 Health care is extremely slow in adopting new technology, like really slow. A Texas jury awards $21 million to the family of a botched anesthesia case. Welcome back to the channel everybody. For those of you who are new around here, my name is Michael, aka Dr. Trilini, and I'm a board certified diagnostic and interventional radiologist. On today's video, we are going to be talking about a recent story that just broke in the news yesterday or so involving a 27 year old who went in for a routine surgery and was never the same again. Let's go ahead and get into it. So who is the patient and what happened? This case involves Carlos Rojas, who was an immigrant from Venezuela and was 27 years old at the time of this incident. He used to earn extra money by hanging Christmas lights and on one of his jobs, he fell off of the ladder and fractured his leg and to fix that broken bone, Rojas needed surgery, which requires general anesthesia and at the end of that routine surgery, he was unresponsive. Experts say that Rojas suffered permanent brain damage after a lack of oxygen to his brain during the operation. So how would something like this even happen? Well, it didn't happen when your blood pressure is too low for a certain period of time during the operation. However, a handwritten surgical record during this operation didn't demonstrate any drop in blood pressure at all. Although the nurse anesthetists actually gave Carlos multiple medications to help raise the blood pressure during the operation, starting to sound a little fishy. So let's break this down. First off, why is a place like Baylor Medical Center still using paper charts? Oh, and I forgot to mention, this took place at Baylor Medical Center in Texas. So why are they still using paper charts in 2022? Like, isn't everything electronic at this point? It's 2022. Well, not really. You see, healthcare is extremely slow in adopting new technology, like really slow and mostly because it's expensive. We still use pagers to contact people in the hospital, like a beeper. Here's a beeper or a pager for those of you who have no idea what I'm talking about. We still use fax machines to fax patient information and prescriptions. And yes, some hospitals even have paper charts still in 2022. In fact, my entire surgery intern year, we use paper charts. Like I was at a big academic hospital in New York City and we still used paper charts. We would have to hand write full page progress notes and then stand them into the computer. There was literally a person whose only job was to take all of our progress notes that we wrote and stand them in a computer. And now obviously we type almost every note at every hospital around the country, maybe except not Baylor. Or maybe it's just the anesthesia department, who knows? After all, I was writing paper notes in paper charts seven years ago, so maybe something's changed. So we should all be in the electronic medical records based by now, I'm assuming, but I digress. The point I'm trying to make here is that hospitals are way behind technologically. Also, who uses fax machines anymore? Okay, so now let's talk about what a CRNA is before we go any further in this discussion. A CRNA is a certified registered nurse anesthetist. And according to a quick Google search, they can administer and provide anesthesia and provide related care to patients before, during, and after surgery. Okay, so the logical next question that most people on Google seem to also wanna know is what's the difference between a CRNA and an anesthesiologist? Well, the main difference is a CRNA is a nurse and an anesthesiologist is a doctor. CRNAs must be a licensed nurse and have worked in an ICU setting for at least one year. And then they receive a three-year degree from an accredited nurse anesthesia program. While anesthesiologists have a four-year medical degree and spend a minimum of four years additional in residency training and sometimes even further subspecialty training in fellowship. So the most obvious difference between the two is the amount of training. CRNAs can also practice independently in 17 states and Texas is not one of them. In Texas, CRNAs must practice under a supervising physician. In fact, one physician can supervise four CRNAs at the same time. So four different CRNAs can be in four different operating rooms and be supervised by one physician or anesthesiologist. Okay, so let's get back to the case. So Rojas experienced low blood pressure during the case and was given medications to help raise his blood pressure. Per the attorney in the case, we believe they created the handwritten record in order to cover up what really happened here, which was that Rojas' blood pressure dropped and they didn't address it quickly enough to protect his brain. Apparently, like I said prior, there was an electronic record of Rojas' blood pressure, but evidence in the case showed that the hospital failed to save it. The CRNA responsible for this case also didn't monitor the patient's brain activity during the case, despite the fact that the head of anesthesia at Baylor requires this. Furthermore, the CRNA left the case for 12 minutes. Let that sink in. Now I tried to find some information on this, but I failed. I don't know if the media is trying to hype this up and make it sound worse than it is because CRNAs take breaks all the time and get coverage from other CRNAs or anesthesiologists, but if the CRNA actually left for those 12 minutes and there was nobody monitoring the patient, that's a problem, but more on that later. Either way, the result of this whole situation was an anoxid brain injury to Mr. Rojas, which left him in an irreversible vegetative state the rest of his life. So how does this happen? Well, he apparently had low blood pressure during the case, although we don't know how low, which means the brain wasn't getting appropriate blood flow to allow it to function properly. Just think of the brain as this monster that's like super hungry for oxygen and blood flow at all times. It has to get its blood supply 100% of the time all the time and blood carries oxygen. So you can imagine if you don't get proper blood flow to the brain, you don't get oxygen to the brain and the brain doesn't like it and it starts to die. And if the brain doesn't get oxygen for a certain amount of time and this goes on too long or a large area is affected, then you have an irreversible, devastating neurologic injury. Just like this. It's basically a stroke, but a stroke to your entire brain. So to sum it all up here, the lawyer stated that the hospital failed to preserve electronic blood pressure records in the CRNA that elected to monitor the brain activity during a two hour operation. Now, Mr. Rojas will unfortunately need 24-hour care the rest of his life. Okay, so as usual with these cases, it's now time to discuss a few things pretty quickly here. First, why did the CRNA allow the blood pressure to get so low during the case? And it