest after the CRNA had given report and moved on ( maybe to do the next case)? Was the PACU monitoring SP02? They never mention it.

Typically they do measure pOx, but not the first monitor to be placed. The priority of most of the PACU nurses when I was there was BP cuff, ekg, temp, then pOx. I'd made them put the pOx on first when I arrived.

That's the usual MO. Drop a patient off, give report, go to the other end of the hospital for the next preop.

 

[teacher2md]

1. Slide the patient up in bed, fuss over the blanket that’s wadded up to the side.
2. Say “Oh boy, what is going on here?” and Re-arrange all of the IVs
3. Take off existing EKG stickers and replace them all
4. Hook up EKG monitor
5. Try to cycle BP, declare that the patient needs a different size BP cuff. Apply said cuff
6. Hook up SP02
7.Realize it’s low
8. Realize that patient isn’t breathing

 

[deleted1147063]

Off-topic rant:

It drives me nuts that somebody can work in the PACU/ICU/ED and not get fired when the first monitor they put on an unconscious/distressed patient is not the pulse ox, and not within 15 seconds from arrival (door to pulse ox).

 

[Crabbygas]

1. Slide the patient up in bed, fuss over the blanket that’s wadded up to the side.
2. Say “Oh boy, what is going on here?” and Re-arrange all of the IVs
3. Take off existing EKG stickers and replace them all
4. Hook up EKG monitor
5. Try to cycle BP, declare that the patient needs a different size BP cuff. Apply said cuff
6. Hook up SP02
7.Realize it’s low
8. Realize that patient isn’t breathing

Meanwhile the ABA/ASA is torturing me with MOCA practice improvement for a couple of credits for stuff like cardiac arrest under spinal. If I could actually get the PACU to put the pulse ox on immediately every single time I should score a full 50 points just for that. Of course I'd also probably get fired for being, "Disruptive"

 

[GassYous]

I just put the pulse ox on myself

 

[MirrorTodd]

I just put the pulse ox on myself

Agreed, honestly easiest thing to do and less stress for me during handoff.

 

[Southpaw]

I just put the pulse ox on myself

What’re you sat’ing these days?

 

[anaesthetic]

"Collaborative model" is a CRNA creation to give the illusion that a physician anesthesiologist is involved with a case. It's meaningless and has no legal definition that I'm aware of.

Just a point of contention from a cranky doctor physician anesthesiologist M.D., the term “anesthesiologist” should be enough to convey “physician.” I know you know the difference. I think we should continue to work to eliminate the ambiguity and undo the erosion from the AANA clowns.

 

[nimbus]

Just a point of contention from a cranky doctor physician anesthesiologist M.D., the term “anesthesiologist” should be enough to convey “physician.” I know you know the difference. I think we should continue to work to eliminate the ambiguity and undo the erosion from the AANA clowns.

I still think we should adopt anaesthetist, anaesthetics and sontimeters. Residents can say, “I’m studying anaesthetics” and academics can say, “I’m a professor of anaesthetics.”

 

[kidthor]

1. Slide the patient up in bed, fuss over the blanket that’s wadded up to the side.
2. Say “Oh boy, what is going on here?” and Re-arrange all of the IVs
3. Take off existing EKG stickers and replace them all
4. Hook up EKG monitor
5. Try to cycle BP, declare that the patient needs a different size BP cuff. Apply said cuff
6. Hook up SP02
7.Realize it’s low
8. Realize that patient isn’t breathing

The other day I took a patient to the ICU and all steps through 6 happened as you described. Except step 0 was for them to remove the facemask/oxygen and step 7 onward didn't occur (the patient was breathing fine, they were just 200kg and had a 10 hour surgery so they needed oxygen and their sat on RA was 82% with nobody seeming to care). Had I not put the oxygen back on myself, the entire receiving team seemed set to ignore it.

Good, competent PACU and ICU nurses are important and essential. Unfortunately with the hospitals squeezing them their quality and motivation (for what's available to us) has really dropped off a cliff.

 

[nimbus]

1. Slide the patient up in bed, fuss over the blanket that’s wadded up to the side.
2. Say “Oh boy, what is going on here?” and Re-arrange all of the IVs
3. Take off existing EKG stickers and replace them all
4. Hook up EKG monitor
5. Try to cycle BP, declare that the patient needs a different size BP cuff. Apply said cuff
6. Hook up SP02
7.Realize it’s low
8. Realize that patient isn’t breathing

Diabetic patients get a finger stick glucose between steps 2 and 3.

