Archive for the ‘News Commentary’ Category
Sunday, July 22nd, 2012
This is probably a record length post for me, but I thought it was important to respond to Mr. Dwyer’s comments to a post written on this blog regarding the article he wrote that appears in the NY Times.
I had planned to leave my comments after his, but they became too long and involved and I also wanted to paste a couple of pictures from Mr. Dwyer’s article, so I instead decided to answer his criticisms in a post.
If any of you were wondering, I was not the anonymous physician who authored the previous post on Mr. Dwyer’s article. I spent most of my afternoon creating this response because Mr. Dwyer’s original article was somewhat frustrating to me, but I found his justifications and explanations for what was contained in his article to be misleading.
See additional commentary about Mr. Dwyer’s articles here and here.
Dear Mr. Dwyer,
When re-reading your article, I absolutely agree with Rory’s wish that no other child – and no other family for that matter – should have to go through what Rory went through. He sounded like a great kid and he obviously had a close family and a bright future. As you also mentioned, Rory’s uncle was a friend of yours, so I can imagine that this incident affected you more than most other investigations you have performed. This topic hit home for me as well. My daughter nearly died from an invasive pneumococcal infection when she was younger. She was hospitalized for a week in a university medical center on triple antibiotics. Very scary times and we thank God that things turned out well.
So let’s go through your article and responses you made to the criticism about your article so that we can determine how to prevent kids from dying from sepsis due to invasive organisms.
JIM DWYER COMMENT:
1. You say that the stop sepsis campaign is for tracking severe sepsis. That misstates both the nature of the campaign and my citation of it in the article. The campaign’s goal is to aggressively identify sepsis and begin treatment within an hour. (The tracking of cases you cite is secondary.) To begin the process of identification, the initiative created a triage screening tool which gives a list of 8 signs and calls for additional investigation if a patient has three of them. As I wrote, Rory Staunton had two when he came into the ER. He had three when he was leaving. (BTW — his heart rate over a period of two hours ranged from 131 to 143. That’s in the article, too.) In the distribution literature with the screening tool, there is no distinction between pediatric and adult patients. Whether or not you think the values are relevant to a 12 year old, 5’9″, 169 lb boy, Rory was assessed for possible sepsis in triage.
Let’s look at the sepsis criteria according to the checklist that you posted. Then let’s apply them to children.
1. Pulse greater than 90. In children up to 2 years of age, a pulse rate less than 90 is considered too slow. In other words, ALL children up to 2 years of age should have a pulse rate greater than 90.
2. Respiratory rate greater than 20. In children up to 5 years of age, a respiratory rate less than 20 is considered too slow. In other words, ALL children up to 5 years of age should have a respiratory rate greater than 20.
So now in children who have entirely normal vital signs for their age, right away you have two of the three “danger signs” your article repeatedly emphasizes.
Add a temperature of 100.5 degrees which is essentially not a temperature at all.
Let’s give the child a runny nose which causes us to suspect a viral URI – the suspicion of an “infection” required by the criteria.
This two year old child, running around the room and laughing with his parents, with essentially normal vital signs for age, now has 4 of the criteria on the screening tool you cite.
According to the premise of your article, we must rigidly follow the criteria on the “screening tool,” which means that on every such child, doctors should get a mandatory serum lactate level, order immediate IV antibiotics, and hospitalize the patient. Heck, we should probably throw in a central line and urinary catheter as well to monitor central venous pressure and input/output.
Can you even begin to imagine all of the unnecessary added expense and adverse reactions from the antibiotics/invasive monitoring that would occur if every medical center in the country adopted Jim Dwyer’s rules of pediatric management? Every influenza season, there would be no hospital beds available for months as hospitals were forced to overtreat healthy well-appearing children while delays for care of other emergent patients precipitously increased.
The problem with your article, and something that you conveniently hid from your readers, was the disclaimer at the bottom of your so colorfully highlighted checklist
Doesn’t the disclaimer at the bottom of the checklist say something to the effect that it “should not be used as a substitute for clinical judgment”? Can’t really see the whole sentence because your placement of Rory’s labs just happens to obscure the rest of the wording. But I’ve read enough checklists and disclaimers to know that the disclaimer most likely states that the checklist should not be substituted for a physician’s clinical judgment.
