supervision and running own case in emergency?

[TaoistDoc]

So I'm a fresh attending in private practice where we supervise crna's typically up to 1:4. when I'm on call, I'm the only attending here. Let's say I'm supervising 3 rooms on call and a stat c section is called or a stat trauma came in. I don't have any anesthetist available and it would take too long for another md to come in. Am I right to start the emergency case while "supervising" the 3 other rooms? We have walkie talkies so if one of the anesthetists get into trouble, I can still direct them that way. I'm just not sure what the rules are.

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[IlDestriero]

It depends on how your CRNAs are covered/billing.

For billing purposes, CRNA and AA services are considered either medically directed or medically supervised. AAs must work under the medical direction of an anesthesiologist who is physically present during the provision of services. CRNAs may be either medically directed by an anesthesiologist or medically supervised by the attending physician.

Medically Directed Anesthesia Services

Medically directed anesthesia services are those services performed by a CRNA or an AA and directed by an anesthesiologist. When a CRNA or AA is medically directed, the anesthesiologist must do all of the following:

Perform pre-anesthesia examination and evaluation.
Prescribe the anesthesia plan.
Personally participate in the most demanding procedures of the anesthesia plan, including induction and emergence, if applicable.
Monitor at frequent intervals the course of anesthesia administered.
Remain physically present and available for immediate diagnosis and treatment of emergencies.
Indicate post-anesthesia care.
Medically Supervised Anesthesia Services

Medically supervised anesthesia services are those services performed by a CRNA and supervised by the attending physician. When a CRNA is medically supervised, the attending physician:

Reviews and verifies the pre-anesthesia evaluation performed by the CRNA.
Reviews the anesthesia plan, including medication.
Reviews and comments during pre-anesthesia care.
Reviews and comments during post-anesthesia care.

Medically Directed vs. Medically Supervised Anesthesia Services

For medically directed anesthesia services, an anesthesiologist is present during critical points in the procedure and is immediately available for diagnosis and treatment of emergencies. However, when a CRNA is medically supervised by the attending physician, an anesthesiologist does not have to be present during critical points in the procedure or immediately available for diagnosis and treatment of an emergency.

 

[urge]

I believe there is some exception in medicare for emergency scenarios like this but I think you can only claim it for half an hr or so.

I'm sure it can be googled.

 

[IlDestriero]

We have medical direction of CRNAs.
On nights/weekends we have Residents and fellows only.
If I was tied up in multiple emergency cases and a trauma came in, I'd call in the 2nd call person and enlist the PICU attending to line and/or resuscitate the patient or leave them in the ER until someone was free.
We also have an OB anesthesiologist in house who could potentially cover stable OR cases of we had to take a true emergency emergently to the OR.

 

[TaoistDoc]

Okay. I get the whole medical direction vs supervision thing. But billings aside, from a medical standpoint, if I'm doing my own emergency case and one of the rooms I was "supervising" coded and I am not physically available, but can still direct care via a walkie talkie, is that defensible if a bad outcome occurs?

 

[TaoistDoc]

We have medical direction of CRNAs.
On nights/weekends we have Residents and fellows only.
If I was tied up in multiple emergency cases and a trauma came in, I'd call in the 2nd call person and enlist the PICU attending to line and/or resuscitate the patient or leave them in the ER until someone was free.
We also have an OB anesthesiologist in house who could potentially cover stable OR cases of we had to take a true emergency emergently to the OR.

It's nice being in an academic center where you have all those people available, but what about for us private practice folks?

 

[Man o War]

For me personally, no way would I do that. Too much liability if something goes down in one of the supervision rooms and ends in a lawsuit, regardless of whether it's being billed properly or not. The plaintiff's attorney will eat your lunch on this. The CRNA is still working under your license. We always had 2 CRNAs on OB and a partner on back up call for these scenarios.

 

[TaoistDoc]

For me personally, no way would I do that. Too much liability if something goes down in one of the supervision rooms and ends in a lawsuit, regardless of whether it's being billed properly or not. The plaintiff's attorney will eat your lunch on this. The CRNA is still working under your license. We always had 2 CRNAs on OB and a partner on back up call for these scenarios.

Interesting. I have a partner on call too, but it could take them 30 minutes to come in. And that's just not enough time for a stat c-section or a bad trauma. If you refuse to do the emergency, could you be liable for that as well? Especially a bad outcome from not doing a c section in time.

 

[IlDestriero]

Okay. I get the whole medical direction vs supervision thing. But billings aside, from a medical standpoint, if I'm doing my own emergency case and one of the rooms I was "supervising" coded and I am not physically available, but can still direct care via a walkie talkie, is that defensible if a bad outcome occurs?

I would say no, that's not defensible.
I was doing another emergency when I abandoned your wife, child, etc. in their moment of need doesn't go over well. Who knew they would laryngospasm and go into NPPE at extubation and had a hypoxic injury while the CRNA was googling the right dose of lasix and hoping the second call guy gets in soon.

 

[Man o War]

Interesting. I have a partner on call too, but it could take them 30 minutes to come in. And that's just not enough time for a stat c-section or a bad trauma. If you refuse to do the emergency, could you be liable for that as well? Especially a bad outcome from not doing a c section in time.

I'm not sure about that, I think the key is keeping a free body at all times. In my 10 years in private practice, I never had a situation where I was put in this predicament, and I took a lot of call (Q6). We did sacrifice some income to maintain the extra body for these situations (a CRNA), but that was a decision we made for peace of mind. The hospital I worked at didn't have any more OR staff than we had bodies in house at any given time, so that was a big part of not having issues I think.

 

[IlDestriero]

Interesting. I have a partner on call too, but it could take them 30 minutes to come in. And that's just not enough time for a stat c-section or a bad trauma. If you refuse to do the emergency, could you be liable for that as well? Especially a bad outcome from not doing a c section in time.

