Disrespect And Assault In The Operating Room: Our Nightmares Are Real

clown-in-the-operating-room

“A few moments later, the anesthesiologist walks in the room and asks, ‘What do you got?’ Dr. Canby says, ‘Vaginal delivery. Uterine atony. External massage failed. Give her some ketamine.’”…I look at Mrs. Lopez—her eyes are half-closed and vacant. Dr. Canby instructs me to hold her knee. A fellow medical student holds her other knee….Canby then performs an internal bimanual uterine massage. He places his left hand inside her vagina, makes a fist, and presses it against her uterus. I look down and see only his wrist; his entire hand is inside her. Canby puts his right hand on her abdomen and then massages her uterus between his hands. After a few minutes, he feels the uterus contract and harden. He says something like, ‘Atta girl. That’s what I like. A nice, tight uterus.’ And the bleeding stops. The guy saved her life…But then something happened that I’ll never forget. Dr. Canby raises his right hand into the air. He starts to sing ‘La Cucaracha.’ He sings, ‘La Cucaracha, la cucaracha, dada, dada, dada-daaa.’ It looks like he is dancing with her. He stomps his feet, twists his body, and waves his right arm above his head. All the while, he holds her, his whole hand still inside her vagina. He starts laughing. He keeps dancing. And then he looks at me. I begin to sway to his beat. My feet shuffle. I hum and laugh along with him. Moments later, the anesthesiologist yells, ‘Knock it off, assholes!’ And we stop.”

This is an operating room anecdote related in an anonymously authored article published this week in the Annals of Internal Medicine, a respected medical journal. The publication says that the piece is intended to shine light in a dark corner of the medical profession. Oh-oh. The essay is anonymous, I assume, because the author is afraid that there would be professional repercussions from his revealing this—what? Bad habit? Dirty secret? Crime? Reason for us to go stark, raving mad?

Dr. Christine Laine, the journal’s editor-in-chief, has said that idea of publishing the essay in the first place was controversial enough to have sparked a contentious debate  among the journal’s editorial team. “We all agreed that the piece was disgusting and scandalous and could damage the profession’s reputation,” Laine and the editorial staff wrote in an editorial accompanying the piece. “Some believed that this was reason not to publish the story. Others believed that it was precisely why we should publish it.”

“This was obviously an extreme example,” Laine said in an interview. “It’s not common, but even if it only happens rarely, that’s too often. Our main motivation in publishing it was to prompt discussion. We didn’t want the journal to stuff this behavior under the rug.”

Wait…how do we know “it’s not common”?

This has certainly been a slowly unfolding ethics scandal. For decades there have been jokes, rumors and paranoia about doctors and nurses  mocking or otherwise abusing unconscious and defenseless—and trusting—patients.  From “The Simpsons”:

Nurse: Oh boy, what a mug!

Surgeon: Yea, you should see his genitals, would you like to see his genitals?

The Patient (Moe): I’m awake here!

In 2014, a doctor took a selfie with Joan Rivers while she was under anesthesia for what turned into a fatal endoscopy scheduled with a different doctor. In April of this year, I wrote about the Washington Post op-ed by a nurse who used serial rationalizations to defend such conduct, arguing that the ridicule acts to “rejuvenate [the medical personnel] and bond them to their teams, while helping to produce high-quality work. In other words, the benefits to the staff — and to the patients they heal — outweigh occasional wounded feelings.” In June, we discussed a Virginia case where a jury awarded $500,000 to a patient who accidentally recorded the verbal abuse he was subjected to while anesthetized for a colonoscopy. Now this.

Oh-oh…

I suspect such incidents are not as rare as we would like to think. I suspect that the medical profession has exploited its prestige, power and arrogance to allow an ugly practice to infect its culture, and that it will take a lot more than an anonymous medical journal article to purge it.  This is a breach of trust and professionalism that violates medical ethics at their source. Quoth the relevant section of the ancient Hippocratic Oath...

“Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.”

Where’s that part that adds, “unless it’s a really funny gag, I’m compensating for my anxiety or if it rejuvenates the medical team”?

Laine argues that her journal aspires “to generate discussion that will empower people to stand up to colleagues when they see colleagues acting in a disrespectful manner toward patients.” Sorry, I don’t care to trust doctors and nurses to do that at this point, though of course their doing so is part of the remedy. Still, it is only part. I am unaware of such conduct ever being reported to authorities as a serious ethics breach, or of medical professionals being disciplined for it as a result of collegial  reporting. It wasn’t reported in the instances related by the article, and the author wasn’t anonymous because he’s shy.

