Ethical Question Regarding Errors in Care and the Poor

[RxnMan]

Here's the situation: Volunteer is working in the ER one night and watches a doc (a psych on first night of ER rotation) suture up a patient's hand. Patient had fallen on an outstretched hand onto a broken bottle, cutting three of his fingers down to the bone, just distal of where they join the hand. The patient is drunk and is poor/homeless.

Volunteer notices two things:

1) The doc is using deep sutures on the hand. To the volunteer's knowledge, this is poor procedure because the suture will often snag a tendon and restrict the movement of the patient's finger. Furthermore, the doc does not remember how to tie the knots until the volunteer shows him.

2) Halfway through the procedure, but the volunteer notices that the patient has not been given anesthetic. The volunteer tells the doc, who then checks the patient's neurological function. Only then does doc discover that the patient has no feeling in any of the injured extremities. The doc decides to proceed with suturing.

What would you do if you were the volunteer?

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[bootz]

That's a tough one. First of all, I would communicate with the patient while the doc and others are in the room to make sure that everyone hears what the patient is feeling. As a volunteer, you should try to be an advocate for the patient, but you have no authority to question what the doctor is doing. By having the patient communicate their problem, you eliminate having to question the doctor and also allow others (possibly superiors) to hear what is going on. In the hospital that I volunteered in charge nurses had the ability to write up people.

As for the acutal technique, the minute the doctor asked you for help you should have said that you didn't know even though you did. Then you should have gone for help. You are a volunteer, not a doctor, and the knot that you showed the doctor could have been the wrong one. This could have led to legal action against the hospital... If you are volunteer, you cannot do anything invasive and the doctor doing the suturing should be reminded of this fact.

The patient's socioeconomic status has no bearing in the example. The doctor is just being careless. You can't assume discrimnation based on the evidence given. It is the doctor's first day.

 

[gottalovemilk]

the doctor is an idiot. report him to the ER administrator showing what he did and the chart will support your story on the doctors inaccuracy in properly diagnosing and treating the patient. then, try to push to have the docs previliges at the ER revoked. i little harder since you are only a volunteer and the ER admin and other docs would be the one that would have to initiate the process, etc etc. beaucracy sucks.

 

[Rafa]

What would you do if you were the volunteer?

Get the hell out of there.

 

[RxnMan]

That's a tough one. First of all, I would communicate with the patient while the doc and others are in the room to make sure that everyone hears what the patient is feeling.

Patient was drunk to the point of incoherence - he couldn't put together this complex of a thought.

...but you have no authority to question what the doctor is doing. By having the patient communicate their problem, you eliminate having to question the doctor and also allow others (possibly superiors) to hear what is going on. In the hospital that I volunteered in charge nurses had the ability to write up people.

This is key - the volunteer has no authority. As above, the patient had no ability to make his wishes known. Furthermore, at the hospital in question, the policy on reporting errors was not available to volunteers.

...the minute the doctor asked you for help you should have said that you didn't know even though you did.

The doc asked "How do you tie an overhand knot?", not "How do I start this procedure?" One is common knowledge, the other not.

Then you should have gone for help.

This also presumes that the volunteer knows more than the doc. This is not the case (as it would appear in court), as one was a uncertified volunteer and the doctor was a degreed professional.

The patient's socioeconomic status has no bearing in the example. The doctor is just being careless. You can't assume discrimnation based on the evidence given.

I disagree. Docs make decisions for people (who cannot make decisions for themselves, e.g. drunk, psychotic,) all the time. But despite obvious gaps in knowledge and serious procedural errors, the doc in question pressed on. Other, more experienced physicians were within a moment's reach if he wanted help. I think the patient's poverty and low likelihood (sp?) of coming back pushed the doc's decision to not admit failure and not get help.

It is the doctor's first day.

Not exactly. This guy was on a mandatory ER rotation as a part of his being an ER psychiatrist. He had already completed his residency. Forgetting that, he should know how to suture from his clinical rotations during 3rd and 4th year of med school.

 

[Law2Doc]

Patient was drunk to the point of incoherence

Perhaps this is the reason the doc chose not to use anesthetic? Why run up charges for a superficial procedure on a patient who is feeling no pain already.
As for the procedural stuff, none of us saw what happened and are going on your word that the stitching was abberant. But if you are correct, it may well have been a crummy doctor -- I see no evidence of the patients socioeconomic status having any bearing. This doctor may not be any good at stitching or tieing nots, whether his "victim" be rich or poor. I'm sure there are whistleblower procedures in any medical center where you can report what you saw to an administrator.