This was an issue at my little navy hospital. Only me on call, no back up at all, and covering low volume OB and the OR.
Usually I would hold the urgent cases if there was a woman in labor. If I had to do an OR case, I would call the OB and tell them that I wouldn't be available for 60-90 minutes for an ORIF, appy, etc. It was up to them to divert patients. We weren't a trauma center, so I don't think we had any obligation to do any OR cases, so they could be medically stabilized and transferred out as well.
It was an uncomfortable situation that relied on the surgeons to accept the limitations of the facility. It was only a problem one weekend when I was stuck doing a nasty perforated gangrenous appy that was much sicker than they looked and took way too long in the OR. They knew I wasn't available, and with a complex patient, and admitted a labor patient anyway who shortly later started in with the late decells, etc. I said it was entirely their fault and they could wait until I was available or do it with local and ketamine with the ED physician (which was the emergency back up plan). They waited, we did a crash general the second I was free and the kid was apgar 8/9. 🙂
I blew up on that dunce OB like Fat Man over Nagasaki. She could have caused some kid permanent disability because she didn't want to justify a transfer to the local hospital when the mom and fetus were perfectly stable.

 

[urge]

Okay. I get the whole medical direction vs supervision thing. But billings aside, from a medical standpoint, if I'm doing my own emergency case and one of the rooms I was "supervising" coded and I am not physically available, but can still direct care via a walkie talkie, is that defensible if a bad outcome occurs?

It is a no win scenario.

I'm not sure about that, I think the key is keeping a free body at all times. In my 10 years in private practice, I never had a situation where I was put in this predicament, and I took a lot of call (Q6). We did sacrifice some income to maintain the extra body for these situations (a CRNA), but that was a decision we made for peace of mind. The hospital I worked at didn't have any more OR staff than we had bodies in house at any given time, so that was a big part of not having issues I think.

This is the most sensible approach.

 

[Impromptu]

Since medical supervision doesn't receive the full anesthesia payments (probably only 70%), I've heard that most places that medically supervise actually bill it as solo CRNA work, even if you do all the work of medical supervision or even direction. Billing this way gives some flexibility to the charge doctor to handle emergencies. If I understand things correctly.

 

[oldguy55]

Here's our "solution" to this scenario:

We have one MD and one CRNA on call. Call cases (or even just cases running late into the afternoon or evening) are not uncommon.

Just about the only truly STAT cases we have are C-sections. Serious trauma almost always gets shipped. Most other cases can wait at least a little while.

If we need a second room during call time they try to find someone willing to come in. With the widespread use of caller-ID, that gets to be problematic.

If the CRNA and I are doing a case, I have a commitment to that patient; the CRNA really doesn't. I can't leave the case I started.

If a truly STAT case comes along and we are busy and nobody can come in to help out, the CRNA must start that case under the supervision of the OB physician. The OBs (reluctantly) accept this plan.

This should only occur in dire emergency situations and in such an emergency the C-section will be done in the main OR, across the hall from the running OR, so that I am immediately available for an induction problem. An inconvenience for a lot of people but that's too bad.

Not a perfect solution but the alternatives are either having a second call CRNA (that won't fly in a group of six) or telling surgeons not to do non-emergent cases after hours. Right.

 

[BLADEMDA]

So I'm a fresh attending in private practice where we supervise crna's typically up to 1:4. when I'm on call, I'm the only attending here. Let's say I'm supervising 3 rooms on call and a stat c section is called or a stat trauma came in. I don't have any anesthetist available and it would take too long for another md to come in. Am I right to start the emergency case while "supervising" the 3 other rooms? We have walkie talkies so if one of the anesthetists get into trouble, I can still direct them that way. I'm just not sure what the rules are.

It's perfectly legal to cover emergencies by doing those cases yourself. But, you can't bill medical direction for the other cases the CRNAs are doing at the same time.

You are legally liable for the actions of all your CRNAs while you are busy doing your own case unless the hospital has a policy where CRNAs are permitted to be solo providers.

So, the rules are you can get away with your current emergency plan but if anything goes wrong you will be held liable. I'd advise to call in your backup Anesthesiologist even if he/she takes 40 min to arrive at the hospital. This way you can testify under oath you followed your group's protocol.

 

[B-Bone]

This happens infrequently in my practice. Always with stat c/s while another case is going (one md, one crna in house, one of each on backup call from home ~30 min away). There is an exception to medical direction rules for "emergency of short duration". I decide which situation is more urgent (ongoing case or c/s). If it's the c/s (which it pretty much always is), I run to OB and start the case while the OR nurse calls my backup in. C/s is usually almost done by the time they get there, and I am available by phone to main OR the whole time. There is medico legal risk with this scenario, but the billing is on the level. I use common sense. Most OR cases are stable enough for me to step away from for 30 min (come on guys, we do this all day long while supervising. What's the difference in the middle of the night?). If I have a situation I truly can't leave (e.g. Starting a ruptured AAA, a situation which I have encountered in this scenario), backup gets called and the OB waits or starts the case under local. In every instance ever, they have waited. No bad outcomes (yet...). Also happens when the code pager goes off while supervising my only CRNA. One of us goes to the code (i always stay/go to the sickest patient). This scenario is medico legally reasonable in my mind. It could happen no matter how many providers are around. All it takes is "n+1" emergencies simultaneously.

A much more sketchy scenario is in an MD only practice where you are sitting your own case as the only in house guy and a stat c/s walks in off the street. Do you abandon your (likely) stable OR pt and save a life (or two), or do you let a baby (and possibly mother) die because you're concerned about liability?

 

[BLADEMDA]

The following is a list of procedures performed and billed by anesthesiologists that I randomly pulled from the spreadsheets to illustrate how little money they made from the program. The first column is the average amount they charged for the procedure while the second column is the average they received from Medicare.


As you can see, anesthesiologists barely make back ten cents on the dollar for interventions that have life and death consequences. Only $99 for an emergency intubation? That is somebody's life on the line. If we failed and the patient dies, or worse suffers anoxic brain injury, that $99 wouldn't even cover the lawyer's lunch bill. A brachial plexus block for only $48? It take at least twelve years of education after high school and thousands of hours of training to be able to confidently and successfully place a block. For all that hard work we don't get paid enough to take a family out to see a movie? If there is nerve injury or a catastrophic complication, that $48 suddenly doesn't seem worth the risks.

The worse news for anesthesiologists though, if it could possibly get worse, is that our reimbursements from Medicare aren't all that different from CRNA's who bill for the same procedures. Again here is just a quick random sampling of the spreadsheet. The amounts that are reimbursed are determined by complicated formulas that is beyond my scope to explain here. This tiny sample does not imply an overall trend, which will require analysis of thousands of numbers for which I'm not getting paid enough to do, as in zero.


From the great Z blog

 

[seinfeld]

Our emergency Csections take 30 minutes. By the time I get the phone call, get out of bed and make it to the hospital as the backup guy, the section is over.