Well, here, let me highlight the area I’m talking about. You can click on the image to get a bigger view if you want:
Yet, despite the checklist specifically telling you NOT to do so, that’s exactly what you did, isn’t it, Mr. Dwyer? You published an article asserting that regardless of the clinical judgment of a physician who has many years of training in medicine and who is described in your article as being “hyper-conscientious”, this protocol must be rigidly followed. You misused this guideline in order to inappropriately attack the qualifications of physicians you never met and to whom you never even spoke.
You state that the guideline and its literature made “no distinction between pediatric and adult patients,” yet you didn’t even know enough or didn’t care enough to ask what patient populations the guidelines were created for.
You keep asserting that Rory was the size of an adult. Fine. I agree. But he was still 12 years old. Unless you have evidence that the criteria have been validated in children – even adult-sized children - don’t assert that the criteria are valid in children. You know darn well that if the situation was different, the medical treatment involved medications not approved in “children,” and Rory died after receiving the medications, you’d be the first one writing about “warnings ignored” in giving the medication. 20/20 hindsight is just crystal clear.
See a more balanced article about the same topic at ABC News.
Wednesday, July 18th, 2012
By an Anonymous Emergency Physician
The opinion piece below was written by an emergency physician regarding a New York Times article by Jim Dwyer (picture at right). The author did not want to be identified due to fears of retribution from either the NY Times or from the hospital at which the physician is employed.
In addition to the points the author raises below, I would add these additional points of information:
1. The “Stop Sepsis” campaign cited in Mr. Dwyer’s article specifically stated that it is only to be used for tracking patients with severe sepsis and that “only those patients who are hypotensive after being given 2L of fluids or that have an elevated lactate should be entered in the data portal for this Collaborative.” Rory was not hypotensive and no lactate level was included in the labs pictured in Mr. Dwyer’s article. Mr. Dwyer never mentions any of these facts. The Collaborative does not allow access to links on this page describing its screening tools or to how it believes that a determination for ordering a lactate level should be made.
I will also note that Mr. Dwyer responded to some of the more than 1600 comments to his article, including some of the issues raised below, in this follow up article.
UPDATE JULY 22, 2012
Also see an important update to this debate at this link.
The New York Times published an incredibly sad story about a 12 year old boy named Rory who went into the NYU emergency department, was diagnosed with gastroenteritis (a viral stomach bug), and who was dead two days later from septic shock. Those are just about the only facts that are not in dispute. The rest of the New York Times article seems to build a mountain of evidence as to why the emergency physician screwed up. However, as is frequently the case, the truth is much more complicated than the media would have you believe. There are lots of comments from other doctors using the almighty retrospectoscope and so many clinical inaccuracies discussed that this sad story is turned into a piece of sensationalistic journalism.
This post is mostly for the non-medical people that read this blog to help you understand the medical issues a little better. This is a scientific discussion of the main inaccuracies of the article followed by what possibly could have been done better. I say “possibly” because I did not examine the patient and all of my information is through the New York Times article. If you have already read the article and decided that the ED doctor screwed up and nothing can change your mind, then stop reading. If you want a fair and evidence-based discussion of the article then read on.
- The article references the “Stop Sepsis” campaign and says that the vital signs that should have triggered an evaluation for severe sepsis. The article says that Rory had initial vital signs of a temperature of 102, a heart rate of 140, and then points to the Stop Sepsis guidelines. There are two problems with this: First, the Stop Sepsis guidelines are intended to be used in adults, not in children. Second, just because a patient has abnormal vital signs doesn’t mean that they have severe sepsis. Most patients in a pediatric ED waiting room would meet these criteria and yet they don’t have severe sepsis. The “Stop Sepsis” guidelines are a screening tool that can suggest sepsis but they have to be used in the right clinical context. Most physicians see pediatric patients every day who meet the “Stop Sepsis” criteria and who would best be described as having “the sniffles.”
- The article states that Rory’s temperature at home was “104, his highest ever.” The implication is that this high fever, in of itself, should have triggered a more thorough investigation. This is a misconception that must be dispelled. A temperature of 106.7 degrees and above is the only time a fever by itself is dangerous. Significant literature shows that a fever less than 106.7 degrees is not harmful. We see children in the ED all the time with “high fevers” but that look great and would not have been considered sick without their temperature being taken at home.
