What happens in the operating room after a patient is put to sleep?

Although virtually any type of healthcare involves some level of patient risks, there are some unique ones when it comes to care in the operating room (OR). One challenge is that when patients are placed under general anesthesia, they have no idea what’s  happened in their care until they wake up, usually in the recovery room.

For instance, patients might think they know the answers to these questions before being wheeled off to the OR, but could be wrong:

• Who’s going to be handling my anesthesia care?

• Is my surgeon going to be in the OR during my entire surgery?

Anesthesia care

In American healthcare, there are two different types of anesthesia professionals: physician anesthesiologists and certified registered nurse anesthetists (CRNAs).

Physician anesthesiologists are doctors who attended medical school. As the name suggests, CRNAs did their training in nursing school, rather than medical school. CRNAs aren’t physicians.

As a whole, CRNAs feel strongly about their training, qualifications, and competence. Their professional organizations have sponsored studies that concluded that CRNA aesthesia care is at least as safe as that provided by anesthesiologist physicians. The American Society of Anesthesiologists strongly disagrees.

In some states, CRNAs have completely independent practice, meaning they aren’t medically directed or supervised by a physician. In Texas, that’s not the case and the relationship between CRNAs and anesthesiologists is governed by one of two models.

Medical direction: A physician anesthesiologist is medically directing up to four CRNAs at the same time. The anesthesiologist must perform a pre-anesthetic evaluation of the patient, prescribe the anesthesia plan, participate in the most demanding parts of the anesthesia plan (induction and emergence), and remain physically present and immediately available to handle emergencies.

Medical supervision: A physician anesthesiologist is medically supervising up five or more CRNAs at the same time. The supervising anesthesiologist must be immediately available to all 5+ CRNAs.

In my experience, the informed consent process for anesthetic care is a typically vague. In most Texas hospitals that I’ve encountered professionally, CRNAs provide most of the OR anesthesia care. This fact isn’t typically explicitly discussed with patients during the informed consent conversation, which the anesthesiologist physician handles. My clients have consistently reported that they were unaware that most or all of their direct anesthesia care would be handled by a CRNA, rather than a doctor.

As a patient, it’s your right to provide informed consent (or not) to both the anesthetic plan and the anesthesia professional who will be implementing it. You can even request anesthesiologist-only anesthesia care (or CRNA-only anesthesia care, for that matter) if you so choose.

You have the right to ask questions, including:

• Will the anesthesiologist physician be in the OR during the entire case?

• What are the qualifications and experience of the anesthesiologist physician?

• Will the anesthesia care be provided by a CRNA who will be, at times, the only anesthesia professional in the OR?

• What are the qualifications and experience of the CRNA?

In the numerous anesthesia medical malpractice claims that I’ve handled, there’s one overarching theme: Inexperience. A poorly trained, inexperienced CRNA providing anesthesia care under medical supervision model can lead to disaster when there’s an emergency. The same is true when there is a poorly trained, inexperienced anesthesiology physician at the helm.

Experience matters. As a patient, your time to ask questions and make sure you’re comfortable with the anesthesia staffing and plan is before anesthesia administration or you’re taken to the OR.

Where’s the surgeon?

While anesthesia care is often an afterthought to patients, many patients conduct significant research into selecting the most experienced surgeon they can find to handle their particular surgery.

Paradoxically, picking the most experienced surgeon sometimes means that a surgeon who’s still in training performs a significant part of a surgical procedure. That’s because of an increasingly common concept that’s called overlapping or concurrent surgeries.

In 2015, the Boston Globe reported findings from a survey of 47 hospitals nationwide found that it was common for surgeons to begin a second operation for the first one was complete. In fact, scheduling was often deliberately done to overlap cases.

In 2019, National Public Radio discussed a Stanford study on overlapping surgeries, which found that it placed high-risk patients at a further risk for complications and poor outcomes. Older patients and those with pre-existing medical conditions were found to face a significantly higher risk of post-operative complications, including infections, pneumonia, heart attack, or death.

Other studies have found that when surgeries are double booked, there are problems with:

• Lead surgeons being unavailable when there was an urgent or emergency need

• Leaving the surgery to a resident or fellow (physician still in training)

• Having patients under anesthesia for an extended period of time while waiting for the surgeon to arrive. The longer a patient is under general anesthesia, the higher the risk of complications occurring.

The time to learn about your hospital, surgery facility, and surgeon’s practice on being present in the OR is before even scheduling the procedure. During the informed consent conversation, ask if the surgeon will be in the operating room and participating in the case during the entire procedure. Make sure you’re comfortable with the answer before agreeing to proceed.

If you’ve been seriously injured because of operating room or anesthesia care in Texas, then contact a top-rated experienced Texas medical malpractice lawyer for free consultation about your potential case.

Robert Painter
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Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.