Archive for the ‘Safety’ Category

Six-year-old Caleb Sears:  His death was preventable

I’m not a pediatric anesthesiologist. Most of us in anesthesiology – even those who take care of children in the operating room or the ICU every day – probably will never give anesthesia to a child in a dentist’s or oral surgeon’s office. So why should we care what happens there? Dental anesthesia permits and regulations, after all, are under the authority of state dental boards, not medical boards.

The reason we should care is that healthy children have died under anesthesia in dental office settings, children like Marvelena Rady, age 3, and Caleb Sears, age 6. Unfortunately, they aren’t the first children to suffer serious complications or death in our state after dental procedures under sedation or general anesthesia, and unless California laws change, they won’t be the last.

In 2016, officers and past presidents of the California Society of Anesthesiologists (CSA) have made multiple trips to meetings of the Dental Board of California (DBC) to discuss pediatric anesthesia. We’ve provided detailed written recommendations about how California laws concerning pediatric dental anesthesia should be updated and revised. We’ve explained in testimony before the Dental Board, and in meetings with lawmakers, why we believe so strongly that the single “operator-anesthetist” model (currently practiced by dentists and oral surgeons in many states) cannot possibly be safe.

The DBC on December 30 published new recommendations for revision of California laws pertaining to pediatric dental anesthesia, posted them on its website, and sent them to the Senate Committee on Business, Professions, and Economic Development. But these recommendations ignored many of our concerns, and don’t go nearly far enough to protect children.

Further, the DBC cites statistics claiming that pediatric dental anesthesia is currently safe. But there is no database! The Dental Board has admitted to discarding records after review. They have reported on “only nine” recent cases involving death, ignoring other tragic cases of permanent brain damage and prolonged ICU admissions. Pediatricians in California recently surveyed 100 of their members and found that 29 of them — nearly one-third — knew of patients in their practices who had experienced adverse events in a dental office.

What is a single “operator-anesthetist”?

You may never have heard of a single “operator-anesthetist” because such a thing doesn’t exist in medical practice.

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Is it always wrong for a surgeon to book cases that will be done in two operating rooms during the same timeframe?

If you’ve paid much attention to the overheated commentary on social media since the Boston Globe published its investigative report, “Clash in the name of care“, you might easily conclude that the surgeon who runs two rooms ought to be drawn and quartered, or at least stripped of his or her medical license.

John Mandrola, MD, a Kentucky cardiologist who I’ll bet doesn’t spend a lot of time in operating rooms, weighed in on Medscape with a post called “The Wrongness of a Doctor Being in Two Places at Once“, accusing surgeons of hubris and greed.

Respectfully, I disagree.

The Globe’s story tells the dramatic tale of how a prominent surgeon at Massachusetts General Hospital often scheduled two difficult spine operations at the same time. According to the Globe’s reporters, the surgeon typically moved back and forth between two operating rooms, performing key parts of each procedure but delegating some of the work to residents or fellows in training.

On one particular day, a complex case ended with a tragic outcome. The patient, a 41-year-old man, sustained spinal cord injury at the level of his neck, leaving him permanently unable to move his arms or legs. Another prominent MGH surgeon leaked details of the case to the press, and was summarily fired.

Of course, I have no special access to information about what goes on at the MGH, and can’t comment on the specific cases highlighted in the Globe’s report. But I’ve been giving anesthesia for a long time in first-class hospitals. On countless occasions, I’ve seen surgeons run two rooms, and have administered anesthesia to a patient in one of them.

Have I ever seen a patient come to harm because the surgeon scheduled concurrent cases?  No.

Have I ever been annoyed because a surgeon delayed the start of my patient’s case because of the demands of the case in the other room? Yes, but I always agreed with the decision to delay, and the wisdom behind it. If the surgeon is at a critical portion of the first case, we have no business starting the second case until the surgeon gives the go-ahead.

Have I ever been thankful that the surgeon had two rooms? Yes indeed. Here’s why.

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I admit, I was taken aback at the headline in the Houston Press:

GOING UNDER:  WHAT CAN HAPPEN IF YOUR ANESTHESIOLOGIST LEAVES THE ROOM DURING AN OPERATION

The curious reader is bound to wonder why the anesthesiologist would leave the operating room in the first place.

Of course, reporter Dianna Wray explains that in many hospitals, one physician anesthesiologist often supervises multiple cases staffed by nurse anesthetists. This model of care is called the “anesthesia care team“, and has a very long record of safe practice in nearly all major hospitals in the United States. Typically, the anesthesiologist makes rounds from one operating room to the next, checking on each case frequently, just as an internal medicine physician would round on patients in the hospital who are being monitored by their nurses.

