Saturday, September 30, 2006
The botched student intubation continued
Thanks to various commenters from the prior post for the links.Apparently the patient didn't want any student touching her. More details:
Mullins sued because several weeks before the procedure, her surgeon, Dr. Marvin E. Eastlund provided her with an informed consent document on which she indicated she did not want health care students in the operating room.Also, the student was studying to be an EMT and the intubation was part of her training. This case was her first live intubation:
"Whose responsibility is it when a patient says they donÂt want a learner to ensure that?" Chief Justice Randall T. Shepard asked.
The injury occurred when the student tried to intubate Mullins. An intubation is a common medical procedure where a tube is inserted into a patientÂs throat to ensure that airways remain open during surgery.
But the damage required a second surgery and required Mullins to spend more than a month in the hospital recovering.
Mullins also signed a document from anesthesiologist Dr. Kathryn Carboneau that said only Carboneau or "a physician privileged to practice" anesthesia care would perform specified duties.
VanHoey made two attempts to intubate Ruth using a laryngoscope. After her second attempt, both Dr. Carboneau and Dr. Eastlund saw blood on the type of the laryngoscope, but apparently, the presence of blood on the laryngoscope following intubation is not unusual, and neither doctor was alarmed at the time. After VanHoey failed to intubate Ruth successfully, Dr. Carboneau performed the procedure and completed RuthÂs anesthesia.More than the issue of battery, is the issue of consent - which the patient clearly stated that she didn't want any teaching to be done on her.
On December 6, 2000, two days after RuthÂs hysterectomy, the attending nurse noticed that RuthÂs face and neck were beginning to swell. After running some tests, Dr. Carboneau, Dr. Eastlund, and Dr. John Csicsko, a cardiovascular surgeon, met with Ruth to explain that VanHoey had lacerated RuthÂs esophagus when she attempted to perform the intubation procedure. The doctors explained to Ruth that she needed to undergo another surgical procedure to repair the damage to her esophagus. Although Ruth was reluctant to undergo another surgical procedure because she had just undergone the hysterectomy, the doctors strongly encouraged her to have the procedure that day because waiting until the next day could have been fatal. Thus, on the same day, Ruth had surgery to repair her esophagus, and as a result of this second procedure, she had to remain in the hospital for over a month until her dismissal on January 5, 2001.
Posted by Kevin |
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Comments:
There is a shared responsibility between physician and patient if the patient wishes to alter a hospital's standard operating procedure.
When a patient shows up to my university hospital it should be quite obvious to all that trainees of various levels of qualification and certification will participate in their care.
If the patient wishes a particular service to alter its routine practices for who does what then the patient should express their wishes. Talking to the surgeon or making notation on the surgical consent is not sufficient notice to alter the pratices of other physicians, such as the anesthesiologist. In this case it is alleged that a written consent was obtained for the anesthesia care specifying who could do what. In the absence of an unforseen emergency there should then be no deviation from the agreed plan.
I always insist that my non-anesthesia residents (emergency medicine, pediatrics, cardiology fellows, critical care fellows etc.) introduce themselves to the patient/family as part of the consent process. The anesthesia resident or fellow always meets the family preoperatively so their presence also is known.
Whenever a family objects to resident physician care I describe the attending/resident care team model again. If they still defer resident care then the case is delayed until I can personally perform things myself. Of course there is a down side they might not have forseen, but when working solo I will routinely start the IV in the child awake rather than do an inhalation induction without anyone available to assist with either the IV or airway.
When a patient shows up to my university hospital it should be quite obvious to all that trainees of various levels of qualification and certification will participate in their care.
If the patient wishes a particular service to alter its routine practices for who does what then the patient should express their wishes. Talking to the surgeon or making notation on the surgical consent is not sufficient notice to alter the pratices of other physicians, such as the anesthesiologist. In this case it is alleged that a written consent was obtained for the anesthesia care specifying who could do what. In the absence of an unforseen emergency there should then be no deviation from the agreed plan.
