This document is a decision from the Health Professions Review Board regarding a complaint made against a physician and surgeon. It summarizes the complaint, which involved a patient who declined rapidly after surgery where a spinal anesthesia failed and general anesthesia was used instead, against her previous request. The Review Board found that the Inquiry Committee's investigation was adequate but that the disposition dismissing the complaint was not reasonable, as it failed to address a critical conclusion from the expert opinion obtained. The matter is sent back to the Inquiry Committee with directions.
This document discusses pre-operative assessment and preparation of surgical patients. It outlines the goals of pre-operative evaluation which include identifying medical issues, determining if further information is needed, and ensuring the patient is medically optimized for surgery. It also discusses informed consent, appropriate pre-operative tests and investigations, prophylactic measures to prevent complications, anesthesia considerations, and assessing post-operative intensive care needs.
The document discusses perioperative nursing, which describes the nursing care provided during the surgical experience. It is divided into three phases: preoperative, intraoperative, and postoperative.
The preoperative phase extends from admission to the surgical unit until being transported to the operating room. The intraoperative phase is from admission to the OR until being transported to the recovery room. The postoperative phase is from the recovery room until follow-up care.
The document also discusses the goals, assessments, screening tests, and interventions of the preoperative phase, including addressing patient fears and obtaining informed consent.
The document discusses the care of surgical patients from pre-operation through recovery. It covers preparing the patient physically and psychologically for surgery, different types of surgeries and anesthesia, and the roles and responsibilities of staff in caring for surgical patients before, during, and after a procedure. Common patient fears are also addressed.
This document outlines guidelines for patient care in anesthesiology. It defines anesthesiology as focusing on preoperative, intraoperative, and postoperative evaluation and treatment of patients who are rendered unconscious or insensible to pain during medical procedures. It describes anesthesiologists' responsibilities, which include assessing patients' medical status, developing anesthesia care plans, providing anesthesia and postoperative care, and directing non-physician providers. The guidelines specify that anesthesiologists should be available 24/7 to provide the same standards of care to all patients, and cover pre-anesthetic evaluation, perianesthetic care including monitoring and recovery, and quality assurance programs.
The document provides an overview of perioperative nursing care. It discusses the three phases of surgery: preoperative, intraoperative, and postoperative. In the preoperative phase, the nurse conducts assessments, provides education to the client, and ensures informed consent is obtained. During surgery, nurses manage risks and ensure proper technique is maintained. In post-op, nurses monitor for complications and promote recovery. Perioperative nursing aims to provide excellent care before, during, and after surgery by addressing clients' physical and psychosocial needs.
Nurse-led pre-operative assessment ensures patients are prepared for surgery through a systematic 4-stage process: 1) collecting medical history, 2) nursing assessment, 3) ordering relevant investigations/tests, and 4) providing information. This identifies risks and needs to improve outcomes by reducing cancellations. Pre-operative assessment by nurses trained to advanced levels can provide equivalent care to doctors. Effective communication among the healthcare team during assessment benefits patients.
- Junior doctors displayed poorer knowledge of surgical informed consent (SIC) compared to senior doctors. The majority of junior doctors believed SIC was only needed for elective cases and did not consistently inform patients about risks and alternatives.
- Current practices around obtaining SIC among both junior and senior doctors showed significant problems. Consent was often obtained from attendants instead of patients and without ensuring understanding. Standardized processes and documentation of SIC were lacking.
- The study concluded there is a need to improve knowledge and practices regarding the informed consent process, which should be viewed as an important part of patient care rather than a casual formality. Formal training for doctors on SIC was recommended.
DNR in Emergency Department - The Practice and the Islamic view Rashid Abuelhassan
The document discusses end-of-life care and do-not-resuscitate (DNR) orders. It provides guidance on when DNR is appropriate according to different medical conditions and opinions of specialists. DNR policies are discussed for different countries and regions, noting they can vary significantly. The key messages are that palliative care does not automatically mean DNR; DNR only refers to chest compressions and not other interventions like airway maneuvers or fluids in some cases; and the validity and requirements of DNR orders should be confirmed according to the local hospital policies. Communication with families is also emphasized.
This document discusses pre-operative assessment and preparation of surgical patients. It outlines the goals of pre-operative evaluation which include identifying medical issues, determining if further information is needed, and ensuring the patient is medically optimized for surgery. It also discusses informed consent, appropriate pre-operative tests and investigations, prophylactic measures to prevent complications, anesthesia considerations, and assessing post-operative intensive care needs.
The document discusses perioperative nursing, which describes the nursing care provided during the surgical experience. It is divided into three phases: preoperative, intraoperative, and postoperative.
The preoperative phase extends from admission to the surgical unit until being transported to the operating room. The intraoperative phase is from admission to the OR until being transported to the recovery room. The postoperative phase is from the recovery room until follow-up care.
The document also discusses the goals, assessments, screening tests, and interventions of the preoperative phase, including addressing patient fears and obtaining informed consent.
The document discusses the care of surgical patients from pre-operation through recovery. It covers preparing the patient physically and psychologically for surgery, different types of surgeries and anesthesia, and the roles and responsibilities of staff in caring for surgical patients before, during, and after a procedure. Common patient fears are also addressed.
This document outlines guidelines for patient care in anesthesiology. It defines anesthesiology as focusing on preoperative, intraoperative, and postoperative evaluation and treatment of patients who are rendered unconscious or insensible to pain during medical procedures. It describes anesthesiologists' responsibilities, which include assessing patients' medical status, developing anesthesia care plans, providing anesthesia and postoperative care, and directing non-physician providers. The guidelines specify that anesthesiologists should be available 24/7 to provide the same standards of care to all patients, and cover pre-anesthetic evaluation, perianesthetic care including monitoring and recovery, and quality assurance programs.
The document provides an overview of perioperative nursing care. It discusses the three phases of surgery: preoperative, intraoperative, and postoperative. In the preoperative phase, the nurse conducts assessments, provides education to the client, and ensures informed consent is obtained. During surgery, nurses manage risks and ensure proper technique is maintained. In post-op, nurses monitor for complications and promote recovery. Perioperative nursing aims to provide excellent care before, during, and after surgery by addressing clients' physical and psychosocial needs.
Nurse-led pre-operative assessment ensures patients are prepared for surgery through a systematic 4-stage process: 1) collecting medical history, 2) nursing assessment, 3) ordering relevant investigations/tests, and 4) providing information. This identifies risks and needs to improve outcomes by reducing cancellations. Pre-operative assessment by nurses trained to advanced levels can provide equivalent care to doctors. Effective communication among the healthcare team during assessment benefits patients.
- Junior doctors displayed poorer knowledge of surgical informed consent (SIC) compared to senior doctors. The majority of junior doctors believed SIC was only needed for elective cases and did not consistently inform patients about risks and alternatives.
- Current practices around obtaining SIC among both junior and senior doctors showed significant problems. Consent was often obtained from attendants instead of patients and without ensuring understanding. Standardized processes and documentation of SIC were lacking.
- The study concluded there is a need to improve knowledge and practices regarding the informed consent process, which should be viewed as an important part of patient care rather than a casual formality. Formal training for doctors on SIC was recommended.
DNR in Emergency Department - The Practice and the Islamic view Rashid Abuelhassan
The document discusses end-of-life care and do-not-resuscitate (DNR) orders. It provides guidance on when DNR is appropriate according to different medical conditions and opinions of specialists. DNR policies are discussed for different countries and regions, noting they can vary significantly. The key messages are that palliative care does not automatically mean DNR; DNR only refers to chest compressions and not other interventions like airway maneuvers or fluids in some cases; and the validity and requirements of DNR orders should be confirmed according to the local hospital policies. Communication with families is also emphasized.
This document outlines the roles and responsibilities of various members of the surgical team. It discusses preoperative, intraoperative, and postoperative care processes. The key members of the surgical team include the surgeon, anesthesiologist, certified registered nurse anesthetist, circulating nurse, and scrub nurse. Their roles involve ensuring patient safety and performing tasks like administering anesthesia, setting up the operating room, assisting with the procedure, and maintaining sterility.
Pre operative assessment of patient schedule for oral surgeryNuhafadhil
This document discusses pre-operative assessment and risk assessment for oral surgery patients. It covers evaluating four key components: the patient's medical condition, functional capacity, emotional status, and the planned procedure. A thorough medical history is essential to determine if a medically compromised patient can safely undergo the planned procedure. The document then examines risk factors and considerations for patients with cardiovascular diseases, hematologic disorders, and respiratory diseases. It provides examples of how certain conditions may require modifications to dental treatment or precautions with certain medications.
