Why quality of anesthesia matters: who is administering your anesthesia?
I know some readers find some of my reporting dry and uninspired, particularly when talking about methodology, measurements and scales such as Surgical Apgar Scoring. But the use of appropriate protocols, safety procedures and specialized personnel is crucial for continued patient safety.
There is a saying among medical professionals about our patients.. We want them all to be boring and routine. That is what I strive for, for each and every one of my readers – safe, boring and routine.
Excitement and drama are only enjoyable when watching Grey’s Anatomy or other fictionalized medical dramas. In real life, it means something has drastically and horribly gone awry. Unlike many of its fictional counterparts – outcomes are not usually good.
this patient is in trouble.. But at least someone is watching the monitor.. (and there is a monitor)..
In a not-so-sleepy hollow of upstate New York, a medical tragedy serves to illustrate this point, while also bringing up questions regarding the procedure. While we don’t know the circumstances behind this case – (and don’t really want to speculate on this specific case), it does open the discussion on the quality of anesthesia and anesthesia-monitoring for non-general anesthesia procedures. This includes procedures using sedative-hypnotics, epidurals and anesthetic combinations. This is often referred to as “twilight” or “conscious sedation” procedures.
People tend to think of these procedures as being entirely safe – whether it is so-called “sleep dentistry’ or any variety of scope procedures (endoscopy, colonscopy, bronchoscopy). In fact, many of these procedures are often done in out-patient settings; dentists’ and doctors’ offices without the services of an anesthesiologist or CRNA (nurse anesthetist) and/or appropriate monitoring.
This is extremely troubling – especially since a slew of research papers over the years have clearly demonstrated that this is not safe. In an eye-opening paper published several years ago, over 70% of non-anesthesia trained physicians underestimated the patient’s level of sedation during gastroenterology procedures. (While I can not find a copy of this article online – its publication led to changes in the recommendations related to administration of anesthesia by non-anesthesia providers).
In an notable survey published on dental anesthesia, 35% of respondents providing anesthesia during dental procedures had no formal training in anesthesia.
Too often, the medical professionals (non-anesthesia specialty) underestimate the level of anesthesia achieved and critical safeguards to prevent potential patient injury are not taken. One weekend course, or online continuing education course is not sufficient training.
In the case cited above, a young woman underwent an endoscopy procedure. During this procedure – the patient became hypotensive (low blood pressure) and hypoxic (oxygen-starved) resulting in severe brain damage and disability. The patient is now unable to see, or speak. This devastating outcome is a clear example of the risks during these types of procedures due to anesthesia.
While the details of the case above differ (patient was in a hospital) the family is now suing claiming that the patient did not receive prompt medical attention when these events occurred.
Unconscious, overmedicated and unmonitored in the office: Recipe for disaster
More concerning in my view, is for all of those patients undergoing these very procedures outside of hospital facilities – away from trained experts. In many cases, the office patients are given medications without any continuous monitoring devices such as continuous telemetry and oxymetry (which detect low blood pressure and hypoxia immediately) versus ‘spot-check’ methods that office staff may employ.
For example; several years ago, one of my good friends worked as a nurse in a gastroenterologists office. While she was a well-trained and excellent nurse – she was not a trained anesthesia provider – nor was she provided with the adequate equipment to monitor or treat anesthesia complications.
What equipment, you ask? The office had no cardiac monitoring – (hemodynamic monitoring). There were no reversal agents available in case of oversedation, no supplemental oxygen for respiratory depression/ hypoxia - and most critically – no crash cart in case of cardiac or respiratory arrest. (While the law requires this in some states, that doesn’t guarantee that the provider has the appropriate equipment.)
In the office where my friend worked, the nurse administered a set amount of sedation under the guidance of the gastroenterologist. During the procedure, vital signs were checked every 15 minutes (giving the patient 14 minute intervals to develop serious procedures unnoticed by anyone).
Was this the right or safe way to care for patients? No, absolutely not – but it remains a common practice in doctors’ offices around the country.
The death of Michael Jackson
Another more extreme but famous example of the dangers of ‘unmonitored anesthesia’ is the death of Michael Jackson during the administration of propofol by a Dr. Conrad Murray in Mr. Jackson’s home. During the investigation, it was noted that not only was the patient (Michael Jackson) without continuous hemodynamic monitoring (and oxymetry) – he was left unattended for significant periods while Dr. Murray conducted business and placed numerous telephone calls. While this is an extreme example – it also demonstrates the dangers of anesthesia administration without qualified personnel, appropriate monitoring or rescue equipment.
