Patient dies during routine colonoscopy after cost-cutting 'private equity' anesthesia takeover

In April 2020, Beaumont Health, Michigan’s largest healthcare system, made the decision to terminate its established anesthesia group in favor of Texas-based NorthStar Anesthesia, a private equity firm that promised the health system lower staffing costs.  According to reports, more than a dozen physicians and surgeons resigned from the hospital system due to concerns over NorthStar’s reputation.

NorthStar’s contract began on January 1 of this year, and on January 25, Eric Starkman, a reporter at Deadline Detroit, reported the death of a patient due to an anesthesia-related complication during one of the most routine medical procedures: a colonoscopy. 

Did the replacement of Beaumont's anesthesia team by a private equity firm contribute to the death of this patient?  Not only is Beaumont not talking, but according to reports, staff members are being threatened and intimidated into silence.

To help us we will discuss how private equity takeovers in medicine may be harming patients, and what you can do to protect yourself, we are joined by Karen Sibert MD, Clinical Professor in the Dept of Anesthesiology and Perioperative Medicine at UCLA, and a past president of the California Society of Anesthesiologists.

Dr. Sibert's advice to all patients undergoing anesthesia: "Ask, 'who is my anesthesiologist?' And if the answer is, 'there isn't one,' they should leave."  Further, "if there isn't a physician overseeing your anesthesia care, I can't reassure you that's going to be a safe situation. I think that every patient has a right to know who is taking care of them. There should be complete transparency, and I think physician-led care is the safest care."

Get the book!  https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/

Dr. Karen Sibert's blogs:  https://apennedpoint.com/how-could-a-patient-die-from-anesthesia-for-a-colonoscopy/ 
https://www.kevinmd.com/blog/post-author/karen-s-sibert

One of our personal favorites, which we cite in our book: https://www.kevinmd.com/blog/2011/11/unsupervised-anesthesia-care-nurse-anesthetist-threat-patient-safety.html

PhysiciansForPatientProtection.org

Transcript

Rebekah Bernard MD: 0:00

Welcome to'patients at risk' a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm Dr. Rebekah Bernard, and I'm joined by my co host and the co author of our book patients at risk, the rise of the nurse practitioner and physician assistant in healthcare.

Karen Sibert MD: 1:15

issue here. The issue is what kind of collaborative or supervisory model you're working under. And when that model is working happily for everybody. I think the anesthesia care team is incredibly safe. it's when nurse anesthetists are asked to substitute for anesthesiologists or when even worse, when in an effort to cut costs. anesthesiologists are asked to supervise more nurse anesthetists than is really feasible or safe. That's when problems can occur. And that's what we're wondering might have happened in this case. And so you recently blogged about this scenario that just happened. And of course, I know you weren't involved in the care of this patient. So you're just speculating based on what you've read in the media. But can you tell our listeners a little bit about the situation and this tragic death of this patient during a colonoscopy, I really can't in the sense that I don't know anything firsthand about what happened. What I can tell you is that everyone is under tremendous stress and even threat from NorthStar not to speak publicly about this case. And as I understand it, people have been threatened with the loss of their jobs. So really, all I can say for sure, is that a decision was made to intubate the patient which means put a breathing tube in and that may have been done because the patient was obese. He was we are told six foot one and 300 pounds. Now that's not actually morbidly obese, that's only a body mass index of 39, which is getting up there but we 39 is a blip really these days. We take care of patients with a BMI of 39 all the time and that wouldn't necessarily be perceived as a requirement to intubate. So I don't understand why the decision would have been made to intubate. Typically colonoscopies are just done under sedation.

Niran Al-Agba MD: 5:11

And I understand I think it's great. We don't even have to talk about this case just to answer some basic questions. For some of us like pediatricians who maybe don't aren't involved with colonoscopies very often, you know, what percentage just on average of colonoscopies that you've participated in? Or how common is it that anesthesia is participating in a colonoscopy? Maybe that's a better question to ask just at the front end.

