Problems Spark Debate
By Charles Ornstein, Times Staff Writer
February 24, 2003
Posted from but since removed
Infant Anesthesia Problems
At Kaiser in Woodland Hills, doctors say pediatric specialists are
needed. Hospital says a death and a near-death were aberrations.
By Charles Ornstein
Times Staff Writer
February 24, 2003
The soul-searching among anesthesiologists at
Kaiser Permanente's Woodland
Hills hospital began in 1999, after 2-month-old Grant Wray nearly died
as he was being sedated for hernia surgery.
Doubts grew the following year when 19-month-old
Jose Fajardo III suffered
throat spasms during anesthesia, then died.
General anesthesiologists at Woodland Hills
questioned whether they
could safely care for children so young; they implored hospital leaders
to send these patients elsewhere or hire pediatric specialists.
Hospital administrators said the two cases were
aberrations and strongly
defended using general anesthesiologists for pediatric surgeries. They
did, however, make some changes, such as enlisting neonatologists, who
specialize in caring for newborns, to help sedate the youngest infants.
Today, hospital officials and many of the
anesthesiologists remain at
odds. But the dispute has wider significance: It dramatizes a national
debate about how much training and experience anesthesiologists need to
safely care for young children.
Most experts agree that pediatric anesthesia is a
different from its adult counterpart, involving different equipment,
Children are not miniature adults. Their bodies
and reactions to anesthesia
are different, sometimes making surgery more difficult and risky,
Experts say that children fare better when their
doctors handle a steady
But many hospitals don't have such a stream of
patients, and pediatric
expertise is in short supply. As a result, some community hospitals
on general anesthesiologists for pediatric cases -- sometimes with the
help of neonatologists.
Task Force Formed
Several states, including California, have formed
task forces to study
the issue. California Children's Services, a state program that pays
specialized pediatric care, is considering a proposal to require
anesthesiologists to treat at least 25 infants and children annually.
"There's a general consensus among people ... that
who take care of kids all the time are more comfortable with what
doing and do a better job," said Dr. Mark Singleton, a San Jose
who is on the state's task force.
At Woodland Hills, doctors trace the turmoil to
what should have been
a routine hernia operation on a 2-month-old boy in November 1999.
At the start of the operation, anesthesiologists
were unable to get
enough air into Grant Wray's lungs, so they inserted a tube into his
according to medical records obtained by The Times with the permission
of Grant's parents.
The boy's heart rate slowed, and he had a cardiac
Grant's parents remember hearing the hospital's
a "code pink" in Operating Room No. 7, where Grant was. Moments later,
three doctors walked toward them in the waiting area.
" 'There's been complications,' " Kelly Wray
remembers the physicians
telling her. "My heart dropped. I thought he was gone at that point. I
thought he had died."
He nearly did. The OR staff called the neonatology
unit for help, performed
CPR and other procedures -- and the boy was revived.
In the child's medical record, pediatric
neurologist Dr. William Goldie
-- who examined Grant after he was stabilized -- wrote: "It is
to determine exactly what went wrong."
But an independent expert who reviewed Grant's
medical records for The
Times said he has a good idea: The anesthesiologist initially used a
tube that was too narrow to provide sufficient oxygen to a child of
age and weight.
"The tube size they put in clearly shows that they
didn't know what
they were doing," said Dr. William J. Greeley, chair of anesthesiology
and critical care medicine at Children's Hospital of Philadelphia, a
"You wonder about their capability if they can't
judge something as
simple as the right size tube," added Greeley, past president of the
for Pediatric Anesthesia.
Dr. Denise Emmons, the Kaiser anesthesiologist who
handled Grant's case,
declined to comment. Dr. Thomas Schares, the current chairman of the
department, was not at the hospital at the time of Grant's case, but
in a recent interview that the tube may have been too small.
Eight months after Grant's case, the Fajardo boy
was brought to the
outpatient surgery center at the Woodland Hills hospital for an
to correct a muscular condition that caused his eyes to wander.
Moments after anesthesia was delivered, the boy
experienced throat spasms,
according to medical records obtained by The Times, with his parents'
Doctors also had difficulty inserting an IV into his arm and getting
into his lungs.
This time, the patient died.
After reviewing Jose's records at The Times'
request, Greeley blamed
-- at least in part -- anesthesiologists' use of isoflurane, a pungent
anesthetic gas that irritates the airway and causes some children to
vocal-cord spasms. Several other gases are considered better and safer
to start anesthesia, he said.