For True stat csections we do what is in the best interest of the patient and provide anesthesia. There are exemptions for OB emergencies.

 

[B-Bone]

Our emergency Csections take 30 minutes. By the time I get the phone call, get out of bed and make it to the hospital as the backup guy, the section is over.

For True stat csections we do what is in the best interest of the patient and provide anesthesia. There are exemptions for OB emergencies.

Ours are frequently done before the backup gets there, but our insurance and billing companies feel it's important to document that they've been called and are on the way in.

 

[Magnus67]

You do the emergency case, have your other rooms bill out QZ. Not ideal but if it's rare, it will keep u from billing fraud.

 

[sleepallday]

One of the most important skills I've learned after residency was how to triage cases. Know your resources and surgeons so that you don't screw yourself later. Sometimes you just have to tell the orthopod that they can't start the elective spine at 7pm on a sunday.

 

[Noyac]

I think the issue has been cleared up by the other comments so I will just throw out there one more thing.
Always do what's right for the pt. You can clean up the mess later.

 

[pjl]

I am in same situation as B-bone but only backup MD, not CRNA.
We are in opt out state. If a true emergency comes while case is running, I call backup in, and drop supervision of CRNA. This has happened 1 time for 20 minutes in 4 years. Once backup arrives we go back to business as usual. If we run 3 cases on call, the CRNA supervision would have been dropped and the hospital would be on divert. With our volume that has only happened once with a partner in same 4 years.

Like he stated, there is always the potential of n+1 emergencies, which admin has a hard time understanding when we discuss backup plans (every time this happens). Calling all the anesthesiologists to see if any can come in even not on call was deemed acceptable.

 

[Mman]

You are always allowed to respond to a true emergency. If need be, the CRNAs you aren't able to physically help can be supervised by the surgeons doing those cases. CMS only requires that it be a physician, not an anesthesiologist. We have our hospital by laws set up to allow surgeon to supervise the CRNA in event the anesthesiologist is tied up with another emergency. If it's an opt out state, it's even easier. The only issue that needs cleaning up is the billing when it's all said and done.

I'm in the exact same scenario as OP. If stuff is hitting fan overnight and everybody is in a room doing a case and another emergency popus up, I'll call an MD in from home to come take over the currently running rooms while I do the newest emergency myself. This is an extremely rare scenario in my setting (probably < 1/1000 chance in a given night).

 

[TaoistDoc]

You are always allowed to respond to a true emergency. If need be, the CRNAs you aren't able to physically help can be supervised by the surgeons doing those cases. CMS only requires that it be a physician, not an anesthesiologist. We have our hospital by laws set up to allow surgeon to supervise the CRNA in event the anesthesiologist is tied up with another emergency. If it's an opt out state, it's even easier. The only issue that needs cleaning up is the billing when it's all said and done.

I'm in the exact same scenario as OP. If stuff is hitting fan overnight and everybody is in a room doing a case and another emergency popus up, I'll call an MD in from home to come take over the currently running rooms while I do the newest emergency myself. This is an extremely rare scenario in my setting (probably < 1/1000 chance in a given night).

Unfortunately its not that rare for me. In addition, it seems the culture of my practice is to not call the back up md in unless Armageddon is happening. I've been told that if the anesthetist is doing a stable case and an emergency happens, just do the emergency myself without calling in backup. Theoretically, this is fine 99% of the time since bad **** is unlikely to occur during a stable anesthetic, but that potential 1% scares me.

I'm new to the group and hate to be telling the partners that I think their way of doing things is a little too cavalier, but that's how I feel about it. Maybe I'll be the douchebag everyone hates to be on 2nd call with since I'll be calling them in for emergencies

 

[Planktonmd]

You do the emergency case and you stop supervising the other rooms.
In other words you tell the CRNA's that they are now flying solo and you bill with a QZ modifier (CRNA working alone).

 

[TaoistDoc]

You do the emergency case and you stop supervising the other rooms.
In other words you tell the CRNA's that they are now flying solo and you bill with a QZ modifier (CRNA working alone).

So are you saying I shouldn't be such a p$@#y and just do the case, and not call in backup? But I don't live in an opt out state, and a lot of the time, I have an AA, not a CRNA. Does that change anything?

 

[jwk]

A much more sketchy scenario is in an MD only practice where you are sitting your own case as the only in house guy and a stat c/s walks in off the street. Do you abandon your (likely) stable OR pt and save a life (or two), or do you let a baby (and possibly mother) die because you're concerned about liability?

Never.

 

[jwk]

I am in same situation as B-bone but only backup MD, not CRNA.
We are in opt out state. If a true emergency comes while case is running, I call backup in, and drop supervision of CRNA. .

"Opt out" is a billing issue only. It's not a consideration from a clinical standpoint, and the situation would be no different in a non-opt out state.

 

[jwk]

So are you saying I shouldn't be such a p$@#y and just do the case, and not call in backup? But I don't live in an opt out state, and a lot of the time, I have an AA, not a CRNA. Does that change anything?

I can't speak to the billing nuances but, by law, AA's can act in an emergency without the presence of an anesthesiologist - always have. My very first case on call, ever, was a ruptured uterus with twins. I was already pushing the pentothal as the anesthesiologist was walking in the OR door.

 

[Planktonmd]

So are you saying I shouldn't be such a p$@#y and just do the case, and not call in backup? But I don't live in an opt out state, and a lot of the time, I have an AA, not a CRNA. Does that change anything?

You call the backup but until he gets there you start the case and let the CRNAs fly solo.
If you have AAs it's a problem!

 

[deleted171991]

So are you saying I shouldn't be such a p$@#y and just do the case, and not call in backup? But I don't live in an opt out state, and a lot of the time, I have an AA, not a CRNA. Does that change anything?

CRNAs are APRNs, hence can work independently in certain conditions in most (if not all) states. I strongly doubt that's the case with AAs - see your state law.

From what I understand, the QZ modifier only applies to CRNAs, which suggests that AAs are not supposed to work unsupervised. (Compare it with QY!)