 

[CubsDynasty]

You seem to forget about checking the patients temperature and removing the oral airway first.

 

[jwk]

Off-topic rant:

It drives me nuts that somebody can work in the PACU/ICU/ED and not get fired when the first monitor they put on an unconscious/distressed patient is not the pulse ox, and not within 15 seconds from arrival (door to pulse ox).

Common problem. Should be the first monitor period, whether patient is conscious or otherwise. I get really irritated when they start getting their OR circulator report first and start putting on monitors second. Sometimes the first thing done is checking residual bladder volume on total joints because the surgeons are so concerned about urinary retention delaying discharge.

 

[jwk]

Just a point of contention from a cranky doctor physician anesthesiologist M.D., the term “anesthesiologist” should be enough to convey “physician.” I know you know the difference. I think we should continue to work to eliminate the ambiguity and undo the erosion from the AANA clowns.

WIth you 100%. I wanted to clearly differentiate since we're discussing CRNAs in this thread. BTW - I never use MDA. That's starting to creep in among our nursing staff.

 

[IMGASMD]

WIth you 100%. I wanted to clearly differentiate since we're discussing CRNAs in this thread. BTW - I never use MDA. That's starting to creep in among our nursing staff.

Worked at a place, called us ologist….. never liked that term either.

one of these days, I will just call them nurses, maybe, in their face….

 

[Ashers]

WIth you 100%. I wanted to clearly differentiate since we're discussing CRNAs in this thread. BTW - I never use MDA. That's starting to creep in among our nursing staff.

I despise "provider" too.

 

[nimbus]

I despise "provider" too.

We had a travel nurse a few years ago write “ologist” on the whiteboard. Glad I never saw that again.

 

[2Fast2Des]

We had a travel nurse a few years ago write “ologist” on the whiteboard. Glad I never saw that again.

Yikes... Why is our profession so weak.... This is like being bullied at school and begging for more shame and hits. Is it because we get paid enough and just need to turn the cheek and not look the gift horse in the mouth?

 

[dannyboy1]

Yikes... Why is our profession so weak.... This is like being bullied at school and begging for more shame and hits. Is it because we get paid enough and just need to turn the cheek and not look the gift horse in the mouth?

Yes. Also anesthesia attracts the whole “go along, get along” crowd

 

[deleted1147063]

Yikes... Why is our profession so weak.... This is like being bullied at school and begging for more shame and hits. Is it because we get paid enough and just need to turn the cheek and not look the gift horse in the mouth?

Because we're selected based on submissiveness. I remember when I talked back to a surgeon in residency, and I was promptly "educated" by my PD. We are like a race of dogs bread to lick the surgeon's arse. To the day, if one has the wrong attitude toward surgeons (meaning that one behaves like a consulting physician from most other specialties), one is promptly labeled. It's all about keeping the surgeons, and the admins who make their money from the OR, happy.

We used to rationalize it was because of the money. Nowadays it's more like: What money? (in my neck of woods)

Students should try to never get into a specialty where the patients wouldn't follow the doctor to a different place of work, and where the customer is not really the patient.

 

[vector2]

Yikes... Why is our profession so weak.... This is like being bullied at school and begging for more shame and hits. Is it because we get paid enough and just need to turn the cheek and not look the gift horse in the mouth?

At the end of the day, the unfortunate truth is that the patient came to the hospital to get surgery, not anesthesia. Everyone along the path of that pt's journey including the ED doc, hospitalist, radiologist, anesthesiologist, lab worker, cafeteria worker, and the custodian are merely interchangeable topline expenses to be minimized along the way, and thus they get treated as such.

 

[Ashers]

At the end of the day, the unfortunate truth is that the patient came to the hospital to get surgery, not anesthesia. Everyone along the path of that pt's journey including the ED doc, hospitalist, radiologist, anesthesiologist, lab worker, cafeteria worker, and the custodian are merely interchangeable topline expenses to be minimized along the way, and thus they get treated as such.

He's trying to change that in support of patient safety. He had a friend who walked out of a surgery center before a procedure because the surgery center wouldn't give details of who was supervising the CRNAs saying it may come down to patients taking a stand. He wants this podcast spread far and wide.

 

[yourhumbleservant]

At the end of the day, the unfortunate truth is that the patient came to the hospital to get surgery, not anesthesia. Everyone along the path of that pt's journey including the ED doc, hospitalist, radiologist, anesthesiologist, lab worker, cafeteria worker, and the custodian are merely interchangeable topline expenses to be minimized along the way, and thus they get treated as such.

