Clinical pits, invincible!
The author | the rushing emergency room old Liu
The source | Medical Pulse
Cases of cerebral infarction and myocardial infarction after surgery have long been common in this column, but this week's case is definitely worthy of careful consideration by all pulse friends.
The sincere ten questions of the doctor, the "soul" reply (reply) of the appraiser, let Lao Liu "Mao Sai suddenly open", it turns out that our understanding of the core system is "biased".
Case Review
The patient, an elderly male, 67 years old, was admitted to a tertiary general hospital on 9 January 2019 due to 4 years of pain and pain in the right groin mass for 2 hours, and was hospitalized. A history of hypertension is 20 years, and a history of cerebral infarction is 5 years. Diagnosis of admission: unilateral incarcerated inguinal hernia, hypertension grade 3, stale cerebral infarction, post-prostate surgery.
Unilateral inguinal hernia repair + testicular hydrocele resection was performed on 14 January. At 2 a.m. on January 15, the patient suddenly became unconscious and should not be called. Consult an emergency neurologist to improve head CT and consider cerebral infarction. Thrombolytic therapy is given after communicating with the patient's family and obtaining consent.
Consultation records record: treatment: the patient is currently diagnosed with acute cerebral infarction, and the patient communicates with the hernia surgeon if the patient has a venous thrombolysis, and the risk of bleeding at the surgical site is small. After repeated confirmation of the medical history with the family, it is recommended to perform intravenous thrombolytic therapy, fully explain the condition to the patient and the family before taking the drug, inform the indications, contraindications and risks of intravenous thrombolysis, and the patient and his family agree to intravenous thrombolytic therapy and sign an informed consent form... Discharged on January 31, 2019, discharged from the hospital, pay attention to rest, avoid colds, colds, strengthen nutrition; take a full week off, outpatient review after one month; avoid heavy physical activity; continue oral antihypertensive drugs, detect blood pressure; continue oral Pollivir; rehabilitation hospital for further rehabilitation treatment, neurology follow-up, hernia surgery follow-up. After the patient was rehabilitated in several hospitals, the patient still had right acroplegia left after treatment.
The patient believes that the doctor, as a professional, has not fulfilled the duty of care, due to negligence, lack of diagnosis and treatment, insufficient preoperative preparation, and the necessary treatment has not been carried out, resulting in the patient's postoperative cerebral infarction, and has not given the correct treatment to cause the patient's major disability. In the whole process of diagnosis and treatment, the tort liability law was violated, and many core systems in the eighteen core systems were violated, resulting in serious disability of patients.
The medical practitioner's conduct has a direct causal relationship with the patient's significant disability and should bear full responsibility. The patient sued the doctor to the court, demanding compensation for the patient's various losses, totaling 3,170,700 yuan. Including: (1) disability compensation: 952812 yuan, (2) assistive device fee: 391619 yuan (including: I., orthoses total: 49,000 yuan. II. Daily care consumables: 260232 yuan. III. Total number of daily living utensils: 82299 yuan. (3) Medical expenses, hospital meal subsidies: 70361 yuan, (4) nursing fees and post-identification nursing fees: 1451426 yuan, (5) mental damage compensation: 90,000 yuan, (6) nutrition expenses: 39,650 yuan, (7) transportation expenses: 2,122 yuan, (8) rehabilitation equipment during rehabilitation, medicines purchased outside the hospital during hospitalization: a total of 45,660 yuan, (9) judicial appraisal fees: 22,050 yuan, (10) lawyer fees: 50,000 yuan, (11) Accommodation fee: 55,000 yuan. In addition, the medical party was required to bear all the litigation costs of the case.
The court entrusted an appraisal institution to conduct an appraisal of the case, and the appraisal center issued a judicial appraisal opinion stating:
(1) The doctor's evaluation of the patient's diagnosis and treatment behavior:
1. On January 14, the patient was informed that the unilateral inguinal hernia repair + testicular hydrocele resection was performed after informed notification, and the operation was smooth and returned to the ward after surgery. The patient's diagnosis is clear, there are indications for surgical treatment, there are no contraindications to surgery, and the above diagnosis and treatment process of the doctor complies with the diagnosis and treatment specifications.
