In this episode, I speak to Kristen Hull, a CRNA. CRNAs are the elite of nurses, and some of the brightest even among APRNs. Kristen explains what her role is in the OR, and how CRNAs may more readily identify issues in the O.R. procedures. We talk about issues affecting CRNAs specifically, and about documentation and continuity of care from the OR to recovery
In this episode, I speak to Kristen Hull, a CRNA. CRNAs are the elite of nurses, and some of the brightest even among APRNs. Kristen explains what her role is in the OR, and how CRNAs may more readily identify issues in the O.R. procedures. We talk about issues affecting CRNAs specifically, and about documentation and continuity of care from the OR to recovery
This is episode 15 of your MedMal podcast, discovering the needle nurse consultants help you discover what you didn't know that you didn't know about how to win your medical malpractice case. In this podcast, we look at anonymized true examples of how a behind the scenes non testifying nurse consultant was able to quickly locate. Isolate and articulate the core issues in common and not so common medical malpractice scenarios using his or her nursing expertise to save the firm upfront costs resulting in higher profits and higher compensation to your deserving client. If you're new to our podcast, welcome, you can learn more about how behind the scenes legal nurse consulting can improve your firm's win rates and profitability. By following us on LinkedIn or visiting our website@wwwdotnplegalconsultants.com. By following our weekly podcast, you can use your commute to sharpen your own standard of care issue, spotting and causation narrative skills. Grow your virtual Rolodex of top nurse consultants of all specialties and discover the med ma plaintiff attorneys secret weapon for slaying the medical corporate giant it's time to discover the nurse consultant advantage. Let's get started. Today our guest is Kristen Hull. Welcome Kristen.
Kristin:Thanks. Thanks for having me.
Elisa:Tell us about your clinical background to start us off.
Kristin:I've been a nurse for 15 years. I have known since I was very, very little girl, I wanted to be a CRNA: certified registered nurse anesthetist. I had surgery when I was 12 years old; I loved my CRNA. I knew I wanted to be a CRNA. My mom was a nurse. So I went straight to get my bachelor's out of high school. I worked for several years. My background initially was in cardiac step-down; did some ICU training: heart and lung transplants, crashing patients on the ECMO, lots of high adrenaline ICU work. It was extremely good experience.
Elisa:Yeah. CRNAs usually require some level of intensive care nursing prior to going in, right? So you entered that space knowing,"Okay, I have to jump through these hoops and I've got to have these experiences."
Kristin:I was a nurse for five years, went to CRNA school; I've been practicing as a CRNA for 10, then the rest is history.
Elisa:You still didn't know you were gonna wind up doing legal nurse consulting?
Kristin:I didn't. I had a bad experience when my son was born. That kind of brought me into the space, and I thought,"This is a great place to advocate for people who are not able to have the voice that they deserve and get the care that they deserve." So through that trauma that we lived, to be able to help others on the other side.
Elisa:Kristen can be reached at her webiste at themisnurseconsulting.com. That's T-H-E-M-I-S- nurseconsulting.com. Yeah, CRNA, even other APRNs consider that the elite in nursing.
Kristin:It was brutal training, but totally necessary for the type of work that we do. I loved all of my training. We went to 18 different hospitals. You walk into a new hospital every day, it's"Okay, here's a new anesthesia machine. Here's a new way to chart. Here's paper charting, here's electronic medical records." So just with that experience, I can get thrown into any, situation and be like,"Okay, I'm gonna be able to, make this happen." And that's carried on into my clinical practice,'cause I've worked at several different teaching institutions and you just get thrown in and you're like,"Okay, there's different stuff. We're gonna make it work." And I think my training had a lot to do with that.
Elisa:Yeah. I'm sure that really helps you when you come across different types of medical malpractice cases where you just have to orient yourself and say,"Okay, this is how they're doing this. This is the equivalent of XYZ that I did in my practice at this facility." And just be able to quickly find yourself and get your bearings and move forward with it.
Kristin:Absolutely. The anesthesia records can really look like chicken scratch because everybody has their own way of writing something.
Elisa:Well, yeah, because you're the only one that really is gonna read it unless something happens. You're the only one that really needs to know what it says for that moment. And we all know at the back of our minds that there could always be legal problems, but you can't think about that every single day. If you did, you'd go crazy.
