Manipulation Under Anesthesia in a Solo Chiropractic Office
Dr. K is a Hawaii-licensed chiropractor in solo practice. A 38-year-old patient has adhesive capsulitis and has not improved after six weeks of office adjustments and home exercises. Dr. K proposes manipulation under anesthesia (MUA) in his office. He contracts with a certified registered nurse anesthetist (CRNA) to administer propofol; no physician or anesthesiologist will be present. The office has a treatment room, oxygen, and a crash cart, but it is not licensed as an ambulatory surgery center. Dr. K plans to advertise pain-free adjustments while you sleep and to bill the patient's medical insurer using MUA codes. The CRNA asks Dr. K to sign a supervision agreement. Dr. K has completed a weekend MUA certification course and believes this brings the procedure within his scope. The patient has not been told that anesthesia carries risks of aspiration, respiratory depression, and death, and has not signed an anesthesia consent. The clinic receptionist has already scheduled three more MUA cases for next month.
1. Does Hawaii chiropractic licensure authorize Dr. K to perform or supervise office-based MUA? Analyze the scope question and the CRNA supervision issue.
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No. The threshold question is not whether Dr. K completed a weekend course; it is whether the Hawaii chiropractic license reaches the conduct. HRS chapter 442 defines chiropractic practice around the adjustment of articulations of the body by manual or mechanical means, with limited adjunctive procedures recognized by board rule. Anesthesia is not an adjustment, and a private certification course cannot enlarge the statutory scope. Administering propofol and managing anesthesia are activities governed by other licensure laws, not by the chiropractic license.
The CRNA issue is separate but equally fatal. A CRNA's authority to provide anesthesia depends on compliance with Hawaii nursing law and any required physician supervision or collaboration. Dr. K, as a chiropractor, is not a physician and cannot supply that supervision. Signing a supervision agreement would not cure the problem; it would document an arrangement outside both licenses. The office also is not licensed as an ambulatory surgery center, so the facility, monitoring, and emergency-transfer standards for anesthesia are absent.
The Board is likely to view the plan as unprofessional conduct and as aiding unlicensed activity. The correct course is to cancel the scheduled cases, refer the patient to an appropriate physician or facility, and not advertise MUA as a chiropractic service.
2. What informed-consent and advertising problems exist, and what should Dr. K tell the three scheduled patients?
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The informed-consent problem is not solved by the chiropractic consent form. Anesthesia has its own material risks, including aspiration, respiratory depression, failed airway, and death. The person administering anesthesia must obtain anesthesia consent or confirm that a qualified provider has done so; a chiropractor who is not trained or licensed in anesthesia should not be the one explaining anesthesia risk as though it were routine chiropractic care. The patient also needs alternatives: continued conservative care, referral to orthopedics, and corticosteroid injection or surgery evaluation where appropriate.
The advertising is misleading because pain-free adjustments while you sleep implies a benign sleep-like experience and omits anesthesia risk. Advertising must be accurate, not create an unreasonable expectation, and not promote services outside the licensee's scope. Dr. K should withdraw the ads immediately.
For the three scheduled patients, Dr. K should personally contact each one before the appointment, explain that the office cannot provide anesthesia-based MUA, cancel the procedure, and refund any prepayment. He should offer a referral and document the conversation. He should not let staff merely reschedule them or describe the cancellation as a temporary equipment problem.
3. If the Board opens an investigation, what should Dr. K do and not do?
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Dr. K should treat the Board inquiry as a legal proceeding from the first contact. He should retain all scheduling records, advertisements, consent forms, emails with the CRNA, and financial records; suspend any routine destruction; and notify his malpractice carrier. He should respond through counsel within the time allowed, answer factual questions truthfully, and avoid volunteering opinions about scope that he cannot support.
He should not alter or backdate records, create a new consent form for a procedure that was never performed, ask staff to change their memories, or contact the patient to discourage a complaint. Retaliation or record alteration typically becomes a separate disciplinary problem.
Under HRS chapter 436B, the Board may investigate, issue a notice of hearing, and proceed to a contested case if the matter is not resolved. Dr. K has rights to notice, counsel, presentation of evidence, and cross-examination. Early cooperation and corrective action can affect sanctions, but they do not guarantee dismissal. Possible outcomes include reprimand, fine, probation, CE, practice restrictions, or suspension.