"If you showed this to 100 anesthesiologists in
the country, I bet a
large majority would say that this is inappropriate," Greeley said.
anesthetic care is so egregious ... it's clearly injurious to the
Dr. Rodolfo Amaya, a former Kaiser
anesthesiologist who supervised Jose's
procedure, told The Times that a certified registered nurse anesthetist
gave the child isoflurane without his approval. He said the anesthetic
was quickly switched to sevoflurane, which is easier to tolerate.
The drug switch is not noted in the medical
In addition, Amaya said that he was unaware of a
noted in the medical records of Jose's Kaiser pediatrician: a
heart condition. Had he known, Amaya said, he would probably have given
the case to an anesthesiologist more experienced with children.
After an autopsy, a Los Angeles County coroner
listed a malformation
of Jose's pulmonary artery as the cause of death, and said the boy's
to anesthesia was a significant contributing factor.
In the months afterward, tensions at Woodland
Hills escalated. Early
last year, 11 of the hospital's 12 anesthesiologists wrote in an e-mail
to hospital administrators that they didn't feel comfortable handling
for babies and sick children.
"We have neither the resources nor relevant
experience to safely manage
these high-risk patients," they wrote on Feb. 7. "Either these patients
can be referred out to another Kaiser facility for their care, or this
medical center can contract with an outside pediatric anesthesia group
to provide anesthesia support services...."
The e-mail was written on the account of
anesthesiologist Dr. Robert
Watson, who declined to comment on its contents.
Three Woodland Hills anesthesiologists, who spoke
on condition that
they not be identified, told The Times that the problems cited in the
were never corrected to their satisfaction.
Woodland Hills administrators, however, say they
were careful to respond
to the issues raised by the death and near-death, and vigorously defend
the hospital's current practices.
After Grant Wray's case, the hospital began
requiring that neonatologists
be on hand for all surgeries involving babies younger than 4 weeks
if the baby is premature).
And after reviewing Jose Fajardo's case, the
hospital required that
anesthesiologists evaluate children days or weeks before surgery to
that doctors know about medical conditions that may pose complications.
Also, the hospital last year hired Schares, an
in pediatrics, as chairman of the department. He has handled some
cases there, but said he could not recall how many.
Kaiser officials said that Jose's death in 2000 is
the only pediatric
anesthesia-related fatality in the hospital's 16 years of operation.
also said that individual anesthesiologists can request an exemption
handling pediatric cases, but that none have.
"No patients have been put at risk in this medical
center. I wouldn't
allow it," said Dr. Jeffrey Weisz, the hospital's medical director.
Weisz said he believes the anesthesiologists'
objections stem from personal
resentments against management, not medical concerns.
"All of our anesthesiologists are qualified to
give superior care. That
doesn't mean they don't have trouble with their personalities," said
who was recently selected as medical director for all Kaiser's Southern
Though the dispute at Woodland Hills has at times
become personal, experts
say the broader issue is relevant to any hospital that anesthetizes
Research has shown that infants and young children
have a higher incidence
of complications from anesthesia, including cardiac arrest and death,
with adult patients. And two studies have suggested that infants cared
for by general anesthesiologists have a higher incidence of cardiac
and oxygen loss during surgery than those cared for by pediatric
But research hasn't determined exactly how much
experience is required
to produce better outcomes.
Kaiser officials say that all anesthesiologists
receive some training
during their residencies in caring for children.
Data compiled by the state, however, show that
Kaiser Woodland Hills have relatively little experience with young
The hospital performed 26 inpatient surgeries on children under age 1
2000, compared with 993 such surgeries at Children's Hospital Los
and 389 at UCLA Medical Center.
(Including outpatient surgeries, Kaiser Woodland
Hills says it handled
88 surgeries on children under age 1 in 2000, 48 in 2001, and 41 in
Fewer Young Patients
Many hospitals -- especially in rural areas --
don't get a high volume
of young surgery patients. And, as it is, the state doesn't have enough
pediatric anesthesiologists to go around, given that children account
about a quarter of all inpatient anesthesia cases.
Anesthesiologists themselves have different
notions of what should be
Singleton, who is advising the state, said general
can handle children's surgeries as long as they are comfortable doing
He doesn't object to neonatologists helping out,
but he said the anesthesiologists
should remain in charge.
But Dr. Randall Wetzel, chief of anesthesia and
critical care medicine
at Children's Hospital Los Angeles, said he's troubled by the use of
as a backup, except in rare cases, because they do not have broad
"If the anesthesiologist is uncomfortable with the
baby in the room
and the neonatologist thinks he has to be there, then the baby
be," he said.
Copyright 2003 Los Angeles Times