Patient Nearly Dies After CRNA Mishap

[GassYous]

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..

It takes 5 seconds to draw up a med

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[nimbus]

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.

Off topic but curious. How much opioid did that patient receive? Sinus endoscopy is not a painful procedure.

 

[Greenbayslacker]

Sinus endoscopy is not a painful procedure.

Disagree

 

[nimbus]

Disagree

Personal experience?

I do these with 50-100mcg fentanyl. They often go home with nothing more in PACU. Maybe it depends on how much local the surgeon injects.

 

[anaesthetic]

Personal experience?

I do these with 50-100mcg fentanyl. They often go home with nothing more in PACU. Maybe it depends on how much local the surgeon injects.

Same, if not less. Some stimulating portions that can be controlled by non-opioids. Otherwise, once that scope comes out… well, you’ll be giving a lot more medications than intended as above. I’ve seen some headaches afterwards which acetaminophen/fluids usually takes care of.

 

[DocMcCoy]

Personal experience?

I do these with 50-100mcg fentanyl. They often go home with nothing more in PACU. Maybe it depends on how much local the surgeon injects.

I agree it doesn’t take much during the case but these always seem to be age 30 something gorillas that get coked up by surgeon and wake up spitting blood ready to put staff in headlocks when I do them.

 

[nimbus]

I agree it doesn’t take much during the case but these always seem to be age 30 something gorillas that get coked up by surgeon and wake up spitting blood ready to put staff in headlocks when I do them.

Our ents usually use lidocaine with epi. Also in my experience, a little precedex (16-20mcg) during the case usually makes them very chill in PACU.

 

[coffeebythelake]

It takes 5 seconds to draw up a med

Maybe 15 seconds but yeah i get your point. We had propofol in line already

 

[coffeebythelake]

Off topic but curious. How much opioid did that patient receive? Sinus endoscopy is not a painful procedure.

I dont remember. It was less than 1 mg dilaudid.

 

[Dr. Anonymouss]

Crazy to listen to. I wonder when legislation will finally change to prevent this loophole of supervision... Also, as the legislation stands it does not seem appropriate to have a surgeon as a supervisor to a CRNA. What does a surgeon know about anesthesia? They are two completely different fields of medicine and in addition to this how can a surgeon adequately supervise a CRNA while they are doing surgery?

We all know that it comes down to profitability and that is the sole reason for employing as many CRNAs as possible and as little anesthesiologists as possible, but I wonder if instances like these will change this paradigm. Are examples like this costly enough to the business model after being sued? This I don't know. Not sure how much he would be awarded and how much the surgery center is liable for since they wanted to push everything on the surgeon.

 

[coffeebythelake]

What does a surgeon know about anesthesia? They are two completely different fields of medicine and in addition to this how can a surgeon adequately supervise a CRNA while they are doing surgery?

I know as much about surgery as the surgeon knows about anesthesia. Not enough. Some surgeons think supervision of a CRNA means yelling that the "patient is waking up" when they move.

 

[Gasmd98]

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”.

My personal “favorite” is the demand for “anesthesia” coverage in the ICU so that GI can do an EGD on an intubated patient on a propofol infusion at 1800. Yeah, I am not available.

 

[coffeebythelake]

My personal “favorite” is the demand for “anesthesia” coverage in the ICU so that GI can do an EGD on an intubated patient on a propofol infusion at 1800. Yeah, I am not available.

I never understand why they need us for this. They have an icu nurse and the patient is already on sedation

 

[Ashers]

Crazy to listen to. I wonder when legislation will finally change to prevent this loophole of supervision... Also, as the legislation stands it does not seem appropriate to have a surgeon as a supervisor to a CRNA. What does a surgeon know about anesthesia? They are two completely different fields of medicine and in addition to this how can a surgeon adequately supervise a CRNA while they are doing surgery?

We all know that it comes down to profitability and that is the sole reason for employing as many CRNAs as possible and as little anesthesiologists as possible, but I wonder if instances like these will change this paradigm. Are examples like this costly enough to the business model after being sued? This I don't know. Not sure how much he would be awarded and how much the surgery center is liable for since they wanted to push everything on the surgeon.

It's an all too common law in the US. I heard about it initially from my dad (ortho) when he was doing locums in critical access hospitals back when I was in residency. He said when he was told he had to sign the anesthetic record, he said he had no idea what the CRNA was doing, and couldn't vouch for them. I think he eventually signed, but they didn't tell him before the case that he was supervising. He then did only the smallest cases on healthy patients in the tiny hospitals and transferred everything else out. I bet the hospitals didn't like it, but he didn't want to be in charge of the anesthesia as well as the operation. He's since retired from locums.

