Attending Surgeries With Limited On Call: Who Will Have Your Back?

When attending to a weekend surgery at the hospital, make sure you don’t find yourself all alone with too much to do.

A 61-year-old patient was the only scheduled surgery on a Saturday morning, where he was to undergo an ERCP for suspected inflamed gallbladder/bile duct gallstones. The gentleman had Type 2 diabetes, major depressive disorder, essential hypertension, and a remote history of a CVA. Dr. A, the anesthesiologist for the surgery, classified the patient as ASA III and anticipated a difficult intubation.

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On the morning of the scheduled surgery, Dr. A — the only anesthesiologist on call at the hospital that weekend — learned that he was also to attend to a Cesarean section for a patient with failed labor.

The ERCP started at 8:15 that morning and after a difficult intubation, proceeded without incident. Surgery concluded at 9:25 but hospital staff notes at 9:35 showed the extubated, bag-masked patient in the PACU as unresponsive. Dr. A ordered new dosages of relaxant-reversals without improvement. Dr. A then re-administered a muscle relaxant and attempted to re-intubate the patient. When the reintubation failed, Dr. A was successful in placing a laryngeal mask airway. At 10 a.m. with the LMA in place and connected to a ventilator, Dr. A left the patient in the care of the nursing staff and respiratory therapists as he began general anesthesia for the Cesarean section in the OR next door.

With Dr. A at the Cesarean section, the GI patient desaturated and staff called the emergency room physician, who arrived at 10:05 a.m. According to his records, the ER physician noted no breath sounds or chest rise. The ER physician asked the staff to call Dr. A back to the PACU stat to re-establish an airway and to call any other available anesthesiologist – as well as a general surgeon in the event of a cricothyrotomy. The ER physician made several unsuccessful attempts to intubate the patient and began an emergency cricothyrotomy when Dr. A returned to the PACU. The ER physician asked Dr. A to assist in establishing an airway, but Dr. A stated he did not think he could do that successfully as he had previously been unable to re-intubate the patient and that he needed to return to the Cesarean delivery. The ER physician unsuccessfully attempted the cricothyrotomy and a Code Blue was called at 10:22 a.m. Another anesthesiologist arrived at 10:40 a.m. and successfully intubated the patient. The patient remained pulseless, however, and was declared dead at 11:07 a.m.

In a subsequent lawsuit, the family sued Dr. A for medical negligence and for patient abandonment. Dr. A and the family resolved the litigation without going to trial.

In his deposition, Dr. A testified that he advised the OB surgeon to speak to the GI surgeon regarding whether the Cesarean delivery could be performed first. No such change occurred. Dr. A also testified that staff was unable to get another anesthesiologist to take the Cesarean section or to get a surgeon for a possible cricothyrotomy.

Jurors expect physicians to make more than just technical medical decisions:  When a situation puts patient safety at risk, they will look for a physician’s assertiveness. These are the times for the “patient’s advocate” to be heard. 

 

Gordon Ownby is CAP’s General Counsel. Questions or comments related to “Case of the Month” should be directed to gownby@CAPphysicians.com.