Surgeon Reinstated After Whistleblowing Regarding Anesthesiology

[2021Doctor]

OSC Negotiates Reinstatement of VA Physician Whistleblower with Significant Financial Compensation
7/7/2022
PROHIBITED PERSONNEL PRACTICES
The U.S. Office of Special Counsel (OSC) today announced a favorable settlement reached between the U.S. Department of Veterans Affairs (VA) and Dr. Robert Cameron, Chief of Thoracic Surgery for the VA's Greater Los Angeles Healthcare System (GLA), West Los Angeles VA Medical Center (West LA).

In early 2018, Dr. Cameron disclosed two near deaths of VA patients during the administration of anesthesia in thoracic surgeries. Dr. Cameron had long raised concerns about GLA's anesthesia staffing practices for complex thoracic surgeries, but the most recent adverse event, during which a patient suffered a near fatal tear of their windpipe, compelled Dr. Cameron to more emphatically express his belief that the past two complications were avoidable, had anesthesiologists with greater thoracic experience been present.

OSC Negotiates Reinstatement of VA Physician Whistleblower with Significant Financial Compensation

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[Iso4ane]

was the tear of the windpipe from a surgical complication or a anesthesia one? I’m curious how much of this is bad anesthesiologist vs bad surgeon.

 

[GassYous]

was the tear of the windpipe from a surgical complication or a anesthesia one? I’m curious how much of this is bad anesthesiologist vs bad surgeon.

My guess is that there was resistance with placing the dlt and too much force was applied

 

[DrOwnage]

Having trained at this specific program during this time period and knowing some of the untold details I can tell you this was controversial to say the least...

 

[Iso4ane]

My guess is that there was resistance with placing the dlt and too much force was applied

That’s definitely a possibility. But, not the only explanation. I’m also trying to figure out what made it near fatal. A lower airway tear in of itself is a major morbidity for sure, but not necessarily fatal. Depending on the location and situation, it can be treated conservatively.

Having trained at this specific program during this time period and knowing some of the untold details I can tell you this was controversial to say the least...

Controversial in what way? Like the fact that he was reinstated, the fact that he has to blow the whistle. I know this is a public forum, but I’m feel like this should be moved to private.

 

[nimbus]

Inexperienced personnel and thoracic surgery is not a good combination. If an inexperienced person is staffing a lung isolation case, somebody with experience and expertise should be there to help them until they’re proficient. I’ve personally witnessed preventable arrests and near arrests in these situations.

 

[Arch Guillotti]

Inexperienced personnel and thoracic surgery is not a good combination. If an inexperienced person is staffing a lung isolation case, somebody with experience and expertise should be there to help them until they’re proficient. I’ve personally witnessed preventable arrests and near arrests in these situations.

What was the cause of the arrests?

Personally I don’t staff these cases very often so I am loathe to do them.

 

[nimbus]

What was the cause of the arrests?

Personally I don’t staff these cases very often so I am loathe to do them.

Malposition of DLT in one case, unable to ventilate. A couple instances of DLT being completely pulled out during attempted repositioning in lateral position.

And you’re right, the cases should be staffed by people who do them all the time. Just like neonates or awake cranis (I don’t do either) or anything else. Better to have someone who does it twice a week rather than twice a year. It results in less drama.

 

[anaesthetic]

Malposition of DLT in one case, unable to ventilate. A couple instances of DLT being completely pulled out during attempted repositioning in lateral position.

And you’re right, the cases should be staffed by people who do them all the time. Just like neonates or awake cranis (I don’t do either) or anything else. Better to have someone who does it twice a week rather than twice a year. It results in less drama.

I do a good amount of thoracic every week, and we do lung transplants as well (solo). There are cases every so often that make me thankful for the extra training (eg., crashing on ECMO from an outpatient procedure, COPD bleb popping mid-case, hypoxia/hypercarbia/arrhythmias prior to donor lung implantation, etc.). I imagine none of these situations would appeal to my colleagues who do mostly plastics and general cases.

