Cosmetic Surgery Leaves Thornton Teen Brain Damaged

[dhb]

the nurse anesthetist that completely botched her anesthesia

Redundant and mild wording for murder.

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[fakin' the funk]

Most likely airway/respiratory. It’s always that. Probably “sedation” and CRNA left the room and patient obstructed. That being said it never hurts to give a young patient some glyco before incision .....

Dude what.

 

[PieOHmy]

LMA for tonsils/septoplasty is not dumb ****.

Yes it is.

 

[fakin' the funk]

The legal complaint and degree of brain injury in 15 minutes suggests anoxia. How that could be (? unrecognized esophageal intubation) and how there were no monitors makes no sense though. I retract my vagal tone theory.

 

[deleted875186]

Crazy story. My geuss is sedation that resulted in apnea with no monitors attached. I don’t think anyone is truely dumb enough to induce GA, than leave the room without monitors attached for 15 minutes. But who knows, all we know for sure is this injury resulted from anoxia for a prolonged amount of time.

 

[TheLesPaul]

Yes it is.

I do LMA for my endoscopic DCR and MAC for most of my other cases (eyelids, browlift, facelift) which can be anywhere from 1-4 hours. Why is MAC such a bad idea if the anesthesiologist can manage it?

 

[PieOHmy]

I do LMA for my endoscopic DCR and MAC for most of my other cases (eyelids, browlift, facelift) which can be anywhere from 1-4 hours. Why is MAC such a bad idea if the anesthesiologist can manage it?

I didnt say MAC was bad for eyelids browlift facelift.... Thats diff from an LMA for a tonsil, or a LMA for septoplasty. I bet less than 10 percent of people on this board would consider this anesthetic.. If you dont know the pitfalls of putting an lma for those cases, you need to go back in time where you were a first year

 

[BLADEMDA]

I have seen more than one anesthesiologist do seriously questionable **** to please a surgeon And keep their job. Sketchy things that some docs do get discussed on this board all the time. They are just less likely to get burned than a CRNA because they are more skilled.


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I agree with you. But, anyone (CRNA or MD) that abandons a patient (willfully and repeatedly) should be stripped of his/her license to practice. There are lines you do not cross even for money and/or to keep your job. Patient safety is our priority at all times. When I do cross a line every now and then in terms of doing an "iffy" case I typically regret the decision even though nothing happens. We must constantly strive to be our own worse critics and if you need any help with that concept simply post on SDN. We need to learn from others mishaps as well as our own. Once you have been around this gig long enough and done enough cases 0.1-0.2% of patients means a lot of people in terms of names/faces. People with lives, families and loved ones. 0.1% won't seem so rare or 99.9% so safe if that person who gets injured matters to you.

 

[Noyac]

I’m a cardiologist but I feel for you guys. NP/PA are encroaching everywhere and it needs to stop. Their training and education is a joke while our so-called MD leaders keep adding years to our already extremely rigorous education and training in the name of patient care. It doesn’t add up until you realize we are all part of a cost cutting effort by hospital administrators—we are cheap labor when we are trainees hence the incentive to keep adding years to our training and mid levels are cheaper alternatives to paying anesthesiologist level salary. None of this should have been ever allowed to get to this level if we had actual MD/DO leaders.

I’m with you!
But we need to follow the money as you alluded too. Our so-called “leaders” are training these Midlevels because it is financially rewarding to them. Our administrators hire for the same reason. And our continuing education demands keep increasing for the same financial reason.

 

[Noyac]

https://localtvkdvr.files.wordpress.com/2019/12/nguyen-complaint-docketed.pdf

court files from the case thus far. The plaintiff's attorney and email are listed on the first page: [email protected]

“30. Prior to the beginning of Ms. Nguyen’s procedure, Defendant Kim entered orders for anesthesia, including intercostal, intramuscular (intravascular) and subcutaneous injections of 4mg versed, fentanyl and propofol localized anesthesia.” Direct quote from court file.

it appears that the crna may have performed an intercostal block while sedating with verses, fentanyl and propofol. This could be the result of LAST (intercostal blocks are a higher risk) or over sedation. No mention of local anesthestic used. I wonder if this plastics clinic splurges for EXPAREL?

btw The wording of claim 30 is so poorly written.

 

[dpmd]

“30. Prior to the beginning of Ms. Nguyen’s procedure, Defendant Kim entered orders for anesthesia, including intercostal, intramuscular (intravascular) and subcutaneous injections of 4mg versed, fentanyl and propofol localized anesthesia.” Direct quote from court file.

it appears that the crna may have performed an intercostal block while sedating with verses, fentanyl and propofol. This could be the result of LAST (intercostal blocks are a higher risk) or over sedation. No mention of local anesthestic used. I wonder if this plastics clinic splurges for EXPAREL?

btw The wording of claim 30 is so poorly written.