 

[Noyac]

Sometimes in this business you have to make a decision and act on it. It's a gamble at times but with experience hopefully the odds are in your favor. Nothing we do is 100% but some here are quibbling about a 1% risk as they state.
So let me offer a few options since I would hate to be on call and have someone call me in as backup to do a case while they supervise a crna or aa.
If the mid levels case is going well then start the emegency case. If it is touch and go then have the midlevel start the emergency. If things are still not to your liking then call your backup but as anesthesiologists we do plenty of call and work late hours frequently. I wouldn't want to add to that unnecessarily.
If you need to call in backup then do the emergency yourself and let the backup supervise at least if they choose. It's not that difficult but someone that abuses the situation rapidly will lose support from the group.

Not long ago I brought a pt from the ICU to the OR for an ex lap. Just before starting the case I placed a labor epidural and told the OB I would be busy for a couple hours. They said no problem. Next thing I know the surgeon is washing up and sticks his head in the OR to say," what's going on in room 1?" I knew exactly what it was, a C section. So I called the pacu nurse into the OR and told her to use the gas to keep the BP in a certain range and the surgeon assisted with the norepinephrine drip changes as needed while I ran to do the c/s. I returned 45 minutes later and we resumed the ex lap. Luckily we had not started the case yet. I don't have the luxury of extra hands. And I did a spinal in the c/s so I was able to run back and forth as needed.

 

[vector2]

Not long ago I brought a pt from the ICU to the OR for an ex lap. Just before starting the case I placed a labor epidural and told the OB I would be busy for a couple hours. They said no problem. Next thing I know the surgeon is washing up and sticks his head in the OR to say," what's going on in room 1?" I knew exactly what it was, a C section. So I called the pacu nurse into the OR and told her to use the gas to keep the BP in a certain range and the surgeon assisted with the norepinephrine drip changes as needed while I ran to do the c/s. I returned 45 minutes later and we resumed the ex lap. Luckily we had not started the case yet. I don't have the luxury of extra hands. And I did a spinal in the c/s so I was able to run back and forth as needed.

What do you mean, luckily?? Are you telling me that there was a chance the surgeon was gonna cut on your ICU player when you still weren't in the room? Maybe it's cause this hairy case I had last week on this 380lb'er with a horribly infected pancreatic pseudocyst and ARDS is still fresh in my mind, but the thought of a PACU nurse titrating my gas while the surgeon makes changes to the levophed is giving me palpitations.

And just to further my resident education, can you guys tell me the legal ramifications if say the OB patient was having a touch of refractory hypotension post-spinal placement or uterine atony after delivery and the ICU guy happened to code in the other room at the same time you were dealing with her?

 

[BLADEMDA]

Remember the Anesthesiologist is LIABLE for his/her actions in all these scenarios. This means you are responsible for the patients' outcomes in these situations. That AA or CRNA is still your responsibility if anything goes wrong while you are handling that emergency case. The fact that your group chose to not adequately staff the OR and OB will be discussed in your deposition. The hospital will likely be liable as well for that poor decision.

As for how you handle the emergency case it is simple: You do the emergency case while your AA/CRNA handles the other case. You call your partner in to "supervise" the midlevel while you personally do the emergency case. Even if your partner never arrives your arse is covered because you followed protocol.

If you have an AA doing the other case then the billing/revenue from that case may be sacrificed due to your involvement with the emergency.

 

[BLADEMDA]

What do you mean, luckily?? Are you telling me that there was a chance the surgeon was gonna cut on your ICU player when you still weren't in the room? Maybe it's cause this hairy case I had last week on this 380lb'er with a horribly infected pancreatic pseudocyst and ARDS is still fresh in my mind, but the thought of a PACU nurse titrating my gas while the surgeon makes changes to the levophed is giving me palpitations.

And just to further my resident education, can you guys tell me the legal ramifications if say the OB patient was having a touch of refractory hypotension post-spinal placement or uterine atony after delivery and the ICU guy happened to code in the other room at the same time you were dealing with her?

You are liable the actions/inactions of everything going on here. You may be able to convince a jury you acted reasonably in this situation but I doubt they will approve of your staffing model. Both the hospital and the Anesthesiologist will settle the cases prior to going to a jury trial.

 

[BLADEMDA]

