What don't you like about your field

[VolatileAgent]

there was never a study that showed clincally significant damage in humans from low flow Sevo regardless of the duratiuon.

fyi...

In three studies in human volunteers and one in surgical patients, prolonged (8-hour) sevoflurane exposures and low fresh gas flow rates resulted in significant exposures to compound A. Transient abnormalities were found in biochemical markers of renal injury measured in urine. These studies suggested that sevoflurane can result in renal toxicity, mediated by compound A, under specific circumstances.

....

Therefore, the United States Food and Drug Administration recommends the use of sevoflurane with fresh gas flow rates at least 1 L/min for exposures up to 1 hour and at least 2 L/min for exposures greater than 1 hour.

http://www.ingentaconnect.com/content/adis/dgs/2001/00000061/00000015/art00001

... and...

Although data from controlled clinical studies at low flow rates are limited, findings taken from patient and animal studies suggest that there is a potential for renal injury which is presumed due to Compound A. Animal and human studies demonstrate that sevoflurane administered for more than 2 MAC&#215;hours and at fresh gas flow rates of < 2 L/min may be associated with proteinuria and glycosuria.

http://www.rxlist.com/cgi/generic2/sevoflurane_wcp.htm

remember, lawyers aren't concerned with what you think is "clinically significant" damage. if something happens to that kidney - whether it's really your fault or not - they're going to tell the jury that you should've known better.

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Members don't see this ad.

 

[militarymd]

Like I said, the guys across the pond are quite advanced when compared to us.......they do what they believe is right...and not what is shoved down their throats by lawyers.......people who know very little about taking care of patients.

... but know a lot about making you look like you did something wrong, even if you didn't.

Folks who know very little about take care of patients can only make other people who know very little about taking care of patients look bad.

 

[VolatileAgent]

Folks who know very little about take care of patients can only make other people who know very little about taking care of patients look bad.

well, i couldn't agree more with the sentiment. but, unfortunately this is the system in which we practice medicine. we are never tried in front of a jury of OUR peers.

you haven't been sued yet, apparently.

 

[militarymd]

fyi...



http://www.ingentaconnect.com/content/adis/dgs/2001/00000061/00000015/art00001

... and...



http://www.rxlist.com/cgi/generic2/sevoflurane_wcp.htm

remember, lawyers aren't concerned with what you think is "clinically significant" damage. if something happens to that kidney - whether it's really your fault or not - they're going to tell the jury that you should've known better.

Can we say "surrogate endpoints"?

If one doesn't know what "surrogate endpoints" are? One should ask an experienced attending.

 

[VolatileAgent]

Can we say "surrogate endpoints"?

If one doesn't know what "surrogate endpoints" are? One should ask an experienced attending.

in court, it doesn't matter what the studies say. it matters what the package label says and what your reasons for ignoring it were. do you think the jury understands the concept of surrogate markers and endpoints? as further example, do you think that most clinicians, for that matter, even understand that a blood pressure reading is a surrogate marker?

you have more confidence in the system than i do, apparently.

 

[militarymd]

Like I said, the guys across the pond are quite advanced when compared to us.......they do what they believe is right...and not what is shoved down their throats by lawyers.......people who know very little about taking care of patients.

in court, it doesn't matter what the studies say. it matters what the package label says and what your reasons for ignoring it were. do you think the jury understands the concept of surrogate markers and endpoints? as further example, do you think that most clinicians, for that matter, even understand that a blood pressure reading is a surrogate marker?

you have more confidence in the system than i do, apparently.

As I stated, the guys across the pond are more advanced than we are....they do what they believe is right....

As for us.....I do what I believe is right.....I don't worry about the lawyers....My highly paid lawyers will take care of their lawyers.

 

[militarymd]

The other option is ....don't practice medicine....just do what the lawyers expect you to do..... .

....sort of like a mid-level.....just do what a physician expects you to do.

 

[VolatileAgent]

The other option is ....don't practice medicine....just do what the lawyers expect you to do..... .

....sort of like a mid-level.....just do what a physician expects you to do.

you'll be singing a different tune after you've been sued a couple of times. it's funny how the docs i've worked with who've gotten nailed in court are hypervigilant about those things they were burned on.

iow, it's amazing how subjective "doing what you believe is the right thing to do" truly is... and it certainly isn't necessarily practicing evidence based medicine, as you have adeptly illustrated here.

 

[sevoflurane]

....My highly paid lawyers will take care of their lawyers.

Ha.. ha... that has a really funny ring to it

It reminds me of a text message I received a week ago or so... I was in an OR that had a glass window to another OR. A fellow resident and I both had med. students and he was next door.... The text message on my beeper said the following:

"I bet my med student can beat up your med student" As I looked through the window into my neighboring OR they were both tauntingly flexing.

No, but seriuosly... how often does the average anesthesiologist get dragged into court? And to what degeree should it drive your anesthetic practice?

 

[sallyjoe]

No, but seriuosly... how often does the average anesthesiologist get dragged into court? And to what degeree should it drive your anesthetic practice?

I was told the average Anesthesiologist gets sued once every ten years. Those living in Texas, Florida Illinois, Pennsylvania, New York, New Jersey and other judicial cesspools get sued every five years.