 

[RxnMan]

Perhaps this is the reason the doc chose not to use anesthetic? Why run up charges for a superficial procedure on a patient who is feeling no pain already.

You're missing the point: This lapse in care was only found out well into the procedure (e.g. the doc did not check before starting. What would happen to a surgeon that cut into a patient before knocking them out?) and tells you that the patient's nerves were cut. After an intial screening, anyone could see that an experienced hand surgeon, not some psych guy on scut detail, should have seen the patient. This goes to the question of socioeconomic status. Give the poor guy sub-par care because he'll never pay for it anyways.

As for the procedural stuff, none of us saw what happened and are going on your word that the stitching was abberant. But if you are correct, it may well have been a crummy doctor -- I see no evidence of the patients socioeconomic status having any bearing. This doctor may not be any good at stitching or tieing nots, whether his "victim" be rich or poor. I'm sure there are whistleblower procedures in any medical center where you can report what you saw to an administrator.

Yes, we are going on my retelling of the situation. The point of this post was to place readers in the difficult position where they had knowledge of something going wrong and were motivated to stop it, but were seemingly powerless to do so. The facts are stated to create a situation. Questioning their veracity defeats the purpose of the exercise.

Does anyone have any useful comments?

 

[Law2Doc]

Does anyone have any useful comments?

I think my last sentence on the whistleblower procedure is the only useful comment anyone could give you.
[Reading between the lines here: If there's another option you are hoping someone will suggest, then air it out and we will tell you why it's not advisable.]

 

[noonday]

i would say to the doc: "listen, i know i'm only a volunteer, not a doctor, but something doesn't seem right here. if the patient has no movement or feeling in the extremity past the wound, doesn't that mean that the nerves have been cut? it seems to my layperson eyes that maybe there's more going on than just a cut that needs suturing. i know you're new to this ER, would you like me to get the charge nurse to call for the hand surgeon? i only ask because i know that if someone came in having a schizophrenic break, you'd want to be called instead of having, say, an OB?GYN deal with them, and part of my job as a volunteer to to help make sure thing run smoothly and that both the doctors and patients get what they need."

if the doc did not respond positively to that, i would say "listen, again, i'm not a doctor. but i'm a human being who's had medical care and who's watched medical care being given, and i KNOW that what's going on here is not right. you need to stop what you're doing and get someone else. this patient is passed out and can't stand up for his right to comprehensive care, so i'm doing it for him."

again, if no stopping, i would leave the room, talk to the doc's supervisor, find a way to file a complaint formally, and if there was no way or if that complaint just got filed and never read/acted upon, quit the position and either write a letter to the local newspaper revealing the incident publically.

but that's me.

 

[Apparition]

i would say to the doc: "listen, i know i'm only a volunteer, not a doctor, but something doesn't seem right here. if the patient has no movement or feeling in the extremity past the wound, doesn't that mean that the nerves have been cut? it seems to my layperson eyes that maybe there's more going on than just a cut that needs suturing. i know you're new to this ER, would you like me to get the charge nurse to call for the hand surgeon? i only ask because i know that if someone came in having a schizophrenic break, you'd want to be called instead of having, say, an OB?GYN deal with them, and part of my job as a volunteer to to help make sure thing run smoothly and that both the doctors and patients get what they need."

if the doc did not respond positively to that, i would say "listen, again, i'm not a doctor. but i'm a human being who's had medical care and who's watched medical care being given, and i KNOW that what's going on here is not right. you need to stop what you're doing and get someone else. this patient is passed out and can't stand up for his right to comprehensive care, so i'm doing it for him."

again, if no stopping, i would leave the room, talk to the doc's supervisor, find a way to file a complaint formally, and if there was no way or if that complaint just got filed and never read/acted upon, quit the position and either write a letter to the local newspaper revealing the incident publically.

but that's me.

 

[MN81]

In my experience, a volunteer's opinion/recommendation is about as useful as a third butt cheek.



Somebody please add Chuck Norris to this thread...

 

[RxnMan]

In my experience, a volunteer's opinion/recommendation is about as useful as a third butt cheek.



