Ethical Question, regarding refusal to provide anesthesia

[sevo85288]

A colleague of mine this weekend had to do a CABG in a 55 y/o m. long h/o of IVDA, hep B,C, HIV, etc. My colleague was hesistant about lines, etc, and felt that he was placing himself and his family at jeapordy by doing the case. Do we have RIGHTS as physicians, or just RESPONSIBILTIES? Have you guys ever come across a case that you felt endangered you? How would you approach this situation.
Regards
SEVO

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[urge]

He is in the wrong business. He should get a desk job.

 

[coprolalia]

I don't get it. Was this an issue of universal precautions?

I've treated Hep C, HIV (etc.) patients, put lines in them (etc.) done their intubations (etc.) and you get it (etc.). I think this is an issue of ignorance, not self-endangerment. Forget for a second about the number of patients who come in with a productive cough... could be tuberculosis, after all, right? I'm with urge.

-copro

 

[Planktonmd]

From a legal point of view, I think you can refuse to treat any patient for any reason as long as there are other providers available, and your refusal is not going to cause harm to the patient.
On the other hand, refusing to treat a patient because you know they have blood borne infections is silly, because everyday you treat people who might have all kinds of infections and you don't even know it.

 

[deleted126335]

.

 

[cchoukal]

I have to admit, I've had thoughts like the one your colleague is expressing. Most recently, I had a patient transfer into our CT ICU with a type B dissection and she needed lines and an OR. She was a crack ***** with the hep and the hiv and she was not combative, per se, but not super cooperative. And I thought to myself, "one jerk of her head while I'm jamming this huge needle into her neck, and I'm toast. And all for someone who won't appreciate it, whose life thus far has been of marginal value, an in preparation for a surgery which has a good chance of a terrible outcome."

Honestly, I'm not really sure how I reconciled all that. it was in the middle of the night and I just did it because it "had to be done." I think what "has to be done" is actually pretty relative, but I guess in that case, as a resident, and in your colleague's case, as an anesthesiologist, it seems like that's a decision you don't get to make.

 

[gasnewby]

A colleague of mine this weekend had to do a CABG in a 55 y/o m. long h/o of IVDA, hep B,C, HIV, etc. My colleague was hesistant about lines, etc, and felt that he was placing himself and his family at jeapordy by doing the case. Do we have RIGHTS as physicians, or just RESPONSIBILTIES? Have you guys ever come across a case that you felt endangered you? How would you approach this situation.
Regards
SEVO

what a pansy. his risk is essentially zero with proper technique. try closing the sternum with steel sutures and then you can complain about risk.

 

[gasnewby]

She was a crack ***** with the hep and the hiv and she was not combative, per se, but not super cooperative. And I thought to myself, "one jerk of her head while I'm jamming this huge needle into her neck, and I'm toast.

If the patient doesn't cooperate = No line. Get whatever peripheral access you can and do the rest after induction. It's not worth sticking yourself or getting a pneumo b/c they're wriggling around.

She was a crack *****

Did you really write that?

 

[cchoukal]

I did because it's true. I like to ask my patients what they do for work/money. She and her mom sorta danced around it, but ultimately revealed that's how she got by.

peripheral access is always a good thought. She had a pretty crappy 22g from the OSH, but was going to need drips for BP control before getting her TEE to help decide whether she would go to surgery or not. She had ESRD on HD via a fistula, so her options for peripheral access were limited. In hindsight, I suppose maybe I could've looked harder for peripheral access. At the time, there was a lot of pressure to get access, get her drugs to get her BP down (200s/100s after 30 mg IV metoprolol) so a TEE could be done. I thought since she was going to need central access for the case anyway, I ought to just get after it.

 

[gasnewby]

gotta love how the outside hospitals send them with one 22...they should have started her on esmolol in the ER instead of farting around with increasing doses of lopressor.

she's on HD? then you're really screwed- probably no peripherals, can't go subclavian since you want to avoid central venous stenosis, can't go femoral b/c they may need groin access in the OR...i understand the need for central access, but if she's fighting you in the least, it's not worth it. and these disasters always come in the middle of the night.

did she end up going to the OR?

 

[cchoukal]

gotta love how the outside hospitals send them with one 22...they should have started her on esmolol in the ER instead of farting around with increasing doses of lopressor.

she's on HD? then you're really screwed- probably no peripherals, can't go subclavian since you want to avoid central venous stenosis, can't go femoral b/c they may need groin access in the OR...i understand the need for central access, but if she's fighting you in the least, it's not worth it. and these disasters always come in the middle of the night.

did she end up going to the OR?