I wonder if that is just because lawyers aren't medically trained or because the charting was that ****ty.

 

[coffeebythelake]

Still unclear whether it was a block plus general?

 

[somedumbDO]

I could see this happening a prepo intercostal block w versed and propofol, poor to no preop monitoring. Everyone grabs lunch in between. Come back blue patient (last vs obstruction). Probably more like obstruction due to coming back quick without intralipid. Anyone else do intercostal?!? Occasionally I’ll do a pec 1/2 on a chronic pain or delicate flower. Especially if these are not submuscular this is a quick 20 min a side Mac case. Regardless someone should of not left the pt if she was blocked preop. That’s the best of worse argument I can see. If they induced and then left the patient, license at a minimum should be gone, plus or minus criminal charges for second go around.

 

[Ezekiel2517]

“30. Prior to the beginning of Ms. Nguyen’s procedure, Defendant Kim entered orders for anesthesia, including intercostal, intramuscular (intravascular) and subcutaneous injections of 4mg versed, fentanyl and propofol localized anesthesia.” Direct quote from court file.

it appears that the crna may have performed an intercostal block while sedating with verses, fentanyl and propofol. This could be the result of LAST (intercostal blocks are a higher risk) or over sedation. No mention of local anesthestic used. I wonder if this plastics clinic splurges for EXPAREL?

btw The wording of claim 30 is so poorly written.

The wording in these things is typically terrible bc they're written by lawyers but it seems much more likely that the order was not for the crna to perform an intercostal block, but for the local anesthetic for the surgeon to do the block intraoperatively. I've never heard of a plastic surgeon requesting intercostal blocks to be performed by the anesthesiologist for their breast augs. And it's repeatedly documented that general anesthesia was induced.

 

[surgndoc]

Haven’t read all the docs l, but it sounds like GA was induced and the CRNA proceeded to leave the room. Given the pts body habitus I doubt this was an unrecognized goose.

Even if he left the room and the pt was untouched, 0.7 MAC or above and the pt could probably stay that way for hours and hours. Unless you forget to do this one thing, which will kill the patient every time, and that’s not turn the ventilator on.

As someone said earlier, tube in and tunes on, and you may not notice a flurry of alarms until it’s too late. Or the alarms were all disabled.

I don’t think he induced and tubed without even placing EKG, pulse ox etc. but then again who knows.
Guess We could expect to see some answers as this goes to trial.

anyone have the court details of first time this crnas Had a similar outcome?

 

[deleted126335]

Remember the complaint is full of allegations. Not facts.

 

[BLADEMDA]

I had a 22 year old girl brady down on me during a cosmetic procedure (breast implants). She was an ASA 1 and in perfect health. Her HR went to 20 and I needed to give Atropine x 1 IV to restore her heart rate. If I was not paying attention or out of the O.R. I think she would have coded and possibly died. But, I was in the room doing the case and quickly took action. That young girl went home without any issues 2 hours later.

If you are doing bilateral Pecs1 and 2 blocks for a 50-52 kg girl or intercostal blocks the absorption of local can be rapid and reach high peak concentrations. Even using Ropivacaine the addition of epi to the local will reduce peak local anesthetic blood levels combined with a maximum dosage limit of 3.5 mg/kg for Ropivacaine. Also, the availability of lipids to treat LAST is standard of care IMHO. Failure to promptly treat LAST may result in death.

 

[deleted697535]

This is pure greed and laziness. Not present for first 15 mins after induction=criminal.

Not transferring for 5 hours= stupidity of an arrogant undertrained CRNA.

When something similar ish happened in the UK it became nationwide news and was shown to all trainees in the hope it would change practice and prevent a repeat. Google bromley UK video.

or a LMA for septoplasty. I bet less than 10 percent of people on this board would consider this anesthetic.. If you dont know the pitfalls of putting an lma for those cases, you need to go back in time where you were a first year

Well with respect you're fairly wrong there. We did 1000s of fess with lma. Works great.

I've done adenoids with lma, not tonsils

 

[AMEHigh]

I had a 22 year old girl brady down on me during a cosmetic procedure (breast implants). She was an ASA 1 and in perfect health. Her HR went to 20 and I needed to give Atropine x 1 IV to restore her heart rate. If I was not paying attention or out of the O.R. I think she would have coded and possibly died. But, I was in the room doing the case and quickly took action. That young girl went home without any issues 2 hours later.

If you are doing bilateral Pecs1 and 2 blocks for a 50-52 kg girl or intercostal blocks the absorption of local can be rapid and reach high peak concentrations. Even using Ropivacaine the addition of epi to the local will reduce peak local anesthetic blood levels combined with a maximum dosage limit of 3.5 mg/kg for Ropivacaine. Also, the availability of lipids to treat LAST is standard of care IMHO. Failure to promptly treat LAST may result in death.

