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MEDICINE DEEP SLEEP

Exploring the dangers of anesthesia.
By Joan Rapfogel |

A NEEDLE attached to a tube is skillfully placed into one of your veins. Sodium penathol flows through the tube and enters your body. Within seconds you become unconscious. You are then given a large enough dose of a muscle relaxant to paralyze your entire system. You can no longer breathe on your own, and without oxygen you will die within five minutes.

This is not a description of the Texas Penal System’s procedure for death by injection; it is a description of two phases of the induction of general anesthesia used during surgery. And, of course, you do not expect to die from the anesthetic. Instead, you willingly submit yourself to it, assuming that because of the anesthesia, your operation will be painless. Any feelings of apprehension are chemically relieved by a preoperative injection you receive in your hospital room before they wheel you down to surgery. You arrive relaxed and ready to fall asleep and you fully expect to wake up when it’s over. But whether or not you survive largely depends upon the competence of the person monitoring you during this unnatural state.

To keep you alive under anesthesia, an endotracheal tube is inserted into your throat to carry vital oxygen directly into your lungs. An electrocardiogram (EKG) monitors your heart’s activities while a stethoscope picks up breathing sounds. Your pulse rate, blood pressure, temperature, skin color, blood color, and chest movements all give crucial information about your condition. Any change could be the first indication that you are in trouble. Your life is literally in the hands of the person in charge of your anesthetic.

A great deal of attention has been focused on anesthesia since Shonia Crump-ton, a 17-year-old Fort Worth girl, died from oxygen deprivation when the tube supplying her oxygen dislodged during surgery at Harris Hospital last May. So intense was the public concern that the Tarrant County Medical Examiner’s Office conducted an unprecedented public inquest into the matter. Most of the questioning focused on the individual actions of the surgical staff in charge of the girl’s care to investigate the possibility of criminal negligence. Although the medical examiner’s office could find no such evidence, the hearings did afford the public a rare opportunity to examine the inter-workings of the surgical unit. Among the more important things the hearings revealed was a common practice called “double-posting” or “supervision.”

Double-posting means an anesthesiologist is scheduled, or “posted,” to administer two anesthetics in different operating rooms at the same time. The anesthesiologist accomplishes this by assigning one Certified Registered Nurse Anesthetist (CRNA) for each surgery to remain with the patient throughout the procedure while the anesthesiologist moves in and out of the operating room. This sharing of the anesthesia responsibility is sometimes referred to as “team care.” Many physicians don’t trust the practice of double-posting or the concept of team care used during Shonia Crumpton’s surgery because they believe it can hinder the quality of anesthesia care and can endanger lives unnecessarily.

Most Fort Worth hospitals practice double-posting (unless the individual patients request otherwise); only one Fort Worth hospital, St. Joseph, refuses to do it at all. In Dallas, the policy on double-posting varies from hospital to hospital. Parkland Memorial Hospital, a teaching hospital, has no CRNAs on staff, but the medical students who administer anesthetics are supervised by faculty physicians. At Presbyterian Hospital, consultant anesthesiologists always supervise the CRNAs, whereas at Baylor University, the surgeon decides who will administer the anesthetics. The obstetrical unit at Baylor uses a team care approach to anesthesia with anesthesiologists and CRNAs working together on each case. At both Medical City Hospital and St. Paul Hospital, CRNAs and anesthesiologists work independently one-on-one with the surgeon.

During Miss Crumpton’s surgery, the anesthesiologist, Dr. Cyrus Worrall, supervised a registered nurse who was a student attending the School of Nurse Anesthesia at Harris Hospital. Testimony states that Worrall was in and out of the surgical room at various times.

Deputy Medical Examiner Dr. Marc Krouse says anesthesiologists frequently leave student nurse anesthetists alone with anesthetized patients. “From my experience, it’s an idiot’s job. It doesn’t take much of your attention or much intelligence at all to just watch an EKG or to listen to breath sounds.”

Because endotracheal tubes do not slip out easily, the medical examiner’s inquiry placed great importance on what might have caused the tube to dislodge. Regardless of how or why the endotracheal tube dislodged, the question of why no changes in Miss Crumpton’s vital signs were noted by the person monitoring her during the 10-minute period of oxygen deprivation still remains unanswered. Vital signs are supposed to be checked and recorded on the anesthesia record every five minutes, yet no one noticed any problems with Miss Crumpton until her vital signs had collapsed.

