No anesthesia during cataract surgery?
October 27, 2015 9:56 AM   Subscribe

My Dad recently had cataract surgery. In addition to cataracts, my dad has Fuch's corneal dystrophy. He also receives medication for anxiety. Prior to the cataract surgery, the surgeon verbally told my dad that he would receive "twilight anesthesia" during the procedure. We researched online and twilight anesthesia seems to be common protocol for cataract surgery. In fact, it appears to be a "must have" for patients with anxiety.

The anesthesiologist came in to shake my dad's hand during the pre-op portion of the surgery. My dad asked if he would get twilight anesthesia in the IV. My mom said "he's going to need it." The anesthesiologist said that they didn't do that during pre op and quickly left.

During the surgery, however, the surgeon only applied topical anesthesia to my dad's eye. My dad had made the assumption that the anesthesia was going into the IV bag -- this was not the case. The surgeon admonished my dad repeatedly for moving his eye during the procedure. The surgery took 40 minutes (my research online generally indicates that it should have taken 20 minutes).

When my dad went in for the follow up appointment the next day, the surgeon said that she always orders twilight anesthesia, and that she had calls and emails into the anesthesiologist to figure out why it wasn't given. My dad's appointment was at 9 am. The surgeon indicated that he was the third person that day to complain about not receiving anesthesia. The surgeon said that she didn't know what happened.

In our quest to get answers, we are trying to figure out what happened with the anesthesia. Now the surgeon's story has changed. She claims that topical anesthesia is the standard, and that if my dad wanted something else he needed to ask for it (but she told him he was going to have twilight anesthesia -- is it common to expect him to ask for it again, without any written documentation?). The surgeon also says that she does not check to see if anesthesia has been administered to any of her patients. She says that she has been doing this for 25 years and she trusts that anesthesiologist to do his job.

We have received copies of the operative reports. The instructions to the anesthesiologist simply read "eye care per doctor's orders." The nurse associated with the anesthesiologist has resigned. We can't get straight answers and the stories keep changing. We have taken this to the head of anesthesiology and talked extensively to the anesthesiologist and surgeon in questions. They are looking out for each other at this point.

- Should a surgeon check to make sure that a patient has received anesthesia before performing surgery?
- Is it really up to a patient to demand twilight anesthesia in a situation like this? Given that my Dad receives treatment and medication for anxiety, shouldn't it have been part of the procedure?
- How long does cataract surgery typically take? The surgeon is backpedaling now and says that there was no additional trauma to the eye even though it took longer than normal. She says that surgery like this is just as successful without twilight anesthesia.
- My dad wants to record future conversations about this since the stories keep changing. He has a landline. What's the best way to record the conversations?

Looking for any insight into this. It seems like medical negligence to me and I'd appreciate your thoughts on the subject.
posted by Ostara to Health & Fitness (25 answers total) 1 user marked this as a favorite
You are pretty deeply into "hire an attorney" territory at this point. That's what you need to do, particularly before recording any conversations (with or without consent from the other party).
posted by anastasiav at 9:59 AM on October 27, 2015 [16 favorites]

Someone messed up. The surgery was successful anyway and your dad suffered no harm. If we know what you're hoping to accomplish, we might be able to give better advice.
posted by metasarah at 10:13 AM on October 27, 2015 [2 favorites]

Response by poster: This lens was implanted, but his vision is still blurry in that particular eye.
posted by Ostara at 10:16 AM on October 27, 2015

What are you looking to get out of this situation? If it's an admission of wrongdoing, you're never going to get it unless you're willing to invest serious time and (likely) money in to it. Add to that the stress and anxiety of a lawsuit - and that's if you can even get an attorney to take the case.

If you're looking to have the next eye surgery done WITH twilight sedation, that's easy. Find another doctor and specify that he requires sedation. In the pre-op processing, if the anesthesiologist seems flaky again, your dad can refuse to have the procedure.

