A Penned Point
Every death related to anesthesia is a tragedy; even more so when a minor procedure such as a colonoscopy leads to a completely unexpected death. Everyone knows that open heart surgery carries a mortality risk, but few of us walk into the hospital for a colonoscopy thinking that death is a plausible outcome.
We know so few facts at this point about what happened on January 21 at Beaumont Royal Oak Hospital in Michigan. The patient who died, sources say, was a 51-year-old man who walked into the hospital for a routine colonoscopy. He was obese, with a BMI of 39, and suffered from obstructive sleep apnea, a common problem, where people snore heavily and their breathing may obstruct intermittently while they’re sleeping. Author Charles Dickens described a portly gentleman’s sleep apnea perfectly in The Pickwick Papers:
“His head was sunk upon his bosom, and perpetual snoring, with a partial choke occasionally, were the only audible indications of the great man’s presence.”
Sleep apnea is a risk factor for anesthesia complications, especially airway obstruction, but every anesthesiologist is taught how to recognize and manage it. With the obesity epidemic in America today, sleep apnea is part of daily reality in anesthesiology practice.
According to recent reports in Deadline Detroit by journalist Eric Starkman, who has reported extensively on problems at Beaumont Health, the patient was intubated by a nurse anesthetist who ordinarily worked at another Beaumont Hospital. At the end of the procedure, the nurse anesthetist removed the breathing tube, and the patient began to “thrash around”. It isn’t clear from reports if he was trying unsuccessfully to breathe or wasn’t breathing at all. The nurse anesthetist called for help from an anesthesiologist, and an emergency back-up team was summoned, but the patient went into cardiac arrest and couldn’t be resuscitated.
How could this happen?
We’re not likely to learn further details any time soon, as NorthStar Anesthesia has refused to comment. NorthStar took over the contract for anesthesiology services at Beaumont in 2020, leading to the resignation of a number of experienced anesthesiologists and nurse anesthetists who had worked there for years. Prominent surgeons, specialists, and nurses also resigned, according to reports, concerned that extreme cost-cutting measures would compromise patient care. Senior cardiologists wrote a letter in September, according to Deadline Detroit, expressing “serious concerns that Northstar will not be able to provide the quality of cardiac anesthesia services that we have received for several decades.”
“We oppose the concept that any Beaumont physicians can be considered replaceable commodities, or that corporate leadership can assume that we would blindly accept another group of physicians to care for our patients with life-threatening cardiac conditions,” the cardiologists’ letter stated.
In the context of this upheaval at Beaumont, we can ask these questions.
What kind of preoperative evaluation did the patient undergo before he was scheduled for his colonoscopy? Was it a cursory “clearance” by a mid-level practitioner, as opposed to a thorough history and physical examination by a physician? Did the patient have underlying heart or lung problems that weren’t noticed or treated in advance? Did the anesthesiologist have an adequate opportunity to evaluate the patient before the procedure began, or did production pressure not allow time?
Why was the decision made to intubate the patient, and who made the decision? Most patients who undergo colonoscopy receive sedation with medications such as midazolam, fentanyl, or propofol. They continue breathing on their own, without needing a breathing tube. Sedation can be safely managed even in the case of an obese patient with sleep apnea. Unless there is evidence of severe reflux, impaired stomach emptying, or bowel obstruction, intubation is rarely necessary and carries its own risks.
Were the nurse anesthetist and the anesthesiologist new to the hospital, and perhaps unfamiliar with the set-up and supplies in the endoscopy suite? Were they adequately oriented to the hospital’s resources before starting to work? Did they know where to find emergency equipment and how to reach colleagues for backup?
Was the nurse anesthetist working in an endoscopy procedure room located far from the operating rooms, where no other anesthesia professional was readily available to provide an extra pair of hands?
How many other locations and cases was the anesthesiologist responsible for at the time the patient’s condition started to deteriorate? How far away was the anesthesiologist, in terms of physical distance, and how long did it take to reach the endoscopy suite? The anesthesiologist should be readily available if the nurse anesthetist needs help. The standard for medical direction is that the anesthesiologist may be responsible for no more than four cases at one time. However, to cut costs, some employers may require one anesthesiologist to supervise six, eight, or more anesthesia locations.
Was the endoscopy suite adequately stocked with emergency airway equipment including supraglottic airway devices, laryngeal mask airways (LMAs), intubating bougies, and video laryngoscopy? Was succinylcholine available to treat laryngospasm? The right equipment and medications might have enabled the team to rescue the patient with no harm done, let alone a fatal outcome. They may have discovered only too late what was lacking.
Who’s to blame?
Every anesthesiologist has a healthy respect for obese patients and the risks of managing their airways. Though it may not always be easy to intubate these patients, extubation – taking out the breathing tube – may be even scarier. The patient may have a thick neck, a large tongue, and extra fatty tissue inside the mouth and throat, resulting in higher risk of airway obstruction once the breathing tube comes out. Ventilation by mask may be difficult or impossible.
If the patient isn’t breathing adequately or stops breathing, the oxygen level in the bloodstream will drop faster than it will in a thin patient. The time available for successful rescue is limited, and if there is no rescue, brain damage or death will be the inevitable result.
I will hazard a guess that the nurse anesthetist and the anesthesiologist will be blamed for this tragic death even though cost-cutting decisions made by hospital administration may be at the heart of what went wrong. They may have lacked experience; their training may have been less than first-class; but I guarantee that they didn’t go to work that day expecting to have a fatal outcome from anesthesia for a colonoscopy. I can only imagine their grief. Sudden, shocking adverse events in healthcare cause emotional trauma to everyone involved. It’s fair to say that they are victims too.
There are two frightening forces at work in healthcare today. One is the financial pressures that are threatening many hospitals with bankruptcy and leading them to sacrifice quality in order to cut costs. The second is the push to substitute nurse practitioners or nurse anesthetists for physicians, running the risk of putting these nurses in crisis situations that they aren’t trained to diagnose or manage. If an investigation uncovers the full facts in this case, it could turn out to be that the Beaumont patient was the victim of both.