I agree whole heatedly with the sentiments expressed. There is almost
nothing in routine practice more irritating than to be woken at some
unearthly hour by a houseperson saying her SHO has phoned Guy's about this
case and they say that the patient needs analyte X measuring and she says
you have got to do it. Now. No, she can't discuss the patient; she's only
covering for another houseman. And her SHO is too busy to come to the
phone. Recognise the scenario??
Several responses come to mind when the test is patently unnecessary or
inappropriate; many are non constructive and unparliamentary. The one I
would like to make and have never had the bottle to is to suggest that they
ask Guy's if they could get the analysis demanded done in their own
laboratory under similar circumstances. A more useful one is to tell the
houseperson to collect the samples, which we will analyse at the next
opportunity and if they are unhappy with that, I will be delighted to
discuss the case at the bedside with the consultant caring for the patient.
Experience dictates that one will usually get a good nights sleep after that
little exchange. However, there is the non apocryphal story of the chemical
pathologist who tried a similar ploy and was invited to take over the total
care of the patient....
More fundamentally, what is the legal position? There can only be legal
action in tort if the patient comes to harm. If they do come to harm, has
the harm flowed from your action or inaction in not executing there and then
the test recommended by the clerkess at Guy's hunched over her VDU? Proving
that might be difficult even at the level of the balance of probabilities in
the civil courts. Once causation has been established, was your action or
inaction in not complying with the recommendation from Guy's neglectful?
Here again, this might be difficult to prove. The Bolam/Bolitho test will
apply. Basically, if your action was such as to be rightfully regarded by a
reasonable body of your professional peers as appropriate then it would not
be regarded as neglect and you would not be liable.
Finally, this is not about apparently inappropriate advice, rude junior
medical staff (sorry, medical staff in training), lost sleep or legal
liability. It is about the care of very vulnerable patients. If in doubt one
should try to get the tests suggested organised. The problem is often
finding someone willing and able to discuss the case and the options for
investigation that are available with local resources.
I did suggest to our clinical audit folk a year or three ago that auditing
the use made by junior medical staff of the Guys's poison unit advice would
be a nice project. It fell on stony ground. One study that would require
very little effort would be to look at the frequency with which different
medical teams ring The Poison Unit number (using the printouts available
from most hospital switchboards), against the number of overdoses they
admit.
Robert Forrest
> -----Original Message-----
> From: [log in to unmask]
> [mailto:[log in to unmask]]On Behalf Of Doug Hirst
> (Biochem)
> Sent: 09 November 1998 09:31
> To: [log in to unmask]
> Subject: Thyroxine overdose
>
>
> On Saturday night a patient was admitted to ICU in a critical condition,
> suspected of taking a multiple overdose including alcohol, chicken tikka
> masala, coproxamol and thyroxine.
>
> On Sunday the clinician requested an urgent T4 and T3, claiming that
> these tests had been recommended by the Guy's Poisons Information Unit.
>
> Can anyone advise what the medico-legal position is if I am unable or
> unwilling to provide an assay which has been recommended by the Poisons
> Information Unit?
>
> Doug Hirst
> Biochemistry
> Bradford Royal Infirmary
>
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