November 27, 2012

Is Patient Abandonment in the Operating Room Ever Justified?

I ask this question mainly because there WAS an ENT who WAS sued for NOT abandoning his patient in the operating room [link]. No way to verify, but additional details can be found in this facebook post.

Imagine this hypothetical scenario (as details from original case are not available)...

You are an ENT surgeon in a rural community hospital performing a fairly difficult but elective sinus surgery on a 12 years old child with cystic fibrosis with extensive pan-sinus nasal polypoid disease. Given the extensive nasal polypoid disease, a fair amount of bleeding is occurring which was not unanticipated.

Suddenly, you get a phone call from the emergency room regarding a patient with progressive difficulty breathing suspected to have epiglottitis.

What do you do if you are the only ENT in the hospital?

Do you "abandon" the 12 years old child in the operating room, still bleeding, still under general anesthesia and attend to the ER patient who himself might die without an emergency tracheostomy? Doing an evaluation to determine how critical the ER patient may take anywhere from 15 - 60 minutes including the tracheostomy itself. Keep in mind that 99% of the time, a tracheostomy is NOT necessary.

And, if a tracheostomy WAS needed, you are now performing two different surgeries in two different rooms simultaneously which must break some rule somewhere... perhaps JCAHO?

Or, would you finish the surgical case first, and than proceed to see the ER patient?

What if you are the only ENT available in the region let alone the hospital? No fellow ENT colleagues to call upon for help. General surgery is "unavailable" or not comfortable with performing tracheostomies especially given ENT performs all tracheostomies in the hospital?

Patient abandonment is defined as:
  • Failing to transfer a patient to an appropriate level of care
  • Failing to respond to calls from a hospital regarding a patient
  • Refusing to care for a patient after arranging the patient's admission
  • Failing to treat a patient until new coverage is arranged

Proving patient abandonment includes:
  • Your doctor had a duty to treat you - a duty was created when the physician-patient relationship was established
  • You had a reasonable expectation that your doctor would treat you
  • Your doctor failed to treat you although he or she was obligated to do so
  • You suffered injury as a result

Well, according to one lawsuit, it seems that the ENT was required to abandon his patient in the operating room and attend to the ER patient. The lawsuit stemmed from the fact that the ENT did not abandon his patient in the operating room and the ER patient did die as a result of not being attended to quickly and competent emergency tracheostomy performed. Of course, the settled lawsuit also blamed the hospital, general surgery, and anesthesiology.

However, abandoning a patient on the operating room table is also tantamount to medical malpractice according to the very definition of patient abandonment.

And, I would not be surprised if the patient on the operating room table would have sued the ENT if he DID leave the operating room in the middle of surgery to attend to another patient for a long period of time (and even starting another operation without ever finishing the abandoned patient's surgery first).

What to do?

I have no answer...

Doing an emergency tracheostomy is HARD, even for someone who has performed hundreds of elective tracheostomies. I know... I've done perhaps a half-dozen emergency trachs in my career so far. In this particular lawsuit, I found it incredible that a hospitalist (not a surgeon) was the one who finally attempted the emergency tracheostomy (albeit unsuccessfully).

Do you consider the patient you are CURRENTLY caring for has a higher priority than a patient you have never met, even if possible life-threatening illness is involved? (Keep in mind that when called for an airway problem, that 99% of the time, an emergency tracheostomy is not needed.)

OR, do you prioritize the patient you have never met given the possible life-and-death circumstances involved, even if 99% of the time, no surgical airway is required.

What would YOU do? What should you do? Feel free to comment below!

The way I see it, the ENT would have been sued no matter what decision was made. It would have been a lose-lose and lose proposition.

By deciding to stay with his current patient, the ENT was sued by the ER patient's family. If the ENT left his current patient on the operating room table, the ENT would have been sued for abandonment. If the ENT did abandon the current patient and the ER patient still died in spite of an emergency tracheostomy, the ENT would probably be sued for wrongful death by the ER patient's family AND the patient he abandoned on the operating room table.

Hospital settles wrongful death lawsuit. Curry Coastal Pilot 10/31/12

ADDENDUM 12/5/12:
Information obtained from an anonymous source reported that the ENT who was sued ultimately had charges dismissed with prejudice. It was maintained from the beginning that the ENT's obligation was to the patient on the table and that there was no doctor-patient relationship with the deceased.

I also find it interesting that the hospital where the lawsuit occurred, now does not even have ENT coverage at all. I guess that's what happens when a lawsuit occurs when there's only solo specialist coverage. I'm predicting that this hospital will have a very difficult time to recruit another ENT to work there given this case even though the ENT was ultimately found blameless.
Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.


Emma Malmström said...

Its a difficult question, but I would, as a ENT surgeon (which I am) pack the boy's nose with tamponades to hold the bleeding for the moment.

Then I would demand that the patient and anesthesiologist would come straight up to another room in the OR, where I am (I suppose). If there are no free rooms, The patient should comes straight in to the room where I am operating. In this emergency situation I wouldn't consider privacy for the patient or the hygien of "mixing" two patients in the same room.

The patient at the emergency has a higher priority, due to his threatend airways. But I would not leave the boy bleeding to go down to the emergency.

As I work in Sweden, the concern of a lawsuit isn't as big as in the states. Maybe that explains why I think I would act the way I described above.

Anonymous said...

I'm the ENT in question. The case was settled with the hospital and the ER, but several of us (including me and the hospitalist) had no part in this settlement. They dropped the case against me and 2 other doctors. The facts of the case were much different than what you've laid out in your hypothetical situation above, but I wouldn't share those facts as it would be a HIPAA violation (or treacherously close!)

Suffice to say that my answer to your question is NO, patient abandonment is never justified. My obligation is to the patient on the table, not to someone whom I've never met.

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