When it comes to an airway emergency, there’s no time to waste. Some circumstances require immediate placement of a breathing (endotracheal) tube into the patient’s trachea (windpipe) to secure the airway. This is a medical procedure called intubation.
Anesthesiologists are physicians who are airway experts. Sometimes an anesthesiologist is in the operating room (OR) providing anesthesia care. Other times, the hands-on OR anesthesia care is provided by a non-physician certified registered nurse anesthetist (CRNA).
Nurse anesthetist oversight
Some states allow CRNAs to administer anesthetic medications and monitor anesthesia care independent of physician oversight.
Other states, like Texas, require CRNAs to be medically directed or supervised by an anesthesiologist physician. When physicians medically direct a CRNA, they can be responsible for up to four simultaneous procedures or ORs. Under the medical supervision model, one physician can be responsible for five or more CRNAs at the same time.
Regardless of the model, in Texas an anesthesiologist physician must participate in the pre-anesthetic evaluation, forming the anesthetic plan, and the most demanding parts of the anesthetic care (putting the patient to sleep and waking up the patient), and also be immediately available in the case there’s an emergency.
CRNA quality of care
There’s currently a robust and sometimes nasty debate over whether CRNA training and outcomes are on par with anesthesiologist physicians. It’s undeniable, though, that CRNAs have an effective lobbying organization that has succeeded in expanding the scope of practice available to nurse anesthetists in numerous states. CRNAs are in ORs all over America and are here to stay.
In fact, the odds are that most patients who require anesthesia care in a hospital or ambulatory surgery center OR setting will have a CRNA involved in their care. For most of those patients, the CRNA will likely be calling the shots and providing direct patient anesthetic care.
Fortunately, in the overwhelming majority of cases involving anesthesia care, there aren’t complications or adverse events. It’s when something unexpected occurs, though, that emergency airway experience and training are so important.
That’s what happened in a case I recently reviewed involving a man in his 40s who had a relatively minor procedure by an ophthalmologist at a surgery center. A CRNA’s anesthesia care was called into question after the patient died. The wrongful death medical malpractice lawsuit alleged that the nurse anesthetist’s emergency airway training and experience wasn’t up to snuff.
The surgery was scheduled when a diabetic patient developed a hemorrhage in his right eye after cataract surgery. The ophthalmologist recommended a vitrectomy procedure under local anesthesia at a surgery center OR. Vitreous is the gel-like substance that fills the eye. When vitreous detaches and forms strands, it can cause traction, bleeding, and vision problems. Ophthalmologists perform vitrectomy surgery to remove vitreous strands and stop the leak.
During this patient’s vitrectomy surgery, the CRNA administered local anesthetic and intravenous (IV) sedation. As the ophthalmologist began the procedure, the patient became agitated and was experiencing pain, so the CRNA bumped up the level of sedation. Momentarily, the patient turned pale and stopped breathing.
The CRNA recognized the problem and immediately tried to resuscitate the patient by giving supplemental oxygen with an Ambu bag, but it didn’t work to increase oxygen saturation levels. The ophthalmologist told the CRNA to intubate the patient, while he called 911.
As mentioned earlier, intubation is the process of inserting a breathing tube into the patient’s trachea, which secures the airway. When performing an intubation, it’s a standard practice to visualize the vocal cords to ensure proper placement in the trachea, and then check to make sure there’s carbon dioxide return. If the endotracheal tube isn’t properly positioned, it’s a worthless intervention.
When emergency medical services (EMS) arrived at the surgery center, they quickly determined that the carbon dioxide monitor, which is part of the intubation equipment, hadn’t changed color. They recognized that this was a clear sign that the CRNA had placed the endotracheal tube in the patient’s esophagus, rather than the trachea.
The esophagus is the muscular tube that goes from the mouth and throat to the stomach. It has nothing to do with breathing. When the endotracheal tube is placed into the esophagus, it’s called a failed intubation, meaning the patient will continue to be deprived of oxygen.
According to the lawsuit, the CRNA didn’t like the EMS conclusion and got into a shouting match with a paramedic. Ultimately, though, the paramedic re-intubated the patient and the oxygen saturation levels began to go up. That suggests that EMS was right.
Unfortunately, by that time it was too late to save the patient’s life. Although EMS got the patient to a hospital, he died eight days later.
In the wrongful death medical malpractice lawsuit, the CRNA testified that:
• He was responsible for providing anesthesia care to the patient
• At the time of the incident, the CRNA had not performed an intubation in five years.
• The CRNA never discussed the risks and complications of anesthesia with the patient because he didn’t want to scare him before the procedure.
While the CRNA contended that he properly inserted the breathing tube, expert witnesses testified that the CRNA didn’t intubate the patient properly and failed to monitor and communicate a low oxygen level to the ophthalmologist before the patient went into cardiopulmonary arrest.
You have a choice
It’s disappointing that the CRNA in this case undisputedly didn’t have an appropriate informed consent conversation with the patient. If you’re facing a surgery or procedure that requires anesthesia, it’s important to ask questions so you understand the risks and benefits of the procedure. One of those risks involves reaching a comfort level with the human being who will be providing anesthesia care, including that person’s education, training, and experience.
When given all of the necessary information, some people choose to have a physician anesthesiologist handle their anesthetic care. Others will be comfortable with the involvement of an experienced CRNA. It’s all within the patient’s choice, though, and must be disclosed and discussed.
If you’ve been seriously injured because of poor anesthesia care in Texas, then contact a top-rated, experienced Texas medical malpractice attorney for a free consultation about your potential case.