In 2009 Metzer et. al. reviewed all liability claims and summarized this along with their previous research regarding related anesthesia injury and concluded, “Data from the American Society of Anesthesiologists, Closed Claims database suggest that anesthesia at remote locations poses a significant risk for the patient, particularly related to oversedation and inadequate oxygenation/ventilation during monitored anesthesia care.”
If you are planning to have any sort of procedure requiring any sedation or anesthesia (other than local anesthesia like lidocaine), ask the following questions:
- Who will be administering my anesthesia/ sedation? What are their credentials and training in anesthesia?
- How will I be monitored during this procedure? Who will be monitoring me? What type of safety protocols are in place for peri-procedural monitoring?
- What if there is a problem? Do you have the equipment necessary to reverse sedation? perform urgent intubation? resuscitation?
If this procedure is being performed in a doctor’s office or outpatient surgery center: - What happens if a complication develops during this procedure? Is there a hospital nearby for emergencies?
References / Resources
Boynes SG, Moore PA, Tan PM Jr, Zovko J. (2010). Practice characteristics among dental anesthesia providers in the United States. Anesth Prog. 2010 Summer;57(2):52-8. doi: 10.2344/0003-3006-57.2.52. (free full text – linked in article above).
Cheney FW, Posner KL, Lee LA, Caplan RA, Domino KB. (2006). Trends in anesthesia-related death and brain damage: A closed claims analysis. Anesthesiology. 2006 Dec;105(6):1081-6. (full text available). This study clearly showed the benefit of continuous pulse oxymetry and other hemodynamic monitoring to prevent catastrophic complications.
Cohen, L. & Aisenburg, J. (2008). Endoscopic sedation: Preparing for the future. Gastrointestinal endoscopy clinics of north America; 18(4).
Hangsheng Liu, PhD; Daniel A. Waxman, MD; Regan Main, Soeren Mattke, MD, DSc (2012). Endoscopies and Colonoscopies and Associated Spending in 2003-2009. JAMA. 2012;307(11):1178-1184. doi:10.1001/jama.2012.270 The authors attempt to estimate the frequency in which qualified anesthesia providers are used during gastroendoscopy procedures.
Metzner J, Posner KL, Domino KB (2009). The risk and safety of anesthesia at remote locations: the US closed claims analysis. Curr Opin Anaesthesiol. 2009 Aug;22(4):502-8. doi: 10.1097/ACO.0b013e32832dba50.
Paspatis GA, Tribonias G, Paraskeva K. (2010). Level of intended sedation. Digestion. 2010;82(2):84-6. doi: 10.1159/000285504. Epub 2010 Apr 21. Article discussing the issues regarding sedation during endoscopy procedures.
Robbertze R, Posner KL, Domino KB. (2006). Closed claims review of anesthesia for procedures outside the operating room. Curr Opin Anaesthesiol. 2006 Aug;19(4):436-42. Review.
Anthony Bourdain does Colombia
It’s not his first visit – he’s done several other programs highlighting Colombia, but tonight’s episode on his new CNN show, “Parts Unknown” is definitely his best. It’s the first time I think he actually ‘got it’ and was really able to convey a real sense of Colombia to his viewers.
While his previous shows were primarily about food, and local food culture – his episodes on Colombian cuisine were always very wide from the mark.. Sure, he had the names of dishes and such – but he didn’t really bring home the feel of Colombia and it’s people.
http://www.youtube.com/watch?v=qNiF0R1QJpk&feature=share&list=SP6XRrncXkMaVZxpButSnMywWvtINMmjXv
Or that Colombian food isn’t really about intense spices, it’s about the intense and rich flavors that comes from the rich textures of the foods themselves – without overpowering curries or heavy sauces..
Better quality, fresher ingredients and a wide variety make for richer flavors
Catastrophic surgical mistakes – and bold red headlines…
Many of you may have seen the bold red headlines for the weekend edition of USA Today, which screams, “What surgeons leave behind.” If you haven’t read it, this article by Mr. Eisler makes for riveting reading on one of surgery’s most catastrophic mistakes.
