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The CMG Voice

Is a hospital negligent for not having your blood type when you need a blood transfusion?

Posted Monday, October 23, 2017 by Tyler Goldberg-Hoss

Consider a situation where a patient is in the hospital and has surgery. During the surgery there is a complication, resulting in increased bleeding and the need for a transfusion. There is just one problem: the hospital doesn’t have the right blood type to match to the patient. What can be done? Is a hospital legally responsible for any harm that occurs as a result of this lack of blood?

To begin, there are four major blood groups: A, B, AB and O. In each of these groups, the presence of an Rh factor determines if a person is + or -. So there are 8 different blood types all together.

Depending on your blood type, you can accept transfusions safely from other blood types, and other people can accept your blood type safely. For example, if you have Group O blood, you can donate to any other blood group. However, if you have Group AB blood, you can only donate to another person with AB blood.

Further, if you have Rh-negative blood type, you can donate your blood to patients who are either Rh-positive or negative. If you are Rh-positive, you can generally only donate to Rh-positive folks.

Here is a handy chart from the American Red Cross that shows this:

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In the United States, hospitals and other health care providers who are responsible for providing blood products to patients must rely on donations of blood. There are Blood Banks where you can go and donate blood, and often there are blood drives set up where mobile buses park and people can donate.

Given that supplies are made by donation only, it can be difficult for hospitals to always have enough blood on hand to handle any possible situation.

So back to the hypothetical above. Certainly, it is possible that the hospital failed to follow its own policies and procedures regarding having blood products on hand. Perhaps it failed to have a system in place for alerting staff when levels were low so they could initiate a plan to receive more. Or perhaps staff knew or should have known of the low levels of blood on hand, and decided surgeries should be done somewhere with more blood available in case of an emergency.

And, it is also possible that there is just not enough blood around the area for the hospital to have enough. In such a situation, and because the hospital is at the mercy of the general public donating blood, it is difficult to find fault.

And the doctors in those situations are between a rock and a hard place. On one hand, the patient may die without a transfusion. On the other, there are risks to giving a patient a blood type that is different than their own. In particular, the patient may suffer an ABO incompatibility reaction, which results in the immune system producing antibodies against the incompatible blood. This can be life threatening itself.

Of course, there are times when the wrong blood is given in a hospital because the blood is mislabeled, or some other human error occurred. In such situations, the hospital may be legally responsible for the harms caused. However, there are other circumstances that are out of a hospital’s control. Until we as a society improve the supply of blood products, there will continue to be instances where a patient needs blood, and the hospital doesn’t have it.

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Does Chronic Pain Amplify The Pain From New Injuries?

Posted Thursday, October 19, 2017 by Gene Moen

A recent study presented at the American Pain Society annual meeting, shows that if you have chronic pain in one body part, your brain’s reaction to pain in another body part is intensified. The reason is that chronic pain tends to re-wire circuits in the brain region (anterior cingulate cortex or ACC) that regulates how the brain reacts to pain.

Prior studies emphasized “nociception,” which is the sensory nervous system’s response to certain harmful or potentially harmful stimuli. But nociception focuses on the signals from, for example, a burned finger, not on how the brain reacts or deals with the signals once they arrive.

The study arose from clinician’s observation that when patients had chronic back pain they often reported higher than normal paid after surgery in the knee or abdomen. According to Dr. Jing Wang, one of the researchers, “our study results argue that chronic pain causes distortion in how the ACC calculates pain intensity with system-wide consequences.”

In past research, it has been shown that a body part that produces chronic pain can trigger magnified pain when the same part is injured again. But the new study, for the first time, shows that chronic pain tends to increase the reaction to pain-causing stimuli throughout the body. The study authors used rats to study how chronic pain dramatically altered ACC activity. Interestingly, the study results also implied that chronic pain can magnify responses to light (e.g., in migraines) and the ACC can be involved in emotional processes. Thus, anxiety and depression may also amplify the brain’s reaction to painful stimuli.

Focusing on the ACC region of the brain may allow new technologies, like deep brain stimulation and transcranial magnetic stimulation, to deliver electric current to reverse nerve cell signaling patterns that can cause disease.

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Is your plastic surgeon going to live broadcast your surgery on Snapchat?

