Archive for the ‘Safety’ Category

If you think about scope-of-practice creep at all, you may think immediately of the advocacy efforts so many physicians have made to preserve physician-led care and discourage independent practice by nurse anesthetists or physician assistants.

You may not have paid as much attention to the current momentum to grant independent practice to nurse practitioners, or NPs, nationwide.

In addition to the District of Columbia, 28 states allow NPs full practice authority to treat and prescribe without formal oversight. Half of these states grant NPs full practice authority as soon as they gain their licenses; the other half allow it after the NP practices with physician oversight for a period of time.

My home state, California, is one of the states that has always required physician oversight. Last fall, however, Governor Newsom signed a bill, Assembly Bill 890, that will allow NPs to practice independently after they have completed a three-year transition period, practicing under physician supervision.

That was when I started to worry.

Preop assessments that make us laugh or cry

No doubt everyone who practices anesthesiology or surgery has encountered preoperative medical assessments, H & Ps, or “clearance” notes that have been so far off the mark they’re laughable. I’m not just talking about the three-word “cleared for surgery” note scrawled on a prescription pad. I recall in particular:

A consultation at a VA hospital that “cleared” my cirrhotic patient with massive ascites and coagulopathy for his inguinal hernia repair under spinal anesthesia but not general.

A cardiologist who opined that my patient needed a permanent pacemaker, but it could wait until after his carotid endarterectomy because “this patient has a low risk of perioperative bradycardia. If he were to develop AV block intraoperatively, a temporary transvenous pacemaker could be placed.” (Wait. What? Carotid procedures are notorious for bradycardia. We’re going to insert a transvenous pacing wire through his open neck incision?)

An H & P from a community internist that “cleared” my patient with lung cancer for lobectomy so long as it could be done under local with sedation.

Then we have to deal with the widespread misconception that “minimally invasive” is synonymous with “trivial” when it comes to surgical procedures. My husband, Steven Haddy, MD, a cardiac anesthesiologist, loves to give a lecture to an internal medicine audience on pulmonary hypertension and anesthesia, and wait for the gasps when he shows the photo of a “minimally invasive” robotic prostatectomy with the robot docked, the abdomen insufflated, and the patient in steep Trendelenburg.

If non-anesthesiologist physicians can do such an inept job with preoperative assessments, what are we to expect from nurse practitioners?

What could go wrong?

I rely with complete confidence on the H & Ps of one experienced nurse practitioner who works in the office of a thoracic surgeon. She understands thoracic surgery procedures and their risks, knows the patients and their history, and orders exactly the right preoperative tests, every time.

What causes me anxiety, as an anesthesiologist, is thinking about the accuracy and thoroughness of a preoperative assessment I might receive from a primary care NP, working in an outpatient clinic with no physician consultation. In a brief H & P, we have no way to know what information may have been omitted. If there is little understanding of the surgery or the anesthetic impact of the patient’s underlying medical problems, how would that person know what’s important to include?

Currently, there are more than 290,000 licensed NPs in the US, and Becker’s Hospital Review reports that the number of FTEs surged 109% in the past decade. More than 30,000 NPs complete their academic programs each year.

Until I read the book, Patients at Risk, by Niran Al-Agba, MD, and Rebekah Bernard, MD, I had no idea how little breadth or depth there might be to a nurse practitioner’s education. “Registered nurses who already have a bachelor’s degree in nursing can become a Family Nurse Practitioner in under two years, with coursework completed entirely online,” the authors report. “Schools are now fiercely competing for students to fill their classrooms. One of the downsides of the increased capacity for students is that the criteria for entry have declined. In fact, at least nine programs boast 100% acceptance rates – every student who applies is guaranteed acceptance.”

Since nurse practitioners can earn higher pay than registered nurses, there is an ongoing exodus of RNs into NP programs. They have the option to select a patient population focus on acute care, either for adults or children. But most students – nearly 90%, according to the American Association of Nurse Practitioners (AANP) – certify in an area of primary care. Their certification exams are specific to primary care, and require no additional education or clinical precepting in perioperative care.

