Tuesday, December 13, 2005

Not all slippery slopes in Colorado are at the ski resorts

Something interesting occurred in Denver, Colorado the other day -- a physician was arrested and charged with manslaughter. This is not a typical case of jealousy, financial problems, an auto accident, etc. He was arrested for something he did in the care of a patient. Obviously, all of the facts of the case are not well known, but there has been some new information come to light since the original charges were filed and noted in the news.

The physician, Dr. Greg Hogle, is a 56-year-old Denver ENT specialist. He was referred a patient with a tracheostomy tube in place, and saw her on April 8, 2005.

(another physician) referred the case to Hogle after concluding the patient likely needed surgery to repair blockage, court records show. She sent images of the blockage with the medical records. But Hogle told investigators that the patient was accompanied by a woman who had trouble translating from Russian to English. The doctor decided based on his examination to remove the tracheostomy tube, records show.
The patient, Khusni Yusupova, age 46, developed swelling at the tracheostomy site and therefore difficulty breathing after she left Dr. Hogle's office. She was taken to the hospital, but suffered significant anoxic brain injury before a new tracheostomy tube could be placed. She was taken off life support and died two days later.

So, what happened? Without the records, it's difficult to speculate; it does seem, however, that this patient had upper airway obstruction and was not able to breathe without a tracheostomy.
According to the Denver Medical Examiner report, the only way she could have breathed at the time of her death is through her neck.
It also appears that the treating physician did not adequately review the patient's history and records; the history was likely difficult to obtain due to translation issues.
Denver Police say Dr. Hogle admitted he removed the tube without reviewing Yusupova's medical records, which she had brought to the appointment.
So, based upon his examination, Dr. Hogle decided that it was safe to remove the tube -- this presumably involved an examination of the upper airway with a determination that it was patent enough to allow breathing through the mouth and nose, with no obstruction to air flow. He was wrong, and admits he made an error in judgement:
Hogle admitted to police, "I made a serious mistake." He went on to tell police, "she did need the tube for her airway...because she had an obstructed airway, it means she did need the tube and I made a mistake."
Criminal charges might seem to be unthinkable in delivery of medical care, but actually occur -- including relatively recently in Colorado.
In a highly publicized case, a Denver anesthesiologist was charged with manslaughter after prosecutors alleged he fell asleep during a routine surgery in 1993 at St. Joseph Hospital. The patient, an 8-year-old boy, died during the operation. After two manslaughter trials, the doctor, Joseph Verbrugge, was ultimately convicted of a misdemeanor, but that conviction was later thrown out on appeal. He was stripped of his medical license.
But there are other wrinkles to this case. To muddy the waters further, the coroner ruled the death a suicide. Why? Be cause this relatively young lady had a tracheostomy and an obstructed upper airway as a result of an attempt to take her own life.
The report doesn't dispute that Dr. Hogle's decision played a role in the death. However,the report reveals that the reason Yusupova had the tracheostomy tube in the first place was because she had " ... Ingest(ed) ... A caustic liquid (concentrated acetic acid) in a suicide attempt months earlier." Therefore, the coroner ruled "the manner of death is suicide."
What is interesting to me is the apparent lack of involvement by the Board of Medical Examiners, with criminal charges being filed before the BME has made even preliminary recommendations public. Under most circumstances, cases that appear to be egregious failures of judgement and care are rapidly dealt with by the Board. That process allows a complete review of the medical issues and facts, so that an appropriate action can be taken (see the case above where despite the anesthesiologist not being convicted, he was stripped of his license).

While I do not have at my disposal all of the case data, the fact that criminal charges have been filed, for an error in judgement in the delivery of medical care, is worrisome to me. All physicians make errors, just like the remainder of humanity. What about this case rises to the level of criminality? And as we stand atop that slippery slope, that is the crux of the issue. When I or one of my colleagues makes an error in judgement that results in death, will we too be criminally charged?

UPDATE: Colorado Medical Society President Dr. Rick May issued this statement about the charges against Dr. Hogle:
"In medical practice, bad things can happen to good people, and good doctors can and do make mistakes. These are not purposeful assaults. They are errors, however rare, that we all work very diligently to prevent. Medical mistakes are not criminal, clear and simple, and should never be dumped in the criminal justice system. Colorado's civil justice system allows our patients broad rights to seek redress through the courts, and the State Medical Board has full legal authority to discipline an errant physician, including license revocation."