Should operating room standard of care apply outside the operating room?

by Michael Wong

What happens when the accepted standard of care in one situation is not applied in another situation?

As a recent USA Today investigation indicates, the consequences to the patient can be deadly or debilitating. As well, it can be costly for the healthcare provider and facility found liable for damages.

(Please click on the picture below to view USA Today’s video. Note that the news video will be delayed by a commercial by USA Today.)

Take for example the case of Dr. Omar Brito who performed liposuction on Ms. Rohie Kah-Orukotan. According to Ms. Kah-Orukotan’s lawyer, Michael Freedman, she was rushed to the hospital and taken off life support about a week later. The cause of death, according to the Florida medical examiner, was “lidocaine toxicity”. In short, Ms. Kah-Orukotan died because of an overdose.

On the surface, this investigation is about doctors, who are, as USA Today puts it, “trained in other medical specialities, such as vision or obstetrics, but have branched into the more lucrative field of cosmetic surgery.”

However, more broadly, it is about the application of different standards of care. For example, if Ms. Kah-Orukotan had had to have her appendix removed, she would have found herself in an operating room with trained personnel and equipment being used that have come to be the accepted standard of care.

As Mr. Freedland explains, patients need to make sure procedures are “done in a facility with the equipment to handle an emergency” by people who are “properly trained to handle that emergency.”

“The past few decades have witnessed an accelerated growth in the number and types of procedures performed outside the operating room,” states the study by Drs. Julia Metzner and Karen Domino, “Risks of anesthesia or sedation outside the operating room: the role of the anesthesia care provider”.

there is an increasing trend among nonanesthesia providers (e.g. gastroenterologists, pediatricians, emergency medicine) to use potent sedatives/hypnotics/analgesics (e.g. propofol, remifentanil) for sedation, drugs once consecrated to the domain of anesthesiology. As these drugs have a narrow therapeutic window with a rapid progression from moderate sedation to general anesthesia, there is a safety concern when they are administered by nonanesthesia providers.

In examining the 2009 claims from the American Society of Anesthesiologists (ASA) database, Drs. Metzner and Domino found that “substandard care, preventable by better monitoring, was implicated in the majority of claims associated with death”:

Claims arising from anesthesia care in out-of-operating room locations had a higher proportion of death and were primarily caused by an adverse respiratory event (44%). Monitored anesthesia care (MAC) was the leading anesthetic technique, accounting for 50% of out-of-operating room claims. Respiratory depression secondary to oversedation and polypharmacy (propofol combined with other sedatives/analgesics) accounted for over a third of claims. A capnograph was employed in only a minority of claims associated with oversedation (15%), and no respiratory monitoring was used in 15% of these claims.

As this study concludes:

Sedation and anesthesia out of the operating room is an evolving practice that involves an increasing array of medical specialties, and not just anesthesiology providers.

So, what do you think? Should operating room standard of care apply outside the operating room?

3 thoughts on “Should operating room standard of care apply outside the operating room?

  1. What I find notable about this question is the source of the data upon which the question is based – civil liability claims, aka malpractice lawsuits. There are many in our society including an overwhelming majority of physicians who regard malpractice suits as nuisances which seek only to profit upon the ‘honest’ mistakes made by doctors. But consider the context of such mistakes here and then ask yourself: If these injured patients or their next-of-kin had not pursued civil liability claims against the physicians involved, how might the general public. medical regulators and others have ever learned that such events have been occurring?

    The answer is that this dangerous trend would simply have gone unnoticed, or at least would have taken far longer for the trend to achieve notoriety. Malpractice claims are about money, yes, but in essence the award of cash damages in civil cases acts as a substitute for the prison time which acts as a deterrent to wrongful acts in criminal prosecutions. But the goals of both civil liability lawsuits and criminal prosecutions are the same: to provide a disincentive to those who, but for the consequences of being ‘caught’, would more freely engage in conduct which is harmful to others.

    A highly publicized and very rare trial is in progress right now in Los Angeles; A physician, Conrad Murray, is on trial for manslaughter in the death of singer Michael Jackson. Dr. Murray is not charged because he intentionally killed Jackson but rather because the medical treatment he provided to Jackson was ill-conceived and outside the boundaries of the standard of medical care he was obligated to provide.

    What is most interesting is that the crime for which Dr. Murray is being prosecuted is centered, as were the purely civil lawsuits cited in the question posed here by PPAHS, upon his use of a sedating drug intended for use in hospital settings, in this instance propofol, in a non-hospital setting.

    Which raises an intriguing question: If Dr. Murray is facing substantial prison time for administering to his patient a drug intended only for hospital use, why were the offending doctors mentioned in this article only facing monetary damages in civil court proceedings?

    1. Bruce I was thinking the same thing. Immediately, Dr. Murray’s trial came to mind when I read this article. Probably the decision to try Dr. Murray in court that could result in prison time has to with who his patient was. It may seem crude of me but we’re talking about a powerful wronged family who has no interest in money. It’s important to keep in mind that people rarely sue for money but instead want to feel repaid and that the doctor was punished. In the Jackson family that punishment may only be acceptable as prison.

      I do believe that Dr. Murray’s trial should draw attention to how equal should standard of care be as well as which measures of determent will be used. However, I believe his verdict could be very well change everything. We’ll have to wait and see.

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