- After Zofran and IV fluids, Rory felt better. His vitals before discharge were a temp of 102 and a pulse of 131. The article continues to allege that these vital signs met sepsis criteria. However, a heart rate of 110 is the upper limit of normal for a 12 year old and, in general, a patient’s heart rate increases by about 10 beats per minute for every 2 degree increase in body temperature. In Rory’s case, a heart rate of 131 was appropriate or just above the upper limits of normal for his temperature. The persistence of a fever should also not cause worry just by itself. Physicians frequently discharge febrile children from the ED without any adverse consequences. When assessing patients for discharge, what matters most is how the patient looks. According to the documentation in this case, Rory looked better before he was discharged.
- The article alleges that the emergency physician didn’t see the vital signs before she wrote the discharge instructions. While this may be true, there are several more likely explanations. In order to be efficient, I sometimes write discharge orders on patients that I think are going home because I have a minute free to put the order in. Technically, the orders are entered before the vital signs are entered, but this is for the sake of efficiency. I still evaluate the patient prior to discharge. Another possibility is that it the nurse didn’t have the time to put Rory’s vital signs into the computer before he was discharged. It is likely that the ED physician saw Rory’s vital signs while she was in the room re-evaluating Rory and signed the discharge order before the nurse entered the vital signs. The way the article is written, it implies that the ED physician could never have seen the vital signs, but in reality, there is no way to tell for sure without asking the physician.
- The article implies that the white blood cell count of 14.7 should have triggered a more aggressive workup. There is a mountain of evidence to say that a high WBC count does not rule in or rule out an infection or severe sepsis.
In order to keep this balanced, here are some things that I believe could possibly have been done better in Rory’s case.
- Discharging the patient before labs were back. While this is sometimes done in cases of cultures or other “send out” tests, it is generally not a good idea to discharge patients before labs results are reported. The most concerning lab in Rory’s case was the elevated number of bands or immature white blood cells at 53%. High band count can be a red flag in the right clinical situation, but may also be a sign of a vigorous immune system response to a viral infection. In addition, Rory’s carbon dioxide was normal. In severe sepsis one would expect Rory to have acidosis and a low carbon dioxide level. A normal carbon dioxide level suggests that Rory may not have had severe sepsis at the time of his first ED visit. Instead, he was probably in the early stages of sepsis which can be very difficult to distinguish from a simple viral illness. A more thorough review of the labs may have prompted an admission for observation, but without having examined the patient no one can make that call.
- Rory’s vital signs at discharge were at the upper limits of what could be considered normal given his fever. While the vital signs did improve, when I read the article the first time I admit that the discharge vitals raised an eyebrow. However, as I previously noted, a child’s appearance is probably the most important indicator of severe illness and the ED physician is the only person who examined Rory.
I would like to end this article with a plea to the public to not crucify this ED doctor. The New York Times should not have published the doctor’s name. She is not a public figure and she has not been named in a lawsuit. It is egregious that the New York Times published her name and thus unleashed the public venom on a private citizen. I can guarantee that the ED doctor feels terrible about this case. We don’t need the rest of the world coming down on her as well. Even worse, due to federal patient privacy laws, the physician is prohibited from speaking about this case. In any other profession, if a newspaper published something condemning your professional abilities you would be able to give your side of the story.
This case is every ED doctor’s worst nightmare and it can happen to the best of us. As Greg Henry says, cases like this make you say to yourself “only by the grace of God go I.” Cases like this keep physicians up at night. The New York Times didn’t see it that way and wrote a sensational article condemning the ED doctor involved. The reality is that very rarely, kids get sick and die. Sepsis is a cruel disease and it can take a child that is otherwise healthy and looks great and kill them within hours to days. It is no one’s fault – it is just bad luck. Sometimes we catch that needle in the haystack and no one hears about it. Sometimes we don’t and then it becomes front page news. Let’s not make this situation worse by placing all the blame on this ED doctor. This is a terrible case and while we should always try to learn and be better for the next patient, sometimes bad things just happen.
