Scenarios

1. Scenarios

2. Scenario #1, Drug Diversion: Paul and Paula are CRNA co-workers who have worked together for five years at Mercy Hospital. They have a friendly and cordial relationship, their families often spending time together at cookouts and other activities. Paula has recently had a new baby. The baby, now four months old, continues to have severe bouts of colic that often keep her awake at night despite having to work the next day. She often complains to Paul of being fatigued.

3. In addition, Paula’s husband, Ned, has recently started working at a new job after an 18 month period of unemployment. It is not a job he particularly likes, but he feels obligated to keep at it because he resented the financial strife that occurred when Paula was the sole breadwinner for her family. In the past two weeks, Paul has noticed a change in Paula’s behavior. She appears more fatigued, lacks concentration, gets easily annoyed, and is snapping at her co-workers over minor incidents. Paul knows Paula is under a great deal of stress and he tries to be supportive. Three days ago, another CRNA in the department, Frank, told Paul he thought he had witnessed Paula divert a milliliter of fentanyl during a case she was doing, but he wasn’t sure. Still, Paul wonders whether Paula might be succumbing to the pressures in her life by beginning to divert drugs intended for patients to her own use.

4. Scenario #1, Questions for discussion: 1. If you were Paul, what would you do? 2. Is Paul legally or morally obligated to discuss his concerns with the department head? With hospital administration? With a state agency? 3. Must Paul report Paula to the Board of Nursing for drug abuse? 4. If Paula is found to be diverting drugs and Frank informs the authorities that he had made Paul aware of it, can Paul be arrested or lose his job for being an accessory to Paula’s crime?

5. Scenario #2, Privacy concerns under HIPAA: Brendan Braggy is the anesthesia department’s best CRNA, or so he tells everyone. Brendan has worked in this busy 12 room OR for 17 years. He is one of the department’s most experienced clinicians. While everyone in the department is used to his ways, Brendan’s reputation as a loudmouth and gossip is well known throughout the hospital. Today, Brendan will be providing anesthesia to a close friend, John, for an inguinal hernia repair. In reviewing John’s chart prior to surgery, he discovers that John was recently treated for a presumptive diagnosis of tuberculosis, something which Brendan was unaware.

6. As John is about to be wheeled into the operating room, Laura the OR nurse asks Brendan if the patient has signed a HIPPA authorization form. Brendan says he’s unsure and cannot find the form in John’s chart. Brendan is aware that all patients in the hospital are asked to complete a HIPPA form prior to receiving treatment. The surgery goes uneventfully and Brendan takes John to the anesthesia recovery room. On exiting the PACU, Brendan runs into John’s girlfriend, Amanda, and John’s clergyman, Father Bob. They ask how John is doing. Brendan answers that John is OK and should be discharged from the hospital later in the day. He also informs them about John’s potential tuberculosis diagnosis since they may have been exposed to that disease.

7. Scenario # 2, Questions for Discussion? 1. Was Brendan in violation of HIPAA rules when he proceeded to administer an anesthetic to John and allowed the surgery to proceed while knowing there was no signed HIPAA authorization? 2. Did Brendan violate HIPAA rules by sharing personal health information about John to Amanda and Father Bob? 3. As a clergyman, was Father Bob entitled to the information about John’s health status in order to better prepare to administer the last rites should the need have arisen? What if Father Bob was, instead, a policeman? 4. Is Amanda entitled to John’s health information given that she is John’s significant other and they were expecting to soon get married? 5. What government agency/office is responsible for oversight of HIPAA rules? Note: The acronym is HIPAA, not HIPPA

8. Scenario #3, Safety Requirements: Henry and Andy are both CRNAs working in a recently opened ambulatory care facility run by the Lottabucks anesthesiology group where they will be involved primarily in administering sedation and anesthesia for colonoscopies and similar procedures. Henry is an experienced old-timer who has worked for this same anesthesia group for seven years. Andy is a recent CRNA graduate from a DNP academic program that Henry views as a “finishing school for “nursey” types who have lots of “book knowledge” but not much practical ability. The facility has just acquired a new Sedasyst machine that automatically provides patients with minimal to moderate sedation based on “feedback” from the attached monitors. It is cutting edge technology. Because the machines are new, it was felt that CRNAs should monitor their function during the “break-in” period. While Andy used a similar machine twice while in his training program, Henry had never even heard of them and he regarded the machines as “claptrap equipment that will drive me to an early retirement—before I earn my millions.”

9. On the first day of use, Andy is monitoring the machine and patient when an alarm begins to beep. Not quite sure what to do, Andy calls for Henry’s assistance, figuring he would be able to deal with the problem. When Henry arrives, he looks the situation over, finds what he believes is the alarm button and shuts it off. He is unsure, however, as to whether he has fixed the problem. Ten minutes later, the patient becomes slightly cyanotic, starts “bucking” and vomits up green bile during the middle of the surgical procedure. Others rush to help, suction the patient, let him awaken and safely transport him to the PACU for further monitoring and evaluation. Henry then tells Andy not to mention to the clinic’s administration that it was he who had shut off the alarm. Andy responds that, when in school, he had been instructed to report equipment failures and problems to the FDA (Food and Drug Administration) and the manufacturer.

