Pearls on avoiding malpractice suits

[po_boy]

Woke up in severe pain or complained intraop. Presentation in both was more of weakness than radiculopathy. True dermatomal distribution hard to characterize as you might imagine. Operative Images showed nothing unusual but MRI done 24-48 show new findings at area of interest.

Hard to say what would happen under local. Area of controversy. I use local or PO Valium. I had one patient two years into practice who complained of pain with perfect epidurograms. I withdrew. Symptoms went away immediately. No sequelae.. That shaped my practice for next 20 years to follow. Not implying what others should do. Just sharing my story.

Pain where? Is it not common for an epidural injection to cause discomfort/ pain?

 

[mille125]

Midaz and fentanyl for all for me.

But recall that none of those procedures say in their LCD that MAC sedation should be rare.

 

[mille125]

Pain where? Is it not common for an epidural injection to cause discomfort/ pain?

Pain in neck and arm with lots of weakness.

I agree that pain is not uncommon in the first 24-48 hours after an epidural. Many of us blow it off.

Weakness is not. If you hear pain and weakness, I wouldn't blow that off.

 

[lobelsteve]

Physicians should be judicious in the safe use of sedation. Patients should be advised during informed consent that sedation is not necessary, but elective. The physician and patient need to weigh the risks and benefits of procedural harm with any potential advantage attributed to intravenous sedation. Providing patient educational material regarding sedation can assist patients in making informed decisions. If the physician performing the procedure decides to administer and supervise the sedation, they should be trained and qualified to do so. In these situations, a separate healthcare provider is required to assist with the administration of the medications and monitoring of the patient.

Factfinder from IPSIS

 

[Ducttape]

LCD - Epidural Steroid Injections for Pain Management (L39054)

Use this page to view details for the Local Coverage Determination for Epidural Steroid Injections for Pain Management.

www.cms.gov

1. Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and therefore not considered medically reasonable and necessary.16 Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice. In exceptional and unique cases, documentation must clearly establish the need for such sedation in the specific patient.

LCD - Facet Joint Interventions for Pain Management (L38803)

Use this page to view details for the Local Coverage Determination for Facet Joint Interventions for Pain Management.

www.cms.gov

1. The use of Moderate Sedation for RFA or cyst rupture/aspiration will be considered in individual cases with documentation of medical necessity such as a longstanding well-documented history of inability to cooperate, medical conditions that would prohibit performance of the procedure, or inability to remain motionless. Patient anxiety or preference alone is not sufficient justification. Routine use of Moderate Sedation or Monitored Anesthesia Care (MAC) or use of General Anesthesia or Deep Sedation for RFA is not considered reasonable and necessary.

LCD - Sacroiliac Joint Injections and Procedures (L39462)

Use this page to view details for the Local Coverage Determination for Sacroiliac Joint Injections and Procedures.

www.cms.gov

1. Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for SIJ injections and therefore not considered medically reasonable and necessary.10 Even in patients with a needle phobia and anxiety, typically oral anxiolytics suffice.

which bread and butter injection type am i missing?

 

[mille125]

LCD - Epidural Steroid Injections for Pain Management (L39054)

Use this page to view details for the Local Coverage Determination for Epidural Steroid Injections for Pain Management.

www.cms.gov

LCD - Facet Joint Interventions for Pain Management (L38803)

Use this page to view details for the Local Coverage Determination for Facet Joint Interventions for Pain Management.

www.cms.gov

LCD - Sacroiliac Joint Injections and Procedures (L39462)

Use this page to view details for the Local Coverage Determination for Sacroiliac Joint Injections and Procedures.

www.cms.gov

which bread and butter injection type am i missing?

Yes...that is what I was referring to..

 

[Ducttape]

Yes...that is what I was referring to..

um....

Midaz and fentanyl for all for me.

But recall that none of those procedures say in their LCD that MAC sedation should be rare.

all of those procedures say that sedation should be rare....

 

[mille125]

um....


all of those procedures say that sedation should be rare....

You might have missed it but the question asked to me that brought this response was what sedation I use for kyphos, RFAs, and SCS.

I am quite aware of what the LCD says for the cases you mention. If you scroll back in the discussion you will see that I brought this up before.

 

[Ducttape]

my apologies.

the "for all" confused me.

 

[mille125]

What type of sedation if any do you use for RFA? Kypho? SCS trial?

This was the question I was addressing

 

[mille125]

my apologies.

the "for all" confused me.

No worries. I am making the same point as you and it is a point that docs I defend have to contend with

Not insurmountable but like entering a football game down 14-0 fron turnovers.

My job is to help you get touchdowns to get back into the game. If you don't have the "players" to score I usually recommend settling. You can always win but it is far preferable to start game at 0-0 than down 14-0.

 

[mille125]

With that said I have been totally shocked at times to find that in over half the cases the defense experts don't even bring this obvious LCD issue up. If they don't, I obviously don't.

I only do defense work.