First, let’s have video cameras running every time a patient is unconscious and at the mercy of these merry pranksters with God complexes.

Then we can wait for the medical profession to  clean up its culture and its ethics without fearing being made into puppets, props and victims in the operating room.

___________________

Pointer and Source: IBT

Graphic: Very Funny Pics

Ethics Alarms attempts to give proper attribution and credit to all sources of facts, analysis and other assistance that go into its blog posts, and seek written permission when appropriate. If you are aware of one I missed, or believe your own work or property was used in any way without proper attribution, credit or permission, please contact me, Jack Marshall, at jamproethics@verizon.net.

30 thoughts on “Disrespect And Assault In The Operating Room: Our Nightmares Are Real

  1. After careful consideration, I have come to the conclusion that there is no profession nor service which is inherently ethical, because we humans are inherently flawed and constantly hovering on the balance beam of behavior. We, however, place our trust in certain professions — medical, legal, religious, nonprofit, financial, governmental, etc. — because we believe, apparently erroneously, that humans in those professions will not succeed if they perform their services in any way other than the best light. We know that humans are capable of the best and the worst of behavior, and yet we think that these professions are immune to anything other than the best. Hah.

    I am not cynical about this, although it may sound that way. Part of me still wants to declare with the tragic heroine Anne Frank that “In spite of everything I still believe that people are really good at heart. I simply can’t build up my hopes on a foundation consisting of confusion, misery and death.” And so, we trust and hope that we have put ourselves into the hands of people who are ethical. Sometimes we perform our due diligence in researching backgrounds, but those I KNOW are incomplete if not often misleading searches.

    This is why we need people like Jack Marshall helping us to sift through the muck of human life to find the pearl of decency.

  2. Love the idea of video in O.R.s.

    I wonder how much the pompous T.V. series M*A*S*H had to do with this development in the medical profession? When I was a kid back in the ‘fifties and ‘sixties, the physicians that were most highly regarded were WWII trained guys. Wars are evidently great for fostering great improvements in triage and orthopedics and making for decisive surgeons and so forth. I suspect Hollywood twisted this around with Hawkeye and Hotlips Houlihan and all the rest. Maybe it’s infected the medical schools and residency programs.

    And let’s hear it for that anesthesiologist.

      • At least these proto-physicians seem to be behaving very professionally so far, at least in terms of demeanor. And hey, their practice procedures are probably state of the art and irreproachable for their time.

        Great cartoon though.

  3. And before the rejoinders arise along the lines of “professionals in tough environments need to build camaraderie” or “need to get through with dark humor” or “need to build rapport and trust with each other” or “need to deal with stress”-

    Sure, those are great objectives and worthy to be reached. But not by violating another person’s dignity and autonomy (without their consent) as a vehicle for achieving those objectives.

    Sorry, but no.

    • Tex, I am trying to recall, and am too lazy to research, so I am asking in case you recall: wasn’t one of the rationalizations for the Tailhook assaults, back in…wow, was it really 1990 or early 1990s? at least something like “professionals in tough environments need to build camaraderie” or “need to deal with stress?” I suppose the same was said in defense of the wannabe mockumentary-making jailers at Abu Ghraib, too.

      • Quite probably. I crafted tht last sentence with hazing, among other things, in mind. More egregious forms of hazing are certainly off limits, but milder forms in certain military settings? I’m not entirely against, which led to parenthetical caveat.

        • I agree with you, but then, we both have that military background, so we both almost certainly experienced hazing in various degrees. I would not want to be a basic military trainer these days, not with the probabilities of responses by typical recruits of today. It’s all but impossible to trust that trainees can even think to the level of accepting “beneficial stress.” And of course, you can’t just weed-out all but the “self-starters,” either – so many more opportunities for a trainee to self-stop and have the trainer fired for violating some “basic human right”…

  4. Not included in either Oath, but probably should be, “First, do no harm.” Heard that on a TV show somewhere, and it would cure a variety of ills, if followed.

  5. Not to intentionally gross anyone out, but I distinctly remember my ob/gyn’s arm being completely inside of me while in labor. He was making jokes at the time — not about me or my condition but jokes nonetheless — and I think he was doing it to distract me from the pain and the bad news that was coming. I needed a c-section.

    I was completely fine with it. But my husband found it very disturbing. I probably would have been upset if he sang a little song. I don’t know — but I also was awake, so there is no sense of violation as in the example above. I mention this only to say that it was interesting that my husband and I had completely different reactions to the same medical experience.

