How could a patient die from anesthesia for a colonoscopy?

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.

What kind of preoperative evaluation did the patient undergo before he was scheduled for his colonoscopy? Was it a cursory “clearance” by a mid-level practitioner, as opposed to a thorough history and physical examination by a physician? Did the patient have underlying heart or lung problems that weren’t noticed or treated in advance? Did the anesthesiologist have an adequate opportunity to evaluate the patient before the procedure began, or did production pressure not allow time?

Why was the decision made to intubate the patient, and who made the decision? Most patients who undergo colonoscopy receive sedation with medications such as midazolam, fentanyl, or propofol. They continue breathing on their own, without needing a breathing tube. Sedation can be safely managed even in the case of an obese patient with sleep apnea. Unless there is evidence of severe reflux, impaired stomach emptying, or bowel obstruction, intubation is rarely necessary and carries its own risks.

Were the nurse anesthetist and the anesthesiologist new to the hospital, and perhaps unfamiliar with the set-up and supplies in the endoscopy suite? Were they adequately oriented to the hospital’s resources before starting to work? Did they know where to find emergency equipment and how to reach colleagues for backup?

Was the nurse anesthetist working in an endoscopy procedure room located far from the operating rooms, where no other anesthesia professional was readily available to provide an extra pair of hands?

How many other locations and cases was the anesthesiologist responsible for at the time the patient’s condition started to deteriorate? How far away was the anesthesiologist, in terms of physical distance, and how long did it take to reach the endoscopy suite? The anesthesiologist should be readily available if the nurse anesthetist needs help. The standard for medical direction is that the anesthesiologist may be responsible for no more than four cases at one time. However, to cut costs, some employers may require one anesthesiologist to supervise six, eight, or more anesthesia locations.

Was the endoscopy suite adequately stocked with emergency airway equipment including supraglottic airway devices, laryngeal mask airways (LMAs), intubating bougies, and video laryngoscopy? Was succinylcholine available to treat laryngospasm? The right equipment and medications might have enabled the team to rescue the patient with no harm done, let alone a fatal outcome. They may have discovered only too late what was lacking.

Who’s to blame?

Every anesthesiologist has a healthy respect for obese patients and the risks of managing their airways. Though it may not always be easy to intubate these patients, extubation – taking out the breathing tube – may be even scarier. The patient may have a thick neck, a large tongue, and extra fatty tissue inside the mouth and throat, resulting in higher risk of airway obstruction once the breathing tube comes out. Ventilation by mask may be difficult or impossible.

If the patient isn’t breathing adequately or stops breathing, the oxygen level in the bloodstream will drop faster than it will in a thin patient. The time available for successful rescue is limited, and if there is no rescue, brain damage or death will be the inevitable result.

I will hazard a guess that the nurse anesthetist and the anesthesiologist will be blamed for this tragic death even though cost-cutting decisions made by hospital administration may be at the heart of what went wrong. They may have lacked experience; their training may have been less than first-class; but I guarantee that they didn’t go to work that day expecting to have a fatal outcome from anesthesia for a colonoscopy. I can only imagine their grief. Sudden, shocking adverse events in healthcare cause emotional trauma to everyone involved. It’s fair to say that they are victims too.

There are two frightening forces at work in healthcare today. One is the financial pressures that are threatening many hospitals with bankruptcy and leading them to sacrifice quality in order to cut costs. The second is the push to substitute nurse practitioners or nurse anesthetists for physicians, running the risk of putting these nurses in crisis situations that they aren’t trained to diagnose or manage. If an investigation uncovers the full facts in this case, it could turn out to be that the Beaumont patient was the victim of both.

9 COMMENTS

Dheeraj Nagpal

Thanks for writing about this case which we see quite often in our anesthesiology practice.
“thrash around” should indicate hypoxia until proven otherwise, with the endoscopy suites far away from the main OR help is hard to reach in a time.
With the insurance’s ultimate aim for “drive through” procedure this will happen more often if the medical professionals don’t stop it.

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MP

Awesome commentary, Dr Siebert. I am glad you brought to light the issues regarding substitution of nurses for physicians. This was clearly a factor in this patient’s untimely death from a minor procedure. As anesthesiologists, we recognize the issues, but this was seemingly entirely avoidable. I am sure Northstar Anesthesia will pay heavily.

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Eric

As a CRNA that has worked in the hospital setting and a free standing endo center, it is critical to assess the patient history and decide if an out patient setting is appropriate or not. Our center chose a cut off of 50 BMI and sadly, I see many patients in the mid to high 40s for BMI. Rarely do they present with just OSA. Co-morbidites usually accompany these large patients. Not being present, I won’t speculate on what went wrong in this scenario but I have personally experienced morbidly obese patients de-satting, spasming, bucking, etc. with appropriate preparation. For an anesthesia provider to claim they have not experienced this, they’re either lying or haven’t done anesthesia long enough. In response to the author and commenters that have remarked CRNAs as inferior, or “replacing” physician anesthesiologists, I’ll leave with this, many hands make for light work. I’ve seen MDs get in over their heads just as often as CRNAs. Titles are not always predictive vs experience in good anesthesia outcomes.

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karen

Dear readers,

I have elected to publish here three comments concerning scope of practice, but will not publish more from this point forward. I also prefer not to publish comments from anyone who doesn’t list his or her own real name.

I hope it is clear from my blog that I do not think it is reasonable to “blame” the anesthesia team, or either person on it, for what happened in this sad case. It is likely that the circumstances of the upheaval at Beaumont and possibly a lack of adequate staffing and/or equipment played a major role. Maybe we’ll learn more about what really happened; maybe we won’t. I am a firm supporter of a collegial anesthesia team model of medical direction, and work very happily with nurse anesthetists and residents all the time.