Better Than Good: Trade Secrets of Low-Risk Anesthesia Groups

Malpractice litigation is a fact of life for most anesthesiologists today. The average anesthesiologist is sued approximately every eight years. Some large groups, however, consistently defy the odds by remaining almost claims-free year after year. This track record occurs in spite of a group's location in a litigious state with an unfavorable legal climate.

The material for this article comes from interviews conducted by risk management experts Laura Dixon and Shirley Koch-Steiner, who asked members of two low-risk anesthesia groups to talk about what makes their groups successul and what helps them to prevent malpractice claims.

Knowing Your Patient
Whenever possible, the physicians perform their own preoperative assessments. They have found that this avoids the potential for important information not being transmitted to another provider and also helps establish a physician-patient relationship prior to entering the operating room. Outpatients are telephoned at home the night prior to surgery, which helps to build rapport, communicate information about oral medication and NPO status, and identify potential problems in advance. Inpatients are seen in-house the night before surgery.

When the patient first registers at the hospital, an outpatient surgery nurse obtains a thorough history. The anesthesiologist can then review this assessment with the patient, along with the surgeon's history and physical, laboratory work, and old medical records, which have been placed with the chart. Anesthesiologists are encouraged to review the nurse's notes thoroughly, as these entries often contain valuable information that the patient did not communicate to the physician, such as extreme anxiety about the procedure. One suggestion is to ask patients very specific questions. For example, rather than asking "Did you have any problems with anesthesia before?" inquire directly about any problems with nausea, vomiting, pain, or postspinal headaches.

Patients are also routinely seen or called postoperatively. Such personal interaction projects concern for the patient and provides the physician with firsthand insight into potential problems or complaints that the patient might have regarding the anesthetic. Patients who have been given a chance to ventilate their concerns are also less likely to take their grievances to another level.

Working with Others
Both groups have excellent working relationships with the nursing staff in the preop, OR, and recovery areas. They feel that the nurses are caring and competent and will notify the physicians whenever the circumstances call for it. The physicians strongly encourage the nurses to call them or another partner whenever they are concerned about a patient. The anesthesiologists provide education to the recovery room nurses on a regular basis on subjects such as new anesthetic techniques.

One group provides a daily "free physician," who carries a cell phone and pager and is available for immediate response within a few minutes. This physician is responsible for the recovery room, where events can precipitate rapidly, and also provides backup or assistance to any area of the hospital. When a problem arises in the OR, not only does the free physician respond, but any available member of the group is also expected to arrive at the scene to see if help is needed. As many as six anesthesiologists might work on a single emergency. As the group leader states, "We simply manpower problems to death."

The anesthesiologists feel that it is essential to be comfortable with the other physicians with whom they interact. Professional disagreements regarding patient care are unavoidable, but group members make an effort to keep the focus on patient safety, to stay calm and professional, and to avoid having winners and losers in interactions with surgeons. Anesthesiologists are encouraged to participate in hospital committees and to attend all group meetings. As one anesthesiologist put it, "Be accountable to your practice with a focus that your provision of services impacts everyone in the group, not just you."

Group Dynamics
All group members are either partners or on a partnership track. The ownership component helps to ensure that physicians feel responsible for how the group is perceived and how their individual performance affects that perception. One group tried employing other physicians on a locum tenens basis but found that those physicians, although competent, were more focused on their individual day-to-day events rather than on the overall picture and that they were less likely to go the extra mile or do extra work when needed. Group members readily support each other for bathroom and lunch breaks and work together to cover late cases if someone has to leave. Issues that arise regarding compensation inequities are promptly discussed by the entire group so that all members feel fairly treated and part of the team.

Both groups allow members to specialize in areas like obstetrics, cardiac, or neurosurgical anesthesia. They feel that this allows for development of a strong skill set and enhances rapport with a small group of surgeons. They also feel that it enhances accountability for ensuring the smooth functioning of their particular "unit."

New members are selected based on their extensive experience and expertise. Both groups have rigorous selection procedures in place. Each applicant must have a good record, and the groups obtain extensive references&#8212;not only standard peer references but also recommendations from nurses and surgeons with whom the applicant has worked. Even with such high scrutiny, one of the groups still regards new anesthesiologists as being on probation for one year, during which time the new anesthesiologist is repeatedly reviewed. After one year, the new anesthesiologist is re-evaluated and, if all group members agree, he or she moves into a partial partnership slot and is observed for another year.

Quality Assurance
All physicians in the group take part in formal quality assurance committee activities, which keep them up to date on current issues. With all physicians participating in medical records reviews, they are more aware of the importance of good documentation. The spirit is one of helping each other to look at things from a different perspective. They all accept and understand this process so that it doesn't degenerate into one-upmanship. All anesthesiologists are encouraged to proactively develop new methods to ensure safe patient care and avoid complications.

Group members also participate in hospital or surgery center committees. This keeps them informed on new developments and enhances rapport with other physicians. The groups commented on the excellence of the credentialing process for the other hospital physicians. As a result, they feel confident that the surgeons and Ob/Gyns with whom they work have also been carefully selected. Anesthesia equipment is described as state of the art, and routine maintenance is continually assured.

