CRNA horror stories

[deleted162650]

You can delegate the authority, but not the responsibility.

I completely understand what you are saying, and of course in an ACT model the buck ultimately stops with the MD. But, if you leave what amounts to written order that the nurse or other midlevel fails to follow, fails to notify you, and fails to document why they did not follow your order it would seam to me that that should offer some protection for you from being squarely blamed for a midlevel's F-up. Maybe I'm just being naive and idealistic though?? I admit I'm ignorant on the topic since I don't supervise.

At least I think if the same thing were to happen in say the ICU between the intensivist and the CCRN he/she would be protected to some extent??

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[IlDestriero]

I wonder if that would even be worse. You can always hire an expert to argue that a MAP of 50 should be safe, but if you wrote to keep it above 60 and the CRNA didn't, they'll question why you didn't insure that they kept the map>60. I can't imagine covering 4:1 while doing blocks, pre and post op notes, etc.
This is also why it's important to hire your own CRNAs. If they are not following direction, not calling for help (or even recognizing they need it), etc. you need to fire them before they hurt your patient, expose you to liability, and jeopardize your career.


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Il Destriero

 

[deleted171991]

I can't imagine anything beyond 2:1 to remotely satisfy the concept of proper supervision for most procedures. If I were a malpractice lawyer, I would start by having the defending anesthesiologist demonstrate how they could properly supervise, based on the day's schedule. Most often than not, it will prove that the CRNAs were completely unsupervised at least 50% of the time, because the attending was doing something else than watching them. It's not like there is somebody watching all rooms at all times, both on EMR and live video, ready to alert one when a CRNA does something stupid in one's absence.

And that, by the way, defines your malpractice risks, too, future anesthesiologists. Would you really like to let people work on your license unsupervised for many hours every day? This while your employer is the one getting rich on your malpractice and career risk? If yes, you have found the right specialty.

 

[jwk]

I wonder if that would even be worse. You can always hire an expert to argue that a MAP of 50 should be safe, but if you wrote to keep it above 60 and the CRNA didn't, they'll question why you didn't insure that they kept the map>60. I can't imagine covering 4:1 while doing blocks, pre and post op notes, etc.
This is also why it's important to hire your own CRNAs. If they are not following direction, not calling for help (or even recognizing they need it), etc. you need to fire them before they hurt your patient, expose you to liability, and jeopardize your career.

I can't imagine anything beyond 2:1 to remotely satisfy the concept of proper supervision for most procedures. If I were a malpractice lawyer, I would start by having the defending anesthesiologist demonstrate how they could properly supervise, based on the day's schedule. Most often than not, it will prove that the CRNAs were completely unsupervised at least 50% of the time, because the attending was doing something else than watching them. It's not like there is somebody watching all rooms at all times, both on EMR and live video, ready to alert one when a CRNA does something stupid in one's absence.

Among the seven TEFRA requirements, medical direction requires the presence of the anesthesiologist at induction and emergence, at intervals during the case, and available for emergencies. There is no requirement for the attending to be "watching" anesthetists constantly either in person or remotely or by following an EMR. Staffing ratios depend on types of procedures, time of day, their complexity or lack thereof, patients ASA status, and myriad other things. We run 1:3 most of the day, and sometimes 1:4 - but sometimes it may only be 1:2. It all depends. We comply with TEFRA requirements on every one and bill as medical direction on every case unless it is personally performed by an anesthesiologist. Attendings must be physically present in the OR to log into our EMR - it can't be done remotely - so there is no doubt they're there. If another anesthesiologist assumed medical direction, that has to be logged into the EMR at that time. Also - remember that Medicare allows medical direction responsibilities to be shared within a group. Anesthesiologists do all blocks, regionals, and CVLs in our practice. Those procedures are allowable while providing medical direction.

IlDest has the best advice - hire good people that do what you tell them to do and get rid of them if they don't. Our anesthetists are on orientation for a couple months. The first several weeks, they are one-on-one with an experienced anesthetist - that includes CRNAs from training programs where they may have done their own cases as a student. Too bad. You do it our way now. New anesthetists are watched far more closely than those with experience, and we emphasize from day one that this is a care team practice. Anesthetists are expected to call if there are problems that aren't resolved quickly. Single dose of phenylephrine? No problem. Neo drip needed? Call and let them know. Our anesthetists will never be criticized for calling with questions, concerns, or asking for help in any situation. You want to insure someone doesn't call? Make them feel stupid and they won't next time. The attending is the boss - that's never in question - but there is mutual respect for knowledge and capabilities between MD, CAA, and CRNA and recognition that the patients welfare is the primary duty of all.

