Patient’s Death blamed on Mistaken Religion

Merle Piper was not feeling too good for some time now, and finally, Roberta, his wife, took him for a check up to the Cumberland Medical Center in Crossville, Tenn.  There, based on his urine analysis, Merle was diagnosed with stage 4 kidney failure.  He was admitted to the hospital for treatment.  However, ten days later, the medical personnel refrained from giving Merle what would have been potentially a life saving treatment.  When Dr. Kabasakal informed Roberta, on that afternoon of October 28, 2014, that he could not provide the required treatment to her husband due to his religious beliefs, she was stunned.  On questioning the doctor further, she discovered that Merle’s medical chart stated that he was a Jehovah’s Witness.  Roberta immediately pointed out the error to Dr. Kabasakal, clarifying that Merle was definitely not a Jehovah’s Witness and gave him permission to put in a port for his treatment.  Unfortunately, by then it was too late and Merle passed away that night.

The fact that Merle’s medical chart stated his religion as Jehovah’s Witness led them to deny him the required medical treatment.  The attending medical personnel believed that particular religious beliefs of the Jehovah’s Witness prohibited that type of treatment.

While there are many cases of death of a patient due to medical errors or medical negligence, cases such as Merle Piper’s seem uncommon.  What remains a mystery is how did Merle’s medical chart state his religion as a Jehovah’s Witness?  How come nobody, including Roberta, managed to find this error in the ten days that Merle was under treatment?

Last month, Roberta sued the Cumberland Medical Center, Ayca Kabasakal MD, Merhaf Zenio MD, John Doe individuals and corporations in Cumberland County, Tenn.  The lawsuit, filed on October 13, 2015, alleges medical malpractice and wrongful death and seeks an unspecified amount in damages.

While this does seem like a mistake was made, there are hundreds of cases, where medical personnel have been helpless in saving a patient merely because of the patient’s religious belief, which does not allow a particular line of treatment.  The cases of Emma Gough in 2007 and Rockwell Sevy in 2011 are examples.  These issues put the medical personnel in a dilemma – should they follow their medical ethics and do everything possible to save the patient or should they give in to the patient’s religious beliefs and watch helplessly as the patient passes away?  What would you do in either of the cases – as a patient and as a doctor?


References:

  1. LESSMILLER, K. (2015, November 12). Religion Mistake Blamed for Patient’s Death. Retrieved November 25, 2015, from courthousenews.com: http://www.courthousenews.com/2015/11/12/religion-mistake-blamed-for-patients-death.htm
  2. Religion and refusing medical treatment: Would you die for your religion? (2007, November 07). Retrieved November 25, 2015, from scienceblogs.com: http://scienceblogs.com/insolence/2007/11/07/religion-and-healthcare-would-you-die-fo/

Medical mistakes – the hidden truth

Case 1

Donald Adanich, a 69 year old Vietnam veteran, had gone to Louis Stokes Cleveland VA Medical Center, for a dental implant surgery in February 2014.  It was a routine surgical procedure, one that the medical center had performed countless number of times.  However, post the surgery, Donald found himself feeling very sick, to the extent that Lyn, his wife, took him back to the VA center the very next day after the surgery.  Donald was admitted to the hospital complaining of stomach ache, and upon investigation was found with high fever and an equally high white blood cell count.  Doctors attending to Donald admitted to Lyn that they could not figure out what caused this infection.  Three weeks later, Donald was discharged from the hospital.  Donald still complained of feeling unwell and so Lyn decided to take a second opinion at another hospital.  What she was told by the doctor there left her shocked.

The physician at the second hospital obtained Donald’s medical reports from VA hospital.  The reports also included a document which stated that Donald had swallowed a surgical gauge during the dental implant procedure.  However, this only came to light when Donald was brought back to the hospital.  The doctors there removed the surgical gauge from Donald’s stomach, but did not inform Donald and Lyn about what had taken place.  Sadly, Donald never recovered from his illness and passed away six months later in August 2014.

