Medical disputes have become the focus and difficult problem of social concern, and the tension between doctors and patients has become one of the main contradictions in China today. Although people have made various efforts to alleviate the contradiction between doctors and patients, the relationship between doctors and patients has not developed in the direction that people strive and expect. Not only in China, but also in countries with advanced science and technology, medical disputes have been increasing in recent years. In this issue, Jiang, director of the Technical Appraisal Office of Medical Accidents of Jiangsu Medical Association, analyzed and commented on typical cases, so that both doctors and patients can understand medical accidents from different angles, resolve the contradictions between doctors and patients to the maximum extent, and build a harmonious doctor-patient relationship.
[Case 1] Appendix that should not be deleted
Case: Jane Doe, 2 1 year old. Because of "menopause for 38 weeks", abdominal distension and pain for more than 4 hours "lived in a health care center. Because the abnormal fetal position was breech position, cesarean section was performed under continuous epidural anesthesia, and appendectomy was added during the operation. From the second day after operation, the patient continued to have fever. On the 1 1 day after operation, the condition did not improve. He was transferred to a municipal hospital and diagnosed with colon-uterus-vagina fistula. After/0/4 days of operation, appendix stump repair, intestinal adhesion release, partial enterotomy and uterine fistula repair were performed under general anesthesia. After operation 18 days, he got better and was discharged. Half a year later, he was admitted to the municipal hospital because of "abdominal pain for 6 hours" and was diagnosed as adhesive intestinal obstruction.
Final identification: the doctor performed appendectomy at the same time of cesarean section without the consent and signature of his family, which violated the medical routine; Moreover, the rough operation and improper treatment of appendix stump caused postoperative pelvic infection, intestinal adhesion and colon-uterus-vagina fistula, which led to the secondary repair of appendix stump, intestinal adhesion release, partial ileectomy and uterine fistula repair, which damaged the physical and mental health of patients. The above consequences have a direct causal relationship with the doctor's medical operation behavior, which constitutes a three-level and three-level medical accident, and the doctor is fully responsible.
Comments: When a doctor treats a patient, the patient must first have a disease. If the patient is not ill, it is inconceivable to operate on the patient and remove a seemingly useless organ. This kind of thing did happen. Reading the whole medical record carefully, there is no record that the patient has ever had the symptoms and diagnosis of acute appendicitis, and there is no reason to do this operation. The operation approval form is useless, that is, the family asked for the appendix to be removed. According to the patient's clinical manifestations, the doctor should not agree. Moreover, the operation was performed by a person with midwife qualification, which violated the Law on Medical Practitioners, and the doctor was obviously negligent. Postoperative infection of lower abdomen, which gradually forms abdominal abscess, colonic uterine fistula and intestinal adhesion, is a postoperative complication caused by improper appendectomy, which not only brings pain to patients, but also causes the consequences of partial colectomy. The painful lesson brought by an unreasonable operation is worth pondering.
[Case 2] It is not the doctor's responsibility to get worse.
Case: male, 56 years old. He was admitted to the neurosurgery department of a hospital because of "weakness of both lower limbs with unstable walking for more than 2 months". Diagnosis: cervical spondylosis; Cervical vertebrae 2-3, 4-5, 5-6 disc herniation; Chest 12- waist 1 disc herniation; Lumbar 1-2 disc herniation. Anterior cervical decompression, bone grafting and locking plate internal fixation under general anesthesia. Pathological diagnosis: degeneration of nucleus pulposus (cervical vertebrae 3-4). He was discharged from the hospital two weeks after the operation. After leaving the hospital, the patient complained that his condition was not relieved and his symptoms were aggravated. He went to several hospitals successively. After hyperbaric oxygen and other treatments, the symptoms improved slightly but not obviously.
Final identification: the doctor diagnosed correctly, had the indication of operation, the operation method was correct, and the postoperative treatment was in line with medical principles. The symptoms of patients were aggravated after operation, and spinal cord degeneration led to some limb dysfunction. There is no causal relationship with medical operations. This case is not a medical accident.
