An anesthesiologist once told me that she and others in her field were trained to use medications to take patients to the edge of death—and then bring them back. When I heard and thought about her statement, it really clicked in my mind how risky general anesthesia is and that it’s incredibly important to have a well-trained, experienced provider.
I want to share two things from my experience as a Houston, Texas medical malpractice attorney that can help keep you safer when it comes to general anesthesia care.
Consenting to the right provider
One of the unusual things about going under general anesthesia is the patient doesn’t really know who’s handling their anesthesia care once they’re asleep. What I’ve learned from handling scores of medical negligence cases is it’s almost never a board-certified anesthesiologist physician.
Anesthesiologists typically see the patient before surgery as part of a pre-anesthesia evaluation (more on that later).
During these pre-operative visits, I’ve never heard of them mentioning to a patient that they won’t be in the operating room (OR) during surgery but instead will be sitting at a desk or wandering among OR rooms where multiple procedures are being performed at once. Not one client has told me that an anesthesiologist explained that the direct anesthesia care will be done by a specially-trained nurse.
To me, this is a misleading bait and switch—and it happens every day, I bet, at pretty much every hospital in Texas.
You see, hospitals, ambulatory surgery centers, and practice groups have figured out that they can make more money if they use certified registered nurse anesthetists (CRNAs) to handle direct OR care for patients, rather than anesthesiologist doctors. After all, nurses are cheaper to pay than doctors.
Now if you listen to CRNA lobbying and professional groups, you’d think that CRNAs are the best thing since sliced bread. They cite their own studies that conclude that that anesthesia care delivered by CRNAs is just as good as anesthesiologist-delivered care. These groups are pushing for these nurses to have the same unsupervised scope to provide anesthesia medical care as physicians.
Under current Texas law, a CRNA can provide direct general anesthesia patient care under a delegation agreement from a licensed physician, which gives the CRNA delegated authority to prescribe drugs.
From a practical perspective, though, Medicare and most insurance company guidelines reimburse for anesthesia care by CRNAs under one of two models.
Medical delegation means that there’s an anesthesiologist physician watching over CRNA care in up to four procedures at one time. The medical delegation type of practice requires documentation of seven points of substantial involvement by the anesthesiologist.
The more common and less demanding model is medical supervision, where the anesthesiologist doctor can supervise five or more procedures at once. The anesthesiologist is supposed to be in the OR during the most dangerous parts of the procedure, including induction (putting the patient to sleep) and emergence (bring them out of anesthesia). Plus, anesthesiologist physicians are supposed to be immediately available if something goes wrong, so they can get back to the OR quickly.
I’m sure you’ve already keyed into some concerns, like the big one to me—what happens if something goes wrong in two ORs at once? After all, like any other human being, an anesthesiologist can only be in one place at one time.
Each patient needs to decide what he or she’s comfortable with when it comes to who’s providing anesthesia care. I think that ethics and common sense should demand, though, that patients should know what they’re agreeing to. During the pre-operative visit with the anesthesiologist, ask if he or she will be in the OR with you the whole time, and see what you’re told. That should lead to an interesting and informative discussion.
I’ve handled numerous Texas medical malpractice cases where patients died because they went into respiratory or cardiac arrest during or immediately following a surgery. Our medical experts believed that a significant factor in each case was that a CRNA, not an anesthesiologist, was the provider managing care in the OR when things went downhill. By the time the anesthesiologists made their way to the ORs, it was always too late for the patients.
The pre-anesthesia assessment is important
I’ve already mentioned the pre-anesthesia assessment, and how it’s typically done by an anesthesiologist physician. In my opinion, the main reason that anesthesiologists, instead of nurses, still do this is for the bait and switch scheme to work. Another reason, though, is the important part of what’s supposed to happen in the pre-anesthesia visit.
Before proceeding to administer anesthetic drugs, the standard of care requires the anesthesia provider to review the patient’s medical records, look closely at all lab work, obtain a detailed history, study current and recent medications, and assess and consider any factor that would raise the patient’s risk of going under general anesthesia. At the conclusion, the anesthesia provider makes a decision on whether it’s safe to proceed and then forms an anesthesia plan.
When anesthesia providers breeze through the pre-anesthesia assessment, it places the patient at an unnecessary risk. I’ve handled several cases where a botched pre-anesthesia assessment led to a patient death in routine elective procedures.
For example, I handled a case involving the death of a woman in her 40s at a major academic hospital in the Texas Medical Center. She was going to a procedure room for a short elective procedure called an endoscopy or upper GI. An anesthesiologist did the pre-anesthesia evaluation and didn’t pay much attention to her abnormal EKG, which showed an ST elevation.
The CRNA handling the patient’s anesthesia administered Zofran, which interacted with the abnormal heart rhythm, putting her in a deadly cascade called Toursades de pointes. The CRNA was over her head and by the time the anesthesiologist showed up, things had really gone south. The patient died.
If you’re going to have an operation requiring general anesthesia, I urge you to be thorough and comprehensive with the anesthesia provider who comes to see you before surgery.
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. A member of the board of directors of the Houston Bar Association, he was honored, in 2018, by H Texas as one of Houston’s top lawyers. Also, in 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.