Both groups emphasize the importance of the informed-consent process. One group uses written consents for both the anesthetic and for any invasive procedures that are also anticipated, with copies going to the patient. Patients are thoroughly educated regarding the planned anesthetic and, should that not prove possible, what alternatives are available. Common side effects and complications are discussed. These groups describe themselves as "careful" and "selective" regarding the patients taken to surgery, meaning that they are not reluctant to cancel or postpone cases when appropriate.

Risk Management
Some negative outcomes are unavoidable, but these groups have found that immediate interaction with the patient or family after an event is invaluable in avoiding claims. For example, with known dental injuries, they don't wait for the patients to complain; they approach them immediately. Without promising any payment or reimbursement, the anesthesiologists tell the patients that they are more than willing to work with them to resolve the problem. For small repairs, the anesthesiologists may simply pay for it themselves. If extensive, it is reported to The Doctors Company as a potential claim. (See our Risk Management Strategies article, "Guidelines for Decreasing Dental Injury Claims," in the Publications section of our Web site at www.thedoctors.com.) For other bad outcomes, the group always follows up as soon as possible with the patient or family and keeps the lines of communication open.

When an error occurs, everyone in the group is informed. All group members are encouraged to report any unusual events immediately. They then work on the problem collectively to assure the best possible outcome. All suspected errors go through the formal peer review process. Interestingly, both groups have members who perform expert witness services for malpractice litigation. When completed, they use these case studies as lessons for the entire group so they can avoid making the same mistakes in their own institutions.

Conclusion
While not all of these suggestions are appropriate or feasible for every anesthesia group or provider, we offer them here as food for thought. These groups are clearly doing something right&#8212;and nothing succeeds like success.

Many of the ideas presented here can also be applied to other medical specialties. The examples of open communication within the group and between coworkers and other physicians are useful guides for successful practices and decreased litigation.
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[militarymd]

No, but seriuosly... how often does the average anesthesiologist get dragged into court? And to what degeree should it drive your anesthetic practice?

1 in 10 sounds about right.

My partner (in practice 30 years ) in different states...has been sued 3 times.

I've in in practice almost 10 years....I've had legal issues 1 time.

And I stick to my belief....I do what I think is right........

 

[Planktonmd]

fyi...



http://www.ingentaconnect.com/content/adis/dgs/2001/00000061/00000015/art00001

... and...



http://www.rxlist.com/cgi/generic2/sevoflurane_wcp.htm

remember, lawyers aren't concerned with what you think is "clinically significant" damage. if something happens to that kidney - whether it's really your fault or not - they're going to tell the jury that you should've known better.

I am aware of all that shaky data out there and I have to agree that it could conceivably be grounds to a litigation although I don't think it has happened to anyone yet!
There is many gray zones in anesthesia and it's really your personal level of comfort. An example to that is a drug you use every day: Propofol !
As you know propofol is not recommended in obstetrics and not recommended in children under 3 years old! According to the product insert!
Are you still inducing all stat sections with thiopental??

 

[jetproppilot]

Ha.. ha... that has a really funny ring to it

It reminds me of a text message I received a week ago or so... I was in an OR that had a glass window to another OR. A fellow resident and I both had med. students and he was next door.... The text message on my beeper said the following:

"I bet my med student can beat up your med student" As I looked through the window into my neighboring OR they were both tauntingly flexing.

No, but seriuosly... how often does the average anesthesiologist get dragged into court? And to what degeree should it drive your anesthetic practice?

I feel ya'll's comments to Mil.

But I made the same commitment to myself years ago that Mil did....

I'm gonna do whats right for the patient, and postoperatively if a lawyer has an issue with it, well, blow me. thats why I pay thirty-large annually for malpractice insurance. Prove I delved below standard of care, you bone-rollercoaster-riding J.D.

Aint gonna practice sphincter-enhanced-looking-over-my-shoulder-every-night medicine.

I'm deft at what I do.

If I've slipped below standard of care, I deserve the criticism.

But if I have not slipped below standard of care and you're trying to prove I did, again, good luck, and, uhhhh, blow me.

 

[VolatileAgent]

But if I have not slipped below standard of care and you're trying to prove I did, again, good luck, and, uhhhh, blow me.

this also just reminded me of the fact that what's charted isn't always what happened. it's amazing how we have to practice "defensive medicine" these days, which essentially consists of a ****load of paperwork that exists solely to c.y.a.

 

[ZA_Gasman]

Actually, we are in the enviable postion of being able to cull the best of what you guys in the States do, and mix that up with what the best guys in Europe do, and we ge too toss the rest if we feel like it. Not much input from lawyers in our practice either, in the rare malpractice claim, judges tend to find in favour of the literature, and what a reasonable anaesthetist would do. So as long as we're not too way out there, probably OK.
Brings me back onto thread topic - what I DO like about our profession is that there are so many right ways of doing things, and at least in SA, not too many lawyers sticking their honourable noses into our business!

BTW Jet - I really love your attitude. More people need to put patient care above cover your *ss maneuvers