Some local medical professionals are suggesting that the system is at fault. These physicians, critical of team care and the practice of double-posting, have asked that their names not be mentioned. One surgeon explains: “It would be professional suicide to be quoted by name. I would be ostracized by my colleagues. It is unacceptable for a physician to speak out as an individual.”

Nevertheless, some surgeons are quietly voicing their concern about the quality of anesthesia care. “Anesthesia care is unpredictable at the hospitals where there is double-posting,” one surgeon complains. “There are just too many variables.” The surgeon prefers to work with an anesthesiologist one-on-one (one surgeon to one anesthesiologist doing one surgery without supervision). “Anesthesiologists don’t want to give you their services if you won’t let them do another case at the same time,” he says. “Anesthesiologists have turned it into a mass production line.”

Some believe double-posting is a matter of economics since the anesthesiologist charges the same fee for supervising as he charges for monitoring the anesthesia himself. When he is responsible for two anesthetics at the same time, he makes twice as much money.

Sometimes the patient ends up paying two people for the same service; he receives one bill from the hospital that employs the CRNA and a separate bill from the anesthesiologist.

One Fort Worth surgeon doesn’t believe all CRNAs necessarily need to be supervised. “I think there are better CRNAs than anesthesiologists in terms of putting a patient to sleep and monitoring,” he says. Some surgeons don’t use unsupervised CRNAs because if malpractice suits are filed, the surgeon is legally responsible. According to Texas law, nurses cannot administer drugs without the direct order of a physician. Therefore, a surgeon must be responsible for the actions of the CRNA unless an anesthesiologist supervises. “I’m captain of the ship and if I have a doctor of anesthesiology with me, then he’s the captain of his ship. I don’t want to be responsible where I don’t need to be,” says another Fort Worth surgeon. “I want an anesthesiologist.”

At Harris, both anesthesiologists and CRNAs supervise the student nurse anesthetists. “If I want an anesthesiologist at Harris, I automatically get a student also,” says a surgeon. “But I insist that the anesthesiologist on the case has only one other student to supervise and that he is in and out of the operating room often.”

Although anesthesiologists are supposed to supervise only two students at a time, the surgeon says that there is occasionally triple-posting with students. He’s also concerned about anesthesiologists who leave the operating room and go to the doctor’s lounge. “Some go and get coffee during the surgery, but I won’t use the ones who do that,” he says. In the evenings at Harris, nurse anesthetists will supervise students because anesthesiologists on call are sometimes difficult to contact. “You may have to wait one and a half or two hours for an anesthesiologist,” the surgeon says. “And some surgeries can’t wait that long.”

The surgeon also says that some anesthesiologists, when conferring with their patients, omit the fact that a student is part of the anesthesia team. Yet the Guidelines to the Ethical Practice of Anesthesiology as outlined by the American Society of Anesthesiologists (ASA) states that the arrangement of supervision must be clearly explained to and understood by the patient.

Even some anesthesiologists disagree with the practice of double-posting. “It’s how you look at your responsibility. If a person’s life is my responsibility, I don’t want to ask a nurse or another doctor to take care of the patient,” one says. Another anesthesiologist says that he does not feel safe with double-posting. “I’m just not comfortable with it.” And some anesthesiologists feel it’s the surgeons who make the supervision necessary.

Dr. James N. Tulloh, division chief of anesthesiology at Harris Hospital, says that triple-posting rarely occurs. “When it does happen, the surgeons cause it. The anesthesiologist is accommodating the wishes of the surgeon who requests that the surgery be done at a specific time. It’s the surgeon’s -not the anesthesiologist’s – fault.” Tulloh says the anesthesiologist can, and sometimes does, refuse the surgeon’s request. He also says he always tells his patients if a student will be a part of the team. “I ask if that’s all right with them, and no one has turned me down yet.” Tulloh doesn’t see any difference in the quality of anesthesia care between multiple- and single-postings.

Dr. Noel V. Ice, a Fort Worth anesthesiologist, says double-posting was born out of necessity. “There has always been a shortage of anesthesiologists,” he says. One advantage to double-posting, he adds, is that it can offer an anesthesiologist the opportunity to take a break. “Watching surgeons is like watching paint dry,” Ice says. “That is why it is good to get someone to let you out so you can walk around and stretch a bit.”