I always insist that my non-anesthesia residents (emergency medicine, pediatrics, cardiology fellows, critical care fellows etc.) introduce themselves to the patient/family as part of the consent process. The anesthesia resident or fellow always meets the family preoperatively so their presence also is known.
Whenever a family objects to resident physician care I describe the attending/resident care team model again. If they still defer resident care then the case is delayed until I can personally perform things myself. Of course there is a down side they might not have forseen, but when working solo I will routinely start the IV in the child awake rather than do an inhalation induction without anyone available to assist with either the IV or airway.
Certainly sounds fair. I suppose if the patient/family only wanted certified specialists and no residents, and there was a need for a second person--such as you describe with a child IV awake vs anaesthetized-- then the added personnel resources should be charged to the patient, if that kind of support would not otherwise ordinarily be covered. Advance beneficiary notice ought also be included in the discussion before that procedure.
Extraordinary demands should have to bear the additional costs too. That too is only fair.
Extraordinary demands should have to bear the additional costs too. That too is only fair.
Patients retain the right to be treated by professionals who have completed training, even in the setting of a teaching hospital.
Most hospitals include this fact in their patient "bill of rights". It IS "standard operating procedure."
FWIW, the issue of "battery" IS one of consent. It is the core of a battery claim.
This woman was severely harmed by an unpermitted touching.
Most hospitals include this fact in their patient "bill of rights". It IS "standard operating procedure."
FWIW, the issue of "battery" IS one of consent. It is the core of a battery claim.
This woman was severely harmed by an unpermitted touching.
This incident of the botched student intubation took place at Parkview Hospital in Indiana. Below is the link to the Hospital's Patient Rights and Responsibilities statement:
http://www.parkview.com/body.cfm?id=409&oTopID=409&PLinkID=201
In the first section of this document on patient care decisions, there is the following:
"(the patient has the right to) Know of any experimental, research or educational activities that may affect your care or treatment and the right to refuse to take part. "
So, by the hospital's own standards, which they state are in accordance with Indiana's laws, the patient in this intubation case had the right to know that a EMT-to-be would be involved in her care. And the patient also had the right to refuse to take part in this educational activity.
Are these hospital statements really meant to be followed, or are they just so much window-dressing, only meant to fool the public into a false sense of security?
http://www.parkview.com/body.cfm?id=409&oTopID=409&PLinkID=201
In the first section of this document on patient care decisions, there is the following:
"(the patient has the right to) Know of any experimental, research or educational activities that may affect your care or treatment and the right to refuse to take part. "
So, by the hospital's own standards, which they state are in accordance with Indiana's laws, the patient in this intubation case had the right to know that a EMT-to-be would be involved in her care. And the patient also had the right to refuse to take part in this educational activity.
Are these hospital statements really meant to be followed, or are they just so much window-dressing, only meant to fool the public into a false sense of security?
It doesn't really matter what the standard of the hospital is. If patients are given the informed consent to sign, that leads people to believe that care by medical students is optional.
" that leads people to believe that care by medical students is optional." Clare is correct here.
But the caveat still remains that when you elect to come to a teaching hospital where the delivery of care integrally relys upon the participation of trainees of various levels of experience (and varying levels of direct supervision) that asking for special treatment, that is attending only, will inevitably lead to delays and other issues forseen as well as unforseen related to receiving non-standard care.
But the caveat still remains that when you elect to come to a teaching hospital where the delivery of care integrally relys upon the participation of trainees of various levels of experience (and varying levels of direct supervision) that asking for special treatment, that is attending only, will inevitably lead to delays and other issues forseen as well as unforseen related to receiving non-standard care.
There seems to be a clear beliefe here that people who go to a teching hospital do so with the full knowledge and understanding of exactly what that implies.
We all know this isn't true.