(The other catastrophic surgical mistake is a topic we’ve covered before, Wrong-site surgery (wrong side, etc.) Readers will remember the previous stories about an American neurosurgeon who was found to have performed wrong-sided surgery, on not just one – but several patients. Readers will also recall that said surgeon has a habit of moving from state to state as each medical board catches up to her*.
The How and Why of Retained Surgical Items is our own contribution to the topic – over at Examiner.com, where we review much of the information regarding retained surgical items or forgotten foreign bodies including risk factors for this phenomenon, and how current practices may actually inhibit efforts to prevent this from occurring.
* This surgeon was previously mentioned by name in both my posts, and several news stories about her numerous medical/ surgical errors.. Of course – disclosing her name on this site led to multiple threats of legal action – quite the long story, for new readers.
the ethical, moral and health hazards of transplant tourism
Now that’s a mighty long title – for a very small section of medical tourism, which alternates in generating world-wide headlines and being swept quietly under the rug.
Bathtub full of ice
Everyone has heard ‘urban folklore’ regarding the unwary/ drunken/ duped young man who goes looking for sex, and wakes up in a bathtub full of ice.. Conventional wisdom is that these tales serve as a modern-day fairy tale with an underlying moral message. In this case – cautioning young people against the vices of alcohol/ drugs and anonymous/ promiscuous sex.. If only the truth were really just such a cautionary tale.
But, as readers know, the truth is considerably darker – involving the exploitation and even outright murder of citizens around the world to feed the organ trade.
This division of medical tourism, “Transplant tourism“, is the sanitized term for organ selling, or diversion of transplantable organs to wealthy consumers (outside of the formal donor networks like UNOS).
Transplant tourism/ murder for organs is making headlines again this week as Taiwanese legislators try to ban the practice among their citizens and residents. The Taiwanese lawmakers are trying to prevent the practice of wealthy patients (and companies making money from the sale of organs/ transplantation) using China as a ‘spare parts’ playground.
As widely reported over the last several years – China has become notorious for widespread ethical violations, including the murder (execution) of political prisoners for organ sales and transplantation to wealthy buyers. Many of these political prisoners are people accused of such crimes as the practice of the religion, Falun Gong, or for expressing ideas that challenge the traditional Chinese culture or current government practices.
Not illegal in the United States
Unfortunately, despite multiple scientific, medical, governmental papers and sporadic media coverage of this issue – it is not illegal for Americans to engage in this practice, nor for American companies to offer transplantation services based on these practices. (It is illegal for organs to be sold in the USA, but not for people to travel to engage in these practices.)
While the United Nations, New Zealand, Australia and now, Taiwan have begun addressing this practice – the US government remains silent.
Protecting citizens from the wealthy foreigner
Other nations, like Pakistan have acted to try to prevent their citizens from becoming donor sources for wealthy foreigners. Just today, a new law was passed to prevent organs obtained in Pakistan from being given to non-Pakistani residents.
While these laws will not eliminate the practice outright, these countries and their citizens have taken a moral and legal stance against the practices.
Now, it’s our turn.
Resources/ More information on this topic
More about the people “criminals” the Chinese government is executing – and taking organs from – Washington Post, November 2012
List of famous Chinese dissidents - Wikipedia
More about the murder and torture of practitioners of Falun Gong
The Ugly Side of Medical Tourism – a related post with links to scholarly articles and media reports regarding transplant tourism in China and Latin America.
A look at why transplant tourism is not safe for recipients, either.
Medical Tourist death under inquest
Was it a medical mistake/ an accident of fate / or…. was it the Cocaine? An inquest is held on the intra-operative death of an Irish medical tourist..
In a recent inquest, the wife of an Irish tourist who died while undergoing liposuction with a well-known Colombian plastic surgeon talked about her husband and his decision to pursue plastic surgery with Dr. Ricardo Lancheros Pedraza.
In a published story by Gareth Naughton of the Irish Independent, the wife of Pierre Christian Lawlor detailed her husband’s decision to undergo cosmetic surgery with the Bogotá surgeon due to unhappiness with his physique.
During her testimony, she also conceded that her husband had taken cocaine in the days and hours immediately prior to surgery – despite being advised specifically to refrain from smoking, alcohol or taking medications.
In a story published in Irish Central - Ms. Andrea Galeano, the Venezuelan-borne wife of Mr. Farrell reported that her husband had taken cocaine on several occasions after arriving in Bogotá for his surgical procedure.
Mr. Farrell is believed to have died from intra-operative myocardial infarction (heart attack during surgery).