$6,500,000 SETTLEMENT IN ANESTHESIA CASE RESULTING IN BRAIN DAMAGE* (Structured Settlement payout of $45,000,000) Medical Malpractice Trial Report ANESTHESIA Medical Malpractice Lawsuit: 
 Failure to Monitor Anesthesia Results in Brain Damage. The Plaintiff, age 7, was admitted to the Hospital for the performance of a tonsillectomy and adenoidectomy. The morning of the surgery the Plaintiff’s father met with the Anesthesiologist briefly. The Anesthesiologist never told the family that the Nurse Anesthetist would actually be inducing anesthesia and monitoring the Plaintiff during the surgery, and that he, the Anesthesiologist would not be physically in the operating room for the majority of the time. After intubation and induction, the Anesthesiologist left the operating room leaving the Plaintiff to be monitored by Nurse Anesthetist. The Hospital had five working operating rooms. On the date in question four operating rooms were in use. Nurse-anesthetists manned three of the operating rooms with the fourth room manned by an anesthesiologist other than the Defendant Anesthesiologist. The Defendant Anesthesiologist's sole responsibility that day, pursuant to the guidelines of the Hospital, was to be the director and supervisor of the Nurse-Anesthetists in the three operating rooms. Following intubation the Plaintiff underwent anesthesia induction with the drug Halothane through the endotracheal tube. Anesthesia is the practice of rendering someone unconscious so that they will not feel pain. Halothane does this by affecting the central nervous system. When given in too high of a dose, the central nervous system will shut down to too large of a degree affecting the transfer of oxygen in the body. This failure of the body to transfer oxygen and oxygenate the blood leads to a condition as know hypoxia. Hypoxia is defined as a decrease below normal levels of oxygen in arterial blood or tissue. When the body is faced with hypoxia it attempts to protect itself from damage. This is done by autoregulation of the blood flow. The brain shunts blood away from the periphery and increases flow to the brain and heart to insure that they are not damaged. Unfortunately, the body can only autoregulate itself for a period of time. Eventually, if the hypoxia continues, there is cardiovascular- collapse and brain damage. One sign of hypoxia is a lowering of the blood pressure and an increase in the pulse rate. The low blood pressure is due to the shunting of the blood; the high pulse rate is the bodies attempt to counteract the decreased oxygen content by increasing the amount of heartbeats. In effect, by having additional beats of low oxygenated blood the body hopes to maintain the same tissue oxygenation that was being supplied by fewer beats of properly oxygenated blood. The Plaintiff was started with an induction dose of O-3.O percent. The standard of care then calls for a tapering of the induction dose to a smaller maintenance dose during surgery. During surgery the Plaintiff was monitored at a dose of 2.5 percent. It was the opinion of the Plaintiff’s various medical experts that Defendants Anesthesiologist and Nurse Anesthetist fell below the standard in the administration and maintenance of the Halothane in that the Plaintiff was overdosed on Halothane. The Plaintiffs expert testified in deposition that the loading dose of 3.O percent and the maintenance dose of 2.5 percent were too high. Also, the anesthesia record for the Plaintiff indicates that during surgery the Plaintiff's pulse became tachycardic (very fast) and his blood pressure was dropping. These symptoms were apparently ignored by the Nurse Anesthetist. Another manner of confirming the patients well being during surgery is through the use of a pulse oximiter. This is a process by which a machine determines the oxygen saturation of blood. This is done through a clip or wrap piece that is placed on a patients finger. Pulse Oximitry was used on the Plaintiff. The pulse oximitry will provide a reading of the percentage of oxygen content. Clearly the percentage should be high in a normal person, 98-100 percent. The Plaintiff was receiving oxygenate during surgery through the intubation tube and therefore his oximitry reading should have been 100%. During surgery the oximitry reading was only 97%. Further, during surgery the pulse oximitry actually dropped on two occasions from 97 to 0. This was a sign of lack of oxygenation that was also ignored by the Nurse Anesthetist. Nurse Anesthetist who simply asked that the clip for the oximitry be replaced did not aggressively investigate this situation. The clip was replaced and again showed readings that went from 97 to 0. Again the Nurse Anesthetist asked for the clip to be replaced. The Nurse Anesthetist did not consider that the oximitry reading might actually be evidence of the Plaintiff becoming hypoxic, which was the case. The Nurse Anesthetists simply assumed that the machinery was not working, and did not confirm the Plaintiffs well being. had the Nurse Anesthetist done so it would have been evident that the Plaintiff was hypoxic, and would have taken action to reverse the hypoxia, well before cardiovascular collapse and brain damage. The pulse oximetry equipment was later checked and found to be properly working without any difficulty. Therefore, the drop in the pulse oximetry from 97 to 0 was not caused by a machine malfunction, as was at one point suggested by the Defendants, but was an indication of hypoxia. Either because of concern due to the abnormal oximetry readings or because it was the conclusion of the surgery, depending upon which deponent was to be believed, the surgical table was turned so that the Plaintiff’s head was away from the surgeon and in front of the Nurse Anesthetists. At that time the Plaintiff was found to be severely cyanotic. Cyanosis is a bluish coloration of the skin due to deficient oxygenation content of the blood. Cyanosis is one of the indications of hypoxia. The bluish color of the child’s sin was not noticed earlier by the surgeon or the Nurse Anesthetist because the child was draped for surgery. Faced with what was now a medical emergency, the Nurse Anesthetist called for a code blue. The supervising Anesthesiologist responded with another Anesthesiologist and CPR was begun. At that time the Plaintiff had no pulse. The second anesthesiologist managed the care of the Plaintiff during the code. This second anesthesiologist stated that he saw a wide QRS rhythm on the EKG. This wide complex rhythm is evidence of a long standing duration of hypoxia rather than an acute event. Due to the long-standing delay in recognizing the Plaintiff’s hypoxia, his condition had deteriorated so badly that it was extremely difficult to regain a pulse. By this time, extensive brain damage had already occurred. Eventually the Plaintiff did regain a pulse and was transferred to another facility. Following the events in question the Plaintiff was diagnosed as being significantly and profoundly brain damaged. The actual diagnosis is anoxic encephalopathy. Apart form the brain damage, he is otherwise physically healthy. The Plaintiff has little cognitive function but does smile appropriately, laughs when tickled and responds to his mother’s voice. The Plaintiff will now be cared for at home with his family. Following the close of discovery, the case was settled at mediation for the amount of Six Million Five Hundred Thousand ($6,500,000.00) Dollars. A portion of the settlement amount was structured. Should the child live for a normal life expectancy, which it is expected he will, the payout for the structure will be in the amount of Forty Five Million ($45,000,000.00) Dollar

 

[BLADEMDA]

4 Questions You Should Ask Your Anesthesiologist Before The Day of Surgery

Written by Spencer Aronfeld on May 2, 2012. Posted in Medical Malpractice

As a South Florida lawyer who sues anesthesiologist for medical malpractice I am deeply concerned about patient safety and the quality of anesthesia care that is being provided in Florida’s hospitals and ambulatory surgical centers. Anesthesia care is not only very complex and demanding, but when not performed properly, it can have a devastating affect on patients and their families.

http://www.floridainjurylawyer-blog.com/2012/05/6-questions-you-should-ask-you.html

 

[BLADEMDA]

Court case, study raise question: Should your CRNAs be supervised?

A patient goes in for a colonoscopy in which a certified registered nurse anesthetist (CRNA) provides anesthesia care. According to the subsequent lawsuit filed by the family, the patient told the CRNA that he had sleep apnea and used a continuous positive airway pressure machine (CPAP) when sleeping.1 The CRNA looked at the patient's neck, said it looked normal, and administered a reduced dose of propofol, the lawsuit says.

The patient deteriorated, and the CRNA tried to intubate but couldn't, according to the lawsuit. The CRNA performed a cricothyroidotomy to open the airway and administered CPR for 45 minutes, it says. The patient died. The family maintains that because the patient had a history of sleep apnea and difficult intubations in prior surgeries, the CRNA should have been supervised by an anesthesiologist and should not have used propofol. The CRNA and the hospital have maintained that they were not negligent.

"I think this case is an excellent example of why an anesthesiologist should be involved in difficult or potentially difficult cases and/or why an anesthesiologist should be available to immediately to respond to a problem," says Stephen Trosty, JD, MHA, CPHRM, ARM, president of Risk Management Consulting Corp., in Haslett, MI.

A CRNA must understand when to call an anesthesiologist and should be required to do so when merited, Trosty maintains. "The fact that there had been previous problems with intubation, coupled with the sleep apnea, are indications that this should have been done by an anesthesiologist and not a CRNA," he comments.