This document contains messages and information about an upcoming CME & workshop in 2009. It includes messages from Dr. S.S.C. Chakra Rao, President of ISA-National, Dr. M.V. Bhimeswar, Honorary Secretary of ISA-National, and Dr. S Bala Bhaskar, Editor of the Indian Journal of Anaesthesia expressing support for the workshop and journal being launched by the Madhya Pradesh chapter of the Indian Society of Anaesthesiologists. It also contains the names and contact information of the office bearers for the Madhya Pradesh chapter for 2013-2014. The bulk of the document consists of papers and summaries of presentations to be
The document discusses preoperative evaluation and management. It aims to identify any medical comorbidities that could affect surgical outcomes rather than broadly screening for disease. A thorough history and physical exam are important to understand preexisting conditions and risks. Investigations should be ordered selectively based on medical history. Preoperative preparation includes securing IV access, emptying bowels if needed, and providing thromboprophylaxis or antibiotics if required. Special considerations depend on the surgery and any cardiovascular, respiratory, or other system involvement.
A C S0105 Postoperative Management Of The Hospitalized Patientmedbookonline
This document discusses postoperative management of surgical patients. It describes the different levels of postoperative care including same-day surgery, the surgical floor, telemetry ward, and intensive care unit. Factors determining a patient's disposition include their preoperative health, procedure performed, and postoperative clinical status. The document also discusses common postoperative orders related to tubes, drains, oxygen therapy, and wound care to guide nursing staff.
1. This document provides guidelines for day case and short stay surgery from a working party established by the Association of Anaesthetists of Great Britain and Ireland and the British Association of Day Surgery.
2. Effective pre-operative preparation and protocol-driven, nurse-led discharge are fundamental to safe and effective day and short stay surgery.
3. Selection of patients for day surgery considers social factors like having a caregiver at home, medical factors like fitness and stability of chronic conditions, and surgical factors like risk of complications requiring immediate medical attention.
This study summarizes the treatment of 187 patients with penetrating thoracic injuries admitted to a hospital in Taiz, Yemen during 2015-2016. It finds that most patients were male (90.9%), between 18-60 years old (83.4%), and injured by gunshot wounds (70.1%). The majority of injuries were isolated penetrating thoracic injuries (74.9%) rather than combined with abdominal injuries (25.1%). The most common treatment was tube thoracostomy (84.5%), while a minority (15%) required thoracotomy. Treatment options correlated with injury type and mechanism, with more thoracotomies performed for gunshot wounds compared to blast injuries. The study aims to describe management
Preoperative preparation of patients for surgeryErum Khateeb
The document discusses preoperative preparation and optimization of patients for surgery. It covers preoperative care, investigations, assessing surgical risk, and preparing specific patient groups. The goals of preoperative preparation are to anticipate difficulties, enhance patient safety, minimize complications, and optimize high-risk patients. Key aspects include obtaining medical history, conducting physical exams and tests, discussing risks and obtaining consent, and providing prophylaxis for issues like thrombosis. Careful preoperative preparation helps improve surgical outcomes.
1. Perioperative nursing involves nursing care before, during, and after surgery. The goals are to assist clients through the surgical experience and help promote positive outcomes and optimal function.
2. The preoperative phase involves assessing the client's medical and health history, performing examinations of key body systems, obtaining informed consent, and providing teaching to prepare the client for surgery.
3. Teaching in the preoperative phase addresses what the client will experience in the operating room, helps address their psychosocial concerns, and explains what will happen throughout the perioperative period.
The document provides guidelines for ambulatory anesthesia and surgery. It recommends that anesthesiologists play a leadership role in all ambulatory surgical facilities. The guidelines apply to all settings involving anesthesiology and are meant to encourage high quality patient care. Facilities must be properly equipped and staffed to handle emergencies. Patient care should include a pre-anesthesia evaluation, anesthesia plan, administration or supervision of anesthesia by qualified professionals, and discharge only when medically appropriate.
Jyothis Venus is a highly skilled and experienced nurse anesthetist currently completing her Doctorate of Nursing Practice. She has over 15 years of critical care nursing experience and is proficient in all aspects of anesthesia delivery including general, regional, and specialty cases. Venus is also competent in preoperative assessments, postoperative care, and pain management. She has worked in both urban and rural clinical settings and seeks to provide the highest quality of anesthesia care for all patients.
This document provides information on preoperative assessments for anesthesia. It discusses performing a clinical assessment of patients including medical history, physical exam, and necessary investigations. Patients are categorized based on medical complexity, with low-risk patients able to schedule surgery and higher-risk patients requiring further testing or specialist consultation. The goals of preoperative assessment are to optimize patient health and identify risks so surgeries are not cancelled due to medical issues. Post-anesthesia care and potential complications are also outlined.
Principles of preoperative and operative surgeryMEEQAT HOSPITAL
This document discusses principles of preoperative and operative surgery. It covers four main principles: preoperative preparation of the patient, a systems approach to preoperative evaluation, additional preoperative considerations, and a preoperative checklist. For preoperative evaluation and preparation, the document emphasizes assessing patient risk factors, especially cardiovascular risk, and optimizing high-risk patients prior to surgery through testing, medication, and consultation with specialists. The goal is to identify any medical issues that could impact the surgical outcome and take steps to improve the patient's status and reduce perioperative risk.
Anesthetic risk, quality improvement and liability●๋•αηкιтα madan
This document discusses anesthesia risk and mortality. It provides estimates from various studies that anesthesia-related mortality rates range from less than 1 per 10,000 anesthetics to 1 per 1,560 anesthetics historically. Common complications discussed include nerve injuries, awareness during general anesthesia, eye/dental injuries, and postoperative cognitive dysfunction in elderly patients. Risk management strategies to minimize liability like adherence to standards of care, vigilance, documentation, and informed consent are also outlined.
Perioperative care involves three phases: preoperative, intraoperative, and postoperative. The preoperative phase begins with the decision for surgery and continues until the patient reaches the operating area. The intraoperative phase is the duration of the surgical procedure. The postoperative phase begins in the recovery area and continues until follow up evaluation or discharge. Perioperative care requires evaluation of the patient's history and medical optimization for surgery through tests, medications, and skin/digestive preparation depending on the type, risk level, and urgency of the procedure. Immediate postoperative care focuses on airway, respiration, circulation, fluid balance, and pain level along with ongoing assessment of the patient's general condition and recovery.
This document provides an overview of pre-anesthetic patient assessment. It discusses the goals of evaluating a patient's general health and anticipating complications. The pre-anesthetic checkup process involves collecting medical history, performing a physical exam, and ordering relevant medical investigations. This allows doctors to understand patient risk factors, create an anesthesia plan, and gain informed consent. The document outlines steps for history taking, examination, airway assessment, common investigations, risk classification, and medication management guidelines to safely prepare a patient for anesthesia and surgery.
Basic principles of surgery ,exam oriented part 1Salah Ahmed
This document summarizes key topics related to day case surgery and surgical ethics. It provides an overview of day case surgery, including definitions, selection criteria, advantages, disadvantages and common procedures. It also lists previous exam questions on topics like day case surgery units, discharge criteria and selection criteria. The document then summarizes principles of informed consent, including components of a valid consent and maintaining confidentiality. It concludes with concepts of good surgical practice and protocols for delivering bad news.
Medicolegal aspects of head and neck endocrine surgeryDr Utkal Mishra
The document discusses medicolegal aspects of head and neck endocrine surgery. It notes that the most common reasons for litigation related to thyroid surgery are vocal cord paralysis and recurrent laryngeal nerve injury. For parathyroid surgery, failure to document maneuvers to preserve the parathyroids or measure intraoperative parathyroid hormone can make malpractice suits difficult to defend. The document emphasizes the importance of obtaining proper informed consent, documenting surgical notes and postoperative care, using accepted surgical techniques, and referring cases that exceed a surgeon's expertise.
Element descriptionthe problem ofdescribe the problemaffectRAHUL126667
Massachusetts General Hospital's Pre-Admission Testing Area (PATA) was struggling with long patient wait times and inefficiencies. PATA was responsible for completing pre-operative work-ups for outpatient surgical patients, but faced challenges including limited capacity, lack of clear prioritization guidelines for surgeons, and shared ownership between departments. This resulted in patients spending hours in the clinic with minimal face time with providers, delays in surgeries, and overworked staff. A task force was formed to address these challenges, and brought on an MBA intern to conduct an assessment of PATA's processes.
