Daily Quandaries of Medical Law Counsel Joseph A. Procaccino Jr.

1. TYPICAL DAILY QUANDARIES IN THE LIFE OF A MEDICAL LAW COUNSEL JOSEPH A. PROCACCINO, JR.LEGAL ADVISOR TO THE Surgeon General , USAF&robin l. brodricksenior medical law attorney tort claims and litigation divisionAir Force legal operations agency

2. WORDS TO LIVE BY Allo sciogliere della neve si vedono gli stronzi.

3. Hospital General Counsel Issues • A patient, a 47 year old retiree who tells the Primary Care physician that he is now a pilot for a commercial airline, presents w/ recurrent headaches, transient dizziness, and infrequent lightheadedness. The physician orders further work-up and suggests that the pilot inform his employer of his condition. The patient refuses. The physician calls for guidance.

4. Hospital General Counsel Issues • An OB/GYN calls you for advice. His patient, dependent wife of an AD member , mother of 3 healthy children, previously underwent tubal ligation. She now wants it reversed so she can have a child with her new husband, the AD member. The provider can perform the procedure, but is uncomfortable ethically. He knows from family medical history the AD husband has a rare genetic condition with 50% likelihood of passing the condition on to his children. The condition causes severe neurological debilitation, arising in the late 30’s/early 40’s. AD member is 35 and asymptomatic. The OB/GYN consulted with 3 DoD colleagues and all unwilling to perform the reversal.

5. Hospital General Counsel Issues • A pediatrician treating a two-week old child believes the child is not the biological child of the AD father. The pediatrician noticed that the child’s blood type is + while the mother’s blood is Rh -, and the AD father’s Rh factor is -.  The parents are married and indicated that the AD husband is the father on the application for birth certificate.  The pediatrician wants to know if he should tell the parents that the AD husband is not the child’s father.

6. Hospital General Counsel Issues • A 30-week pregnant patient has submitted a rather demanding birth plan to her OB/GYN at an overseas base. In the plan the patient requests no IV, no continuous fetal monitoring, no eye drops administered to infant, early releases for both mother and infant (within 4 hours of delivery), and no vitamin K shot for infant. The patient also wishes for her husband to assist in the delivery, suctioning the baby once the head appears and helping the shoulders spiral out of the birth canal. She also requests that no male doctors, nurses, or attendants be present during labor.

7. Hospital General Counsel Issues • The same 30-week pregnant patient has agreed with your recommendations. However, she’s just learned that her husband has been tasked with a short-notice deployment. She requests that the birth be “broadcast” via VTC so that her husband can participate from his deployed location. She also asks that her mother be allowed to videotape the entire procedure.

8. Hospital General Counsel Issues • An 18-year old dependent is diagnosed with leukemia. Two weeks later she realizes she is pregnant. Standard chemotherapeutic agents are almost certain to cause severe fetal deformities. Standard practice is to terminate the pregnancy. There is no medical evidence that continuing the pregnancy would complicate the disease process or compromise the mother’s treatment. Abortion must be performed as an inpatient procedure. Sponsor wants the procedure done at the MTF.

9. Hospital General Counsel Issues • A 35 year old dependent wife is diagnosed with a fatal kidney disease. Despite extensive testing, no compatible donors match. Dialysis may extend her life for only up to a year. Patient is discharged from MTF. She returns to MTF 7 months later, 6 months pregnant. She presents findings from reputable medical journals where fetal kidneys have been transplanted into “born” individuals with success. As the studies indicate a high compatibility rate between parent/child, patient requests her fetus be aborted and the kidneys transplanted into her. A transplant surgeon at the MTF is willing to do the procedure. The MTF asks for advice.

10. Hospital General Counsel Issues • The Chief of Medical Services (SGH) calls for guidance prior to meeting with an ER nurse. Hospital members allege the nurse has been walking around taking notes on how staff provides care. The nurse comments (in front of patients) that standard of care is not being met. Staff is justifiably upset and believes the nurse will go public with some of the “deficiencies” she has uncovered. The SGH is also interested in his options as to any potential disciplinary action to be taken against the nurse.

11. Hospital General Counsel Issues • The 30-year old spouse of an active duty member receives all of her prenatal care at the MTF. At the 32nd week of gestation, a benign tumor was found to be partially covering her cervix. The couple was informed of the risk to the mother (and her fetus) of a spontaneous vaginal delivery. A cesarean section delivery is highly recommended. The couple refused. They insist upon a “natural birthing experience.” You are invited to the Executive Committee to discuss these concerns.

12. Hospital General Counsel Issues • An active duty member presents to sick call. It is determined the member suffers from a cancer that is highly amenable to treatment. Standard treatment typically involves temporary discomfort due to the drug’s side effects. The member refuses standard treatment options and opts for herbal tea, acupuncture, and “meditation” therapy. He claims to hold deeply held religious beliefs which support his medical judgments.

13. Hospital General Counsel Issues • The Emergency Department contacts you. An irate Active Duty member brought his 14-year old daughter to the ER. He alleges she was raped and demands we perform a gynecological exam to confirm the rape. The daughter is visibly upset and is non-compliant with her father’s demands. As it turns out, the “suspect” is the daughter’s 20-year old boyfriend.

14. Hospital General Counsel Issues • The installation has a Juvenile Misconduct Board.  This is a voluntary program for minors who get in trouble on base that keeps them out of trouble downtown.  The Base Vice-Commander runs the board and wants to be able to order certain participants to random drug testing at the MTF.  This would be done with the parent’s consent.