Karen Sibert MD: 5:34

It's getting to be more and more frequent in the last 20 years, and that's very simply because of the invention of propofol which really came into clinical practice about 1990. Many gastroenterologists grew up just using nurse given sedation for colonoscopies, that would be medications like Valium, or more recently Versed, Fentanyl or Demerol and so it was sort of conscious sedation or twilight or whatever word you want to use, patients would drift in and out a little bit. Occasionally they'd feel some discomfort, but that was the norm and some patients even choose to undergo it with no sedation whatsoever. That's just a personal choice and it depends on personal tolerance of discomfort.

Rebekah Bernard MD: 6:13

Yeah, Nowadays most people get some kind of sedation propofol or something but not they don't generally get intubated, like a like a general anesthesia. Like if you were having an operation, right?

Karen Sibert MD: 6:24

Correct that but propofol is an anesthetic drug. So a regular RN in a gastroenterologist office cannot give propofol. They just they're not allowed to do it. So there should be an anestheiologist or nurse anesthetist administering propofol? That's correct. So propofol is it's an incredibly useful drug, but it depends on how you're administering it. And really small doses you can be conscious and still be receiving it and so it's used a lot at low doses. For example, for ICU patients to kind of lightly sedate them. The more you give, the more crosses the line into complete unconsciousness. But even though we may be using enough propofol to make people unconscious for a routine colonoscopy, usually they would still be breathing on their own. And it's very, very rare to intubate someone for a routine screening colonoscopy. That's not the situation where you might be taking care of an inpatient who has a belly obstruction are someone who has delayed gastric emptying from severe diabetes, or something like that. But for a healthy outpatient who walks in from the street for routine screening colonoscopy, I would say it's it's really rare to intubate.

Rebekah Bernard MD: 7:38

so this person had sleep apnea was part of his history is what we were told we're told in the reports, and so perhaps that contributed to their decision. But what we do know from the reports is that when they went to extubate him or remove his breathing tube, things started to go poorly at that point. And what the report from the media was that he quote, began to thrash around, and then stopped breathing. And that at that point, the nurse anesthetist called for the supervising anesthesiologist to come and re intubate the patient, but they were not successful. So is that a scenario that I'm sure you've had that scenario happen in your practice where you've had someone where you've taken the breathing tube out, and they've had trouble breathing? Is that fairly common?

Karen Sibert MD: 8:28

No, it's not. In fact, my whole job is to try to make sure that people are getting ready when they get the breathing tube taken out. In fact, I would say that in terms of obese patients, and certainly morbidly obese patients, they can be tricky to intubate. But I worry far more about extubating them than to do about intubating them because that is the point where they're probably at the highest risk of getting into problematic airway obstruction. And if they do encounter airway obstruction, the level of oxygen in their bloodstream, you know, their oxygen saturation will plummet far more quickly than a thin person as well. So it's just a riskier business all the way around. And that's one of the reasons why well managed, relatively light sedation can be a much better choice for colonoscopy and the obese population.

Niran Al-Agba MD: 9:19

Can you talk to me again, separate from the case per se, but you said something about when you extubate an obese or morbidly obese patient, there's things you look at to make sure they're ready? What kinds of things would those be?

Karen Sibert MD: 9:32

Sure. Well, it depends if the person giving the anesthesia and this is just true for every case, if they have given a muscle relaxer, and that can be something like succinylcholine or other types of muscle relaxants, then we use you have to make sure it's gone, either in the case of succinylcholine worn off completely, or on the case of other kinds that you've used a reversal agent to get completely rid of them because if the patient has any residual muscle weakness that can impair their ability to breathe. And of course, it's going to be worse with an obese patient than with a slender patient. We look for - we measure their tidal volume, we measure their respiratory rate, we we look at all kinds of different variables to assess readiness for extubation. You know, whole chapters and articles have been written on extubation criteria, complications after extubation, all kinds of things. And so, you know, that's a that's a really huge part of my job is expertise in determining even for sick patients or high risk patients. Are they ready for extubation? Or are they not? Because premature extubation, or extubation of the patient who's still weak from residual muscle relaxant can be catastrophic. And I don't know that that's what happened with this patient. But it would certainly be in the differential.

