Dallas Jury awards $21M for anoxic brain injury under anesthesia at BUMC

[chocomorsel]

I work in a poor but not particularly underserved area. There are 7 PICUs within 90 minutes by ground transport. Even a year ago it would have taken me less than ten minutes to get that kid accepted to any one of them. It’s bad right now.

Third world resources, plus EMTALA and malpractice hanging over our heads .. working on an ulcer TBH

Well I am moving back to my “third world”. Figured if I am gonna be practicing this kind of medicine I may as well be doing it back home where my heart is. The US is just becoming untenable.

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[NITRAS]

Who pays in this situation?
Certainly doc/and CRNA don’t have that $$. Malpractice insurance has a cap (usually 1 million).
We have no details about what went on in the case but I’m assuming lost airway. Pretty hard to fu(k up a 27 year old without involvement of the airway, and a lost airway is pretty much indefensible these days….

If you, the physican, agree to settle for an amount your insurance will cover, then your insurance company is liable for the amount if they lose if they decide to go to trial, even if it is above your limit.

Moral of the story, always agree to settle.

 

[nimbus]

I work in a poor but not particularly underserved area. There are 7 PICUs within 90 minutes by ground transport. Even a year ago it would have taken me less than ten minutes to get that kid accepted to any one of them. It’s bad right now.

Third world resources, plus EMTALA and malpractice hanging over our heads .. working on an ulcer TBH

Is it bad due to flu+RSV? Or something else? In our city, we have a high school where 1000/2600 kids were out sick.

 

[CoolDoc1729]

Is it bad due to flu+RSV? Or something else?

As far as I know , the biggest problem re: acute picu shortage is RSV taking up beds. But my hospital and many around us are functioning with way less staff than we need. I’m regularly getting transfers from 8-12 hours away because we’re the closest place that has something so simple as cards or neuro consults available, even a staffed tele bed. My own hospital ER currently has 1/3 of our precovid staffing level, for about 3/4 precovid volumes.

 

[dchz]

Bingo. Cerebral saturation declined with carotid crossclamp, then returned to baseline after shunt was inserted and opened.

We routinely use it for pump cases and carotids. I use it for higher risk beach chair shoulders, mostly for my own reassurance.

This shows later in the case. Saturation declines again when the shunt is removed, then climbs back to baseline when the carotid is unclamped.

View attachment 361685

This brand, somanetics, is rarely accurate on someone with heavy skin pigment/melonin.

I remember doing that experiment in fellowship, the somanetics would show a much lower (40s) baseline on patients darker complexion (we put them on awake before induction).

We used the Edwards version at most of our sites I trust the brand much more.

 

[gtb]

Paper charting. What reason do you have to believe any of it?

Agree! I've seen anesthesiologists, CRNAs, and AAs have empty charts with just minutes are left on the clock before emergence. The paper records are complete before leaving the room.

 

[gtb]

They call for help too late. The most dangerous thing is when you don’t know that you don’t know

Unskilled and Unaware of It: How Difficulties in Recognizing One's Own Incompetence Lead to Inflated Self-Assessments​

researchgate.net/publication/12688660_Unskilled_and_Unaware_of_It_How_Difficulties_in_Recognizing_One's_Own_Incompetence_Lead_to_Inflated_Self-Assessments

 

[nimbus]

This brand, somanetics, is rarely accurate on someone with heavy skin pigment/melonin.

I remember doing that experiment in fellowship, the somanetics would show a much lower (40s) baseline on patients darker complexion (we put them on awake before induction).

We used the Edwards version at most of our sites I trust the brand much more.

Yes. We just got the Edwards. We’re an all Edwards shop now.

 

[UscGhost]

I'm saying at best it's neutral and at worst it hurts you.

As I said, just look at the case in question in this thread. Does anyone, layperson or not, actually believe the pristine vitals that were documented are accurate?

That's not really how it works in a malpractice case though.

You have a lawyer with no medical or anesthesia expertise deposing you. All they have to go on is the chart and they take it as gospel. They can try to spin it or interpret it in their favor..but they can't generally accuse you of simply lying without having some evidence that refutes your charting.

Now if the RN or surgeon charts that patient was unstable or hypotensive, and your vitals are pristine..they can then question the validity.