 

[FiO2@21]

Rusch EZ blocker makes many of these cases so much easier. Only used DLT for the classic indications (bleeding, etc), high RUL take off, or learning purposes.

 

[nimbus]

Rusch EZ blocker makes many of these cases so much easier. Only used DLT for the classic indications (bleeding, etc), high RUL take off, or learning purposes.

I love the ezblocker. It’s a great improvement over what we had before. But I still prefer a dlt which gives you more flexibility and troubleshooting options…eg applying suction to down lung or conversely CPAP to down lung.

 

[FiO2@21]

I love the ezblocker. It’s a great improvement over what we had before. But I still prefer a dlt which gives you more flexibility and troubleshooting options…eg applying suction to down lung or conversely CPAP to down lung.

Is CPAPing the down lung done much anymore? I might have done maybe 1 or 2 open thoracotomies. For VATs I never bothered to try because of the risk of messing up visualization.

I felt that DLTs were way finickier than EZ blockers.

 

[aneftp]

It’s always the lowest common denominator. My friends at the VA tell me if this was a full time surgeon. It would be harder to get rid of him. Part time surgeons or any part time employees do not have the same federal protection as full time staff.

Seems like anesthesia was full time staff. So harder to get rid of. And surgeon was part time. My friend told me the part time surgeon (at a different VA hospital) just made some political enemies. Didn’t feel some patients should be operated on. So disagreeing with admin. and they got rid of him on zero days notice. Walked him out the hospital.

Looks like this surgeon had 3-4 weeks notice.

As always. The truth lies somewhere in the middle.

 

[anaesthetic]

Is CPAPing the down lung done much anymore? I might have done maybe 1 or 2 open thoracotomies. For VATs I never bothered to try because of the risk of messing up visualization.

I felt that DLTs were way finickier than EZ blockers.

Had to CPAP the down lung the other week. Have had to do it once or twice in the past couple of years, so it’s rare but does happen. Ended up converting to open anyway because of the poor visualization. It’s worth a shot but usually doesn’t end well. Have had to do intermittent apnea/two lung ventilation as well in some cases. Not fun IMO.

I’ve used all available bronchial blockers and still prefer the DLT except in situations where it’s hard to get the DLT in. I think it comes down to familiarity and preference, but I’ve had to troubleshoot a lot less with a good DLT.

 

[Twiggidy]

Is CPAPing the down lung done much anymore? I might have done maybe 1 or 2 open thoracotomies. For VATs I never bothered to try because of the risk of messing up visualization.

I felt that DLTs were way finickier than EZ blockers.

CPAP to the down lung is certainly done and it helps to have a thoracic surgeon who on your side instead of one that panics at every desat.


No matter how much they hate it, the correct answer in all troubled situations in thoracic surgery is “bring up the lung”

 

[Twiggidy]

Rusch EZ blocker makes many of these cases so much easier. Only used DLT for the classic indications (bleeding, etc), high RUL take off, or learning purposes.

i feel like surgeons like bronchial blockers because they get impatient with us placing the DLT. DLT are better and really aren’t that difficult to place.

 

[Twiggidy]

Personally, I think the most important factors of placing a double lumen tube are:

1) Secure the airway by any means. If you need to place a SLT by DL or video since we do that most often, then do so. This way the airway is secured and you can ventilate and you avoid problems. Then upgrade to DLT however you choose (boogie, boogie with video, etc)

2) Weekends worth of lube on the DLT

3) 37f is great for just about everyone. If it’s Shaq used a 41f. If it’s LOL in NAD then sure a 35f

4) Communicate your plan. If the surgeon is irritated by your plan then tell them to put in the tube, otherwise, go have some coffee while we safely take care of the patient.

5) if I’m doubt, second set of hands and refer to point 1)

 

[nimbus]

Is CPAPing the down lung done much anymore? I might have done maybe 1 or 2 open thoracotomies. For VATs I never bothered to try because of the risk of messing up visualization.

I felt that DLTs were way finickier than EZ blockers.

