Thursday, January 15, 2009

Incompetent Indian doctor kills woman in NHS hospital

A doctor killed a patient being treated for an infected bunion by injecting her with adrenaline against the advice of colleagues, a court heard yesterday. Priya Ramnath ignored two doctors' and a nursing sister's express instructions and failed to speak to a consultant anaesthetist before administering the fatal dose to 51-year-old Patricia Leighton in 1998, a jury was told. Mother-of-two Ramnath moved to America soon after. She denies the manslaughter of Mrs Leighton by gross negligence.

Ramnath, now 40, was working as a registrar in the intensive therapy unit at Stafford District General Hospital where Mrs Leighton was being treated for septic shock from the infection on her left foot. Ramnath, who was on a seven-week placement at the hospital, became concerned about Mrs Leighton's weak pulse and low blood pressure. She says she thought adrenaline was necessary because she believed the patient was about to go into cardiac arrest, the court heard.

Her colleagues advised her not to use adrenaline as they believed Mrs Leighton's condition could have been controlled without it. But Ramnath gave her a 3ml injection of it, Birmingham Crown Court was told. Prosecutor Michael Burrows QC, said: 'The effects of adrenaline are unpredictable and can be fatal. In the case of Mrs Leighton, they were fatal. 'Within moments of the injection, Mrs Leighton jerked forward and sat bolt upright in her bed. She shouted out "What's happening to me? I am going to die".' Mrs Leighton, of Burntwood, Staffordshire, then lost consciousness, her heart stopped and she died despite attempts to resucitate her.

Mr Burrows said: 'Mrs Leighton was not in cardiac arrest, the injection of a bolus of adrenaline was not necessary and should not have been given. 'She owed Mrs Leighton a duty of care, that duty was breached by giving her the adrenaline. There was no clinical indication that such treatment was necessary.' Mr Burrows said the Crown would call an expert witness who believed that Ramnath's alleged decision to ignore advice was arrogant and reckless.

He added that when writing up her notes Ramnath said she injected the adrenaline after Mrs Leighton went into cardiac arrest. He said: 'When someone does something wrong they may seek to conceal what they have done wrong. 'This is a case where you will have to consider whether Dr Ramnath sought to conceal what she has done and whether others helped her.'

Ramnath handed in her resignation less than a week after Mrs Leighton's death stating she had been planning to move to the US with her husband. Mr Burrows told the jury: 'You will have to consider whether she fled the country in order to hinder or escape the investigation into Mrs Leighton's death.' Ramnath, whose address cannot be published for legal reasons, came back to Britain in February last year after dropping her opposition to extradition proceedings.


Britain worse off for hospital beds than Macedonia

The provision of hospital beds in Britain has plunged in the past eight years to one of the lowest levels in Europe. The number of beds per person has dropped 14 per cent since 2000 - to below the rate for Latvia, Estonia and Macedonia. The UK has only 389 hospital beds per 100,000 inhabitants, even when taking into account both private and NHS beds. This is well below the EU average of 590 beds per 100,000 inhabitants.

The UK is ranked 25th out of 32 European countries. Only Cyprus, Portugal, Denmark, Spain, Sweden, Turkey and Malta perform worse. In 2000/01 the NHS had 186,091 beds, falling to 160,297 in 2007/08. Maternity beds have almost halved in number in some parts of the UK. In 2000/01 the NHS had 186,091 beds, falling to 160,297 in 2007/08. Maternity beds have almost halved in number in some parts of the UK.

Tory health spokesman Andrew Lansley, who obtained the figures from the European Commission, said: 'The objective of the NHS is to deliver world-class healthcare, not to maintain a certain number of hospital beds. 'It is madness to cut beds when wards are overcrowded, there aren't enough isolation rooms to control hospital infections and patients are still in mixed-sex accommodation. 'In 2000 Labour said that bed numbers needed to increase but these figures demonstrate again how badly they have failed.'

Health Minister Ben Bradshaw said: 'Given that the Conservatives are pledged to cut NHS funding, we await with interest a commitment by Andrew Lansley to increase expenditure on this or any other aspect of the work of the NHS that he frequently criticises.'

A Department of Health spokesman said: 'Bed numbers have fallen because people are being treated much more quickly - spending less time in hospital - and for many conditions medical advances mean they do not need to go to hospital at all. 'Detailed analysis of the past three years' MRSA and bed occupancy rates has shown no correlation between the two.'


