Category Archives: Ethics

The blur that is ethics

This was a rather interesting article from today. Although more likely to run across poems, anecdotes, and grammatical philosophizing as one strolls down Mulberry Street, sometimes the reader might encounter something a bit more complicated. In these cases, one should tread carefully, remembering that there are two sides of the street.

Take that to mean whatever you want. I found this article interesting since I remember hearing a different spin on the story a year or two ago after the hurricane. “Euthanasia” and “homicide” were terms more apt than “abandoned by his government.” I don’t mean to imply that all ethical issues are gray, but reading the doctor’s perspective provided me with another occasion to imagine the sights and sounds of Memorial Medical Center in the aftermath of the post-Katrina flooding. (It was the fact that the city is built below sea level and that the levees could not hold the surge, more so than the actual hurricane, that did so much damage, if I recall correctly.)

In this sweltering hospital with no electricity and no operational pharmacy, patients languish and the staff is stretched thin in terms of both numbers and emotions. At the time, no one knows if help will come in a day, a week, or weeks. (Pre-Katrina, a week would have been inconceivable. However, now’s not the time to discuss the politics of it.) Doctors and nurses are doing their best to take care of patients, night and day, that they may know little about. If the staff’s suffering is difficult to imagine, how much more so that of the ailing patients.

The facts are that morphine and midazolam hydrochloride were given to some patients. This sounds like a very reasonable regimen for ICU sedation. The doses given, curiously, are absent from the article. In any case, I suppose the question comes down to one of intent: did the physician intend to kill the patients, or to relieve their suffering? The ethical dilemma stems from the paradox that actions based on divergent intentions may appear very similar.

In other words, a dose of morphine and midazolam that is necessary to treat a patient who is hyperventilating, anxious, in pain, or otherwise decompensating may lead to a fatal respiratory depression. Goodness knows that if the congestive heart failure exacerbation patients weren’t getting their diurectics and ACE inhibitors (because, as I understand, the pharmacies were shut down), or if the septic patients were not getting their antibiotics, then there is no fine line between easing suffering and hastening death in these patients already on the brink. Rather, they overlap to the degree that there may be no difference, other than that of intent.

As I recall, the Hippocratic Oath does state that the physician shall not “prescribe a deadly drug…” To take this literally would mean that nearly no drug could be prescribed. After all, Tylenol is deadly in large doses. So is water. Coumadin (a common blood thinner) was developed first as rat poison. So what the oath is getting at, I believe, is the intention behind the prescription. Medicines don’t treat patients; physicians do.

In this case I cannot make a clear judgement, other than simply to say that from the facts presented, I cannot disprove that the doctor intended only to relieve suffering. And I can also say that I noticed the author used the everyday term “morphine” but included the very technical “midazolam hydrochloride”, the latter word being thoroughly unnecessary to all but the pharmacosynthetic chemists out there.

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My first call: Rounds the next morning

Seeing the patients went smoothly and was easier than two days before when the patients were new to me. I notice how much more confident and comprehensive I felt on the patient’s I’d admitted. One of my first orders of business was to check on my patient with the dropping hematocrit. His next lab draw showed a further decrease in Hct, so I called the daughter’s home again. A granddaughter answered and gave me her mother’s vacation home number. I reached the daughter finally, explained the situation, and got telephone consent. A nurse listened in and co-signed the consent paperwork. At last! I could finally write the orders, “1. Transfuse 2 units Packed Red Blood Cells. 2. Premedicate with Benadryl 25mg PO and Tylenol 650 mg PO.” The premedication prevents minor allergic and pyrogenic reactions.

Then there was my patient who’d had a stroke. One week before admission, she’d been functional, able to care for herself, cook for herself, etc. This Asian woman had had a stroke in her cerebellum which affected her ability to walk and her coordination. Not so bad, really, considering what could have happened. My impression is that on the day of discharge (July 1st), she was still able to walk with a walker, and was totally lucid. She had perhaps a little difficulty with using her left arm. And she was not anticoagulated since the stroke had converted to a hemorrhagic one. But then the night prior to admission, she’d fallen in the bathroom while her daughter was trying to assist her. It was more of a slump than a slip. She’d bumped hit her head on the tile wall. The daughter walked her back to bed, but then noted some hours later that her mother was disoriented, not responsive, and staring constantly to the left. At this point they brought her in to the hospital, one day after she’d left. She would mumble some unintelligible words, and could barely move her extremities.