 

[vector2]

That's not really how it works in a malpractice case though.

You have a lawyer with no medical or anesthesia expertise deposing you. All they have to go on is the chart and they take it as gospel. They can try to spin it or interpret it in their favor..but they can't generally accuse you of simply lying without having some evidence that refutes your charting.

Now if the RN or surgeon charts that patient was unstable or hypotensive, and your vitals are pristine..they can then question the validity.

Dude, what?

1. A medmal lawyer is not an anesthesiologist, but to state that they have no expertise is absurd. An experienced one has been involved in hundreds of cases and has examined and/or cross-examined a similar number of expert witnesses on the stand. They know what scenarios pass the sniff test when a suit is brought. Regardless, the idea that anyone, - let alone the plaintiff's attorney - would take a self-generated paper record as gospel is hilariously wrong.

2. Of course they can accuse you of lying. Or at the very least have their expert witness confirm that paper anesthesia records are rarely 100% accurate, which plants a significant amount of doubt in a jury or judge's mind. In this case, the patient had a damned anoxic injury, pressors were charted, but the vitals were perfect. It's so bad that the accusation of falsification is one of the main tenets of the Rojas vs USAP case.

 

[ambiturner]

Dude, what?

1. A medmal lawyer is not an anesthesiologist, but to state that they have no expertise is absurd. An experienced one has been involved in hundreds of cases and has examined and/or cross-examined a similar number of expert witnesses on the stand. They know what scenarios pass the sniff test when a suit is brought. Regardless, the idea that anyone, - let alone the plaintiff's attorney - would take a self-generated paper record as gospel is hilariously wrong.

2. Of course they can accuse you of lying. Or at the very least have their expert witness confirm that paper anesthesia records are rarely 100% accurate, which plants a significant amount of doubt in a jury or judge's mind. In this case, the patient had a damned anoxic injury, pressors were charted, but the vitals were perfect. It's so bad that the accusation of falsification is one of the main tenets of the Rojas vs USAP case.

Your point about the perfect vitals with pressors is a good one - if making a fake chart, it would be better to chart an occasional low BP that returns to the railroad tracks every time the pressor is given.

 

[teacher2md]

Your point about the perfect vitals with pressors is a good one - if making a fake chart, it would be better to chart an occasional low BP that returns to the railroad tracks every time the pressor is given.

You want to hear something wild?

At one of the sites that I staffed for my old job, we used a crappy anesthesia EMR system that required manually inputting vital signs into the chart. One time I came in to break the CRNA, and saw that the whole case had been 'pre-charted' with perfect vital signs, extubation, pacu handoff, etc. When she came back from break I told her not to do that, because the entries are time-stamped and anyone reviewing the chart in the case of a bad outcome would clearly see that she had pre-charted everything.

I explained that she is painting a picture for the jury of both of us being lazy and incompetent liars, and we would go ahead and write a blank check.

She argued with me in front of the OR staff and the surgeon and told her not to disrespect her practice expertise.

 

[coffeebythelake]

You want to hear something wild?

At one of the sites that I staffed for my old job, we used a crappy anesthesia EMR system that required manually inputting vital signs into the chart. One time I came in to break the CRNA, and saw that the whole case had been 'pre-charted' with perfect vital signs, extubation, pacu handoff, etc. When she came back from break I told her not to do that, because the entries are time-stamped and anyone reviewing the chart in the case of a bad outcome would clearly see that she had pre-charted everything.

I explained that she is painting a picture for the jury of both of us being lazy and incompetent liars, and we would go ahead and write a blank check.

She argued with me in front of the OR staff and the surgeon and told her not to disrespect her practice expertise.

i hope this fraudulent practice was escalated to hospital administration

 

[UscGhost]

Dude, what?

1. A medmal lawyer is not an anesthesiologist, but to state that they have no expertise is absurd. An experienced one has been involved in hundreds of cases and has examined and/or cross-examined a similar number of expert witnesses on the stand. They know what scenarios pass the sniff test when a suit is brought. Regardless, the idea that anyone, - let alone the plaintiff's attorney - would take a self-generated paper record as gospel is hilariously wrong.