Rebekah Bernard MD: 10:52

You've said in your writing Dr. Sibert, that anesthesiologists are a victim of their own success in anesthesia because anesthesia has come so far. I mean, when it first came out, the nurse anesthetist like to say that nurses were the first to give anesthesia on the Civil War battlefields and, and I read an article that said, Well, back then anesthesia was delivering ether through a paper cone. And now we have all these machines and monitors and, and there's been so much scientific advancements, that those of you guys who know what you're doing, make it look like it's so easy, but it's really not. It's extremely complicated. And even though things don't go wrong, very often, when they do go wrong, you only have seconds to respond. And you know, that's a matter of life and death.

Karen Sibert MD: 11:39

I think that's all very fair to say, the monitoring has has really improved the safety of anaesthesia tremendously, there was just a nice review article in JAMA that talked about how mortality from anesthetics has gone down from one in a 1000 to one or two in hundreds of 1000s of patients now when you're talking about mortality directly related to anesthesia, and we take a great deal of pride and credit for that, because inventions like pulse oximetry, and tidal co2 monitoring, and the fight to get those universally implemented, because people who've wanted to cut costs, didn't want to use those either. You know, They just felt like, Well, we've gotten we've done without this all these years. Why do we need it now? Well, we do need it now. But nonetheless, there's an element of art and judgment and experience that goes into so many medical decisions. And anesthesiology is, is no different. And you can't teach that. And some people seem impervious to learning it. Most do. But if that's not there, you can get into trouble no matter how good your monitoring equipment is. But you can get into worse trouble. If for example, your institution might not have end tidal co2 monitoring in an endoscopy suite, or they might not have every resuscitator drug you might want to have they sometimes the equipment in endoscopy suites is woefully less than what you would find in an operating room, even though you may be doing anesthesia, just like you would do in an operating room.

Rebekah Bernard MD: 13:11

Well, those were some of the points that you made in this article that you recently wrote where you were discussing this tragic case of the patient who died. And again, we don't know all the circumstances. But we do know that they the nurse anesthetist called for the anesthesiologist who was in charge to come, they attempted to re intubate the patient, and then they were unsuccessful. They called an emergency backup team. But at that point, the patient went into cardiac arrest, and from that point, could not be resuscitated and passed away.

Karen Sibert MD: 13:41

So let me let me say that we don't know that. We have been told -

Rebekah Bernard MD: 13:46

The media reporting.

Karen Sibert MD: 13:47

Exactly. So I would just emphasize that this is what reports have said. And I don't know that we know that any of those things are true, we know I think we can conclude that the patient died after the procedure had ended before being successfully awakened from anesthesia. And that's about as far as I would feel comfortable, right? We'd feel comfortable knowing I don't know, where the anesthesiologist was how far away how long it took to get there, that you know, there's just so many questions. And that was what my blog really tried to emphasize. We have so many questions that so few answers, right? It does underscore the fact that anesthesia, there are minor procedures, there are no minor anesthetics.

Rebekah Bernard MD: 14:28

Very good point. Right. So some of the points that you made were exactly what you were saying is, you know, we don't know how far away was the anesthesiologist. How familiar was the new that were the new staff with working in this facility when this is this company just took over less than one month ago? We don't know the answer to that. We don't know how comfortable the anesthetist and the anesthesiologist were working together. So those were some of the things that you brought up, and I think they were you know, very fair points. Ask and we do know from reporting that there were some concerns about this new anesthesia group taking over. And we know that private equity getting involved in anesthesiology among other parts of medicine has become a greater and greater phenomenon and you've written about that in past blogs. What are your thoughts when you see that this is sort of a new a new setup that's taken over in town?