La pedagogía crítica, JHC segundo semestre G "A"juliohedezcortes
El documento describe los orígenes y principios de la pedagogía crítica. Surge a partir de la Escuela de Frankfurt y teóricos como Horkheimer, Adorno y Marcuse criticaron cómo la razón se había convertido en un instrumento de dominación. La pedagogía crítica busca comprender las implicaciones sociales de la educación y promover el conocimiento emancipatorio. Analiza cómo el poder influye en los contenidos de enseñanza y las relaciones en la escuela.
La pedagogía crítica se basa en transformar las prácticas educativas convencionales para promover el pensamiento crítico en los estudiantes. Se enfoca en que los estudiantes cuestionen las creencias dominantes y desarrollen habilidades analíticas para cambiar la sociedad. Rechaza la noción de que el maestro solo transmite conocimiento y el estudiante es pasivo. Más bien, busca que maestro y estudiante creen conocimiento de forma dialéctica y contextualizada cultural y socialmente.
This document outlines the roles and responsibilities of various members of the surgical team. It discusses preoperative, intraoperative, and postoperative care processes. The key members of the surgical team include the surgeon, anesthesiologist, certified registered nurse anesthetist, circulating nurse, and scrub nurse. Their roles involve ensuring patient safety and performing tasks like administering anesthesia, setting up the operating room, assisting with the procedure, and maintaining sterility.
Pre operative assessment of patient schedule for oral surgeryNuhafadhil
This document discusses pre-operative assessment and risk assessment for oral surgery patients. It covers evaluating four key components: the patient's medical condition, functional capacity, emotional status, and the planned procedure. A thorough medical history is essential to determine if a medically compromised patient can safely undergo the planned procedure. The document then examines risk factors and considerations for patients with cardiovascular diseases, hematologic disorders, and respiratory diseases. It provides examples of how certain conditions may require modifications to dental treatment or precautions with certain medications.
This document contains messages and information about an upcoming CME & workshop in 2009. It includes messages from Dr. S.S.C. Chakra Rao, President of ISA-National, Dr. M.V. Bhimeswar, Honorary Secretary of ISA-National, and Dr. S Bala Bhaskar, Editor of the Indian Journal of Anaesthesia expressing support for the workshop and journal being launched by the Madhya Pradesh chapter of the Indian Society of Anaesthesiologists. It also contains the names and contact information of the office bearers for the Madhya Pradesh chapter for 2013-2014. The bulk of the document consists of papers and summaries of presentations to be
The document discusses preoperative evaluation and management. It aims to identify any medical comorbidities that could affect surgical outcomes rather than broadly screening for disease. A thorough history and physical exam are important to understand preexisting conditions and risks. Investigations should be ordered selectively based on medical history. Preoperative preparation includes securing IV access, emptying bowels if needed, and providing thromboprophylaxis or antibiotics if required. Special considerations depend on the surgery and any cardiovascular, respiratory, or other system involvement.
A C S0105 Postoperative Management Of The Hospitalized Patientmedbookonline
This document discusses postoperative management of surgical patients. It describes the different levels of postoperative care including same-day surgery, the surgical floor, telemetry ward, and intensive care unit. Factors determining a patient's disposition include their preoperative health, procedure performed, and postoperative clinical status. The document also discusses common postoperative orders related to tubes, drains, oxygen therapy, and wound care to guide nursing staff.
1. This document provides guidelines for day case and short stay surgery from a working party established by the Association of Anaesthetists of Great Britain and Ireland and the British Association of Day Surgery.
2. Effective pre-operative preparation and protocol-driven, nurse-led discharge are fundamental to safe and effective day and short stay surgery.
3. Selection of patients for day surgery considers social factors like having a caregiver at home, medical factors like fitness and stability of chronic conditions, and surgical factors like risk of complications requiring immediate medical attention.
This study summarizes the treatment of 187 patients with penetrating thoracic injuries admitted to a hospital in Taiz, Yemen during 2015-2016. It finds that most patients were male (90.9%), between 18-60 years old (83.4%), and injured by gunshot wounds (70.1%). The majority of injuries were isolated penetrating thoracic injuries (74.9%) rather than combined with abdominal injuries (25.1%). The most common treatment was tube thoracostomy (84.5%), while a minority (15%) required thoracotomy. Treatment options correlated with injury type and mechanism, with more thoracotomies performed for gunshot wounds compared to blast injuries. The study aims to describe management
Preoperative preparation of patients for surgeryErum Khateeb
The document discusses preoperative preparation and optimization of patients for surgery. It covers preoperative care, investigations, assessing surgical risk, and preparing specific patient groups. The goals of preoperative preparation are to anticipate difficulties, enhance patient safety, minimize complications, and optimize high-risk patients. Key aspects include obtaining medical history, conducting physical exams and tests, discussing risks and obtaining consent, and providing prophylaxis for issues like thrombosis. Careful preoperative preparation helps improve surgical outcomes.
1. Perioperative nursing involves nursing care before, during, and after surgery. The goals are to assist clients through the surgical experience and help promote positive outcomes and optimal function.
2. The preoperative phase involves assessing the client's medical and health history, performing examinations of key body systems, obtaining informed consent, and providing teaching to prepare the client for surgery.
3. Teaching in the preoperative phase addresses what the client will experience in the operating room, helps address their psychosocial concerns, and explains what will happen throughout the perioperative period.
The document provides guidelines for ambulatory anesthesia and surgery. It recommends that anesthesiologists play a leadership role in all ambulatory surgical facilities. The guidelines apply to all settings involving anesthesiology and are meant to encourage high quality patient care. Facilities must be properly equipped and staffed to handle emergencies. Patient care should include a pre-anesthesia evaluation, anesthesia plan, administration or supervision of anesthesia by qualified professionals, and discharge only when medically appropriate.
Jyothis Venus is a highly skilled and experienced nurse anesthetist currently completing her Doctorate of Nursing Practice. She has over 15 years of critical care nursing experience and is proficient in all aspects of anesthesia delivery including general, regional, and specialty cases. Venus is also competent in preoperative assessments, postoperative care, and pain management. She has worked in both urban and rural clinical settings and seeks to provide the highest quality of anesthesia care for all patients.
This document provides information on preoperative assessments for anesthesia. It discusses performing a clinical assessment of patients including medical history, physical exam, and necessary investigations. Patients are categorized based on medical complexity, with low-risk patients able to schedule surgery and higher-risk patients requiring further testing or specialist consultation. The goals of preoperative assessment are to optimize patient health and identify risks so surgeries are not cancelled due to medical issues. Post-anesthesia care and potential complications are also outlined.
Principles of preoperative and operative surgeryMEEQAT HOSPITAL
This document discusses principles of preoperative and operative surgery. It covers four main principles: preoperative preparation of the patient, a systems approach to preoperative evaluation, additional preoperative considerations, and a preoperative checklist. For preoperative evaluation and preparation, the document emphasizes assessing patient risk factors, especially cardiovascular risk, and optimizing high-risk patients prior to surgery through testing, medication, and consultation with specialists. The goal is to identify any medical issues that could impact the surgical outcome and take steps to improve the patient's status and reduce perioperative risk.
Anesthetic risk, quality improvement and liability●๋•αηкιтα madan
This document discusses anesthesia risk and mortality. It provides estimates from various studies that anesthesia-related mortality rates range from less than 1 per 10,000 anesthetics to 1 per 1,560 anesthetics historically. Common complications discussed include nerve injuries, awareness during general anesthesia, eye/dental injuries, and postoperative cognitive dysfunction in elderly patients. Risk management strategies to minimize liability like adherence to standards of care, vigilance, documentation, and informed consent are also outlined.
Perioperative care involves three phases: preoperative, intraoperative, and postoperative. The preoperative phase begins with the decision for surgery and continues until the patient reaches the operating area. The intraoperative phase is the duration of the surgical procedure. The postoperative phase begins in the recovery area and continues until follow up evaluation or discharge. Perioperative care requires evaluation of the patient's history and medical optimization for surgery through tests, medications, and skin/digestive preparation depending on the type, risk level, and urgency of the procedure. Immediate postoperative care focuses on airway, respiration, circulation, fluid balance, and pain level along with ongoing assessment of the patient's general condition and recovery.
This document provides an overview of pre-anesthetic patient assessment. It discusses the goals of evaluating a patient's general health and anticipating complications. The pre-anesthetic checkup process involves collecting medical history, performing a physical exam, and ordering relevant medical investigations. This allows doctors to understand patient risk factors, create an anesthesia plan, and gain informed consent. The document outlines steps for history taking, examination, airway assessment, common investigations, risk classification, and medication management guidelines to safely prepare a patient for anesthesia and surgery.