 Case 2

At the age of 20, Lauren Wargo, then in college, decided to get a mole on her face removed through medical procedure.  In December 2006, she underwent the procedure, which left her with first, second and third degree burns, covering more than half her face.  What should have been a normal and simple procedure; went horribly wrong for her.  The doctor offered no explanation to Lauren’s parents on how this could have happened.

The Wargo’s took the doctor to court and that is when the truth came out.  During the procedure, the doctor failed to inform the anesthetist to switch off the oxygen, when he was using an electrical tool that was capable of igniting a fire.  This resulted in Lauren suffering horrible burns on most of her face.

The Issue

Most hospitals and doctors keep a careful track of medical mistakes.  However, this information is not revealed to the patients, their families or the public.  News Channel5 Investigators have now revealed how deep this culture of secrecy surrounding medical malpractice is.  According to their investigation, numerous government agencies regularly collect data and records of medical mistakes in hospitals.  This data, however, is not revealed to the public.  Nor is it possible for the public to find details about the number and type of medical malpractice cases against specific doctors or hospitals.

The US Congress ordered the creation of a data bank under the National Practitioner Data Bank, where hospitals are required to report any serious disciplinary action that has been taken against medical professionals by them.  The purpose of this data bank is to ensure that medical professionals, who lose their license in one state, cannot start their practice in another.  But, the names of the medical professionals and their employers are not revealed and kept private by law.

This effectively means that a person has no way of knowing if the doctor or hospital where he wants to be treated has been reported for any serious disciplinary action or medical malpractice.  For example, there were 2210 disciplinary actions reported in 2014 in Ohio.  However, the names of the medical professionals against whom these actions were taken are not known to the general public.  So, how does a person living in Ohio get himself treated by a doctor, without a doubt in his mind?

These two cases, are examples of how hospitals and doctors hide their medical mistakes, making it not only difficult for the patients and their families to know the truth, but in a lot of cases, also finding it difficult to get further proper treatment.

The Follow up    

NewsChannel5 Investigators approached the Cleveland VA Medical Center to enquire about Donald’s case.  The spokesperson of the hospital refused to take part in the on-camera interview.  However, he sent them this statement – “The Cleveland VA Medical Center offers our deepest condolences to the Adanich family for their loss.  We will forever be grateful for Mr. Adanich’s service to our nation.”  That is no solace for Lyn, who lost her husband due to the hospitals mistake.

Lauren and her family are still waiting for a simple apology from the doctor – which so far has not been offered.


References:

  1. “Culture of Secrecy”: NewsChannel5 Report Echoes Warnings of Ohio Medical Malpractice Lawyers. (2015, November 13). Retrieved November 17, 2015, from lewlaw.com: http://blog.lewlaw.com/blog/culture-of-secrecy-newschannel5-report-echoes-warnings-of-ohio-medical-practices-lawyers
  2. Buduson, S. (2015, November 11). EXCLUSIVE NewsChannel5 Investigation | Culture of Secrecy: How hospitals hide medical malpractice. Retrieved November 18, 2015, from newsnet5.com: http://www.newsnet5.com/news/local-news/investigations/exclusive-newschannel5-investigation-culture-of-secrecy-how-hospitals-hide-medical-malpractice
  3. Kiernan, S. (2003, June 15). Breaking the Medical Malpractice Code of Secrecy. Retrieved November 17, 2015, from niemanreports.org: http://niemanreports.org/articles/breaking-the-medical-malpractice-code-of-secrecy/

Guidelines for treating pulmonary hypertension in children

Pulmonary Hypertension in children

Nearly 1 in 500 babies are born with pulmonary hypertension (PH) every year.  Although rare in newborns, pulmonary hypertension is a heart and lung disease with the potential to be fatal.  Children suffering from pulmonary hypertension have blockages in their pulmonary artery.  This makes it difficult for the right ventricle in the heart to pump blood through their lungs.  Although in some cases pulmonary hypertension is caused in isolation due to circulatory problems in the lungs, more often it is due to complications brought on by other serious issues of the heart or lungs.  Congenital heart disease, congenital diaphragmatic hernia, bronchopulmonary dysplasia are some of the issues which cause pulmonary hypertension.