Thursday, April 12th, 2012
As if drug shortages aren’t enough.
Remember the post about Medco patients “accidentally” running out of their prescriptions because Medco “didn’t receive” faxes, because Medco was trying to pitch your doctor to prescribe other medications, and because of “delays” from the mail?
Well you don’t have to worry about Medco anymore.
The Federal Trade Commission just approved a buyout of Medco by Express Scripts. Now there are just two mail order houses – Express Script/Medco and CVS/Caremark.
Think your mail order prescription problems were bad before?
You ain’t seen nah-thing yet.
Tuesday, April 10th, 2012
I’m surprised that this case hasn’t gotten more press.
A patient named Anna Brown was unhappy with the care she received at several hospital emergency departments. When she was discharged from the last emergency department, she refused to leave. Police were called and the patient was carried to a police car. She said that she couldn’t walk. Police took her to jail, carried her into the cell and left her laying on the floor. About an hour later, she was still laying there … dead.
From the public’s point of view, the case appears outrageous. But as I read through the description of what happened and thought about what could have been done different, from a physician’s point of view, I’m not sure what else could have been done.
Christine Byers wrote an excellent article describing events that took place, and then wrote a follow up article in which the hospital defended its care. I’m hoping that the St. Louis Post-Dispatch commends her for her work. She did a great job with the stories.
A summary taken from Ms. Byers’ article shows that Anna Brown was admitted to the hospital for spraining her ankle while walking near a ditch. EKGs, blood tests, and lab work were performed. Ms. Brown was in the hospital from Sept 13 to Sept 15 and then discharged. She walked on crutches after her discharge.
Wednesday, March 28th, 2012
Just got word that several additional medications have been added to the national list of “drug shortages”. Doctors better start learning more about wilderness medicine at this rate.
I can see the management of our next unstable patient now …
[Call comes in on telemetry line]
“We’re coming to you with a 44 year old male hypotensive and unresponsive. Short transport time.”
[15 minutes later, the crew arrives]
“Sorry it took so long, our ambulance ran out of gas because we couldn’t afford to fill the tank due to the high gas prices and low Medicare/Medicaid reimbursements. We had to call for assist with transport from the Amish Ambulance Service with its horse and buggy. By the way, do you know where I can get a broom and a very large shovel?”
[Patient is hooked up to the monitor. Wide complex bradycardia. Pressure 60/40. Dialysis graft is noticed in his arm.]
“Dialysis patient. He may be acidotic and hyperkalemic. Give him an amp of bicarb STAT.”
“Sorry doc, we’re out. There’s a national shortage.”
“Keep that fluid bolus going. Let’s start some Levophed on him to raise his blood pressure.”
“Sorry, doc. We don’t have any of that either. National shortage.”
“Well let’s at least give him some Vancomycin in case he’s septic.”
“I’d like to, but I can’t. That’s on national shortage, too.”
“Well, he’s not responding very well. At least let’s get him intubated. Can someone push some Rocuronium?”
“Don’t have that, either. National shortage.”
“Nope. That’s out, too.”
“Nope. National shortage.”
[patient now loses his pulse]
“He’s CODING! Start CPR. Give him an amp of epinephrine, STAT.”
“Sorry, doc. National shortage. Don’t have any.”
“OoooKayyy. Give him an amp of atropine, then.”
“Don’t you know that atropine isn’t part of ACLS protocol any more? Besides, we don’t have any and there’s a national shortage of atropine, too.”
[patient is unable to be resuscitated and dies]
Six weeks later, the doctor receives a letter from the Arizona State Nursing Board [for those who don't regularly follow this blog, this is parody -- background here] informing him that he is being investigated for failure to properly manage the patient and failure to properly look out for the patient’s best interests, too. He must submit to a psychiatric evaluation, must submit to a genetic test to assess his future intellectual capacity, and must submit to a hearing in front of the whole nursing board to explain himself or else his name will be posted somewhere on the Arizona State Nursing Board’s web site and he will never be allowed to be a nurse in Arizona.
“I think I’m going to be sick.”
“Hope not. We’re out of Zofran, too. National shortage.”
[fade to black]
Good thing I had extra coffee and some old jumper cables laying around to jolt my heart back into a normal rhythm after seeing the Instalanche! Thanks, Glenn!