What I actually do is attach an ambu bag to the down lung and give “microbreaths” by hand while watching the video monitor. I can very often get the O2 sat up without causing any changes to the surgical field or visualization. I also communicate what I’m doing to the surgeon, “I’m going to give a few tiny breaths, let me know if it bothers you.”

 

[nimbus]

i feel like surgeons like bronchial blockers because they get impatient with us placing the DLT. DLT are better and really aren’t that difficult to place.

Our surgeon very much prefers DLT because they give more reliable lung isolation.

 

[abolt18]

Our surgeon very much prefers DLT because they give more reliable lung isolation.

Our thoracic surgeon a throw a fit if you try to place a bronchial blocker. They want a DLT for that reason unless it's impossible for us to place one.

 

[GassYous]

What I actually do is attach an ambu bag to the down lung and give “microbreaths” by hand while watching the video monitor. I can very often get the O2 sat up without causing any changes to the surgical field or visualization. I also communicate what I’m doing to the surgeon, “I’m going to give a few tiny breaths, let me know if it bothers you.”

I just hook up the nasal cannula to the down lung

 

[OTCAwesome]

Rusch EZ blocker makes many of these cases so much easier. Only used DLT for the classic indications (bleeding, etc), high RUL take off, or learning purposes.

This 100%

 

[drmwvr]

Passive O2 to the down lung is OK when it works...sometimes I need to drive the cardiac output with it to get a sat over 89. IME, if I have to add pressure, I'll keep the CPAP to no more than 4... it doesn't blow things up and gives just enough to offset the shunt. In the end tho, the more vessels the surgeons staple, the better the oxygenation gets so whatever I end up having to do, it's very temporary...

 

[Iso4ane]

Rusch EZ blocker makes many of these cases so much easier. Only used DLT for the classic indications (bleeding, etc), high RUL take off, or learning purposes.

In select circumstances it is possible to use a EZ blocker in a patient with a high RUL take off. I have a colleague writing something up that relates to this effect.

 

[pgg]

I just hook up the nasal cannula to the down lung

Agreed, apneic oxygenation of the nonventilated lung is usually a better option than CPAP. I'll typically take one of the suction catheters that comes with the DLTs, connect it to the supplemental O2 port at 0.5-1 LPM, and slide it down toward the lung. Leave the cap off so pressure doesn't build up. All the oxygenation benefits of CPAP minus the operative lung expansion that the surgeons gripe about.

 

[fakin' the funk]

I supervise, assist with, or do 5-10 lung isolation cases a week typically
- rarely use any bronchial blocker; DLT is superior in many ways except ease of initial placement; EZ blocker should be called Difficult Blocker
- Agree that need to oxygenate the operative lung in "normal" patients is rare; recruitment of nonop lung is effective for vast majority of mild hypoxemia in "normal" patients
- oxygenation in "abnormal" patients like decort, current PNA, leak, ILD, etc etc is typically predictably poor and how you oxygenate via operative side lung is very individualized to case and patient. Need to have apneic oxygenation, FOB-directed oxygenation, pulmonary toilet via FOB, CPAP, iNO, and intermittent two lung ventilation in your toolkit
- agree that having folks around who routinely do these cases makes it much more straightforward for when primary providers are not as accustomed/ experienced

 

[FiO2@21]

I don't think we even have the equipment to set up actual CPAP for the down lung. There are a couple attendings and surgeons who insisted on DLT, but everyone else in my residency used the EZ Blocker and had been doing so for years without issue.

 

[Iso4ane]

I don't think we even have the equipment to set up actual CPAP for the down lung. There are a couple attendings and surgeons who insisted on DLT, but everyone else in my residency used the EZ Blocker and had been doing so for years without issue.

Do you not have soft bags for transport? You can use thsoe to supply CPAP through a bronchial blocker.

 

[deleted875186]

Agreed, apneic oxygenation of the nonventilated lung is usually a better option than CPAP. I'll typically take one of the suction catheters that comes with the DLTs, connect it to the supplemental O2 port at 0.5-1 LPM, and slide it down toward the lung. Leave the cap off so pressure doesn't build up. All the oxygenation benefits of CPAP minus the operative lung expansion that the surgeons gripe about.