Additional Information
This Daily Mail article from 2012 describes how the use of cocaine can cause heart attacks, and sudden cardiac death.
Scholarly articles:
Finkel JB, Marhefka GD. (2011). Rethinking cocaine-associated chest pain and acute coronary syndromes. Mayo Clin Proc. 2011 Dec;86(12):1198-207. doi: 10.4065/mcp.2011.0338.
Schwartz BG, Rezkalla S, Kloner RA. (2010). Cardiovascular effects of cocaine.
Circulation. 2010 Dec 14;122(24):2558-69. doi: 10.1161/CIRCULATIONAHA.110.940569. Review.
Images of Colombia
While I am back here in the United States, I wanted to share many of the images I’ve gathered and collected during my most recent visit to Colombia.. Some of these images will be familiar to long-term readers from various posts about my trips to Lerida, visits to the finca, and day-to-day encounters with different and interesting people in Colombia.
I hope you enjoy!
Happy Anniversary…
As my long-time readers know – I am a huge fan of Adriaan Alsema, a Dutch-borne journalist in Medellin, Colombia. He is the founder/ creator/ and genius behind Colombia Reports.com – the English language news source for all things Colombiano.
Mr. Alsema, Editor-in-chief, Colombia Reports
It’s the fifth anniversary of Colombia Reports – so I wanted to wish Adriaan a Happy Anniversary..
Dear Edward
In the middle of all the news about Lance Armstrong and his upcoming interview with Oprah Winfrey - where he has reportedly expressed his apologies for his years of lies and cover-ups over blood doping and steroid use, came this interesting piece by Lance Pugmire at The Los Angeles Times. In the article, several of Armstrong’s teammates and their families talk about what they consider to be the worst aspect of this entire scandal – the years of intimidation, threats and forced silence. Armstrong committed these abuses of the system, and flagrant cheating for years, and got away with it for over a decade. Not only that – but he had a team comprised to maintain this conspiracy of silence, of lawyers and such to protect Armstrong - while his unwilling colleagues paid the price for their honesty and integrity..
In a similar, but much smaller scale – I am publishing an open letter here at Bogota Surgery. As my regular readers know – we have had our own legal encounters (with threats and intimidation) over several of our previous posts about patient safety.
This all started due to a blog post on patient safety – based on an article from another website, verified by the original news agency and the original investigative reporter.
These fact-based, well-researched posts with supporting documents told the story of a surgeon who had committed multiple surgical errors including several different ‘wrong-sided’ surgeries. This surgeon, after being reported to the medical board in her state answered this action by moving to another state (where malpractice charges are now pending) and ultimately moved to a third state to practice.
However, one of the limitations of having state-based medical regulatory boards (versus a nationalized system) was that these complaints did not follow the doctor.. Meaning that when current patients / hospitals/ potential employers investigate or look up her licensure or credentials – they will have no idea of the previous charges against her. However, by publishing a blog post about this individual and re-posting links to original news articles and court documents, her lawyers threatened me with legal action to enact my silence.
So this is my response – in an open letter to her lawyer:
Dear Edward;
First, I would like to extend my sincerest sympathies to you. I am guessing that you are a nice person, and are working hard to perform your occupation to the best of your abilities. But by taking on this client, you are doing yourself and American patients a great disservice.
Your client has been found to be medically negligent in multiple cases in the state of Colorado. She acknowledged that through her own actions, and she now stands accused of the same in Illinois. Not only that, her brazen disregard for the health and safety of the unfortunate people who came under her care led to changes in the laws and regulations of the Colorado Medical Board. She may claim that she did not ‘lose’ her license in that state, but it was her actions that demonstrated to the medical board that there were significant loopholes in their processes that allowed physicians who admitted guilt, like your client, to move on to another state without penalty.
However, all of this is fact, and it is public record, so you and your client have no cause or claim against me for writing about these published facts. In my previous writing, I included supporting articles and documents to demonstrate that what I reported, was indeed, fact.
One of those facts in particular, is that – yes, you are targeting and bullying me. It is bullying and an intimidation tactic to threaten to sue someone for writing an established truth. It is bullying and a targeted attack, when it has been confirmed that you have not approached or sent similar letters to major news outlets such as the news agency that wrote and produced the original story, or another large agency that republished the story. But then again, large agencies have legal departments. So, yes, it is a targeted intimidation when you threaten me.