2. The patient's postoperative blood pressure fluctuates, and the doctor does not consult the relevant departments in time, which is insufficient. After the patient diagnosed cerebral infarction, the neurology consultation recommended thrombolytic therapy, but the degree of neurological deficit was not evaluated; at the same time, the medical thrombolytic treatment process and post-dissolution monitoring records were not standardized, and the dose of 50mg alteplase (rt-PA) thrombolytic drugs was insufficient, and the method of administration was improper, and the doctor was at fault...
(2) The doctor's causal analysis of the patient's diagnosis and treatment behavior and the patient's damage consequences:
The patient had a clear diagnosis of "incarcerated inguinal hernia" and had indications for surgery; antiplatelet drugs were discontinued and given alternative drug therapy 4 days before surgery, and the surgical methods and operations were in line with the diagnosis and treatment norms. Postoperative patients blood pressure continued to be high, the doctor in the administration of 30mg nifedipine controlled-release tablets oral administration, about 6 hours after the patient sudden loss of consciousness, should not be called, blood pressure dropped to 123/78 mmHg, the patient's blood pressure changes and the use of antihypertensive drugs and the same day's intake is relatively small; after CT examination, the diagnosis of acute cerebral infarction, neurology consultation after thrombolytic treatment, but the medical fault of the doctor and post-thrombolytic monitoring, treatment is not standardized, may affect the effect of thrombolysis and lead to poor prognosis of the disease and the recovery of nerve function. There is a certain causal relationship between the doctor's diagnosis and treatment fault and the patient's damage consequences. Patients have a history of cerebral infarction and long-term hypertension before admission, hyperglycemia after admission, carotid and cerebrovascular arteriosclerosis, and the nature and extent of their underlying diseases are the main causes of their damage consequences.
Final Appraisal Conclusion:
1. The doctor is at fault in the process of diagnosing and treating the patient, and the fault has a causal relationship with the patient's damage consequences, which is a secondary cause.
2. The patient has severe intellectual decline (mild), serious damage to social function, can not live completely independently, needs to be supervised frequently, is a third-degree disability; right side paralysis; upper limb muscle strength 1, lower limb muscle strength 5-level, is a fifth-degree disability.
3. It is recommended that the patient's nutrition period and nursing period be until the day before the disability assessment, and the number of nursing patients is recommended to be 1 person.
After the appraisal conclusion was issued, the doctor made a written inquiry to the appraisal opinion: since blood pressure control is the conventional treatment of clinicians, it does not belong to the statutory situation of consulting the relevant departments, and the patient in this case has a risk of bleeding, and the hospital prescribes aplatise 50mg thrombolytic therapy according to the patient's individual situation after comprehensive consideration, taking into account the effect of "avoiding bleeding" and "thrombolytic therapy", which is reasonable and also in line with the provisions of the drug manual, and the patient's condition is unstable when cerebral infarction occurs. Therefore, the degree of neurological deficit cannot be assessed, and it has nothing to do with the patient's damage consequences.
The expert responded to the doctor's questions:
1. According to the requirements of the "Law on Practicing Physicians": within the scope of the registered occupation, conduct medical diagnosis, disease investigation, medical treatment, issue corresponding supporting documents, and select reasonable medical, preventive and health care programs. The "hernia and abdominal wall surgery" where the patient is admitted to the hospital, the blood pressure is 167/93mHg when the patient is admitted to the hospital, the antihypertensive drugs are adjusted after admission, and the blood pressure on the day after the operation is up to 189/95mmHg, indicating that the patient's blood pressure control is not well controlled The doctor did not ask the relevant department to consult This diagnosis and treatment behavior is not in line with the requirements of the practicing physician law, and the opinion of the appraiser of our firm only determines that the doctor is insufficient, which is based on evidence.
2. According to the "China Acute Ischemic Stroke Intravenous Thrombolysis Guidance Specification" 2016 and related industry standards, the rt-PA administration dose is required to be 0.9mg/kg, and the doctor calculates 63.9mg, which is not at fault, but only 50mg is given, and the treatment is not given according to the standardized dose, and the medical prescription administration method is not standardized, the thrombolytic effect is not achieved, and the doctor is at fault.
3. For patients with cerebral infarction, neurofunction assessment is required before thrombolytic therapy to determine the indications for thrombolytic therapy. The degree of neurological deficit was not assessed before thrombolytic therapy, and the degree of fault of the doctor was not increased in the causal analysis of this problem.