2. Of course they can accuse you of lying. Or at the very least have their expert witness confirm that paper anesthesia records are rarely 100% accurate, which plants a significant amount of doubt in a jury or judge's mind. In this case, the patient had a damned anoxic injury, pressors were charted, but the vitals were perfect. It's so bad that the accusation of falsification is one of the main tenets of the Rojas vs USAP case.

Have you been in any depositions? The lawyers have little clue as to what actually happens in an OR and a jury even less so.

How many surgeons do you know that understand anything we do or what medications we use and how they are dosed or charted? You expect a lawyer or jury to know?

The Conrad Murray lawyers argued that MJ died because he Drank propofol.

If I have a patient that has a MI in pacu, unrelated to my anesthetic..you better believe that those few random low BPs in your EMR will be used against you. So you better hope that you meticulously document every BP artifact or every dose of neo/ephedrine that you give you in every case you do.

It's much harder for a lawyer or expert to convince a jury that you are lying simply by suggesting your chart is inaccurate unless he has supportive evidence.

A paper chart shouldn't be used to cover malpractice... but it certainly can help prevent you from getting blamed for issues that aren't your fault

 

[deleted1147063]

Have you been in any depositions? The lawyers have little clue as to what actually happens in an OR and a jury even less so.

How many surgeons do you know that understand anything we do or what medications we use and how they are dosed or charted? You expect a lawyer or jury to know?

The Conrad Murray lawyers argued that MJ died because he Drank propofol.

If I have a patient that has a MI in pacu, unrelated to my anesthetic..you better believe that those few random low BPs in your EMR will be used against you. So you better hope that you meticulously document every BP artifact or every dose of neo/ephedrine that you give you in every case you do.

It's much harder for a lawyer or expert to convince a jury that you are lying simply by suggesting your chart is inaccurate unless he has supportive evidence.

A paper chart shouldn't be used to cover malpractice... but it certainly can help prevent you from getting blamed for issues that aren't your fault

Unfortunately many paper "chartists" document fake tram tracks, not exact values, and a lot of people don't document pressors even electronically.

One should look at the chart with the eyes of a third-party, and document anything that is not straightforward (e.g. surgeon leaning on BP cuff - to explain an unusual value).

 

[vector2]

Have you been in any depositions? The lawyers have little clue as to what actually happens in an OR and a jury even less so.

How many surgeons do you know that understand anything we do or what medications we use and how they are dosed or charted? You expect a lawyer or jury to know?

The Conrad Murray lawyers argued that MJ died because he Drank propofol.

If I have a patient that has a MI in pacu, unrelated to my anesthetic..you better believe that those few random low BPs in your EMR will be used against you. So you better hope that you meticulously document every BP artifact or every dose of neo/ephedrine that you give you in every case you do.

A paper chart shouldn't be used to cover malpractice... but it certainly can help prevent you from getting blamed for issues that aren't your fault

No, I haven't personally been deposed. But our chairman who's been an expert witness for 20 years has talked to our dept in depth about medicolegal issues in anesthesia and how they play out in actual lawsuits he's been involved with.

And it's notable you keep perseverating on what a lawyer knows or what a jury knows or what a surgeon knows while time and time again ignoring my main point..which, to reiterate, is: *An expert witness in anesthesiology is going to explain to the jury in 3rd grade language that John Q. CRNA can literally write 120/80 forty five times in a row on the paper record if he wants to...even if those weren't the actual vitals. And he could do it 5,000 times in a row without anyone ever double checking him. "

That fact alone casts immediate doubt on a paper anesthesia record when an apparent anesthesia complication occurs . Furthermore, you bringing up the downsides of an EMR doesn't change those paper chart downsides I keep harping about. It just highlights that all types records have weaknesses.

It's much harder for a lawyer or expert to convince a jury that you are lying simply by suggesting your chart is inaccurate unless he has supportive evidence.

An anoxic injury occurring in a record where pressors were charted - while simultaneously perfect vitals were also documented - is the supporting evidence. So much so that that particular accusation of fraud is in the lawsuit. It literally says:

The need for multiple doses of vasoactive medications means that Carlos’ blood pressure was much lower than was being recorded by CRNA Martin.​

An accusation of fraud like that is simply an impossibility with an anesthesia EMR given that there is underlying code that logs keystrokes and manual vital sign changes/dose changes/event back timing etc

 

[UscGhost]

Unfortunately many paper "chartists" document fake tram tracks, not exact values, and a lot of people don't document pressors even electronically.

