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SEATTLE,
WA— A large and expanding body of data indicates
that propofol is safe and effective in the ambulatory setting for
procedures ranging from upper endoscopy and ERCP to colonoscopy.
Furthermore, evidence is mounting that properly trained registered
nurses can safely administer the drug and monitor patients while
the gastroenterologist performs the endoscopy, Joseph Vicari, MD,
said.
Dr. John Walker’s group in Medford, OR, for instance, has used
trained RNs to administer propofol to 11,000 patients to date, with
only one adverse respiratory event. “There were no significant
residual effects from the drug, and 70 per cent of patients were
capable of returning to work within about three hours,” said
Dr. Vicari, Clinical Assistant Professor of Medicine, University
of Illinois College of Medicine, Rockford, IL.
“So they concluded that propofol is safe and effective for
the community gastroenterologist with the assistance of a properly
trained nurse.”
Gastroenterologists are responsible for any work done by a nurse-
anesthetist under their supervision—however well-trained. “You
have vicarious liability. You are the final line of responsibility.
“The most effective risk management program comes from a constant
retrospective monitoring of your practice to identify areas of liability.
If you identify an area of liability, this must be brought to the
attention of your management body, a formal investigation done and
corrective action implemented.”
What lawyers look for
In the context of a potential lawsuit, lawyers look at four issues:
duty, breach of duty, damages and causation. Duty is the physician’s
obligation to meet the standard of care in treating the patient.
Breach is the violation of that standard of care. Damages enter
the picture when a principal injury has occurred. Causation exists
when injury is the result of the physician’s violation of the
standard of care. “All these criteria need to be met before
a suit can be brought,” Dr. Vicari said. As in sports, a good
offence is always offset by a better defence, so you need to know
the malpractice data.”
The main causes of lawsuits in gastroenterology are perforation,
complications of ERCP, medications (allergies and interactions),
and adverse reactions (respiratory depression and cardiovascular
events). Dr. Vicari strongly advises physicians to carry with them
the Eppocrates software program. “This is a wonderful program
that allows you to look up drug interactions on your Palm Pilot.”
Ultimately, the gastroenterologist’s best legal protection
is the principle of self-determination. “You need to give patients
a very detailed explanation of sedation and analgesia in your written
consent document. You also need to talk about your personal experience.
There is case law that revolves around a lack of discussion of your
training and your personal experience with adverse events.”
Documentation of care is important in a legal defence. It should
reflect current guidelines, local or national, and evidence-based
medicine, and it should be accurate and consistent.
Dr. Vicari urged physicians to make a point of staying up to date
on the cognitive and technological aspects of their field and to
set up a quality improvement committee at their centre with an anesthesiologist
and/or a pharmacist on board. “Also, practise patient-centred
medicine and communicate, communicate, communicate. Spend time with
patients. Talk to them in language they can understand and show
compassion. There’s a wealth of evidence showing that when
patients like and respect you as physicians and persons, they are
far less likely to bring a suit.”
He also advised
gastroenterologists not to relinquish control over sedation and
analgesia. but to get expert training in these areas and be fully
aware of the legal risks involved and the strategies for managing
these risks.
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