US Surgeon Shortage Pushes Hospitals to Hire Temps

With miserly Medicare payments being a big part of the problem

When someone doubles over from stomach pain, the general surgeon is the one who performs an appendectomy. Gallstones? The general surgeon removes the gallbladder. Breast and colon tumors and hernias are also matters for the surgeon's scalpel. Now the economic and cultural forces reshaping U.S. medicine are prompting an exodus from this once venerable field, creating a growing market for temporary surgeons-for-hire.

As a general surgeon in her hometown of Franklin, Tenn., Jennifer Peppers could no longer keep her practice going after eight years in business. Faced with rising overhead costs and declines in reimbursements, she and her partners stopped drawing salaries last winter. To pay her home mortgage, Dr. Peppers had to borrow from a credit line.

So the surgeons shuttered their practice, and Dr. Peppers, 42 years old, hit the road. Her typical month might now include a weekend in Springfield, Ore., removing ruptured spleens or repairing obstructed bowels, followed by two weeks at a rural Kentucky or New Hampshire hospital. Though she misses her husband, she earns double her old salary and has paid off a big chunk of her medical-school debt. "I'd much prefer to be in my hospital in my little town," says Dr. Peppers, who is now licensed in five states. "But I don't see how that's possible."

The shift toward temporary assignments comes as the traditional way of practicing general surgery is fading in many parts of the country. For decades, general surgeons have been the backbone and economic engine of the community hospital. While maintaining their own private practices, they staff trauma and critical-care units and perform most common abdominal procedures. Without them, hospitals couldn't provide many emergency-room services. In rural areas, their backup is necessary for everything from complicated births to inserting chest tubes.

But the increasingly grueling schedules, shrinking payments and the temptation of more profitable surgical niches have made the field less attractive. Over the past 25 years, the number of general surgeons per capita has declined 25%, according to a study published in the Archives of Surgery earlier this year. Other specialties are also seeing shortages as their ranks grow more slowly than the overall population, but the decline in general surgery is steeper than most. And while the number of physicians overall isn't in decline, general surgery is one of the few fields where the absolute number of surgeons is actually shrinking.

It's possible that the implosion of Wall Street will rekindle an interest in medicine as a career, but future medical-school graduates could continue to flock to specialties that pay more than general surgery. Nearly three-quarters of surgeons-in-training already are opting for lucrative subspecialties with more predictable hours, such as cardiovascular surgery and neurosurgery, the American College of Surgeons says. That's left community hospitals around the U.S. struggling to provide some of their most basic services.

Some are turning to temporary physicians to fill the void. General surgery is now among the fastest-growing areas of a temporary-medical-staffing industry that's expected to double to $2.1 billion in 2009 from five years ago, according to, a staffing agency. The company, which takes its name from the Latin phrase meaning "to stand in another's place," matches hospitals with what the medical field calls locum tenens doctors. Rising demand for these services, in turn, is prompting more of the remaining general surgeons to choose a life on the road and in hotels.

Staffing agencies estimate that at least 1 in 20 of America's 17,000 general surgeons now work on a temporary basis some or all of the time. Full-time temporary surgeons can earn $250,000 or more a year, in some cases nearly twice as much as in private practice. That's largely because they don't have to pay overhead costs anymore.

Critics of the practice worry that it carries potential safety risks. A new surgeon arriving in town may not be familiar with a hospital's staff, for example, or with surgical patients coming in for follow-up visits. "That continuity of care in surgical diseases is really important," says Phillip Burns, chairman of the University of Tennessee's surgical department. As the one who performs the surgery, "you are the best one to handle [any problems] because you were the one inside."

Some who've switched to temporary work say patients often fare better with a surgeon who can focus entirely on providing care instead of the administrative hassles of a private practice. "I don't pay a penny of overhead now and I feel better than I have in years," says Kenneth Lawson, 55. Dr. Lawson left his practice in Roseburg, Ore., in 2005 to travel as a temporary surgeon.

While in private practice, Dr. Lawson says he would often spend five nights in a row on call, "bleary eyed," performing emergency surgeries. Increasingly, he says, these patients had no insurance. Hospitals typically have the means to pursue debts from patients or write the losses off as charity care, but doctors don't always have the manpower to collect on their portion of the bill. "We got to the point we wouldn't waste a stamp trying to get that money," says Dr. Lawson.

Locum tenens isn't a bargain for hospitals or a health-care system that is already the world's costliest and accounts for nearly 17% of the U.S. economy, according to federal government data. A temporary surgeon who comes in to perform scheduled procedures and emergency operations can cost a hospital about $1,500 a day -- between $650 and $900 for the physician and about the same for the staffing agency, according to Staff Care, a temporary-medical-placement firm. That's in addition to travel and lodging expenses. In traditional practice, hospitals don't pay surgeons directly: They give them "privileges" to use their operating rooms in exchange for sharing in emergency-call duty.