One should look at the chart with the eyes of a third-party, and document anything that is not straightforward (e.g. surgeon leaning on BP cuff - to explain an unusual value).

Yup. But the question is...when an EMR is doing the charting for you...after 10 years of practice..are you going to meticulously note every time that the surgeon leans in the cuff like you said?

I'd much prefer the option of being able to disregard it as a paper chartist than have to type in an explanation everytime the BP cuff is erroneous

 

[anaesthetic]

Yup. But the question is...when an EMR is doing the charting for you...after 10 years of practice..are you going to meticulously note every time that the surgeon leans in the cuff like you said?

I'd much prefer the option of being able to disregard it as a paper chartist than have to type in an explanation everytime the BP cuff is erroneous

It takes me about 1.5 seconds to document “data artifact” or “surgeon on cuff” via the EMR. All vital signs and notes are automatically timestamped on the electronic record as raw data and any edits to the data/notes are recorded automatically. IMO, that has more staying power than simply writing what you thought the BP should have been or disregarding the measured BP by not writing it down.

 

[pgg]

Yup. But the question is...when an EMR is doing the charting for you...after 10 years of practice..are you going to meticulously note every time that the surgeon leans in the cuff like you said?

13 years out and that's exactly what I do.

I'm surprised that there's anyone who doesn't use the artifact event. If I draw blood off an a-line and it records a MAP of 270 (which is obviously an artifact) I still hit the "labs drawn" event in Epic. Any time Epic records something wrong I hit the artifact button. It's too easy, and too dumb not to.

The EMR does 99% of the charting. It's not like occasionally clicking a couple clicks is a huge hassle - especially since you don't have to draw a bunch of dots and carrots and write numbers and other scribbles on paper.

 

[Arantius]

When the crna left the room for 12 minutes it is because he was given a break by another crna. There was always a crna in the room. This article has a lot of missing information and a huge bias. I would really like to post the facts of the case but I can’t…. When the appeals are settled and I can I will.

Let me ask all of you this- would anyone order a preop echo on a 27 year old with a tibial fracture?
Would anyone suspect embolism in this case?

Embolism was my first thought and NO. I would not order an echo.

 

[sevo00]

 

[sevo00]

^^^response from the AANA

 

[coffeebythelake]

^^^response from the AANA

Lazy tone deaf response

Not surprised by the canned answer from AANA

No amount of evidence will dissuade them from their arrogance and self aggrandizing because their leadership is full of the same CRNAs who would have no qualms falsifying the anesthesia record or letting a patient stroke out while pretending everything is OK.

Minimum of 7 to 8.5 years of training to be a CRNA? Facts don't matter to these clowns. What a ****ing joke.

 

[Arantius]

13 years out and that's exactly what I do.

I'm surprised that there's anyone who doesn't use the artifact event. If I draw blood off an a-line and it records a MAP of 270 (which is obviously an artifact) I still hit the "labs drawn" event in Epic. Any time Epic records something wrong I hit the artifact button. It's too easy, and too dumb not to.

The EMR does 99% of the charting. It's not like occasionally clicking a couple clicks is a huge hassle - especially since you don't have to draw a bunch of dots and carrots and write numbers and other scribbles on paper.

Yup- I add a million artifact buttons and lots and lots of notes of fact: surgeon states hole in IVC. Starting MTP now, blah blah.

 

[IlDestriero]

Crna documented perfect vitals while pushing phenylephrine and even calcium chloride. Patient had a rash. Never woke up. Sounds like anaphylaxis or emboli? (But urticarial rash) and did not call anesthesiologist about trouble til too late. Treating symptoms and not the problem......

I’ve seen that before. I appreciate having an electronic anesthesia record. If you’re going to ignore bad vitals, own it and accept the consequences.

 

[coffeebythelake]

I’ve seen that before. I appreciate having an electronic anesthesia record. If you’re going to ignore bad vitals, own it and accept the consequences.