After written questioning, the doctor applies for an expert to testify in court:
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1. The doctor asks: "Patient blood pressure fluctuations" that is, need to consult whether there are clear and specific medical norms?
The appraiser said: If the blood pressure is stable, it is not okay not to consult, but the patient's blood pressure is unstable and needs to consult the relevant department. According to the Law on Practicing Physicians, physicians may, after registration, engage in medical obligations in accordance with the scope of registered occupational institutions in medical security institutions.
2. The doctor asks: The patient has more bleeding after surgery, and the bleeding liquid in the surgical area is 200ml, and a large number of thrombolytic drugs are given to cause the patient to bleed after surgery?
Appraisers said: May cause bleeding, surgical bleeding is controllable, but not a contraindication to thrombolysis. A large number of thrombolytic drugs are standardized doses, not a large number of thrombolytic drugs.
3. The doctor asks: Is the dosage of 0.6 mg standardized?
The appraiser said: Did not follow the norms. 0.9 mg is the norm. Considering that the bleeding reduction dose is not achieved for thrombolytic purposes may lead to bleeding risk.
4. The doctor asks: What is the medical basis for patients to be treated with a large number of thrombolytic drugs after surgery? Should actual condition adjustments such as long-term use of antiplatelet drugs be considered?
The appraiser said: The medical basis is the textbook of the medical diagnosis and treatment specification of the practicing physician and the drug instructions. Long-term use of antiplatelet drugs is not contraindicated in thrombolysis, and thrombolysis can be used according to the norms. Patients are indicated for thrombolysis and do not require adjustment. Reducing the dosage does not achieve the thrombolytic effect, which will increase the chance of bleeding, and the patient's thrombolytic effect is not.
5. The doctor asks: Does the patient have a history of cerebral infarction and has been taking anticoagulants for five years?
Appraiser: Know.
6. Doctor's question: Is the thrombolytic dose recommended by surgical guidelines 0.6 mg?
The appraiser said: Thrombolysis should be performed by a neurologist, only an experienced neurologist can perform thrombolysis, and the surgeon needs to communicate with the neurologist about the dosage of thrombolysis. The doctor has no record of communicating with the neurology department.
7. The doctor asked: At the same time that the cerebral infarction occurred on the same day, the consultation record of the director of the neurology department was asked.
The appraiser said: The consultation wrote that it was recommended to thrombolysis, but it was not written that it was recommended to adjust to 0.6 mg. Thrombolytic therapy is brought out of the stroke center, if there is no stroke center, it should also be treated by a doctor in neurology, and surgery does not fall within the scope of thrombolysis treatment.
8. The doctor asks: After the neurology department gives suggestions, due to the OA system office system, it is impossible to issue a medical order directly from the neurology department, and can only issue a medical order in its own department, and hernia surgery is based on the opinion of the neurology department.
The appraiser said: The information he saw was consultation, but there was no specific treatment plan given by the neurologist, the surgeon did not complete the administration according to the treatment guidelines, the administration should be adequately treated, the medical prescription was insufficient, and the dosage did not reach the standard.
9. The doctor asked: The patient of this case has a history of high blood pressure 20 years, 5 years ago diagnosed cerebral infarction, the risk of cerebral infarction after surgery is extremely high, the occurrence of cerebral infarction again cannot be avoided, our hospital's treatment of this is not illegal, but also in line with the actual situation of the patient, please ask: What is the basis for the appraisal opinion to assume secondary responsibility in our hospital?
The appraiser said: The nursing record clearly records that on January 15, 3:27 follow the doctor's instructions to use thrombolysis, alteplase powder injection 50mg intravenous infusion, 4:47 to complete the input, it took 1 hour and 20 minutes, the drug should be injected 10%, and the rest should be infused within one hour. The nursing record did not push 10% first, and the way, time, and dosage of use were all problematic. The patient's cerebral infarction and hypertension itself are also relatively poor, giving the hospital secondary responsibility.