Posted Monday, October 16, 2017 by Tyler Goldberg-Hoss

For years, surgeons have uploaded videos on YouTube and other sites for marketing and educations purposes. With the rise of other sites like Snapchat and Instagram, some surgeons have gained significant followings by live broadcasting their surgeries, including the use of “theatrics” such as dressing up in costumes and dancing.

These developments raise significant ethical concerns, prompting the Journal of the American Society of Plastic Surgeons to come out with guidelines regarding the practice. These including making sure the patient consents to such videotaping and/or broadcasting and all that go with it. For example, if the surgery is going to be uploaded to one of the above websites, other social media users can download the videos, share them, and even manipulate them.

Further, the proposed guidelines include considering hiring a trained videographer, so that the amount of operative time isn’t increased because the surgeon him or herself is tasked with taking the video.

You can read the full journal article here:

The Ethics of Sharing Plastic Surgery Videos on Social Media: Systematic Literature Review, Ethical Analysis, and Proposed Guidelines

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Scope of Practice for Physician Assistants expanding nationally

Posted Friday, October 13, 2017 by Tyler Goldberg-Hoss

Most anyone who has received medical care from a doctor’s office, emergency room or hospital has encountered not only doctors and nurses, but also so-called “mid-level” providers, including Advanced Registered Nurse Practitioners (ARNPs) and Physician Assistants (PAs).

For some, primary care these days does not even involve a doctor directly, as many of us have come to view ARNPs and PAs as essentially fulfilling this role. This is due in part to a general shortage of primary care doctors and a general increase in demand for healthcare, particularly with so many additional insured patients under the Affordable Care Act. Additionally, we as a society of health care consumers have become more comfortable with PAs and ARNPs providing us this medical care.

In Washington the PA scope of practice is broad already. Like many states, PAs and ARNPs can do just about anything a doctor can do, other than surgery. They can diagnose illnesses, write prescriptions, and order diagnostic tests. While they necessarily have a supervising physician, that does not mean that the doctor is side by side with the PA during her work day. Rather, often it means, depending on the experience of the PA, the relationship between PA and doctor, and the complexity of care at involved, that the doctor is only overseeing the work done by the PA after the care has been provided.

In recent past, many states have increased the autonomy given to PAs to practice, resulting in an increase in the number of PAs, including in Washington. Expect this to continue as institutional providers look for ways to offer competent, but cheaper, health care to its patient population.

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Washington State, Cities of Everett and Seattle Latest Governmental Entities to sue opioid drug maker for harming communities

Posted Wednesday, October 11, 2017 by Tyler Goldberg-Hoss

The opioid epidemic in the United States is without question concerning. In Washington alone, 718 citizens died from opioid overdoses in 2015. Nationwide, 1 in 4 people who receive prescription opioids for chronic pain struggle with addiction.

Often, the use and misuse of narcotic pain medication touches issues in our practice, including evaluating whether to investigate possible claims, or in cases we are currently litigated.

Sometimes the issue is at the forefront - an allegation that a medical provider negligently prescribed or monitored the use of such medications, resulting in harm. Or an allegation that a person was “drug seeking” when he or she went to the emergency room, explaining why proper care was not provided.

At a 20,000 foot view, it is difficult to answer who or what is responsible for the current opioid crisis in our country. Answers can reasonably include, depending on the circumstances, the patient him or herself, the health care provider prescribing the medication, perhaps even the pharmacy for failing to catch an excessive amount of medication prescribed.

Another possible responsible party is the manufacturer of the medication itself. Lawsuits have been filed all over the country, including in New York, Ohio and Missouri.

Now Washington State and the Cities of Everett and Seattle have filed similar claims against Purdue Pharma. The lawsuits allege that the drug maker should be responsible for the considerable social and economic costs of the problems it asserts is caused by its drug OxyContin.

In the Everett lawsuit, the City alleges that Purdue Pharma knew that its pills were being illegally bought and sold on the black market but did nothing. The Washington State lawsuit alleges in part that the company used deceptive marketing to convince patients and doctors that the drug carried a low risk of addiction.

Recently a judge declined to dismiss the Everett case at the request of the defendant, and the case continues toward resolution at trial. Some of the damages the suits are claiming include specific costs it incurred because of Purdue Pharma’s negligence, including money spent on police, emergency medical services, and social services.

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