Month: October 2015

The unwanted

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Helen lay on a trolley in the Emergency Department. So far the care had been good. Her leg still hurt, but the staff seemed to be getting on with things – taking blood, injecting antibiotics, dressing the horrible wound through which bacteria had gained access to her system. When would they put her in proper bed though? They hadn’t yet decided which ward to send her to; that seemed to be the problem. The trolley was hard and narrow. Her arms were pressed against the cold metal of the side-rails. And the noise! So many people calling out or giving instructions.

A voice she recognised pierced the hubbub. A man’s voice, distinctive. It was the doctor who had come down to examine her leg. Her doctor! She could just about make out his shape through the gap in the curtain. He was on the phone, and he was agitated. She followed his words. Of course, Helen could only hear half the conversation.

“No. Sorry, but no. It’s not surgical, there’s no way this lady will need surgical management…”

A pause.

“It doesn’t matter what the protocol says, I’m not accepting her. There’s no compartment syndrome, no bony involvement…”

Another pause.

“Well call my consultant if you like, I’m not taking her onto my list. There’s no indication. She’ll just sit on our ward getting antibiotics, my consultant won’t want to see her, she’s got other complex problems that need medical care… no!”

He hung up. A more junior colleague, a female doctor, joined him. He gestured emphatically in Helen’s direction and said,

“In future please don’t accept referrals like that. I’ve had to turf her back to medics, they started going on about what if she needs plastic surgery or debridement. We can come and give an opinion if her foot goes bad, but we’re not having her on our list. Waste of time.”

He walked away from the station and passed Helen’s bay. He kept his eyes down but Helen followed him with her gaze and made the briefest of eye contact when he glanced in. The doctor smiled weakly. He had no idea that she had heard him. He carried on walking, but Helen called out,

“Ah doctor!” He stopped and stood by the curtain.

“Yes Mrs Thomas?”

“So will you be looking after me? Am I going to your ward?”

“Errr… no. The kind of infection you have is best looked after by the medical team. I’m a surgeon, so I’ve asked that the medical team look after you on their ward.”

“I see. But they said I might need an operation on the wound. It’s very severe.”

“We can always do that later if need be. But you’re better off under the medical doctors to start with.” He moved on, but before he was out of earshot Helen muttered,

“I wouldn’t want to be a waste of time.”

The doctor slowed for an instant, then carried on. Helen had no idea whether he felt bad, embarrassed, or if he just didn’t care.

 

 

We all know that negotiation over the ownership of patients is a reality. Imagine if they could hear the arguments that sometimes take place. That is what I have done here – imagine a sad scenario in which a patient hears ‘her doctor’ doing his best to wash his hands of her. I’m not sure if such accidental indiscretions have occurred in reality; I suspect they have.

Medical diagnosis and early management are not clear-cut exercises, and working which teams should look after patients can take time. Robust conversations take place in which doctors explain why they should, or more commonly should not, take responsibility. If it’s a 50:50 call it can come down to pure assertiveness. Or, sometimes, the heartfelt intervention by a senior nurse who recognises that ‘Someone’s got to look after this poor lady! Sort yourselves out!’

It may be shocking for non-medical readers to hear that patients are not automatically welcomed onto the lists of medical teams. It sounds inhumane. Yet there can be good reasons. The worst thing for a patient is to be admitted under a team that is inexpert in the management of their medical condition. This can lead to delays, avoidable deterioration or even clinical disengagement. It is important to be taken over by the most appropriate team, but determining which team this is can be a struggle.

There are unseemly struggles behind the scenes in many customer-, client- or user-facing organisations. In acute and emergency medicine, where patients are by definition experiencing vulnerability and disempowerment, any sense of rejection is bound to have a very negative effect. So, doctors, next time you feel the need to argue over a referral and start horse-trading over individuals, imagine what impact your words might have on the patient, should they accidentally hear you!

 

spokenunspokenPAPER

 

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You choose: the case of the absent surgeon

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The judgement against Royal Devon & Exeter Foundation Trust in the case of Kathleen Jones appears to have created a precedent that gives patients the right to choose who performs their surgery. KJ needed a spinal operation, and a certain surgeon, Mr C, was recommended to her by the GP. She was referred and assessed, and the decision to operate was made. Hearing that Mr C was on extended leave for several weeks, KJ opted to put off the operation until he was back. A new date for surgery was fixed. KJ attended the hospital and in the hours leading up to the operation said,

“I haven’t seen Mr C yet this morning, I assume he is the doing the operation?”