10. Doctor's Question: Regarding the assessment of the level of disability.
The appraiser said: According to the admission situation, there is a history of cerebral infarction, and the description of muscle strength problems is slightly worse, because it is not written several levels, it cannot be proved that the patient could not walk at that time. If there is a record of muscle strength at that time, the degree of disability can be reduced, and the appraisal agency judges it to be assessed by mental intelligence. Originally mental intelligence was normal. The identification agency in the examination of the body of the muscle strength of both lower limbs is generally normal, the right lower limb is five minus state, the right upper limb is the first degree, the assessment of disability of the limb considers the muscle strength of the right upper limb, regarding mental intelligence, according to the last hospitalization case records that speech dysfunction worsened before April, after treatment, the right limb is not active, memory is significantly reduced, speech is unclear, and most of the anastomosis is consistent with the disability identification examination.
In the end, the court adopted the appraisal opinion and ruled that the doctor should bear 20% of the civil compensation liability, and compensated the patient for medical expenses, hospital meal subsidies, disability compensation, transportation expenses, nutrition expenses, nursing expenses, and mental damage pensions totaling 282,783.74 yuan. The case acceptance fee is 32166 yuan, which is borne by the patient 25733 yuan and the doctor is 6433 yuan. The appraisal fee is 22,050 yuan, which is borne by the patient 17,640 yuan and the doctor is 4,410 yuan. The cost of the expert evaluator appearing in court is 2,000 yuan, which is borne by the doctor.
Old Liu Read Case: We must turn principles into habits
Carefully study the entire process of trial of the case, the final appraisal conclusion, and the information conveyed by the doctor and the appraisal expert after written questioning. Lao Liu summed up some experiences.
1. Specialists do their own specialized things, and other specialist problems should be consulted.
Lao Liu used to be a cardiovascular physician, and his colleague went to a special cattle cardiovascular hospital for further training, and after returning, he told a "funny thing" about further training. A patient with coronary heart disease has arranged elective surgery, but the day before the operation, the patient suddenly had a sore throat, and a colleague who is a trainee doctor found that the patient's pharyngeal tonsils were enlarged and had pus, considering acute purulent tonsillitis, so he reported to the teacher with the teaching and recommended that antibiotic treatment be given before surgery. As a result, the teacher was shocked, praised and agreed that even this disease would be diagnosed and treated, and then told colleagues about the diagnosis and treatment process of this hospital - please consult the respiratory department of the outer hospital (there is no respiratory medicine department in this hospital).
It felt like a joke at the time, but now it seems to be a "master". In this case, the surgeon gave antihypertensive treatment to a patient with elevated blood pressure, which was judged by the experts to be in violation of the practicing physician law, because hypertension itself is a cardiovascular disease, which is an internal medicine disease and should be treated by a cardiovascular specialist or internal medicine doctor. Cerebral infarction belongs to the category of neurology, and the diagnosis and treatment plan for this disease must be determined by a neurologist, not a surgeon can intervene.
2. Treatment plans, indications, and contraindications must strictly follow the diagnosis and treatment norms, guidelines, and drug instructions.
This point has been repeatedly emphasized in the column. How experts judge whether a doctor's diagnosis and treatment behavior is at fault is based on these authoritative documents. The diagnosis of diseases should meet the diagnostic criteria, the auxiliary examination should be perfect (at least not less than the guideline recommendations or clinical path requirements), the treatment measures must not violate the principle of treatment, the indications and contraindications for drug use should also refer to the instructions, and the surgery should have indications and no contraindications. The literature sometimes simply gives a therapeutic principle that does not accurately cover all clinically encountered situations, and doctors often have time to make decisions based on experience. However, there are clearly defined dosages, medication methods, inspections that must be done, and other matters must be "strictly" observed. Due to special circumstances, if it is necessary to change the dosage and method of medication of drugs, there must be a basis, it must be written in the medical record, and there must be a notification.
3. Pay attention to the consultation time, attach importance to the consultation record, and attach importance to the content of the consultation record.
After seeing the content of the previous experts' interpretation of the practicing physician law, Lao Liu was a little confused, as if he had done a lot of wrong things in his 20-year career as a practicing physician, and some questions seemed to be incomprehensible. For example, as a cardiologist, should a patient with poor diabetes control consult a consultation? Often it is their own to get it done, this is illegal is not it?
A more clear point is that surgical patients must consult with the internal medicine department when encountering internal medicine specialty diseases; when it comes to special professional situations, such as thrombolysis and PCI options, it must be decided by a specialist. However, the question arises again, what should I do when I encounter an emergency and it is too late to ask for an internal medicine consultation?