Basic principles of surgery ,exam oriented part 1Salah Ahmed
This document summarizes key topics related to day case surgery and surgical ethics. It provides an overview of day case surgery, including definitions, selection criteria, advantages, disadvantages and common procedures. It also lists previous exam questions on topics like day case surgery units, discharge criteria and selection criteria. The document then summarizes principles of informed consent, including components of a valid consent and maintaining confidentiality. It concludes with concepts of good surgical practice and protocols for delivering bad news.
Medicolegal aspects of head and neck endocrine surgeryDr Utkal Mishra
The document discusses medicolegal aspects of head and neck endocrine surgery. It notes that the most common reasons for litigation related to thyroid surgery are vocal cord paralysis and recurrent laryngeal nerve injury. For parathyroid surgery, failure to document maneuvers to preserve the parathyroids or measure intraoperative parathyroid hormone can make malpractice suits difficult to defend. The document emphasizes the importance of obtaining proper informed consent, documenting surgical notes and postoperative care, using accepted surgical techniques, and referring cases that exceed a surgeon's expertise.
Element descriptionthe problem ofdescribe the problemaffectRAHUL126667
Massachusetts General Hospital's Pre-Admission Testing Area (PATA) was struggling with long patient wait times and inefficiencies. PATA was responsible for completing pre-operative work-ups for outpatient surgical patients, but faced challenges including limited capacity, lack of clear prioritization guidelines for surgeons, and shared ownership between departments. This resulted in patients spending hours in the clinic with minimal face time with providers, delays in surgeries, and overworked staff. A task force was formed to address these challenges, and brought on an MBA intern to conduct an assessment of PATA's processes.
La pedagogía crítica, JHC segundo semestre G "A"juliohedezcortes
El documento describe los orígenes y principios de la pedagogía crítica. Surge a partir de la Escuela de Frankfurt y teóricos como Horkheimer, Adorno y Marcuse criticaron cómo la razón se había convertido en un instrumento de dominación. La pedagogía crítica busca comprender las implicaciones sociales de la educación y promover el conocimiento emancipatorio. Analiza cómo el poder influye en los contenidos de enseñanza y las relaciones en la escuela.
La pedagogía crítica se basa en transformar las prácticas educativas convencionales para promover el pensamiento crítico en los estudiantes. Se enfoca en que los estudiantes cuestionen las creencias dominantes y desarrollen habilidades analíticas para cambiar la sociedad. Rechaza la noción de que el maestro solo transmite conocimiento y el estudiante es pasivo. Más bien, busca que maestro y estudiante creen conocimiento de forma dialéctica y contextualizada cultural y socialmente.
La pedagogía crítica es un modelo de educación que fomenta el cuestionamiento de las creencias y prácticas de los estudiantes para promover la conciencia crítica. Se basa en concebir el aula como un espacio para analizar situaciones del contexto del estudiante y formar un pensamiento más autónomo y crítico. El docente desarrolla la capacidad crítica en los estudiantes mediante estrategias didácticas que incluyen el análisis de textos, la solución de problemas y la profundización del entorno y
La pedagogía crítica se basa en los siguientes principios: 1) La relación dialéctica entre teoría y práctica, donde el conocimiento se genera a través de la reflexión crítica sobre la experiencia. 2) El pensamiento crítico y dialéctico que permite a los docentes liberarse de dogmas. 3) La contextualización del aprendizaje considerando factores socioeconómicos y culturales.
Este documento presenta información sobre cuatro teóricos de la pedagogía crítica: Paulo Freire, Peter Mclaren, Henry Giroux y Stephen Kemmis. Detalla los logros y contribuciones de Paulo Freire y Peter Mclaren a la pedagogía crítica, incluidos sus libros y posiciones educativas. También menciona brevemente a Henry Giroux y Stephen Kemmis como influencias en la pedagogía crítica.
“Excepto para aquellos a quienes cautive la idea de llegar a una especie de “mundo feliz” de Huxley o de “1984” de Orwell, la sociedad y la educación actuales presentan muchos motivos para que los profesores y profesoras adoptemos una postura crítica.
Ahora ya no se muere de hambre una persona cada dos segundos como en 1968; ahora se muere de hambre un niño cada dos segundos. Ahora la diferencia no está entre trabajar con la cabeza o con las manos, sino entre trabajar o estar en el paro. Ahora ya no se utiliza el principio de igualdad de oportunidades como máscara de las desigualdades, sino que con el motivo de la diversidad se abandonan las finalidades formalmente igualitarias de la enseñanza.”
El documento discute la importancia de una pedagogía crítica para la formación ciudadana y el desarrollo local. Propone que la educación popular debe empoderar a los ciudadanos y sectores oprimidos, reconociendo sus derechos y capacitándolos para transformar su realidad a través de la organización y la incidencia política. Asimismo, enfatiza la necesidad de crear nuevos conocimientos basados en la experiencia de los pueblos y de promover un paradigma educativo alternativo al neoliberalismo.
Este documento presenta las visiones humanistas de la educación según la pedagogía crítica de Paulo Freire y la propuesta de pensamiento complejo de Edgar Morín. Discute los principales enfoques de Freire sobre la concientización y liberación de los oprimidos, así como los siete saberes necesarios para la educación del futuro según Morín, incluyendo la condición humana, la identidad terrestre y la comprensión. El documento también analiza las características de la pedagogía crítica y el enfoque crítico-reflexivo
La pedagogía crítica es una propuesta de enseñanza que ayuda a los estudiantes a cuestionar y desafiar las creencias y prácticas que generan dominación. Promueve la individualidad, autonomía, libertad, apertura al mundo y desarrollo de la inteligencia de cada estudiante. Se basa en una ruptura con la epistemología estrecha y se apoya en fuentes como la pedagogía experimental, psicología, antropología y teorías como la dialéctica, hermenéutica crítica y modelo hab
El documento resume la historia de la pedagogía desde sus orígenes en las sociedades primitivas hasta la pedagogía contemporánea. Explica las diferentes épocas como la época feudal, la reforma, la contrarreforma y la pedagogía moderna y tradicional. También describe los diferentes enfoques pedagógicos como la escolástica, el humanismo, el pragmatismo y el funcionalismo. Finalmente, destaca que la pedagogía busca formar generaciones más competentes y capacitadas mediante nuevos métodos didácticos y la
La pedagogía crítica se originó en la Escuela de Frankfurt y propone una enseñanza que ayuda a los estudiantes a cuestionar las estructuras sociales y creencias dominantes. Busca desarrollar un pensamiento crítico para transformar la sociedad. Algunos de sus principales exponentes son Paulo Freire, Henry Giroux y Michael Apple. Utiliza la investigación-acción para analizar críticamente las prácticas educativas y mejorarlas.
Peter Mclaren es un destacado pedagogo crítico que promueve una educación comprometida con la justicia social y la liberación de los oprimidos. Considera que la escuela reproduce las desigualdades de la sociedad y busca empoderar a los estudiantes a través de un conocimiento emancipatorio que les permita cuestionar críticamente la realidad y luchar contra la injusticia.
La Escuela de Frankfurt surgió en Alemania en la década de 1920, inspirada en las teorías de Marx, Freud y Weber. Sintetizó filosofía y teoría social para desarrollar una crítica de la sociedad capitalista contemporánea. Sus principales teóricos incluyeron a Horkheimer, Adorno, Benjamin y Marcuse. Criticaron el positivismo, el capitalismo y la racionalización de la cultura occidental. Más tarde, Habermas reformuló la teoría crítica para adaptarse a los cambios en las formas de opres
Introducción a la Escuela de Frankfurt con texto de Horkheimer enfocada a la materia de Historia de la Filosofía en Bachillerato, realizada por Ana Rosa Moya Escobar.
El documento resume la evolución histórica de la pedagogía desde las comunidades primitivas hasta la Edad Media. Los griegos como Sócrates, Platón y Aristóteles sentaron las bases de la pedagogía occidental al enseñar disciplinas como la música, poesía, literatura, gimnasia y filosofía. En la Edad Media, la iglesia cristiana estableció escuelas y monasterios donde se enseñaba la lectura y escritura. Finalmente, surgieron las primeras universidades donde se ofrecían grados en
This document summarizes key points from a presentation on medical law and ethics:
1. It discusses concepts like medical malpractice, negligence, fraud, and professional liability. It also outlines strategies for doctors to protect themselves, like obtaining liability and malpractice insurance.
2. Several medical malpractice cases are summarized that resulted from errors like surgical instruments or glass being left in patients' bodies.
3. The principles of consent in medical law are examined, including the landmark case of Abdul Razak Datuk Abu Samah v Raja Badrul Hisham Raja Zezeman Shah, where a patient died due to a lack of informed consent regarding risks of surgery.
NP AA's patient encounters from a certain period were reviewed. The review found:
1) Nine encounters where NP AA failed to recognize or respond to critical health issues, placing patients at risk of harm.
