A half-assed contribution

Disclaimer: I wrote this essay for an ethics assignment a few days ago. It was a throw-away paper, so I probably put less time into it than I would have put into a real blog post. I don't even know exactly what the hell I'm talking about by the end, but if you have some time to kill, you might find this interesting.

Our last patient of the day was a middle-aged gentleman with terminal lung cancer. He was being discharged from the hospital back to his home to begin hospice care, where he would likely die within a few weeks. He needed a constant supply of high levels of supplemental oxygen just to stay conscious, but when we entered the room, he smiled and waved.

I was working as an Emergency Medical Technician (EMT) for a small, private ambulance company and we were dispatched to transport this patient to his home. This trip would likely take close to an hour, but long-distance transfers were common for our company. However, when we reviewed his chart and noticed the amount of oxygen this patient would require, my partner and I realized we did not have enough on the ambulance that day to make the trip. We called our supervisor on the radio to give him this news, and he informed us that it could be another hour before the next available ambulance could get to the hospital. To our surprise, we were then advised to transport the patient anyway, while giving him less oxygen than he needed.

With this case, I can identify a conflict between patient care and business. First, with patient care, we were being asked to place the patient in a situation that could easily have been harmful to him. However, in terms of the business, it was likely that our superior had feared that delaying this patient’s transport for another hour would have reflected poorly on the company, which could have jeopardized future business with this particular hospital.

My partner and I were in agreement that it was simply too risky to transport this patient with the limited supply of oxygen we had on-hand. By knowingly placing the patient in a potentially dangerous situation, we would have been violating our professional ethics as EMTs, as well as our moral standards as human beings. In addition, we clearly would have been acting under negligence and could have faced legal repercussions if the patient had suffered any injuries. For these reasons, it was an easy decision to refuse to transport the patient and request that our supervisor call the next available ambulance.

Though I was taken aback by my supervisor’s request, I was also able to see the issue from his point of view. Like the operator of any small business, his top priority is the company. As a small business, his company must remain competitive with larger companies. Consequently, a single contract with a single hospital comprises a larger percentage of the total revenue earned. In an economic sense, a single contract is more valuable to a smaller company than it would be to a larger company. This is a reasonable business model for most companies; however, there are many more ethical issues at stake when the product being sold is patient care.

At our patient’s bedside, it was clear to us that we could not transport him. As EMTs, we had been trained to think with protocol in mind, and to always remember the legal consequences of negligent action. I do not know of a single EMT, paramedic, or physician who would have made a different decision than we did, and even our supervisor later admitted that he had been hasty and careless in his handling of the situation. This situation was unfair to everyone involved: we were asked to knowingly endanger a patient, and as a result, we were forced to stand up to our supervisor and put our own positions as employees on the line. Even if we had agreed to transport the patient, he would most likely have preferred to wait for the next ambulance.

Though I have never operated an ambulance company and have no experience with medical administration, I imagine that balancing business and medicine is a formidable task. As a former EMT and current medical student, I have been trained to think of the patient as priority number one. But medical administrators have to balance patient care with the demands of the business; if the company suffers or fails, patients may be negatively impacted as well.

So how is this balance determined? In the case I have described above, it might have been useful to have a third party mediator who could look at the case from both my perspective as an EMT and my supervisor’s perspective as the company operator. From my perspective, the refusal to transport the patient put him in no additional harm, but did have the consequence of placing me in an uncomfortable position with my supervisor. From my supervisor’s perspective, my decision may have somewhat tarnished the ambulance company’s reputation as a fast and reliable provider of care, but in the long run, it likely protected the company’s reputation as a safe provider of care. It would have been helpful to have a third party mediator who could have identified these issues and presented them to both parties.

I believe that the best patient care is delivered when both the healthcare provider and the administrator has a basic understanding of the issues that the other party faces. It is easy as a healthcare provider to only think of the patient in front of you and forget about all of the other hidden elements that contribute to (or detract from) that patient’s care. As a newcomer to medicine, I hope that there will be communication between the healthcare providers and the administrators wherever I decide to work in the future. If I do not get involved in medical administration myself, I can only hope to have the opportunity to learn enough about it to begin to see these hidden elements, and to use this knowledge to the advantage of my patients.

Touched for the very first time

While I was a medical assistant for the ER, I worked with a diverse team of health care providers who all had a role in patient care. The team could be divided into three basic groups: doctors, nurses, and support staff (this group included medical assistants like myself). The doctor group could then be further divided according to each person’s level of experience: medical students, residents, and attendings.