While making my rounds, I walked into a room full of people. Daughters, sons-in-law, granddaughter…all had come to be with this matriarch. And with tearful, expectant eyes, they looked up at me (one month into officially being a doctor and two days into my new job) and began pouring out their questions in broken English. “What happened?” “What does the MRI test show?” “Will she get better?” “Did her fall do this?”

The last question was the biggest challenge. Even though I wondered if there was some possibility that minor trauma could lead to an embolus coming loose and causing an ischemic stroke, I thought in the elderly a bump to the head would more likely result in a subdural hemorrhage or something of the sort. More importantly, I realized that the patient’s daughter was in a position to blame herself for her split second of inattention during which her mother fell. Even though it may have been technically correct to say, “Will you please wait a minute while I go look that up?” or “Why don’t you ask the neurologist when he comes by?”, I believed, and still believe, that at that moment it was more important for me to go out on a limb. I’ve had four years of medical school for a reason, and I think that gives me some grounding for spontaneous answers that I can’t back up right away with statistics and figures. In this case, my role was not statistician but healer. I looked the daughter in the eye, and slowly, such that she could understand in her limited English, I told her, “No. I don’t believe the fall caused your mother to have a stroke. There was nothing that could have prevented that stroke. I know you hate to see your mother this way, but I can tell you she is one fortunate woman to be surrounded by all this family that loves her.”

Rounding next brought me to my elderly patient with the UTI and suspicious cardiac enzymes. The nurse met me at the nursing station.
“Doctor, are you taking care of Mrs. C?”
“Yes, I am.”
“Could you do something? She’s really agitated!”
I paced over to her room, hearing noise through the door. Upon opening it a sight met my eyes. There, attempting to restrain a feisty, naked, and agitated 92-year-old were a nurse and an assistant. “I’ll write some orders,” I said, turning on my heels.
“Make it intra-muscular!” I heard behind me. “She’s pulled out her I.V.!” This time, it was “Haldol 2mg IM” I wrote in her chart. Multiple shifts in the psych ER proved beneficial in this case. I reviewed the patient’s vital signs and nursing notes at the nursing station, and ten minutes later, she was lying clothed and tucked into bed, peaceful and cooperative when I went in to see her!

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My first call: Calls in the night

Several interesting things occurred that night. Stress on the word night. My fourth patient came in around 2200, so of course it was nearing eleven o’clock when I began writing the admit orders. I got a page for cross-cover. My resident told me to write the orders, and he would check out this patient on the floor. Soon after I joined him. A patient with ascites and intra-abdominal abscesses had fallen on the floor on his way to the bathroom. Subsequent vital signs revealed a dropping blood pressure and fever—worrisome for developing sepsis. The resident had already talked to the primary team’s attending and wanted to write for vancomycin. When I got there and offered to help, I examined the patient, and then offered to page the ID attending. After approval, I wrote my first cross-cover order: “Vancomycin 1 g IV x1, please give over one hour.”

In the meantime, I was paged a nurse who was concerned about my patient with hyponatremia. The day before, some blood was noted in his Foley bag. We figured this demented fellow most likely had tugged on the catheter, leading to hematuria. I discontinued his aspirin and Lovenox to help the blood coagulate at the site of trauma. However, the bleeding continued. We began measuring his hematocrit every six hours. And by this time, the night of Day Two in the hospital, his hematocrit had dropped nearly 10 points. Even the budding anesthesiologist in me felt ready to transfuse. My resident agreed, so I wrote the orders. The nurse, however, realized we didn’t have consent on the chart. I called the patient’s daughter who had medical power of attorney and left a message at her contact number, to no avail. Same with her cell. Called both numbers again with no response. The nurse called the nurse manager, and together they stood firm about not initiating the transfusion without proper consent. Given that the patient was alert and oriented, comfortable, and had stable vital signs, I began to question the need to transfuse at 0200. (It should be noted that my phone message to the patient’s daughter was carefully crafted so as not to worry her.) We’d keep an eye on him, and in the morning transfuse after consent. I ran this plan by my resident, who disagreed. This was a medical emergency: we needed to transfuse, he said. I quickly realized that the nurse and her manager were flat out refusing to transfuse. I felt myself leaning toward their side, so I made the decision to call my own attending. Our conversation went something like this,