You may be just doing your job today, but what about tomorrow or ten years from now? Unfortunately, you are just part of a bigger problem in regards physicians and medical malpractice, which is what the heart of this discussion is really about; a surgeon who makes repeated surgical mistakes and then denies they ever occurred. That may not affect you, personally today but what about when one of your loved ones needs care for heart surgery, cancer or maybe even a brain tumor? How much confidence can you have in a system that allows surgeons such as this one to continue to practice? How much confidence will you have, knowing how easy it is to threaten others into silence?
My heart goes out to you, but my only advice is – give the money back to your client. Take no part in her actions and let people like myself continue our efforts; of trying to promote patient safety, education and protect this public, and people like you.
Readers: If you’d like to donate to my legal defense fund, so I can continue to publish the truth while fighting BS legal intimidation – please email me. Thank you to the anonymous donor for the generous contribution.. I can’t thank you personally, but thank you..
If I don’t need the money, I’ll happily send it back ..
Know before you go: Medical tourism and patient safety
The file download for the latest radio program, “Know before you go” with Ilene Little is available. It’s from the Christmas broadcast with Dr. Freddy Sanabria.
Image courtesy of Ilene Little
(I am on the periphery of the show – introducing Dr. Sanabria and talking about safety guidelines and intra-operative safety protocols. (Same stuff I talk about here – just a different medium.)
Dr. Sanabria, plastic surgeon
Dr. Sanabria joined us to talk about his experiences, and his clinic in Bogotá, as well as his ongoing projects and patient safety protocols. It was nice to be able to share some of my observations from my visits to his operating room.
Dr. Alejandro Jadad and Jose Vergara
Much thanks to Jose Vergara for sending me a link to an article on Dr. Alejandro Jadad. Jose Vergara, aka Frankie Jazz, as some readers may remember, is a Cartagena native and talented artist in his own right.
Frankie Jazz/ Jose Vergara
We try to keep up with each other – so he knows all about my interest in Colombian medicine and surgery, and I love his new album (so I try not to gush and be too much of a groupie when I hear from him) but he recently sent me a link to one of his more recent projects. The Voxxi article by Silvia Casablanca is pretty interesting, so I wanted to share it with readers.
For starters – Jose Vergara is the photographer for the article..
Dr. Alejandro Jadad, MD, PhD
But it’s the life of Dr. Alejandro Jadad that is so inspiring.. Dr. Jadad is a Colombian anesthesiologist, textbook author and founder of the Centre for Global eHealth Innovation in Toronto, Canada (among other things). He has been credited with being one of the major innovators in the fields of clinical research, medicine and information technology.
While at Oxford, as a research fellow in Anesthesiology, he developed a validation tool (the Jadad scale) to critically evaluate and analyze clinical research studies. This is an important tool to distinguish the quality (and value) of individual research studies – or how much weight a study (and its findings) should have. We talk about the importance of objective scales and measures quite a bit here at Bogotá Surgery, and the Jadad scale is one of the best known and most widely used scales for clinical research.
Clinical research is how surgeons know whether a patient has a better chance for survival with surgery or chemotherapy/ radiation, for example.
So as you can imagine – having a tool like this is particularly vital when talking about clinical medicine / or health research where the findings of research studies are used to guide and determine medical decisions – aka the medical treatments for people like in our example above.
As the Casablanca article points out – Dr. Jadad didn’t stop with writing textbooks and creating the Jadad scale. After completing his fellowship in the United Kingdom, he moved to Ontario, Canada to continue his research at McMaster University. Since then, he has continued to innovate and create tools to help both clinicians and the public. One of the ways he helps clinicians is by further creating and refining tools to evaluate medical research.
He has also been a major creator and contributor to the development of internet and computer based applications to connect doctors and their patients. His efforts are based on more that the patient – provider dyad, and are part of a larger, global framework for reforming and transforming healthcare.
More about Dr. Alejandro Jadad, MD, PhD
Casablanca, Silvia (2013, January). Dr. Alejandro Jadad: Redefining health and making it global. Voxxi [on-line article].
(Canadian) Pioneers for Change
“Making Longer Life Worth Living“, lecture by Dr. Jedad at Singularity webblog as part of the ‘Singularity University lecture’ series.
More about Jose Vergara / Frankie Jazz
Let Me Take My Way – which is one of my personal favorites…