 

[deleted875186]

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.

My personal experience is that nearly everyone pulls an ETT before the patient has truely emerged because they don’t want to watch the patient buck. Which in most cases is fine, so long as the CRNA is aware of this and is vigilant, and the patient is maskable and you can manage the airway. In this case patient probably coughed once, tube came out, patient still emerging and breath holding or apnic ….

 

[Beeftenderloin]

I never understand why they need us for this. They have an icu nurse and the patient is already on sedation

Our group has drawn a hard line on these. First question asked when called about an ICU patient for a scope, “are they intubated?” If the answer is yes the conversation stops there. ICU manages sedation.

 

[deleted875186]

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

I remember in residency intubating a sick ICU patient. Induced, tube goes in, ventilation ok, immediate hemodynamics are ok, then about 60 seconds after the tubes in, my attending and I are standing at the foot watching the vitals and the ICU nurse proceeds to disconnect all the monitors to “tidy up” the lines and monitors, and commences to leave them all disconnect while they untangle things for a couple mins ….

 

[VisionaryTics]

It's an all too common law in the US. I heard about it initially from my dad (ortho) when he was doing locums in critical access hospitals back when I was in residency. He said when he was told he had to sign the anesthetic record, he said he had no idea what the CRNA was doing, and couldn't vouch for them. I think he eventually signed, but they didn't tell him before the case that he was supervising. He then did only the smallest cases on healthy patients in the tiny hospitals and transferred everything else out. I bet the hospitals didn't like it, but he didn't want to be in charge of the anesthesia as well as the operation. He's since retired from locums.

Similar situation when I did locums briefly. I had access to both a surgery center located at outpatient medical office building or main OR at the regional hospital. I was told I would be "supervising" the CRNAs at the surgery center ("Who are all amazing and super experienced!") and that in case of emergency they would have to call the anesthesiologists from the main hospital (a two-mile drive down the road).

I told them in no uncertain terms that I thought asking surgeons to supervise anesthesia while also performing surgery was unconscionable and that I would not be doing any cases at the surgery center as a result. Bunch of clipboard nurses and supervisors at the surgery center were stunned.

 

[gtb]

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.

It's my experience, speaking as an anesthesiologist, opioid missteps also occur with physicians.

 

[Urzuz]

and commences to leave them all disconnect while they untangle things for a couple mins ….

Why didn't you or your attending say something? (When you say they had them disconnected for a couple minutes, it sounds like you guys let them finish whatever untangling they were doing). I feel like that would have been a perfect educational opportunity.

 

[cincincyreds]

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.

 

[anes12]

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.

Working in Phoenix is very weird. There is an over abundance and a mishmash of groups or contractors (AMCs, physician groups, midlevel-only groups, etc.) dispersed across the valley. Most cities and regions have 2-4 established groups for hospitals and surgery centers to select from.
Phoenix area hospitals and facilities have too many options resulting in a paradox of choices. The over abundance and decentralization of groups leads to driving down prices/rates allowing the lowest bidder new AMC to come in and enter the Phoenix market. Yet due to shortages, the locum market is good.

It is not unusual in Phoenix to have 2 or more anesthesia groups to simultaneously staff a hospital or surgery center which means no group has a truly "exclusive contract" with the hospital and can be terminated at any point. Bottom line is there is no real stability in Phoenix.

 

[Maz777]

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.

This happens about weekly at our institution. It's pretty normal to be called into the room after extubation with sats in the 50-60s and you have to clean up their mess when they are befuddled with what to do. CRNAs think it's super slick to arbitrarily pull the ETT early and hope they continue to breathe post-extubation. Hope for the best, call overhead when things don't work out. CRNA mantra.

 

[GassYous]

Working in Phoenix is very weird. There is an over abundance and a mishmash of groups or contractors (AMCs, physician groups, midlevel-only groups, etc.) dispersed across the valley. Most cities and regions have 2-4 established groups for hospitals and surgery centers to select from.
Phoenix area hospitals and facilities have too many options resulting in a paradox of choices. The over abundance and decentralization of groups leads to driving down prices/rates allowing the lowest bidder new AMC to come in and enter the Phoenix market. Yet due to shortages, the locum market is good.

It is not unusual in Phoenix to have 2 or more anesthesia groups to simultaneously staff a hospital or surgery center which means no group has a truly "exclusive contract" with the hospital and can be terminated at any point. Bottom line is there is no real stability in Phoenix.

Especially with the climate

 

[Airway]

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.”

Eh, tried (Midwest academic institution) this at a visiting professor lecture, was not appreciated. No humor in this field

 

[Gern Blansten]

Eh, tried (Midwest academic institution) this at a visiting professor lecture, was not appreciated. No humor in this field

Tons of humor in this field. Gotta bring actual jokes.