This is 100% the easiest and most effective method. Just have to make sure the flow meter is on very low and it’s not inflating the lung.

 

[WholeLottaGame7]

We have to use bronchial blockers for most of our kids that need lung isolation, and they're a huge pain in the ass, especially on the right. As soon as they're big enough to throw a DLT in, that's my preferred plan.

 

[zizzer]

Man, I'm getting some very divided opinions here about bronchial blockers. I'm a generalist who does thoracic cases about once every couple weeks or so, and I use only DLTs, as was pretty much the case in residency for me too (save for one time we needed an Arndt blocker). The EZ blocker seems easy enough according to videos. Some here say it's easier to use and some say it's a pain. What's the deal?

 

[vector2]

Man, I'm getting some very divided opinions here about bronchial blockers. I'm a generalist who does thoracic cases about once every couple weeks or so, and I use only DLTs, as was pretty much the case in residency for me too (save for one time we needed an Arndt blocker). The EZ blocker seems easy enough according to videos. Some here say it's easier to use and some say it's a pain. What's the deal?

Use a DLT.

 

[FiO2@21]

Man, I'm getting some very divided opinions here about bronchial blockers. I'm a generalist who does thoracic cases about once every couple weeks or so, and I use only DLTs, as was pretty much the case in residency for me too (save for one time we needed an Arndt blocker). The EZ blocker seems easy enough according to videos. Some here say it's easier to use and some say it's a pain. What's the deal?

Just try it yourself! Like I mentioned, in a moderately sized city with a good volume of bread and butter thoracic cases, most of the anesthesiologists have switched to bronchial blockers. A couple still use DLTs exclusively.

You might try it out and find that you like it. As soon as we flip lateral I disconnect the circuit for a few seconds to allow for complete exhalation, inflate the balloon, re-attach the circuit. The lung isolation by the time the trochars are in range from excellent to acceptable. I keep the flexible bronch in the trachea to confirm the bronchial balloon doesn't slip out unless I'm using a 7.5 ETT.

I intubate very high (just past the chords) to allow the blocker to open up and once that is in I advance the ETT a little before tightening the cap and taping the tube in.

 

[aneftp]

It’s weird people on these forums talking about double lumen tubes and not the real purpose of the article. The purpose of the article is that the Va in los angles got rid of a part time Va surgeon. And let the full time anesthesia docs stay.

VA can let go of part time docs easier than full time docs.

Most VA facilities are academically affiliated so will
Have part time surgeons who go between academic hospitals and Va hospitals.

Most VA hospitals have full time anesthesiogists. Not all but most.

If the anesthesia docs were part time and surgeon was full time. Chances are the anesthesia docs would be gone if complication happen. Just the way the system works. That’s really the crux of the article for those who don’t know how the VA system operates. And yes. I know a ton of people who work in academics and VA hospitals. Hope the young docs in here read what I just wrote.

Forget double lumen tubes discussions. Focus on the real article. That’s real life world situation when blame is assigned

 

[vector2]

I disconnect the circuit for a few seconds to allow for complete exhalation,

inflate the balloon,

re-attach the circuit.

I keep the flexible bronch in the trachea to confirm the bronchial balloon doesn't slip out unless I'm using a 7.5 ETT.

I intubate very high (just past the chords) to allow the blocker to open up

and once that is in I advance the ETT a little

before tightening the cap and taping the tube in.

Or just put a DLT in, open nondependent lumen, clamp, and resume sudoku

 

[pgg]

Forget double lumen tubes discussions. Focus on the real article. That’s real life world situation when blame is assigned

It's the internet

There's no per-electron charge that increases when threads drift

It's OK to talk about both things

 

[FiO2@21]

It’s weird people on these forums talking about double lumen tubes and not the real purpose of the article. The purpose of the article is that the Va in los angles got rid of a part time Va surgeon. And let the full time anesthesia docs stay.