Karen Sibert MD: 15:22

I find it really alarming and distressing, to be honest, this is happened over and over again, that's happened in my state, California. It's happened all over the country, that a private equity group a corporation will underbid the contract of an established anesthesiology group that may have worked in its hospital for 30 years or more, and underbid the contract and some administrator decides, well, this is a good idea because this is going to save us a whole lot of money and maybe provide us with better service. Maybe they won't cancel cases as much. Maybe they'll speed up turnover. Who knows what promises were made, they displaced the established group. And if the hospital was employing nurse anesthetists, they will offer the nurse anesthetists the opportunity to join the new entity, but if they don't want to join them, they lose their positions. The anesthesiologists, they may or may not offer positions to because very typically, the model is that they will want far fewer anesthesiologists that were there before and higher ratios of supervision were the standard of care for medical direction. You know the the CMS Conditions of Participation are that you can only supervise up to four cases at a time, but they very often will not seek to meet the Medicare Conditions of Participation for medical direction. And they'll have one anesthesiologist tried to supervise 6, 8, 12, who knows how many anesthetizing locations? And I'm sorry, you just cannot provide immediate backup or, frankly, any kind of reasonable oversight of that many cases at a time.

Niran Al-Agba MD: 17:06

What would you say? is one of the safest? Or is the safest or best ratio? What do you find ideal in this kind of situation?

Karen Sibert MD: 17:13

That's really impossible to answer. I mean, there have certainly been times when I had something like a patient with a septic abdominal aortic aneurysm that we're going to take out where I fit this is it's one to one, you know, I cannot, I cannot really do anything else until we get through some of the critical portions of this case, at most academic centers, they adhere to the one to four ratio, it is possible depending on how your operating room is configured. And some very forward looking groups are moving to a situation where, for example, anesthesiologists aren't really linked to specific operating rooms, they monitor from a central sort of command station, and have anesthesiologists free to go to whatever room at whatever time is either starting the case, or perhaps encountering some kind of difficulty bleeding or whatever in the middle, somebody is always there to wake up. So it's not a direct, my name is associated with this case, in sending this bill situation there. They're providing more zone coverage. And frankly, I think that that can be safe, depending on the equipment and the monitoring capabilities and the wireless capabilities in your operating suite. And I think that's probably the way things will tend to evolve because we really want the right care in the right place at the right time. And artificial ratios can't really ever meet that one to four can be way too many. And you know, one to eight might be fine with the right monitoring capability. I think these ratios are very artificial. And they stem from billing, rather from any actual care need at that time, if that makes sense.

Rebekah Bernard MD: 18:51

Dr. Sibert, you've written some pretty amazing articles both Niran and I love your writing. And I look I took a look at some of them again recently, you wrote an article back in 2015 called'will your anesthesiologist

leave the OR: 19:04

patients deserve to know' and you talk about it that your opening statement is the fact is anesthesia is dangerous. And we've made huge strides when a person is unconscious. There's always a risk involved in induction and what's it called when you take them out of anesthesia?

Karen Sibert MD: 19:22

Emergence

Rebekah Bernard MD: 19:23

Emergence. You can tell I'm primary care doctor - so induction and emergence are the most dangerous times usually right in anaesthesia.

Karen Sibert MD: 19:32

A lot of people make the analogy to airline you know to pilots, that takeoff and landing are the most risky parts of the procedure. And most operations, particularly long ones will have a long, steady sort of cruising altitude when it's very unlikely that anything is going to change acutely unless something happens during the course of the surgery. So that's Yeah, it would be flying the plane in that case as long as the pilot is nearby in case God forbid something unusual happen. exactly and that's how we supervise residents. And we're training residents, the usual, the usual ratio was one to two

for residents. And then 1: 20:09

2, 1:3, or one to four for nurse anesthetists and most I would say, most academic hospitals. So and that is the actually the standard for residency training that the residents must be supervised one to two. So there's never going to be a situation that I'm going to be in the room all the time, because there's only one of me. But the point is that they're supposed to stay in touch. First of all, even when I'm in my office, I have a monitor that I can watch what's going on, I can literally see the anesthesia record and the vital signs every minute in both operating rooms. And I can communicate with the person and say, 'Okay, do this now' without having to even pick up the phone, you know, just send them a text message right there on that on the screen. And then you know, I follow the case, I know when to be there. Obviously, I'm there at the start, I'm there at the finish, and I'm there anytime in between that's necessary. And it is a safe model. But patients do need to have that disclosed. So in an academic hospital, for example, the patient would meet the resident and meet me. And occasionally they will ask me, are you is this going to be your only room? And I say, No, no, I will be supervising a room nearby. But I'm immediately available at all times. And that's just the truth. And people who are very unhappy with that typically don't go to teaching hospitals. But on the other hand, if a patient if we have the staffing and you know, I could do the case solo, I'm delighted to do it. But there is the care team model is pretty standard across the board. It just has to be done right.