 

[norwood]

You want to insure someone doesn't call? Make them feel stupid and they won't next time. The attending is the boss - that's never in question - but there is mutual respect for knowledge and capabilities between MD, CAA, and CRNA and recognition that the patients welfare is the primary duty of all.

Excellent point.

 

[deleted171991]

I am not talking about TEFRA requirements. I am talking about malpractice cases, and what satisfies the concept of proper supervision for those. Relying on the CRNA to call for help is laughable, as my own experience above illustrates. And that doesn't fix all the other stupid mistakes they make, which usually stem from a disrespect towards the attending anesthesiologist, and the "I am as good if not better" syndrome. Most of the CRNAs I have worked with have always asked too few questions, and definitely not the most important ones: what would you like me to do and not do with this patient, doctor? Not only that, but there were occasions where I specifically said I want A and they did B, without checking with me first.

I respect their education and professionalism, when it exists, but as long as the buck stops with me, every single important decision is mine to make, and I am the captain of the ship, without debate. I am not just their friggin consultant.

 

[Ronin786]

Reversing with zero twitches!

Extubating without reversing!

Not hooking up the circuit and actually administering anesthesia after LMA/intubation.

Overdosing propofol on EGD pt's who have terrible pulmonary status. Bc, you know, so they don't move during the 2 minute procedure.

And it's NEVER their fault. Never a "Crap, I won't do that ever again," or a "Sorry, I was wrong for doing that." They have a serious humility allergy. Pisses me off.

A theory I have is that a lot of what they do is based on their background as nurses as opposed to physicians. They have a hard time balancing patient comfort with patient safety. I'll always take safety over comfort for my patients if I have to make the choice, but I think the whole overuse of narcotics and keeping patients extremely deep has roots in the nurse background. That and their inability to think outside the algorithm.

 

[criticalelement]

If they are not following direction, not calling for help (or even recognizing they need it), etc. you need to fire them before they hurt your patient, expose you to liability, and jeopardize your career.

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Il Destriero

You are so cute. What the F*** world are you living in? FIre them? You cant fire them!! Your employer has to fire them. And guess who the employer wants to fire.. And the answer is.. NOT THEM........ ITS YOU!!!!!!!!!!!!!!!!!!!!!!!!
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[IlDestriero]

My employer is my physician practice LLC and sort of the University. The CRNAs work for my employer, my group. That's the world I live in. It's nice here.

 

[Ezekiel2517]

Oh and by the way, regarding the spine case I posted, both the anesthesiologist and CRNA ended up being terminated by the group. No idea about what litigation may have ensued.

 

[IlDestriero]

Oh and by the way, regarding the spine case I posted, both the anesthesiologist and CRNA ended up being terminated by the group. No idea about what litigation may have ensued.

There you go.
Not all firing is security walking you to the car and taking your key cards on the way out. It can also be, "I noticed that your contract is due for renewal next year, be aware we won't be renewing it. Good luck."
There are probably a lot more fired physicians running around than you think. You'd never know about the latter, unless the person who got canned told you. You'd hear about all the reasons why they quit. I know my group has "helped" people move on to better opportunities. It's not like the corporate world where you can steal proprietary info/tech, steal clients, leave a bunch of wreckage behind. It's patient care, you still show up, take care of patients, and cash the check. Though I'd resign from all my collateral duties!


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Il Destriero

 

[psychMDhopefully]

Happened during my residency. Long spine case. No art line. Episodes of hypotension during case. Record showed Pt's MAPs below 50 for one period of nearly 30 min intraop. Pt woke up at the end paralyzed permanently. Pt also happened to be one of the gastroenterologists at our hospital. Not sure if the hypotension was the definite cause but it doesn't look good

So the guy goes in for a routine case, and ends up paralyzed permanently? I 'm having surgery soon and this scares the crap out of me. And he was a doctor? Will he ever have any type of career again?

 

[Doctor4Life1769]

So the guy goes in for a routine case, and ends up paralyzed permanently? I 'm having surgery soon and this scares the crap out of me. And he was a doctor? Will he ever have any type of career again?

Good luck!!

 

[criticalelement]

My employer is my physician practice LLC and sort of the University. The CRNAs work for my employer, my group. That's the world I live in. It's nice here.