2) Multiple medication errors and instances of prescribing medications incorrectly or without proper documentation.
3) Eight unnecessary referrals to specialists for issues treatable by NP AA and four incorrect specialty referrals.
4) Questionable and contradictory documentation in all 110 patient encounters, including excessive exams irrelevant to the presenting issue.
The review concludes NP AA failed to properly assess, diagnose, treat and document patient encounters, failing to meet standards of care for nurse practitioners in areas like critical thinking, differential diagnosis, appropriate
1) The document provides details of medical treatment received by George Washington for injuries sustained in a motor vehicle accident on September 15, 2010, including multiple physician visits, diagnostic imaging, physical therapy, and two left shoulder surgeries.
2) It argues that the medical treatment received was medically necessary and causally related to the accident, noting that deference should be given to the opinion of the treating physician.
3) It cites legal precedent establishing that medically necessary expenses include those that provide temporary relief from symptoms and do not need to result in a cure, as long as the treatment is reasonable.
This is an actual TMLT medical malpractice case. It involves a pain management specialist who was treating a patient for back pain. This presentation illustrates how action or inaction on the part of the physician led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician's defensibility. The case has been modified to protect the privacy of the physician and the patient.
Mr. Doe underwent a colonoscopy at an endoscopy center and was given anesthesia. After the procedure, he was told to get dressed and that his son would pick him up soon. Still feeling sedated, Mr. Doe attempted to get dressed unassisted and fell, fracturing his wrist. The medical records show failures in post-procedure care including inadequate monitoring and assessment of Mr. Doe's condition before allowing him to ambulate unassisted in his sedated state. This resulted in injuries requiring surgery. The case has merit as the standard of care requires appropriate oversight and evaluation of patients recovering from anesthesia to ensure safe discharge.
This document defines a source document as an original document where clinical trial data is first recorded, such as medical records, laboratory notes, or subjects' diaries. Source documents can be either electronic or paper. Electronic source documents must meet requirements regarding computer system validation, electronic records, electronic signatures, and technical support. Paper source documents are typically handwritten forms or records with the investigator's original signature. The document discusses challenges of source document verification like informed consent processes and adverse event reporting. It provides examples of informed consent procedures for patients who cannot read, are disabled, or lack decision-making capacity.
This document is a decision from the Health Professions Review Board regarding a complaint filed against a physician. It summarizes the complaint, which alleges that the physician failed to protect the complainant from further injury by reporting to WorkSafeBC that he could return to work without limitations after his first hand injury, which then led to a second devastating hand injury. It describes the investigation process undertaken by the College's Inquiry Committee in response to the complaint. It also provides background details on the complainant's two hand injuries, his treatment and return to work.
Judicial approach in medical negligence in malaysiaSiti Azhar
It gives a overview on the current judicial approach on medical negligence cases in Malaysia. The opinion formed in this is the personal opinion of the writer.
This study surveyed ICU physicians and nurses about how they make decisions regarding allocating a final ICU bed between two patients. The researchers identified four major themes in clinicians' responses: prioritizing the identifiable patient over anonymous others, considering medical factors, considering non-medical factors, and feeling constrained by external rules. Some clinicians felt conflicted between their desired decision and what external factors allowed. A minority suggested both patients could be accommodated.
A painter who worked at the Navy Pier in Chicago sustained an injury to his cervical spine which arose out of and in the course of his employment. Ankin Law Office attorney Josh Rudolfi represented the painter in the appellate court hearing where the Illinois Workers Compensation Commission award of temporary total disability benefits, medical expenses, and wage differential benefits were affirmed.
This document is a court ruling in an Article 78 proceeding brought by William Feng seeking to overturn the denial of his application for an accident disability retirement (ADR) pension by the New York City Police Pension Fund. The court summarizes Feng's medical history and injuries claimed to have occurred in the line of duty. While some doctors found his injuries were caused by these incidents, the Pension Fund's Medical Board determined his condition was due to a pre-existing congenital scoliosis. The court finds the Medical Board's determination was based on credible evidence and was not arbitrary or capricious, so the denial of an ADR pension is upheld.
Unxpected Changes in Pt Condition during Transport.pptxmlstllc
- A study found that patients who experienced adverse effects during transport had significantly higher mortality within 24 hours compared to patients who did not experience adverse effects. Adverse effects included changes in oxygen saturation, blood pressure, respiratory rate, and arrhythmias.
- Transporting critically ill patients involves risks like equipment malfunctions and changes in patient physiology. Multiple studies have found high rates of oxygen desaturation, arrhythmias, and changes in blood pressure during transport.
- Proper preparation and treating transport like providing ICU-level care can help reduce risks to critically ill patients during inter-hospital transport.
Dr. Kellie Leitch glanced at the data on wait times collected from t.pdffaxteldelhi
Dr. Kellie Leitch glanced at the data on wait times collected from the patients in one of her
clinics. As Chief of Paediatric1 Orthopaedic surgery at the Children\'s Hospital of Western
Ontario (CHWO), she was very concerned by the long times that the young patients (and their
parents) were experiencing in the daily clinic. Long wait times tended to aggravate the already
pent-up distress and concern that they were feeling, and parents were understandably irritated at
missing significant time at work. Currently, on an average, patients were spending roughly two
hours in the clinic.
Patient health was not Dr. Leitch\'s only concern. Clinical staff had increasingly complained
about being overextended, yet budgetary pressures to reduce the cost of service continued to
mount. She was not convinced that all staff was being effectively utilized, and there was an
unresolved request from the Radiology department for more advanced equipment. Dr. Leitch
also served on several government task forces. From these, she knew that federal and provincial
policymakers were increasingly concerned with the economic impact that health-care wait times
had on national economic productivity.
In a moment of weakness, Dr. Leitch recently had volunteered her clinic to hospital management
as a “test case” to demonstrate that patient care could be done in a more timely fashion, without
increasing costs. An objective of reducing wait times by 20 per cent was established to show
meaningful improvement that would be clearly evident to patients, staff and management. A
monthly executive meeting was fast approaching, and expectations were starting to run high that
Dr. Leitch would present preliminary recommendations that would offer significant reductions.
PAEDIATRIC ORTHOPAEDIC CLINIC
As part of London Health Sciences Centre, located in the city of London, Ontario, Canada,
CHWO was a large, regional health-care centre that provided specialized paediatric services to
children. The population of the 10 counties forming the primary catchment area for CHWO was
1.4 million, including approximately 400,000 children. Many of the CHWO\'s specialty services
also attracted referrals from across Ontario, as well as from neighboring provinces and states in
Canada and the United States.
The Clinic was open for three half-day sessions per week, Monday through Wednesday, from
8:30 a.m. to 1:00 p.m. During the remainder of the week, the facilities were used by other sub-
specialties of surgery. Staffed by a surgeon, two senior resident students, three clerks and four
registered nurses, the Clinic examined about 80 patients during each half-day session, of which
60 per cent were returning for a follow-up appointment (and so termed follow-up patients). In
addition to the staff noted above, other medical students might spend up to one month training in
the Clinic.
PATIENT FLOW AT THE CLINIC
Front Desk: Registration & Verification of Documents
The Registration desk was the first point of contact.
Test bank for critical care nursing a holistic approach 11th edition morton f...robinsonayot
Test bank for critical care nursing a holistic approach 11th edition morton fontaine.pdf
Test bank for critical care nursing a holistic approach 11th edition morton fontaine.pdf
1 what is clnical gait analysis (cga ifa 2015)Richard Baker
This document discusses clinical gait analysis and its role in evaluating patients and informing treatment. It proposes two models for clinical gait analysis: integration, where gait analysis and clinical decision making are combined; and separation, where gait analysis identifies impairments but clinical decisions are made separately. The key aspects of clinical gait analysis are determining the impairments causing a patient's walking pattern through objective measurement and interpretation. While analysis identifies impairments, clinical decision making considers additional factors and decides on management. The document emphasizes that gait analysis reports should clearly link conclusions to underlying data and evidence to inform clinicians' treatment decisions.
The document discusses clinical gait analysis and provides principles for reporting on gait analysis. It defines clinical gait analysis as determining what is causing a patient to walk a certain way based on instrumented measurement and biomechanical interpretation. It advocates separating gait analysis, which identifies impairments affecting walking, from clinical decision making, which considers other factors. The document outlines two models of provision and stresses that gait analysis reports should identify impairments, be relevant, succinct, transparent, evidence-based, comprehensive, within the authors' competence, and time efficient.