I’ve never had surgery, so sorry if this is a dumb question. Do you tell patients about these things when they happen? Do you think there could be a possible underlying pathology or that’s just the overall risk for anyone undergoing GA?

Although I don’t wish med school were longer I do wish I were exposed more to all specialties that aren’t required like anesthesia, neurosurgery, etc in a no-pressure environment since I’ll likely never have the opportunity again.

 

[surgndoc]

I’ve never had surgery, so sorry if this is a dumb question. Do you tell patients about these things when they happen? Do you think there could be a possible underlying pathology or that’s just the overall risk for anyone undergoing GA?

Not sure what others may say, however I’ve carried over something I used to say in residency along the lines of “chances of anything more severe such as heart attack, stroke, major blood loss, arrhythmias etc. are in the neighborhood of 1 in 30-50,000. Similar to riding in a commercial airliner” and then I mitigate that by saying we’ll be watching vitals, pulse ox, BP HR at all times or you’re a relatively healthy patient for a low risk surgery if that’s appropriate, .....here’s the consent form to sign.

 

[AMEHigh]

Not sure what others may say, however I’ve carried over something I used to say in residency along the lines of “chances of anything more severe such as heart attack, stroke, major blood loss, arrhythmias etc. are in the neighborhood of 1 in 30-50,000. Similar to riding in a commercial airliner” and then I mitigate that by saying we’ll be watching vitals, pulse ox, BP HR at all times or you’re a relatively healthy patient for a low risk surgery if that’s appropriate, .....here’s the consent form to sign.

Yes but I mean afterwards. If the young healthy person has bradycardia down to the 20s, and you give them atropine, do you tell them about it? Is it clinically relevant? Should they tell the next anesthesiologist? Or is that something you expect can happen to everyone even young and healthy, so it's not worth mentioning to them afterwards?

 

[TheLesPaul]

I didnt say MAC was bad for eyelids browlift facelift.... Thats diff from an LMA for a tonsil, or a LMA for septoplasty. I bet less than 10 percent of people on this board would consider this anesthetic.. If you dont know the pitfalls of putting an lma for those cases, you need to go back in time where you were a first year

I’m not an anesthesiologist I’m a plastic surgeon. People in this thread are dumping on surgeons for preferring sedation but I really feel it’s better for my patients, not to mention necessary for some eyelid work. My typical CRNAs and anesthesiologists can handle it beautifully but every once in a while I get someone who rolls their eyes when I ask for MAC and it turns out they suck at it. Why is it considered twisting your arm to insist on good sedation?

And I’ve used LMA on hundreds of endoscopic intranasal cases and the staff seem to have to problem. I haven’t seen an ETT in ages outside of the peds or very long cases. Why is it so bad? Apart from the blanket “airway protection” rationale. I’m curious and just want to be safer, I’ve learned lot on this thread.


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[okayplayer]

I’m not an anesthesiologist I’m a plastic surgeon. People in this thread are dumping on surgeons for preferring sedation but I really feel it’s better for my patients, not to mention necessary for some eyelid work. My typical CRNAs and anesthesiologists can handle it beautifully but every once in a while I get someone who rolls their eyes when I ask for MAC and it turns out they suck at it. Why is it considered twisting your arm to insist on good sedation?

And I’ve used LMA on hundreds of endoscopic intranasal cases and the staff seem to have to problem. I haven’t seen an ETT in ages outside of the peds or very long cases. Why is it so bad? Apart from the blanket “airway protection” rationale. I’m curious and just want to be safer, I’ve learned lot on this thread.

You dictating the type of anesthetic I do is no different than me dictating the type of breast implant you put in. I went to a 4 year residency to make the subtle determinations about which patients are good MAC candidates, LMA candidates, GETA candidates. That's my call. This is also why I work in a hospital with surgeons who are respected peers and not in plastic surgery offices.

 

[PieOHmy]

I’m not an anesthesiologist I’m a plastic surgeon. People in this thread are dumping on surgeons for preferring sedation but I really feel it’s better for my patients, not to mention necessary for some eyelid work. My typical CRNAs and anesthesiologists can handle it beautifully but every once in a while I get someone who rolls their eyes when I ask for MAC and it turns out they suck at it. Why is it considered twisting your arm to insist on good sedation?

And I’ve used LMA on hundreds of endoscopic intranasal cases and the staff seem to have to problem. I haven’t seen an ETT in ages outside of the peds or very long cases. Why is it so bad? Apart from the blanket “airway protection” rationale. I’m curious and just want to be safer.