I disagree. The patient came to the hospital to get anesthesia, it's just never occurred to them that this is the case. Otherwise they'd iust have surgery at the surgeon's office.

Incidentally tomorrow is my last day at my current job. The day after I leave there will be 4 empty OR's every day for the foreseeable future. A lot of surgeons will not be happy and might take their patients elsewhere to hospitals that have adequate anesthesia coverage. If they can find one.

 

[deleted1147063]

The solution is not training more anesthesiologists or CRNAs, or allowing midlevels to take over the field.

The solution is calling a spade a spade: Americans have a ton of useless elective surgeries (think ortho) or uselessly fancy-shmancy and long ones (think robots instead of laparoscopic, or laparoscopic when open would be fine, too).

Of course, the ASA will never say that, and will never support MD-only anesthesia. They are completely sold-out to the corporations financing them, slowly as representative as the AMA.

 

[vector2]

I disagree. The patient came to the hospital to get anesthesia, it's just never occurred to them that this is the case. Otherwise they'd iust have surgery at the surgeon's office.

Incidentally tomorrow is my last day at my current job. The day after I leave there will be 4 empty OR's every day for the foreseeable future. A lot of surgeons will not be happy and might take their patients elsewhere to hospitals that have adequate anesthesia coverage. If they can find one.

I'm not saying we're not valuable or that the surgery can proceed without us, but the pt's ultimate purpose was still getting their knee replaced or their arteries bypassed by the surgeon who did their consultation and then asked them to come to the hospital.

It's not like the patient was seeking you out to provide your professional services in a vacuum, , and that's where the downside of the so-called "service" specialties lies because 1. You're dependent on the surgeon/proceduralist bringing pts in, 2. The hospital sees you as sucking value out, not adding it

 

[kidthor]

I'm not saying we're not valuable or that the surgery can proceed without us, but the pt's ultimate purpose was still getting their knee replaced or their arteries bypassed by the surgeon who did their consultation and then asked them to come to the hospital.

It's not like the patient was seeking you out to provide your professional services in a vacuum, , and that's where the downside of the so-called "service" specialties lies because 1. You're dependent on the surgeon/proceduralist bringing pts in, 2. The hospital sees you as sucking value out, not adding it

Put another way though the surgeon is entirely dependent on us to do anything and everything they do, as is the hospital. Without us none of it can happen - we’re flying the plane.

 

[kidthor]

The solution is not training more anesthesiologists or CRNAs, or allowing midlevels to take over the field.

The solution is calling a spade a spade: Americans have a ton of useless elective surgeries (think ortho) or uselessly fancy-shmancy and long ones (think robots instead of laparoscopic, or laparoscopic when open would be fine, too).

Of course, the ASA will never say that, and will never support MD-only anesthesia. They are completely sold-out to the corporations financing them, slowly as representative as the AMA.

Absolutely agreed. The number of absurd and needlessly complicated surgeries is shocking. Plus too much stuff gets anesthesia that doesn’t really need anesthesia.

I remember at a prior job I had the gall to suggest a fully functional football-playing 17yo did not need general anesthesia for a lumbar puncture. Noting also the LP was to be done by a PA, because the oncologists don’t have time for such petty invasive procedure procedures - they’re just there to skim off the top and profit off the chemo.

Anyway I was told at a meeting filled with administrators and midlevels that I was the problem, that if they say the patients needs GA then they will get it when, where, and how they say… and the hospital then peer reviewed me.

Needless to say I don’t work there anymore. My department told me not to question anything like that because “we need the business”. But that’s all a microcosm of the problem our profession has allowed. Advocate for sense and you’re the bad guy because of “the money”.

 

[vector2]

Put another way though the surgeon is entirely dependent on us to do anything and everything they do, as is the hospital. Without us none of it can happen - we’re flying the plane.

Sure, much like the hospital is dependent on EVS cleaning the OR between cases or the pharmacy tech restocking all the pyxises with ancef. Without them none of it can happen.

The way I'd put it I guess (especially for the lurkers like the med studs) is to consider what the thing is in this equation that is actually massively revenue positive to the hospital. It's the facility fee and all the ancillary charges that come from a big surgery. For the sake of simplicity, say this is a bundled payment surgery model. The more surgeries the hospital does, the more money they make.

But in the bundled payment structure it's a flat fee, so every single top line item the hospital has to pay for to get that surgery done, the smaller that bottom line gets. Yes, there will be mandatory expenses, but the administration's goal is to lower these expenses as much as humanly possible (a task which especially hurts us due to horrible medicare/medicaid anesthesia reimbursement necessitating subsidies). That's why short sighted c-suite idiots will blow up longstanding anesthesia contracts just to save pennies with an AMC.

