Yet ANOTHER patient disaster. Was standard of care really breached?

Discussion in 'Anesthesiology' started by BuzzPhreed, 05.19.14.

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  1. BuzzPhreed

    BuzzPhreed

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    We do a lot of endoscopy, EBUS, bronchs, etc. at my current gig. A lot of times I'm 2:1 and (rarely) 3:1 supervision. For EGDs we almost never intubate unless there are extenuating circumstances (food bolus impaction, severe varices, etc.).

    Below is a case where the anesthesiologist and the CRNA, in this case the hospital employing and indemnifying said CRNA, were successfully sued following a disaster with an EGD for a Mallory-Weiss tear. The assumption was that intubation was "standard of care" for this type of case and the fault lies with the anesthesia team who failed to recognize this. There were other mitigating factors we'll discuss downstream. But, here are the facts as presented...

    If you have an actively bleeding patient nothing can be worse in this situation. If they are not paralyzed and still breathing sometimes it's just look for where the bubbles are coming from. The only cric case I've been involved in was in a similar situation in the ICU when I was a resident.

    Okay. Wait a minute. This implies that Crane, the CRNA, was discussing the procedure beforehand, just not the risks. Does this mean he was obtaining informed consent? It also suggests that Crane "didn't know there was a risk for aspiration". What? There is always the risk for aspiration in an EGD. Any EGD. Sure it doesn't happen most of the time. But there's always a risk. Where was Dr. Williams in this discussion? I'm not sure how things go in Texas but I always discuss the risk, benefits, and plan with the patient myself. Whatever the CRNA reiterates or wants to add to that is fine provided they don't contradict what I said. It is certainly not their job to get consent. I can forgive him that he didn't know about the tear because a lot of times the reason you're doing the procedure is to diagnose the very thing you suspect.

    I can't get to the actual court documents. So I don't know who the expert was. But does everyone (or anyone) agree with this statement? It also implies that Williams wasn't immediately present for the portions of the procedure where Crane (rightfully so) chose to intubate. I'd hope he came to the room when the 'stuff' hit the fan (I'm sure he did). It's not clear to me what the writer of this article meant.

    The hospital indemnified the CRNA. So it was a 50/50 liability case.

    http://www.outpatientsurgery.net/ou...wards-widow-1-9m-in-intubation-case--02-27-13

    More next...
     
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  3. BuzzPhreed

    BuzzPhreed

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    http://www.news-journal.com/news/lo...cle_e887d181-be11-5b0e-b276-6bf00002c981.html

    This might be the crux of why the lawsuit was raised in the first place.

    Again I think it was perceived to be a cover-up by the family. But the issue is still whether intubation is the 'standard of care' in a Mallory-Weiss tear EGD. Your thoughts?
     
  4. Outrigger

    Outrigger 5+ Year Member

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    How do you know for sure there is a Mallory-Weiss tear prior to doing the EGD? However, if you know there is one ahead of time, I would always intubate.
     
  5. Spinach Dip

    Spinach Dip Delicious with nachos 2+ Year Member

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    Question:

    In the three cases on the first page of this forum right now, each one resulted in death. Death itself was the result of loss of airway control and hypoxic brain injury.

    In each of these cases, why was an emergency trach not performed?



    As a patient, I would much rather wake up with a hole in my throat than with permenant cerebral injury.
     
  6. Mman

    Mman Senior Member 10+ Year Member

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    It says the CRNA didn't discuss the risks with the anesthesiologist, not that they didn't discuss it with the patient. I'm assuming the anesthesiologist obtained correct informed consent but the CRNA is saying the MD never told me he might aspirate.

    We intubate the vast majority of EGDs and EUSs and what not that we get involved with. Then again we only get involved when the patient failed under the gastroenterologists normal sedation.
     
  7. BuzzPhreed

    BuzzPhreed

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    You're right. I misread that the first time. The anesthesiologist and the CRNA did not discuss the case beforehand. I'm not sure why. It appears that Williams (the anesthesiologist) probably did the H&P and got the consent. Then Crane (the CRNA) just started the case as per usual. "What we have here is... failure to communicate." That seems to be a recurring theme. I'm not sure why. In my current gig I always discuss the cases I'm supervising with the CRNA I'm working with on it. Even in endo.

    We do a lot of EGDs at our institution. We are almost always involved in the routine ones. Much like colonoscopies the get a propofol infusion +/- topicalization. Rarely are these patients intubated. If the patient has known varices or minor bleeding then I almost invariable have that patient intubated. Not all of my colleagues do though.

    I wonder if this is truly a breach in the standard of care or if this case is a result of how the outcome was handled by the docs involved. Sad case.
     
  8. BuzzPhreed

    BuzzPhreed

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    I'm not sure how this would've helped if he was massively aspirating blood. Maybe. But it might have just made more of a mess. And I don't know if cric equipment is routinely found in endoscopy units. It isn't at my institution. Maybe it should be.
     
  9. aneftp

    aneftp 5+ Year Member

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    I dunno know. But a known Mallory Weiss tear? I'd just Intubate.

    Where's the GI doctor in the lawsuit?

    Who caused Mallory Weiss tear? Or was it due to patient co morbidity.
     