Somebody please add Chuck Norris to this thread...

Volunteers don't amount for much. One look from Chuck Norris and they spontaneously combust!

 

[bootz]

Somebody please add Chuck Norris to this thread...

For real. This thread should be moved to the ethics forum anyways.

 

[Rafa]

Chuck Norris uses cobra fangs for stitches.

 

[McDoctor]

Said vollunteer is an outtstanding advocate for the patient no doubt.

That being said, I'm curious which major nerves were severed in this patient's fingers that would have precluded closure of the wound. Median?, Ulnar? Radial? I thought the lacerations were on the patients fingers, which are supplied by superficial branches of the median nerve. What nerve is being compromised in this scenario? Surely the critical eye of the vollunteer in this scenario is well versed on the neuroanatomy of the hand.

I'm going to have to go ahead and give the physician some benefit of the doubt here and assume that the integrity of the tendon was assessed (would not necessarily have been done in the presence of the vollunteer) before the patient was blindly sutured. I would respect the knowledge and training of the physician enough to let him complete his procedure and address any concerns either before or after, not during the procedure.

I'm not sure what ethical question is being posed. Sounds like a vollunteer who is admittedly not well versed in delicate anatomy of the hand lacks confidence in the ED physician of the institution on his/her particular shift. An uncomfortable position to be in without a doubt, but not quite an earth shattering genesis for ethical ponderance and discourse.

 

[BKN]

Here's the situation: Volunteer is working in the ER one night and watches a doc (a psych on first night of ER rotation) suture up a patient's hand. Patient had fallen on an outstretched hand onto a broken bottle, cutting three of his fingers down to the bone, just distal of where they join the hand. The patient is drunk and is poor/homeless.

Volunteer notices two things:

1) The doc is using deep sutures on the hand. To the volunteer's knowledge, this is poor procedure because the suture will often snag a tendon and restrict the movement of the patient's finger. Furthermore, the doc does not remember how to tie the knots until the volunteer shows him.

2) Halfway through the procedure, but the volunteer notices that the patient has not been given anesthetic. The volunteer tells the doc, who then checks the patient's neurological function. Only then does doc discover that the patient has no feeling in any of the injured extremities. The doc decides to proceed with suturing.

What would you do if you were the volunteer?

I think you're mixing up questions of competence and questions of ethics.

Here is what I think (EM attending 30 years):

1. The examination of an injured forearm or hand is far more important than suturing technique. The physician must see the bottom of the wound, all structures within it, remove any foreign material and with the patient's cooperaton do a careful functional exam for tendon and nerve injury.
2.A drunken patient is incapable of cooperating for the exam and will be for many hours. Often exams attempted on them give very confusing deficits which disapppear when they're sober.
3. Relatively few physicians are competent to do this exam, senior residents or above in surgery, orthopedics, plastics and EM. A psychiatrist who doesn't remember how to throw an overhand knot is almost surely not able to do the exam.
4. Exposed major structures (arteries, veins, tendons and nerves) must not dry out-they will die and function will be lost. They must be covered.
5. Immediate repair of tendon or nerve lacerations is not necessary.

So at the end of the day, with a completely drunken patient, the correct approach is to have the most experienced EP or the orthopedist to explore the wound as well as possible. If no major structure is seen to be injured, the skin is closed. When the patient is sobered up a proper functional exam can be done.

The only ethical question here is supervision. Why is a psychiatrist on a EM rotation doing major wound care without supervision? If there was no supervision available, closing the skin for later evaluation by an orthopedist when the patient is sober is exactly the correct approach.

As to what you should have done, feeling that something was wrong. All you could do is go talk to the attending. If this guy is truly alone in the ED, you are in the wrong place.

 

[QuikClot]

Seems like there are a couple different questions here, and the answers are pretty easy if you consider them seperately:

A) Medical: What would be the correct care?

-- The above post is great! Thanks for the lowdown.

B) Ethical: What if someone far above you in the hirearchy appears to be doing something seriously stupid/careless/unethical?

-- You give them the opportunity to explain, and if the explaination doesn't satifsy you, you make a stink. This could cost you, but it is obviously the right thing to do -- it's idiotic to pretend that all physicians are such evolved beings that a volunteer is never going to catch them in a serious mistake.