Читать книгу Bad Blood - James Baehler - Страница 6

Dr. Andrew Lassiter, chairman of the surgical committee, reviewed Victor Wallberg’s chart, presented the details to the committee to familiarize them with the case and to provide an opportunity to ask questions. Five days after the death of Victor Wallberg, Harris was called before the committee. Lassiter opened the discussion. He was a seventy-year-old general surgeon who still worked part time. At his age, and by medical staff rule, he was no longer allowed to take emergency room call. He was a soft-spoken, plain-looking man with a subtle sense of humor, well respected by hospital personnel. He had been chairperson of the surgical case review committee for twelve years, a position he held at the insistence of the surgeons who recognized him as totally impartial, knowledgeable, and honest.

“I thoroughly reviewed your case Cliff,” Lassiter said, “I’ve had a few congenital bands in my day, but I can’t remember one this patient’s age.”

“Yes, it’s unusual. I was surprised.”

“As I evaluate your work in the chart I do want to say that your documentation was superb, and as best as I could tell you corrected all the problems that your patient presented so acutely.”

“Thank you.”

Lassiter continued, “We have no problem with your initial operative procedure. You promptly made a correct diagnosis, and the case, although a difficult one, did go smoothly. So take it from there please. Tell us what happened after the first procedure.”

Gathering himself Harris said, “Well as you know, the patient initially left the operating room in good condition. There was no bleeding, and his vital signs, except for his temperature were all normal. After he was made comfortable in the ICU, I issued the usual written orders for the nurses and went down to the surgical locker room. While I was still there, I got a call from ICU and I rushed up to find the patient in extremis with severe pallor, tachycardia and a distended, tense abdomen. My first thought, although I couldn’t believe it, was that maybe an arterial tie broke loose and he was bleeding internally. My decision was to return him to surgery immediately. When I opened him up his belly was full of blood. I suctioned what I could, and I found no discrete bleeding source, but admittedly it was difficult through all that blood. The anastomosis was intact. But as I suctioned out the blood, more would appear, so this suggested that a DIC had developed, and indeed his fingers were cyanotic and his urinary output was nil. Since his blood pressure at that point was still stable, the significance of his physical findings took on greater meaning and impelled me to a diagnosis of disseminated intravascular coagulation. Then I had to make a rapid decision because his blood pressure was falling and he was in extremis. I gave him heparin to reverse what I diagnosed as the endstage thrombotic manifestations of DIC. But it was to no avail. The patient died.”

“So as best as you can say there was no surgical misadventure. You didn’t leave an oozer or a surgical tie that broke loose.”

“No. I don’t believe I did.”

Dr. Lassiter said, “When I started out in practice we knew of no such an entity as DIC. And I don’t recall ever having a patient who bled so profusely as did yours after surgery. Refresh my memory, doctor. I’m not ashamed to say that I need some update on DIC.”

“In an acute fulminating disseminated intravascular coagulation, clotting factors are consumed you might say, and this results in a severe bleeding tendency. It’s seen as a complication of some obstetrical emergencies, severe infections, surgery, malignancy, and shock from any cause. My patient had some of those causative triggers.”

“Yes that’s clear. What are the treatment options?”

“At milder and chronic levels of DIC, the elimination of the underlying trigger could reverse the process. In severe acute cases, such as this one, treatment is usually futile, but believe it or not heparin is sometimes used.”

“Heparin? In a patient who is bleeding? It sounds counterintuitive. I need your explanation, please.” Lassiter was skeptical but willing to listen.

“The use of heparin may be appropriate when developing thrombotic complications manifest themselves by absent urine output caused by kidney capillary bed glomerular fibrin deposition or when progressive cyanosis of the fingers and toes suggest the development of incipient gangrene. My patient had both of these clinical manifestations. It was all academic however because the patient died.”

“One unlucky guy,” said Dr. Lassiter. “I note that the wife refused autopsy.”

“Yes. She was adamant, and I didn’t argue with her, of course.”

“Does anyone have any further questions,” asked Dr. Lassiter.

Receiving none, Dr. Lassiter said, “Thank you. You’re excused doctor.”

