an arterial tie broke loose and he was bleeding internally. My decision was to return him to surgery immediately. When I opened him up his belly was full of blood. I suctioned what I could, and I found no discrete bleeding source, but admittedly it was difficult through all that blood. The anastomosis was intact. But as I suctioned out the blood, more would appear, so this suggested that a DIC had developed, and indeed his fingers were cyanotic and his urinary output was nil. Since his blood pressure at that point was still stable, the significance of his physical findings took on greater meaning and impelled me to a diagnosis of disseminated intravascular coagulation. Then I had to make a rapid decision because his blood pressure was falling and he was in extremis. I gave him heparin to reverse what I diagnosed as the endstage thrombotic manifestations of DIC. But it was to no avail. The patient died.”
“So as best as you can say there was no surgical misadventure. You didn’t leave an oozer or a surgical tie that broke loose.”
“No. I don’t believe I did.”
Dr. Lassiter said, “When I started out in practice we knew of no such an entity as DIC. And I don’t recall ever having a patient who bled so profusely as did yours after surgery. Refresh my memory, doctor. I’m not ashamed to say that I need some update on DIC.”
“In an acute fulminating disseminated intravascular coagulation, clotting factors are consumed you might say, and this results in a severe bleeding tendency. It’s seen as a complication of some obstetrical emergencies, severe infections, surgery, malignancy, and shock from any cause. My patient had some of those causative triggers.”
“Yes that’s clear. What are the treatment options?”
“At milder and chronic levels of DIC, the elimination of the underlying trigger could reverse the process. In severe acute cases, such as this one, treatment is usually futile, but believe it or not heparin is sometimes used.”
“Heparin? In a patient who is bleeding? It sounds counterintuitive. I need your explanation, please.” Lassiter was skeptical but willing to listen.
“The use of heparin may be appropriate when developing thrombotic complications manifest themselves by absent urine output caused by kidney capillary bed glomerular fibrin deposition or when progressive cyanosis of the fingers and toes suggest the development of incipient gangrene. My patient had both of these clinical manifestations. It was all academic however because the patient died.”
“One unlucky guy,” said Dr. Lassiter. “I note that the wife refused autopsy.”
“Yes. She was adamant, and I didn’t argue with her, of course.”
“Does anyone have any further questions,” asked Dr. Lassiter.
Receiving none, Dr. Lassiter said, “Thank you. You’re excused doctor.”
The questions before the committee were did Dr. Harris’s treatment meet the accepted standard of care for this hospitalized patient? Did he do what any reasonable physician would have done under the circumstances? Was there any omission or deviation from the accepted standard of care? As chairman of the committee Dr. Lassiter asked the other members, “Does anyone have any questions or comments now that the doctor has left?”
One young general surgeon offered, “I think under the circumstances he did an outstanding job and was able to think quickly on his feet.”
Another surgeon said, “Frankly I wouldn’t have given the heparin, but to be honest I doubt that I would have had the smarts to think of DIC in the first place.”
“Yes, I know what you mean,” said another surgeon. “Even if I had thought of DIC, I don’t think I would have had the courage to give the heparin, because at that point the patient was clearly heading south, and there was a good chance that, regardless of what was done, it was too late. So now this doctor is on the record of giving a drug that probably had a ten percent chance of doing anything. That’s medico-legal dynamite. I’m not criticizing the therapy mind you; he has made a compelling case for what he did.”
Silent up to this point, Dr. James Philips, a senior attending general surgeon who had been on the staff almost as long as Dr. Lassiter, raised his hand.
“What is it, Jim,” said Dr. Lassiter.
“You guys are all talking as if you are qualified to make a judgment about the treatment of DIC. When’s the last time any of you dealt with a case?”
There was no response.
Finally Lassiter said, “What are you getting at, Jim?”
“What I’m getting at is this: is it appropriate for us to be giving our opinion based upon admitted incomplete knowledge about a rare event in the medical world?”
“So?”
“So I’m saying, first of all, I wouldn’t have used heparin. Dr. Harris did. To me that means one of two things: he has a superior knowledge base from which to draw, or he doesn’t know what the hell he was doing. You couldn’t get vindication of his action from me and I’ve been around longer than any surgeon on the staff with the exception of our good chairman here. None of us have enough foundation upon which to make an educated judgment, and if we are given the responsibility to judge our peers we better make that judgment a sound one.”
Another surgeon who had not participated spoke up, “I am concerned about the fact that the anesthesiologist refused to administer the heparin until he was literally forced to do so by Dr. Harris. There must be some basis for Dr. Madhava’s refusal.”
There were nods of approval around the table. Dr. Lassiter said, “I also have a bit of concern about that episode and I agree with Dr. Philips that our judgment must be sound, but that’s why we have seven of us on committee. We should be able to come to a conclusion.”
“Is this committee ready to come to a conclusion after the discussion we’ve had?” asked Dr. Phillips in a skeptical voice.
“Let me ask this,” Dr. Lassiter said. “Given the unusual use of heparin and the dispute with the anesthesiologist, does this committee feel that this case should be cleared and there was no deviation from the standard of care?”
With some hesitation, the majority of the committee members present nodded in agreement.
“Are you willing to make a motion to that effect?”
“I so move.”
“Any second.”
“I second the motion.”
“Any more discussion?”
“Yes, I have something to say,” said Dr. Phillips.
“You have the floor, Jim.” Replied Lassiter.
“I move we table the motion until we get some help on this one. I’m suggesting we forward this case to the internal medicine quality committee, and defer judgment until we hear from them.”
“Do you think the average general internist has any more knowledge about DIC than a surgeon does?” asked Lassiter.
“You beat me to my next suggestion,” said Phillips. “That is, that we insist on a hematologist on the internal