And to be honest , its not better for your patients. You tthink its better.
Anesthesiologists have seen all sorts of 'badness happen'. That must be respected



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I absolutely not dumping on surgeons for requesting anything. But here is the thing, most surgeons don't really know what they are asking for? For example, some breast surgeons ask for sedation when they really mean general without a endo tube. In other words, they want the patient snowed but not intubated. You have to realize, that anesthetic is a lot more challenging and frankly not appropriate for many patients ( osa, obesity, etc etc). An endotracheal tube is more appropriate and safer. Even an LMA in this particular circumstance is better in my opinion.
With regards to brow lifts, eye lid work etc the only 2 anesthetics that are appropriate for these are minimal sedation(no propofol) and/ or endotracheal tube. WHy do I say that? Because when sedation with propofol is enacted one must constantly adjusting patient's airway and have access to airway if patient reacts negatively to propofol or becomes apneic or obstructs. It is difficult to rescue a patient when they are away from you and the whole face is draped.

With regards to intranasal cases, same concept.
LMA, gets dislodged all the time, patients vocal cords spasm, all manner of dysfunction has happened and will continue to happen with LMAs. It is not operator error, these are things that happen. How do you rescue a patient whose lma gets dislodged if 90-180 degrees away from you and the whole face is draped and instruments everywhere? Im just trying to avoid brain death or outright death all the time..

This is NOT an indictment on your surgical skills but these are real life considerations that run through my mind when im doing these..

 

[cockblockandrun]

I absolutely not dumping on surgeons for requesting anything. But here is the thing, most surgeons don't really know what they are asking for? For example, some breast surgeons ask for sedation when they really mean general without a endo tube. In other words, they want the patient snowed but not intubated. You have to realize, that anesthetic is a lot more challenging and frankly not appropriate for many patients ( osa, obesity, etc etc). An endotracheal tube is more appropriate and safer. Even an LMA in this particular circumstance is better in my opinion.
With regards to brow lifts, eye lid work etc the only 2 anesthetics that are appropriate for these are minimal sedation(no propofol) and/ or endotracheal tube. WHy do I say that? Because when sedation with propofol is enacted one must constantly adjusting patient's airway and have access to airway if patient reacts negatively to propofol or becomes apneic or obstructs. It is difficult to rescue a patient when they are away from you and the whole face is draped.

With regards to intranasal cases, same concept.
LMA, gets dislodged all the time, patients vocal cords spasm, all manner of dysfunction has happened and will continue to happen with LMAs. It is not operator error, these are things that happen. How do you rescue a patient whose lma gets dislodged if 90-180 degrees away from you and the whole face is draped and instruments everywhere? Im just trying to avoid brain death or outright death all the time..

This is NOT an indictment on your surgical skills but these are real life considerations that run through my mind when im doing these..

Just like when surgeons tells me "no general, just heavy MAC"....

WTF

 

[eagle0990]

I’m not an anesthesiologist I’m a plastic surgeon. People in this thread are dumping on surgeons for preferring sedation but I really feel it’s better for my patients, not to mention necessary for some eyelid work. My typical CRNAs and anesthesiologists can handle it beautifully but every once in a while I get someone who rolls their eyes when I ask for MAC and it turns out they suck at it. Why is it considered twisting your arm to insist on good sedation?

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It is important to remember that general anesthesia vs sedation (MAC) is not defined by presence/absence of an ETT. It is defined by a patient's response to verbal, tactile or surgical stimulation. Most surgeons do not appreciate that. They merely assume that no tube means sedation. This is a complete misunderstanding of what is occurring.

Most surgeons I have worked with ask for sedation when they really mean they want general anesthesia with no airway present. Not sure how that is better for their patients.

 

[GaseousClay]

good ol Mike McKinnon DNP FNP-C CRNA RN BSN gave his 2 cents on the forum. they will start coming out in full force. too lazy to screen shot it but go read if you're bored and want to get mad on christmas eve

 

[sevo00]

good ol Mike McKinnon DNP FNP-C CRNA RN BSN gave his 2 cents on the forum. they will start coming out in full force. too lazy to screen shot it but go read if you're bored and want to get mad on christmas eve

where do we read it

 

[Man o War]

good ol Mike McKinnon DNP FNP-C CRNA RN BSN gave his 2 cents on the forum. they will start coming out in full force. too lazy to screen shot it but go read if you're bored and want to get mad on christmas eve

I feel so sorry for that guy. Dude clearly has an incredible complex about being a nurse vs a doctor.
Search his past posts on SDN before he became a CRNA. I am serious when I say I feel sorry for him. This is why I tell people deciding between being a mid level and a doctor to really do some soul searching...Regardless of whatever independent practice rights you think you have, you’re still a nurse...the surgeon knows it, the staff knows it, and most importantly you know it. Some people don’t care about that, and it really eats at others.

 

[TheLesPaul]

Thanks for the interesting discussion.

