MedMal Confidential # 03 - US Healthcare's Dirty Little Secret

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Hey 👋- David here!

Happy May 1st to you and the other 6,505 Insiders reading this.

Here’s what we’ll be uncovering in this edition of MedMal Confidential …

Today’s ‘Insider Information’ At-A-Glance

Read Time: 2.6 minutes

🧠Musings: The 5 levels of sedation (and why they matter)

⚖Litigation: Blood Pressure Limbo - “How low can you go?”

📰News: US Healthcare’s dirty little secret

Read on for your insider info …

🧠Musings: The 5 levels of sedation (and why they matter)

When most people think of anesthesia, they think of it as a binary:

Option A: wide awake

Option B: snoring

But the truth is, there are levels to it:

1. Unsedated

2. Minimal sedation (anxiolysis)

3. Moderate sedation/analgesia (conscious sedation)

4. Deep sedation/analgesia

5. General anesthesia

There’s also numerous clinical factors being evaluated:

1. Responsiveness

2. Airway

3. Spontaneous ventilation

4. Cardiovascular function

Why does this matter?

Because complications arise from oversedation and airway compromise.

And some healthcare workers are much better trained to deal with it than others.

Take a look at the intervention required for different levels of sedation:

The Insider Info

• Anesthesia is a continuum, not a binary. And patients can reside at different levels of sedation at different points of a procedure.

  • The same medications may achieve drastically different results when used across different patients, illnesses, and ages,

  • “I always give this dose” and “My standard dose is” are obsolete concepts

• The intention to achieve a certain level is only half the equation

  • The final achieved level of sedation is more important

• Countless medical malpractice lawsuits stem from a failure to monitor and failure to rescue patients that go “too deep” on the sedation continuum

  • A team administering moderate sedation must have the skill and knowledge to “rescue” an oversedated patient…

    • Unfortunately, they often don’t.

  • A team administering moderate sedation must dose medication appropriately, be vigilant, and document accordingly…

    • Unfortunately, they often don’t.

Excessive sedation by an undisciplined team may lead to catastrophic patient outcomes, opening that team up to medicolegal liability.

⚖Litigation: Blood pressure limbo - “How low can you go?”

Let’s start with some blood pressure facts:

1. Blood pressure is a core “vital sign”.

2. Blood pressure is typically measured non-invasively (with a blood pressure cuff) or invasively (with an arterial line).

3. Blood pressure is recorded as systolic over diastolic and as mean arterial pressure (MAP).

4. The body, and especially vital organs, are perfused in accordance with blood pressure

Low Blood Pressure = Low Perfusion

1. Low perfusion to brain = Stroke

2. Low perfusion to heart = Heart attack

3. Low perfusion to kidney = Kidney injury

4. Low perfusion to the gut = Dead bowel

The Insider Info

• Intraoperative hypotension is treatable and preventable

• Altered mentation post-operation may be due to intraoperative hypotension, and should be examined

• Lack of timely and successful blood pressure intervention constitutes a breach in standard of care

Hypotension is a medical emergency, and the anesthesia team is responsible for intervening accordingly to reverse it.

📰News: US Healthcare Climate Change Failures

Healthcare generates an obscene amount of waste

In the US, healthcare accounts for 8.5% of its own greenhouse gas emissions, and 4.5% of the world’s emissions

And while US hospitals pay lip service to combating climate change, most barely manage to track their own emissions, let alone reduce them.

But the biggest obstacle to the above …

The policies and procedures mandated by The Joint Commission, which accredits 80% of US hospitals

The Insider Info

• In anesthesiology, the major source of emissions is the volatile anesthetic Desflurane

• There is a growing push to increase use of total intravenous anesthesia (or TIVA) via Propofol for both anesthetic and environmental purposes

  • TIVA administration is typically paired with use of the Bispectral Index (BIS) monitor to ensure sufficient depth of anesthesia, and to avoid intra-operative awareness

The US healthcare system has a long way to go in order to comply with the environmental mandates it allegedly supports.

In the next issue of MedMal Confidential …

• Penicillin Allergy Hyperbole

• Had a baby … now paralyzed?

• I’d rather be awake for my colonoscopy