FWIW, my MIL had both her eyes done and DID have twilight sedation. I was told that it's standard procedure. Depending on the type of lense he had implanted, it's completely normal to have blurry vision without correction though I wouldn't expect it if he had a multifocal lense put in. Honestly, it just sounds like new doctor time to me.
posted by PorcineWithMe at 10:20 AM on October 27, 2015 [1 favorite]

Note that medical malpractice in the US requires the following criteria (according to wikipedia)

A plaintiff must establish all five elements of the tort of negligence for a successful medical malpractice claim.[7]

1. A duty was owed: a legal duty exists whenever a hospital or health care provider undertakes care or treatment of a patient.
2. A duty was breached: the provider failed to conform to the relevant standard care.
3. The breach caused an injury: The breach of duty was a direct cause and the proximate cause of the injury.
4. Deviation from the accepted standard: It must be shown that the practitioner was acting in a manner which was contrary to the generally accepted standard in his/her profession.
5. Damage: Without damage (losses which may be pecuniary or emotional), there is no basis for a claim, regardless of whether the medical provider was negligent. Likewise, damage can occur without negligence, for example, when someone dies from a fatal disease.

I'm guessing the challenging parts would be proving a) injury was caused, and b) damage occured (though obviously legal advice should come from a legal professional, not some stranger on the internet quoting wikipedia...)
posted by DrRotcod at 10:23 AM on October 27, 2015

Speaking as someone who's had a fair amount of surgery, but I AM NOT A DOCTOR OR AN ATTORNEY, it sounds to me like your dad's anesthesiologist messed up and all the other doctors are circling the wagons around him. None of what happened to him sounds like my cataract surgery or any other surgery, or any other normal medical procedure. The only thing you can do is get a lawyer and try to sue, but I don't know what your chances are. When he gets the other eye done he may want to go to a different doctor and get a different anesthesiologist.
posted by The Underpants Monster at 10:30 AM on October 27, 2015

I underwent abdominal surgery fully awake with failed anesthesia.

Despite PTSD and PPD associated directly with the surgery, nothing was done to either make me feel better about what happened, to explain what happened, and no "restorative justice" efforts were made.

I had no plans to sue. I just wanted someone to take ownership for their failings. I didn't need money or anything. My emotional well being suffered terribly for a long time, and I have an implicit distrust of doctors who work in that field and of anesthesiologists and refuse to deal with them any more if I can avoid it (and mostly I've been successful).

All this to say........if that is what happened to me with nothing to show for it except some serious emotional scars and a physical one, then you're probably not going to be able to get any more than you've gotten......and it sucks. I've been there. Doctors are sometimes the worst people to deal with, especially when they make mistakes and refuse to be adults about owning up to them.
posted by zizzle at 10:35 AM on October 27, 2015 [2 favorites]

What did the anesthesiologist bill your dad or your dad's insurance company for? Why was (s)he even there if there was no anesthesia to administer?
posted by AugustWest at 10:40 AM on October 27, 2015 [1 favorite]

Why was (s)he even there if there was no anesthesia to administer?

The anesthesiologist's role in the OR goes beyond administering anesthesia. They are responsible for monitoring the patients vital signs and performing cardiac and respiratory assessments. Of course, this is especially important when anesthesia is given but still needs to happen regardless.
posted by pintapicasso at 11:07 AM on October 27, 2015 [2 favorites]

Actually, the question I would ask is not about the anesthesia--probably optional depending on the procedure. I have Fuch's Corneal Dystrophy and it is my understanding that cataract surgery is contraindicated unless the FCD is corrected at the same time. Removing the cataract exacerbates the Fuch's which could explain the continued blurriness. Even if not exacerbated the primary symptom of Fuch's is blurriness. I go to the Kellog Eye Institute at the University of Michigan which is where I will have both surgeries (simultaneous) next spring.
posted by rmhsinc at 12:04 PM on October 27, 2015

Response by poster: rmhsinc -- that is interesting. My dad was told that they'd do the cataract surgery, let his eye "heal up" and then they'd do surgery for the cornea at a later date.

