I DID MY BEST FOR MY PATIENT
I am writing this letter in response to the article "Critical Condition" by Kara Platoni in your January 16 issue.
Margaret Utterback died six years ago at 74 years of age following surgery for a ruptured abdominal aortic aneurysm, but her spirit lives on as a major legal battle between the California government and Kaiser Permanente. Her three daughters have provoked this battle by using every legal, administrative, and media channel available to promote the idea that Mrs. Utterback's death was due to mistreatment by Kaiser Permanente in general and me in particular. This is simply untrue.
Mrs. Utterback had been a Kaiser member for fifty years, and had used the Kaiser Hayward ER as well as the various clinics. On the day she developed abdominal pain, she decided to see me in the internal medicine clinic, where patients are seen by appointment. When informed that all appointments with me were taken, she nevertheless insisted on seeing me -- personally -- that day. I agreed to add her to my schedule, inevitably inconveniencing the other twenty-four patients I saw that day. I warned her there might be delays. I did not, as alleged, prescribe her a narcotic over the phone.
Mrs. Utterback walked into my exam room within twenty minutes of the appointed time. I diagnosed her, made arrangements for ambulance transport to the hospital, alerted the emergency and surgical staff to her case, and informed her and her daughter of the need for urgent surgical consultation and probable emergency surgery for a life-threatening condition. She arrived in the ER with stable vital signs, and was taken promptly to the Operating Room. There she had the typically arduous six-hour operation to replace her diseased aorta. But, with the help of transfused blood products, she emerged stable from the OR. The following day she needed the expected ICU care, including ventilator and blood pressure support, but was alert and responsive to her family. That night, apparently discouraged by her critical illness and guarded prognosis for recovery, Mrs. Utterback, in consultation with her family, exercised her right to refuse further care. Her medications were discontinued, she was given morphine for comfort, and she died.
Patients' Rights has been a rallying cry as we move away from a paternalistic medical system. Mrs. Utterback exercised her rights under the Kaiser system by insisting on seeing me instead of going to the emergency room. She and her family exercised her rights further in refusing further ICU care. Unfortunately, exercising your rights does not ensure a good outcome, but does make you responsible for that outcome. That can be hard for a person, or a person's survivors, to live with.
The Department of Managed Care investigated this case and levied a fine against Kaiser without once approaching me, who had figured prominently in their accusation. Their complaints focus on what I did not do, rather than what I did, which was to succeed in getting Mrs. Utterback from my medical office to the operating room two miles away, in stable enough condition for immediate surgery. But to address the technical issues: 1. The IV equipment in our office was too small to be useful to Mrs. Utterback in transfer. I was concerned that starting an IV in our office would only delay her transfer. I did not order an IV. 2. Though Mrs. Utterback was uncomfortable in our office, her vital signs were stable. Pain or blood pressure medications might easily have destabilized her in a catastrophic way. I withheld these medications pending safe transfer to the hospital. 3. Transporting Mrs. Utterback to the hospital by private car, as she had been transported to my office, would have been the quickest way there. As the only realistic hope of saving her life lay not with treatment in an ambulance, but with getting her to an operating room, it was my duty to offer to her daughter the possibility of saving her mother's life by driving her immediately to the hospital. Her daughter clearly did not want to shoulder this responsibility, so we waited for the ambulance, which arrived promptly.
The Department of Managed Care's questions to me when they recently did require me to testify revolved around whether, in treating Mrs. Utterback, I was following written procedures. The answer is no: I was drawing on my then-twenty years of practice experience (residency, private practice, and Kaiser), my human and medical instincts, and common sense to try to save my patient's life. Before Mrs. Utterback, and since, people have walked into my office with these conditions and more: ruptured cerebral aneurysm, acute pulmonary embolism, acute myocardial infarction, perforated duodenal ulcer, malignant ventricular tachycardia, acute pulmonary edema, septic shock. These people are alive today not because I got out my rulebook, but because I responded immediately to their situation the best way I could. The real issue at stake in the current litigation between the state and Kaiser is whether medical care will be rigidly circumscribed by government regulation, or whether patients will continue to be able to expect their doctors to combine medical knowledge with experience, instincts and common sense in trying to help them.
I assume Mrs. Utterback chose to see me on this critical day because she thought I would do my best for her, and I did. It's hard for me to imagine that she would want me to be harried in the press for years after the Medical Quality Board rejected her family's attempts to have my license revoked and end my career. It's hard to imagine that she would want medical care at Kaiser strangled by rigid regulations and procedures imposed by a State bureaucracy. May she rest in peace.
Rod Perry, MD, Oakland
Last week, we reported the assertion of Oakland mayoral candidate Wilson Riles Jr. that San Francisco Chronicle Executive Editor Phil Bronstein and reporter Rick Delvecchio attended his endorsement interview. Chronicle representatives say neither man was at the meeting. Bronstein and another Chronicle editor did not return our phone calls last week.
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