Yet surgeons say they leave their patients only during an unusually long procedure. “Surgeons don’t get a permit to operate on you and then go get a technician to do the surgery,” one surgeon says. “Surgeons stay the entire time. People deserve what they’re paying for, but to charge a doctor’s anesthesia fee for not doing the case -I think that’s dishonest.”

Ice says he charges the same fee whether he supervises an anesthesia or actually does one. “I’m still making the same decisions.” He believes students have to be left alone with the patient to some degree or they won’t learn to take responsibility for a case. “You’ll turn out a product to society that could be dangerous,” he says.

Harriet Waring, president of the Texas Association of Nurse Anesthetists and associate director of the School of Nurse Anesthesia at Harris Hospital, agrees. “The general public may never quite understand this, but it is important for students to work alone some of the time.”

Nurses are taught a hands-on approach to anesthesia, which Ms. Waring believes gives the nurse anesthetist more control. “Hands-on means looking, feeling, and touching. This way problems can be picked up immediately,” she says. Harris’ students have the advantage of using anesthesiologists as role models. “Our students walk out of our two-year program with both the nurse’s and the doctor’s approach to anesthesia.”

Many CRNAs consider the team approach to anesthesia to be the best system. “The bottom line is that the best anesthesia is when a group of people work harmoniously, each bringing their talents to the group-anesthesiologist and nurse anesthetist,” says one CRNA.

Various testimonies pieced together from the Shonia Crumpton hearings offer some insight into how team care and dou-and double-posting work. The actions of the surgical staff before the crisis and throughout the resuscitation efforts are not very clear because of conflicting information-information that may in itself help explain Shonia Crumpton’s death.

Ella Boren, the registered nurse and student anesthetist on the Crumpton case, was considered an excellent technician by one of her superiors – before the Crumpton surgery she had inserted endotracheal tubes in about 400 patients. In fact, her resuscitation measures were deemed so appropriate by Worrall that he allowed her to continue resuscitation efforts on her own without offering any oral instructions.

The sequence of events leading up to Miss Crumpton’s death began when the tube first dislodged. Ms. Boren noted the problem when the patient’s pulse rate varied slightly. She found the dislodged tube, reinserted it, and stabilized the patient. Worrall said he became concerned when the tube dislodged, so he relieved Ms. Boren and planned to stay with the patient throughout the remainder of the procedure.

Ms. Boren left the operating room to go home but returned 10 to 15 minutes later to offer any last-minute assistance. She was either asked or she offered (it was not clear) to get some more ethrane, the anesthesia agent used during Miss Crumpton’s surgery. When Ms. Boren returned, Wor-rall asked her to stay with the patient while he left to get a chair in another room. Before he left, Ms. Boren pointed out to Worrall that the patient’s pulse rate had slowed to 60 beats per minute. Worrall told her not to be concerned since the pulse had fallen before. (According to testimony, Miss Crumpton’s pulse had dropped earlier from a normal 100 beats per minute to 40 beats per minute, and Worrall had administered atropine, a stimulant, to bring it back up.) As Worrall left, Ms. Boren noticed the air bag that assists respiration was “compliant.” Then she was unable to get a blood pressure. The surgeon smelled ethrane, which indicated the tube was out, and the EKG went flat.

Worrall said he was there when the problem occurred, but that Ms. Boren was not. Ms. Boren said Worrall was not in the operating room at that time and that she had to have him paged. The surgeon recalled seeing Worrall in the operating room during the crisis, but a scrub nurse supported Ms. Boren’s testimony. Ms. Boren testified that when he returned, she asked Worrall three times if she should administer atropine before he finally responded affirmatively. Worrall testified that he had just given atropine (he had not told Ms. Boren) and delayed his answer in order to consider the advisability of a second dose. The scrub nurse testified that Ms. Boren headed the resuscitation process while Worrall was in the room. Worrall said he replaced the tube and began heart massage immediately.

Worrall testified that in an emergency everyone shares responsibility equally, and since everyone was responding appropriately, he saw no reason to direct the staffs efforts in reviving the patient. When asked who is responsible for anesthesia, Worrall testified that operating room procedures are a “team effort,” where everyone advises and keeps track of everyone else. But Krouse explained that the answers the medical examiner’s office received from the others in the operating room indicate they weren’t really watching out for the anesthesia; they were more concerned with their own duties.