“Oh no, he is outpatients today, does it make any difference?” replied the nurse.

“Yes it does! I have waited all this time to have my operation undertaken by Mr C.”

She was unhappy, but signed the consent form. The operation did not go well, the lining of the spinal canal was torn, more senior help was called into the operating room, and KJ was left with chronic disability. KJ sued. The judge concluded, having heard expert opinion and after referring to precedent, that although the operation was not performed negligently the patient would in all likelihood not have been injured if Mr C had done the operation. Her right of autonomy had been breached. The informed consent that she had given was undermined – ‘…I consider that her decision to allow the operation to go ahead was not freely taken…’ He awarded £190,000.

The judgement dwells on conversations, correspondence and snippets from GP and hospital notes – in an effort to determine if KJ was told who would operate, or warned that it might not be Mr C – but its conclusion raises important questions about what patients can expect when they submit themselves to the care of the NHS.

As a patient, it is understandable that you would be anxious to know who was going to do your operation and how much experience they had. A solid local or national reputation would be a comfort as you approached the date, and you would go into hospital with a greater sense of confidence. You might check their statistics on-line, or read testimonials. It is only natural to focus one’s hope, the antidote to fear and uncertainty, on an individual. To be told at the last minute that the person you thought was going to do the operation was in clinic, and was unavailable, would immediately undermine that confidence. Not only that, it would make you feel part of the machine, just another case, a unit allocated according to whichever personnel were around that week. But of course by the time you were starved, dressed in a gown, marked with black ink and transferred to a trolley, any sense of power over the situation would have been removed. Looking at the picture that I have just painted, I can see the judge’s point. I can see the patient’s point!

Is there a valid counterargument?

KJ’s operation was elective, so there was a great deal of time for it to be considered and arranged. A lot of time for the patient to hear and read about the surgery and the relative merits of various surgeons. In the elective arena there is opportunity for choice, and space for the exercise of autonomy. We only have to look across to the arena of emergency care to see that choice is limited to particular types of medical care.

A patient with acute chest pain might be aware that there is a particularly good cardiologist in the region, famed for his ability to open arteries in the blink of an eye and save people from severe infarction. The other five cardiologists attached to the hospital are good, but not quite as good. The patient will have no idea whether he is on duty or not. There is a one-in-six rota, so it will be, literally, a ‘roll of the dice’. There is nothing wrong with this situation. All the cardiologists are trained (just as both spinal surgeons in the legal case were trained). So we must accept that in the acute situation autonomy over who one sees or who one is operated on by does not truly exist. Nevertheless, if we have faith in the quality of the hospital, or the NHS in general, we do not mind. We submit ourselves to the health service in our hour of dire need, when the risks are arguably greater than in the elective arena.

If such a lack of autonomy is broadly acceptable in an emergency, why was it not acceptable in the case of KJ? Why was the Trust found guilty?

Comparing emergency and elective patients may not be valid. The judge in this case was clearly swayed by the evidence that KJ had changed her operation date in order to guarantee that Mr C did the surgery. Her consent was founded on the assumption that Mr C would be there. In the judge’s eyes her expectations trumped the internal arrangements made by the Trust which resulted in Mr C being in clinic that day. The principles of patient-centred care clash with the complex necessities of a busy department. The luxury of choice, perhaps never more than a veneer, is stripped away. This is a bleak depiction, and not one with which I would like to characterise the whole NHS, but there is truth in the picture. Patient choice is limited. The big choices – who treats us, where they treat us, when they treat us – are rarely available (unless we pay to go privately). If patients remain under the illusion that choice extends this far, future disappointments, and legal challenges, are bound to occur.

Exercises in candour

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I am presenting some cases on the Duty of Candour next week, so I thought I would explore them on the blog first. The Duty of Candour is now a legal requirement rather than a vague, moral imperative. If a patient comes to avoidable and significant harm the patient must be informed within 10 days of it being recognised, an apology must be made and an explanation given which should include what will be done to ensure that it does not happen again.

Error is a fact of life in medicine. Not all error leads to harm, and not all harm is significant. But working out when the Duty of Candour should be invoked is harder than it looks on paper. Over the last few months many of us will have been involved in discussions with colleagues, or in our own heads, as to whether something that happened that was not quite right should be explored with the patients or their family as part of this Duty. You cannot check an adverse event off against a list of significant harms. A judgement first needs to be made whether the harm was significant, but even having done that it is not easy to progress.

These cases are intended to be based on everyday life in hospital, and the responses to these cases are just my first thoughts. I don’t know the right answers!

