NEW YORK—In this issue, our series exploring anesthesia-related litigation examines a case in which physicians involved in an endoscopy were accused of improper management of both the anesthesia and the procedure, which was performed at an ambulatory surgery center (ASC)–a setting that may be particularly vulnerable to mishaps and litigation.
“As these ASCs have proliferated, the number of cases and claims against them have skyrocketed and continue to climb,” said Michael Schoppmann, JD, the CEO of MLMIC Insurance Co.
“If you have a contract with one of these facilities, be very careful. I would recommend going there ahead of time to inspect the facility, the protocols, the equipment, and ask questions because the standards you might take for granted as normal quality of care don’t always exist here. Remember, if you work somewhere and their equipment or protocols are subpar, you inherit that responsibility.”
Schoppmann and Patricia Fogarty Mack, MD, a professor of clinical anesthesiology at Weill Cornell Medical College, in New York City, discussed the case at the 2024 annual PostGraduate Assembly in Anesthesiology.
The Case and Outcomes
The patient was a 69-year-old man referred to gastroenterology with pain and bloating. He had a complicated past medical history, with comorbidities including coronary artery disease with stent placement, sleep apnea, hypertension, diabetes, chronic obstructive pulmonary disease, obesity, and end-stage renal disease (ESRD) with hemodialysis.
The initial exam showed that the patient needed an upper endoscopy. The anesthesiologist, noting the patient’s comorbidities, classified him as ASA physical status class III, and the patient signed consent for both anesthesia and the procedure. The anesthesiologist proceeded with sedation, administering an initial 50 mg of propofol, and subsequently 50 mg. The patient’s oxygen saturation fell from 99% to 85%, and the endoscopy was discontinued. The anesthesiologist placed oral and nasal airways and attempted to mask the patient. The patient’s heart rate decreased to 40 beats per minute, so the anesthesiologist administered atropine; and the patient’s heart rate increased to 70 beats per minute and blood pressure rose to 206/102 mm Hg. To treat the high blood pressure, the anesthesiologist administered labetalol. The patient’s blood pressure stabilized at 155/86 mm Hg and he was transported to recovery. There, he was stable and breathing spontaneously, but remained unresponsive.
Emergency medical services transported the patient to an emergency department. Further evaluation determined the patient had experienced a hypoxic event. He was diagnosed with anoxic brain injury with subsequent cognitive defects, and required assistance in activities of daily living until his death four years later.
The experts who reviewed the case identified the following as liability issues: lack of documentation of preoperative history and physical or preoperative vital signs, failure to obtain medical clearance to ensure the patient was optimized, and the choice of an ASC setting as the site of care for this patient with significant comorbidities. An initial demand for $10 million by the family was made of all parties; eventually the case was settled on behalf of the anesthesiologist for $2.1 million in indemnity after $147,175 in expenses was paid in defense costs.
What Could Have Been Done Better?
By stopping the procedure, placing oral and nasal airways, starting bag-valve-mask ventilation, and managing the patient’s heart rate and blood pressure, the anesthesiologist did a lot of things right when things started to go wrong. But considering the patient’s medical history, they should have insisted on ensuring the patient was optimized, especially regarding his ESRD. There did not appear to be any plan for managing his coronary stent. The number of medical conditions and the lack of documentation of recent assessment of those conditions made the patient a less than ideal candidate for care in an ASC, Mack said.
“Given the stent, end-stage renal disease and other comorbidities, how many of us would even allow this patient to be scheduled at our hospital-affiliated ASC? In my opinion, this is the crux of the matter: This patient could have had medical clearance and the blessings of every subspeciality in the world, but this is not a great case for an office-based procedure.”
Schoppmann added that the very thought of obtaining medical clearance is a sign that you need to get it.
“I know it can be difficult with scheduling, but if you’re thinking about it, if that little voice in the back of your head is asking, ‘should we get medical clearance,’ you already know the answer. The ability to defend the case will be so much stronger if someone else says, ‘I agreed with the anesthesiologist, and I cleared the patient.’”
By Monica J. Smith
Mack and Schoppmann reported no relevant financial disclosures.
Editor’s note: None of the cases explored in this series occurred at Weill Cornell Medical Center.
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The only one who can completely "clear" my patient is ME. Full stop.
I may, and often do, ask the opinion of other medical specialties, but the buck stops wit me (and my MedMal carrier).
NO way this patient should have been done in an ASC, hospital affiliated or not. This is a classical case of medical malpractice likely motivated by the Anesthesiologist's desire to not offend his employers.
This is a classic case of routine malpractice that is “standard of care” simply because “everybody does it that way.” CONSENSUS IS NO SUBSTITUTE FOR SCIENCE!!!!
In the first place, outpatient surgery is an ABOMINATION forced upon medical practitioners by INSURANCE COMPANIES. This began around 1995 when insurance companies imposed “fast tracking” by refusing reimbursement for procedures performed in hospitals, and insisting that most surgical procedures be performed in outpatient clinics where patients are sent home in the care of medically ignorant friends and family. SINCE WHEN DID INSURANCE COMPANIES GAIN THE RIGHT TO DICTATE MEDICAL SAFETY STANDARDS?????????