In this case the crna dragged everyone down with her hubris

 

[amyl]

In this case the crna dragged everyone down with her hubris

Just curious why you say her hubris

 

[nimbus]

Just curious why you say her hubris

Both plaintiffs and defendants are public record but I guess we shouldn’t assume preferred pronouns these days.

 

[deleted1147063]

Both plaintiffs and defendants are public record but I guess we shouldn’t assume preferred pronouns these days.

Why not? About 99% of people still use expected gender-conforming pronouns.

 

[nimbus]

Why not? About 99% of people still use expected gender-conforming pronouns.

I was kidding.

I recently went through a state mandated sexual harassment prevention training which included some DEI training. I learned that I can opt to use no pronouns at all if that is my preference. But I’ll stick with the tried n true ze/zir

 

[VA Hopeful Dr]

View attachment 361788

So to my uninformed FP self, there are 3 groups that provide anesthesia - physicians, CRNAs, and AAs.

By saying that CRNAs are "one of the safest" means they aren't THE safest so they admit to not being the safest option here.

 

[deleted1147063]

So to my uninformed FP self, there are 3 groups that provide anesthesia - physicians, CRNAs, and AAs.

By saying that CRNAs are "one of the safest" means they aren't THE safest so they admit to not being the safest option here.

One can have:
- a solo anesthesiologist
- a solo CRNA (in certain medical facilities from certain "opt-out" states)
- a CRNA under the "supervision" of any MD (up to 1:8 coverage)
- a CRNA under the "medical direction" of any MD (the traditional physician extender model, up to 1:4 coverage, requires satisfying 7 TEFRA criteria for Medicare billing)
- an AA always under the medical direction of an anesthesiologist
- an anesthesiology resident or fellow under the medical direction of an anesthesiologist (up to 1:2 coverage)

Did I miss anything?

 

[coffeebythelake]

You can have:
- solo anesthesiologist
- solo CRNA (in certain medical facilities from certain "opt-out" states)
- CRNA under the "supervision" of any MD (up to 1:8 coverage)
- CRNA under the "medical direction" of any MD (the traditional physician extender model, up to 1:4 coverage, requires satisfying 7 TEFRA criteria for Medicare billing)
- AA always under the medical direction of an anesthesiologist
- anesthesiology resident or fellow under the medical direction of an anesthesiologist (up to 1:2 coverage)

Did I miss anything?

Solo CRNA would be the least safe choice out of all options

 

[chocomorsel]

One can have:
- a solo anesthesiologist
- a solo CRNA (in certain medical facilities from certain "opt-out" states)
- a CRNA under the "supervision" of any MD (up to 1:8 coverage)
- a CRNA under the "medical direction" of any MD (the traditional physician extender model, up to 1:4 coverage, requires satisfying 7 TEFRA criteria for Medicare billing)
- an AA always under the medical direction of an anesthesiologist
- an anesthesiology resident or fellow under the medical direction of an anesthesiologist (up to 1:2 coverage)

Did I miss anything?

Dentist anesthesiologist.

 

[Dr. Rude]

One can have:
- a solo anesthesiologist
- a solo CRNA (in certain medical facilities from certain "opt-out" states)
- a CRNA under the "supervision" of any MD (up to 1:8 coverage)
- a CRNA under the "medical direction" of any MD (the traditional physician extender model, up to 1:4 coverage, requires satisfying 7 TEFRA criteria for Medicare billing)
- an AA always under the medical direction of an anesthesiologist
- an anesthesiology resident or fellow under the medical direction of an anesthesiologist (up to 1:2 coverage)

Did I miss anything?

Don’t know if there are any still out there, but there were still some GP Anesthetists as recently as the early 2000s in some rural hospitals.

 

[coffeebythelake]

Don’t know if there are any still out there, but there were still some GP Anesthetists as recently as the early 2000s in some rural hospitals.

Surely not in America

 

[amyl]

Both plaintiffs and defendants are public record but I guess we shouldn’t assume preferred pronouns these days.
Crna in this case is a man

 

[Dr. Rude]

Surely not in America

Yes in America. Indiana.

 

[Agast]

Crna in this case was make

Crna in this case is a man

Do you have a link to the case details?

 

[aneftp]

Do you have a link to the case details?