 

[Ashers]

Tons of humor in this field. Gotta bring actual jokes.

I made an attending laugh when I told him I wanted to do elective retrograde wires. He gave me a monologue about them. And I just said, "Nah, I really want to do lightwands." He said I was like his kids making him think they had done something bad when really they hadn't done their homework.

 

[jon stewart]

"an anesthesiologist from another group helped with resuscitation in PACU"

how does this work, is that anesthesiologist required to fix the messes of this independent CRNA? What happens when they intervene with patient care, do they now have some liability because they helped out?

are they required to rescue someone else mess when that person has not required supervision by an anesthesiologist but rather by a surgeon?

 

[barn80]

"an anesthesiologist from another group helped with resuscitation in PACU"

how does this work, is that anesthesiologist required to fix the messes of this independent CRNA? What happens when they intervene with patient care, do they now have some liability because they helped out?

are they required to rescue someone else mess when that person has not required supervision by an anesthesiologist but rather by a surgeon?

Good question and point. This is and will be an issue when hospitals and ASCs use multiple anesthesia groups.

Anyone know what anesthesia group this CRNA belonged to or what anesthesia group contracted out this independent CRNA?

 

[coffeebythelake]

"an anesthesiologist from another group helped with resuscitation in PACU"

how does this work, is that anesthesiologist required to fix the messes of this independent CRNA? What happens when they intervene with patient care, do they now have some liability because they helped out?

are they required to rescue someone else mess when that person has not required supervision by an anesthesiologist but rather by a surgeon?

I doubt they would be required. There is no established relationship to the patient. Where is the CRNA? In my mind the anesthesiologist who responded to this emergency did so as a good Samaritan.

 

[Ashers]

Good question and point. This is and will be an issue when hospitals and ASCs use multiple anesthesia groups.

Anyone know what anesthesia group this CRNA belonged to or what anesthesia group contracted out this independent CRNA?

It's mentioned in the podcast. It's AZAS Arizona Anesthesia Solutions they have a few ads hiring for doctors on gasworks.

 

[nimbus]

It's mentioned in the podcast. It's AZAS Arizona Anesthesia Solutions they have a few ads hiring for doctors on gasworks.

Interesting that is the infamous Joe Rodriguez’s group.

 

[coffeebythelake]

Interesting that is the infamous Joe Rodriguez’s group.

Can u elaborate.. what does that mean..?

 

[GassYous]

Interesting that is the infamous Joe Rodriguez’s group.

Who?

 

[CubsDynasty]

He’s the TikTok star of the independent CRNA movement, so that’s hilarious that that was his group

 

[barn80]

He’s the TikTok star of the independent CRNA movement, so that’s hilarious that that was his group

How ironic. Wonder if he fired the CRNA from his group because of this adverse event.

 

[Fpg1245]

How ironic. Wonder if he fired the CRNA from his group because of this adverse event.

There’s a shortage so they probably dumped him at another ASC or something kind of like what the CC did with “problematic” clergy

 

[coffeebythelake]

He’s the TikTok star of the independent CRNA movement, so that’s hilarious that that was his group

Independent CRNA movement... but when **** hit the fan patient needed to be bailed out by an anesthesiologist. That Rodriguez clown probably blood boiling from that. He would rather the patient die than admit a CRNA couldn't handle it.

 

[Bru]

On a related note, saw this gem littered around our anesthesia areas today.

 

[sevoflurane]

AANA is just so toxic.

 

[sevoflurane]

Honestly surprised your group would stand for these type of flyers.

 

[OTCAwesome]

On a related note, saw this gem littered around our anesthesia areas today.

View attachment 365081

Please tell me you took that down....

 

[MirrorTodd]

Honestly surprised your group would stand for these type of flyers.

Ya I would say that ish needs to be addressed in a group meeting.

 

[Iso4ane]

On a related note, saw this gem littered around our anesthesia areas today.

View attachment 365081

Should've added a post-it note, 'They did so poorly they had to bring in the doctors.'

 

[nimbus]

Honestly surprised your group would stand for these type of flyers.

Gotta play along to get along.

 

[vector2]

On a related note, saw this gem littered around our anesthesia areas today.

View attachment 365081

Yeah we got a couple of those stupidass posters hanging around.

The tagline is about as salient as "Horse and buggy drivers: The original transportation experts"

 

[Gern Blansten]

Yeah we got a couple of those stupidass posters hanging around.

The tagline is about as salient as "Horse and buggy drivers: The original transportation experts"

Barbers, the original surgeons...

 

[sevoflurane]

Gotta play along to get along.

I wouldn’t know… 😉 🌝