Newborns with congenital heart disease generally suffer from high blood pressure in their lungs.  In many cases the blood pressure normalizes after correcting the heart defect through surgery.  In cases where this does not happen, it becomes harder for the heart to pump.  Although rare, sometimes the pressure is so high that corrective surgery is not possible or is too risky.  Medications and/or oxygen are used to relax the blood vessels – both in the case of post surgery or in case s where surgery has not been possible.

Pulmonary hypertension symptoms include fainting, shortness of breath and cyanosis.  Pulmonary hypertension can lead to death from heart failure, if not diagnosed and managed correctly. Those who survive, suffer from health issues throughout their lives.

The Guidelines

For the first time, guidelines towards the diagnosis and treatment of pulmonary hypertension in children have been laid out and recently published in the journal Circulation.  There have been guideline in place for the treatment of pulmonary hypertension in adults since a long time, but the same cannot be applied to the diagnosis and treatment in children.  It needs to be understood here that the under laying causes for pulmonary hypertension differ amongst adults and children.

Based on data collected from over 600 studies, these guidelines have been created by an interdisciplinary team of 27 physicians.  A result of the collaboration between the American Thoracic Society (ATS) and the American Heart Association (AHA), the guidelines are set as an aim to provide the best medical care to children suffering from pulmonary hypertension.

Some of the key features of the guidelines cover:

  • Classification of the different types of pulmonary hypertension;
  • Proven and emerging surgical and medical therapies;
  • Approved treatments and dosages including their appropriateness;
  • Optimal care of the patient;
  • Advice on supportive care and the social aspects of care of the patient;
  • Advice on exercise and travel restrictions;
  • The role of centers specializing in the treatment of pulmonary hypertension in children.

There are gaps in our knowledge about treating pulmonary hypertension in children.  These guidelines point to these gaps; along with offering advice on issues that health care providers and parents of children suffering from pulmonary hypertension find themselves struggling with.  Areas like whether a child should receive antiplatelet blood thinning agents or anticoagulants; parents concerns with safe exercise regime for their children, concerns regarding air travel; these and much more are covered by these guidelines.

The future

The guidelines are a first major step towards developing a proper diagnosis and treatment regime for pulmonary hypertension in children.  However, it is important to remember that further research with more specific data is required to improve the care and treatment of children suffering from pulmonary hypertension.  It is equally important for parents of children suffering from this condition to search and find doctors and care centers that offer better diagnostic and surgery facilities which can include new molecular diagnostics, latest drug therapies and recently developed surgery protocols.


References:

  1. Dunbar Ivy, M., Steven H. Abman, M., Robyn J. Barst, M., Rolf M.F. Berger, M., Damien Bonnet, M., Thomas R. Fleming, P., et al. (2013, December). Pediatric Pulmonary Hypertension. Retrieved November 02, 2015, from JACC Journals: http://content.onlinejacc.org/article.aspx?articleid=1790598
  2. First Ever Guidelines for Pediatric Pulmonary Hypertension . (2015, October 27). Retrieved Nvember 02, 2015, from RT Magazine: http://www.rtmagazine.com/2015/10/first-ever-guidelines-for-pediatric-pulmonary-hypertension/
  3. Heiner Latus, T. D. (2015, February 03). Treatment of pulmonary arterial hypertension in children. Retrieved November 02, 2015, from NATURE REVIEWS CARDIOLOGY | REVIEW: http://www.nature.com/nrcardio/journal/v12/n4/full/nrcardio.2015.6.html
  4. Melvyn Rubenfire, M. F. (2015, September 15). Guidelines for Diagnosis and Treatment of Pulmonary Hypertension . Retrieved November 02, 2015, from American College of Cardiology: https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2015/09/15/15/19/2015-esc-ers-guidelines-for-the-diagnosis-and-treatment-of-ph?w_nav=Tab
  5. Rosenthal, M. (2015, October). Guidelines First To Focus on Children With Pulmonary Hypertension. Retrieved November 02, 2015, from Pharmacy Practise News: http://www.pharmacypracticenews.com/ViewArticle.aspx?d=Web+Only&d_id=239&i=October+2015&i_id=1235&a_id=34114

Is my child susceptible to pediatric pneumonia?