Still, your employer would like to fire you more than he wants to fire the crna. Irregardless of how nice you think where you work is

 

[IlDestriero]

Still, your employer would like to fire you more than he wants to fire the crna. Irregardless of how nice you think where you work is

Yes, the 7-5 CRNA is more valued than the mid career professor. I'm not sure what you're smoking.

 

[deleted547339]

Still, your employer would like to fire you more than he wants to fire the crna. Irregardless of how nice you think where you work is

Irregardless??

 

[Consigliere]

You are so cute. What the F*** world are you living in? FIre them? You cant fire them!! Your employer has to fire them. And guess who the employer wants to fire.. And the answer is.. NOT THEM........ ITS YOU!!!!!!!!!!!!!!!!!!!!!!!!
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My group hires and fires the CRNAs...why just this week we fired someone who couldn't cut the mustard.

 

[Consigliere]

I respect their education and professionalism

I don't. Their education is a joke and their "professionalism" ends the second their shift does. Want to see professionalism disappear quicker than a CRNA referring to their easy credentialing exam as boards? See what happens when a CRNA has to stay a few minutes past the end of their shift.

 

[criticalelement]

Irregardless??

I like the word f*** you. I know it doesn't exist

 

[criticalelement]

Yes, the 7-5 CRNA is more valued than the mid career professor. I'm not sure what you're smoking.

Mid-career professor. You get cuter and cuter with each post. LOL

 

[IlDestriero]

Maybe you need a better job. CRNAs are a dime a dozen in a big city. Experienced physicians without personality disorders aren't.

 

[jwk]

Relying on the CRNA to call for help is laughable, as my own experience above illustrates. And that doesn't fix all the other stupid mistakes they make, which usually stem from a disrespect towards the attending anesthesiologist, and the "I am as good if not better" syndrome. Most of the CRNAs I have worked with have always asked too few questions, and definitely not the most important ones: what would you like me to do and not do with this patient, doctor? Not only that, but there were occasions where I specifically said I want A and they did B, without checking with me first.

We don't tolerate this type of attitude in our practice. This type of anesthetist would and should be out the door.

 

[dannyboy1]

I don't. Their education is a joke and their "professionalism" ends the second their shift does. Want to see professionalism disappear quicker than a CRNA referring to their easy credentialing exam as boards? See what happens when a CRNA has to stay a few minutes past the end of their shift.

Not sure how someone not wanting to work for longer than they are scheduled to (and usually uncompensated work) became "unprofessional". I wish that physicians had as as much balls as nurses do when it comes to standing up for themselves.

 

[Chloroform4Life]

Not sure how someone not wanting to work for longer than they are scheduled to (and usually uncompensated work) became "unprofessional". I wish that physicians had as as much balls as nurses do when it comes to standing up for themselves.

I think you're making his point. It's not that we want to work longer. It's that we have a responsibility to care for the patient. Unless we can be sure that the level of care required continues to be achieved after we leave, we don't get to leave. That's professionalism.

 

[dannyboy1]

I think you're making his point. It's not that we want to work longer. It's that we have a responsibility to care for the patient. Unless we can be sure that the level of care required continues to be achieved after we leave, we don't get to leave. That's professionalism.

Yes, but if you hire someone to cover a set shift it is your responsibility to ensure that the appropriate level of care is available when the shift ends (or have some overtime mechanism in place) you are suggesting that the employee is responsible for what the employer should be, under the guise of professionalism.

 

[soorg]

F**k you is a phrase, not a word.

Ok, ok...

 

[deleted162650]

Still, your employer would like to fire you more than he wants to fire the crna. Irregardless of how nice you think where you work is

Dude, will you sack up and go find a decent job already so the rest of us can stop hearing about how sad and miserable you are.

 

[Consigliere]

Not sure how someone not wanting to work for longer than they are scheduled to (and usually uncompensated work) became "unprofessional". I wish that physicians had as as much balls as nurses do when it comes to standing up for themselves.

I'm sure you'll make a great CRNA some day.

 

[Consigliere]

Yes, but if you hire someone to cover a set shift it is your responsibility to ensure that the appropriate level of care is available when the shift ends (or have some overtime mechanism in place) you are suggesting that the employee is responsible for what the employer should be, under the guise of professionalism.

(sing to the tune of Danny Boy) Oh Danny Boy, you are an idiot.....I'm referring to what I see almost daily: CRNA dumps a pt. in PACU hypotensive and tachycardia, barely breathing, and is elbowing people out of the way since it's 2:59 p.m. and they're done at 3:00. Also, as the CRNAs are salaried and employed by me, should I subtract money from their paychecks when they often times leave before the end of their shift? It all evens out; they just have selective memory and can only remember when they stayed for 4 minutes past their shift. They never remember the multitude of times they left several hours early. You'll understand all this once you get a little experience.

