Table Top Test - CALL to you "an on call medical supervisor"

[Bjorn, Pret]

I'm willing to take either physician or administrative call, given that
this is the Trauma-List.  On "the internets," nobody knows you're a dog.

1.  The patient is NOT underage (19) given any statute with which I'm
familiar.  But then, I'm not familiar with Texas (for which I and
certainly Texas are grateful).  In Maine, if she's pregnant and living
independently, she's emancipated -- even if she's twelve.  She has made
the requisite decisions to survive in the world and become pregnant,
after all.

2.  The first and overwhelming rule for EMTALA, albeit unwritten, but
ESPECIALLY in the setting of active labor, is "Do the right freaking
thing and let the lawyers clean up the details."

3.  Even IF a psychiatrist's note recommends otherwise, competency is a
LEGAL issue, not a clinical one.  If a judge has not declared her
incompetent, then see #2.  Else, you and the psychiatrist (or the
anesthesiologist or the OB/Gyn or the EM clinician or a passing podiatry
fellow) can declare appropriate analgesia as being in the best interests
of your supposedly incompetent patient and her pending progeny.

4.  This girl is in active labor and in extreme pain.  You're mucking
around with administrative approval for long-distance charges to
estranged grandparents while delaying her care and permitting her
suffering.  Moreover, the intended content of your communication with
Granny would inevitably include details of the patient's protected
health information (including, conspicuously, her mental illness and her
pregnancy).  This is not only an absolute HIPAA (one p, two a's)
violation, it's a patently stupid approach.  CNN's gonna love this
story, and your hospital will suffer for the inevitable attention.

Treat the patient.  Do the right frigging thing.  Inform your lawyers
and your admins, but NEVER ask their permission for practicing
appropriate and utterly defensible clinical medicine.

Pret Bjorn, RN, MD*, MHA* 
Bangor, ME USA

*as far as you know

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of KMATTOX at aol.com
Sent: Thursday, July 19, 2007 11:07 PM
To: trauma-list at trauma.org
Subject: Table Top Test - CALL to you "an on call medical supervisor"

 
This is a real time Table Top TEST for ALL persons willing to take
physician 
or administrative Call.   We live with this  DAILY.     I have had at
least 6 
frustrating policy, system,  ethical, moral, and ethical issues just
this 
afternoon.    Not  any were patient safety issues (YET), but were close
to system 
issues which  cause frustrations.    This is real time, and NOT any
HIPPA  
violations.   Take this table top and keep your own  score.     I will
leave a 
space between decisions.  
 
You get from a senior faculty to assist with a problem, relating to
legal  
and ethical policies as well as a rapidly unfolding clinical  need.     
 
A 19 year old woman is in full labor, with her first pregancy.  It is  a

tough progress and she is in a great deal of pain.   She has reached  a
stage 
where most women are clinically ready for a spinal block to aid in the
progress 
of the delivery.    She is underage and  unmarried.   She has not
revealed the 
name of the baby's  father.   No parents are present.     Can she give  
PERMISSION for the spinal anesthesia?
 
 
 
Good try, but we have a problem.     She is severely  hampered by a
mental 
health problem and the psychiatriast has written note in  the chart that
the 
patient cannot give permission for herself.     The chief of obstetrics
strongly 
desires that a spinal anesthesia be  administered.    NO PERMISSION
available 
from the  patient.    No parents, available.   No father  available.   
Anesthesia service states that they cannot give spinal  anesthesia
without permission 
either from a fully aware patient, a surrogate  permission giver, or an
ad 
lidum.
What to do?
 
 
 
While calling for help, it is discovered that there is a phone number in
the 
purse of the patient of a grandmother in a distant city.   Can  this 
grandmother give permission?     
 
 
 
 
 
GOOD ANSWER and you had a good thought there.   Permission is  granted
from 
administration to use HCHD funds to call this very long distanced
telephone 
number and the grandmother answers the phone.      GREAT STROKE OF LUCK.

 
 
Problem.   This grandmother has already disowned her own children  and
only 
vaguely knows of even the existence of this now your  patient.     She
states 
that she cannot and will not give  permission and states some words I
cannot 
print here.      She hangs UP.     What to do?
 
 
 
 
 
One of the faculty has a good friend that is a family court judge
(actually  
a neighbor).     She calls that judge for  "advice"    It is 5:20 PM and
the 
judge and court are CLOSED for  the week end.   "Call back Monday"
message is  
heard.      What to do?     
 
 
You guessed it.   The chief of OB calls YOU and asks for the  options?

I now ask you to answer this  inquiry?    If you wait long enough to
find a 
court person, the  baby will be delivered with great pain and suffering
and a 
huge amount of  horrible screams heard two floors down .     The nurses
are  
crying that something be done.   The patient is getting more and more
mentally 
disturbed.   The medicines to be used to sedate her or to  treat her 
psychiatric diagnosis can harm her  baby.         HELP
 
 
 
 
Woops.    It is late.   I will have to give you  the next installment 
tomorrow.    
 
K Mattox




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