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MDLinxCRNA Wearing White Coat Administers Fatal Treatment

A fatal case at a Texas surgical center highlights critical concerns regarding scope of practice, patient understanding of provider credentials, and safety protocols in outpatient procedures. The incident, involving a 42-year-old patient who received anesthesia during a rhizotomy procedure, raises important questions about provider identification and emergency response protocols in ambulatory settings.


Key Points:

  • A CRNA administered anesthesia during a rhizotomy procedure at Integrity Wellness (now Cedarwood Surgical Center), where the patient never regained consciousness after experiencing complications attributed to improper administration causing muscle paralysis that prevented breathing
  • Emergency response was delayed as the second CRNA present failed to recognize the patient’s lack of pulse and breathing until after the procedure was completed, with EMS describing the facility as “chaotic and unorganized”
  • Patient identification of provider credentials was compromised by the CRNA’s attire (white coat/scrubs), leading to confusion about the provider’s role and qualifications
  • Despite prior workplace concerns about one CRNA’s behavior at another facility in 2019, no disciplinary actions or complaints were documented in their record
  • The case highlights systemic issues in outpatient surgical centers regarding emergency preparedness, provider identification, and supervision protocols

“The problem is largely marketing to patients that they are receiving equivalent care when they see a non-physician practitioner.”
– Sulagna Misra, MD, BCMAS


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