 

[soorg]

"Well, I'm owed 10 minutes from last year."

 

[WholeLottaGame7]

Yes, but if you hire someone to cover a set shift it is your responsibility to ensure that the appropriate level of care is available when the shift ends (or have some overtime mechanism in place) you are suggesting that the employee is responsible for what the employer should be, under the guise of professionalism.

We're not talking about staying an extra 2 hours to finish a case, we're talking about people b****ing about an extra 5-10 minutes. When I was a senior resident I had a CRNA complain that she didn't get relieved at the end of her shift. They were out of OR to ICU at 1845; she was upset because by the time she gave sign out and got back from ICU it was going to be like 1905. Don't know if she wanted to leave at like 1815 or if she wanted someone else to transport/give report for her after a long case; didn't care. It was her last shift, too, before leaving for a job at the beach.

But sure, it's really the CRNAs that actually care about the patient, not the greedy selfish MDs.

 

[Mad Jack]

We had a CRNA that forgot to carry a couple zeroes with a paralytic many years back where I used to work. Was working peds, gave the kid 100x the dose he was supposed to get. I didn't know enough at the time to ask what drug it was, but, long story short, it was something that wasn't reversible, and it stopped the kid's heart. They did CPR on him for an hour hoping that it would wear off, but they'd done the math, they knew there wasn't a chance. He died. Massive lawsuit, etc.

Not that the MDs fared much better- looking for an article on it, I dug up a 3 year old kid that died of a really routine outpatient dental procedure under an anesthesiologist's care, who was fined a mere $5,000 and 40 hours of remedial medical education lol...

 

[deleted171991]

We're not talking about staying an extra 2 hours to finish a case, we're talking about people b****ing about an extra 5-10 minutes. When I was a senior resident I had a CRNA complain that she didn't get relieved at the end of her shift. They were out of OR to ICU at 1845; she was upset because by the time she gave sign out and got back from ICU it was going to be like 1905. Don't know if she wanted to leave at like 1815 or if she wanted someone else to transport/give report for her after a long case; didn't care.

+1. Same experience here. Actually, it should be like +10, because I have seen this story so many times in residency.

The department wasn't happy either about us not relieving them, because they were getting paid extra when they stayed longer.

 

[Mad Jack]

Oh, and said CRNA was neither fired nor lost her license, for the record. Though people would still mention behind her back that, "she's the one that killed that kid, you ever hear about that?" She also had one of the worst attitudes of any of the CRNAs, and got all militant when a physician would insist on checking anything she did or asked any questions.

 

[btbam]

We had a CRNA that forgot to carry a couple zeroes with a paralytic many years back where I used to work. Was working peds, gave the kid 100x the dose he was supposed to get. I didn't know enough at the time to ask what drug it was, but, long story short, it was something that wasn't reversible, and it stopped the kid's heart. They did CPR on him for an hour hoping that it would wear off, but they'd done the math, they knew there wasn't a chance. He died. Massive lawsuit, etc.

Not that the MDs fared much better- looking for an article on it, I dug up a 3 year old kid that died of a really routine outpatient dental procedure under an anesthesiologist's care, who was fined a mere $5,000 and 40 hours of remedial medical education lol...

How on earth could someone possibly give 100x a standard paralytic dose?

 

[Mad Jack]

How on earth could someone possibly give 100x a standard paralytic dose?

Could be wrong on the numbers- maybe it was just 10x. All I know is it was many, MANY times the standard dose- pretty sure she was trying to inject something else and grabbed the wrong bottle when drawing it up.

 

[Spinach Dip]

How on earth could someone possibly give 100x a standard paralytic dose?

-miligram v microgram confusion.
-knows standard dose for 100kg adult, fails to realize this kid is 10kg.
-what was the concentration in this vial again? 10 mg/ml? 1 mg/ml? 0.1 mg/ml?

etc.