The history of prior problems with intubation, combined with the sleep apnea, make this a more difficult case than usual, Trosty says. "To say that 'the neck looked normal' is not adequate in a case such as this," he says.

 

[BLADEMDA]

Lawsuit: Botched propofol anesthesia care kills 33-year old father and teacher


Propofol is the same powerful anesthetic drug that caused the deaths of Michael Jackson and Joan Rivers


OCTOBER 5, 2013

Painter Law Firm filed a wrongful death medical malpractice lawsuit involving the tragic, avoidable death of Eli Tella. Mr. Tella, age 33, died at Knapp Medical Center, in Weslaco, Texas.

In February 2013, Mr. Tella went to the emergency room at Knapp Medical Center, with stomach pain and nausea. Prior to this illness, he had had a pretty clean bill of health. The emergency room doctor diagnosed Mr. Tella with pancreatitis and related conditions and admitted him to the intensive care unit.

Eventually, Mr. Tella was diagnosed with necrotizing pancreatitis, which required surgeries to remove decaying pancreatic tissue. As is common with this condition, he was also diagnosed with acute respiratory distress syndrome (ARDS) and needed respiratory support.

By March 2013, Mr. Tella had improved—to the point that he was scheduled to be transferred to San Antonio for closure of his abdominal wound and then discharge to home. He certainly looked forward to returning home to be with his wife, Veronica, and their newborn one-year old twin boys, and his job as a teacher at Mercedes Independent School District, in Mercedes, Texas.

Mr. Tella was taken to the operating room for an exploratory surgery to evaluate his abdominal wound and make sure he was ready to be transferred to San Antonio.

A nurse anesthetist, Robert Rene Solis, CRNA, started the anesthesia process with no doctor present in the operating room. As the anesthesia was being given in the operating room, only nursing and tech personnel were present.

Nurse Anesthetist Solis gave Mr. Tella Propofol (the same anesthetic drug involved in Michael Jackson’s death) and other medications. Although anesthesiologist Natalie Ganceres, M.D. was responsible for medically directing the nurse anesthetist, she was not in the operating room area.

Mr. Tella quickly started having problems breathing right after the anesthesia started. Despite the extreme risk to Mr. Tella’s well-being, it took around 20 minutes before the Mr. Solis and the hospital nurses and employees got Dr. Ganceres or any doctor into the operating room for life-saving help.

In fact, it was almost 20 minutes after Mr. Tella’s breathing problems began before Dr. Ganceres finally arrived at the operating room. By then, Mr. Tella had permanent, irreversible brain damage.

Knapp Medical Center’s physicians concluded that Mr. Tella died of a mucous plug that was blocking his airway. Whether from a mucous plug or some other blockage or dislodging of Mr. Tella’s airway, his death was caused by a lack of oxygen to his brain.

Anesthesiologists, like Dr. Ganceres, and other types of doctors, too, are trained in ways to remove those plugs and treat other conditions that cause a blocked or dislodged airway. According to our expert critical care doctor, Mr. Tella’s tragic death would have been avoided if Dr. Ganceres had been supervising the nurse anesthetist, Mr. Solis, and if Mr. Solis, and the nurses and techs in the operating room had promptly called Dr. Ganceres or another physician for help.

Painter Law Firm filed the lawsuit on behalf of Veronica Tella, Individually and As Next Friend of Eli Tella and Mateo Tella, Rosa Hilda Villarreal de Tella, Jose Tella, Claudia Tella, and Mariana Tella, against Knapp Medical Center, Natalie Ganceres, M.D. and Robert Rene Solis, CRNA. The case is pending as Cause No. C-6160-13-E, in the 275th District Court of Hidalgo County, Texas, where Judge Juan Partida is presiding.

Click here to read the lawsuit petition.

 

[BLADEMDA]

On December 23, 1998, 17-year-old Brandi Timmons underwent elective surgery to correct an overbite.   Approximately 15 minutes after that surgery was completed, CRNA Lil Hayes (“Nurse Hayes”) decided to remove the breathing tube that was used to counteract the effects of anesthetization.   An anesthesiologist was summoned over the hospital speaker system to monitor the removal of the tube, and Dr. Ware arrived to watch Nurse Hayes remove Brandi's breathing tube. Brandi was then disconnected from the equipment that monitored her vital signs and was moved to the postanesthesia care unit (“PACU”).

Minutes after she was reconnected to monitoring equipment in the PACU, Brandi went into cardiac arrest.   Tests later revealed that Brandi's brain had suffered irreversible damage caused by events that occurred during her recovery from anesthesia.   Brandi later died as a result of the brain damage.

Johnnie Timmons, on behalf of her daughter's estate, sued Nurse Hayes;  Dr. Ware;  and Anesthesiology & Pain Medicine of Montgomery, P.C., Nurse Hayes and Dr. Ware's employer at the time of Brandi's surgery, alleging medical malpractice and wrongful death.2  Timmons alleged that the treatment Nurse Hayes provided to Brandi during her postoperative recovery fell below the applicable standard of care.   Invoking the doctrine of respondeat superior, Timmons alleged that both Dr. Ware, as Nurse Hayes's supervising anesthesiologist, and Anesthesiology & Pain Medicine of Montgomery, P.C., as Nurse Hayes's employer, were vicariously liable for Nurse Hayes's conduct.

At trial, the defense objected to Timmons's claim that Dr. Ware could be held vicariously liable for Nurse Hayes's conduct, arguing that Nurse Hayes was an employee of Anesthesiology & Pain Medicine of Montgomery, P.C., not of Dr. Ware individually.   The trial court overruled the objection and gave the jury the following instruction:

“I charge you-as it relates to agency and vicarious liability, I charge you the issue of agency in this case is not in dispute.   Both the physician [Dr. Ware] and the CRNA [Nurse Hayes] were at all times working within the line and scope of their employment with Anesthesiology & Pain Medicine of Montgomery, P.C.

“Therefore, I charge you if you should return a verdict in favor of the plaintiff and against either Dr. Ware or Nurse Hayes, that necessarily requires that you also return a verdict in favor of the plaintiff against Anesthesiology & Pain Medicine of Montgomery, P.C., as well.

“The Court charges you further that the responsibility of Dr. Ware for the acts and omissions of Nurse Hayes is likewise not in dispute.   Therefore, should you return a verdict in favor of the plaintiff and against [Nurse] Hayes, you must necessarily also return a verdict against Dr. Ware as well.”

