Feres, Schmeres! It's CRNA independent MALpractice, Stupid!

--General (Dr.) R., Commander, David Grant Medical Center, Travis AFB, CA, December, 1998, after a similar incident resulting from CRNA independent (mal)practice

Dr. Forner completely missed the point in her recent article in Anesthesiology News (Extubation Case Challenged Long-Standing Legal Doctrine, Dec 2011). She spent 9 paragraphs defending the Feres doctrine from 1950, which shields the U.S. government from lawsuits by active duty members (including derivative lawsuits by their civilian next-of-kin), even in cases of egregious medical (or, in this case, CRNA) malpractice. As the ex-LtCol former "Medical Director" of the Anesthesia Flight at David Grant Medical Center, Travis AFB, CA, I am here to tell the world that what killed the patient was the inappropriate, unsupervised, and deadly independent practice of Nurse Anesthesia at Travis AFB from 1998 onward.

Across the USAF, anesthesiologist manning has been insufficient from about 1997 to today. The Air Force's only anesthesiology residency program at Wilford Hall Medical Center was slashed from 10 slots per year, to 3, to zero. Wilford Hall, the former flagship of Air Force medicine, was subsequently "right-sized" to an urgent care clinic as a cost-cutting measure. At the time of the incident in 2003, due to sheer poor planning by the USAF leadership, only one anesthesiologist was on duty at the Air Force's largest medical center on the West Coast. Sadly, he was not at all involved in the patient's care initially, because the Air Force allowed CRNAs to practice completely independently. In order to run 6 operating rooms plus pediatric sedation plus OB support with inadequate numbers of anesthesiologists for supervision, the Air Force had capitulated to the demands of CRNAs and surgeons to emasculate the role of anesthesiologists, thus totally destroying the Anesthesia Care Team model that had existed in the USAF for decades prior. CRNAs were allowed to practice independently according to Air Force Instruction (AFI) 44-119:

From: http://www.e-publishing.af.mil/shared/media/epubs/afi44-119.pdf

"7.5. Certified Registered Nurse Anesthetists (CRNA).

7.5.1. Background. CRNAs are registered nurses who have obtained advanced didactic education, clinical residency, certification, and are independently licensed to administer anesthesia. Nurse anesthesia practice includes but is not limited to pre-anesthetic evaluation/assessment and patient preparation; intraoperative anesthesia management and postoperative follow-up and evaluation. The CRNA practices within a healthcare system that provides consultation, collaborative patient care management, or referral as indicated by the health status of the client.

7.5.3. Scope of Practice:

7.5.3.1. May act independently in areas of demonstrated competency within their designated scope of practice as indicted by "Fully Competent" or code "1" on the privileges list for all American Society of Anesthesiologists (ASA) Classifications: 1, 2, 3, 4 or 5 including "E" for urgent/emergent obstetric care.

7.5.3.2. CRNAs will consult with an anesthesiologist or any other medical specialty for patients who require such medical consultation based on acuity of the health condition or complexity of the surgical procedure. Consultation will be based on the judgment of the CRNA in coordination with the attending surgeon. The CRNA remains responsible and accountable for determining when consultation with a physician specialist (e.g., anesthesiologist, cardiologist, internist) is needed during any patient encounter. These provider-to-provider consultations may be verbal, written, or electronic; will be documented in the patient’s medical record; should include the name of the specialist consulted; and include a brief outline of the anesthetic plan developed or the recommended course of action."

So, according to the Air Force, anesthesiologists = cardiologists = internists as physician "providers" who may or may NOT be consulted by the all-knowing, all-powerful (and usually higher-ranking) CRNA. Thus, in this sad case, when the anesthesiologist arrived in the PACU with a patient in respiratory arrest, he was not recognized as the leader of the resuscitation team. The Major CRNA had not "consulted" him, so she persisted in mismanaging the patient's airway, including prolonged, unrecognized esophageal intubation. Inadequate experience plus blurred lines of responsibility equals failure to rescue. Military rank trumps clinical knowledge and medical training in today's Air Force "Medical" Service.

This sad outcome should not have been a surprise. The Air Force had known about the dangers of independent CRNA malpractice since a similar, tragic outcome after extubation in October, 1998, also involving unrecognized esophageal intubation, which resulted in brain damage. As Medical Director, I forcefully spoke out, verbally and in writing, as an advocate of the Anesthesia Care Team model, wherein an anesthesiologist is involved in the care of every single patient requiring anesthesia. As a result, I was fired as Medical Director for insisting on medical direction of anesthesia care. I was then immediately given orders for a 3 year unaccompanied assignment "overseas" to Alaska on a usually accompanied tour without my two handicapped children and pregnant, active duty physician wife as retribution for my embarrassment of the entire command at Travis by speaking out against independent CRNA practice and for patient safety. Only appeal to the highest level of Special Needs in the Air Force reversed this petty and punitive attempt to silence me.