Ms. Wray’s article narrates in detail what happened in several anesthesia cases where things went horribly wrong. She points out that the patients and families were not aware that the anesthesiologist would not be present during the entire case.

Complications can develop with patients on the ward, in the intensive care unit, or in the OR. In any medical setting, the nurse’s job is to recognize the problem in time to call for help, so that the physician can respond and the patient can be treated successfully. Sometimes, the call for help may not come in time for successful resuscitation. The results can be tragic — cardiac arrest, brain damage, even death. Hospitals track “Failure to Rescue” events that cause adverse patient outcomes as a Joint Commission and CMS standard for measuring quality in nursing care.

The fact is — anesthesia is dangerous. We have made huge strides in developing safer drugs and better monitoring techniques. But going under anesthesia — losing consciousness from the drugs we give — is really the same thing as inducing coma. Most anesthesia drugs have the potential to depress breathing, lower blood pressure, and decrease the function of the heart. Even regional anesthesia, using proven techniques such as spinal and epidural blocks, can cause major complications.

I can verify that even the most routine procedure — under sedation, regional block, or general anesthesia — has the potential to evolve into a crisis. Some days are completely routine, and some days I find I need every scrap of medical knowledge and experience I can bring to the problems my patients face.

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“Twilight” is a movie

How the advent of propofol — the drug associated with the deaths of Joan Rivers and Michael Jackson — changed the meaning of the term “sedation”

“Twilight! She has to have twilight,” insisted the adult daughter of my frail, 85-year-old patient. “She can’t have general anesthesia. She hasn’t been cleared for general anesthesia!”

We were in the preoperative area of my hospital, where my patient – brightly alert, with a colorful headband and bright red lipstick – was about to undergo surgery. Her skin had broken down on both legs due to poor circulation in her veins, and she needed skin grafts to cover the open wounds. She had a long list of cardiac and other health problems.

This would be a painful procedure, and there would be no way to numb the areas well enough to do the surgery under local anesthesia alone. My job was to figure out the best combination of anesthesia medications to get her safely through her surgery. Her daughter was convinced that a little sedation would be enough. I wasn’t so sure.

“Were you asleep the last time your doctor worked on your legs?” I asked the patient. “Oh, yes,” she said. “Completely asleep.”

“But she didn’t have general,” the daughter interrupted. “She just had twilight.”

Propofol revolutionized anesthesia care

Though “twilight” isn’t a medical term, people often use it to mean sedation or light sleep as opposed to general anesthesia. Most patients don’t want to be awake, even if their operation doesn’t require general anesthesia. They prefer an intravenous “cocktail” to make them oblivious to pain and unaware of anything that’s happening. Today, the main ingredient is likely to be an anesthetic medication called propofol.

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New York Post reporter Susan Edelman revealed on January 4 the name of the unfortunate anesthesiologist allegedly present on August 28 at Yorkville Endoscopy, during the throat procedure that led to the death of comedian Joan Rivers. She is reported to be Renuka Reddy Bankulla, MD, 47, a board-certified anesthesiologist from New Rochelle, NY.

Having her name made public will be a nightmare for Dr. Bankulla, as investigators will certainly target her role in Ms. Rivers’ sedation and the management — or mismanagement — of her resuscitation.

When the news of Ms. Rivers’ cardiac arrest and transfer to Mt. Sinai Hospital became public, many of us guessed that there might have been no qualified anesthesia practitioner — either anesthesiologist or nurse anesthetist — present during the case. The gastroenterologist and then medical director of the clinic, Dr. Lawrence Cohen, argued famously that the sedative propofol, which Ms. Rivers received, could be safely given by a registered nurse under his supervision, and that no anesthesiologist is necessary.

However, with the publication of the Centers for Medicare & Medicaid Services (CMS) report of September 5, it became clear that an anesthesiologist was definitely present. The anesthesiologist was identified only as “Staff #2” in the report. She was interviewed by the CMS surveyors four days after the event, but said she was “advised by her legal representative not to discuss the case.”

Key pieces of information about what happened still haven’t been made public. Nonetheless, the surveyors gathered enough information to reach this conclusion:  “The physicians in charge of the care of the patient failed to identify deteriorating vital signs and provide timely intervention during the procedure.”

By any standard of care, the anesthesiologist clearly would be one of the physicians in charge.

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