I’m not so sure it’s completely your call...I usually need cooperation for certain parts of the case (eyelid) and prefer a deep MAC (“general without a tube”) for the rest of it. The advantages I see are that patients wake up quicker, I can get cooperation if I need it, and it makes the case faster. I don’t think rigid adherence to that philosophy makes sense as my anesthesia colleagues usually can get me what I want with propofol and a nasal cannula. The face is draped but not covered so on the odd occasion the patient starts obstructing, we do a jaw thrust, lighten it up, and if need be, throw an LMA in. You’re right that not every patient is appropriate for this but I feel 80% are.

It does require more monitoring and adjustment, but it is not onerous or impossible, from my viewpoint. Also, it is a huge pain to maneuver around the tube when doing a neck lift compared to nasal cannula.

And for what it’s worth, I would never hire a CRNA and supervise in my office bc I don’t want to take on that responsibility, I only operate at ASCs with MDs supervising.

Am I off base? I’m just surprised that so many feel so strongly against a nice snoring propofol MAC with nasal cannula which is 80% of what I do and ask for.


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[mmag]

good ol Mike McKinnon DNP FNP-C CRNA RN BSN gave his 2 cents on the forum. they will start coming out in full force. too lazy to screen shot it but go read if you're bored and want to get mad on christmas eve

Where did he do that? He wasn't posting about the updated slogan for CRNA week was he?

The AANA changed from from "Every Breath, Every Beat, Every Second WE ARE THERE" to "Your Comfort, Your Care WE ARE THERE" for CRNA week 2020.

 

[BLADEMDA]

Thanks for the interesting discussion.

I’m not so sure it’s completely your call...I usually need cooperation for certain parts of the case (eyelid) and prefer a deep MAC (“general without a tube”) for the rest of it. The advantages I see are that patients wake up quicker, I can get cooperation if I need it, and it makes the case faster. I don’t think rigid adherence to that philosophy makes sense as my anesthesia colleagues usually can get me what I want with propofol and a nasal cannula. The face is draped but not covered so on the odd occasion the patient starts obstructing, we do a jaw thrust, lighten it up, and if need be, throw an LMA in. You’re right that not every patient is appropriate for this but I feel 80% are.

It does require more monitoring and adjustment, but it is not onerous or impossible, from my viewpoint. Also, it is a huge pain to maneuver around the tube when doing a neck lift compared to nasal cannula.

And for what it’s worth, I would never hire a CRNA and supervise in my office bc I don’t want to take on that responsibility, I only operate at ASCs with MDs supervising.

Am I off base? I’m just surprised that so many feel so strongly against a nice snoring propofol MAC with nasal cannula which is 80% of what I do and ask for.


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Happy Holidays my friend. An experienced Anesthesiologist is all you need to do your cases. Preferably, one that has personally performed thousands of cases in an ASC/outpatient setting as well as a hospital. Someone who has seen countless minor and major complications. That said, some of us can "MAC" almost anyone for anything but that doesn't make it the best or safest choice for the patient. We must work with the request of the surgeon, e.g., "MAC", while preserving the safety of the patient.

I'm sure what you are doing is mostly just fine but be aware there will be occasions that an LMA may be "safer" for that patient with severe sleep apnea, Class 3 airway and morbid obesity vs MAC.

What you will find is there are no "absolutes" when taking care of patients and we must be willing to adjust to the situation on demand. So, accommodating your requests 80-85% of the time won't be an issue as long as you understand the other 15% of the time things may need to be done differently.

When you or a loved one are on the table just do what's right for the patient which must include advocacy and vigilance for safety above all else.

One last thing is that "fire safety" has really become an issue when doing MAC cases so be very aware that high flow nasal oxygen with a bovie nearby can be a recipe for disaster.

 

[BLADEMDA]

Emphasis on oxygen delivery is critical not only because of increasing flammability but also because of increased rates of injury when operating close to an oxygen source and/or airway. A review of operating room fire claims found that 85% of fires occurred in the head, neck, or upper chest, and 81% of cases occurred with monitored anesthesia care.4 These fires are typically attributed to increases in oxygen content at the surgical site.
The local oxygen concentration is significantly affected by anesthetic care providing supplementation via “open” or “closed” sources. Open systems include nasal cannula or mask oxygen delivery and will increase surrounding oxygen content in relation to oxygen delivered (fraction of inspired oxygen [Fio2]). When monitored anesthesia care is employed, the onus is on the anesthesiologist to titrate oxygen delivery to the minimal acceptable saturation.15
Given the increased fire risk related to oxygen, the Joint Commission (Oakbrook Terrace, Illinois) and the Emergency Care Research Institute recommend use of air or Fio2 less than or equal to 30% for open delivery.16 Per the Emergency Care Research Institute, this recommended oxygen concentration has not been verified, but should be used as a marker to “establish guidelines for minimizing oxygen concentration under surgical drapes.” These recommendations are echoed by the Anesthesia Patient Safety Foundation, which suggests the use of endotracheal intubation or laryngeal mask airway in any procedure above the xiphoid or if oxygen supplementation greater than 30% is required.9