VA can let go of part time docs easier than full time docs.

Most VA facilities are academically affiliated so will
Have part time surgeons who go between academic hospitals and Va hospitals.

Most VA hospitals have full time anesthesiogists. Not all but most.

If the anesthesia docs were part time and surgeon was full time. Chances are the anesthesia docs would be gone if complication happen. Just the way the system works. That’s really the crux of the article for those who don’t know how the VA system operates. And yes. I know a ton of people who work in academics and VA hospitals. Hope the young docs in here read what I just wrote.

Forget double lumen tubes discussions. Focus on the real article. That’s real life world situation when blame is assigned

One topic was more interesting than the other.

Large systems have a propensity for corruption, not very shocking 🤷🏽‍♂️ So you’re saying don’t work for the VA part time? Is that a punishment or a reward?

 

[aneftp]

It's the internet

There's no per-electron charge that increases when threads drift

It's OK to talk about both things

Of course it’s ok to talk about both things.

But the general student doctor user likely doesn’t know how the real world works at the VA. Having worked in academics at state facility where surgeons go between VA and state academic facility. These stories are more common than you think.

It usually gets brushed aside as docs quietly (forced) to resign and the system thinks it goes away and doesn’t make the news.

I was trying to point out what many folks on these forums probably don’t know. That part time docs at VA aren’t protected as full time docs. That’s why the surgeon got his walking papers. And anesthesia didn’t. It’s much easier to say goodbye to a part time surgeon than a full time federal anesthesia doc when the blame may be in the grey area.

And there are cases where no docs really are to blame and it’s a floor management issue and the nurses really f’d up especially after hours but the docs will always take the hit just the way the world works.

 

[OptionOffense]

Having trained at this specific program during this time period and knowing some of the untold details I can tell you this was controversial to say the least...

What was controversial?

 

[OptionOffense]

It’s weird people on these forums talking about double lumen tubes and not the real purpose of the article. The purpose of the article is that the Va in los angles got rid of a part time Va surgeon. And let the full time anesthesia docs stay.

VA can let go of part time docs easier than full time docs.

Most VA facilities are academically affiliated so will
Have part time surgeons who go between academic hospitals and Va hospitals.

Most VA hospitals have full time anesthesiogists. Not all but most.

If the anesthesia docs were part time and surgeon was full time. Chances are the anesthesia docs would be gone if complication happen. Just the way the system works. That’s really the crux of the article for those who don’t know how the VA system operates. And yes. I know a ton of people who work in academics and VA hospitals. Hope the young docs in here read what I just wrote.

Forget double lumen tubes discussions. Focus on the real article. That’s real life world situation when blame is assigned

No, this has a little to do with part-time/full-time. This has everything to do with exposing the corrupt,fraudulent incompetent and wasteful healthcare system that is DEpt of Veterans Affairs. The surgeon exposed the incompetence (in hopes of making it better) and was dealt with it how VA deals with all people who criticize it. There are **** loads of cases exactly like this one with almost the same exact outcomes and it keeps happening. VA is the pits. and I agree this has nothing to do with double lumen tubes and bronchial blockers. If the surgeon were full time they would have done somthing else to him like go after his privileges

 

[aneftp]

One topic was more interesting than the other.

Large systems have a propensity for corruption, not very shocking 🤷🏽‍♂️ So you’re saying don’t work for the VA part time? Is that a punishment or a reward?

single parent

One topic was more interesting than the other.

Large systems have a propensity for corruption, not very shocking 🤷🏽‍♂️ So you’re saying don’t work for the VA part time? Is that a punishment or a reward?

Two of my single parent buddies (after divorces) with young kids jumped from academics to the VA. The system (7-3pm) works for them especially young kids. But their kids are older now. They are both leaving. Back to private.

Lots of headaches with the VA. It’s works for some of you know how to navigate. Great career option for older docs wanting to wind down as well as single parents with child care issues.

