Informed Consent Violation? Falsified Records

[zoey_d]

What is the name of your state? MA

Okay this is kind of a long post but I would appreciate any advice. Thanks!

I had hand surgery a few months ago. A week before the surgery the surgeon, anesthesia dept. and I all agreed that I would have regional anesthesia (axillary block). The anesthesia nurse rep did express some surprise at my choice of regional which I found inappropriate at the time. I made it clear to her that I had a fear of GA (which she noted on my chart). I signed an Anesthesia Informed Consent for Regional anesthesia with Monitored Anesthesia Care. On the morning of the surgery however, I was assigned a CRNA who was not qualified to do a block. I actually was not aware of this for the first 15 minutes I was in the pre-op area as the CRNA did not talk to me about the anesthesia. When the surgeon came in to mark my site, I asked him about the anesthesia and that is when he told the CRNA that I needed a block.

The CRNA then walked around the pre-op area looking for an anesthesiologist to perform the block. He asked 3 before he found one who agreed to do it. He and the CRNA performed the block then the anesthesiologist asked me to touch my nose. I was able to move my arm but lost coordination after I bent my elbow 90 degrees I lost coordination. The anesthesiologist declared the block complete and left the pre-op area. He never did a sensory or motor check of my hand and he was not present in the OR. About 10 minutes later I was wheeled into the OR. Ten minutes after that the surgeon (who also did not do a motor or sensory check on my hand) made the incision which I felt as if I had no anesthesia at all. I jumped and let him know I could feel what he was doing. The surgeon apologized then told the CRNA to put me under General.

The surgery was successful and I am happy with the result. I was however unhappy with what I saw as a lack of conscientiosness (or competence) with the anesthesia dept. I felt that fromt he very beginning that the hospital did not want to give me the Regional anesthesia. After speaking with my surgeon he implied that the anesthesia dept. prefers GA because it is easier. A day later I received a nice letter from the Director of Surgical Services inviting me to "share my dissapointments" about my surgery. I wrote a very nice letter detailing my concerns (and my excellent memory for events leading up to the surgery). He never responded. About a month later I complained to the Patient Advocate about my experience. She went to the Director for the results of his investigation (which he supposedly did after my letter). His investigation results were as follows:

1) Regional Anesthesia for hand surgery is rare so the CRNA assumed I would be having GA and didn't look at my chart.

2)It is common procedure to just lift the arm to test for numbness.

Both of these things did not make sense. The hospital's website even states that the type of anesthesia I was supposed to have ws "useful for procedures on the hand and wrist". And there are numerous regional anesthesia education resources that confirm that motor and sensory checks on extremities are supposed to be done before declaring a patient ready for surgery. I tried calling the Patient Advocate back. She was very nervous and evasive and responded to my questions about the above with "Well I don't know about these things".

So I got my medical records and my anesthesia chart did not have me down for an axillary block. Also the surgeon's operative report basically lies, saying that they discovered the block didn't work before the incision. The Nurses OR record backs this up and even says that my anesthesia consent type was for GA. (The verification time stamp
on this record shows the nurse modified the record 6 hours after my surgery ended). The pre-op record also does not mention the block or list the anesthesiologist as a case attendee. The anesthesia record has the wrong procedure type and from what I can tell does not even mentoin the block (only GA is checked off int he Anesthesia type box). The only indication that the block and my pain even happened is way down at the bottom of the anesthesia record (cut off on my copy but visible on the original) that says "8:50->incision->pain->GA". Other than that my records make it look like there were no complications at all.

Okay let me say that I am not looking to sue the hospital. I'm okay physically and aside from some trust issues with the medical profession I'm okay emotionally too. I know I really don't have a case worth pursuing and I'm sure the hospital realizes this too. So my question is why all the lies and falsified records? I mean the surgeon and I discussed what happened so he knows I remember being cut into and he acknowledged it to me. Why would he lie on the operating report. If I were the type I could report him to the Medical Board. And the nurse who changed her report? Why risk her license? And the hospital? Clearly they either purposely or in error, assigned me the wrong anesthesiology provider. Why not admit it? Am I missing some legal issue here? Did they violate my informed consent? Is that what they are worried about?