Operating Room Fires

Operating room fires are rare but devastating events; their prevention and management require our understanding of the three ingredients of a fire (oxidizer, fuel, ignition source), an accurate preoperative assessment of risk, and teamwork to extinguish.

anesthesiology.pubs.asahq.org

 

[dannyboy1]

I’m not an anesthesiologist I’m a plastic surgeon. People in this thread are dumping on surgeons for preferring sedation but I really feel it’s better for my patients, not to mention necessary for some eyelid work. My typical CRNAs and anesthesiologists can handle it beautifully but every once in a while I get someone who rolls their eyes when I ask for MAC and it turns out they suck at it. Why is it considered twisting your arm to insist on good sedation?

And I’ve used LMA on hundreds of endoscopic intranasal cases and the staff seem to have to problem. I haven’t seen an ETT in ages outside of the peds or very long cases. Why is it so bad? Apart from the blanket “airway protection” rationale. I’m curious and just want to be safer, I’ve learned lot on this thread.


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The ideal and safest way to manage an airway is usually with an ETT. Do I use LMA’s? Of course, all the time. It it safer? Nope. The reason we use them is because they are great for short cases, with quick wake ups needed (like knee scopes, cysto, d and c same day stuff etc) and they have an acceptable enough safety profile. But as always, sh1t happens. I realized this one day when my 50 kg otherwise healthy little old lady vomited a large amount of green stuff into the circuit through her perfectly seated size 4 LMA. was just a 20 minute hip pinning. Luckily she did ok. As for sedation (GA with no airway) I agree that patients wake up beautifully and quickly from a propofol GTT. Unfortunately you can’t always predict who will be a great candidate for “MAC” some patients will obstruct/cough the whole way through. Does this mean I never do “MAC”. Of course not. I’m a good little anesthesiologist who generally does as he is told. We also, for better or worse, have accepted the slight decrease in safety in favor of convenience and quicker discharges. It is what it is and we have to live with it. However, if I or my family ever need anesthesia I would insist on general with an ETT. It is without question the safest way to do things.

 

[BLADEMDA]

Doctors and CRNAs Disagree on Ruling.

According to the American Medical News article, the regional director of the Colorado Society of Anesthesiologists calls the ruling a safety issue for patients. He believes that by removing a physician’s oversight from the delivery process it diminishes patient care.

Click here to read an opinion article written by a Board Certified Anesthesiologist in Colorado agreeing that unsupervised CRNAs can put patients’ health at risk.

On the other hand, the president of the Colorado Association of Nurse Anesthetist praises the ruling stating, in the article, that research shows no differences in patient morbidity or mortality rates whether or not CRNAs are under a doctor’s supervision.

 

[Consigliere]

I’m not so sure it’s completely your call...

I am. 100% sure. It is our call, not yours. Hire an anesthesia nurse if you want some undertrained sycophant you can bully into doing whatever you want. I ain't that guy.

 

[BLADEMDA]

Your Comfort, Your Care WE ARE THERE" for CRNA week 2020.

National CRNA Week Themes

www.aana.com

 

[Lawpy]

Really sad story, but this thread has been educational and informative. I have a hard stance against midlevels, so this is particularly upsetting. But i learned a lot about anesthesia practices here.

 

[PieOHmy]

I’m just surprised that so many feel so strongly against a nice snoring propofol MAC with nasal cannula which is 80% of what I do and ask for.


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A nice snoring propofol MAC can turn into a not so nice not breathing or obstructing thrashing mess with any change of conditions (surgical stimulation). who wants to deal with that at 90 degrees or 180 degrees?

 

[PieOHmy]

good ol Mike McKinnon DNP FNP-C CRNA RN BSN gave his 2 cents on the forum. they will start coming out in full force. too lazy to screen shot it but go read if you're bored and want to get mad on christmas eve

I would love to read that guys posts when he was a student..
was his name nitecap?

 

[coffeebythelake]

I would love to read that guys posts when he was a student..
was his name nitecap?

Would have thought his name was douche_mcdouchebag

 

[abolt18]

I would love to read that guys posts when he was a student..
was his name nitecap?

Volatile - you wanted proof.