Kristin:You wouldn't have time. In the operating room, time is money, right? Especially on a written record, we kind of write in codes and symbols. And sometimes it's over here and sometimes it's down here. Electronic records have really helped streamline that. So it's more clicking boxes. But still, the way it prints out is very different. And so on the computer screen you could hover over something and it'll say"Lidocaine 2%", but the way it prints off, you can't see what the actual drug is. It's only part of it. And so then you have to go digging more into the record to say,"This is what was pulled out and this is what was charted. And so you have to put all the pieces together. So it makes it-- it's like hieroglyphics at times.
Elisa:Yeah. You have to know what the end results should look like, or what information you're looking for in order to know where to go find it... to piece something together and get a coherent story going. Most documentation exists for several reasons. One of them is to communicate from one caregiver to another. With CRNA documentation, and anesthesia documentation in general, does PACU look at what you're documenting? Or is it pretty much like... it just goes into an abyss and most people really don't look at what you're documenting for a continuity of care standpoint.
Kristin:Yeah, it definitely should be looked at. I think there's certain things that the PACU nurse wouldn't necessarily care about, but things that we always wanna make sure and tell them: we gave Toradol at the end of the case, or we gave IV Tylenol.'Cause those are things, a lot of times, they're looking to give in PACU and you wanna make sure that we didn't just give IV Tylenol and then they're giving it in PACU. So at one of the facilities I work at, the systems are separate, and so if you forget to tell someone, they can't access what we gave and they just go based off of memory-- which is not great. It's a whole system that we've had to improve. There wasn't any way to double-check things-- like someone being a difficult airway: you wanna pass that along."Hey, we had a lot of trouble masking this patient or ventilating them at all." Let the PACU nurse know so that they know if the patient's in trouble, they need to call for help immediately.
Elisa:Yeah. It sounds like you just confirmed what my concern was. In some facilities, not only do they not look at it, but they don't even have access to it, and so they rely wholly on what's told to them verbally. That sounds like a liability landmine.
Kristin:Absolutely. In the operating room, time is money, right? So we're coming in as quickly as we can and we don't wanna delay the surgeon. We don't wanna delay the surgeon who's following us. So everyone gets there allotted amount of time, and if you throw things off track by saying,"Oh, there was an adverse event, and I need to spend time charting," that's not gonna be well-received.'Cause they're like,"Nope, the room's turned over, bring the next patient in." And so I do feel like there is a lot of pressure to be efficient. You have to have great time management, but sometimes you have to say,"Hey, I need someone to come in here and give me a break so I can go sit down and find an open computer and actually chart what happened." But I think there's plenty of instances in my career-- now that I'm on this side of it-- that I would say,"Ooh, I probably didn't chart what I needed to chart." And they're very specific things that we do in our profession: when we intubate someone- putting a breathing tube in- we give very specific information: how many times it's been done, what blade we used, what we saw when we did it, if that worked or didn't work, and what we do next. Because the next time that somebody intubates this person we want to be able to follow those guidelines and say,"Okay, this didn't work, so let's go ahead and go straight to a video laryngoscope to save this person injury to their airway." Our charting is really important, but when you're, in the rush of things, a lot of the records I've looked at have nothing. It's changed how I am charting things in my practice. Sometimes there's not that time and that luxury to include everything that we should.
Elisa:This is all very interesting. These are very specialized legal nurse consulting liability issues. The concern that I think most laypeople have that you won't be out enough or you are gonna remember it. Do you see liability there? Are there legitimate damages? Have you seen cases come through where psychological damages has been an issue in those kinds of scenarios?
Kristin:Sure. There's definitely been cases where someone is fully paralyzed, meaning you cannot use your muscles. We use medicine to paralyze your muscles, and they don't have anesthesia on. So their mind is awake and their body is paralyzed--
Elisa:to include the fact that they can't move their mouth to say,"Hello! I'm awake!"
Kristin:If someone is aware or experiencing pain or experiencing panic, you can see those things on your monitor. You're gonna see an increase in heart rate, an increase in blood pressure, and that's where the practitioner can say,"Is the patient having pain? Let me give some pain medicine. Oh, my anesthesia gas isn't on. Let me turn that up."
Elisa:An increase in heart rate, that could also occur due to loss of blood somewhere, but that would result in a low blood pressure. So you're looking at that all in concert, and you're making those clinical judgments of,"Okay, we're seeing an increased heart rate and increased blood pressure. We've got a patient who's possibly conscious to some degree that needs a little bit more anesthesia." As opposed to,"Okay, we've got an increased heart rate and a low blood pressure, we've got a bleeder." And those are the kinds of things that you're all, simultaneously analyzing there in the O.R.?"
Kristin:You look at the numbers, and all the different things start going through your head. You're moving through everything so quickly. Anesthesia is like taking off on an airplane. So the beginning's really busy, you get to a place where you're flying at a level altitude. You have turbulence in the middle. You have some bleeding or high or low blood pressures and you're kind of fixing everything. In order to get that level altitude, you definitely have to know what you're doing.
Elisa:This is all very interesting. So Kristen, you brought a story with you today out of the operating room. Tell us what happened in that story, and how you-- as a legal nurse consultant-- were able to help your attorney figure out where that liability was.
Kristin:This was a really sad case. She was a 23-year-old. She is 260 pounds. She's about five feet tall, so she was a BMI of 50 Really no other history other than obesity and probably some undiagnosed sleep apnea. Coming in for a nose job. So already when I start reviewing the case, the red flags are going off in my head. Most of the cases that are anesthesia-related are brain injury cases: intubations that people can't get, problems on extubation-- so anything airway-related; respiratory collapse, that kind of thing. But with this case, they actually had no trouble with the intubation. She did have some indicators she was gonna be a difficult airway, but everything was uneventful. The surgery was gonna be about 3 hours. It progressed 5+ hours. So then we've got a girl who's laying flat under general anesthesia for an extended period of time, and a lengthy case. So they wake her up at the end, she gets to PACU. And you would imagine that after surgery, if you're having a nose job that maybe your throat's a little sore, maybe your nose hurts, but she wakes up screaming that she can't move either arm. The right arm was worse than the left arm, but she couldn't lift them off the bed. The arms were red and visibly swollen. Definitely not normal. This was done in a surgery center, so she ended up taking an ambulance. Was admitted to the hospital, and everyone started freaking out."She's got MH!" So"MH": malignant hypothermia. An allergic reaction to our anesthesia gases in one of our paralytic medicines. Just, basically, a hypermetabolic state that can be deadly.
Elisa:This is the reason why every time you go under anesthesia, they always ask,"Have you ever had problems with anesthesia before?"
Kristin:Exactly.
Elisa:Really uncommon, but very dangerous.
Kristin:It's very possible to go your entire career and you may never see a case of MH. It's why we have a malignant hypothermia cart. There is a national hotline that, if you do have a case of it, you call the hotline, there's very specific protocols. What struck me on this case was that she was only having problems with her arms and knowing the positioning during this type of surgery... so the beginning of the surgery kind of goes: you come into the operating room, anesthesia get about five minutes at the beginning of the case and five minutes at the end of the case. Variable times, but that's really what surgeons like. So once we are done intubating, and we tape the tube and we start our anesthesia gases, we turn the patient over. In ENT surgeries, we spin the bed 180 degrees, so the head of the bed is completely away from us. Our joke with everyone is if you take it out, you gotta be able to put it back in. And so an ENT surgeon is trained in the airway, and so ENT surgeries, they're"shared airway" cases. So the way she was positioned-- which was not documented in the record-- was with her arms tucked at her sides. And because she is almost a BMI of 50, you have to take that extra care to properly position and pad people. ASA-- American Society of Anesthesiologists-- have a committee that runs all these closed claims about anesthesia injuries, respiratory complications, brain injury and positioning injuries. So this was a positioning injury that got the horn going about it being MH. She was in the hospital, she almost got a dantrolene drip started, and an anesthesiologist came to see her, and was like,"This is not MH you don't get MH just in your arms. She doesn't have a temperature. She's sitting up breathing on her own. Her CK's really elevated. This is a crush injury."
Elisa:So had they moved forward with treating this as MH, would there have been repercussions to the treatment itself... for a condition that she didn't have?
Kristin:They would've just stopped the dantrolene at some point had they started it. There are a lot of suspected MH cases that probably get treated that don't actually end up coming to fruition, but--
Elisa:They just treat just in case because it is such a dangerous condition. You have to move that way empirically until you know any different...?
Kristin:Exactly. An extreme hypermetabolic state, so you're gonna see increased heart rate, increased body temperature, really high co2. It's one of those things where you look at the monitor and you're like,"Wait, my end title CO2 was 35, now it's 85..." Typically it's gonna happen during a case, but there are delayed cases where people have gotten it in PACU as well, which is not very common.
Elisa:This is all very interesting because it's not something that people outside of the O.R. or PACU really encounter at all, so it's all news to most of us who are listening and don't have that kind of experience.
Kristin:I remember hearing about this story-- the treatment for malignant hypothermia, was dantroline, and we have the malignant hypothermia cart. The concentration that the dantroline came in-- and still comes in most facilities-- you require 30 vials. There's a specific way you have to mix it with sterile water; there's a whole protocol of how you do these things. There was a surgery center: young girl, 19, I think, like on the way to college, and she developed MH in the operating room and only had one vial of dantroline in the surgery center... and she died.
Elisa:Not being prepared for an emergency like that. the liability here is problematic
Kristin:It was really sad. But with this case, This is a crush injury. When this girl woke up from anesthesia and her arms were visibly red and swollen, that is like clue- right there- that she was tucked way too tight. So things that they should have been doing during a long case: checking under the drapes... yeah, it's annoying to tell the surgeon,"Hey, I'm gonna crawl up here and check on the blood pressure cuff." But it's necessary'cause you would've seen the redness and the swelling. A lot of times you can see where the tubing is indented into the skin and stuff like that. So had you crawled up under the drapes, you would've seen it right?
Elisa:I mean, Knowing what to look for, yeah. Because you know,"I am looking for indicators of positional injury." It's hard to necessarily notice swelling, for example, if you don't know that's what you're looking for. But if you're like,"Okay, looking for swelling, looking for redness," you'll see it if it's there.
Kristin:Her injuries were worse on the right side than the left side. And because of the surgery, we knew the surgeon was standing on the right side, he was leaning on the blood pressure cuff. Under general anesthesia, the blood pressure cuff goes off every three minutes. If you're getting that constant compression on that arm, her injuries on the right arm were much worse than the left arm. There are case studies that show even the blood pressure cuff itself can cause nerve injuries. In the obese population, you have to get creative. Some of the cuffs, they don't fit, and so maybe you have to go to the forearm, maybe you have to go to the leg; get creative where you put the IV. Another thing that could have been done was we have arm sleds. So extends the bed a little bit, but still allows the surgeon to stand close enough to get the case done safely, and you can put them on the arm sleds, have your foam, and then protect the ulnar nerve at the elbow.
Elisa:So it sounds like the way that you were able to identify the liability here is just that physical assessment following the procedure...?
Kristin:When I was going back through the charting with a fine tooth comb... everybody in the operating room has responsibility to take care of the patient. And specifically the anesthesia team,'cause we've put them asleep, they can't protect themselves, so therefore, we are there to protect them. No one from the surgical team, no one from the nursing team, and no one from the anesthesia team commented on pressure points being padded, arms tucked by side, foam used, arm cradles used. And so that, in itself, is a standard of care violation. How were her arms tucked? I know how they should have been tucked. But without that thorough documentation of saying,"This woman BMI is 49, and we had to take, a few extra minutes to make sure that these things were done extra." I did see a note that the nurse circulator had commented"Patient put themselves in an area of comfort", which we do say a lot for cases when someone's just under sedation; that they can put their arms by their side and it's a short procedure. But when someone's under general anesthesia, we don't position them before they go to sleep"in an area of comfort". That's not the documentation that you're looking for. And if someone's visibly swollen, it's from, compression. And now she's developed a condition we called"rhabdo", where she got extensive muscle injury and that leaks bad stuff into your blood, can cause kidney damage, can cause, heart problems. It is never normal to come in for a cosmetic nose procedure and not be able to move your arms afterwards. There are things we can do to mitigate having injury issues afterwards. I have never seen somebody wake up visibly red and swollen; and that has to be, from severe compression from the draw sheet. I have seen people's arms tucked up under them. So if you imagine it's a 5-hour case, and now their body is laying on their arms. Sleeping at night, your brain would just tell you,"This isn't comfortable, let's, move positions..." When someone is under anesthesia, they're not able to do those things, and so we have to be able to do what we know is best and safest for them. And working as a team, a lot of times, if I'm busy giving blood or documenting, and the nursing staff has several people in there, it's in my chart,"Nurse A and B tucked arms with pads. Elbows free from pressure,"--depending on whatever surgery we're doing,"Arms supinated", meaning that the palm is up."Arms less than 90 degrees...", that type of thing. Or you can say-- some surgeons are great--"Dr. Smith came in, he helped position. This is what he did..." so then when you have to go back and say"What did you guys do for this case three years ago?" that your notes make enough sense that you can say,"This is what we did."
Elisa:Is positioning something that first assists, or O.R. nurses...?--Are there on-the-job inservices? Are there CME's? Is this something they learn in nursing school? Is this something you learn in CRNA school? Like, where is the education come from?
Kristin:In my program, there was extensive training. Actually, we talked about it endlessly. And once the patient is asleep, it's everyone's time to shine. So whoever has the available hand, I'm gonna make sure everything's okay. The patient's been draped before, and then their arm's hanging out under the drape, and you're like,"Time out. Let's pull it back. Let's strap the arms; let's get some pads." I'm sure that doctors receive that training as well. I can't really speak to what training doctors receive. Different facilities that I have worked at, nurses have had different levels of education in terms of it. But there are some that are very thorough, and it may just depend on where you're trained, or our experiences that we have clinically shape who we are as practitioners moving forward. So could have been a bad event that they had and they said,"Okay, now I'm gonna do this different." Because that's what we're always wanting to do is process improvement, and--especially in the O.R.--Any part of the hospital! How can we make a patient have a great experience and be cared for the way that they should be?
Elisa:Is there a specific individual who is responsible for positioning? You made it sound like it's really everybody's responsibility. I grew up in a household with 10 children, and they tried the whole,"It's everybody's responsibility to keep the house clean", and that doesn't work very well.
Kristin:Right?
Elisa:So we had to say,"Okay, Elisa cleans the kitchen, Steven cleans the living room. And I wonder, is that just hospital-based as to their own policies, and there's some hospitals that just say"it's everyone's responsibility to keep the house clean."'Cause I feel like that's problematic, personally. I don't work in an O.R.; I never have. But are there hospitals or facilities where you've worked at where they did have explicit responsibilities for individual roles vs where it's just"everybody's responsible" kinda thing?
Kristin:The hospitals I have worked at, it is the anesthesia team's responsibility. I have worked in outside facilities where you can tell that the nurses have been told it's their responsibility, where they take on that role. But, especially in my practice, I'm always gonna double-check everything and make sure. Because at our hospitals, it is us.
Elisa:Yeah. The buck stops there. Yeah. And ultimately, you have those higher credentials than the registered nurses. The intensity of the work that CRNAs do-- even though there's always this joke about how they really don't do a lot of work, there's a lot of critical thinking that has to happen to prevent fires all day long. But also, the liability that... it's like, the higher up the line you go with the credentialing, yeah, there's higher paychecks, but there's also higher liability. And the buck stops here.
Kristin:Exactly.
Elisa:Kristen, thank you so much for coming on to our show. Really great conversation. I really appreciate you coming on. Is there anything else you would like to share to our attorney audience about CRNAs in the legal nurse consulting space?
Kristin:Having these particular cases, when you have the eyes of an anesthesia provider who can fill in those gaps, identify what actually happened... we have that experience, and we can read the chart through the eyes of a medical provider and explain exactly what happened to your client and why they couldn't move their arms after surgery, and what kind of treatment they needed to get to minimize their suffering. It's been a really interesting field just investigating these charts, and helping fill in the gaps for everyone.
Elisa:These are really great topics: MH and about not fully falling asleep, and things like that. There's all sorts of very specialized legal nurse consulting liability issues that come up when you're talking about the operating room as it relates to positioning to airway to MH. I really recommend that attorneys find a CRNA to review their records when the case involves those specific issues. It really should be a CRNA, not an RN. Kristen, thank you so much for coming on.
Kristin:Thanks. Thanks for having me.
Elisa:You've been listening to discovering the needle nurse consultants help you discover what you didn't know that you didn't know about how to win your medical malpractice case. This podcast is a production of discovery, NP legal consultants. Discovery is the largest unified growing force of specialty nurse practitioners offering consulting services to medical malpractice attorneys who take cases for the plaintiff
nurse practitioners, specialty consultants to the legal profession at Discovery, np legal consultants include specialists In anesthesia as a certified registered nurse anesthetist or C R N A.
Heidi:To request a consultation or to be featured as a legal nurse consultant on our podcast, you may reach us on our website@ourwebsiteatwwwdotnplegalconsultants.com. Or by calling 2 0 8 7 7 9 1 9 9 0. That's 2 0 8 7 7 9 1 9 9 0.