Tuesday, March 20th, 2012
Why does the Huffington Post allow Joanne Doroshow to keep posting misinformation?
For those of you who didn’t know, Ms. Doroshow is an attorney who is the executive director for New York Law School’s Center for Justice and Democracy.
Attorney Doroshow’s latest blog post on HuffPo alleges that medical malpractice caps are an “attack on women” and therefore any Republican who votes for medical malpractice caps is risks alienating himself (or herself) from half of all the voters in the United States.
Half of Attorney Doroshow’s post cites opinions from others that the Republican party is engaging in “mass misogyny.”
When she finally tries to justify her kindergarten logic, Attorney Doroshow quotes University of Buffalo law professor Lucinda Finley, stating that
“[C]ertain injuries that happen primarily to women are compensated predominantly or almost exclusively through non-economic loss damages. These injuries include sexual or reproductive harm, pregnancy loss, and sexual assault injuries.”
Let’s look at the legal arguments that Attorney Doroshow has adopted.
Sexual or reproductive harm happens primarily to women.
Is Attorney Doroshow attempting to argue that there are so many fewer lawsuits relating to testicular/prostate cancer, male urologic injuries, testicular torsion, and hernia-related injuries such that malpractice caps would be de facto misogynistic? I notice a deafening lack of statistics to support her assertions. Professor Finley’s article didn’t address the issue, either, but Professor Finley’s article wasn’t limited to medical malpractice caps — it discussed general caps on noneconomic damages.
Pregnancy loss happens primarily to women.
True. Women are the ones who get pregnant. But is Attorney Doroshow attempting to argue that only one parent is allowed to file a lawsuit on behalf of the child when there is a pregnancy-related loss? As an attorney, what is her legal basis for such a claim? How are malpractice caps on a “pregnancy loss” lawsuit discriminatory toward women?
Sexual assault injuries happen primarily to women and are compensated predominantly or almost exclusively through non-economic loss damages.
I agree that sexual assault injuries primarily happen to women. However, sexual assault injuries have little to do with medical malpractice caps. Sexual assault is a criminal issue. Often, victims of crimes receive compensation from a Crime Victims Compensation Fund. Caps on medical malpractice have nothing to do with sexual assault injuries – unless the physician is the one assaulting the patient. And even if a physician did sexually assault a patient, the litigation wouldn’t be a “medical malpractice” issue subject to malpractice caps, it would be a civil tort issue where malpractice caps do not apply.
As further justification for how noneconomic medical malpractice damage caps are discriminatory toward women, Ms. Doroshow again cites Professor Finley, stating
“[J]uries consistently award women more in noneconomic loss damages than men … [A]ny cap on noneconomic loss damages will deprive women of a much greater proportion and amount of a jury award than men.”
There is no comment from Attorney Doroshow on why it is acceptable for juries to discriminate against men in awarding noneconomic damages. However, if legislatures take some action that would potentially neutralize the “discrimination,” Attorney Dorshow alleges the action would constitutes a sleight so severe to the female gender as to amount to instant political suicide. That is simple pig pen effluent.
I agree that $250,000 caps on noneconomic damages are not fair to patients. I also think that we need to find some middle ground where patients can be fairly compensated for their injuries but where medical providers are not subject to bankruptcy from “super losses“.
Joanne Doroshow’s attempts to scare people into opposing H.R. 5 through a campaign of misinformation is wholly inappropriate. Based on her writings, I can only come to one conclusion:
Attorney Joanne Doroshow’s writings demonstrate misandry more than medical malpractice caps demonstrate misogyny.
Tsk. Tsk. Tsk.
Friday, March 16th, 2012
A study just published in the Annals of Emergency Medicine shows something that many people suspected: Patients with Medicaid (i.e. government “insurance”) tend to use the emergency department much more often than patients with private insurance.
After studying 230,000 participants in the National Health Interview Survey, the researchers found that Medicaid patients were more than twice as likely to use the emergency department as their privately-insured counterparts. When barriers to timely primary care were added into the picture (including difficulty reaching doctor on telephone, difficulty obtaining timely appointment, long waits in the physician’s office, limited clinic hours, and lack of transportation), emergency department utilization increased significantly. 40% of Medicaid patients had used the emergency department more than once in the prior year. 51% of Medicaid patients with one barrier had more than one ED visit in the prior year and 61% of patients with two or more barriers had more than one ED visit in the prior year.