CHAPTER 15 r Evaiuation and Management (EM) Services,fA,.docxbartholomeocoombs
CHAPTER 15 r Evaiuation and Management (E/M) Services
,/fA, four types of medical decision making, in order of complexity from most to
List the fi
least risk
,d--A-
A-
,lr,
-lr-
Inpatient time spent at the bedside or nursing station during or after
the visit is what kind of time?
21. Thepatient's will reflect the
. nrm-ber of systems examined by a brief statement of the findings.
/ZZ. I discussion with a patient andlor family concerning one or more of
the following areas: diagnostic results, impressions and/or
recommended diagnostic studies; prognosis; risks and benefits of
treatment; instruciions for treatment; importance of compliance with
treatment; risk factor reduction; and patient and family education is
23. The history is the
physician.
information the Patient tells the
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Iffir Ecsorrrces on Erolve.
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13. Complexity of medical decision making is based on three
ve types of presenting problems from the most risk and least recovery to
and most recovery:
19. Counseling and coordination of care are what kind of factors in most
cases?
U/O. ,r*"that is used as a guide for outpatient services is what kind of time?
Cop].right @ 2015 by Saunders, an impdnt of Elsevier Inc' A1I rights reserved'
CHAI{ER 15 r Evaluation and Management (E/l[l Sersices
6n. ,n"re is no distinction made between the new and established patients
in this service department of a hospital:
25. Those services rendered by a physician whose opinion or advice is
requested by another physician or agency in the evaluation and/or
treatment of a patient is a(n) whereas the
physician who has primary responsibility for the patient in the hospital
is called
r'26. Whencritically ill patients in medical emergencies require the constant
attendance of the physician (e.g., cardiac arrest, shock, bleeding, and
respiratory failure) to stabilize them, what kind of care is needed?
27. When care is provided
same patient by more
conditions, the care is
for similar services
than one physician
(e.g., hospital visits) to the
on the same day for different
,6. *nuris the name for the assumption of the total or speciflc care of a
patient from one physician to another that does not constitute a
consultation?
29. An inventory of body systems obtained
signs and/or symptoms that the patient
."{o. ,tthe physician who is standing by does so for 25 minutes, can he ot
she round the time up to 30 minutes for reporting purposes?
through questioning to identifY
may be experiencing is a(n)
of
Odd-numbered answers are located in Appendlx B, while the full answer key is only avaitrablc ir ft TEI'€E
Instructor Resources on Evolve.
Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved.
CIL{PTER 15 r fyil*5on irnd Management (E/}vf) Services
PRACTICAT
Office or Other Outpatlent Services and Hospltal lnpatient Service
With the use of t.
Background: The transition from resident physician to independent practitioner is an important period for young physicians.Optimally, they would feel well prepared to independently care for all patients presenting to them for anesthesia, however, this is unlikely Methods: A survey was emailed to all accredited anesthesiology residency program coordinators in April 2018 for further distribution to their CA3 residents. The survey collected data on the resident’s perception of his or her preparedness to manage a variety of anesthesia cases, patients with comorbid conditions, and ethical issues as well as perform various procedures.
American Journal of Anesthesia & Clinical Research
2014-HPA-027(a)
1. Health Professions Review Board
Suite 900, 747 Fort Street
Victoria British Columbia
Telephone: 250 953-4956
Toll Free: 1-888-953-4986 (within BC)
Facsimile: 250 953-3195
Mailing Address:
PO 9429 STN PROV GOVT
Victoria BC V8W 9V1
Website: www.hprb.gov.bc.ca
Email: hprbinfo@gov.bc.ca
DECISION NO. 2014-HPA-027(a)
In the matter of an application under section 50.6 of the Health Professions Act,
R.S.B.C. 1996, c. 183, as amended, (the “Act”) for review of a complaint disposition
made by an Inquiry Committee
BETWEEN: The Complainant COMPLAINANT
AND: The College of Physicians and Surgeons of BC COLLEGE
AND: A Physician and Surgeon REGISTRANT
BEFORE: Lorne R. Borgal, Panel Chair REVIEW BOARD
DATE: Conducted by way of written submissions concluding on
January 12, 2015
APPEARING: For the Complainant:
For the College:
For the Registrant:
Self-represented
Sarah Hellmann, Counsel
Raj Samfani, Counsel
DECISION ON APPLICATION FOR REVIEW
I STAGE 2 HEARING
[1] Having been previously directed to Stage 2 of the hearing process, this review of
a disposition by the Inquiry Committee is based on the record of investigation provided
by the College with submissions received from the Complainant, the Registrant and the
College.
II INTRODUCTION
[2] The Complainant was the husband of the patient for whom the Registrant was
the anesthesiologist. The patient had previously undergone radiation therapy in
treatment for a tumor in her brain and was scheduled to have elective surgery for a total
knee replacement. In preparation for the knee surgery the patient requested spinal
anesthesia as this had worked well for her previously and she believed it was important
that she not have general anesthesia due to the radiation therapy.
2. DECISION NO. 2014-HPA-027(a) Page 2
[3] At the time of the surgery the Registrant attempted a spinal anesthesia and after
multiple attempts he administered a routine general anaesthetic. The patient’s general
practitioner (“Doctor A”) reported that she declined rapidly following the surgery. Prior
to this hearing the patient succumbed to her illness.
[4] Upon receipt of the complaint the Inquiry Committee completed an investigation
and issued a disposition letter which found that the Registrant met the standard of care.
In his application for review the Complainant challenged the decision of the Inquiry
Committee and asked for a review by the Review Board.
[5] The Review Board exists, in part, in order to provide for impartial and objective
reviews of complaint dispositions of Inquiry Committees of the health colleges of British
Columbia upon application for review by a Complainant. These are reviews of
dispositions and not fresh examinations of complaints. In completing a review I
examine the entire record of the matter pertaining to the complaint. My mandate in this
case is to determine whether the Inquiry Committee conducted an adequate
investigation and if it was, then I am to determine whether the disposition of the matter
was reasonable.
[6] In the event that I find that the Inquiry Committee disposition was either not
adequate or not reasonable then the Act provides me with the authority to direct the
Inquiry Committee to make a disposition that it could have made or (more typically) to
send the matter back to the Inquiry Committee with specific directions.
III DECISION
[7] In the course of this review I have considered all of the information before me
whether I specifically referenced it herein or not. I have, for the reasons presented
below, found that the investigation of this complaint was adequate; however, I find that
the disposition failed to satisfy the basic criteria of a reasonable decision and for that
reason I am returning this matter to the Inquiry Committee with directions.
IV BACKGROUND FACTS
[8] The patient had previously had treatment related to a tumor in her brain and had
a total knee replacement of her left knee in the period before the current surgery.
Having made the decision to have elective surgery for the replacement of her right knee
and in anticipation of this surgery which has led to this review, the patient and the
Complainant state that they repeatedly expressed their concerns regarding the risk of
general anesthesia on her brain function given her medical history
[9] Their request for spinal anesthesia was known to Doctor A and was recorded in
the pre-anesthesia consultation report of October 31, 2012. This report noted that the
use of spinal anesthesia in her 2008 operation was successful and that the patient is
presently a suitable candidate for anesthesia for the proposed knee replacement. The
last line in this report states that the “…final decision regarding anesthetic
3. DECISION NO. 2014-HPA-027(a) Page 3
management…” will be made by the attending anesthesiologist on the day of the
procedure.
[10] In his response the Registrant noted that he had no specific recall of the patient
and that his response would be based on the medical records and on his usual practice.
The Registrant reported that he would have reviewed the pre-anesthesia consultation
report and that he was aware of the patient’s preference for spinal anesthesia. He was
also aware of her medical condition and prior treatment related to her brain tumor. He
confirmed that having tried unsuccessfully to administer a spinal anesthesia he did
administer a general anesthesia and upon his turnover of the patient to the recovery
room her vital signs were stable.
[11] Doctor A submitted that while she “…cannot answer with certainty the cause of
her rapid decline postoperatively” she does, based on having been her doctor since
2004 and having seen her 4 to 6 times each year, believe that “…the turning point,
when she went from a relatively independent adult to a totally dependent and frail
elderly woman, occurred immediately postoperatively.” Doctor A noted that the patient
“…has suffered a rapid and grossly significant cognitive decline in the months following
(the surgery)”.
[12] Six months following the surgery the patient was seen by her neurologist (“Doctor
B”). He noted that “…she had quite a severe postoperative delirium and has never
really regained good cognitive function…” He reported they completed a neurological
exam on an urgent basis given her worsening condition. The conclusion Doctor B wrote
was that “…it does show significant leukoencephalopathy seen on her previous scans
without any clear significant worsening. There is no sign of recurrent tumor. There is
no subdural hematomas.” In the final assessment, Doctor B noted that the patient
“…has clearly slid in regards to her cognitive function and from the imaging it all points
to post treatment leukoencephalopathy as the likely cause.”