The questions before the committee were did Dr. Harris’s treatment meet the accepted standard of care for this hospitalized patient? Did he do what any reasonable physician would have done under the circumstances? Was there any omission or deviation from the accepted standard of care? As chairman of the committee Dr. Lassiter asked the other members, “Does anyone have any questions or comments now that the doctor has left?”

One young general surgeon offered, “I think under the circumstances he did an outstanding job and was able to think quickly on his feet.”

Another surgeon said, “Frankly I wouldn’t have given the heparin, but to be honest I doubt that I would have had the smarts to think of DIC in the first place.”

“Yes, I know what you mean,” said another surgeon. “Even if I had thought of DIC, I don’t think I would have had the courage to give the heparin, because at that point the patient was clearly heading south, and there was a good chance that, regardless of what was done, it was too late. So now this doctor is on the record of giving a drug that probably had a ten percent chance of doing anything. That’s medico-legal dynamite. I’m not criticizing the therapy mind you; he has made a compelling case for what he did.”

Silent up to this point, Dr. James Philips, a senior attending general surgeon who had been on the staff almost as long as Dr. Lassiter, raised his hand.

“What is it, Jim,” said Dr. Lassiter.

“You guys are all talking as if you are qualified to make a judgment about the treatment of DIC. When’s the last time any of you dealt with a case?”

There was no response.

Finally Lassiter said, “What are you getting at, Jim?”

“What I’m getting at is this: is it appropriate for us to be giving our opinion based upon admitted incomplete knowledge about a rare event in the medical world?”

“So?”

“So I’m saying, first of all, I wouldn’t have used heparin. Dr. Harris did. To me that means one of two things: he has a superior knowledge base from which to draw, or he doesn’t know what the hell he was doing. You couldn’t get vindication of his action from me and I’ve been around longer than any surgeon on the staff with the exception of our good chairman here. None of us have enough foundation upon which to make an educated judgment, and if we are given the responsibility to judge our peers we better make that judgment a sound one.”

Another surgeon who had not participated spoke up, “I am concerned about the fact that the anesthesiologist refused to administer the heparin until he was literally forced to do so by Dr. Harris. There must be some basis for Dr. Madhava’s refusal.”

There were nods of approval around the table. Dr. Lassiter said, “I also have a bit of concern about that episode and I agree with Dr. Philips that our judgment must be sound, but that’s why we have seven of us on committee. We should be able to come to a conclusion.”

“Is this committee ready to come to a conclusion after the discussion we’ve had?” asked Dr. Phillips in a skeptical voice.

“Let me ask this,” Dr. Lassiter said. “Given the unusual use of heparin and the dispute with the anesthesiologist, does this committee feel that this case should be cleared and there was no deviation from the standard of care?”

With some hesitation, the majority of the committee members present nodded in agreement.

“Are you willing to make a motion to that effect?”

“I so move.”

“Any second.”

“I second the motion.”

“Any more discussion?”

“Yes, I have something to say,” said Dr. Phillips.

“You have the floor, Jim.” Replied Lassiter.

“I move we table the motion until we get some help on this one. I’m suggesting we forward this case to the internal medicine quality committee, and defer judgment until we hear from them.”

“Do you think the average general internist has any more knowledge about DIC than a surgeon does?” asked Lassiter.

“You beat me to my next suggestion,” said Phillips. “That is, that we insist on a hematologist on the internal medicine committee to be available to review this case.”

Dr. Lassiter turned to the surgical committee’s confidential secretary, Gail Ellen and said, “Gail, is there a hematologist on the internal medicine peer review committee?”

“Yes there is.”

“Good. What does the committee feel about Jim’s suggestion?”

Heads nodded affirmatively.

“All right. Do I have a motion to accept Dr. Phillips amendment?

“I so move, said the young surgeon.”

“I second.”

“All in favor raise your hand.”

Seeing the vote was unanimous, Dr. Lassiter turned to Gail. He said, “I’ll dictate a letter to you for the chairperson of the internal medicine committee requesting that this case be placed on the agenda of their next meeting. Also request that a hematologist be available to review the case and report his findings to the internal medicine committee and then back to the surgical committee. If we are all in agreement we’ll take up this case again at next months meeting after hearing from the internal medicine committee. Do I have a motion to that effect?”