Caused by viruses, bacteria, parasites and fungi, pneumonia is an infection in the lungs, which can affect either one or both of them.  In the case of children, the most common cause of pneumonia is viruses.  However, viral pneumonia can also develop bacterial pneumonia.  Pneumonia, generally begins with an infection in the nose or throat (upper respiratory track), resulting in fluid collection in the lungs.  Pneumonia can also occur in case any foreign material is mistakenly inhaled into the lungs – common culprits are food or acid from the stomach.

Pneumonia is the leading infectious cause of death in children worldwide, accounting for 15% of all deaths in children below 5 years of age.  According to UNICEF, pediatric pneumonia is responsible for the death of 3 million children globally each year.  However, the majority of these deaths occur in children with underlying conditions, such as congenital heart disease, chronic lung disease of prematurity and immune-suppression.  The majority of these deaths occur in developing countries; however, pediatric pneumonia is a significant cause of death in industrialized nations too.

What are the factors that increase the risk of pneumonia in my child?

Pneumonia spreads in a number of ways including person to person contact through the saliva or mucus from the infected person and through air-borne droplets from a sneeze or a cough.  Inhalation of the bacteria or virus, commonly found in the child’s nose and throat, can lead to pneumonia.  Pneumonia can also infect the child through the blood, especially during or immediately after birth.  Some of the common risk factors are listed below:

  • Premature birth;
  • Asthma or certain genetic disorders, such as sickle-cell anemia;
  • Heart defects, such as ventricular septal defect (VSD), atrial septal defect (ASD), or patent ductus arteriosus (PDA);
  • Poor nutrition;
  • A weak immune system;
  • Spending time in a crowded place, such as a daycare center;
  • Breathing secondhand smoke.

What are the signs and symptoms that indicate pneumonia in my child?

The signs and symptoms depend on the type of pneumonia and the age of the child.  The most common symptom of pneumonia in infants is the cough, along with retractions, tachypnea and hypoxemia.  Often these may be accompanied by fever, congestion, irritability and suppressed appetite.  While adolescents experience similar symptoms, they may show other constitutional symptoms such as pleuritic chest pain, abdominal pain, headaches, vomiting, diarrhea, otalgia / otitis and pharyngitis.  Most children will show either or all of the following symptoms:

  • Fever;
  • Difficulty in breathing;
  • Abdominal pain near the ribs;
  • Poor appetite;
  • Cough;
  • Excessive crying, or more irritable or fussy than normal;
  • Pale or bluish lips, fingernails, or toenails.

What are the signs of breathing problems in my child?

While it is fairly easy to pick up signs of discomfort in the child, the following symptoms indicate that your child is facing difficulties in breathing.

  • Increased pulling of the breathing muscles below and between the ribs and above the collarbone;
  • Flaring (widening) of the nostrils;
  • Pain in the chest, particularly with coughing or deep breathing;
  • Wheezing;
  • Your child is breathing fast:
  • More than 60 breaths in one minute for newborn babies up to 2 months old
  • More than 50 breaths in one minute for a baby 2 months to 12 months old
  • More than 40 breaths in one minute for a child older than 1 year

How will they diagnose if my child has pneumonia?

The first thing that your child’s doctor will observe is the respiratory efforts of the child during his physical examination.  In case there are respiratory symptoms present, he would then undertake an assessment of the oxygen saturation by pulse oximetry.  Following this, other diagnostic tests may include:

  • Auscultation by stethoscope;
  • Cultures;
  • Serology;
  • Complete blood cell count (CBC);
  • Chest radiography;
  • Ultrasonography

How will my child be treated for pneumonia?