One thing Dr. Forner neglected to point out in her extensive essay was the fact that "medical director" means something totally different in the Air Force than in civilian practice. In the civilian world, a medical director is a senior physician who has the "line authority" to call the shots, and who customarily has the final say in determination of medical quality of care issues in his or her practice. The faux position of "medical director of anesthesia" was instituted in the Air Force as a fig leaf after the implementation of the Objective Medical Group (OMG) fiasco circa 1997, which made all "providers" equal, regardless of corps, when it came to military command. Nurses, CRNAs, pharmacists, optometrists, nurse midwives, PAs, and housekeepers became eligible to wield command authority over physicians, with the power to break the doctors' morale and careers at a whim. Fun fact: the Surgeon General of the Army in 2007 was a CRNA. Since the "medical director" of anesthesia has zero line authority over his/her subordinates, it is really the high-ranking nurses, CRNAs, and surgeons who run the show. Like the SGH (chief physician of a Medical Group), the military anesthesia "medical director" is a useless appendix on the org chart who risks career immolation if he or she speaks out as a patient safety advocate.

In view of the above, after having served my country in uniform from ROTC at Harvard in 1981, through USUHS, through military anesthesiology residency, until the end of my 11 years of payback after residency, I resigned my Regular commission as a LtCol in the USAF and forfeited all retirement benefits after 19 years on active duty in 2005. Unless the Air Force and the other U.S. military branches reverse the dangerous policy of allowing CRNA independent (mal)practice based on military rank, rather than medical training and knowledge, tragedies such as those at Travis will continue to occur, to the permanent detriment of our brave active duty members, their dependents, and our honored military retirees. The Feres doctrine is completely irrelevant to medical care standards, except to the extent that it shields incompetent military "providers" from legal sanctions for their malpractice, thus encouraging military commanders to "do more with less" by enabling substandard care. Since 2006, my website, Medicalcorpse.com, which I pay for out of my pocket and which does not accept ads, has documented this lamentable and worsening state of affairs. In the future, I would welcome Anesthesiology News to investigate the true nature of CRNA-run anesthesia care in the U.S. military before publishing self-serving and misinformed government propaganda pieces written by active duty anesthesiologists which extol the current broken, demoralizing (for anesthesiologists), and deadly (for patients) status quo.

Robert C. Jones, M.D.
ex-LtCol, USAF, MC
Harvard '85, USUHS '90, WHMC Residency '94
ex-Medical Director of Anesthesia, David Grant Med. Ctr, Travis AFB, CA
ex-Assistant Chief Anesthesiologist, Malcolm Grow Medical Center, Andrews AFB, MD
www.medicalcorpse.com
webmaster AT medicalcorpse DOT com

Dr. Forner wrote:

"Shortly after Sgt. Witt died, the Air Force barred the nurse anesthetist responsible for his death from practicing medicine within a military institution, and the state of California revoked her medical license."

The Major CRNA was still a nurse. I doubt that she had a medical license. As far as the claim that she was "practicing medicine"...that's certainly debatable. However, it's much too simplistic to blame one person for the patient's death in this case. In truth, the entire USAF medical care system failed the patient. Let me count the ways:

1) Inadequate planning at HQ USAF level for anesthesiologist shortage due to failure to train/accession anesthesiologists in the late 1990s. HQ USAF and anesthesiologist consultants (Hi, Jay and Ann!) allowed AFI 44-119 to be instantiated without resigning their commissions in disgust (in order to protect their retirement benefits, cushy positions, and power, among other reasons). Boneheaded decision to place anesthesiologists under command of surgeons in the first place (given that many surgeons see us as the enemy who viciously cancel their sexy cases, rather than as board-certified colleagues who are trying to keep their patients safe).

2) Inadequate response by MAJCOM (AMC) to prior Sentinel Event findings from 1998. Approximately zero of the recommendations from the prior tragedy were implemented.

3) Inadequate measures taken by Medical Group to insure that previous OI 160-1, which mandated anesthesiologist involvement in medical care of very sick patients, superseded the requirements of the AFI (yes, a Medical Group OI can be more restrictive than an AFI...it takes intestinal fortitude, but it is possible).

4) Inadequate action taken by the Surgical Squadron Commander (SQ/CC) regarding prior episodes of poor performance by CRNA. SQ/CC allowed/encouraged CRNA independent practice to increase throughput (number of cases surgeons could do), regardless of medical appropriateness and quality of care. Hey, we always have the Feres doctrine to protect us if the patient dies, right?

5) Spineless "Medical Director" of anesthesia who allowed CRNAs to practice independently, even though he recognized the patient safety dangers.

6) Chief CRNA unwilling to police own ranks prior to tragic disasters, in order to save face and protect independent practice tradition at Travis.

Almost every Sentinel Event involves a cascade of failures throughout the medical care system, leading to the final adverse outcome. To quote the movie "Rising Sun": Fix the problem, not the blame (note: this is not a real Japanese proverb...but it is relevant to how the military works: find a fall guy/gal, destroy his/her life, and exonerate the Generals and Colonels who really caused the tragedy [see: Abu Ghraib, Wikileaks, the ongoing travesty of military "medicine", etc.]).

--
Rob Jones, M.D.

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