Wednesday, January 21, 2009

Is it going to be a morbidity or a mortality?

(morbitity and mortality moment) In training you had to present cases to all the other surgeons and surgeons in training any case that went wrong. Sometimes the cases were those were things were going wrong and you were called in when there just wasn't much that you could do. I had one of those yesterday. I got called stat to the ICU. A very complicated patient with an ejection fraction of 20%, bilateral pulmonary emboli, bilateral severe carotid 90% occlusion and recent mesentaric ischemia who had a respiratory code the prior week secondary to a mi was bleeding. She was bleeding just fast enough that we could barely keep her pressure up with a level one infusion pump. She was on coumadin for her clots. Blood was coming out of both ends.

We get the critical care team and then starts the big decisions. We seem to be maintaining her by keeping up with the blood. It does not seem to be slowing down. We can try to reverse her coumadin and give stymate but this might cause her to clot her coronary arteries or her bowel and that could kill her. As she bleeds, she is losing what ever clotting factors she has so at some point we will have to giver her FFP no matter what. Anesthesia feels that with her recent heart attack and her other conditions that we will most likely lose her on the table. In 2 minutes the decision is made, family is talked to as we roll into the or. With divine help, the bleeder is rapidly found and she makes it out the OR. We had to give ffp, platelets and stymate and she doesn't infarct. Once she is bact in the ICU, we talk to the family.

Then we get back to the lounge and start freaking out. She did well, but we got lucky. If we didn't find the bleeder rapidly I am sure that she would not have made it. These are the cases that land you in court. They are the D if you do and D if you dont. If she had a MI, an attorney would argue that we should not have reversed her coags, if she bled out, they would have an expert argue that we should have reversed them. If she died in the OR, they will say we should have stayed in the ICU. If she died in the ICU they will argue that we should have gone to the OR. It is a no win situation. The family had gone through the shock of her original problems and was seeing her get better, and then they see that she is suddenly about to die and immediately they jump to it must be some doctors fault. My relationship to them lasted the one minute they saw me run into the ICU. People argue that malpractice is when the standard of care is deviated, the problem is that the standard is whatever you can pay someone to say it is. When you have coin flip cases, no matter what you can get sued. All you can hope is that everyting comes out ok.

I am so glad that I still can say that I do not think of the medical legal bullseye on my back till after the cases are over. You still document and dictate everything though just in case.

1 comment:

SeaSpray said...

It's a calling. being a doctor, particularly certain specialties are a definite calling because the average person could not and would not do it.

I admit... i am really curious what it is that drives doctors to be doctors and then why they pick the specialties they do.??

Keagirl over at urostream was going to discuss why she became a urologist but never did.

Did you have an early interest in science... more fascination than most with frogs, bugs and what makes them tick?

I think it would be really interesting if all the medblogger's told their story.

I know off topic. But while reading about your dramatic case I vacillated between thoughts of "Thank God we have doctors like that willing to take on responsibility like that" to "Why did they want to be doctors and take on responsibility like that?"

Is it a deep drive to save humanity?

It can't be just the could be a lawyer or something else.

Is that just where your strengths and gifts are?

You sound like an EXCELLENT doctor and I am sure your patients are blessed to have you.

I hope my docs would react and jump in to help me vs worrying about lawsuits. I believe my docs are that way. Well I only have 2 now but I believe they would react and help me first/think later. I hope so.

I am sorry that you have to think so defensively. It actually bothers me to think my docs probably see me the same way because they have to look at everyone that way. I just want to be seen as a trusting and loyal patient. It hurts me to think they could ever think I would hurt them. i am not saying they do... but after reading your blog and others...I do doctors ever just see "the Patient"?

I am glad your patient is alright.

Interesting post!