Split Thread Do Doctors cover for each other's misconduct? (Split from "Wakefield")

[Criticalist]

When a doctor is on call, I would imagine that he is at home waiting for his pager to go off. It would, IMO, be irresponsible for the doctor not to have a sleep during that period.

As for the late night/early morning emergencies, are there not sufficient on duty doctors at the hospital to deal with these emergencies?

I don't expect the top specialists to be there at all times, but surely the on duty doctors can deal with the initial diagnosis and treatment.

Of course a doctor on call from home will attempt to get some sleep. However calls from the hospital may prevent that, and he may need to go in. Most of the stuff that presents to the hospital can be handled by the night staff, but there are quite a few things that the "top specialists" will need to be called in for. Ruptured aortic aneurysms, neurosurgical emergencies, severe burns, just to name a few - often in these case you will have to call a senior surgeon in, and that surgeon may well have spent the whole day operating on elective lists.
Again, you can stipulate that senior surgeon works a night shift system to cover this sort of thing; but then you are preventing him from covering outpatient clinics, elective lists and teaching which is the bulk of the work, and the emergencies he will be needed for are relatively uncommon.

 

[paximperium]

No I am not. Your position appears to be that a doctor who makes an error whilst they are fatigued is guilty of misconduct; not because of the error per se, but because they allowed themselves to work while fatigued which presumably contributed to the error in the first place. Your comment :

"While the excuse 'I was just following orders' is understandable, it is not a valid defence."

seems to bear this out. I am saying that is inappropriate to censure a doctor for performing when fatigued when a number of factors outside of their control, including clinical urgency, lack of staffing, funding etc, force them to do so.

I see you're enjoying the wonderful "Ivor Experience" and his...viewpoints about medicine and physicians.

 

[Ivor the Engineer]

No I am not. Your position appears to be that a doctor who makes an error whilst they are fatigued is guilty of misconduct; not because of the error per se, but because they allowed themselves to work while fatigued which presumably contributed to the error in the first place. Your comment :

"While the excuse 'I was just following orders' is understandable, it is not a valid defence."

seems to bear this out. I am saying that is inappropriate to censure a doctor for performing when fatigued when a number of factors outside of their control, including clinical urgency, lack of staffing, funding etc, force them to do so.

Do you feel the same about a HGV driver who uses the same excuses when he kills several people on the motorway after falling asleep at the wheel for a few moments and ploughing into a line of stationary traffic?

ETA: Perhaps he'd never driven that vehicle or route before and felt couldn't pass up the chance to get the experience.

ETA2: Perhaps his cargo was aid for victims of the Hatian earthquake and felt that if he didn't do it people would die.

 

[Criticalist]

Do you feel the same about a HGV driver who uses the same excuses when he kills several people on the motorway after falling asleep at the wheel for a few moments and ploughing into a line of stationary traffic?

ETA: Perhaps he'd never driven that vehicle or route before and felt couldn't pass up the chance to get the experience.

ETA2: Perhaps his cargo was aid for victims of the Hatian earthquake and felt that if he didn't do it people would die.

I specifically used a medical example of a vascular surgeon who had been operating all night. You have just arrived in the emergency department with a ruptured abdominal aortic aneurysm. You have 30 minutes to get to theatre before you die. I asked what you would have her do; operate on you or decline to do on the basis of fatigue. Why don't you answer?

 

[Ivor the Engineer]

I specifically used a medical example of a vascular surgeon who had been operating all night. You have just arrived in the emergency department with a ruptured abdominal aortic aneurysm. You have 30 minutes to get to theatre before you die. I asked what you would have her do; operate on you or decline to do on the basis of fatigue. Why don't you answer?

Because your hypothetical moral dilemma is merely to defend the status quo.

Why is there not another vascular surgeon about to come on shift who could operation on the patient?

 

[paximperium]

Because your hypothetical moral dilemma is merely to defend the status quo.

Nah...I'd love the surgeons to be at my beck and call...or in my case yesterday, a nice chopper delivery of a patient that needed a neurosurgeon for a massive head bleed en route from a small community hospital to the big academic center who coded en route and therefore forcing the chopper to land at my hospital. Patient died on course but then the neurosurgeons need their sleep.