She was helicoptered directly to the unit, so no chance for the ER to tune her up. It could be argued the OSH should've done a better job, but that argument is a fool's errand. And it was the middle of the night. And in truth, she wasn't fighting so much as just pissing and moaning a lot.

The escalating doses of metoprolol were mine. HR and BP didn't budge for 30 mg or so. Although she denied any recent crack use, I wondered if the metoprolol was just leaving her with unopposed alpha stimulation that was keeping the BP up, but since the HR was steady as a rock, and the BP didn't actually go UP, I thought this was less likely.

When I got access, she took esmolol, nifedipine, and, ultimately NTG before she came down (i wish I remembered the doses, but the esmo and nifedipine were maxed). I tried to be pretty aggressive because the cardiologists were pretty nervous about doing the TEE without adequate control. I'd say within an hour or so of rolling in, she was lined, controlled, and ready to rock. She ultimately went to the OR and had a really good outcome, despite her poor attitude. The day I gave her the boot from the unit, I saw this Sodoku book on her bed. She had done them all, even the really hard ones. Sometimes you just never know about people.

Anyway, didn't mean to hijack this thread. It's an interesting issue...

 

[climbingdocs]

wouldn't you want to do drug screen on someone like that before you give them beta blocker???

 

[Trisomy13]

whose life thus far has been of marginal value

thanks judge judy

try to remember you are seeing one snapshot in time of this person's life and not what led to her current situation.


having worked with many addicts, and having seen a few recover to go on and lead very productive lives with... value...

eh, whatever

 

[bigdan]

thanks judge judy

...he did give her credit for having done the Sudoku

 

[gasnewby]

Completing the advanced sudoku book is a requirement to obtain employment as a sicu nurse in my institution

 

[Trisomy13]

...he did give her credit for having done the Sudoku

which gives her a basic intelligence level at least on par with or greater than your typical OB nurse or Ortho resident.

 

[bubalus]

which gives her a basic intelligence level at least on par with or greater than your typical OB nurse or Ortho resident.

A stool sample has a basic intelligence level on par or greater than an ortho resident.

 

[climbingdocs]

A stool sample has a basic intelligence level on par or greater than an ortho resident.

 

[zippy2u]

Sevo, what you're dealing with is a certifiable "candy ass". Prolly prances around the hospital with a "male bag" and moussed up hair. Ride his a$$ every chance ya get.... Regards, ----Zip

 

[bubalus]

I took care of a heroin addict once. Used for 35 years. Hep B, Hep C, and HIV NEGATIVE. Clearly a smart dude. Taught me quite a bit about drugs (which you don't learn in a med school lecture, but is very applicable to the patient population I was working with) and also taught me a lot about not dismissing a heroin addict as an idiot.

 

[dhb]

Sevo, what you're dealing with is a certifiable "candy ass". Prolly prances around the hospital with a "male bag" and moussed up hair. Ride his a$$ every chance ya get.... Regards, ----Zip

HAHA

 

[Tenesma]

you guys will change your tune after you get a hollow bore deep needle stick with a patient with Hep B, Hep C AND HIV because the patient moved while putting in the line...

this happened to me during training and I had to take interferon and three anti-virals for 4 weeks (and the dosing for those meds was insane i was taking 7 pills in the AM, 5 at noon and another 8 at night) - until further PCR testing came back negative --- and not to mention the nausea from the meds and the peripheral neuropathy that lasted another 8 weeks... it seriously made me think about quitting medicine... thank god i never sero converted

so if it is an elective case then you can refuse to offer your care - just like the surgeon doesn't have to do the case...

just think of all the surgeons who refuse to do operations on Jehovah witnesses?

but if it is an emergency and your contract stipulates it then you got to do it...

 

[coprolalia]

You can take solace in the fact that the actual transmission rate is low. Of course, you are really and truly an idiot if you haven't gotten the Hepatitis B vaccine. And, you are doubly so if you don't take a good history as well as use extreme caution in a patient who's suspected of harboring a nasty virus.