Niran Al-Agba MD: 21:42

You talked about two forces at work in healthcare. Towards the end of your blog post, which I found really interesting. We kind of brought it all to a focused area, which is basically the financial pressures that are threatening many hospitals with going under going bankrupt. And the second was obviously the part about substituting nurse practitioners or nurse anesthetists for physicians. And I guess if I could start with the former, if you were in charge, if you were running your own hospital, how would you mitigate the risk of bankruptcy? How would you do it maybe differently than what we're seeing at North Star or Beaumont or some of these other hospitals?

Karen Sibert MD: 22:18

Wow, I, I don't know I'm not the finance person. I do think that when you look at the numbers of administrators and hospitals, and how they have gone up and up and up, and there aren't good data about that scene, it's really kind of alarming. The ratio of administrative staff to clinical staff has done nothing but climb. And the money that some of those people are paid compared to people who are actually at the frontlines taking care of patients, really does seem to me sometimes kind of obscene. So that would be about the first thing I do is trim some of the administrative staff. On the other hand, and in fairness, I think government regulations have become so onerous, and compliance requirements have become so onerous that that has been the cause of a lot of this administrative bloat a state of government over regulation that practically leads to paralysis, and just clicking a boxes rather than actually focusing on patient care. So I would that those are the things I would really want to start with. But it's really sad, people just don't seem to understand that in life, you get what you pay for. And you don't go to the second hand used car lot, and get a Yugo, and think it's gonna run like a Mercedes. It's just, you just don't, you know, Louis Voittens and Keds are different, different functions, but they seem to think that you can just take a physician whether it's in primary care or pediatrics, anesthesia, and just plugging into a slot and turn the switch on and they'll run and they'll run and one will run just as as well as the next and I think you know, and I know that that's silly, I mean, you don't go to a car mechanic without looking into their background you know, it's certainly not gonna - or a hairdresser without a recommendation from somebody and yet people will walk in and you know, are these administrators will just assume that they can get some locum anesthesiologists from God knows where and there'll be just as good as the one they just let go.

Rebekah Bernard MD: 24:30

or replace it with a person with far less training. And one of the things that I loved in the article that I was talking about earlier was that you cited Dr. Jane Fitch. She was a former president of the American Society of anesthesiologists and what's interesting about her was that she was a crna. And then she decided to go back and went to medical school and did her residency another eight years and that was because she said, quote, I didn't know how much I didn't know And I think that's that is such an important statement. And that's what we hear a lot from nurse practitioners or pa or nurse anesthetist who go on to go become physicians is that they didn't realize that the lack of knowledge that they had

