Sunday, October 17, 2010

Advanced Cardiac Life Support and Tort Reform

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Two days from this writing, I will go mano a mano with a computer screen.   This will be my second gastroenterology (GI) board recertification.   Last week I suggested that the 490 minutes of unfettered fun might not be money well spent.  A reader could infer my view that the $1200 fee has more to do with securing the finances of the American Board of Internal Medicine than it does to enhance my knowledge of GI.   Perhaps, I was hyperventilating about the cost.  When I calculate the GI board CPM (cost per minute), I determine that the exam only costs $2.45 per minute   In other words, a full minute of quality board testing time costs about the same as a slice of pizza.  Clearly, the test is a bargain, and I retract any prior Whistleblower whisperings that contradict this. 
Yesterday, I took another exam, this one to recertify me as a qualified Advanced Cardiac Life Support (ACLS) practitioner.  An excellent paramedic instructed me and my 2 GI partners on new developments in basic life support, medication strategies to resuscitate the moribund, airway management and proper use of a defibrillator. 
Since my internship and GI fellowship,  I have never  had to administer life support.  This is fortunate for me, and for the patients, since I am unqualified to perform ACLS, despite my certification, which I am required to have..
You recall the 3 important initial steps of basic  life support.   These lifesaving ABCs are
  • Airway
  • Breathing
  • Circulation
I have my own 3 step emergency plan that I am always ready to implement.  They are
  • 9
  • 1
  • 1
Practicing physicians are simply not skilled advanced  resuscitators. If an individual collapsed, many physicians nearby would hope that paramedics would arrive before the doctor would have do any doctoring.   Indeed, many physicians are reluctant to identify themselves as doctors in emergency situations.   I’m not suggesting that any of us would stand aside if there was a person in dire need of urgent medical care.   However, if there are 20 physicians in a theater, and a frantic call is issued for a physician, some doctors might hesitate hoping that there is an ER doctor or a cardiologist who will step up.
The public wrongly believes that a medical degree includes lifelong lifesaving skills.   If someone drops while she shops, she might fare better if there is a boy scout nearby, instead of an allergist, dermatologist, psychiatrist, family doctor or even a gastroenterologist.
Jewish law mandates that an individual intervenes to save someone’s life.  The Talmud teaches, "...if  one sees his friend drowning in a river, or if he sees a wild animal atacking him, or bandits coming to attack him, that is he is obligated to save [his friend."   This concept is not part of American jurisprudence.   It is legal to stand idly by when someone needs to be rescued, even if such a choice would be morally reprehensible.   While there is no law requiring that we act to save someone, there are laws in all 50 states and the District of Columbia that try to encourage us to do the right thing.
We are all familiar with the Good Samaritan legal doctrine.  These laws provide immunity to folks who provide good faith emergency care to people who are at risk of death.  If a man suffers cardiac arrest and needs cardiopulmonary resuscitation, the Good Samaritan law protects the rescuer from being sued if the individual dies or survives with a devastating result.   We do not want fear of a lawsuit to restrain an individual from stepping in to save someone’s life.  It would seem difficult to argue against this concept, but nothing would surprise me in the irrational and unfair medical liability arena. 
In my medical practice and yours, if an adverse event develops, despite good faith and proper medical care, there is no Good Samaritan shield to protect me.   To paraphrase an oft quoted line from the New Testament, the truth may not set me free, at least not right away.
I think that the medical liability system needs to be defibrillated, wiped clean to allow society’s moral pacemaker to generate a new rhythm.    I’m ready to charge the paddles.  Are you?

16 comments:

DrJohnM said...

My middle-aged cycling pals always comment something along the lines, "at least we have a cardiologist with us today." But, in the event of a cardiac arrest in the field I would take a teenager with an AED over any ivy-league trained doctor. Without the tools of our trade we docs are humbled mightily.

Good luck with that computer battle.

A. Bailey said...

One of the few good things I can say about the growth of MAC in the endoscopy unit is the round the clock presence of anesthesiologists, who actually know what they're doing in the event of an arrest and have instant access to the tools of the trade.

