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Larbert, Scotland, United Kingdom

Sunday, October 19, 2008

interesting ethical issues

I've been percolating on this one for a week or so now, but want to share it with you all because I need some other opinion.

In a session on peri-operative care, one of the consultants said that it was no longer 'normal practice' to order a chest Xray prior to an operation. Previously, JHO's and Fy1's had always ordered one for the anaesthetist. However, since the Surgeon didn't need it, and the anaesthetist usually didn't need it, the reports attached to the Xray were not read, and on occasion, small tumours etc were missed, which were later investigated and the Radiologist report read "the mass seen on dd/mm/yyyy has enlarged". The family got upset that no one had read the report of the original mass, and sued the NHS.

The consultant then went on to say that we should also never order blood tests that we did not need for the current management of the patient, because if we found an adverse result we would have to act on it.

I guess this comes down to 2 main questions:
a) should NHS hospitals be screening people for common ailments just because they have been admitted with a different condition.
b) if a hospital finds an adverse result and commences management as an in-patient, does the hospital pay instead of the PCT.......

Some patients do seem to fall through. we saw a lady with gallstones who had an irregularly irregular pulse. to us Med students that indicates AF. Yet despite having her pulse taken every 4hours, no one had noted the rhythm/character or done an ECG (she was admitted via GP not via A&E). She was due an operation at the tail end of last week, so it will be interesting to see if she received an ECG / cardiology referral, or if the anaesthetist was the first to notice in theatre! If so, might it be the downside of the assertion that investigations should not be carried out unless necessary. no-one thought it necessary, and they have to deal with the result.

Similarly, we saw a patient on an orthopaedic ward who had a BP of 180/100mmHg, despite being on triple therapy for Hypertension (Angiotensin 2 receptor antagonist, Calcium channel blocker and ACE inhibitor), and despite an inpatient stay of 2 weeks, had not had a review done by anyone from the Medical side of the hospital.

Conversely some departments are very good. Especially those with links. Vascular wards are quite good for getting cardiology to come and check out patients who display any cardiac signs - many get ambulatory ECG or 24hr recording monitoring to establish the nature of any cardiac complaint. But again vascular and cardiology are very closely linked physiologically and pathologically.

3 comments:

Mayhem said...

"The consultant then went on to say that we should also never order blood tests that we did not need for the current management of the patient, because if we found an adverse result we would have to act on it."

Technically this is correct, although it's not so much that they'd have to act on an adverse event. The real issue is that it's wasteful to order a test that won't change your management. For a surgeon, what matters is whether a patient is fit for surgery (or fit for anaesthesia as the anaesthesiologists would say). So even if some test value is elevated, if the abnormality isn't going to affect the consent for anaesthesia then it makes no sense to look.

In a way this might sound unethical but the problem is that the line has to be drawn somewhere. To some extent we have to screen for common problems, no matter what the diagnosis, but everyone can't get a full body MRI. Besides, screening is really primary care. Hospitals have their own purpose.

The other thing is that it depends on which service the patient is on (as you noted). At my school, the medical people are more vigilant about these things than the surgical ones. Medicine tends to do more extensive work-ups and full histories and physicals no matter what. If you come to surgery with a gallbladder problem, they're probably only going to examine the RUQ of your abdomen. We still do an X-ray and ECG for all surgeries on patients over 40. But that's a hospital regulation and it's only so because the Anaesthesiologists won't consent to surgery unless it is done.

Dragonfly said...

The head of anaesthetics at my current hospital said something similar to what Mayhem said. He said "don't order baseline tests "just because" unless they will alter management". Routine tests such as ECGs still happen though. Tests that are indicated such as cross matching or renal function are ordered where indicated only.

Lily said...

I totally agree with the sentiment that tests shouldn't be ordered unless they'll change a management plan, but surely there's another lesson to be learnt here. That if you order a test for whatever reason you need to make sure that you've checked the report.