Worrall apparently had a different understanding of the team concept than the rest of the surgical staff. According to Dr. S.B. Sells, research professor of psychology and director of the Institute of Behavior Research at Texas Christian University, when the conditions that favor highly-effective group operation are not well understood, problems usually result. “If a person is going to work with another person in a position of responsibility, each one has to understand the other one’s role,” Sells explains. “You can have the best players in the world and not have a good team.”

Although it was not the purpose of the Crumpton inquest to evaluate the medical system, Krouse said he believed the medical community would look into the matter. “What we should be doing is turning on the county medical society and the anesthesiologists to look into this.”

But the Tarrant County Medical Society (TCMS) claims its only real function is to approve memberships. “The society has no real power to tell a hospital what to do,” says TCMS’s executive director, Leo Benavides. “Hospitals are individual corporations that set their own standards.”

The medical society suggested that the Texas Hospital Association (THA) might have the authority to evaluate a hospital practice. But Joe DaSilva, director of public information at THA in Austin, explains that the association doesn’t actually provide standards to hospitals although they do support specific standards set forth by other groups.

Harris Hospital’s Quality Assurance Committee is conducting its own investigation into Shonia Crumpton’s death, but no official statement from Harris has been issued. In the meantime, more anesthesia-related deaths have occured, and surgeons and anesthesiologists are reporting an increased patient concern. Many surgeons are pleased to see consumer interest. “It’s going to take patient demand for quality, patients demanding knowledge,” says a surgeon. “If you start making them (the anesthesiologists) responsible for what they do, they’ll start being responsible. Because anesthesia is so routine, the anesthesiologists have become casual about it and that’s dangerous.”

Before surgery involving anesthetics, physicians suggest patients go over the following:

What is the policy of the hospital regarding double-posting?

What is the name of the anesthesiologist? Did the surgeon specifically choose him?

Tell the surgeon that you must meet the anesthesiologist before he puts you to sleep and that you want only single-posting.

Will the anesthesiologist stay the whole time?

A general anesthetic is almost always used for chest, head, neck, and upper ai dominai surgery. But depending on the patient’s condition and the type of surgery he is to undergo, a general anesthetic rna\ not be necessary or even advisable. For some patients, a local anesthetic or a spinal block may be a safer choice.

Although nerve blocks do prevent pain other intravenous sedatives such as valium (which does not prevent pain) are often added to the anesthesia treatment to relax the patient. But this intravenous sedation increases the anesthesia risk because it begins to affect the body in the same way a general anesthetic does.

One month after Shonia Crumpton’s death, 18-year-old Vikram Bajaj of Arlington, scheduled for routine wisdom tooth extraction, died from oxygen deprivation after an oral surgeon administered intravenous sedation before the local anesthetic. Bajaj was administered sublimaze, a short-acting narcotic, 50 times more potent than morphine. According to one nurse anesthetist, sublimaze depresses the respiratory system. “This is not an idiosyncratic effect (respiratory depression). It is an expected side effect,” she says. “Sublimaze should never, never be given without the proper [resuscitation] equipment, or without careful monitoring. If the anesthetist assists the patient’s respiration, the drug’s effect is harmless.”

One physician concerned about office anesthesia says, “Just because you’re not having the surgery done in a hospital doesn’t make the anesthesia safer. All anesthesias must be monitored.”

Before office surgery, patients should ask:

Does the office have the necessary resuscitation equipment?

Will someone monitor the sedated patient’s vital signs throughout the procedure?

In case of an allergic reaction, are the necessary medications to reverse the reaction kept on hand?

If the use of double-posting is even par tially responsible for some of the current anesthesia complications occuring in hospitals in this region today, anesthesiol ogists like Dr. Cyrus Worrall are merely products of the system, and patients like Shonia Crumpton are its victims. While the Fort Worth and Dallas medical com munities are searching for answers to ex plain why a healthy 17-year-old died dur ing routine surgery, perhaps the use of double-posting and team care in surger ies requiring anesthesia could be included in the investigation. As the Fort Worth surgeon critical of double-posting says, “I hope that little girl didn’t die for nothing.”

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