Protecting patients

If you already live in a state with full practice authority for NPs, then the camel – not just the camel’s nose – is already in the tent. There will be little you can do other than to have a low threshold for questioning the information, or lack of it, in a preop H & P generated by a non-physician you don’t know personally.

In California, though AB 890 has already passed, there is work to be done in terms of scrutinizing its language and guiding its implementation.

I find it discouraging that the law’s requirements (Section 4, Article 8.5) “are intended to ensure the new category of licensed nurse practitioners has the least [emphasis mine] restrictive amount of education, training, and testing necessary to ensure competent practice.”

I find it outright alarming that one of the conditions listed that would mandate referral to a physician is “any patient with acute decomposition [sic].” My hope would be that the patient would be referred to a higher level of care before decomposition started, but you never know.

To its credit, the California Medical Association (CMA) has established an AB 890 Task Force to provide “expertise and strategic advice” regarding the implementation of AB 890, and “to make recommendations relating to the education of NPs, patient access to care, and patient safety, among other topics.” I have the honor of representing anesthesiology on this task force, and will do my best to ensure that NP independent practice is never defined to include the practice of anesthesiology, perioperative medicine, or pain medicine.

This underscores the importance of having all physicians become members also of our state and county medical associations. If you don’t join, you won’t have a voice. There is always a need for guardrails and vigilance to ensure that everyone in healthcare – physicians and nurses alike – practices within the safe limits of their knowledge and training.

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An earlier version of this article appears in the April 2021 issue of the ASA Monitor.

Every death related to anesthesia is a tragedy; even more so when a minor procedure such as a colonoscopy leads to a completely unexpected death. Everyone knows that open heart surgery carries a mortality risk, but few of us walk into the hospital for a colonoscopy thinking that death is a plausible outcome.

We know so few facts at this point about what happened on January 21 at Beaumont Royal Oak Hospital in Michigan. The patient who died, sources say, was a 51-year-old man who walked into the hospital for a routine colonoscopy. He was obese, with a BMI of 39, and suffered from obstructive sleep apnea, a common problem, where people snore heavily and their breathing may obstruct intermittently while they’re sleeping. Author Charles Dickens described a portly gentleman’s sleep apnea perfectly in The Pickwick Papers:

“His head was sunk upon his bosom, and perpetual snoring, with a partial choke occasionally, were the only audible indications of the great man’s presence.”

Sleep apnea is a risk factor for anesthesia complications, especially airway obstruction, but every anesthesiologist is taught how to recognize and manage it. With the obesity epidemic in America today, sleep apnea is part of daily reality in anesthesiology practice.

According to recent reports in Deadline Detroit by journalist Eric Starkman, who has reported extensively on problems at Beaumont Health, the patient was intubated by a nurse anesthetist who ordinarily worked at another Beaumont Hospital. At the end of the procedure, the nurse anesthetist removed the breathing tube, and the patient began to “thrash around”. It isn’t clear from reports if he was trying unsuccessfully to breathe or wasn’t breathing at all. The nurse anesthetist called for help from an anesthesiologist, and an emergency back-up team was summoned, but the patient went into cardiac arrest and couldn’t be resuscitated.

How could this happen?

We’re not likely to learn further details any time soon, as NorthStar Anesthesia has refused to comment. NorthStar took over the contract for anesthesiology services at Beaumont in 2020, leading to the resignation of a number of experienced anesthesiologists and nurse anesthetists who had worked there for years. Prominent surgeons, specialists, and nurses also resigned, according to reports, concerned that extreme cost-cutting measures would compromise patient care. Senior cardiologists wrote a letter in September, according to Deadline Detroit, expressing “serious concerns that NorthStar will not be able to provide the quality of cardiac anesthesia services that we have received for several decades.”

“We oppose the concept that any Beaumont physicians can be considered replaceable commodities, or that corporate leadership can assume that we would blindly accept another group of physicians to care for our patients with life-threatening cardiac conditions,” the cardiologists’ letter stated.