The rate of occupational transmission from an HIV-positive source is believed to be 0.3% for a percutaneous exposure and 0.09% for a mucous membrane exposure. The rate of transmission from a hepatitis B-positive source to a nonimmunized host is 6-24% and 1-10% for exposure to hepatitis C.

http://www.emedicine.com/emerg/topic333.htm

-copro

 

[climbingdocs]

you guys will change your tune after you get a hollow bore deep needle stick with a patient with Hep B, Hep C AND HIV because the patient moved while putting in the line...

You are lucky.

I used to work in OR monitoring EMGs, SSEPs, BAERs etc, so I had to place bunch of needle electrodes in patients. At the end of the surgery I had to pull them out fast and they would get all tangled up. So few times when patients was HIV positive, surgeons just told me not to worry about monitoring and send me home. I got stuck before though and had to take HIV drugs but only 48 hours till they tested the patient and she turned out to be negative. But that was scary 48 hours

So when you convert can you still practice???

 

[coprolalia]

I used to work in OR monitoring EMGs, SSEPs, BAERs etc, so I had to place bunch of needle electrodes in patients. At the end of the surgery I had to pull them out fast and they would get all tangled up. So few times when patients was HIV positive, surgeons just told me not to worry about monitoring and send me home. I got stuck before though and had to take HIV drugs but only 48 hours till they tested the patient and she turned out to be negative. But that was scary 48 hours

Those are not hollow needles, so the transmission rate is even lower.

So when you convert can you still practice???

Yes. You are then covered by the ADA.

-copro

 

[gasnewby]

So when you convert can you still practice???

i think if you operate, you have to inform the patient...maybe somebody else can help me remember.

 

[climbingdocs]

Those are not hollow needles, so the transmission rate is even lower.

Yeah, but when it's you it's still scary. Plus it was before med school, I didn't really know. Now I know

 

[coprolalia]

Yeah, but when it's you it's still scary. Plus it was before med school, I didn't really know. Now I know

Hey, I'm not arguing that it's not an "oh ****!" moment. But, you do have some comfort in knowing that the transmission rate, even with an accidental stick, is extremely low.

There is an irony in the human condition here, too. People perceive certain things to be "risky" when they clearly aren't, yet proceed to do blithely do things that are incredibly risky thinking that something bad will never happen to them. This has to do with perceived "control" over the situation and fear of loss of control and the unknown (i.e., why people are scared to fly on planes but will drink 8 beers at a bar, climb into their car afterwards, and drive home at 80 mph not wearing their seatbelt).

There was a program I saw recently that talked about shark attack rates. After a shark attack in an area, people are (probably understandably) scared to go into the water afterwards. But, this commercial says it all...

[YOUTUBE]http://uk.youtube.com/watch?v=F7BPxI4N-go[/YOUTUBE]

http://uk.youtube.com/watch?v=F7BPxI4N-go
-copro

 

[climbingdocs]

Hey, I'm not arguing that it's not an "oh ****!" moment. But, you do have some comfort in knowing that the transmission rate, even with an accidental stick, is extremely low.

There is an irony in the human condition here, too. People perceive certain things to be "risky" when they clearly aren't, yet proceed to do blithely do things that are incredibly risky thinking that something bad will never happen to them. This has to do with perceived "control" over the situation and fear of loss of control and the unknown (i.e., why people are scared to fly on planes but will drink 8 beers at a bar, climb into their car afterwards, and drive home at 80 mph not wearing their seatbelt).

There was a program I saw recently that talked about shark attack rates. After a shark attack in an area, people are (probably understandably) scared to go into the water afterwards. But, this commercial says it all...

[YOUTUBE]http://uk.youtube.com/watch?v=F7BPxI4N-go[/YOUTUBE]

http://uk.youtube.com/watch?v=F7BPxI4N-go
-copro

very true, I completely agree

 

[numbmd]

Hey, I'm not arguing that it's not an "oh ****!" moment. But, you do have some comfort in knowing that the transmission rate, even with an accidental stick, is extremely low.

There is an irony in the human condition here, too. People perceive certain things to be "risky" when they clearly aren't, yet proceed to do blithely do things that are incredibly risky thinking that something bad will never happen to them. This has to do with perceived "control" over the situation and fear of loss of control and the unknown (i.e., why people are scared to fly on planes but will drink 8 beers at a bar, climb into their car afterwards, and drive home at 80 mph not wearing their seatbelt).

There was a program I saw recently that talked about shark attack rates. After a shark attack in an area, people are (probably understandably) scared to go into the water afterwards. But, this commercial says it all...

Dude, if you haven't yet, you need to read Freakonomics. It's up your alley.