“Hi, Dr. ______ , sorry to wake you. I was calling about Mr. _______ , our 73 year old with….” “Just tell me the facts. What is it?”
“His ‘crit is dropping. We need to transfuse, but we don’t have consent and can’t reach his family.”
“Is he stable?”
“Yes, he’s alert, oriented, and his blood pressure and pulse are fine.”
“Then we can’t transfuse without that paper on the chart.” [pause]
“Okay…thank you.”

I felt a sense of relief. I’d been caught between my resident and the nurses, agreeing with the need to transfuse, but also recognizing the ethical delimma. My attending, brusque as she was, backed me up. And the stat H/H I ordered showed the blood count was stable for the last four hours. Several lessons learned.

  1. Get consent before it’s needed. (Think ahead!)
  2. Be aware when you’re in an ethical crisis. If something feels not-quite-right, it probably isn’t.
  3. Learn to stand up to your superiors. For me, this may have meant reasoning with my resident, and trying to convince him not to transfuse.
  4. Even in gray areas, do your best to do what is right. There are risks associated with transfusion. One anesthesiologist I know made sure all students were aware of this. In the case of this cheery, demented fellow who was happy to get the transfusion, I knew he really wasn’t able to give informed consent. And I knew it wasn’t a true emergency, given his stable vital signs and mental status.
  5. And even when nurses seem to get in the way of practicing good medicine, step back and evaluate the situation. They may have a good reason.

I’d crawled into bed and dozed for thirty minutes when I heard two beeps. I fiddled with my cell phone (on which I’d set the alarm), annoyed that it was beeping. Only then I realized that the beeping was my pager. I’d been paged a couple minutes before and slept through it. This time it was a nurse taking care of my elderly woman with the UTI. At the recommendation of my attending, we ordered three sets of cardiac enzymes and serial EKG’s on her to evaluate for MI. The reasoning is that the elderly often don’t complain of chest pain with an MI, and this is a big cause for medical liability. In other words, ordering a few labs can prevent a big lawsuit. This nurse was telling me that the patient was on the floor. (I must have written an order, “Please call M.D. when patient arrives to floor,” or something of the sort. It’s all hazy now.) In any case, this reminded me to check her second set of cardiac enzymes. The first set had shown just a mild elevation of the nonspecific CK enzyme. I napped a few more minutes, and then got up to check the labs. The CK was even higher, and the MB portion (specific for damaged heart muscle) had creeped up into the abnormal range. Great. Do I need to start her on aspirin, a beta-blocker, oxygen, and nitrates? I really wasn’t that worried, and I debated about calling my resident. I called the nurse back and ordered aspirin 325 mg PO, first dose now. Since the troponins (sensitive for heart damage) weren’t elevated, I felt pretty sure she wasn’t having an MI. I crawled back into bed, and thirty minutes later was paged again.

“Mr. W’s sugars have dropped to 135.” It was an ER nurse calling about my severely hyperglycemic patient. We’d wanted him to go to the step-down intensive care unit since patients can develop electrolyte abnormalities with big changes in serum glucose. Unfortunately, neither the ICU nor the step-down unit had beds available, so we left him the ER. The goal was to bring the sugars down slowly with a small but steady insulin drip. In this patient with poorly controlled diabetes, however, his body must have been extremely sensitive to insulin. His sugars plummeted. I asked the nurse to draw a stat electrolyte panel. At this point I called the resident and told him about both situations: The elderly woman’s cardiac enzyme panel, and the dropping sugars. He told me to talk to the attending, ASAP. In sharp contrast to my previous encounter with her, she seemed awake and even chipper. She was down in the ER, and had seen the patient. His stat labs were back, and his electrolytes were fine. She was actually quite happy with his progress. And she agreed with me. The former patient was not having an MI. No need to start additional medications. I thanked her, and crawled back into bed for the third time, with thirty minutes to sleep again. After a quick shower at 5:45—which does amazing things to make a post-call doc feel civilized—it was time to round.

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