Hell, half the people don't even understand the medical procedures they will go through.
Now it seems some folks are expecting uneducated members of the public who don't necessarily have an understanding of how the medical training system work, to... what? See the words "teaching hospital" somewhere in the building (it's almost never a part of the hospital name, FWIW) and magically coprehend that there is ___% change a medical student or other rainee will perform ___ procedure, with/without supervision by ___ doctor?
Come on; isn't this obviously a bit silly? The whole "EVERYONE knows that...." angle only works when, well, everyone DOES know.
And it's moot here anyway. Everyone knows that hospitals give epidurals to most ptients. What on earth does that have to do with whether a certain patient gets one when she does/does not want it?
We all know this isn't true.
Hell, half the people don't even understand the medical procedures they will go through.
Now it seems some folks are expecting uneducated members of the public who don't necessarily have an understanding of how the medical training system work, to... what? See the words "teaching hospital" somewhere in the building (it's almost never a part of the hospital name, FWIW) and magically coprehend that there is ___% change a medical student or other rainee will perform ___ procedure, with/without supervision by ___ doctor?
Come on; isn't this obviously a bit silly? The whole "EVERYONE knows that...." angle only works when, well, everyone DOES know.
And it's moot here anyway. Everyone knows that hospitals give epidurals to most ptients. What on earth does that have to do with whether a certain patient gets one when she does/does not want it?
There seems to be a clear beliefe here that people who go to a teching hospital do so with the full knowledge and understanding of exactly what that implies.
We all know this isn't true.
Hell, half the people don't even understand the medical procedures they will go through.
Now it seems some folks are expecting uneducated members of the public who don't necessarily have an understanding of how the medical training system work, to... what? See the words "teaching hospital" somewhere in the building (it's almost never a part of the hospital name, FWIW) and magically coprehend that there is ___% change a medical student or other rainee will perform ___ procedure, with/without supervision by ___ doctor?
Come on; isn't this obviously a bit silly? The whole "EVERYONE knows that...." angle only works when, well, everyone DOES know.
And it's moot here anyway. Everyone knows that hospitals give epidurals to most ptients. What on earth does that have to do with whether a certain patient gets one when she does/does not want it?
We all know this isn't true.
Hell, half the people don't even understand the medical procedures they will go through.
Now it seems some folks are expecting uneducated members of the public who don't necessarily have an understanding of how the medical training system work, to... what? See the words "teaching hospital" somewhere in the building (it's almost never a part of the hospital name, FWIW) and magically coprehend that there is ___% change a medical student or other rainee will perform ___ procedure, with/without supervision by ___ doctor?
Come on; isn't this obviously a bit silly? The whole "EVERYONE knows that...." angle only works when, well, everyone DOES know.
And it's moot here anyway. Everyone knows that hospitals give epidurals to most ptients. What on earth does that have to do with whether a certain patient gets one when she does/does not want it?
"More than the issue of battery, is the issue of consent..."
To elaborate on sarahw's comment, "consent" is a defense to the tort/crime of "battery". A battery being an offensive/harmful touching, the defense of consent occurs most often in medical and sports contexts.
"Informed consent" is a completely different animal, however. Lack of informed consent is neither a tort nor a crime, although informed consent may be required by statute and/or administrative regulations and/or ethics codes.
Both require signatures on pieces of paper written by lawyers. Thus the confusion. That and the shared word, "consent".
Just in case you were wondering.
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To elaborate on sarahw's comment, "consent" is a defense to the tort/crime of "battery". A battery being an offensive/harmful touching, the defense of consent occurs most often in medical and sports contexts.
"Informed consent" is a completely different animal, however. Lack of informed consent is neither a tort nor a crime, although informed consent may be required by statute and/or administrative regulations and/or ethics codes.
Both require signatures on pieces of paper written by lawyers. Thus the confusion. That and the shared word, "consent".
Just in case you were wondering.