The jury returned a verdict against Nurse Hayes, Dr. Ware, and Anesthesiology & Pain Medicine of Montgomery, P.C. The trial court, entering a judgment on the jury's verdict, awarded Timmons $13.7 million in damages.3  Dr. Ware, Nurse Hayes, and Anesthesiology & Pain Medicine of Montgomery, P.C., appeal.

- See more at: http://caselaw.findlaw.com/al-supreme-court/1292167.html#sthash.eOGh9zMb.dpuf

 

[BLADEMDA]

http://www.nowhabersham.com/10-million-verdict-in-habersham-malpractice-lawsuit/

$10 million verdict against 2 CRNAs and the surgeon for failing to transfuse PRBCs

 

[BLADEMDA]

C-section leads to med mal lawsuit over failed anesthesia
Record News Nov. 11, 2014, 9:51am
0 0 0 14

In a medical malpractice lawsuit, a St. Joseph’s Hospital patient claims she was not given proper anesthesia during a cesarean section procedure.

Plaintiffs Kristina and Joseph Brand failed the six-count complaint against defendants Dr. Bonnie Gelly, Southern Obstetrics & Gynecologic Associates, S.C., and St. Joseph’s Hospital on Oct. 29 in the St. Clair County Circuit Court.

According to the complaint, Kristina was not given appropriate anesthesia during a cesarean section procedure in 2012 while she was a patient at St. Joseph’s Hospital. The plaintiffs claim they relied on the hospital to provide care for her rather than Greg Reynolds, a contracted certified registered nurse anesthetist.

The defendants are accused of negligently and carelessly performing a cesarean section without appropriate anesthesia.

St. Joseph’s Hospital is also accused of providing medical care without informing the plaintiffs that the care provided by Reynolds was that of an alleged independent contractor.

As a result of the defendants’ negligent acts, the plaintiff allegedly underwent surgery with no anesthesia, causing her to experience severe pain and suffering, extreme mental anguish, permanent damage and disfigurement.

The plaintiffs also claim they lost wages and incurred medical expenses and will be liable for future medical expenses in a “substantial amount.”

Additionally, Joseph Brand claims he has been permanently deprived of the love, companionship, consortium, support and services to which he was entitled from his wife.
- See more at: http://madisonrecord.com/stories/51...t-over-failed-anesthesia#sthash.rGadGzms.dpuf

 

[TaoistDoc]

You are liable the actions/inactions of everything going on here. You may be able to convince a jury you acted reasonably in this situation but I doubt they will approve of your staffing model. Both the hospital and the Anesthesiologist will settle the cases prior to going to a jury trial.

My thoughts exactly Blade. My plan is to call in backup and start the emergency case myself. Even if the senior partners don't like being called in to babysit a stable patient, its not their livelihood on the line here.

 

[TaoistDoc]

http://www.nowhabersham.com/10-million-verdict-in-habersham-malpractice-lawsuit/

$10 million verdict against 2 CRNAs and the surgeon for failing to transfuse PRBCs

Holy ****. I guess this was an independent crna practice since no anesthesiologist was mentioned.

 

[BLADEMDA]

JULY 8, 2015
Another State Court Strikes Down Non-Economic Damages Caps in Medical Malpractice Cases
By Wais, Vogelstein & Forman



Earlier this month, a very important case was decided in a Florida court that could have a ripple effect throughout the country. The case involved a woman who went in for routine surgery for her carpal tunnel syndrome but ended up with a perforated esophagus. According to one local Florida news source, the injury occurred when one of the attending medical professionals attempted to insert a tube down the woman’s throat as a part of the anesthesia process.

Evidently, the woman filed suit against the anesthesiologist, a registered nurse anesthetist, and a company that contracts out anesthesiologists and their staff to hospitals in need of qualified staff. After hearing her case, the jury awarded the woman $4.7 million in damages. Of that total, roughly $4 million were “non-economic damages,” meaning that they were designed to compensate the plaintiff not for medical expenses that had previously been incurred, but for her pain and suffering as a result of the defendants’ negligence.

The court had no choice but to reduce the woman’s damages by roughly $2 million because under Florida law there is a maximum amount allowed by law for non-economic damages in personal injury cases.


However, on appeal the court determined that the non-economic damages cap in Florida is a violation of an accident victim’s constitutional rights, and it declared the caps null and void. This is the most recent in a string of cases that have started to look critically at damages caps in personal injury cases because they can act to greatly limit a victim’s potential recovery amount.

 

[TaoistDoc]