Right now I am a lowly medical student, a second year medical student at that. My responsibilities for patient care are zero, while my responsibilities for my schoolwork are everything. But in ten short months, I will begin my third year, which is comprised of clerkships; miniature rotations (usually 4-8 weeks) that will take me through the various medical specialties. It is then that, I am told, I will begin learning the hallowed practice of “how to do stuff to people.”

I like the field of Emergency Medicine, and I am reasonably certain that I will be an ER doc when I grow up. In this field, as in many medical fields, I will be given the legal right to take a knife and perform acts upon another human being that, in any other circumstances, would land me in prison. Of course, my right to perform these acts is based upon the assumption that I will always be acting in the patient’s best interests. “Well, naturally,” you’d say, rolling your eyes. “You’ll be a doctor. Of course you’ll be acting in the patient’s best interests, right?”

A chest tube is a long, plastic tube that is inserted into the thorax to help re-inflate a collapsed lung. The procedure sounds fairly straightforward: make a small, deep slice between the ribs to reach the pleural cavity (the “sac” that contains the lungs). Stick the tube in there to drain any air or liquid that has collected outside of the lung, decompressing the cavity and allowing the lung to re-expand. Stitch the tube to the skin of the chest to keep it in place. That’s it! There are more steps involved in making macaroni and cheese. (You can see a NSFW photo of the finished product here).

Ha, I got you! The gory chest tube photo is here. Many blunt or penetrating traumas to the chest require a chest tube, so this is a very common procedure in the ER. Now, before I ever give somebody a chest tube, I will do everything I can to learn as much as possible about the procedure. I will read about it, I will watch videos of it, I will observe the real thing in the ER. But no matter how prepared I might be, there will be that first time when I actually take the tube in my inexperienced little hands and actually shove it through some guy’s ribcage.

This is the conundrum, laid out in lovely outline-y form:

• If I want to be an ER doc, I will have to learn how to put in a chest tube
• This means I will need to practice on real people
• This means there will be “that first person” who I will operate on with zero experience
  

My question to you: do you want to be “that first person?” Of course not. We all want the best possible care for ourselves and our loved ones. Nobody would prefer the rookie over an experienced doc. But the simple fact is the world needs new doctors, and these new docs need to be trained somehow.

So what is the best way to train the new docs? I have no answer for this, since my real training has yet to begin. Say two patients come in who both need a chest tube: one is a homeless guy with no family and the other is a 35-year-old woman with a husband and two kids. Which patient do I take and which patient does the more experienced attending physician take?

In reality, we would both take both patients. Under no circumstances would a rookie doctor be allowed to do a dangerous procedure without supervision. Now, it is probably a bit riskier to be treated by a rookie under careful supervision than it is to be treated by an experienced doc alone, but I think that’s the price we need to pay now as a society to train the new docs who will take care of us when we’re older.

If it is in fact riskier to be treated by a rookie under supervision, this means people are dying because of their doctors’ lack of experience. This is going on right now, in hospitals all across the country. As an inexperienced doctor, I will be asking my patients to take a chance with their lives. I will be asking them to submit to what may be inferior care in order to contribute to my training and therefore to the betterment of society as a whole. This is huge and, frankly, it scares the hell out of me.

One evening at the hospital, I watched two young residents put a nasogastric tube into a little old lady. This is a long, thin tube that goes down through the nose, down the throat, and into the stomach. I think they were doing this to take a sample of the stomach juices, which they could test for blood and see if she was bleeding somewhere in her upper GI tract. Unfortunately for the patient, these two residents suffered from a common condition called “Immature Doctor In Occupational Training Syndrome” (that is, they were I.D.I.O.T.S.). The whole time that they were doing this procedure, they were ignoring the patient and chatting with each other about their plans for the weekend. They did not notice how roughly they were handling the patient. They did not notice that the patient was crying from the pain of the procedure.

I think the best thing inexperienced doctors can do is to just take it seriously. Every time we perform a procedure in training, we need to recognize that the patient is giving us a gift by helping us become better doctors. We can’t refrain from learning and practicing new procedures, and ethically, we can’t choose who we practice on based on our level of experience. So we thank them by recognizing the added risk, doing our best to minimize that risk, and then making sure that risk is justified by taking it seriously. Every time.

Incidentally, I went a bit overboard with this post with the luxury of the three-day weekend. I hope you enjoyed reading all of this, but future posts will probably be shorter. And thanks to BurnPTCruisers for putting this blog together. This is a great idea, and I hope we can keep it going.

-- DMD