 

[IlDestriero]

I don't see how a paralytic could kill anyone. They'll wear off eventually. Perhaps a CV Med? Even a massive opiate overdose should be recoverable with time +/- pressors


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Il Destriero

 

[criticalelement]

I don't see how a paralytic could kill anyone. They'll wear off eventually. Perhaps a CV Med? Even a massive opiate overdose should be recoverable with time +/- pressors


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Il Destriero

 

[Urzuz]

I don't see how a paralytic could kill anyone. They'll wear off eventually. Perhaps a CV Med? Even a massive opiate overdose should be recoverable with time +/- pressors


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Il Destriero

I have no idea the actual details of the story the previous guy was referring to, but it's not hard to imagine how giving 100x the dose of a paralytic can kill someone. First off, we don't know whether this was succinylcholine or a nondepolarizer. If it was succinylcholine, I'm sure you can see how a massive overdose may lead to a cardiac arrest. Even if it was a nondepolarizer, remember how steroidal muscle relaxants have a tendency to be vagolytic (increase in HR, etc -- for example with pancuronium and to a lesser degree with rocuronium) and that benzylisoquinolones can lead to histamine release (eg: atracurium, mivacurium)? I'm sure giving a patient 100x a normal dose can't be good and can easily lead to a cardiac arrest.

Just to put numbers on this so you can wrap your head around the significance, he's talking about instead of giving a patient 50 mg of rocuronium for intubation, you give the patient 5000 mg.

 

[WholeLottaGame7]

I have no idea the actual details of the story the previous guy was referring to, but it's not hard to imagine how giving 100x the dose of a paralytic can kill someone. First off, we don't know whether this was succinylcholine or a nondepolarizer. If it was succinylcholine, I'm sure you can see how a massive overdose may lead to a cardiac arrest. Even if it was a nondepolarizer, remember how steroidal muscle relaxants have a tendency to be vagolytic (increase in HR, etc -- for example with pancuronium and to a lesser degree with rocuronium) and that benzylisoquinolones can lead to histamine release (eg: atracurium, mivacurium)? I'm sure giving a patient 100x a normal dose can't be good and can easily lead to a cardiac arrest.

Just to put numbers on this so you can wrap your head around the significance, he's talking about instead of giving a patient 50 mg of rocuronium for intubation, you give the patient 5000 mg.

Remember this is coming from a then-med student, so who knows what the drug really was (or the other circumstances of the scenario, for that matter), but my thought was also sux. Pancuronium should increase HR about 10% in a normal dose, even if it were to increase HR by 100% most kids would tolerate that fine (and doesn't sound like the heart stopping).

I don't know what 100mg of sux would do in a 10kg kid (and I don't want to find out), but it would probably look like profound bradycardia and cardiac arrest, either from the drastically reduced CO or the wicked hyperkalemic response --> acidosis --> etc. I would think you could treat the bradycardia w/ a ****-ton of atropine and chest compressions, but the hyperkalemia/acidosis would probably be what did him in.

I don't see how giving 100X any drug would even be possible, unless it were something undiluted like those 10mg phenylephrine vials.

 

[Chloroform4Life]

Speaking of 10mg phenylephrine vials. I heard a story at my old institution where a surgical intern responded to a hypotensive patient in the SICU and asked for phenylephrine. I guess he saw anesthesia pushed 1cc of phenylephrine all the time. So he drew up the 1cc of phenylephrine from the 10mg vial and gave it to the patient...... Patient died.

 

[Laryngophed]

Speaking of 10mg phenylephrine vials. I heard a story at my old institution where a surgical intern responded to a hypotensive patient in the SICU and asked for phenylephrine. I guess he saw anesthesia pushed 1cc of phenylephrine all the time. So he drew up the 1cc of phenylephrine from the 10mg vial and gave it to the patient...... Patient died.

Those vials scare me a bit. I have a very specific method for drawing up the neo (I draw it up into a 3cc syringe clearly labeled, and our drawers have a divider in them. I keep my stock neo in the drawer with the pre-packaged flush. It is the only non-flush syringe I keep there. And I draw up the neo before the case (apparently some folks don't?) and I do not put it into a flush syringe. One of my classmates diluted it like that, went on a break and came back to the break person working hard to correct HTN and no "flush."

 

[deleted171991]

Those vials scare me a bit. I have a very specific method for drawing up the neo (I draw it up into a 3cc syringe clearly labeled, and our drawers have a divider in them. I keep my stock neo in the drawer with the pre-packaged flush. It is the only non-flush syringe I keep there. And I draw up the neo before the case (apparently some folks don't?) and I do not put it into a flush syringe. One of my classmates diluted it like that, went on a break and came back to the break person working hard to correct HTN and no "flush."

I am surprised no label maker has thought about selling "do not inject" labels.