Some extra info: I filed a complaint against the hopsital with the Joint Commision and they responded to me the following day saying they would ask the hospital for a written response to my complaint and asked for permission to release my name and complaint.

 

[lealea1005]

Anesthesiologists/CRNA's rotate through surgical cases. It was probably the CRNA's turn with your case. He appropriately asked for, and received, assistance by the anesthesiologist. Was there a clause in your informed consent stating that general anesthesia would be given in the event that the block failed, or in an emergent sitaution?

 

[zoey_d]

Well I actually know an anesthesiologist at the hopsital and according to him, an anesthesiologist should have been assigned to my case if I needed a regional block. But I am okay with the scheduling error and I don't have an issue with the CRNA and what he had to do. My issue is with the anesthesiologist not doing a sensory check before handing me over to the guy with the knife. But even that I would be okay with if they would just respect me enough to admit that they were rushing and steps got missed. It's about respect and trust. Not all patients are looking for a payday - we want to trust doctors and hospitals.


To answer your question. There was a clause that said "Regional or local anesthesia may not be adequate in which case GA may be administered." And there was a clause that said that if there did need to be a change in anesthesia, I would be informed and asked for consent. That didn't happen but I understand the surgeon probably thought it was an emergency since he had already cut me. But that's my point. If everyone did everything right then why won't the hospital just say that. And why are the medical records made to look like there was no complication?

 

[zoey_d]

Oh and I also found out from my anesthesiologist friend that the company that the hospital outsources for anesthesia services is being sued for non payment of paychecks (my friend is out 50k - he used to work for that company). So beginning last winter the hospital took over anesthesiology but many of the anesthesiologists quit and things are kind of chaotic in that dept. There are not enough anesthesiologists apparently. So what I think happened is that they didn't have enough anesthesiologists so they tried to give me a CRNA (who could only do GA) figuring once the surgery was over, what could I do.

I can't prove that of course but it just seems like assigning a CRNA not qualified to do a block to a patient who had consented to one is an error that shouldn't happen at a hospital like the one I had my surgery at. I mean procedures should be in place for scheduling and protocols for what to do in case of a scheduling error. I mean my surgery began 10 minutes early even though the block was given at least 15 minutes later than it would have been had I been assigned an anesthesiologist who could do one. I have to wonder how that effected how much time was allotted for the block to "set".

 

[lealea1005]

Oh and I also found out from my anesthesiologist friend that the company that the hospital outsources for anesthesia services is being sued for non payment of paychecks (my friend is out 50k - he used to work for that company). So beginning last winter the hospital took over anesthesiology but many of the anesthesiologists quit and things are kind of chaotic in that dept. There are not enough anesthesiologists apparently. So what I think happened is that they didn't have enough anesthesiologists so they tried to give me a CRNA (who could only do GA) figuring once the surgery was over, what could I do.

I can't prove that of course but it just seems like assigning a CRNA not qualified to do a block to a patient who had consented to one is an error that shouldn't happen at a hospital like the one I had my surgery at. I mean procedures should be in place for scheduling and protocols for what to do in case of a scheduling error. I mean my surgery began 10 minutes early even though the block was given at least 15 minutes later than it would have been had I been assigned an anesthesiologist who could do one. I have to wonder how that effected how much time was allotted for the block to "set".

Couldn't your anesthesiologist friend answer that for you?

You already stated there was a clause providing for general anesthesia. Having the initial incision already made, and for your safety, the surgeon made the educated/experienced decision. Everything else you've heard through the grapevine is speculation.

 

[zoey_d]

He is one of the ones that quit so doesn't work at the hospital anymore. Besides I don't want to involve him or put him in an awkward situation as he still has friends who work there.

I realize I am just speculating (I think I even said that in my post

So do you have any idea why the medical records (operative report, OR nursing record) don't mention that the incision was made and THEN GA was performed. The operative report actually says the opposite. And why, if everyone did everything right, the hospital would say that regional anesthesia is rare for hand surgery and that sensory checks aren't done before surgery?