As far as preoperative evaluation is concerned — certainly the words “cleared for surgery” scrawled on a prescription pad are worthless as an assessment, no matter whose signature is on it. I’ve seen cursory evaluations, thorough evaluations, and everything in between. My concern, though, is this. When my son was an internal medicine resident, he spent weeks on the consultation service assessing patient readiness for surgery and ensuring that the patient’s condition was optimized ahead of time. I don’t have the same confidence when the evaluation is done by a non-physician whose main experience may be in primary care and who may know very little about anesthesia procedures and techniques, the details of the specific surgical procedure, and the potential interactions of the patient’s own medications with anesthesia drugs and gases. For example, let’s say an H & P says a patient has had a heart transplant, and doesn’t mention the date. Does the author of the H & P know what a difference it makes in terms of responsiveness to anticholinergic medications whether the transplant was one year ago or 10 years ago? It’s very helpful to have that information. A brief H & P may leave out key information if the person doing it has no idea what may be safely omitted and what the anesthesiologist really needs to know.

Sadly, we repeatedly see patients referred late to the hospital because of errors made in the primary care setting by non-physicians — for example, attributing a diabetic patient’s foot pain to neuropathy over a period of months, and not thinking to refer to a vascular surgeon until gangrene set in because the circulation had been so poor for so long. I’m sure we all have anecdotes, and physicians make errors too. But I think that experience, humility, teamwork, and good backup support are the best guarantees that errors will be caught in time, critical events will be capably managed, and patients will have the best possible outcomes.

Thank you for reading and taking the time to write!

Best,

Karen Sibert

[Reply]

I am an obese patient with sleep apnea. I was sent to a surgery center for a colonoscopy. I could tell the nurse anesthetist was nervous-maybe his first day-and did warn him that my O2 levels could go into the 70’s. He pushed the propofol too fast, and I had spasms. Apparently, I needed to be “bagged!” this I didn’t find out until the follow up colonoscopy when the surgery center refused me as a patient, and sent me to the hospital. There the anesthesiologist and the nurse listened to my story, hyper oxygenated me prior, and procedure done without drams. I find it frightening as a retired RN with multiple health problems, that I have no say in who can provide my care during procedures or surgeries.

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Jimmmmmmm

“Was it a cursory ‘clearance’ by a mid-level practitioner, as opposed to a thorough history and physical examination by a physician?”

Or vice versa? Poor character and laziness are evenly distributed across all disciplines. I’ve never in my 26 plus years as an RN, 19 as an FNP, have I ever seen a “cursory clearance” written by anyone in anesthesia. Everyone, regardless of credentials, does a full and thorough H&P. It’s incredibly insulting and condescending to imply that any RN, let alone there very best nursing has to offer, would not have the intellect, skills and character to perform a full and thorough history and physical prior to a patient undergoing a potentially life-threatening procedure.

I happen to agree that us advanced practice nurses should not practice independently, even though many of us have the skills to do so. Lowering the standards to save money screws is all over. Still, you should be ashamed to imply that we cannot or will not to a thorough H&P.

[Reply]

Mary

Jimmmmmmm,
Dr. Sibert, has stated everything with accuracy. I’m a RN and a former CRNA student and I can tell you that there is no way to by pass medical school, residency and fellowship. We can add more tittles( FNP, CRNA, ADNP..etc..) but we don’t have the knowledge or the training of an physician and what we know and what we can do in an emergency situaciones with complex patients is very limited.
I have respects for a lot of NPs as I have known very few who are extremely knowledgeable. However, when I go to my doctor’s appointments I want to see a physician and not a NP or a PA. I could elaborate further why that is but I think you might already know. And if I have to have any procedures under sedation/anesthesia, I want a ANESTHESIOLOGIST managing my case. I do not want a CRNA because if anything were to go wrong, at least I would rest at peace knowing that the anesthesiologist would do everything possible and imposible to keep me alive.
Even in simple procedures like a Colonoscopy anything could go wrong.
I definitely blame the NorthStart anesthesia. Some hospitals have moved their endoscopy suits in the OR. This way, if anything goes wrong with the procedures under anesthesia, they have immediate access to extra staff and equipments.

[Reply]

Corey Collins

Thx for sharing this sad case.
My two cents. Every asc/ office based death or critical event should be reported to a objective, central agency immediately and “ lessons learned” disseminated immediately/ASAP, similar to aircraft events/ near-misses/ crashes. It’s unreasonable not to have a robust data set to prevent patient harm. Only then can competency be established for any clinician and pt safety be the focus of this discussion, not credentials. Closed-claims analysis is far too blunt to reflect what really happens in practice.
(I’m a Pedi anesthesiologist, work in asc setting, certified patient safety professional)

[Reply]

Philip Snyder, MD

This isn’t about anesthesia per se or CRNAs vs MDs. This is about what happens when a private equity-backed group takes over and tries to turn anesthesia into a disincentivized widget factory to save money. And NorthStar is just the beginning. NAPA, USAP, Envision, TeamHealth, Somnia, etc. are completely changing anesthesiology into a CRNA-driven (cheaper) system that fosters mediocrity and guts productivity. Note the reference in the piece to the fact several MDs and CRNAs left when NorthStar entered. Gee, I wonder why. Sadly, it is fair comment that residency programs are wholly failing to teach residents about the history of anesthesia, the business of anesthesia, and the complex issues they are facing if they leave their academic cacoon for a job in the real world. By the way, if you want to read one of the most succinct, accurate, and recent discussions about how anesthesia evolved in the United States, check out Moon, J. S. “Physicians and Nurses in American Anesthesiology: A Brief History of the Early Years.” California Society of Anesthesiologists Vital Times 2020 at p. 94.

[Reply]

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