 

1] A house officer is tabulating her patients’ blood results first thing on a Friday morning before the ward round. She finds that yesterday a man’s potassium was extremely high at 6.9. The blood was taken in morning and the result was on the system by the middle of the afternoon, but for one reason or another the result was not checked and no action was taken. The doctor knows that this put the patient at risk of cardiac arrest, and even as she sits at the computer looking in horror at the number on the screen, she knows that her patient could drop dead any second. She runs onto the main ward and sees from a short distance that a patient is absolutely fine. He glances up and sees the concern on her face. She steps forward and says… What should she say?

There has been an error, a significant omission. The patient’s life has been put at risk. But the patient is fine. No harm has been done. If she chooses not to tell the patient what she is worried about, but quietly rechecks the blood or prescribes some insulin and dextrose, he may never know the danger he was in. The problem will just receded into history. What would you do?

My feeling here is that the Duty of Candour is not invoked because harm was not done. It is a near miss, and you could argue that the event should be recorded on hospital’s register of adverse events. But I think the reasonable doctor would tell the patient that she was concerned about a blood test, and should probably come out with it and say “we checked your potassium yesterday, it was very high, but I’m afraid the result did not get through to the team,” or something like that. There is no denial, but there is no dramatic telling of what might have happened. Or perhaps she should say more, or her consultant should, along the lines of, “I’m afraid there was a mistake made yesterday. You were at risk of having a heart attack overnight and thankfully that did not happen. We are very sorry… we think we know why it happened, and we have made sure that all results are seen every evening…” That sounds better.

 

2] A registrar inserts a central line into a patient’s neck having obtained their written consent. On the list of potential complications, on the consent form, are infection, bleeding, inadvertant cannulation of the artery and pneumothorax (collapsed lung). Two hours after the central line insertion, while the patient is waiting for the check x-ray which has been somewhat delayed, the patient experiences chest pain and breathlessness. He is examined and there is clear evidence of a pneumothorax on the side where the line was inserted. A portable chest x-ray is done straight away and shows a large pneumothorax. A chest drain is inserted as an emergency, the patient symptoms are relieved, but he stays in for 10 days longer than intended.

Was this an error? It was a known complication certainly, but it was not intended that the sharp needle would pierce the pleura. Whoever pushed the needle pushed it into the wrong place. That sounds like an error. But the patient agreed to have a procedure knowing that this could happen. Is Duty of Candour invoked here?

Well, the patient did come to significant harm (an extra procedure, 10 more days in hospital). If I was the doctor I would certainly come back to the patient, when they were feeling better, and explain what happened; but I would explain also that this is not a particularly infrequent problem, hence the reason we take a focused consent. I would probably say sorry, but not as a personal admission of guilt, but more to say that I was sorry for the situation and sorry that it happened to him. I would feel able to maintain this attitude if I felt that I went into the procedure confident that I was well trained and that I had done everything by the book – be it the use of ultrasound or a good track record of successful insertions. If everything was done as well as it could, then you could argue that the complication was not avoidable.

Such a conversation would be an example of openness, transparency and certainly in the spirit of candour, but I’m not sure if it would tick the box for a formal Duty of Candour response from the Trust.

 

3] An SHO prescribes the antibiotic Tazocin for a patient who is known to be penicillin allergic. Tazocin contains penicillin, and all competent hospital doctors should know that. The drug chart states clearly that the patient is penicillin allergic. It is a grave error and should not have happened. The patient suffers an anaphylactic reaction, spends three days in intensive care and an extra seven days in hospital. Their recovery from a minor operation is seriously impeded.

The SHO is called in by his educational supervisor, and the circumstances behind the mistake and prescription are explored. It was probably just a consequence of the doctor being in a hurry. He admits to that, and says he cannot even recall looking at the front of the drug chart for the list of allergies. The consultant and the SHO agree that the harm must be explained to the patient, and that Duty of Candour requires them to apologise, explain how it happened and how they will try to stop this in the future. There is no question of not admitting that an error occurred, because it is obvious. The question is how to apologise. The SHO decides that he must do this himself, under supervision, but he feels morally obliged to initiate the conversation. He wonders, as the time scheduled for the meeting with the patient and her husband draws near, what he will say. Will he cry? He certainly came close to crying on the day itself. He was horrified with himself. He wanted to give up medicine. He had nearly killed someone who had come in for a minor operation. But he has asked around, and he knows that better people than he have made the same mistake. That is no excuse of course, and he knows he will never do it again because the scar is burned deep into his memory. He cannot talk like this in front of the patient. It will depend on the patient’s attitude. Sometimes they feel sorry for a clearly regretful or distraught doctor, and they wish to comfort them. Sometimes they, or their relatives, appear to be burning with anger and resentment; they want someone to pay a price. He decides that he will say sorry straightaway. Then he will explain how it happened, but he can’t make it sound like he’s blaming the hospital for keeping him busy. He will just have to say that for those few moments he did not pay enough attention during an important task. And then, well, the conversation will go in the direction the conversation wants to go.