Yet, without the ability to perform surgeries, "we lose the business," says Karen Hendren, chief operating officer of Stillwater Medical Center in Oklahoma. The hospital plans to hire temporary surgeons this spring, when one of its three local general surgeons leaves. Ms. Hendren is bracing for a hit to the bottom line. In 2007, it cost the hospital $1.2 million to cover the departure of a few anesthesiologists by hiring temporary replacements, contributing to a $4 million drop in operating income. Hiring temporary doctors adds "a lot of cost to the health-care system, and it's almost certainly going to get worse," says Richard Reynolds, president of MidMichigan Health, which operates four hospitals in the heart of the state. He estimates it costs the company twice as much to hire a temporary doctor than a permanent one. MidMichigan tries to pass on some of these costs in contract negotiations with insurers, says Mr. Reynolds, but it doesn't always succeed.

Steven Bengelsdorf, a 41-year-old doctor from Nashville, formed his own group of temporary surgeons to contract directly with hospitals so they avoid the extra cost of a staffing agency. Spending days or a week at a time away from his wife and three children is tough, Dr. Bengelsdorf says, but, "when I'm home, I'm home. I can participate in their lives and take them to birthday parties." If he were in traditional practice working 12- to 14-hour days, he adds, "I wouldn't get to see my kids."

The American College of Surgeons has long condemned the practice of "itinerant surgery," where doctors operate on patients and leave follow-up care to a family physician. But it has refrained from issuing guidelines on locum tenens. Paul Collicott, a director of the ACS, says it's "a necessary part of surgical practice today," given the overall shortage in the field. He says it's the responsibility of each temporary surgeon to make sure patients are handed off to another surgeon for postoperative care. The ACS also advises doctors who primarily work in urban hospitals, where the work is more specialized, not to do stints in small, rural hospitals, where they typically need to be jacks-of-all-trades.

In 2007, Marlene Tymchuk of Reedsport, Ore., learned she needed a large pool of blood called a hematoma removed from her groin. The hospital in her small coastal town was staffed by a temporary surgeon; the nearest hospital with a full-time surgeon was 45 minutes away. "I talked it over with my family," she says, debating whether it would be smarter to go to the bigger hospital and have consistent care. She decided to stay in Reedsport, in the hospital she knew well and near her family doctor. Though she saw another surgeon for her follow-up care, she says it felt better to be close to home.

Temporary surgeons used to be mostly older physicians who wanted a lighter workload, or those fresh out of training, still deciding where to put down roots. But today, more are midcareer people like Dr. Peppers, who had originally mapped out a more traditional path. Born in the same Franklin hospital she later operated in, she knew by age 10 she wanted to be a surgeon. She told her future husband -- a childhood friend -- she wanted to marry him so she could take his name and be "Dr. Peppers." After medical school, residency and a fellowship in laparoscopic surgery, she came back to her hometown to practice in 2000, saddled with $250,000 in debt. Paying it back turned out to be harder than she thought.

While Dr. Peppers was in training during the 1990s, the federal Medicare program was cutting back what it pays surgeons for many common procedures. For instance, in 2008, Medicare paid a general surgeon $562 for an appendectomy, compared with $580 in 1997. For a complex hemorrhoid removal, a general surgeon got $390 in 2008, compared with $574 in 1997. Private insurers followed suit.

Meanwhile, higher-priced procedures increasingly fell under the purview of more specialized fields. And, reflecting a steady rise in the number of uninsured and underinsured Americans, more of the patients whom surgeons would operate on in the emergency room had limited means to pay for treatment.

By 2007, Dr. Peppers says, she was making roughly $135,000 annually and her practice was struggling to pay its overhead and malpractice insurance. Since shuttering her practice last spring and becoming a full-time surgeon-for-hire, Dr. Peppers says she's earned enough money to whittle her medical-school debt to below $100,000. For the first time, she adds, she can focus exclusively on surgery and patients. "When I had a practice, it was like running a small business," she says. "It's like a huge weight has been lifted."

Dr. Peppers says she is careful to take assignments where she knows the surgeon she'll be handing cases off to and often follows up with a phone call. "I'm very conscientious about telling the patient, 'I'm here until 7 o'clock Monday morning. If there are any problems, after that you need to talk to Dr. so-and-so,'" she says. "I put a lot of responsibility onto patients."


No comments: