Welcome to Patients at Risk, a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm your host and the co author of the book 'patients at risk the rise of the nurse practitioner and physician assistant in healthcare,' Dr. Rebekah Bernard. Imagine this scenario: you are rolled into an operating room in a surgical center for an outpatient elective procedure. But when you wake up, you find that you're not in the surgery
center anymore. You're actually in a totally different hospital in an emergency department, and you learn that you nearly died from anesthesia complications. Even worse, you find out that rather than being treated by an anesthesiologist as you thought you actually received care from a nurse anesthetist working alone. This scenario happened to my guest today, Paul Armbruster. And he is here to share his story. It's a cautionary tale for patients and for physicians involved in the care of surgical
patients. Paul, welcome to the show. Great. Thanks for having me. Paul, when I first heard this story, I was just horrified. This has to be any patient's worst nightmare. So tell me a little bit more about what happened. Yeah, so basically, all I remember is - I remember going to sleep - I've had general anesthesia numerous times. And, I remember going to sleep and I remember waking up and I have no memory of anything in between
that when I did wake up. I want to correct one thing you said- I did wake up in the specialty hospital. So I was revived at the specialty hospital before they took me to a to a University Hospital. So I remember that though. I do remember waking up at this specialty hospital. And one of the reasons I remember that is because I woke up with a tube down my throat. Which is not a very pleasant experience at all. So I regained consciousness after they gave me Narcan at the
specialty hospital. The ambulance was already at this specialty hospital. And then they put me in the back of the ambulance and took me to to a university hospital. I don't remember much for the first 24 hours there were there were bits and pieces that I remember, you know, I was groggy and, you know could barely stay awake. How did you learn about what had actually happened?
Well, when I woke up at the specialty hospital, you know, there was a whole bunch of people around me and they said, 'Hey, we you had some breathing complications, and we think it's best that we take you somewhere else to get checked out.' So that was that's when I was put in the back of the ambulance and taken to a different facility.
I mean, this is when you were already like having a tube down your throat though?
So once I woke up, they they took the tube out of my throat. Okay. Yeah. So once, once I was awake, I don't believe I was intubated again, in the back of the ambulance, but again, you know, my my memories, pretty, pretty foggy. I've got, you know, little 10-second bits of memory, but most of it I don't remember.
And how did you learn - or what did you learn what actually happened?
Well, that that took a while. So obviously, I knew something had happened as I become more alert over the next 24 hours, you know, when they do a shift change, a nurse change within the hospital, right? I assume the procedure is there's a handoff, right? So there's a little back and forth between the nurses. But when they changed nurses, and I got some of that information from there, just listening to them. I got
some information. The resident orthopedic surgeon came to visit me the following two days, he couldn't really give me any information about it. He said, 'Oh, the hip's fine. The surgery went fine.' And the only information he could give me was he said, 'Well, it looks like you're over sedated, and your heart stopped.' So that's the only information that I got. And it really took 10 days before the hospital reached out to me.
So there was no communication from the specialty hospital, there was no phone call to say, 'Hey, how you doing?' There was no, there were no resources, there was no you know, I sort of expected there to be some sort of Patient Advocate person that would reach out to me to see whether I needed anything or, you know, at least how I was doing.
Right, and even greater, to do some type of a root cause analysis to make sure that this doesn't happened to someone else, because I'm looking at a report that you were able to obtain, which is a nursing note from a nurse who assessed you, I guess, when you were taken down to the recovery room. And what it says here is that you arrived in the PACU
31. And it says 'upon arrival I noticed that patient's color was blue, and notified the anesthesiologist who was with my patient my concern of patient not breathing adequately, I began to feel for a pulse and notice the patient was pulseless. I began compressions while the anesthesiologist was managing the patient's airway.' Now, you mentioned that you don't think that you actually had an anesthesiologist in charge of your care. Tell us about that.
Yeah, so when she says anesthesiologist, in that note, she's referring to the CRNA.
So everybody's confused. You thought you had an anesthesiologist. She thought it was an anesthesiologist, but it never was.
It never was, no, there was an anesthesiologist who turned up to my code about a minute and a half after the code. He was part of a different group. So the group that was running my anesthesia, they don't have physicians on staff. So so the way this facility ran its anesthesia. That day was there were two groups that were there was a group called callback anesthesia, I believe they had both physician, anesthesiologist
and CRNAs. The group that did my anesthesia was was a company called Arizona Anesthesia solutions. They don't have any physicians, right? So the guy that ended up coming to my code was not even part of my anesthesia team, he was from a totally different company.
The one that was with you though, initially, was the CRNA. And that was the one that was there through your whole anesthesia. Now, let's talk a minute about your feelings on when you had the preoperative assessment when you were talking to the CRNA. Were you under the impression that that was an anesthesiologist that there would be an anesthesiologist in charge of your care?
He introduced himself as a nurse and make this but this concept is totally foreign to me. Right? I didn't even know. You know, if this event hadn't happened, I wouldn't have even known what a CRNA is, right? So my understanding, when he done like, pre op was simply that, hey, this is, you know, like a physician's assistant. This is the nurse and ethicist who's going to be helping the anesthesiologist. That was the assumption that that I was
given. You know, all along, I never, you know, it was never disclosed to me that he was the only person who was going to be looking after my Anesthesia Care.
Right. And it's kind of crazy, because you said that that group that he worked with was made up of only CRNAs. And yet, in the state of Arizona, the law requires that anesthesia be supervised or directed by an anesthesiologist. Did you know that?
After the fact that I did, I knew that. But going in, I didn't know that and what this hospital is doing is and you know, I've, I've had multiple conversations with my actual surgeon post this event. He was always told that he is not responsible for anesthesia
during his surgeries. Post fact, the hospital is telling him that he is responsible for anesthesia, which unfortunately resulted in a conflict and his termination just a few weeks ago, I was meant to have my other hip, done by him two weeks ago, he was terminated on the Friday, because he wouldn't put his hand up and say, 'Yeah, I was the responsible physician.'
So what you're saying is that there was no anesthesiologist in charge of the CRNA. And instead, when something went wrong, the hospital looked to the operating surgeon and tried to hold him responsible for the supervision of the CRNAs care. And when he said 'no, I can't do that. I'm not trained. I'm not an anesthesiologist.' They fired him.
Correct.
Wow, I wonder if surgeons in the state of Arizona are aware that this could happen to them.
And the funny thing is with with the law in Arizona, that requires that the CRNA be supervised by a physician or surgeon. But then there's a safe harbor clause that sort of that says, hey, the physician or surgeon is not liable for any act or admission by the CRNA. Right. So it's sort of it's a little bit toothless. And what the hospitals are relying on is, you know, well, one, they're telling their surgeons that they're not responsible when really, they are holding them responsible.
They weren't. The surgeon has to be the responsible physician. But, you know, the, what the hospitals are doing is they're relying on this safe harbor provision that says, hey, our folks can't get in trouble anyways. So what they what they're doing is they're, you know, they're essentially staffing surgery rooms with unsupervised CRNAs.
Well, that's exactly what they're doing. And I'm looking at Arizona law that says that a CRNA should be functioning 'under the direction and in the presence of a physician or surgeon in connection with the preoperative, intraoperative or postoperative care of the patient.' And then they list different settings that it has to be in what's your setting
certainly was part of that. And when you go down, you see exactly what you said that 'the physician or surgeon is not liable for any act or omission under the CRNA.' So what that saying is that law requires that the CRNA be under supervision. But the CRNA themselves is the only one held responsible, I guess, in a malpractice type of a case. But yet, what about the law? Is there not any type of recourse in the in this event, they're actually breaking the law?
Right, so that they're intentionally not providing supervision to that CRNA, which is required in Section Eight
I would imagine that that's a financial decision on the part of that organization, wouldn't you?
Exactly. I mean, I don't know what the going rate is. But you know, if you're paying $5000 a day for an anesthesiologist, you're you're only paying $1000 a day for a CRNA. You know, I don't know what those numbers are. But it's obviously cheaper. And that's why they do it.
And yet, I'm guessing that you didn't pay any less money for your anesthesia when it was provided not by a physician.
No, I have, you know, my I have fantastic health insurance, my health insurance covers would have covered the physician, right. But the way I understand it is, you know, that's a that's a flat fee. So I had my hip replaced, right. So and again, I'm making numbers up here. But you know, I think they're pretty close. So the facility, the hospital would have got $45,000 flat fee for my hip replacement, how they how they spend that $45,000 I guess
it's up to them. And one of the ways they make money is well, why would we? Why would we spend $5,000 on a anesthesiologist when we can spend $1,000 on a CRNA?
Well, I'm guessing that your intensive care trip probably ended up costing at least as much if not more than the whole surgery.
Yeah. So I wasn't taken into intensive care. So I didn't end up in ICU, I ended up in the emergency department, where I stayed for two and a half three days.
Oh, they never they just kept you in the emergency room the whole time.
Yes. So So it's funny that I never got admitted to the hospital. There's a there's a little area, sort of like observation. Right. It's admission light. You know, I had my own room and all of that, but it was just right off of the ER, I never went up to a ward.
That's interesting. So you were three days in observation in the emergency room? Yeah. Wow. This is just really hard to believe. And it's also shocking, that you really haven't been able to get any answers from the organization. As far as how this happened, why this happened? How this can be prevented? What do you want to see happen from this?
Well, I mean, the main thing for me is exposure. Right? I mean, they're obviously breaking the law in order to gain financially. And as, as my lawyer has said to me, you know, 'you're worth a lot less when you're alive.' You're worth a lot more when you're dead, you know, in the context of litigation, but but these
This just needs to be exposed. I mean, you know, I'm sure, as you've seen that there were two deaths last year or the couple of years ago from a CRNA doing simple dental procedures, and there doesn't seem to be any - the nurses board didn't sanction this person. So you know, there's no teeth, there doesn't seem to be any teeth in from the
nurses board side of things. It doesn't seem to be any teeth, in the enforcement of the actual statute in Arizona, you know, the only the only recourse seems to be, oh, if you die, you get a lot of money. And, you know, I think they've done the math and, you know, they're willing to take a couple of deaths a year to to make more money.
Well, it really feels that way. And I think the other thing that's really challenging is, here you are, you're a person who basically almost died because of something done wrong, let's just say, and even at a minimum, you just want to say like, 'Hey, this was pretty serious. I'd like to not die, and I'd like
other people not to die. So how about you guys look into this, and make sure that it doesn't happen again.' And it feels like you just reaching out to the proper people, which would be that institution, you're not getting anywhere. So now the next question is, well, what do you do? Do you contact the attorney general? Do you contact the Board of Nursing? Like, how do you even know where to begin with a situation like this?
Yeah, and I don't, I'm just starting that path right now. So I've, I've sent a demand letter. So originally I was talking with, with the CEO of the hospital. So it took 10 days. So after I left, the better hospital, that university hospital, I tried to get in contact with somebody from the Core Institute, which is the specialty hospital that I went to. And it took 10 days to get a response, I was told to call the one 800 Number, call the one 800, number, leave message is nobody would call me
back. So So in about 10 days, I got a I got a phone call from the CEO of the hospital. And she was she was nice and cordial, and seem to be, quote, unquote, interested. And, you know, essentially admitted that, yes, this shouldn't happen, then I put together you know, we were talking about, well, you don't just get to do this and walk away. What does that look like? So I put together a demand letter, and and sent that over to the hospital. And as soon as that happened, you know, the
hospital stepped back. And now it's just in the hands of their lawyers. So now, it's an all litigation posture, I can't get any information, you know, the lawyer. So for example, the lawyers, it took me just to last week to find out who was running my code. I didn't even know that, but ask them half a dozen times, can you tell me who was running my code? And they would just ignore it.
I think that there's now supposed to be this, like open access, where patients are supposed to be able to get their medical records. Has that. So that has not been something that's been forthcoming or within yet.
I've got my medical records, but that process wasn't made easy by the hospital at all. So yes, I have all the medical records. But, you know, as I think I mentioned to you before, if you look at my code sheet, there's no physician signature on it. So there's a section for physician running code, it's blank.
Wow, I'm trying to look up a little bit more information about who owns core Institute. And it looks like they're owned by a company called health care outcomes performance company, also called Hopco is the abbreviation. And it says that they're the largest orthopedic value based care organization in the country. And they have a number of different partners. I was just trying to figure out if this was a for profit company at private equity, do you know anything about that?
I don't know the corporate status at all. I assume it's it's a private company, there was some sort of disclosure about it being a physician owned facility. So there's a clinic that sits often as well. So I think Popko is the umbrella company. And underneath Hopco, you have the hospital, you have a different entity, which is also the clinic. So you'll get a different bill when you go into the doctor's office versus you know, when you have
surgery. You know, the other thing that I wanted to say that was which is bizarre to me, that nurses note - the PACU note that you read from the nurse, her name is nurse fFriedan. She was also the pacu nurse. She was also the nurse that gave me CPR. And she was also the nurse that completed my code sheet. So it seems to me that, that the hospital wasn't prepared that you know, they're not prepared
for a code. I mean, you can, you know, I'm no expert in this area, but from what I've read, you shouldn't have you shouldn't have a separate and distinct code recorder. So she was also you can record the code and be giving CPR at the same time. So you know, the code sheet is done after the fact. Right? And it's it's messy. It's not signed. It's it's, it's incorrect.
Yeah, well, I'll tell you one thing that nurse Friedan, she saved your life. And she's a damn good nurse. I'm just reading this note. I mean, it looks like she was she first of all noticed you were in distress, you know, got the attention of the CRNA, started CPR, called 911. And then, of course, later on, filled out the paperwork. So I mean, this person is an unsung hero, I hope that she's appreciated. But you're 100%,
right. You can't have operations where people are being you know, put to sleep and brought back and not have a proper team. They're ready to manage any possible emergencies that might arise.
Right. And one of the things that I didn't send to you or you haven't seen is the note from the from the CRNA and I'll read just a little bit - it goes to show the extent that they're trying to cover this up, so he goes 'following extubation. patient was placed on 10 liters per minute of O2 by simple facemask and transported to PACU by CRNA and RN, plus spontaneous ventilation plus chest rise plus verbal response noted during the period of
transport. So it's about a it's about a minute from the operating room to the to the pacu. So what he's saying is I was awake, I was breathing by myself, I was responding to him. Now, I don't remember any of that. And then he goes on to say, upon nearing arrival to the backpack, you are suspected upper airway obstruction occurred, the potential for risk residual anesthetic agent combined with the patient's apnea, likely contributing
factors. So essentially, what he's saying is, 'hey, this all happened within this guy, you know, turned blue and went into cardiac arrest in 10 seconds.'
And when is he saying like you have a history of sleep apnea or something like that? Is that what he means by that?
Yeah, so I do have a history of sleep apnea, and that that's noted on his so he was aware of my sleep apnea. And that's noted on his on his initial pre op paperwork.
So from everything that you've gathered from talking to other people, it seems like you had too much anesthetic. Well, that does make sense because you got Narcan, and that reversed it. Right. Although Narcan just reverses narcotics, I don't know how it acts on some of these other anesthetic agents, we'd have to talk with an anesthesiologist. But it's definitely seems like you were over medicated and brought down to recovery before you're actually recovered from anesthesia.
Yeah, I think that's right. I mean, I, for the people that I've spoke to, for me to get to this date, and I've spoken to a cardiologist I've spoken to and anesthesiologist, for me to get to the state that I arrived in at the PACU. That event happened to three minutes prior to that the physicians that I've asked this question to have said, you don't turn blue and go into cardiac arrest in 10 seconds. I mean, you can hold
your breath for 10 seconds. So this is not a this is not a an event that that happened the way that care has described.
Right, but you know, I'm just so happy and grateful, not only that you're alive, but that you didn't suffer any type of serious brain injury, or, you know, imagine you could have been left in some type of a vegetative state, had you been brought back a little bit too late?
No, absolutely. You know, I do have I'm so, you know, if you haven't had CPR, I wouldn't recommend it. I was, you know, I was in some pretty good pain for about a month, my chest. And my jaw, you know, I have ringing in my ears now. So, I'm getting that checked out. But but you know, there's also the emotional side of things as well, that, you know, I'm, I'm a
single dad of a 7 year old. So you know, that has, that has some lingering side effects as well, you know, having to have conversations with your daughter about, hey, if I don't wake up, you know, run outside and call somebody, you know, conversations that you don't necessarily want to have or need to have without something like this having happened to you?
Yeah, it's really traumatic. And I've definitely taken care of patients as a family doctor, that have experienced CPR, and, you know, these very near death experiences, and it leaves a remnant. And some of those patients have had post traumatic stress disorder. And of course, it certainly is going to play into your medical decision making in the future. And you mentioned that you actually need
to have your other hip done. How is this experience going to change the way you're going to approach that?
But you know, good point, because here's what's his the situation that I'm in now is, now I'm informed because I'm informed myself, I'm not getting my I'm not getting anesthesia from a CRNA ever again. But the problem I'm having now is if you call up a surgery center, and this has happened to me twice, in the past month, I go, 'Hey, I just had my other hip replaced, I know I need this hip replaced. I had a bad experience with the
CRNA. You know, I went into cardiac arrest So I want to make sure that, that I get a physician for the procedure.' And that is all too hard for them. I mean, they're not interested. So you know, I can't get or it's a challenge for me to get health care going forward. Because because all of these hospitals are just pushing CRNA days into the operating room.
Well, that's exactly the problem that we're seeing. And patients are advocating for themselves and they're getting a lot of pushback and they're told no or they have to go through great lengths to find physician led, at a minimum, you should have had a physician supervising. But you can't even guarantee that with the way things are happening there in Arizona. So this is a really serious problem. I'm so appreciative to you for talking about it and
sharing your experience. And hopefully, we'll be able to share this information with some of the people in authority so that they can stop these unethical and illegal practices that are possibly going to even kill patients in the future. So thank you so much for being with us. And we'll follow up and hear back more from you as you continue your journey of trying to get accountability.
Thanks so much for for having me on.
If you'd like more information on this topic, we encourage you to get the book 'Patients at risk the rise of the nurse practitioner and physician assistant in health care.' It's available at Amazon and at Barnes and noble.com. And if you're a physician and you'd like to learn more about helping to advocate for physician led care, and truth and transparency among healthcare practitioners, we encourage you to join our group. It's called physicians for
patient protection. Our website is physiciansforpatientprotection.org Thanks so much, and we'll see you on the next podcast.