$6,500,000 SETTLEMENT IN ANESTHESIA CASE RESULTING IN BRAIN DAMAGE* (Structured Settlement payout of $45,000,000) Medical Malpractice Trial Report ANESTHESIA Medical Malpractice Lawsuit: 
 Failure to Monitor Anesthesia Results in Brain Damage. The Plaintiff, age 7, was admitted to the Hospital for the performance of a tonsillectomy and adenoidectomy. The morning of the surgery the Plaintiff’s father met with the Anesthesiologist briefly. The Anesthesiologist never told the family that the Nurse Anesthetist would actually be inducing anesthesia and monitoring the Plaintiff during the surgery, and that he, the Anesthesiologist would not be physically in the operating room for the majority of the time. After intubation and induction, the Anesthesiologist left the operating room leaving the Plaintiff to be monitored by Nurse Anesthetist. The Hospital had five working operating rooms. On the date in question four operating rooms were in use. Nurse-anesthetists manned three of the operating rooms with the fourth room manned by an anesthesiologist other than the Defendant Anesthesiologist. The Defendant Anesthesiologist's sole responsibility that day, pursuant to the guidelines of the Hospital, was to be the director and supervisor of the Nurse-Anesthetists in the three operating rooms. Following intubation the Plaintiff underwent anesthesia induction with the drug Halothane through the endotracheal tube. Anesthesia is the practice of rendering someone unconscious so that they will not feel pain. Halothane does this by affecting the central nervous system. When given in too high of a dose, the central nervous system will shut down to too large of a degree affecting the transfer of oxygen in the body. This failure of the body to transfer oxygen and oxygenate the blood leads to a condition as know hypoxia. Hypoxia is defined as a decrease below normal levels of oxygen in arterial blood or tissue. When the body is faced with hypoxia it attempts to protect itself from damage. This is done by autoregulation of the blood flow. The brain shunts blood away from the periphery and increases flow to the brain and heart to insure that they are not damaged. Unfortunately, the body can only autoregulate itself for a period of time. Eventually, if the hypoxia continues, there is cardiovascular- collapse and brain damage. One sign of hypoxia is a lowering of the blood pressure and an increase in the pulse rate. The low blood pressure is due to the shunting of the blood; the high pulse rate is the bodies attempt to counteract the decreased oxygen content by increasing the amount of heartbeats. In effect, by having additional beats of low oxygenated blood the body hopes to maintain the same tissue oxygenation that was being supplied by fewer beats of properly oxygenated blood. The Plaintiff was started with an induction dose of O-3.O percent. The standard of care then calls for a tapering of the induction dose to a smaller maintenance dose during surgery. During surgery the Plaintiff was monitored at a dose of 2.5 percent. It was the opinion of the Plaintiff’s various medical experts that Defendants Anesthesiologist and Nurse Anesthetist fell below the standard in the administration and maintenance of the Halothane in that the Plaintiff was overdosed on Halothane. The Plaintiffs expert testified in deposition that the loading dose of 3.O percent and the maintenance dose of 2.5 percent were too high. Also, the anesthesia record for the Plaintiff indicates that during surgery the Plaintiff's pulse became tachycardic (very fast) and his blood pressure was dropping. These symptoms were apparently ignored by the Nurse Anesthetist. Another manner of confirming the patients well being during surgery is through the use of a pulse oximiter. This is a process by which a machine determines the oxygen saturation of blood. This is done through a clip or wrap piece that is placed on a patients finger. Pulse Oximitry was used on the Plaintiff. The pulse oximitry will provide a reading of the percentage of oxygen content. Clearly the percentage should be high in a normal person, 98-100 percent. The Plaintiff was receiving oxygenate during surgery through the intubation tube and therefore his oximitry reading should have been 100%. During surgery the oximitry reading was only 97%. Further, during surgery the pulse oximitry actually dropped on two occasions from 97 to 0. This was a sign of lack of oxygenation that was also ignored by the Nurse Anesthetist. Nurse Anesthetist who simply asked that the clip for the oximitry be replaced did not aggressively investigate this situation. The clip was replaced and again showed readings that went from 97 to 0. Again the Nurse Anesthetist asked for the clip to be replaced. The Nurse Anesthetist did not consider that the oximitry reading might actually be evidence of the Plaintiff becoming hypoxic, which was the case. The Nurse Anesthetists simply assumed that the machinery was not working, and did not confirm the Plaintiffs well being. had the Nurse Anesthetist done so it would have been evident that the Plaintiff was hypoxic, and would have taken action to reverse the hypoxia, well before cardiovascular collapse and brain damage. The pulse oximetry equipment was later checked and found to be properly working without any difficulty. Therefore, the drop in the pulse oximetry from 97 to 0 was not caused by a machine malfunction, as was at one point suggested by the Defendants, but was an indication of hypoxia. Either because of concern due to the abnormal oximetry readings or because it was the conclusion of the surgery, depending upon which deponent was to be believed, the surgical table was turned so that the Plaintiff’s head was away from the surgeon and in front of the Nurse Anesthetists. At that time the Plaintiff was found to be severely cyanotic. Cyanosis is a bluish coloration of the skin due to deficient oxygenation content of the blood. Cyanosis is one of the indications of hypoxia. The bluish color of the child’s sin was not noticed earlier by the surgeon or the Nurse Anesthetist because the child was draped for surgery. Faced with what was now a medical emergency, the Nurse Anesthetist called for a code blue. The supervising Anesthesiologist responded with another Anesthesiologist and CPR was begun. At that time the Plaintiff had no pulse. The second anesthesiologist managed the care of the Plaintiff during the code. This second anesthesiologist stated that he saw a wide QRS rhythm on the EKG. This wide complex rhythm is evidence of a long standing duration of hypoxia rather than an acute event. Due to the long-standing delay in recognizing the Plaintiff’s hypoxia, his condition had deteriorated so badly that it was extremely difficult to regain a pulse. By this time, extensive brain damage had already occurred. Eventually the Plaintiff did regain a pulse and was transferred to another facility. Following the events in question the Plaintiff was diagnosed as being significantly and profoundly brain damaged. The actual diagnosis is anoxic encephalopathy. Apart form the brain damage, he is otherwise physically healthy. The Plaintiff has little cognitive function but does smile appropriately, laughs when tickled and responds to his mother’s voice. The Plaintiff will now be cared for at home with his family. Following the close of discovery, the case was settled at mediation for the amount of Six Million Five Hundred Thousand ($6,500,000.00) Dollars. A portion of the settlement amount was structured. Should the child live for a normal life expectancy, which it is expected he will, the payout for the structure will be in the amount of Forty Five Million ($45,000,000.00) Dollar

First, I dont understand why CRNAs love to overdose kids with inhalational agents. At least this was true where I trained. The MAC of halothane is 0.75% and they were running at 2.5% for maintenance. Of course the kid would be tachycardic and hypotensive. Second,why is it okay for a kid to be hypotensive as long as their heart rate is high? This was also a common line of thought among the crnas where I trained. They pretty much never used pressors.

The lawyers description of the events are also pretty rediculous. An O2 sat of 98-100% is acceptable but 97% is malpractice? Also sat dropping from 97% to 0% sounds like reading errors

 

[Man o War]

When you watch one of your fellow anesthesiologists go down for not being there when the s@@t hit the fan, it changes you. I know the risk is small that anything would happen, but it did happen to him. He has lost everything, I believe the judgment against him was well over 10 million, and has destroyed him financially. He also lost his marriage in the process. Just a huge mess.

 

[TaoistDoc]

Also, now I feel like my 1 mil malpractice cap may be inadequate.....

 

[Man o War]

Also, now I feel like my 1 mil malpractice cap may be inadequate.....

Two things here: First, when this case was presented to our attorney for review (sort of a what went wrong type of thing and how can our group avoid it), his comments were that he felt strongly the reason the award was so high against the anesthesiologist was that he showed negligence for not showing up to assist the CRNA. He was asleep in his call room. So, that made me rethink my laissez faire attitude about OB that I may have fallen into at times.

Second, visit a GOOD estate/asset protection attorney. There are ways to protect your assets if something like this were to come to fruition. It depends on the state and your personal situation, but it's worth the $500/hr price tag in my opinion.