Why is there not another vascular surgeon about to come on shift who could operation on the patient?

He's asleep.

 

[Skwinty]

I specifically used a medical example of a vascular surgeon who had been operating all night. You have just arrived in the emergency department with a ruptured abdominal aortic aneurysm. You have 30 minutes to get to theatre before you die. I asked what you would have her do; operate on you or decline to do on the basis of fatigue. Why don't you answer?

The mortality rate for ruptured AAA is substantial. As many as 2 of 3 patients with ruptured AAA die before arriving at the hospital.[URL="javascript:showcontent('active','references');"]30 [/URL]Of those who reach the hospital, as many as one fifth of those who die do so before the operation, and the overall mortality rate still averages approximately 49%.

Given these statistics, the nurse can have a go as far as I'm concerned.

 

[paximperium]

The mortality rate for ruptured AAA is substantial. As many as 2 of 3 patients with ruptured AAA die before arriving at the hospital.[URL="http://javascript<b></b>:showcontent('active','references');"]30 [/URL]Of those who reach the hospital, as many as one fifth of those who die do so before the operation, and the overall mortality rate still averages approximately 49%.

Given these statistics, the nurse can have a go as far as I'm concerned.

Total mortality rate for ruptured AAA without surgery is >98%...as opposed to 75-80% with surgery. I prefer the latter odds.

 

[Skwinty]

Total mortality rate for ruptured AAA without surgery is >98%...as opposed to 75-80% with surgery. I prefer the latter odds.

Me too, thats why I would let the nurse perform the op if a surgeon wasn't available for whatever reason.
I would rather die trying, than just roll over.

 

[Ivor the Engineer]

There's not enough time/money/resources to do a job right, but there's plenty of time/money/resources to deal with the consequences of doing the job wrong.

 

[kellyb]

There's not enough time/money/resources to do a job right, but there's plenty of time/money/resources to deal with the consequences of doing the job wrong.

That might very well be the case if the incidence of errors from sleep deprivation is low enough. Someone would have to do the math to know for sure, though.

 

[Criticalist]

Because your hypothetical moral dilemma is merely to defend the status quo.

Why is there not another vascular surgeon about to come on shift who could operation on the patient?

I don't even understand this.

This so called hypothetical dilemma is one that has been played out at every hospital I have ever worked at or that I know. Its no good saying "well there should be another surgeon" - there isn't. There is not enough funding, personnel or reasonable demand to have a rotating shift system of experienced personnel who can cope with any emergency at any time, without ever being fatigued.
Whether there should or could be is irrelevant to my point, as is the question of survival in this specific situation - if you wouldn't want to be operated on thats up to you - plenty of people disagree, and plenty of operations are performed.

My question (again) is this; Should the surgeon in my example be accused of misconduct if she operates, as she is fatigued. As far as I can tell Ivor thinks she should be. I emphasise again, this is a perfectly real life example,one I have seen again and again, and one any practising physician could attest to. Its not a "defense of the status quo" whatever that means, it is a description of the current situation on the ground in acute care. I am not interested in defending resource allocation, or administration or whatever - I don't care about "well things should be organised better" - I agree that they should be, but they aren't. I want to know whether you think that a physician who is acting in the best interests of the patient in front of her, in a situation as I have described, should be censured for misconduct.
Ivor seems to think she should.

 

[Ivor the Engineer]

I don't even understand this.

This so called hypothetical dilemma is one that has been played out at every hospital I have ever worked at or that I know. Its no good saying "well there should be another surgeon" - there isn't. There is not enough funding, personnel or reasonable demand to have a rotating shift system of experienced personnel who can cope with any emergency at any time, without ever being fatigued.
Whether there should or could be is irrelevant to my point, as is the question of survival in this specific situation - if you wouldn't want to be operated on thats up to you - plenty of people disagree, and plenty of operations are performed.