Karen Sibert MD: 25:12

Well, it's it's so true being I certainly have huge gaps in my knowledge what pediatrics I used to know I don't think I know anymore although I managed to raise children. But the fact is that that you don't know what you don't know. And I was so struck reading your book with the the story of the of the young woman with the pulmonary embolism. And so my husband said today, he said, Well, who are you going to be talking to this afternoon? And I said, the woman that wrote this book, and he said, well, what's it about? My husband's also an anestheseologists, by the way, he's the chief of cardiac anesthesia over over at USC. I said, Well, it's about the scope creep. But it's also weaves in this really fascinating and sad story of a 19 year old girl who walks into an emergency room with tachycardia, shortness of breath, a drooping oxygen saturation, and she'd been on birth control pills. My husband's goes, Well, Duh. Because experienced physicians who've learned the art of differential diagnosis can just plug in those variables. And, you know, develop out a list of possibilities. But always be careful to go for the one that could kill you first. And then once that once been ruled out, then we can go to other ones. And that just doesn't seem to be either the training or the mindset of people with less skill. And this is what frightens me about having pre op clearances done by by non physicians is that now if I get a piece of paper, a prescription pad with cleared for surgery written on it, that's pretty worthless, I don't care who says it, that tells me nothing. It just tells me that you think the patient can fog a mirror. Well, I can probably figure that out for myself. But if I get a reasonably thorough history and physical, from a physician, I have some confidence that at least on a surgery rotation, internal medicine residents, and I just watched my son go through this last year, he spent weeks two months on a consultation service, where he was evaluating patients to assure their their optimization for surgery, not just if they're ready, but you know, I mean, not just if they're alive, and here are the medications they're on, and here's their H&P, but are they are they optimized for surgery, and that is a far more complex issue. And that's where I feel grave doubts about the ability of non physicians to provide me with the level of information I need for even for routine cases, let alone complex cases, like the thoracic and vascular cases that I often give anesthesia for, I really need to know what's going on with those patients. For example, do you think the average non physician in a primary care setting would know the why it matters to me how long ago a patient had their heart transplant? I mean, a lot of physicians don't even know that. But internist probably do, simply because the heart immediately after a heart transplant won't respond to anticholinergic medications. So if that patient develops a severe bradycardia, after glycopyrrolate, and those are drugs that we used to use every day in the reversal of muscle relaxation. So these are fun points, but they can be deadly. If they're appreciated, fine, don't have that sort of complete data set. It makes life really hard.

Rebekah Bernard MD: 28:43

Well, thank God, you know, all that. And thank you for mentioning our book. And in fact, we mentioned you in our book, and we use some of your quotes from this article. And I just wanted to in our last few minutes, I wanted to mention a couple of things that I learned from you that I thought were so interesting, which was how the standard is a little different for the masses as it is for our perhaps our elected representatives. And you pointed out that President Bill Clinton's mom was a nurse anesthetist and President Clinton signed into law in 2001, a rule allowing states to opt out of the requirement that nurse anesthetist be supervised by a physician. However, when Clinton was having his heart surgery, he had a cardiac anesthesiologist physician in charge of his anesthesia. He was not opting out for himself. And the same for Governor Arnold Schwarzenegger in California who signed a letter in 2009, allowing the state of California to opt out. Somehow when he had his heart surgery, he wanted an anesthesiologist in charge. So I think that this is this is a very interesting and ironic point that these same politicians that are saying it's okay to have surgery from a nurse anesthetist, in charge of your care did not make that choice for themselves.

Karen Sibert MD: 29:58

Well, that is absolutely correct. And by sheer coincidence, the anesthesiologist who put the governor Governor Schwarzenegger to sleep just happened to be my husband. So I know a great deal about that case.

Rebekah Bernard MD: 30:15

I think that's why patients need to know this information and patient know whether who's in charge of their anesthesia. Is there a physician involved in what what should patients know? And what should they ask if they're having surgery?

Karen Sibert MD: 30:27

they should ask, Who is my anesthesiologist? And if the answer is there isn't one they should leave? That would be that would be the start. Okay, um, I think the care team is great. I work with nurse anesthetists and residents in a coaching model all the time, that patients know who I am, they get my business card, I'm accountable, I'm reachable afterward if they want to. And if you're in a situation or a facility, where you don't have a physician overseeing the anesthesia care, I can't reassure you that that's that's going to be a safe situation. I really, it might go fine. And it might not. But I think that every patient has a right to know who's taking care of them. There should be complete transparency. And I think physician led care is the safest care.

Rebekah Bernard MD: 31:19

Thank you so much. I want to thank Dr. Karen Sibert, for joining us for this fascinating discussion. To learn more about this topic, please get our book patients at risk the rise of the nurse practitioner and physician assistant in health care. We also encourage you if you're a physician and you'd like to learn more about promoting physician led care, please join our organization physicians for patient protection, our website physicians for patient protection.org Please Subscribe and listen wherever you listen to podcasts and to our YouTube channel patients at risk. Thank you so much and thank you again Dr. Sibert.

Karen Sibert MD: 31:50

It's been a pleasure