 

4] The medical registrar on call, Lucy, spends several hours of the night with one particular patient, trying to make her better. She is 79 and appears to have a horrible infection. Her blood pressure and temperature are very low and however much fluid the registrar gives she cannot increase it. Intensive Care say they will come down to review, but in the meantime the registrar writes up bag after bag of fluid (which is a reasonable initial treatment of severe sepsis.) She does all the other things that she should, takes blood cultures, gives antibiotics, monitors closely, arranges a high dependency bed. The BP eventually comes up a few points, just enough to avoid the patient going to intensive care. The consultant comes in next morning to see the patient with the registrar, and immediately recognises something is wrong. As he examines the patient there is a rapid deterioration. The blood pressure falls to dangerously low levels and the oxygen saturation goes down to less than 60%, barely compatible with life. The consultant, holding the ECG, cannot hold himself back. He turns Lucy and says “Have you seen this? She’s had a posterior infarct, this isn’t sepsis, this is cardiac failure. You’ve drowned her!” And then all hell breaks loose. The patient crashes, the cardiac arrest team run onto the ward and the patient is intubated then rushed off intensive care. She is literally drowning in the fluid the registrar prescribed overnight, 6 litres of it.

Lucy, remaining on the ward, looks at the ECG. She remembers seeing it in the emergency department, but she didn’t make much of it. It was not that dissimilar to a previous one, but it’s all a blur now and she can’t remember correctly. The truth is she missed an acute myocardial infarction, and she treated this patient incorrectly, as incorrectly as it is possible to do. The patient follows a rocky course, but survives intensive care and makes it out of there onto the cardiac ward. Her brain is not what is was, and there is talk that the period of low oxygen levels in her blood led to a mild degree of brain injury.

During this time Lucy subjects herself to much criticism. How could she get it so wrong? She is aware of the ‘new Duty of Candour’ and finally, having considered it carefully, asks her consultant if they should tell the family that their relative was mismanaged for the first five hours of her admission. What would you say, as the consultant?

Treatments given are often on the basis of diagnoses which are not clear cut. This is a case in point. I remember myself mistreating a patient who had cardiogenic shock when I was a junior doctor, and I remember the look on my registrar’s face when she recognised my error the next morning. In this era of candour how do we manage misdiagnosis? Diagnosis is a skill and sometimes an art, and cannot always be correct. The point about the Duty of Candour is avoidable error. To avoid this error the registrar would have had to have been a different person. Let us assume that she is of good medical standing, has maintained her continuing education and is generally up to scratch. Nevertheless a gap in her knowledge was revealed that night. She failed to identifying an important medical condition, one that many would expect a medical registrar to have done successfully. But we all have gaps in our knowledge. She made a diagnosis based on the data before her, processed that data through the mind of someone educated to the same level as any other doctor in the hospital. Yet she made the wrong diagnosis. Was that avoidable? Probably not. Yet this lady, now permanently injured, might well have had a much better outcome if only another doctor had been on duty that night.

This scenario I find very challenging. I honestly do not know whether it should be expected of the medical team, or the doctor in person, to apologise for what happened. Yet the decent doctor, I believe, would want to meet with the family and go through things, to communicate – to tell the story of what happened and why. This might include describing how patients with cardiogenic shock can sometimes look as though they have severe sepsis, and that this is what happened. The diagnostic ‘mistake’ is revealed, but not in way that would categorise it as formal ‘medical error’. Perhaps this is splitting hairs, or over-thinking the whole issue.

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What I take home from these cases is that the formal process of applying the Duty of Candour may not be well suited to the wide spectrum of everyday medical error, and the many grey areas that exist. The message that I take away is that we must develop the habit of explanation, be quick to tell the story of what happened and why, but not to dwell too long on the emotional or moral weight that comes with the concept of apology. If we have made a mistake we must say so, but all error occurs within a context of uncertainty, and without trying to make excuses it is reasonable to explore mitigating circumstances. We must find a way of displaying candour while preserving the ability to pick ourselves up and deliver care to the next patient.