  10. IlDestriero

    IlDestriero Ether Man 7+ Year Member

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    All you need is some kind of blade and your pinkey finger. Betadyne wipe, cut, cut, dialate, ETT in, done. No fancy kits that change, no instruction manual, annual competencies, retrograde wire, etc. Well maybe the retrograde wire, but it is probably not there at 2 am in the IR suite.
    That's how you get shiite done when you're all alone and unafraid and the patient is dying of hypoxia in front of you and you can't intubate or ventilate.
    Know what to do, and just do it. Don't convince yourself that the surgeon will magically get the airway, or your ED/ICU buddy is probably only another minute or two away with some skills you don't possess.
    The stool hit the fan, it all went balls up and the patient is dying. Right now. This is why you get the big bucks champ.

    STEP UP TO THE MIC and save the patient's life. Right now.

    The surgeon will secretly know you're a hero, but he'll still blame you for losing the airway.
     
    Sirach38 and Chip N Sawbones like this.
  11. JobsFan

    JobsFan 10+ Year Member

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    disposable scalpel attached to every anaesthetic machine. horizontal puncture, turn scalpel 90 degrees, insert bougie beside scalpel, railroad ETT.
    never done it - never want to - but will if I have to
     
  12. dpmd

    dpmd Relaxing 10+ Year Member

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    This (small tube will be easier to get in and will be good enough until someone revises things, hell you can jam a big angio cath in there and successfully oxygenate for a while-obviously ventilation will be for **** so will need revision stat). Not pretty, but at least then you have a way of pushing air down the correct tube. If pt has already filled the airways with blood things might still go badly, but at least that way you can defend yourself a little better.
     
  13. Spinach Dip

    Spinach Dip Delicious with nachos 2+ Year Member

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    Once the airway is secure, liberal amounts of suction can clean it out. (Of course, it still might not be enough to save the guy, but at least--as you said--you can cover your ass a little better.)
     
  14. BuzzPhreed

    BuzzPhreed

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    I think it can be challenging to reliably find the cricothyroid membrane in most of the obese pts that come to the OR these days. I wouldn't try to punch a hole anywhere else. Not disagreeing with what you guys are saying about losing the airway and/or the ASA difficult airway algorithm. Just saying you better know where you're sticking that blade.

    This study suggested using the ultrasound:
    http://www.ncbi.nlm.nih.gov/pubmed/24582109

    But who in the hell has the time for that in a crisis? Sheez. Sometimes academicians have the right answer but don't really fully consider the problem.
     
  15. dpmd

    dpmd Relaxing 10+ Year Member

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    No need for all that, just make a bigger hole. As long as you stay midline you should keep out of too much trouble (at least less trouble than what you have if you can't get an airway in otherwise)
     
  16. BuzzPhreed

    BuzzPhreed

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    There's this thing called the innominate artery. Yes it's pretty low. But if you whack it, you're in even deeper sh*t than you were trying to get yourself out of. Might as well just let them die from a lost airway. Because you're going to have even more explaining to do when they die AND they bleed out.
     
  17. dpmd

    dpmd Relaxing 10+ Year Member

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    Umm, I guess it is theoretically possible if someone is nowhere near where they are supposed to be. But even if you did bag it, all you need to do is put pressure on it while you ventilate them through their airway. Still better than what happens if you can't ventilate them.
     
  18. BuzzPhreed

    BuzzPhreed

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    My point was just try to know in advance where you need to go. You don't want to hit the thyroid isthmus either. It may be worthwhile for us all to review a little superficial anatomy every now and again. The cricothyroid membrane is the target. A lot of people have trouble locating this especially in fatties.

    FWIW if you hit the innominate you are doubly-f*cked. I've seen it (in a 'maturing' trach where it rubbed against it for weeks... patient bled out and died in a matter of minutes). There's no way to stop the bleeding if you hit that **cker. Believe me.
     
  19. dpmd

    dpmd Relaxing 10+ Year Member

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    You can divide the thyroid if you need to (but you won't have cautery so it will bleed, but again that is something that can be dealt with). Also, I have dealt with a lot of holes in a lot of arteries in really tricky locations before. It is a much different story when the wound is open and you are the one who poked it versus a tracheoinnominate fistula. It is not a 100% death sentence (which the inability to oxygenate/ventilate will be).
     
  20. pgg

    pgg Laugh at me, will they? SDN Moderator 10+ Year Member

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    Is there more than one innominate artery? Because the one I'm thinking of (brachiocephalic trunk) is pretty far south. I'd think you'd have to get near or past the sternal notch to get there with an #11 blade.
     
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  21. BuzzPhreed

    BuzzPhreed

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    No. There's not. You're probably right. Might be a risk if you hyperextend the neck and go low. But dpmd is probably right too that this is longer term complication and the one I've seen was in an ICU patient that had a perc trach done with a bronchscope, etc. It was a total catastrophe. Nothing anyone could do. Sentinel bleed the day before and the whole nine yards.

    This, though...

    http://www.ncbi.nlm.nih.gov/pubmed/10970087

    Again who the hell has time for ultrasound in this situation? No one. Just grip it it and rip it. Better to have a bleeding patient than a dead one. No disagreement there. Aim for the cricothyroid membrane. That's the main point I was trying to make.
     

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