Regarding cycling and Good Samaritans, there is no more forceful soul to intervene at a crash than a chiropractor. They're never shy about stepping forward and taking control of the situation and have no compunction in elbowing physicians out of the way. I wonder why this is.

Good luck with the boards.

Anonymous said...

is there a tractate on ACLS in the Babylonian Talmud?

Michael Kirsch, M.D. said...

Isn't the entire universe contained there?

Anonymous said...

If you want to not get paid for all the lifesaving work you do, then perhaps you can convince people the Good Samaritan immunities apply to you. Is that what you're advocating?

Anonymous said...

" It would seem difficult to argue against this concept, but nothing would surprise me in the irrational and unfair medical liability arena. "

Only to someone who cannot conceive of being wrong does a trial where each side gets to put their case on before a group of independent people constitute an "irrational and unfair" choice.

Michael Kirsch, M.D. said...

Nice try. Of course, I can conceive of being wrong, and I have been wrong. I also will be wrong in the future. I have been 'right', however, in every instance where I have been dragged into the medical liability arena. Most of my colleagues who have spent time there are also innocent. This is the irrational and unfair aspect I referred to.

Anonymous said...

So it's unfair that people question your actions and you've prevailed in the dispute resolution system we've developed, and indeed was part of the reason we formed this nation? And you want to get a Good Samaritan style shield, but still get paid for your work?

That's rational and fair?

Michael Kirsch, M.D. said...

Please read this column published in yesterday's New York Times. This is not the ranting of a right winger Tea Partier, but the views of a prominent economist who, until recently, was in the Obama administration. Please offer your comments on the blog. http://nyti.ms/bDqLCR

Anonymous said...

Sound like great ideas. I have a hard time embracing the top down approach though, simply because I don't see doctors adopting it. But as the feds pick up more and more of the check, they may have the purse string power to make docs fall in line.

Anonymous said...

Incidentally, the source of an article, be they a Tea Partier or an Obama cabinet member, really don't matter to me.

Michael Kirsch, M.D. said...

@anonymous, Happy to hear. How about a substantive response to Orzsag's op-ed piece?

Anonymous said...

It's just an op-ed. It's not actually a substantive proposal. Those all sound like decent ideas. I have no complaint with them. I don't see them as all that revolutionary - doctors can establish the standard of care now in most situations if they could unite.

However, at trial, if they did deviate, they'd be telling you why this particular patient was different and the guidelines didn't apply.

Anonymous said...

"Most of my colleagues who have spent time there are also innocent."

Either they were defendants in a criminal trial, or you are mixing up legal terms. If you are mixing up legal terms, just because they were not found to be at fault, doesn't mean they didn't operate on the wrong organ and cause paralysis, etc. Sometimes the PI lawyer messes up or the doctor altered documents aka committed criminal fraud.


Last, such a statement exemplifies the "God complex" suffered by many doctors. Over the years, I have learned that many doctors can be more dangerous than certain violent criminals after hearing/ seeing some of their rationalizations.

Anonymous said...

As far as your opinion on chronic pain medicine. The word is "dependence", haven't you learned anything in medical school? Another thing "Doc", if I didn't take a 24 hour chronic pain medicine. I could kiss my career goodbye. There is no way I could sleep, work, or have any kind of quality of life. I don't abuse the drugs(which is our biggest problem for people like me), and I have been on the same strength for years. The key to this is giving the patient a high enough dose to control his/her pain. Otherwise there will be patients that appear to be abusing the medication. I digress to say that there are the abusers out there, that scare the hell out of physicians. Every physician should realize that if you put stringent enough rules on the pain patients, they can follow the rules. The drug users can't. Be careful who your blowing the whistle on. I couldn't live a productive life without them...

Anonymous said...

the first aid box in an airplane has a disclaimer on it stating that if you are involved, good sam will protect you "except in cases of gross negligence." seems to me that a better guarantee is to not identify oneself as a doctor to begin with. seeing that "gross negligence" is determined retrospectively by someone who gets paid if you are deemed grossly negligent. also you pay all legal expenses and travel if you are operating in a setting where your medmal insurance doesn't cover you.

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