I’m sure that there are other reasons for the higher than normal emergency department utilization, the biggest one being lack of a disincentive for using emergency departments versus primary care physicians.
The article concluded that “Expansion of Medicaid eligibility alone may not be sufficient to improve health care access.”
Insurance doesn’t equal access. Wonder where I’ve heard that before ….
Thursday, February 23rd, 2012
Want non-emergency care in the emergency department? Pay up first.
After performing a federally-mandated screening exam, many hospitals are now charging an up-front fee of $100 to $150 to be treated for non-urgent complaints. Don’t want to pay? You’ll get a list of other health care resources and can leave.
And it is happening … all … over … the … country.
ACEP is against such a policy, arguing that 2 to 7 percent of patients determined to have “nonemergency” conditions are admitted to a hospital within 24 hours and that a vast majority of patients have conditions requiring urgent treatment.
I don’t think the policy is a bad idea, provided that patients have an alternative source for routine care. Medical care costs money … a lot of money.
The problem is that when the practice becomes commonplace and a public outcry occurs, I can only imagine what new laws that will be created to force hospitals/providers to provide treatment to all emergency department patients.
Tuesday, February 7th, 2012
I admire this lady’s chutzpah.
If Virginia wants to make an unnecessary ultrasound necessary before a woman can have an abortion, Virginia Senator Janet Howell wants to make unnecessary rectal exams and stress tests a prerequisite before men can receive Viagra prescriptions.
I bookmarked this link from Instapundit which is one of my favorite news aggregator blogs. However, I disagree with Glenn Reynolds’ opinion that the Virginia senator’s rider to the initial bill is “kindergarten payback” and that it is “sad” that Senator Howell is being lauded for her cleverness. OK. Maybe it is kindergarten payback.
The bottom line is that the state wants to make an expensive and unnecessary medical procedure a prerequsite to a woman being able to obtain an abortion. The proposed bill stated that the ultrasound is required to determine the gestational age of the fetus.
Why? If a woman appears to be past her first trimester or near fetal viability, then I can possibly see the utility in obtaining an ultrasound. But requiring the test on every pregnant patient seeking an abortion?
I don’t agree with abortion, and I have harsh feelings toward women who use serial abortions as a form of birth control. However, I still believe that a woman has a right to choose what happens to her body.
To me, it seems like the intent of the law is to put an additional financial burden on women seeking an abortion. Can’t pay for the ultrasound? The doctor is prohibited from performing the abortion.
Glenn Reynolds stated that “presumably the reason for an ultrasound is to let women see what they’re aborting.” That reason doesn’t meet medical necessity. What other reason would a legislature require a useless medical test in order to have a procedure performed?
Eventually, the bill was passed in the Virginia House with a modification requiring that the physician offer to perform an ultrasound prior to performing an abortion. This version has no teeth, but I believe it tees up the matter for further debate in another “addendum” to the law somewhere down the road.
The initial bill was just another example of an unfunded mandate and I am one of those that applaud Senator Howell for standing up to it.
Now it appears that they could use Senator Howell’s help in Kansas. Lawmakers there are proposing a law that provides malpractice immunity to physicians if they hide information from patients in order to prevent an abortion. The law also forces doctors to tell women that abortions potentially increase the risk of breast cancer. Maybe they can also create an addendum to the law requiring that doctors tell the husbands of pregnant women seeking an abortion that touching their woo-hoo while thinking impure thoughts will grow hair on their palms. Have the legislators been drinking on the job?
Utah is probably beyond Senator Howell’s help now. Recently, the Utah Supreme Court ruled that “unborn children” and “minor children” are legally the same for the purposes of wrongful death lawsuits. Great concept. Extending the definition further, under that logic, pregnant women in Utah now need to purchase two plane tickets – one for them and one for their “minor child.” They also need two movie tickets. Ohmigod. What if there are triplets? What if Octomom wanted to board a plane in Utah while she was still pregnant?