In the second place, any patient who requires abolition of consciousness FOR ANY REASON deserves to have a “SECURE AIRWAY” (elective endotracheal intubation). When the anesthetist must share the airway during upper endoscopy, or during dental procedures and ENT procedures, then it is triply mandatory to perform elective endotracheal intubation. Sedating such patients with “dibs and dabs” of toxic Propofol is malpractice on steroids. Loss of the airway under these circumstances CANNOT BE COUNTERACTED WITH DRUGS. The same applies during lower endoscopy procedures when the patient is placed in prone position or the anesthetist doesn’t have direct control of the airway.
There have been countless deaths and disasters due to these slipshod practices.
Anoxic brain injury did not happen from a SpO2 of 85%. Regardless of patient comorbidities, rapid placement of an LMA or ETT probably would have avoided this outcome. Sounds like documentation and/or care was subpar. What is scary is that the endoscopists (who frequently have ownership stakes in these small, remote sites) have an incentive to employ their anesthesia providers. They pay as little as they can get away with and that may mean you are not getting the best providers available.
My thoughts exactly. No way it dropped only to 85%. Who would start banging at 85? And then with bradycardia following..probably associated with the hypoxia, not a separate incident.
Sounds like a weak clinician unfortunately.
I disagree with the previous comment. The case was in an ASC, not an office (as it says in the comment).
I have done many cases like this in an ASC. But I do an in-person preop evaluation a few days before the scheduled procedure.
I usually call a medical clearance “toilet paper.” It usually says nothing, then says avoid hypoxia and hypotension (duh!)
This case is presented with insufficient information. Many unknowns that can make a difference and better select the facility for the patient:
Did they coordinate dialysis for the day before?
What was the EF? Any valve abnormalities? All this information can be obtained from previous encounters and a fax machine.
Should they have used etomidate?
Do they have high flow oxygen?
Obesity? BMI 30 or 55. Big difference.
Stents? When? Aspirin? Plavix?
Should they have inserted a nasal trumpet right after induction?
Experience of the person?
Was the facility accustomed to managing patients like this? Equipment? Help if needed?
So, in summary, there are Propofol pushers and then there are Anesthesiologists.
Leopoldo Rodriguez MD
Past-President SAMBA
"I have done many cases like this in an ASC" - Eminence-based medicine
Thanks Dr Rodriguez. ESRD patients do belong in hospitals. Anoxic brain injury means the hypoxia persisted for TIME. Anyway, we can do better in the 21st century, and our patients deserve it.
Jduncado:
You have not made your case to make this patient ASAP 4.
Read the ASA Physical Status classification
https://www.asahq.org/standards-and-practice-parameters/statement-on-asa-physical-status-classification-system
Dialysis is ASA 3
EF >35% ASA 3
Hx MI over a year ago, sp Stents stable ASA 3
OSA on CPAP
The rest of the information in the article seems emotionally charged, not based on science.
What exactly do they have in a Hospital? In a NORA unit they are usually further from help if needed.
Please make your case.
This patient is not a candidate for ASC. Full stop.
This patient was an ASA 4 not a 3, Therefore that little voice in the back of my head would have told me that this was not the right case to be done in an ASC.
You should read tge ASA Physical Status classification system. It has examples of what is ASA 3 and What’s ASA4.
this was an ASA 3 patient, a lot of unknowns about coordination of care.
i have done 100s of patients like this in ASC, successfully and safely.
I have personally administered over 60,000 one on one EGD or colonoscopy anesthetics, in the ambulatory surgery setting. I am 64 years old, board certified anesthesiologist, 1989. Even in a hospital setting things go wrong. Plenty of key issues not discussed in short article. Airway was the key issue. Was the patient preoxygenated with high flow oxygen and do some deep sighs prior to sedation? . Did the patient choke and buck on inadequate primary dosing? Did the patient get redosed because of inadequate sedation the first time? Was any local used? Was there any aspiration? Was the patient positioned correctly in recovery position? We’re all monitors working? We’re chin lift, jaw thrust administered prior to desaturation? Was the nasopharyngeal, oral airway and LMA rapidly used. 100mg of diprivan rapidly wears off in AlL patients, very small dose for morbid obesity. Skill and speed of GI doctor matters. Skills and experience of anesthesiologist matters too. We are 37 trillion dollars in debt, this patient has outlived his expiration date due to modern medicine, should have already expired like 99% of the rest of our planet. . Appears his critical issue of obesity was his own fault. Some poor doctor got blamed for a bad result on a patient that was 99% responsible. No good deeds go unpunished. The worst person at a malpractice case is the lying expert witnesses. We as a nation have to decrease the cost of medicine or there won’t be ANY healthcare. Life has risk, it’s not someone else’s fault. We can’t do a million dollar work up on everyone or waste our tax payers dollars. The verdict is crazy for such a time bomb, waiting to go off on someone. Were the medical consults going to fix his obesity, renal failure, weight and other issues? Was the hospital going to do it differently? Intubating every patient has real risk too!
It’s hard to criticize others, I may get struck by lighting too! I believe this was an unjust verdict, for such a train wreck.
Many people think clearance means the holy grail and nothing will happen. I have had to explain to the patients clearance means being managed optimally preop and there is no guarantee that a bad outcome can be avoided by the letters. I have noticed , people become laxed when it is a mac or sedation only case, forgetting that each sadation case has the potential for becoming a general. For the sake of saving money, drugs arent drawn up beforehand, and when disaster happens, you cant manage the airway and draw up drugs. I dont agree with the comments of calling the provider weak! Charting is also not doable when you are managing the airway.