has to be pretty low for a pretty long period of time in order to cause such a devastating effect like this. And honestly, I have no clue how this happened. This is like anesthesia 101. I'm not even an anesthesiologist, but I perform a lot of procedures with anesthesiologists and they are constantly monitoring blood pressure throughout the case, like all the time. They are consistently giving medications to help raise the blood pressure or lower the blood pressure and keep it in a specific range throughout the entire case if they have low blood pressure, they will elevate it to that range. If they have high blood pressure, they will bring it down to that range. And if you are a CRNA and you have exhausted everything you know in trying to raise or lower the blood pressure, the next step is to call these supervising anesthesiologists. In fact, that's what they're supposed to do. So I'm not sure why neither of those were done during this case. Speaking of that, where was the supervising anesthesiologists? I'm actually not sure where they were during this case. I do know that they were monitoring for other ORs at the exact same time, which is completely legal by the way in Texas. And when anesthesiologists are supervising CRNAs, they are usually present during the time of intubation and induction of anesthesia. They don't have to be there for the whole case. They can just kind of come in and out of the case as they feel and check on the patient and the CRNA and see how they're doing. And of course they will come in whenever the CRNA needs them. And they're also not actually very far away from the OR. They're probably in some office, like right outside the OR. So if you needed them, they would be there in a few seconds. They're not at some coffee shop, like down the block getting coffee or something while the CRNAs are doing that. Well, at least they're not supposed to be. I can't really speak for this case. The next thing I wanna talk about is what they could have done to prevent this from happening in the first place. And I know this is kind of a rhetorical question here, but this is why certain guidelines are in place to prevent things like this. The hospital required neuro monitoring during the case and that wasn't done. They also required electronic blood pressure documentation and that also wasn't done. Any one of these or obviously both of them could have prevented the result of this case. Next up is why the CRNA left the room for 12 minutes. Again, I'm not sure if this was to make the story sound more juicy than it is, but what I do know is that CRNAs and anesthesiologists leave the OR all the time because sometimes they have to use the restroom or take an emergency phone call or whatnot. And a CRNA or anesthesiologist always covers them during that time. For the longer procedures, CRNAs and anesthesiologists take breaks and they cover each other. So it's not uncommon for them to leave the OR and take a break. However, if the CRNA left for 12 minutes and didn't have coverage, that's the whole other issue here. That is overtly negligent. Again, anesthesia 101 here, never leave your patient. I actually did an anesthesia rotation in med school because I almost went into anesthesia myself and I'm pretty sure an attending told me something similar to that when I was on the rotation because all anesthesia is a balancing act. You're literally just balancing life and death with the use of medication. It's obviously more complex than that, but that's the root of it. And that's what makes anesthesia so crazy. And this is why going under anesthesia should not be taken lightly. Anesthesia is like the ocean. They're both powerful beasts and you have to earn their respect. Otherwise they can take your life at the blink of an eye. I don't know if that's a good analogy, but it's the best I could come up with up top of my head. And this leads me to my next point and the question you are wondering this whole entire time. Would I receive anesthesia from a CRNA over an anesthesiologist? My answer is honestly, I'd probably want a board certified anesthesiologist or maybe a CRNA with one-to-one supervision so that they were only taking care of me and the anesthesiologist was supervising them and only them. The one-to-four patient thing is a little much for my liking. The real reason here why I would prefer an anesthesiologist over a CRNA is because I'm more comfortable with them. I'm a doctor myself. I know the training that they have been through. I know everything I learned in residency that you can't be taught and how much knowledge and skills we acquired during that residency training. We have seen just about every possible situation and have seen anything go wrong that could go wrong and also how to fix it. It's that extra bag of tricks that you can't be taught in school. That Plan B, C, D, E, even F that we as physicians have in our back pockets that we use when things don't follow the textbook. There's anything I've learned in this business nothing ever goes by Plan A. It's always at least Plan B. And just because I prefer a doctor over a CRNA for my anesthesia doesn't mean I don't think CRNAs are capable of delivering anesthesia and delivering it well at that. There are plenty of solid CRNAs that I have personally worked with and know. To me, it's not a competition between the two. It's just what I'm personally more comfortable with. And that's how it should be for everyone. One of the lawyers in the case was quoted the following actually, as a result, it is our position while that may be good business for anesthesia partners, it is not good medicine because there is no way an anesthesiologist can supervise that many CRNAs at one time, the lawyer said. I think patients need to be apprised upfront that they have the choice to get an anesthesiologist who has four years of medical school, three years of training and board certified rather than a CRNA who may have a nursing degree and an extra year of training. The lawyer stated that the patient should have had a choice between an anesthesiologist and a CRNA, but he done it. And in conclusion, after all of this, I will leave you with this final statement from US anesthesia partners, the group that employed the doctor and the CRNA in this case. And it's quite an interesting statement. They said, we receive the jury's verdict and while we respect the civil justice system, we believe strongly that our clinicians provided the patient with excellent care. It's shocking to me how these staff can be grossly negligent and have a horrible patient outcome and then call it excellent care. If this is excellent care, I'd sure hate to see what poor care is. And that concludes this video, hopefully you all enjoyed it. Let me know in the comments below what you think about this case and maybe what you think about anesthesiologists and CRNAs. As always, follow me on TikTok and Instagram if you don't already. And as always, I'll see you all on the next video. Bye.