 

[deleted162650]

Those vials scare me a bit. I have a very specific method for drawing up the neo (I draw it up into a 3cc syringe clearly labeled, and our drawers have a divider in them. I keep my stock neo in the drawer with the pre-packaged flush. It is the only non-flush syringe I keep there. And I draw up the neo before the case (apparently some folks don't?) and I do not put it into a flush syringe. One of my classmates diluted it like that, went on a break and came back to the break person working hard to correct HTN and no "flush."

Every facility I've worked the past few years has switched to pre-drawn Neo syringes. When I had to draw it up myself I would just put the 10mg vial into a 100mL NS bag and have my Neo for the day. That way no sketchy ultra-concentrated syringes floating around.

In residency someone decided he needed to draw up some 100mcg Epi before a case which he did by squirting the 1mg vial into a 10cc NS vial and then labeling it with just some tiny handwriting. Attending gives him a break and realizes he still needs to give Ancef. Guess what "NS" vial he used to mix up the Ancef.

 

[IlDestriero]

When I was a resident, we had the trauma room set up with meds drawn up. I wanted to give someone 50-100 of phenylephrine and it was obviously mislabeled epi, no harm done, but a near miss and a good lesson. That was the last time I used meds someone else drew up.

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Il Destriero

 

[Urzuz]

Remember this is coming from a then-med student, so who knows what the drug really was (or the other circumstances of the scenario, for that matter), but my thought was also sux. Pancuronium should increase HR about 10% in a normal dose, even if it were to increase HR by 100% most kids would tolerate that fine (and doesn't sound like the heart stopping).

I don't know what 100mg of sux would do in a 10kg kid (and I don't want to find out), but it would probably look like profound bradycardia and cardiac arrest, either from the drastically reduced CO or the wicked hyperkalemic response --> acidosis --> etc. I would think you could treat the bradycardia w/ a ****-ton of atropine and chest compressions, but the hyperkalemia/acidosis would probably be what did him in.

I don't see how giving 100X any drug would even be possible, unless it were something undiluted like those 10mg phenylephrine vials.

I guess the point I was trying to make wasn't necessarily that vagolysis is what killed the patient, but that it is easy to forget that these drugs we use have systemic side effects. Though in general a lot of the drugs we use are remarkably precise in accomplishing what we want without any significant long lasting effects, we ARE giving these drugs parenterally, meaning they are being distributed to every organ system. Who knows what kind of crazy side effects we would see from a such a massive overdose. Though we can speculate that this or that may happen, there is no way we are ever going to find out, unless someone is willing to spend the rest of their life in jail for performing such an experiment.

And to repeat, who knows what the heck actually happened...the original poster of the case himself doesn't know. I'm simply pointing out that it is not unreasonable at all to give someone a massive overdose of a paralytic and have it lead to death.

Another way of thinking about it -- something even as benign as water, if you drink 100x more than you normally would, can lead to death. These drugs that are binding to Ach receptors, blocking muscle function, potentially leading to changes in HR, potassium levels, histamine release, and god knows what else at such a massive overdose...it doesn't seem too far fetched that this could lead to death too.

 

[WholeLottaGame7]

I guess the point I was trying to make wasn't necessarily that vagolysis is what killed the patient, but that it is easy to forget that these drugs we use have systemic side effects. Though in general a lot of the drugs we use are remarkably precise in accomplishing what we want without any significant long lasting effects, we ARE giving these drugs parenterally, meaning they are being distributed to every organ system. Who knows what kind of crazy side effects we would see from a such a massive overdose. Though we can speculate that this or that may happen, there is no way we are ever going to find out, unless someone is willing to spend the rest of their life in jail for performing such an experiment.

And to repeat, who knows what the heck actually happened...the original poster of the case himself doesn't know. I'm simply pointing out that it is not unreasonable at all to give someone a massive overdose of a paralytic and have it lead to death.

Another way of thinking about it -- something even as benign as water, if you drink 100x more than you normally would, can lead to death. These drugs that are binding to Ach receptors, blocking muscle function, potentially leading to changes in HR, potassium levels, histamine release, and god knows what else at such a massive overdose...it doesn't seem too far fetched that this could lead to death too.

Oh no I totally agree. I tell residents and med students all the time that you can kill a patient with anything in the drawer or on the vent; some things are just a little bit harder than others.

 

[Chloroform4Life]

In med school, my pharmacology professor used to say that we are in the business of dispensing poisons. It's just a matter of dosage required for fatility.

 

[deleted162650]

There's an old adage in toxicology that "Dose alone makes a poison"