And I'm just angry and confused at the surgeon. During my dad's first post-op visit, the surgeon indicated that she had ordered twilight anesthesia, and that her orders were ignored.

Now her story has changed -- this is a "new procedure" and they just use topical anesthetic and if my dad wanted twilight, he should have made a bigger point of asking for it. It's frustrating and I don't understand why -- what's going on here?
posted by Ostara at 12:44 PM on October 27, 2015

suffered no harm

Actually, it sounds like the surgeon was affected by the amount Ostara's dad moved around during the procedure. This could have led to inferior results and possibly higher charges (for increased time).

In addition, Ostara's dad may now have an aversion to seeking medical care, which could over time lead to dire consequences, for, for example, a skin blemish he refuses to have removed that turns out to metastatic melanoma (which could lead to other cancers in the body).

I'm not a lawyer and I don't know how legally relevant all this is, and I also don't really believe in maximum consequences for every small mistake a professional makes. However, I don't think this should be dismissed becasue "no harm" was done.
posted by amtho at 12:50 PM on October 27, 2015 [4 favorites]

Response by poster: I'll stop thread-sitting, but amtho is right. According to Johns Hopkins:

Some people with cataracts also have Fuchs Endothelial Corneal Dystrophy (FECD). If a Fuchs patient undergoes cataract surgery, the fragile endothelial cells of the cornea may be damaged. The loss of too many of these cells can lead to edema (swelling) of the cornea. This edema can then sometimes lead to painful corneal bullae (blisters), deterioration of vision, and eventually, the need for a corneal transplant.

I would think that increased movement due to no anesthesia would result in greater trauma to these cells, though the surgeon denies it.
posted by Ostara at 1:02 PM on October 27, 2015

I'd say you may have an anaesthetist with a drug problem who used the drugs for themselves. (This is an area I used to work in. We drug tested more anesthetists than any other type of medico.)

This might inform your actions regarding other patient safety going forward.
posted by taff at 1:19 PM on October 27, 2015 [2 favorites]

Oh my gosh, I really think you need to contact a lawyer. All of these answers are 100% speculation.
posted by pintapicasso at 1:46 PM on October 27, 2015

I would contact a lawyer. IANYL, but it sounds as if your dad might have damages. But if you decide not to sue, you do have another option, namely filing a complaint with the professional licensing body in your state.
posted by merejane at 2:40 PM on October 27, 2015 [1 favorite]

I’m an RN who’s done legal nurse consulting work for more than ten years.

Let’s look backward first. Anesthesia is in charge of the patient’s welfare during surgery, not the surgeon. I think the ‘eye care per doctor’s orders’ thing is a post-op order; maybe the facility has an ‘eye care’ standard or standard orders, though standard orders would have been included in your dad’s medial record. However, if the surgeon had wanted pre-op sedation, she could have ordered it herself. IV anesthesia won’t numb the eye itself, which is why she applied the topical stuff.

So let’s look at negligence. The elements of negligence essentially are a duty to act/perform to a standard of care, a breach of that duty and/or a failure to hold to the standard of care, and harm resulting from that breach.

* Did the anesthesiologist have a duty? Yes. Did the surgeon have a duty? Yes.

* Did anesthesia or surgery breach that duty? Maybe - that’s in question since this seems to be a newer procedure. But it’s irrelevant, because...

* Was there harm resulting from that breach? No. Although the procedure took longer than normal, your dad has no visual impairment as a result (unless I’m missing something) and the procedure seems to have been a success. If your dad had suffered vision loss or damage, or another adverse outcome of the procedure, you’d have something with which to consult an attorney.

It’s the harm thing that most people don’t understand about negligence. It’s not enough to say, “She should/shouldn't have done X or Y.” If nothing bad happened as a result, there’s no remedy to be had. The best you can do at this point is file a notice or report with your state medical licensing authority (though much good may it do us all), and find another surgeon.