It’s easily googleable. And the pdf file is there. Basically a non perm immigrant on visa hanging Xmas lights who fell.

 

[Agast]

It’s easily googleable. And the pdf file is there. Basically a non perm immigrant on visa hanging Xmas lights who fell.

I’ve found the news articles about the $21 million settlement and case documents that are password protected, no pdf

 

[GassYous]

It’s easily googleable. And the pdf file is there. Basically a non perm immigrant on visa hanging Xmas lights who fell.

Link? I can't find it

 

[nimbus]

Crna in this case was make

Crna in this case is a man

Ahhh my mistake. There a 2 CRNAs with the same name. One female in CA and one male in TX. Odd because the the CRNA was referred to as “her” in the initial filing. But maybe they misgendered him 🤷. The first name is gender neutral.

 

[nimbus]

Do you have a link to the case details?

Posted earlier in this thread.

Interesting things in the filing:

1. They claim the anesthesiologist was never in the operating room during this procedure.

2. They allude to the relationship between ETCO2 and CBF.

3. They use the term “CYA note”.

The attorneys are pretty sophisticated or had good experts to review the case.

rojas-v-us-anesthesia-partners-of-texas.pdf

FILED 8/30/2019 4:51 PM. JOHN F. WARREN COUNTY CLERK DALLAS COUNTY. CAUSE NO.CC-19-05509-E. WILDA JENNIFFER ROJAS GRATEROL, Individually and as Guardian of CARLOS DAVID CASTRO ROJAS, an incapacitated person,. IN THE COUNTY COURT AT LAW. Plaintz'fiic,. NO. vs. CASEY MARTIN, CRNA; MALLORIE CLINE...

www.docdroid.net

 

[Agast]

Dang, the anesthesiology attending had this case happen within her first year of practice. That must have been incredibly traumatic.

 

[teacher2md]

Posted earlier in this thread.

rojas-v-us-anesthesia-partners-of-texas.pdf

FILED 8/30/2019 4:51 PM. JOHN F. WARREN COUNTY CLERK DALLAS COUNTY. CAUSE NO.CC-19-05509-E. WILDA JENNIFFER ROJAS GRATEROL, Individually and as Guardian of CARLOS DAVID CASTRO ROJAS, an incapacitated person,. IN THE COUNTY COURT AT LAW. Plaintz'fiic,. NO. vs. CASEY MARTIN, CRNA; MALLORIE CLINE...

www.docdroid.net

One other possibility that hasn’t been mentioned—

Was this patient hyperventilated during the case causing cerebral vasoconstriction?

The suit mentions that the ETCO2 was low for several hours, could it be that he had ETCO2 of like 18? Could easily be done if you have too high vent settings and aren’t paying attention.

Also, the case makes it appear that the record was an electronic record, not paper chart. This would make covering up hypotension or hypoxemia harder.

 

[nimbus]

One other possibility that hasn’t been mentioned—

Was this patient hyperventilated during the case causing cerebral vasoconstriction?

The suit mentions that the ETCO2 was low for several hours, could it be that he had ETCO2 of like 18? Could easily be done if you have too high vent settings and aren’t paying attention.

Also, the case makes it appear that the record was an electronic record, not paper chart. This would make covering up hypotension or hypoxemia harder.

Agree about the cerebral vasoconstriction theory but I don’t see why you think it was an electronic record. I think the filing suggests the vitals were fabricated.

 

[amyl]

Crna is a man. It was a paper chart

 

[coffeebythelake]

Dang, the anesthesiology attending had this case happen within her first year of practice. That must have been incredibly traumatic.

Reminds me of the anesthesiologist at WUSL whose CRNA forgot to turn on the anesthetic after intubation. I think he was jn his first year as an attending.

Edit: Patient Awake for 13 Minutes of Surgery

Common theme, CRNA not paying attention and anesthesiologist not notified and blindsided

 

[Agast]

Reminds me of the anesthesiologist at WUSL whose CRNA forgot to turn on the anesthetic after intubation. I think he was jn his first year as an attending.

Edit: Patient Awake for 13 Minutes of Surgery

Common theme, CRNA not paying attention and anesthesiologist not notified and blindsided

And each surgery was a relatively easy case on a young ASA 1