    • Call it a natural masculine reaction to what on the surface is a violation of his wife’s body…

      Men fight the innate urge to deck the doctor because mentally they know it’s for the good of the procedure, though viscerally their instincts are saying “protect the wife”.

      • I remember back when my wife had an appendectomy some years ago. I was very afraid and upset. On her way in, I looked at the surgeon, and I said ” this is a very important surgery. Do you understand? No mistakes.” Of course, I felt a little foolish afterwards, but what can I say? She’s my wife, and if one of these people screwed up and killed her through negligence, there’s no do-overs. Same thing happened with my son’s surgery, even though I tried not to. I’m fiercely protective of my family.

    • On a similar note my urologist was reciting the Goldfinger monologue (“No Mr. Bond, I expect you to die”) in the perfect voice while operating on me (local anesthesia only, so I was perfectly awake). I set him up for that one and the timing was perfect… I couldn’t help but laugh. The assisting nurse though was trying so hard not to laugh that I actually felt bad for her.

      • Akin to what Beth and Alex said, when I was seven (maybe 6), I cut my head open and had to get stitches. For each stitch, he told me to guess whether he was using a needle or a pin. I was so distracted by the question that I barely noticed the work he was doing.

        Of course, when I found out they were ALL NEEDLES (there were no pins at all!), I completely lost faith in the trustworthiness of doctors.

        -Jut

        • Our pediatrician would say, ‘Okay, I’m going to give you a shot.Turn over. I’m going to count to ten now. One, two, (He’d stick the needle in) three, four, (pull out the needle) five. Okay, we’re done.” Amazing how many times that worked.

  6. If the anecdote is true, the ethics point goes to the anesthesiologist for having the exact right response. “Knock it off, assholes.”

  7. Way, way back when I was stationed at the naval hospital at Roosy Roads, PR, an anesthesiologist friend gave me a bottle of Ketalar (ketamine Hcl). Hoo doggy! That was a peek behind the curtain!

  8. Unfortunately, the likelihood of stuff like this being reported and punished is next to nil. When your average medical professional is weighing out harm done to the patient (from his or her perspective) to the potential for damaging or destroying a career so dearly bought, they’re pretty likely to just keep it zipped. Sad but true. They’re likely to reason that it’s not the same as, for example, police brutality, with a few months of training and a pension down the tubes due to overtly criminal behavior. I like the camera idea; might be the only real deterrent.

  9. When the patient is awake and especially if you have a relationship, joking in the right vein is actually highly ethical and professional, like Beth’s story. But fear of being caught shouldn’t be the only thing keeping them from doing inappropriate things with unconscious patients. It’s covered on medical TV shows that you can talk about them AWAY from them and where you can’t be overheard. I wonder what the real-world lessons taught are…

    • I think medical ethics probably is a trickier subject than legal ethics for that reason. What behavior is ethical — and possibly needed — for one patient might be completely inappropriate for another.

  10. Medical Ethics (in the upper case ME) is more akin to spending ones life listing Clarke’s nine billion names of God, or going blind reading the Torah, mute debating it and deaf to the world one lives in. For a fresh and relatively transparent look at the ins and outs of (inherently ethical and pragmatically legal) questions of audio- and videotaping the OR: http://www.kevinmd.com/blog/2009/12/issues-surrounding-videotaping-surgeries-operating-room.html
    or
    http://www.kevinmd.com/blog/2015/08/this-is-great-medical-care-with-a-large-helping-of-unnecessary-suffering.html
    or
    http://www.kevinmd.com/blog/2015/08/happens-moral-physicians-stand-power.html

    • While the articles are telling, the comments are even more so. Defensiveness, aggression and one apparently crazy MD who, in essence, said “Of course we act like God…we ARE!” Makes me extremely grateful for the physician I have.

      • Wow! Which article contained that comment? Not that I have any doubt. I’ve met doctors that are more full of themselves than any SEAL I’ve ever met, and I’ve met many.

        • Couldn’t tell you, Joe. It was fairly lengthy, explained about the years and year of schooling, internship and residency, then said something to the effect that he expected his patients to do what he told them, because he, and apparently ONLY he, knew what he was talking about. Since you are in medicine, my response would be you tell me WHY and maybe, but ONLY maybe, I’ll go along with it. The final decision rests with me, always, since it’s my body we’re talking about. My belief, reading your comments, is that you would be in agreement with that.

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