If you want to record telephone conversations, be absolutely certain you’re complying with state law in doing so. State laws vary widely; in some states both parties must be aware of the recording and express that verbally, in some states only one party must be aware, and in a few states neither party has to be aware. Since you’re looking at doing this in anticipation of some kind of legal claim (let’s be honest here), the recording has to be admissible in court. As for the equipment, it's easy to find using Google.

Finally, I’ll just say this: It’s important not to be a bystander in your own care. If you want a sedative, the physician won’t give one, and it’s important to you, walk away.
posted by lambchop1 at 3:21 PM on October 27, 2015 [4 favorites]

Was there harm resulting from that breach? No. Although the procedure took longer than normal, your dad has no visual impairment as a result (unless I’m missing something) and the procedure seems to have been a success.

But according to the OP, "This lens was implanted, but his vision is still blurry in that particular eye." (Follow-up post at 10:16 AM.)

IANAD, and for all I know, blurry vision at this stage post-op is normal. But it's just not true that the OP's dad has no visual impairment.
posted by merejane at 8:42 PM on October 27, 2015

Response by poster: His vision has not recovered. Fuch's corneal dystrophy makes the cells of the cornea very fragile. I'm sorry that I was not clear in my original post. The surgeon admits that blurry vision is not normal at this point.

My dad was told (verbally) that he would be receiving twilight anesthesia. It was only after the doctor started cutting into his eye that he realized he had not received it. At that point he felt like he just had to "hold still" and let her finish the surgery. My dad is a military veteran -- he's pretty tough -- but it was very hard to handle. The surgeon kept telling him that he was moving his eye too much.

At the first post op follow up visit the surgeon said that she had ordered twilight anesthesia but that it was not administered by the anesthesiologist. At another appointment, she said that it wasn't given because my dad didn't request it. Both my dad and my mom did request it -- verbally, during the pre-op portion of the surgery. They were never given anything to sign or paperwork to indicate their preference.

The story changed from the first post-op appt. -- so that's why I am trying to figure out what is standard procedure.
posted by Ostara at 9:54 PM on October 27, 2015

WHAT!? Lawyer.
posted by thebrokenmuse at 10:06 PM on October 27, 2015 [1 favorite]

Your surgeon is covering for the anaesthetist.
There's a cover up, if what you say is true. Ask the insurance/hospital accounts to account for pain relieving drugs. I'd almost guarantee there's a mismatch. If other patients said the same thing, there's a problem. Even if you don't lawyer up, let hospital admin know of the irregularity. It may well protect future patients.
posted by taff at 1:15 AM on October 28, 2015 [1 favorite]

Call a lawyer, if they believe there is a possibility of damages they'll subpoena the whole medical record and not just the operative notes and look for discrepancies between the work performed and work ordered and possibly even for doctoring of the medical record to cover things up. At this point, you have two choices, pursue legal action or drop it.
posted by Apoch at 5:31 AM on October 28, 2015

I had cataract surgery for both eyes in two separate operations. In both cases, I received twilight anesthesia as a matter of course (I didn't need to request it) and each operation took about 20-25 minutes.

Were both eyes operated on? My experience was after the first surgery my vision was still blurry because the other eye had not been corrected. And after the second surgery my vision was not perfect because of astigmatism. I was very happy with my surgeries and I'm very sorry you had such a negative experience.
posted by Billiken at 9:42 AM on October 28, 2015

This is the detail that would convince me not to let go of this: "The surgeon indicated that he was the third person that day to complain about not receiving anesthesia." I think your best next step is to consult with a qualified lawyer in your jurisdiction.
posted by Corvid at 3:09 PM on October 28, 2015 [2 favorites]

I'd have to go with taff on this one. Very likely that the anaesthetist has a drug issue - either using or dealing.
posted by itsflyable at 4:47 PM on October 28, 2015

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