Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
18 July 2007

MEDICAL LEGAL DILEMMAS

            Last week’s column addressed questions of medical dilemmas.  They are many.  They call upon healthcare providers to figure out what to do when they don’t know what to do.  That question can be presented with equal gravity in the smallest clinic or the largest metropolitan hospital.

            But a new dimension of complexity is presented when LEGAL considerations are added to medical dilemmas.  Since truth is always stranger than fiction, the case below illustrates such a problem.

            The gentleman was 54-years old and pictured himself in very good health.  He was a very busy salesman who came to the emergency room one afternoon with horrible abdominal pain.  He told the physicians in the emergency room that he hadn’t seen a doctor since his military discharge physical 35 years ago.  He admitted to smoking two packs of cigarettes a day but said that he was well until the abdominal pain began in the last hour and it was horrible. 

            The physicians examining him quickly diagnosed an abdominal aortic aneurysm that had ruptured.  This is a situation that is 90% fatal even in centers with excellent surgical capability.  Fortuitously, it just so happened that a chief surgical resident was walking through the emergency room at the time the gentleman was diagnosed.  He and his surgical team were getting ready to make rounds on their multiple patients (many critically ill) on the surgical ward.   Instead, they recognized the medical emergency of this gentleman’s situation and that surgical team rolled his gurney into an emergency surgical suite that was always kept ready in this large metropolitan hospital.  There, anesthesia personnel immediately intubated him and provided adequate anesthesia.  The chief resident and the surgical team working with him heroically corrected the bleeding aneurysm in a 3½ hour operation.  The situation was complicated by the need for over 18 units of blood that were transfused and correction of the associated blood clotting defects.  The surgery had been successful and the patient was taken to the recovery room. 

The patient was still very obtunded as recovery of consciousness from anesthesia had not occurred yet. The patient required an artificial respirator until the anesthesia wore off.  Now it was 7:30 pm, the time of shift change in the recovery room.  The new personnel were getting information regarding the patients that they were going to be taking care of.  The surgical team bringing the patient from the operating room was fatigued.  Their day had been 13 ½ hours long already and they still had all of the rounds to go for the patients that should have been seen at 4:00 pm that afternoon.  The chief resident quickly briefed the recovery room personnel and he and his team then hurried off to complete their rounds that should have been started at 4:00 pm that afternoon.

            The recovery room personnel checked the patient over and everything seemed to be functioning appropriately.  The respirator was working, breathing for the patient who was beginning to wake up with slight movement of his arms and legs.

            When the patient was rechecked a few minutes later, the patient’ movements had disconnected the respirator from the endotracheal tube and he was not receiving respirations.  The respirator had been pumping air as it should but the air that the respirator had been pumping  simply went out into the room and not into the patient.  The respirator was quickly reconnected but the patient had no blood pressure and no pulse.  In spite of resuscitive efforts, he died.

            The cause of the problem was that the respirator had become disconnected and the patient virtually suffocated from inadequate air supply.  The chief resident was called back to the recovery room for the resuscitive effort which was unsuccessful.  As you might imagine, with the surgeons disappoint, frustration and anger, the soup hit the fan about that time with heated angry words flying everywhere.

            This problem of the respirator becoming disconnected from the endotracheal tube had  previously been encountered by the recovery room staff.  They had contacted the hospital administrators indicating that they needed alarm systems to alert the recovery room personnel when such an accident would occur.  The hospital administration had analyzed the situation and determined that alarm systems were not “cost effective”.  The directive from administration was that recovery room personnel were to remain alert to this problem and correct it when it occurred.

            So where does the responsibility for this gentleman’s death reside?  Some might take the position that the patient is victim of his own negliance for his risky lifestyle and neglect of his health maintenance.  Had this gentleman had a medical checkup, the aneurysm could have been found very easily and corrected prior to the disaster that occurred.

            Does the responsibility for his death rest on the surgeon who acted heroically even though “not on-call”?  The surgery was actually successful but like the captain of a ship, the surgeon is the one responsible for the patient’s welfare.  It is 7:30 pm at night, he is 3 ½ hours behind on his other duties and he is already fatigued from a 13 ½ hour day with at least 3 hours of responsibility in front of him.  Even so, should the surgeon have been more attentive?

            Should the hospital administration be held responsible?  They had determined that an alarm system that would have prevented this disaster was “not cost effective”.  Alarm systems for respirators were new at the time although now they are routine and contained on every respirator.

            Does the responsibility lie with the recovery room personnel who did not pick up the abnormality until it was too late?  Note that evening shifts are always understaffed for emergencies and the disaster occurred at one of their most vulnerable times (shift change). 

            Based on this case, alarm systems were finally applied to the hospital’s respirators.  Added personnel were provided for the evening shift.  Recovery room shifts became staggered so that not all of the personnel of the recovery room turned over at one time.  In the years since this case occurred, residents in surgical training have had their duty responsibilities shifted so as to avoid the heavy fatiguing duties and time conflicts they had previously.  However, for all of our efforts, no system will ever be perfect. 

            As you might imagine, this case was discussed over and over again in different hospital groups and I never knew just what the family was told.  Whatever settlement was made between the hospital and the family was never made public. Somehow the evening TV news never got wind of the case.  It would have made magnificent press as a heroic effort gone wrong due to such a tiny mishap and somebody’s negligence.  Such is the nature of medical legal dilemmas. 

This and other columns available at www.macpierre.com.