Comments: To analyze this case, it should be said that the physical examination is comprehensive and the diagnosis is accurate. Because of the clear indications, the surgical scheme of anterior cervical decompression, bone grafting and internal fixation chosen by the doctor meets the requirements of conventional specifications. This surgical scheme is the most commonly used method to treat cervical spondylosis at home and abroad. There are no violations and mistakes during the operation, and there is no direct injury to the cervical spinal cord. Therefore, the reason why the doctor's diagnosis and treatment behavior constitutes a medical accident cannot be established. The reason why the postoperative effect of patients is not ideal is that the cervical spinal cord has been compressed by the prominent cervical intervertebral disc for a long time and has been irreversibly damaged. Once this kind of injury enters the stage of rapid development, the patient may be paralyzed in just a few months. For this kind of injury, the purpose of surgical treatment is to improve the symptoms and signs of patients and delay or prevent the development of the disease. Due to the limitation of current medical technology, it is impossible to accurately judge the degree of spinal cord injury before surgery, so it is impossible to accurately judge the surgical effect before surgery, so some patients are satisfied with the postoperative effect, while some patients are not only ineffective after surgery, but even worse than before surgery.
In this case, there was not enough communication between doctors and patients before operation, especially the doctors didn't explain the patients' preoperative disease status, surgical purpose and possible problems after operation, which led to the patients' high expectations for the surgical effect and insufficient psychological preparation for the surgical risks.
[Case 3] No porcelain work without Jin Gangzuan.
Case: A 40-year-old man was admitted to a township hospital because of "low back pain with numbness of the right lower limb for 5 years, aggravated by 9 days". Diagnosis: Lumbar disc herniation. The day after admission, the nucleus pulposus of Lumbar 4-5 and Lumbar 5- sacrum 1 disc herniation was removed under continuous epidural anesthesia and discharged two weeks later. Two months later, he was admitted to the municipal hospital because of "pain in the right lower back and legs for more than two months after removing the nucleus pulposus from lumbar disc herniation". Give dehydration and neurotrophic treatment. Three months later, the MRI report showed slight hyperplasia of lumbar vertebrae, and the signal of lumbar vertebrae 4-5 and 5- sacrum 1 intervertebral disc decreased. After 5- sacrum 1 operation of lumbar intervertebral disc, part of the right lamina was missing, and local shadow was seen at the right posterior edge of the intervertebral disc, which compressed the dural sac, and no abnormal signal shadow was found in the spinal cord and spinal canal. Four months later, he was admitted to a downtown hospital. Under epidural anesthesia, nucleus pulposus removal and spinal canal exploration were performed, and anti-inflammatory treatment was given after operation.
Final identification: 1. In the process of diagnosis and treatment, the doctor has correct diagnosis and surgical indications, and the lumbosacral area 1 nucleus pulposus removal method is correct, but the indication of simultaneous nucleus pulposus removal in lumbosacral area 4-5 is not strict. 2. The doctor belongs to the first-class medical institution, and the operation of lumbar disc herniation is beyond the scope of medical practice. 3. The doctor didn't do pathological examination on the samples taken during the operation. 4. At present, there is a causal relationship between patients' right foot dysfunction and doctors' medical behavior. If it is classified as a three-level medical accident, the doctor will bear secondary responsibility.
Comments: In this case, the diagnosis of medical prescription is clear. Lumbar 5- sacrum 1 disc herniation is obvious, and there are surgical indications. It is understandable to remove the nucleus pulposus of lumbar 5- sacrum 1 intervertebral disc during the operation, but the lumbar 4-5 intervertebral disc is only slightly swollen and does not need surgery. The indications of medical prescriptions are not strictly controlled. Medical prescription is a township hospital, which belongs to a first-class medical institution. According to the "Regulations on Management of Operation Grading in Hospitals in Jiangsu Province (Provisional)", the first-class and first-class hospitals are not allowed to carry out surgical treatment of lumbar disc herniation, and the behavior of this hospital is beyond the scope of medical practice, and there are violations. Lumbar disc nucleus pulposus removal is an operation around spinal cord and nerve roots, which is difficult and requires certain surgical skills. Careless, it is easy to cause irreparable losses. Although hospitals that can perform this kind of operation are quite popular at present, as township hospitals, their technical level and equipment do not yet have the ability to carry out this kind of operation. Because of the current medical system, it is an indisputable fact that township hospitals are struggling to survive, but we can't ignore the medical safety of patients because of this, and it is absolutely not advisable to take risks blindly. At present, medical disputes caused by out-of-scope medical practice in township hospitals are on the rise, which should attract the necessary attention of township hospital leaders and medical staff.
The above is an excerpt from China Law Network. I suggest you go up and have a look. You can consult online, which is very detailed.