My question (again) is this; Should the surgeon in my example be accused of misconduct if she operates, as she is fatigued. As far as I can tell Ivor thinks she should be. I emphasise again, this is a perfectly real life example,one I have seen again and again, and one any practising physician could attest to. Its not a "defense of the status quo" whatever that means, it is a description of the current situation on the ground in acute care. I am not interested in defending resource allocation, or administration or whatever - I don't care about "well things should be organised better" - I agree that they should be, but they aren't. I want to know whether you think that a physician who is acting in the best interests of the patient in front of her, in a situation as I have described, should be censured for misconduct.
Ivor seems to think she should.

The surgeon and the hospital are taking a gamble. If she screws up and it's considered likely sleep deprivation was a contributing factor, she and the hospital are likely to be sued and/or prosecuted for something like negligent homicide. In a case where death was very likely anyway it would probably be quite easy to cover up any mistakes.

Hopefully it would not take too many similar cases for the hospital to rectify the situation and provide sufficient cover to avoid its employees having to work while their clinical performance was compromised by the effects of sleep deprivation.

 

[Criticalist]

The surgeon and the hospital are taking a gamble. If she screws up and it's considered likely sleep deprivation was a contributing factor, she and the hospital are likely to be sued and/or prosecuted for something like negligent homicide. In a case where death was very likely anyway it would probably be quite easy to cover up any mistakes.

Hopefully it would not take too many similar cases for the hospital to rectify the situation and provide sufficient cover to avoid its employees having to work while their clinical performance was compromised by the effects of sleep deprivation.

You really don't want to answer this do you? I don't care what some court might think if something goes wrong. This is common clinical situation that may well be playing out in some hospital somewhere as I type these words. What do you think the surgeon should do? Your previous comments have given me to understand that you believe a doctor that performs a clinical procedure while sleep deprived is acting unprofessionally, and should be censured for misconduct. Is that the case here? Do, you, personally, judging this extremely plausible scenario believe the surgeon to be unprofessional if she chooses to operate? And, just to be clear, there are no back up vascular surgeons who can leap into the operating theatre and take over.

 

[Ivor the Engineer]

You really don't want to answer this do you? I don't care what some court might think if something goes wrong. This is common clinical situation that may well be playing out in some hospital somewhere as I type these words. What do you think the surgeon should do? Your previous comments have given me to understand that you believe a doctor that performs a clinical procedure while sleep deprived is acting unprofessionally, and should be censured for misconduct. Is that the case here? Do, you, personally, judging this extremely plausible scenario believe the surgeon to be unprofessional if she chooses to operate? And, just to be clear, there are no back up vascular surgeons who can leap into the operating theatre and take over.

I'm sorry, I thought my previous post did answer your question.

I think it is unprofessional to perform tasks while sleep deprived which could result in the injury or death of a third party.

In the hypothetical scenario you described, if no mistakes are made then the surgeon gets away with behaving in an unprofessional way. If mistakes are made and subsequently covered up, she gets away with behaving in an unprofessional way. If mistakes are made and found to be caused by fatigue, the hospital and possibly the surgeon herself should be prosecuted for something like negligent homicide. Hopefully there would not need to be too many similar prosecutions for the situation to be rectified.

 

[paximperium]

Hopefully there would not need to be too many similar prosecutions for the situation to be rectified.

Yup. Provide NO surgeon. Fixes the problem.

 

[Ivor the Engineer]

Yup. Provide NO surgeon. Fixes the problem.

That would be the budget option.

 

[Criticalist]

Well thanks for answering. So what is it that you think the surgeon should do? How does she behave ethically and professionally in this situation?

(I just know I am going to regret asking this)

 

[paximperium]

That would be the budget option.

No. Providing NO care would be the "ethical"(according to you anyway) and apparently legal thing to do.

 

[Ivor the Engineer]

Well thanks for answering. So what is it that you think the surgeon should do? How does she behave ethically and professionally in this situation?

In the situation you describe the surgeon cannot behave ethically and professionally whatever she does.

However, in real life she should be bringing the situation to the attention of her colleagues, professional medical organisation(s) and hospital management and requesting something be done about it.

(I just know I am going to regret asking this)

After a few years you’ll get used to my idiotic, bigoted and short-sighted views on every subject I dare to raise or involve myself in the discussion of.