“I so move,” said a committee member.

“Any second?”

“Second.”

“All in favor raise your hand.” All hands went up.

“Motion carried.”

Dr. Harris’s case was referred to the internal medicine peer review committee and so documented as part of the minutes. In a case where a committee felt that there was a question of substandard care, it would be reported to the department chairperson with a recommendation for appropriate action. Such actions could range from a caution or mandatory consultation on future cases to revocation of hospital privileges for an especially egregious offense.

All peer review activities carried out under hospital committee sanction are exempt from legal discovery and the minutes are so stamped. There have been complaints from lawyers on both sides of courtroom battles who objected to this attempt by physicians to police themselves without having their actions open to public scrutiny. If this were not the case, doctors would be loath to function in a review committee, when what was said might later be used adversely in either a civil or criminal case against them. In addition, few physicians would willingly serve on such a committee, which is voluntary and unpaid, and perhaps, leave themselves open to a suit for damages by a physician who feels he has been wronged.

Cliff was informed of the committee’s action and for the next month Cliff and Laurel were left anxiously awaiting the decision of the internal medicine peer review committee. Cliff felt frustrated at the time it was taking to resolve the question of his surgical care and tried to console himself with the knowledge that the alternative was an absence of the peer review process and the perpetuation of inadequate care whenever it occurred. He accepted that the committee needed to perform its responsibilities in a prudent and thorough manner but it was difficult to continue to work day after day in the operating room knowing his future was under a cloud.

Checking the OR schedule the day after his appearance before the review committee, Cliff saw that Dr. Madhava who had been assigned to two of his cases had been replaced by Charley Pease, one of the other anesthesiologists on the staff. Cliff walked into the scrub room to see Dr. Pease already there. “Hey Cliff, how you holding up?” he asked, his usually cheerful face showing concern.

“I’m okay,” Cliff replied, “but what happened to Sanjay? He call in sick or something?”

Dr. Pease laughed slightly. “Not quite. The Mahatma asked me to switch cases with him and I said, okay. I guess he didn’t want to be in the same OR with a naughty surgeon who might yell at him.”

Cliff managed a small laugh. “I suppose he’s not the only one who feels that way.”

With a cheering smile, Pease said, “Don’t worry about it. No one can really blame you for what happened. A case of runaway DIC is almost always going to be fatal no matter what the surgeon does.”

With a sorrowful look, Cliff said, “I suppose you’re right Charley.”

With a sly smile, Pease said, “Just say to yourself he didn’t die. He just had a less than successful recovery.”

Cliff managed a small laugh. “Okay Charlie, you made me laugh so it’s time to get back to work. We’ve got a couple of easy ones this morning so let’s get this first guy under anesthesia and I’ll try to repair his hernia without yelling at you. You sure you don’t mind switching with Madhava?

”Hell no. What about you? We haven’t worked together that much. Are you sure you wouldn’t rather have someone else?”

Cliff laughed, “No. One gas passer is just like another to me.”

Charley laughed in return. “You got that right. We’re all drones with no people skills. That’s why we went into anesthesiology, we like our patients to be comatose.”

Cliff laughed, knowing that Charley Pease was one of the more personable doctors on the staff. Cliff’s surgeries that morning proceeded uneventfully and he was grateful for the opportunity to lose himself in the work that had engrossed him for more than a decade.

A month of waiting and then, after careful review of the case of Victor Wallberg, the internal medicine peer review committee, led by hematologist Alfred Koenig, approved Dr. Harris’s action in using heparin as meeting the standard of care. In fact the hematologist had the minutes reflect his admiration for the quick thinking displayed by Dr. Harris in so difficult and so rare a case. It was also recommended that the education committee prepare a lecture for the medical staff on this rare topic so that all physicians on the staff could benefit from this unusual case. The surgical peer review committee, armed with the internal medicine peer review committee’s report, cleared Dr. Harris at their next meeting. For what seemed to be the first time in a long time, Cliff and Laurel could relax. Their lives began to resume a more normal routine and they found new pleasure in one another’s company and that of their two daughters.