Thursday, August 14, 2008

Fighting to Bleed: Medical Comment Fetches Comments

M.D.O.D. is an entertaining blog providing important education on valuable medical terms of art, and happens to include an emergency medicine doc's top-ten-style rant on why he's leaving emergency medicine. I commented in response to reason #5, which featured a misprioritizing supervisor's misdirected disciplinary behavior, inspired not by observed wrongdoing on the part of the victim but by the supervisor's own fear of personal consequences for shoddy work. My comment got a few of its own comments, and I thought I'd repost the comment here:

It's amazing what people will do to jeopardize care when they are afraid of liability. Folks think liability is a big problem in the U.S., and I'm willing to hear a case made about it, but I was surprised as can be to discover it was lethally dangerous in Honduras.

I traveled with a volunteer surgical team to perform operations on an impoverished and underserved community in the middle of noplace. While there, we had a patient whose kidney wasn't possible to save. There wasn't an ill part that could be removed; the whole thing was scar tissue, and it had grown in size several times and encroached upon and melded with numerous other structures in the area.

Including the ascending vena cava.

Needless to say, the operation ran long, and was bloodier than hoped. I kept an eye on the patient's face, and she was getting scarily pale.

The hospital didn't have a blood bank.

We went around the room trying to ascertain whether we had among us any plausible donors -- without the ability to test for pathogens, we didn't dare recruit locals -- and it turned out that as an O+, I was the only person in the room whose blood would not kill the B+ patient.

This is where the liability got crazy. The physician with the contract to attend the hospital -- a local Honduranian -- instructed the lab tech not to give me a blood bag. Without the blood bag, my mission to donate a unit of blood was in jeopardy.

After a while arguing -- they claimed the risk involved in not-exactly-type-matched blood was dangerous, and I explained that since they weren't planning to test for minor antigens anyway, it didn't matter, and that without the transfusion she was certainly going to die, which made the theoretical risk she might die due to a fatal mismatch among minor antigens a fairly good bet by comparison.

About this time they decided they didn't speak English any more. So I let into them with my broken Spanish. And, let me tell you, my Spanish was pretty broken. The upshot was that their behavior would kill the patient, and that whatever I was proposing, therefore, had only the possibility of helping.

However, it was more important to the physician contracted to the hospital that he keep his job by avoiding the appearance of having contributed to killing the patient. If the patient died under an American knife, he was blameless. If he allowed a donation using his blood bag and the donation's complications were implicated in the immediate cause of her death, then he could face trouble, and he feared for his position.

And they weren't offering any known clean B+.

Eventually, the tech took a blood bag out of a drawer, placed it on the table behind her counter without giving it to me, and took a break. I understood it was my responsibility to steal the blood bag without permission.

Then I donated into the blood bag, carried it to the OR, and passed out while I watched it given.

Turns out dehydration and blood donation don't mix.

My take-home lesson came in several parts. One, drink lots of fluids in the hot dry mountains of Honduras in the summer. Two, the U.S. isn't the only place folks do silly things for fear of liability. Three, the local nurses will make fun of you in Spanish if you are seen passing out, and they will make jokes about whether the patient will be doomed to pass out after getting your weak-assed gringo blood. But three is OK: they know you kept her alive long enough for the next three donors to get back from a supplies run in the next town, and that without you the poor girl would have died and her husband would have been left alone, so the nurses are smiling at you as they giggle when you pass.

I've worked a bit in the medical field (broadly defined; my activity at times involved psych patients, at times involved pharmaceutical research, and at times involved transplant tissue collection). I presently regard myself as an interested observer but a nonparticipant. That is, I try to stay well enough that I don't need to risk myself near physicians or hospitals, which as everyone knows are strongly associated with sickness and death.

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