In most cases, your child will be treated either at the doctor’s office or at your home.  However, sometimes if the case is severe or if your child is younger than 2 months, the doctor will want to admit your child to the hospital for treatment.  The first line of treatment normally is to provide immediate respiratory support in case of breathing problems.

In case of pneumonia caused by a virus, generally there is no specific treatment other than rest and the usual treatment to control fever.  Viral pneumonia usually improves after a few days, although the cough may linger for several weeks. Ordinarily, no medication is necessary. However, because it is often difficult to tell whether the pneumonia is caused by a virus or by bacteria, the doctor will prescribe an antibiotic, which has to be taken for the full prescribed course and at the recommended specific dosage. You may be tempted to discontinue them early, but you should not do so. Your child will feel better after just a few days and it may tempt you to discontinue with the antibiotic.  However, you should never do that as some bacteria may remain resulting in the infection returning again.

How can I prevent my child from getting pneumonia?

The first and most important step in prevention is immunization against Hib, pneumococcus, measles and whooping cough (pertussis).  The key to improving your child’s natural defense is adequate nutrition, starting with breastfeeding for the first six months.  Some of the other measures are listed below:

  • Do not let anyone smoke around your child.
  • Keep your child away from people with sore throat or cough.
  • Wash your hands and your child’s hands with soap before feeding or eating.
  • Encourage good hygiene around the house.
  • Do not let your child share food, drinks, or utensils with others as far as possible.

References:

  1. Dallas, M. E. (2013, April 12). Pneumonia in Children. Retrieved November 03, 2015, from Everyday Health: http://www.everydayhealth.com/pneumonia/children/
  2. Nicholas John Bennett, M. P. (2015, May 28). Pediatric Pneumonia. Retrieved November 03, 2015, from Medscape.com: http://emedicine.medscape.com/article/967822-overview
  3. Pneumonia. (2014, November). Retrieved November 03, 2015, from World Health Organisation: http://www.who.int/mediacentre/factsheets/fs331/en/
  4. Pneumonia. (2015, August 20). Retrieved November 03, 2015, from healthy children.org: https://www.healthychildren.org/English/health-issues/conditions/chest-lungs/Pages/Pneumonia.aspx
  5. Pneumonia In Children. (2015). Retrieved November 03, 2015, from Drugs.com: http://www.drugs.com/cg/pneumonia-in-children.html
  6. Pnuemonia. (2015). Retrieved November 03, 2015, from Kidshealth.org: http://kidshealth.org/parent/infections/lung/pneumonia.html

Guidelines for CAP treatment in the ER

Paul was not overly concerned about the cough that had developed over the last few days.  When Sarah insisted that he show himself to the doctor, Paul brushed it aside stating that the cough was due to the change in weather and nothing more.  However, since yesterday, Paul started feeling a shortness of breath and was producing sputum when coughing.  He told Sarah that they would go to the doctor the next day.  However, this morning Paul work up feeling feverish – a quick check revealed that his temperature was nearly 3 degrees higher than normal.  He was also complaining of sharp chest pain and breathlessness.  An alarmed Sarah called for an ambulance and rushed Paul to the nearby hospital.

Paul was rushed into the emergency room and after a quick but thorough initial check up, taken for an X-Ray and some other tests.  The results of these tests indicated that Paul was suffering from Community-acquired pneumonia (CAP).  Seeing a rather distraught Sarah, the doctor, who had started the treatment process on Paul, asked one of the healthcare workers to explain Paul’s problem and the treatment process to Sarah.

Community-acquired pneumonia    

Pneumonia is caused when the alveoli (the oxygen absorbing areas of the lungs) fill up with fluids.  This creates problems in the functioning of the lungs and manifests itself through fever, coughing, chest pains and dyspnea.  Community-acquired pneumonia refers to pneumonia that is contracted by someone who has very little or no contact with the healthcare system.  Hospital-acquired pneumonia (HAP) is contracted through either a stay at the hospital or through a visit to one.  Healthcare associated pneumonia (HCAP) gets contracted at nursing homes, healthcare centers, outpatient clinics, dialysis centers etc.