 

[aneftp]

No, this has a little to do with part-time/full-time. This has everything to do with exposing the corrupt,fraudulent incompetent and wasteful healthcare system that is DEpt of Veterans Affairs. The surgeon exposed the incompetence (in hopes of making it better) and was dealt with it how VA deals with all people who criticize it. There are **** loads of cases exactly like this one with almost the same exact outcomes and it keeps happening. VA is the pits. and I agree this has nothing to do with double lumen tubes and bronchial blockers. If the surgeon were full time they would have done somthing else to him like go after his privileges

State medical systems are almost as corrupt especially those are indigent county/state hospitals. I’ve witness that as well. But agree since VA is federal just the sheer size you will get more volume of corruption.

 

[Maverikk]

Ok back to DLTs
Anyone have success with glidescoping or McGrathing a DLT? If I can't get it with regular DL then I put in a single lumen, exchange over a bougie and seldinger the DLT over the bronch while visualizing with a glidescope.
I've a colleague who said they regularly glidescope, with the stylet at a wider angle (less hockey stick, closer to straight) and does a lot more mandible elevation and slowly pulls out stylet.

 

[venacontracta]

Ok back to DLTs
Anyone have success with glidescoping or McGrathing a DLT? If I can't get it with regular DL then I put in a single lumen, exchange over a bougie and seldinger the DLT over the bronch while visualizing with a glidescope.
I've a colleague who said they regularly glidescope, with the stylet at a wider angle (less hockey stick, closer to straight) and does a lot more mandible elevation and slowly pulls out stylet.

I've used and really liked the purpose-made DLT glidescope stylets. Stylets

Without these, I find the use of a glidescope with a DLT infuriating and would rather glidescope a SLT, place a tube exchanger through it, get the DLT into the trachea, bronch down the bronchial lumen, and advance the tube into position over the scope.

 

[nimbus]

Ok back to DLTs
Anyone have success with glidescoping or McGrathing a DLT? If I can't get it with regular DL then I put in a single lumen, exchange over a bougie and seldinger the DLT over the bronch while visualizing with a glidescope.
I've a colleague who said they regularly glidescope, with the stylet at a wider angle (less hockey stick, closer to straight) and does a lot more mandible elevation and slowly pulls out stylet.

I only use glidescope for DLTs (and almost all SLTs.) Put an exaggerated bend on the stylette that comes preloaded in the DLT. Put tip of dlt into the glottic opening, have assistant pull stylette all the way out while you are firmly holding the tube. Advance tube with clockwise or counterclockwise turn. I prefer an exaggerated bend on the stylette. No failures in at least 5 years.

 

[dchz]

+1 for GlideScope for DLTs. Not my standard only use it when DL is bad view, but no issue with glide scope and DLTs. Do it in a similar manner as @nimbus.

Used a lot of EZ blocker in fellowship and currently only use DLTs. I think the benefits of the EZ blocker is overblown. The gold standard should still be a DLT for any lung isolation.

Please don't use silicone lubricant on the DLT. I have made that mistake once...

Also spent lots of time at the VA during residency. This article does not surprise me at all. There are some HORRIBLE surgeons and HORRIBLE anesthesiologists at the VA. The truth is probably somewhere in between.

 

[OptionOffense]

Also spent lots of time at the VA during residency. This article does not surprise me at all. There are some HORRIBLE surgeons and HORRIBLE anesthesiologists at the VA. The truth is probably somewhere in between.

Another main take home is how the federal government retaliates against people who report wrongdoing and go against the status quo.... REmind you of somebody... ?What they are doing to Trump...?

 

[pgg]

What they are doing to Trump...?

Not nearly enough, since we haven't seen any criminal charges yet.

 

[marr65]

Another main take home is how the federal government retaliates against people who report wrongdoing and go against the status quo.... REmind you of somebody... ?What they are doing to Trump...?

Yes I see your point. Prime example is Trump intimidation and retaliation of Lt. Col Vindman for testifying in front of Congress.

 

[OptionOffense]

Not nearly enough, since we haven't seen any criminal charges yet.

And there wont be. just like the three other times they tried to get him