In the context of this upheaval at Beaumont, we can ask these questions.

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Tell me your cosmetic secrets

I live and work in Los Angeles, one of the plastic surgery capitals of the world. Quite a few of my patients have “had a little work done” — the blandly euphemistic term you’ll hear for plastic surgery makeovers of all kinds. That’s fine. Plastic surgeons have children to feed too.

The problem is this: many of my patients want to convince everyone that their “look” is entirely natural. They don’t want to admit that they’ve had a tummy tuck, an eyelid lift, or breast implants. One patient tried to tell me that the perfectly matched scars behind her ears were the result of a car accident, not a face lift. In front of family members, patients will even deny having dentures. That’s understandable, but unwise from a medical point of view.

The fact is that plastic surgery has implications for future medical care. Your anesthesiologist needs to know about it, and your surgeon does too. It may be cosmetic, but it’s still a bigger deal than getting your eyebrows waxed.

Here’s why we need to know the cosmetic secrets our patients may NOT want to tell us.

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We’re very fortunate in anesthesiology. We’re seldom the physicians who have to face families with the terrible news that a patient has died from a gunshot wound.

But all too often we’re right there in the operating room for the frantic attempts to repair the bullet hole in the heart before it stops beating, or the blast wound to the shattered liver before the patient bleeds to death.

Despite all the skills of everyone in the operating room – surgeons, anesthesiologists, nurses, technicians – and all the blood in the blood bank, we’re not always successful. A death on the OR table is a traumatic event and a defeat; we remember it decades later.

So yes, this is our lane too. Memories haunt me of the times when mine was the last voice a gunshot victim heard on this earth, telling him he was about to go to sleep as he went under anesthesia for the last-ditch, futile attempt to save him.

I use the pronoun “he” intentionally, as every one of those cases in my professional life has been a young man. My experience is representative; most gunshot victims aren’t the random targets of mass shootings. They are overwhelmingly male (89 percent), under the age of 30 (61 percent), and over half are from the lowest income quartile.

The National Rifle Association (NRA) is way off base in telling physicians to mind their own business as it did in its infamous November 7 tweet. Human life is our business. Pediatricians have every right to remind parents that gun security, and keeping guns out of the hands of children, are vital to their well-being right up there with getting them vaccinated.

At my house, we’ve always kept our guns padlocked in a safe that our children couldn’t have broken into with a crowbar. We’re not NRA members, but we enjoy going to a shooting range on occasion. I learned gun safety during my officer training in the Army Reserve Medical Corps. My husband and I are firmly in the category of gun-owners who take both the right and the responsibility with the utmost seriousness.

Physician opinions on gun control and gun ownership vary just as much as the opinions of the rest of the population. What doesn’t vary is our collective sense of responsibility for public health and our support for better, more readily available, mental health care.

The solutions to America’s horrific rate of gun-related deaths aren’t easy or obvious. But the NRA isn’t helping matters with its thoughtless and incendiary social media message.

Keep calm and give the Ancef

A true allergic reaction is one of the most terrifying events in medicine. A child or adult who is highly allergic to bee stings or peanuts, for instance, can die within minutes without a life-saving epinephrine injection.

But one of the most commonly reported allergies — to penicillin — often isn’t a true allergy at all. The urgent question that faces physicians every day in emergency rooms and operating rooms is this:  How can we know whether or not the patient is truly allergic to penicillin, and what should we give when antibiotic treatment is indicated?

It’s time for us to stop making these decisions out of fear, and look squarely at the evidence. Withholding the right antibiotic may be exactly the wrong thing to do for our patients. Here’s why.

Can’t we just prescribe a different antibiotic?

When we hear that patients are “PCN-allergic”, we’ve been trained from our first days as medical students to avoid every drug in the penicillin family. We’re also taught to avoid antibiotics called “cephalosporins”, which include common medications like Keflex. This is because penicillin and cephalosporin molecules have some structural features in common, raising the odds that a patient allergic to one may also be allergic to the other.

What does it matter? Can’t physicians just prescribe a different antibiotic?

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