10. Scenario #3, Questions for Discussion: 1. How could the patient’s situation been avoided? 2. Should Henry have been prevented from shutting off the machine alarm? 3. Should Andy have been allowed to monitor the machine function given his limited anesthesia experience and prior exposure to using the Sedasyst? Should Henry not have been allowed to monitor a Sedasyst machine? 4. Where any rules or regulations violated in this incident? 5. Should this incident be reported to either the FDA or manufacturer, or both?

11. Scenario #4, Non-HIPAA Confidentiality (Ethics): Bruce Bigelow, a distant cousin of the President of the United States, is an interventional radiologist at a major mid-West medical center. He is also a candidate for Congress for the Tea Party. While on-call one evening, he is called to the Emergency Room to evaluate a trauma patient injured in an automobile accident. The patient’s injuries are unusual and fascinating to Dr. Bigelow. He whips out his smart phone and takes several pictures of the patient (taking care to not include the patient’s face). Shortly thereafter, the patient dies without being operated on.

12. Later that evening, Dr. Bigelow posts the photos he took of the patient to his Facebook account, adding verbal derogatory comments about the patient. The photos “go viral” and local newspaper reporters flock to Dr. Bigelow’s office to get his comments. Noted reporter, Clark Kent, pointedly asks Dr. Bigelow why he is taking pictures of dead people. Dr. Bigelow answers that: (1) the patient was not yet dead when the photos were taken, and (2) the photos were taken for legitimate medical purposes, including Dr. Bigelow’s teaching of radiology residents. Also, he says, the photos were legally uploaded to public social media. Reporter Kent feels the pictures taken by Dr. Bigelow violated good taste, common sense, and ethical requirements. Seeking validation of his position, he consults with a noted Ethics professor who lives nearby, Carl Jung. Professor Jung calls Dr. Bigelow’s photos “grim, and a violation of the dignity and privacy of the accident victim.” Tea party members and others begin an investigation into Dr. Bigelow’s actions.

13. Scenario #4, Questions for Discussion: 1. Did Dr. Bigelow violate the accident victim’s privacy before he died? After he had died? 2. Were Dr. Bigelow’s actions justifiable as medically necessary or expedient? 3. Does the accident victim’s family have a legal cause of action against Dr. Bigelow? Against the Tea Party? 4. If the photos had been kept by Dr. Bigelow for his own use without publishing them on Facebook, would not that have maintained the victim’s privacy and confidentiality? 5. Would you vote for Dr. Bigelow for Congress?

14. Scenario #5, Emergency Services: Tom Macy, CRNA provides anesthesia services at Goodworks hospital, a medium size community hospital. He lives nearby in a small apartment approximately one-half mile from the hospital. To save money, he walks to and from work. One day, after leaving work, he sees a commotion on the sidewalk about one block from the hospital. As he approaches, he sees a policeman whom he recognizes as Officer Ness, the patrolman who usually walks this beat. Officer Ness knows Tom and is aware that he is a CRNA who is regarded as a very capable provider of anesthesia and resuscitative care. As Tom arrives, he notes that an elderly gentleman has collapsed onto the sidewalk and is obviously have considerable difficulty breathing. The man is pale and clutching his chest.

15. As Tom is about to walk past, Officer Ness calls to him and asks Tom to render care to the gentleman, telling Tom that he thinks the man may be having a heart attack. Tom declines, saying that he is in a hurry to get home and feed his two cats. Besides, says Tom, “I have no professional connection to this man.” This comment riles Officer Ness who then orders Tom to help, saying he will arrest Tom if he doesn’t help. With this pressure, Tom begins to care for the man, noting that there is little he can do since he has no equipment or assistance. A few minutes later, an ambulance called by Officer Ness arrives and the patient is transported to the hospital for additional care in the Emergency Room.

16. As Tom is about to walk past, Officer Ness calls to him and asks Tom to render care to the gentleman, telling Tom that he thinks the man may be having a heart attack. Tom declines, saying that he is in a hurry to get home and feed his two cats. Besides, says Tom, “I have no professional connection to this man.” This comment riles Officer Ness who then orders Tom to help, saying he will arrest Tom if he doesn’t help. With this pressure, Tom begins to care for the man, noting that there is little he can do since he has no equipment or assistance. A few minutes later, an ambulance called by Officer Ness arrives and the patient is transported to the hospital for additional care in the Emergency Room.

17. Scenario #5, Questions for Discussion: 1. Did Tom have an obligation to care for the man when there was no professional relationship between the two? 2. Was it legally permissible for Officer Ness to threaten Tom with arrest if he continued to refuse to help? 3. If the man had died, either on the sidewalk or in the ER, could Tom have been held liable? 4. Was it right for Tom to refuse the policeman’s request for assistance when there was little that Tom could do without appropriate equipment or additional assistance? 5. If, when he first noticed the commotion on the sidewalk, Tom had turned and walked in another direction to avoid the man and the policeman, would he have been in violation of any legal or ethical code?