Buddy In regards to that other thread where you called me the problem. This isnt my first rodeo, just a different sret of clowns. Ive been doing this since you were watching hair grow on your "dinky". I KNOW the rules and I have always followed them. I was right, you are wrong. Here is...

forums.studentdoctor.net

 

[IlDestriero]

Seems like a great time for someone to point out how flawed those non-inferior studies are

I’m happy to work with any attorney to evaluate a claim, if they are paying, but I wouldn’t be able to be their expert witness. Though I’d much rather work with the defense. I certainly won’t be sending unsolicited advice to any attorneys, that’s dumb, and unethical as you don’t know the facts of the case.
We will never know what happened here because there is no chance that this case goes to trial if it is remotely true. The only way this goes to court is if, 1. The pathological ego of those involved outweighs the advice of literally everyone involved who will advise them to settle this (potentially astronomical) loser. Or if the CRNA tries to claim the captain of the ship defense and attempt to dump all the liability on the surgeon. While also ignoring the advice of everyone associated with the claim to settle.
The clinic and the surgeon will 100% settle as they have everything to lose.

 

[d9sccr]

I’m happy to work with any attorney to evaluate a claim, if they are paying, but I wouldn’t be able to be their expert witness. Though I’d much rather work with the defense. I certainly won’t be sending unsolicited advice to any attorneys, that’s dumb, and unethical as you don’t know the facts of the case.
We will never know what happened here because there is no chance that this case goes to trial if it is remotely true. The only way this goes to court is if, 1. The pathological ego of those involved outweighs the advice of literally everyone involved who will advise them to settle this (potentially astronomical) loser. Or if the CRNA tries to claim the captain of the ship defense and attempt to dump all the liability on the surgeon. While also ignoring the advice of everyone associated with the claim to settle.
The clinic and the surgeon will 100% settle as they have everything to lose.

Not sure why you think the CRNA would do anything but try to dump this on the surgeon honestly. Maybe you work w a different breed than I’m accustomed to

 

[Arch Guillotti]

I deleted a few posts that mentioned a particular lawyers name and solicitation for his services

 

[deleted697535]

I’m not an anesthesiologist I’m a plastic surgeon.


but every once in a while I get someone who rolls their eyes when I ask for MAC and it turns out they suck at it.

I’m not an anesthesiologist I’m a plastic surgeon.


1. People in this thread are dumping on surgeons for preferring sedation but I really feel it’s better for my patients, not to mention necessary for some eyelid work. My typical CRNAs and anesthesiologists can handle it beautifully but every once in a while I get someone who rolls their eyes when I ask for MAC and


2.
it turns out they suck at it. Why is it considered twisting your arm to insist on good sedation?

And I’ve used LMA on hundreds of endoscopic intranasal cases and the staff seem to have to problem. I haven’t seen an ETT in ages outside of the peds or very long cases.

3. Why is it so bad? Apart from the blanket “airway protection” rationale. I’m curious and just want to be safer, I’ve learned lot on this thread.


Sent from my iPhone using SDN

You make good points and I appreciate your input. Some surgeons are very pompous and elite ish towards us and that creates the problem. Maybe if we both understood where each other was coming from it would be easier.

We certainly do get some requests from surgeons that make no physiologic or pharmacologic sense and that irks us. Just last week I had a plastic surgeon request prone, in an obese guy with a huge beard and recently reversed trache. She said she would cancel the case if we used any form of paralytic incl sux, mag, cis, roc ever. Not even demonstrable tof after suggamadex would do. (she didn't know what suggamadex was)


Now to your points.

1. This is purely your opinion. I'm sorry. But there is no convincing evidence that any form of Anesthesia is better than any other for anything. Maybe spinals are better for joint arthroplasty but that's it. I'm not aware of any large body of accepted evidence that says one form of Anesthesia is better than another for plastic surgery.

Your colleagues are notorious for not allowing us to use pressors in flap surgery which has been debunked fairly convincingly Esp norepi forcing us to give loads of fluids or run a dangerous line with hypotension. This also adds to mistrust

2. Well this is key to the back and forth your having here and in your office. Yes Mac is actually much hard intraop for us. The easiest thing in the world is fent prop roc tube sit down. Also as I've said many times on this site. Mac means absolutely nothing. To me it means running prop at Ce 2 using Schneider. Probably to others it means midaz fent repeat when they move a bit. So there's massive variety.

3. See point 1. It's more a gestalt of the provider on the day. Personally I've no had too many **** shows with propofol in fasted non Emerg cases but everyone has their stories Esp from the gastro scopes suite.

We have lots of little anecdotes in our field. Umbilicius closer to the ceiling than the nose intubate, intubate everything after 3pm, beware the bearded man, beware the China man(sorry I'm not racist). If you think you're going to have problems intraop have them preop instead ie intubate!

These things mean nothing really but have been handed down by wiser old timers for a reason...

So all that rambling nonsense from me to say, I like your attitude and if you are upfront with your anesthesiologist on the day you'll both have a great day

 

[dannyboy1]

You make good points and I appreciate your input. Some surgeons are very pompous and elite ish towards us and that creates the problem. Maybe if we both understood where each other was coming from it would be easier.