Community-acquired pneumonia is the most common out of these three and is a leading cause of illness and death all over the world.  CAP is caused by viruses, parasites, bacteria or fungi.  Doctors diagnose CAP through a physical examination, by assessing the symptoms and through an X-Ray of the chest.  In some cases, additional tests such as sputum and blood cultures are required, although these are for generally for patients with severe illness.  Patients with CAP are treated primarily with antibiotics, antipyretics and cough medicine at the ER or outpatient department.  However, patients with severe illness require hospitalization and the treatment here differs from that at the ER.  In order to maximize the care provided to patients in terms of the diagnosis, tests and treatment, there are a set of guidelines provided for the same.

The guidelines   

A number of medical societies have issued guidelines for the treatment of community-acquired pneumonia (CAP).  Two of the most widely referenced guidelines are those of the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA).  To remove any confusion regarding differences between their respective guidelines, the IDSA and the ATS developed a unified CAP guideline document.  Although, intended to be used by emergency medicine physicians, primary care practitioners and hospitals, these guidelines are also an appropriate starting point for specialists.  These guidelines cover the following recommendations:

  1. Implementation of Guidelines and recommendations
  2. Documented benefits
  3. Site-of-care decisions
  4. Hospital admission decision
  5. ICU admission decision
  6. Diagnostic Testing
  7. Recommended diagnostic tests for etiology
  8. Antibiotic treatment
  9. Out-patient treatment
  10. In-patient non ICU treatment
  11. Pathogen directed therapy
  12. Pandemic influenza
  13. Time to first antibiotic dose
  14. Duration of antibiotic therapy
  15. Other treatment considerations
  16. Management of Non-responding pneumonia definitions and classification
  17. Prevention

Recommendation and implementation

The strength of each recommendation is graded as “strong,” “moderate,” or “weak” on the basis of not only the supporting evidence but also expert interpretation and clinical applicability.

A strong recommendation implies that most patients should receive that particular intervention.   However, significant variability in the management of patients with CAP is well documented.  But, the rationale for variation from a strongly recommended guideline should be apparent from the medical record.

Moderate or weak recommendations suggest that, even if a majority would follow the recommended management, many practitioners may not.  Deviation from guidelines may occur for a variety of reasons.  One set of guidelines cannot cover all the variable settings, unique hosts, or epidemiologic patterns, which may dictate alternative management strategies; and the judgment of the physician, should always supersede guidelines.

These guidelines may be used as a measure of quality of care for hospitals and individual practitioners. Although these guidelines are evidence based, deviations from them should not necessarily be considered substandard care, unless they are accompanied by evidence for worse outcomes in a studied population.


References:

  1. Burke A Cunha, M., & Chief Editor: Michael Stuart Bronze, M. (2015, August 13). Community-Acquired Pneumonia. Retrieved November 02, 2015, from Medscape.com: http://emedicine.medscape.com/article/234240-overview
  2. Devorah J. Nazarian, M., Orin L. Eddy, M., Thomas W. Lukens, M. P., Scott D. Weingart, M., & Wyatt W. Decker, M. (2015). Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia. Retrieved November 02, 2015, from AMERICAN COLLEGE OF EMERGENCY PHYSICIANS: http://www.acep.org/workarea/DownloadAsset.aspx?id=45809
  3. Lionel A. Mandell, R. G. (2015). Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Retrieved November 02, 2015, from Oxford Journals: http://cid.oxfordjournals.org/content/44/Supplement_2/S27.full
  4. Pneumonia – adults (community acquired). (2014, April 26). Retrieved November 02, 2015, from U.S. National Library of Medicine: https://www.nlm.nih.gov/medlineplus/ency/article/000145.htm
  5. RICHARD R. WATKINS, M. M. (2011, June 01). Diagnosis and Management of Community-Acquired Pneumonia in Adults. Retrieved November 02, 2015, from American Family Physician: http://www.aafp.org/afp/2011/0601/p1299.html