 

[MedMalDoc]

Hi--I'm new to posting on this forum but have read many of the posts because I am a physician that reviews medical records in malpractice cases.
I thought I'd jump in on this one since I am an anesthesiology resident. I'll try to answer your questions succinctly.
I see a great number of patients in pre-operative clinic that have strong feelings about the type of anesthesia that they receive. We always stress the point that although we attempt to do as the patient wishes, sometimes people don't qualify for blocks and need GA-other times just the opposite. I can assure you that this is done for pt safety. I have yet to see a consent that would not allow a provision for GA at the discretion of the anesthesiologist or surgeon. This is done for a host of reasons that are lengthy.
You are probably correct in assuming that the assignment of the CRNA was an oversight due to staffing issues. He responded correctly in getting a doctor to do the block. Blocks are not guaranteed to work!! That's one of the reasons GA must be in the consent.
The reason why he/she didn't do a sensory exam is because of the physiology of nerves. Once a block is injected, you don't test for immediate sensory loss--you test to see if the anesthetic was put in the right place. Confirming that you lost motor coordination would lead him/her to believe that it was in the correct place and should work--note the should.
Once the block is given--since it is not an infusion--if it doesn't work the only option is to repeat the process, which has its own set of problems. Even if an anesthesiologist was in the OR instead of a CRNA, the result would have been the same--GA.
As for the hospital saying that blocks are usually not done on hand cases ect...that depends. Our hospital does a reasonable number o blocks but the hospital down the street is nationally known for the number they do. It depends on howcomfortable the anesthesiologist is with doing them. In my experience, usually hand cases are done with a general. There are many reasons for this. One, there are two main nerves supporting the hand and unless the surgery is confined to one or the other, a regional block has to be done. Contrary to what many people believe, in many cases GA is much safer than a block and I would say that in your case (depending on your general health) this is absolutely true. Also recovery time is shorter, patient satisfaction is higher and there are fewer problems (which you experienced) with GA.
And last before I shut up is the question of testing the area in the OR. Once the patient is prepped and draped on the table, only the surgeon can test a local/regional anesthetic. This is usually done without the patient knowing about it (we use words other than test) because the patient can sometimes react just to the thought of pain. I'm not discounting that you felt pain but it may be possible that they didn't make an incision--they just tested and your block failed. This would put the speculation of falsifying reports to rest.
I hope that helps somewhat. Sorry for the verbose post.

 

[longsally111]

you know, what I dont understand is if you are ok and you are not going to sue, why are you worried? Move on

 

[zoey_d]

Resolved!

I realize that this is a long time in coming but thanks MedMalDoc for a real answer instead of a snotty dismissal of my question. I appreciate it.

Also to update I actually found a note at the bottom of the anesthesia record that corroborated my recollection of the surgery. By using this I was able to get the surgeon to admit that he did indeed cut me open w/o adequate anesthesia and then he put me under GA.

Also I understood that GA might be necessary but I also understood that I would be notified of the change and could refuse anesthesia or the surgery at any time as long as the situation wasn't emergent. The surgeon should have asked me for consent before putting me under or tried to augment the block but that would have taken more of his precious time. I had the right to refuse GA. Consenting to regional anesthesia that might not work is NOT the same as consenting to GA.

And longsally111: The reason I didn't "move on" is because doctors shouldn't lie. I didn't sue him - I just got him to admit what he did (so maybe he won't do it again to another decent human being) and then I "moved on" to a new doctor who I can trust. BTW, you're a tool.

 

[ecmst12]

Stopping the surgery after beginning to cut is not really an option in most cases. Is that really what you wanted? Or is it that you just wanted to be ASKED if GA was ok rather then the dr just using his medical judgement and ordering it?

 

[longsally111]

zoey, if all you wanted was an admission, then you got it amd MOVE ON!!!!!!!!!!!!! Instead, you continue to update and post on a SUCCESSFUL SURGERY!!!!!!