[13] In the course of their investigation the Inquiry Committee engaged an expert to
provide his opinion which they, in turn, relied upon. For reasons presented below I am
including significant portions of the expert opinion in this ruling.
[14] The expert opinion unequivocally highlighted the known risk of postoperative
delirium (“POD”) for this patient regardless of the form of anesthesia:
Use of regional anaesthetic techniques, instead of general anesthesia does not appear
to reduce the incidence of delirium.
Given the age of (the Patient) and her pre-existing cognitive changes and her visual
impairment, she would be considered as a high risk for developing POD. A spinal would
not have any advantages over general anesthesia in this regard…
Also, there appears to be no clear difference between regional and general anesthesia
(in regard to postoperative cognitive dysfunction (“POCD”))
[15] The expert opinion includes the following:
4. DECISION NO. 2014-HPA-027(a) Page 4
In (the Registrant’s) letter, he alleges that he would have discussed with (the patient) the
possibility of a failed spinal and a general anesthesia would be required. Given the
concerns of (the patient) regarding the effects of general anesthesia on her medical
conditions, it would have been of extreme value for (the Registrant) to have recorded the
verbal discussions as documentation in the medical record. (emphasis added)
[16] The disposition letter concluded by stating that “It is fair to say that no physician,
including (the Registrant), anticipated that your wife’s clinical course would unfold so
tragically.” It noted that the Registrant’s response was based on his medical
documentation and his usual practice. The letter further noted that her neurologist
reported that “…decline was attributed to post-treatment leukoencephalopathy.” In
conclusion the disposition letter noted that “An independent anesthesiologist reviewed
the care provided by (the Registrant) and determined that he met the standard required
of an anesthesiologist.”
[17] The application for review noted that much of the information provided by the
Registrant is not in the patient’s medical records and depends on the Registrant’s
assertions of his usual practice. Specifically the application notes that there is nothing
in the medical records that indicates that the Registrant discussed with the patient the
possibility of a failed spinal in which case a general anesthesia would be required.
V RELEVANT LEGISLATION, RUES AND POLICY
[18] The disposition in this matter was by the Registrar of the College pursuant to
s. 32(3)(c) of the Act, which under s. 32(5) of the Act is considered to be a disposition
by the Inquiry Committee.
[19] Section 50.6(5) of the Act defines what the Review Board must consider:
On receipt of an application under ss. (1), the review board must conduct a review of the
disposition and must consider one or both of the following:
(a) the adequacy of the investigation conducted respecting the complaint;
(b) the reasonableness of the disposition.
Section 50.6(6) of the Act stipulates that a review under this section is a review on the
record.
Section 50.6(8) of the Act stipulates that upon completion of its review under this
section, the review board may make an order:
(a) confirming the disposition of the inquiry committee,
(b) directing the inquiry committee to make a disposition that could have
been made by the inquiry committee in the matter, or
(c) sending the matter back to the inquiry committee for reconsideration
with directions.
5. DECISION NO. 2014-HPA-027(a) Page 5
[20] The exclusive jurisdiction of the Review Board is provided in s. 50.63 of the Act:
50.63 (1) The review board has exclusive jurisdiction to inquire into, hear,
and determine all those matters and questions of fact, law and discretion
arising or required to be determined in a review or an investigation and
disposition under this Part and to make any order permitted to be made.
(2) A decision or order of the review board under this Part on a matter
in respect of which the review board has exclusive jurisdiction is final and
conclusive and is not open to question or review in any court.
[21] It is not within the jurisdiction of the Review Board to evaluate medical treatment,
the competency of the Registrant or to order any form of monetary award.
VI ADEQUACY OF THE INVESTIGATION
[22] The Review Board must, on review, determine the adequacy of the investigation.
The investigation that was undertaken by the Inquiry Committee need not have been a
perfect investigation but it must have been adequate. What is considered adequate will
differ from case to case depending primarily on the seriousness of the issues raised in
the complaint and the findings of the investigation.
[23] What constitutes an adequate investigation in the context of the Review Board
was well defined in Review Board Decision No. 2009-HPA-0001(a) to 0004(a)
paragraphs [97] and [98] which reasoning I have adopted herein:
[97] A complainant is not entitled to a perfect investigation, but he or she is entitled to
adequate investigation. Whether an investigation is adequate will depend on the facts.
An investigation does not need to have been exhaustive in order to be adequate,
provided that reasonable steps were taken to obtain the key information that would have
affected the Inquiry Committee’s assessment of the complaint.
[98] The degree of diligence expected of the College – what degree of investigation
was adequate in the circumstances – may well vary from complaint to complaint.
Factors such as the nature of the complaint, the seriousness of the harm alleged, the
complexity of the investigation, the availability of evidence and the resources available to
the college will all be relevant factors in determining whether an investigation was
adequate in the circumstances.
[24] The test of adequacy will be met if I am satisfied that the Inquiry Committee took
reasonable steps to obtain information relevant to their assessment of the complaint.
This test can be met without exhausting all possible avenues of pursuit in the quest for
investigative information.
[25] In this matter I find that, following receipt of the complaint on May 23, 2013, the
Inquiry Committee :
(a) Wrote the Complainant to explain the process of their review;
6. DECISION NO. 2014-HPA-027(a) Page 6
(b) Wrote separate letters to each of the Registrant, Doctor A (the General
Practitioner), the treatment centre for cancer and the Hospital where the
surgery was performed. In each case the Inquiry Committee requested
medical records of the patient and in the case of the Registrant the Inquiry
Committee also requested his response to the complaint. Each party
subsequently responded and provided the appropriate information;
(c) Provided the information that it obtained to the Complainant who then
responded with comments and additional information. The complainant’s
response was provided to the Registrant;
(d) On December 19, 2013, requested the opinion of a third party expert
anesthesiologist which was received on January 14, 2014; and,
(e) Provided their disposition letter on January 27, 2014 and properly informed
the parties of their disposition.
[26] I find that the Inquiry Committee fulfilled the requirements of the Act in their
assembly of information and took all reasonable steps to properly obtain the information
required for their decision in this matter. Given the nature of the complaint and the
seriousness of the harm alleged the Inquiry Committee took the appropriate steps
required for their review of the complaint.
[27] Given the nature of this Complaint and the seriousness of the harm alleged, and
after considering the entire record, I find that the investigation by the Inquiry Committee
was adequate.
VII REASONABLENESS OF THE DISPOSITION
[28] The Review Board is provided by legislation with the exclusive jurisdiction to
define and apply “reasonableness” within the context of reforms of the Act whose
purpose it is to ensure an appropriate degree of accountability on the part of the Inquiry
Committee. The Review Board is not to ignore what the Inquiry Committee has done or
to step into its shoes. Rather the Review Board is to determine the degree of deference
to the Inquiry Committee that is appropriate in particular circumstances and as it is not a
court, the test of reasonableness will necessarily reflect the Review Board’s specialized
role and expertise.
[29] In my view, a functional definition of “reasonable” that accords with the current
state of the law is whether the decision falls within a range of possible, acceptable
outcomes which are defensible in respect of the facts and law. A reasonable disposition
must be transparent in that it is clear as to how the Inquiry Committee arrived at its
conclusion, intelligible in that it is clearly expressed and easy to understand and justified
in that the reader should be able to understand the factual and legal foundation for the
Inquiry Committee’s conclusion. What is “sufficient” transparency, intelligibility and
justification in a particular case is to be determined by the Review Board on a case by
case basis, applying its expertise and specialized role in good faith, and not simply by
comparison to how a generalized court might apply the test.
7. DECISION NO. 2014-HPA-027(a) Page 7
[30] The Review Board is not to determine whether or not a disposition is one which it
would have made, nor is it to determine whether the Inquiry Committee decision was
right or wrong. The Review Board is to determine whether or not the disposition is
supported by the evidence arising from the investigation and whether or not it is one
which fits within the range of acceptable and rationale outcomes as outlined above.
[31] Having engaged an expert for his opinion and then writing in the disposition letter
that the Inquiry Committee accepted the expert opinion, I find several instances which
are examined below, where there are deficiencies in the essential criteria of
transparency, intelligibility or justification as between the expert opinion, the record and
the disposition letter. While being careful not to step into the shoes of the Inquiry
Committee, I am charged with determining the reasonableness of the disposition and to
that end I have the concerns which are documented below.