We certainly do get some requests from surgeons that make no physiologic or pharmacologic sense and that irks us. Just last week I had a plastic surgeon request prone, in an obese guy with a huge beard and recently reversed trache. She said she would cancel the case if we used any form of paralytic incl sux, mag, cis, roc ever. Not even demonstrable tof after suggamadex would do. (she didn't know what suggamadex was)


Now to your points.

1. This is purely your opinion. I'm sorry. But there is no convincing evidence that any form of Anesthesia is better than any other for anything. Maybe spinals are better for joint arthroplasty but that's it. I'm not aware of any large body of accepted evidence that says one form of Anesthesia is better than another for plastic surgery.

Your colleagues are notorious for not allowing us to use pressors in flap surgery which has been debunked fairly convincingly Esp norepi forcing us to give loads of fluids or run a dangerous line with hypotension. This also adds to mistrust

2. Well this is key to the back and forth your having here and in your office. Yes Mac is actually much hard intraop for us. The easiest thing in the world is fent prop roc tube sit down. Also as I've said many times on this site. Mac means absolutely nothing. To me it means running prop at Ce 2 using Schneider. Probably to others it means midaz fent repeat when they move a bit. So there's massive variety.

3. See point 1. It's more a gestalt of the provider on the day. Personally I've no had too many **** shows with propofol in fasted non Emerg cases but everyone has their stories Esp from the gastro scopes suite.

We have lots of little anecdotes in our field. Umbilicius closer to the ceiling than the nose intubate, intubate everything after 3pm, beware the bearded man, beware the China man(sorry I'm not racist). If you think you're going to have problems intraop have them preop instead ie intubate!

These things mean nothing really but have been handed down by wiser old timers for a reason...

So all that rambling nonsense from me to say, I like your attitude and if you are upfront with your anesthesiologist on the day you'll both have a great day

Yup. Plastic surgeons are generally a pain in the ass. Gotta love the guy who thinks you can run a 10 hour anesthetic for a flap case with no pressors. I just nod my head, smile, and lie through my teeth as I lace the iv fluids with phenylephrine.

 

[coffeebythelake]

I’m happy to work with any attorney to evaluate a claim, if they are paying, but I wouldn’t be able to be their expert witness. Though I’d much rather work with the defense. I certainly won’t be sending unsolicited advice to any attorneys, that’s dumb, and unethical as you don’t know the facts of the case.
We will never know what happened here because there is no chance that this case goes to trial if it is remotely true. The only way this goes to court is if, 1. The pathological ego of those involved outweighs the advice of literally everyone involved who will advise them to settle this (potentially astronomical) loser. Or if the CRNA tries to claim the captain of the ship defense and attempt to dump all the liability on the surgeon. While also ignoring the advice of everyone associated with the claim to settle.
The clinic and the surgeon will 100% settle as they have everything to lose.

I wonder realistically how much the family will be able to get from the lawsuit. This is a one surgeon practice unaffiliated with anything larger. The same is said for the CRNA. Even if they go after their personal assets, which I feel is possible here given the absolutely egregious deviation from standard of care, I imagine this would not be more than 10-15 million dollars. Of course, as I've previously said, I think this malpractice case is worth 100 million if it was a hospital system

This and... someone needs to charge Meeker with a crime.

 

[coffeebythelake]

Your colleagues are notorious for not allowing us to use pressors in flap surgery which has been debunked fairly convincingly Esp norepi forcing us to give loads of fluids or run a dangerous line with hypotension. This also adds to mistrust

Hey can u link some references regarding this? We deal w this problem all the time. It's like all these plastic surgeons are trained by the same person. I ofyen work in some neo because it is the best thing for the patient. Next time my residents ask me about this I can show them...

 

[IlDestriero]

There was a comment about not working for an attorney for less than $1M/hr. To that I will tell you that there are people that practice far below what everyone would consider the standard of care. I’ve seen the records. I’ve read the reports. These people deserve to be sued, sanctioned, and potentially lose their license. They cause avoidable harm and destroy lives. I’m not talking about bad luck, surgical misadventures, etc. I’m referring to gross malpractice.
Completely negligent care obvious to everyone in the field.
It happens. It likely happened above if 1/2 the facts are true.
The legal system is appropriate for that and there is no reason to not support those cases. This family should receive compensation for their damages, ongoing care for their neurologically devastated child, etc. If any of the allegations are true it’s indefensible and avoidable harm. Which is why it will settle and the details never known.
Perhaps the patient got “sedation” for the block and then the CRNA left during set up for lunch or a dump or whatever. That’s difficult to defend as anything less than abandonment and malpractice, if not criminal negligence.