In addition, the specialist treatment plan must be decided by the consultant doctor, as detailed as possible (medication methods and dosages, specific examinations that need to be improved), and it is best for a specialist doctor to give medical advice in the system. The consultation form should indicate the consultation time, the actual consultation time of the specialty, and the consulting physician and the consultant must be a qualified physician (see the consultation system in the core system for details).
The main points to be paid attention to in the treatment of cerebrovascular disease thrombolysis
The incidence of ischemic cerebrovascular disease is increasing, and thrombolytic therapy is receiving more and more attention. New guidelines are released almost every year. In 2018, the "Guidelines for the Diagnosis and Treatment of Acute Ischemic Stroke in China 2018" were released, and the "Guidelines for the Clinical Management of Cerebrovascular Diseases in China" were released in 2019, together with various other guidelines and consensuses, the treatment of acute ischemic stroke was clearly stipulated. Lao Liu, as a non-neurologist but has received professional training in stroke centers, came to draw the focus of non-professional doctors and roughly understand it.
Medical Pulse Guide Stroke Column 2018 Guide Query Results
Patients with suspected acute ischemic stroke should have a CT of the skull completed within 30 minutes as much as possible. (This requirement is mainly for emergency departments, and patients in the ward can refer to it)
Emergency evaluation recommends blood glucose, renal function, electrolytes, blood count with platelet count, coagulation function with INR, myocardial ischemic markers, and bedside ECG. (Urgent investigation and examination, but should not delay thrombolysis due to waiting for results)
Intravenous thrombolytic evaluation is performed within 4.5 hours of onset and intravascular therapy is evaluated at 4.5 to 24 hours. (RT-PA thrombolysis time window is 4.5 hours, preferably within 3h)
For patients with intravenous thrombolysis, rt-PA intravenous thrombolysis is recommended. (The drug dose is 0.9 mg/kg, the maximum dose is 90 mg, and it is pumped continuously for 60 minutes, of which 10% of the first dose is injected intravenously within 1 minute)
Within 4.5 h of onset, for patients at high risk of bleeding, intravenous administration of low-dose rt-PA may be an option. Usage: rtPA 0.6 mg/kg (maximum dose is 60 mg), of which 15% of the total amount is infused intravenously within the initial 1 min and the remaining 85% is infused intravenously with an infusion pump for 1 h.
Intravenous thrombolytic therapy may be considered within 14 days after surgery, but caution needs to be given to the risk of bleeding at the surgical site and the benefits of thrombolysis.
Patients should be admitted to an intratherapy ICU or stroke unit and have regular blood pressure and neurofunction assessments: blood pressure and neurologic assessments are measured every 15 minutes after the end of thrombolysis; thereafter every 30 minutes for 6 hours; and thereafter every hour until 24 hours. Blood pressure should be < 180/105 mm Hg within 24 h after intravenous rt-PA thrombolytic therapy.
There are many guidelines and recommendations, the management requirements are very meticulous, and the detailed comparison of each clinical medical record can more or less pick out the "fault", and it is not easy to require the management details to be in place.
Thrombolytic therapy can benefit patients, but the risks must be concomitant. Although the refinement of the guidelines and the complexity of opinions put forward higher requirements for clinical work, they are also conducive to quality control and are also a kind of protection for clinicians. Examination and monitoring means should be in place, treatment methods should strictly follow the guidelines, even if there are complications, the responsibility is quite low.
Finally, it is emphasized that the identification is strictly based on medical records, and what can be reflected in the writing of medical records is done, and what is not written or other supporting evidence is lacking. Therefore, pay attention to the writing of medical records do not become an empty word, after any processing and accounting for the disease, develop the habit of sitting down and writing, remember to write, write, get used to it...
Consultant Xiang Haiman, a lawyer at Beijing Quanzhi Law Firm (formerly Beijing Renchuang Law Firm), has long been engaged in medical legal research and practice, and has rich experience in medical law.
The case in this issue comes from the Beijing Court Trial Information Network (original title: Elderly patients with postoperative cerebral infarction, thrombolytic hemiplegia claim of 3.17 million!) This time the appraiser's "soul ten fears" exposed clinical loopholes 丨 medical eye-catching method)
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