[32] In the Conclusions section of his opinion the expert provided a specific, critical
comment regarding the Registrant not documenting his discussion with the patient,
which the expert characterized as especially significant given the patient’s concern
regarding the anesthesia (paragraph [15]). The disposition letter makes no reference to
this conclusion of the expert. In the Statement of Points to this hearing the College
submitted that while it “…does not disagree with the expert that this would have been
valuable … the College was not critical of the Registrant for not including such a note as
the hospital records document a comprehensive pre-operative consultation with another
anesthesiologist which notes the preference (for a spinal anesthesia).” In his Statement
of Points the Registrant submits that his pre-operative medical record indicated that the
patient had a “challenging looking back, with no real landmarks” and that this meant he
“…would have advised (the patient) that a spinal anaesthetic may not be possible and if
so, a general anaesthetic would be required.” This submission by the Registrant is
made with his full acknowledgement that he has no independent recollection of the
patient.
[33] The expert had access to the same records as are referred to by the College and
the Registrant in considering the matter of what was recorded. The disposition letter is
unqualified in accepting the expert opinion. In considering the College submission
regarding the role of the pre-operative consultation I note that the final paragraph of that
document allocates the final decision regarding anesthetic management to the
Registrant. I find that this obligation to make the final decision is clearly placed on the
Registrant, a fact which the Inquiry Committee noted in the disposition, and therefore
also find it to be a major obstacle to transparency and intelligibility for the College on the
one hand to argue that the decision was the Registrant’s to make, but then on the other
hand to implicitly reject the expert opinion that it would have been “…of extreme
value…” for the Registrant to have documented his discussion. I consider it
unsatisfactory that the Inquiry Committee did not address any aspect of this in the
disposition.
[34] In considering the Registrant’s assertion that his note of a “…challenging looking
back…” meant he would have discussed the form of anesthesia with the patient, I find
8. DECISION NO. 2014-HPA-027(a) Page 8
that this is not a compellingly logical argument in response to the expert opinion. The
expert had access to the original records which included this notation by the Registrant
and yet he devoted a significant portion of his conclusions to stating his opinion that
“…it would have been of extreme value…” for the Registrant to have made a record of
his discussion. I find it extremely unlikely that the expert did not understand that this
phrase signified major difficulties existed in administering the spinal injection. Having
considered the record, the expert made his notation; therefore, the Registrant’s
assertion does not rebut the concern of the expert. If the notation had the same
meaning to the expert as it does to the Registrant then the expert would have had no
basis to make his recommendation for better documentation.
[35] To compound this there is no consistency between the College’s interpretation of
the record in this matter, the Registrant’s assertion and the expert opinion. In order to
meet the standard of being intelligible and transparent I find that the Inquiry Committee
needed to disclose how they considered this aspect of the expert opinion, and provide
the rationale for why they concluded that it did not apply to the Registrant in a manner
that is supported by the evidence.
[36] The expert opinion was unequivocal in stating that the patient, given her
condition prior to surgery, was at a high risk of developing post-operative delirium
regardless of the form of anesthesia (paragraph [14]). The record shows that this
elevated risk was not disclosed to or discussed with the patient during the pre-
anesthesia consultation or by the Registrant prior to surgery. The Registrant reported
that he would have reviewed the pre-anesthesia report. In his review the Registrant
would presumably have noted that the pre-operative anesthesiologist did not discuss
this elevated risk regardless of the form of anesthesia. The Inquiry Committee appears
to have not considered the question as to why the Registrant did not disclose to the
patient that she had a higher than normal degree of risk for post-operative delirium
regardless of the form of anesthesia and that her preference for spinal anesthesia was
not grounded in fact as it did not change the risk profile. Rather the Registrant appears,
by the record, to have let the patient undergo elective surgery ignorant of the fact that
the form of anesthesia did not change her risk profile.
[37] Given the duty to protect the public (s. 16(1)(a) of the Act) that is the statutory
responsibility of the College, I find the absence of transparency on this aspect of the
decision to be sufficient, in and of itself, to render the decision not reasonable. If it is
not the anesthesiologist’s responsibility, in this case the Registrant, to ensure that the
patient knows the risks of anesthesia given the conditions that are unique to that
patient, then the Inquiry Committee needs to have provided the rationale for why it is
not, and by extension, who does bear that responsibility
[38] In the disposition letter the Inquiry Committee wrote that no physician could have
“…anticipated that your wife’s clinical course would unfold so tragically.” Given the
expert opinion regarding the high level of risk of post-operative delirium for this patient,
there is nothing presented in the disposition letter that provides the reader with a logical
flow of reasoning which explains how the Inquiry Committee reached this conclusion.
9. DECISION NO. 2014-HPA-027(a) Page 9
Given that the expert clearly knew of the elevated risks for this patient, the Inquiry
Committee would need to have provided a logical pathway that reconciles their
conclusion (that no physician could have expected the tragic outcome that occurred)
with the fact that at least their own expert appears to have known that POD was highly
likely in this case.
[39] The disposition letter notes that the Registrant concluded that “There was no
contraindication to proceeding with knee surgery.” The disposition letter and the record
state that the surgery in this case was elective and the expert opinion states that this
patient had a high level of risk of developing POD from any form of anesthesia.
Applying only layman’s logic to the analysis I am left to consider what would constitute a
contraindication (“a sign that someone should not continue with a particular medicine or
treatment because it is or might be harmful” (Cambridge Dictionaries Online)) if not the
facts in this case. If there is a logical basis for supporting the conclusion that there
indeed was no contraindication then the disposition letter must provide the analysis that
allows the reader to understand what is meant by “contraindication” and how elective
surgery in light of the risks in this case, does not meet the standard of a
“contraindication”.
[40] The disposition letter includes information provided by Doctor A in regard to the
“…rapid and grossly significant cognitive decline…” of the patient immediately following
the surgery (paragraph [11]) and her loss of ability to function as an independent
person. The expert opinion focused on the elevated risk of POD with any form of
anesthesia for the patient and discussed this issue in some detail. The expert referred
to the report from Doctor B which linked the onset of severe post-operative delirium and
the loss of cognitive function to when the patient was awoken from the general
anesthetic, then referenced that their imaging showed significant leukoencephalopathy
“…without any clear significant worsening” and “…from the imaging it all points to post
treatment leukoencephalopathy as the likely cause” without specifying to which
treatment he was referring. The disposition letter’s conclusive comment is that “We can
only state that (the Registrant) acted reasonably when he made the decision to give
your wife a general anesthetic.” The Registrant then argued in his Statement of Points
that the patient’s “…decline was unrelated to the care provided by (the Registrant).”
[41] I am struck by the apparent lack of consistency in the evidence and submissions
as to the impact of the anesthesia, the on-set of post-operative delirium, the impact of
the unchanged extent of leukoencephalopathy and the lack of precision in regard to
which treatment was being referenced by Doctor B. For this reason I find that the
disposition letter needs to be significantly more precise in establishing a line of
reasoning in support of the conclusion that an anesthesiologist meets the standard of
care by deciding to change from a spinal to a general anesthesia in this case.
[42] In the disposition letter the Inquiry Committee provided the following statement:
An independent anesthesiologist reviewed the care provided by (the Registrant) and
determined that he met the standard required of an anesthesiologist.
10. DECISION NO. 2014-HPA-027(a) Page 10
The actual wording in the expert opinion regarding the standard of care is:
There was no departure from the standard of care for (the Registrant’s) decision to
proceed with a general anesthesia when he was not able to secure spinal anesthesia…
Unless the standard of care of an anesthesiologist is limited to the decision between a general
and a spinal anesthesia, then the expert opinion does not support the generalized statement
that is attributed to it by the Inquiry Committee. By attributing the generalized standard of care
to the expert rather than to a reasoned conclusion by the Inquiry Committee, the disposition
letter cannot be deemed to have met the logical standard of consistency with the evidence in
the record as the expert did not offer a generalized opinion on the standard of care but rather a
narrow one.
[43] I find that the disposition letter has failed to meet the basic requirements of
transparency, intelligibility and justification on significant and material matters of fact
and logic such that the record before me does not adequately support the conclusions
in the disposition and therefore the disposition is not reasonable. In returning this
matter to the Inquiry Committee I direct that the issues identified above be addressed
and a revised disposition letter be provided which resolves the inconsistencies as noted
herein.
VIII CONCLUSION
[44] Having determined, for the above reasons, that the investigation was adequate
and that the disposition was not reasonable, I return the disposition to the Inquiry
Committee, pursuant to s. 50.6(8)(c) of the Act, with the direction to issue a revised
disposition letter that meets the basic requirement of a reasonable decision as defined
above and which resolves the concerns expressed herein.
“Lorne R. Borgal”
Lorne R. Borgal, Panel Chair
Health Professions Review Board
March 17, 2015