On the other hand, administration will bend over backwards to maximize the surgeon's/proceduralists's ability to work and earn. Why? Because unlike us, the surgeon's interests (professional fee) and hospital's interests (facility fee) go hand in hand.

 

[Gaseous Clay]

Absolutely agreed. The number of absurd and needlessly complicated surgeries is shocking. Plus too much stuff gets anesthesia that doesn’t really need anesthesia.

I remember at a prior job I had the gall to suggest a fully functional football-playing 17yo did not need general anesthesia for a lumbar puncture. Noting also the LP was to be done by a PA, because the oncologists don’t have time for such petty invasive procedure procedures - they’re just there to skim off the top and profit off the chemo.

Anyway I was told at a meeting filled with administrators and midlevels that I was the problem, that if they say the patients needs GA then they will get it when, where, and how they say… and the hospital then peer reviewed me.

Needless to say I don’t work there anymore. My department told me not to question anything like that because “we need the business”. But that’s all a microcosm of the problem our profession has allowed. Advocate for sense and you’re the bad guy because of “the money”.

Sounds like you had a spineless medical director and department. Administration is clueless but if they have your leader’s respect, then everyone would’ve backed you on that.

 

[Southpaw]

Anyway I was told at a meeting filled with administrators and midlevels that I was the problem, that if they say the patients needs GA then they will get it when, where, and how they say… and the hospital then peer reviewed me.

Needless to say I don’t work there anymore. My department told me not to question anything like that because “we need the business”. But that’s all a microcosm of the problem our profession has allowed. Advocate for sense and you’re the bad guy because of “the money”.

I've said it before and I'll say it again, we are a spineless specialty and our departments are often run by spineless people. In the end that hurts us and our patients.

 

[Ashers]

I've said it before and I'll say it again, we are a spineless specialty and our departments are often run by spineless people. In the end that hurts us and our patients.

And those of us who want to make changes get shut down. It's frustrating.

 

[coffeebythelake]

I had an experienced CRNA pull the ETT from a sinus surgery case way too early and called for help when she realized patient wasn't breathing. Pt obtunded. No response to sternly rub. The CRNA couldn't mask ventilate so supposed laryngospasm and given prop and little suxx. I took over mask ventilating and was able to move air easily after... but still unclear if it was actually laryngospasm. Still pt wasn't breathing after suxx wore off and we ultimately gave naloxone to effect.

At least she had the right sense to ask for help right away before things turned bad.

 

[Ashers]

I had an experienced CRNA pull the ETT from a sinus surgery case way too early and called for help when she realized patient wasn't breathing. Pt obtunded. No response to sternly rub. The CRNA couldn't mask ventilate so supposed laryngospasm and given prop and little suxx. I took over mask ventilating and was able to move air easily after... but still unclear if it was actually laryngospasm. Still pt wasn't breathing after suxx wore off and we ultimately gave naloxone to effect.

At least she had the right sense to ask for help right away before things turned bad.

I had one who would call me for everything dumb. Put the bair hugger on. Figure out what's wrong with the IV, it was kinked under the drapes, but she didn't call when she have an induction dose of prop to the End stage Duchenne patient for a MAC IHR because the surgeon complained he was moving.

 

[deleted1147063]

I had an experienced CRNA pull the ETT from a sinus surgery case way too early and called for help when she realized patient wasn't breathing. Pt obtunded. No response to sternly rub. The CRNA couldn't mask ventilate so supposed laryngospasm and given prop and little suxx. I took over mask ventilating and was able to move air easily after... but still unclear if it was actually laryngospasm. Still pt wasn't breathing after suxx wore off and we ultimately gave naloxone to effect.

At least she had the right sense to ask for help right away before things turned bad.

That patient hadn't been breathing even before she pulled the tube.

Also, 10-20 mg of sux don't stop the patient from breathing in case of laryngospasm. I've given it to awake patients.

Also, don't give propofol for laryngospasm. Give sux (faster on/off, better effect).

 

[coffeebythelake]

That patient hadn't been breathing even before she pulled the tube.

Also, 10-20 mg of sux don't stop the patient from breathing in case of laryngospasm. I've given it to awake patients.

Also, don't give propofol for laryngospasm. Give sux (faster on/off, better effect).

Yeah sats were still 95%+ so I thought I would give it a shot with propofol. We had it immediately available in a syringe already. Whereas suxx had to be drawn up..