If pregnant women drink alcohol, using the Utah Supreme Court’s logic, they must be endangering the welfare of a child by force feeding their “minor children” alcohol. If they smoke, they must be breaking federal law by providing cigarettes to minor children. Child protective services should require an immediate Caesarian section (after performing an ultrasound and maybe a stress test) and should immediately take custody of all such children.
At least the dissenting Justice Nehring understood the absurd results that would result from the majority’s decision.
What is going on in this country?
Monday, February 6th, 2012
I finally took the time to read some other blogs today. One of the issues that I found disturbing was the case of Amanda Trujillo.
There are a lot of bits and pieces out there about what actually happened in this case. This blog post was reportedly an e-mail from Amanda describing the events. A summary of the post follows.
Amanda was a registered nurse of six years , specializing in cardiology, geriatrics, and end of life/palliative care.
In April 2011, she was caring for a dying patient at Banner Del E. Webb Medical Center who had agreed to a major invasive surgery recommended by a staff surgeon.
Amanda used materials from her hospital to educate the patient about the details of the surgery and the aftercare.
The patient became upset, stating that the surgeon never explained details of the surgery or what had to be done after the surgery (complex lifetime daily self care).
Amanda also discovered that the patient “had no idea” that surgery could be refused or that the patient could enroll in hospice care. She educated the patient on those options as well.
Afterwards, the patient requested a case management consult to visit with hospice.
Amanda documented her discussions with the patient and informed the nurse at shift change that the surgeon needed to clear up a “gross misunderstanding” the patient had about the surgery.
“The surgeon became enraged, threw a well witnessed tantrum in the nursing station, refused to let the patient visit with hospice, and insisted I be fired and my license taken.”
She was fired and she is not able to find employment due to the actions taken against her license.
As a result of this incident, Amanda’s career has been destroyed. She is a single mom with three nursing degrees and now, unemployed and unemployable, she has no other option than public aid to feed her family.
Back in 1913, Supreme Court Justice Louis Brandeis once wrote:
“Publicity is justly commended as a remedy for social and industrial diseases. Sunlight is said to be the best of disinfectants; electric light the most efficient policeman.”
I’ve tweeted to Amanda to contact me so that I can get more information from her. If the above events can be substantiated, what happened to Amanda was deplorable. And if the events can be substantiated, I’m going to shine some sunlight on the actions of other parties involved.
I’ll request the patient’s permission for release of the patient’s medical records from the hospital. With the patient’s permission, I’ll publish them here, including the surgeon’s notes and Amanda’s notes.
I’ll get the names of the nursing supervisor and everyone involved in Amanda’s firing, including the hospital CEO. We’ll take a look at their careers on this blog.
I’ll get the names of the people from the Arizona State Board of Nursing who reviewed this case and who recommended that Amanda lose her license and undergo psychiatric testing. I’ll publish any correspondence that they sent Amanda. We’ll take a look at just how they arrived at their conclusions.
And I’ll get the name of the surgeon who allegedly does not take the legal doctrine of informed consent too seriously and who allegedly uses temper tantrums as a means to bully people into submission. Maybe we can look into his background a little. If he did have a “tantrum” in a patient care area, has the hospital investigated him for his conduct?
Everything will be published here.
And if ends up that Amanda was wrong for what she did I’ll publish that as well.
That reminds me …
When two nurses complained to the Texas Medical Board that a physician was trying to hock herbal medications to hospital clinic patients, they were fired and prosecuted for criminal acts. The Texas Nurse’s Association became outraged, established a legal defense fund for the nurses, and fought for them. In the end, the doctor was the subject of a complaint by the Texas Medical Board, and the hospital at which the nurses worked was fined for firing the nurses.
Why isn’t the Arizona Nurses Association taking any action on Amanda’s behalf? I might have an idea.
It so happens that the President of the Arizona Nurse’s Association, Teri Wicker, is also the Director of Professional Practice at Banner Del E Webb Medical Center – the same hospital where Amanda Trujillo used to work. Has anyone asked her for comment?
More to come …
UPDATE FEBRUARY 26, 2012
See also this update post on Amanda’s case.
A timeline and several documents have been published at www.medbloggers.org. More documents will be added as they are received.