Being a witness: testifying in court

Maria took Anna for a drink after they had both testified. Maria had testified as an independent expert witness, while Anna had given evidence about the treatment she had rendered to the patient. Both had been asked to testify by the same lawyer. Anna complained, “What a vicious, vicious experience. That corss-examination was brutal. How dare that lawyer suggest that I was lying. You looked really cool under pressure, Maria, especially when the lawyer questioned you about your qualifications. You must have felt terribly insulted?” “Not at all” maria replied, “I fully expected that to happen. I made a special effort to be neutral and fair to both sides and that made me feel comfortable during the cross-examination.” Anna though for a while and said, “That is wher I went wrong. I was trying to help my patient and said things that I could not really defend. Next time, I''m going to do it differently.”     

Being a witness: before you appear in court

Maria was surprised to see her colleague Anna in the witness waiting room outside of the courtroom. “I’m here to testify about a patient I treated” Anna explained “and I’m nervous.” Maria said “I’m here as an expert witness, probably on the same case. I think I saw a copy of your chart. I always get nervous before testifying as well, but I always find the rehearsal helps me a lot.” “Rehearsal, what’s that?” Maria explained how, before the hearing, she had met with the lawyer, gone over the questions she would be asked, the answers she would give and the likely areas of cross-examination. “Isn’t that cheating? I thought it was improper to discuss what you are going to say in court before you got on the witness stand?” Anna asked. “Oh no, its quite usual. You just need to have your patient’s consent if you are talking about a patient you treated.” “I wish I had known that” Anna responded “I had a lot of questions I would have liked answered.”     

Recurrent bronchogenic cyst in a Jehovah's witness

A 26-year-old female practising Jehovah's witness presented with a history of recurrent respiratory infections since childhood and more recently, recurrent cardiac dysrhythmias. A large bronchogenic cyst arising beneath the carina and compressing the bronchi was felt to be responsible. The cyst was adherent to the roof of the left atrium. She initially underwent a partial excision through the standard approach of left thoracotomy. Complete resection via this route was hazardous with real danger of laceration of the atrial wall. Repeat surgery was performed on cardiopulmonary bypass 3 years later for recurrence of symptoms. Complete excision was achieved.     

Medical negligence in coloproctology

There has been a significant increase of litigation in the UK in recent years and for this reason it is appropriate to analyse the reasons for civil litigation. Alleged medical negligence in the colorectal field comes from the activity of general surgeons and gynaecologists as well as colorectal surgeons. This communication deals with problems in the coloproctology area irrespective of the surgeon involved.
Two hundred and forty-five cases are reviewed, consisting of 49 anal problems, 160 abdominal problems with 24 laparoscopic and 12 colonoscopic injuries. Thirty-two of 49 anal cases had incontinence and these were often difficult to defend, especially the 20 cases due to childbirth injury because of poor documentation. The abdominal problems were due to delay or complications of surgery. The cases based on delay in diagnosis of cancer were often unsuccessful, but the cases of delay in diagnosis of intra-abdominal infection were difficult to defend. Problems occurring in the operative or early post-operative period produced allegations which were often justified, but the late complications of surgery were rarely due to poor standard of care.
The laparoscopic injuries included bowel perforation, bleeding and major vascular damage which were not recognized at the time. The colonoscopic cases were chiefly due to perforation, which is easily defended provided the endoscopist is experienced and the risk is recorded in the consent.
The cases have yielded a number of lessons which are discussed and compared with the American experience. It is concluded that litigation is traumatic to both plaintiff and surgeon and that better ways should be found to resolve complaints of inadequate care.     

The antigravity suit in neurosurgery

The haemodynamic responses associated with inflation of the antigravity suit (G suit, aviation type) to 8.0 kPa were studied in a series of 40 patients who underwent neurosurgical operations in the sitting position. The study showed statistically significant increases in systolic arterial pressure (p less than 0.005) and mean central venous pressure (p less than 0.001) with inflation of the suit. The systolic arterial and mean central venous pressures remained significantly elevated immediately before deflation of the suit at the end of the operation (p less than 0.001 and p less than 0.005 respectively). The addition of 0.8-1.0 kPa positive end expiratory pressure during suit inflation was also investigated. A further increase in central venous pressure occurred but this did not achieve statistical significance.     

Case report: delivery of a triplet gestation in a Jehovah's witness

Triplet pregnancies are at an increased risk for perinatal complications. Cesarean delivery is the preferred choice in most cases. In the presented case of a Jehovah's witness the special features of anaesthesiological managements are discussed.     

Lung transplantation in a Jehovah's witness. Case report in a twinning procedure

Jehovah's Witnesses, patients who refuse blood transfusions, are generally not considered as candidates for lung transplantation owing to the frequent requirement for transfusions. A successful procedure in a Jehovah's Witness is presented and to our knowledge this is the 2(nd) reported case. The patient, a 38-year-old female, type I diabetes, affected by idiopatic pulmonary fibrosis underwent left lung transplantation. From the same pulmonary bloc a twinning procedure was obtained by means of right lung transplantation in a 58-year-old man affected by the same pathology. Surgical strategies employed in achieving a successful outcome, ethical and moral aspects are discussed.     

Use of erythropoietin for bloodless surgery in a Jehovah's witness infant

We present a case of surgery in a 2-month-old infant of the Jehovah's Witness (JW) faith weighing 2.8 kg scheduled for left upper lobectomy because of congenital lobar emphysema. He presented with physiological anaemia (haematocrit 33.8%) in accordance with his age. Because of the relative emergency of surgery, a short erythropoietin course was instituted. Recombinant human erythropoietin (rHuEPO) at a dosage of 180 U x kg-1x day-1 was administered for 10 days preoperatively and for 4 days postoperatively. Iron was administered orally and intravenously over the entire perioperative period. No side-effects from either erythropoietin or intravenously administered iron were observed. To our knowledge, this is the first case published of a short perioperative rHuEPO course in an infant.     

The expert witness in malpractice suits

This survey of 1,097 Fellows resulted in usable data from 336 surgeons, of whom 129 had claims (n = 212) against them from January 1, 1984, through December 31, 1989. Risk by specialty varied greatly, but population of practice area seemed unimportant. Plaintiff expert witnesses could be identified by 28 surgeons; four of these were from medical school faculties. Defense expert witnesses were identified by 37 surgeons, 18 of whom were from university faculties. We were unable to identify any repeat "itinerant" plaintiffs' expert witnesses from this five-year period in Tennessee. It seems obvious that surgeons, even those who have been sued, pay little attention to even the identification of opposing expert witnesses.     

Being a responsible leader

People who administer organizations of various types, including medical practices, are finding it increasingly necessary to demonstrate leadership. The challenge is to understand the meaning of effective leadership and to have guiding principles with regard to its implementation. It is argued here that responsibility represents a key guiding theme that doctors and practice managers can use to chart their day-to-day actions as leaders. Responsibility implies accountability to a broad array of groups and individuals who increasingly expect that leaders act in a manner that is aligned with their interests. This new era of leader accountability raises the question, to whom and what are organizational leaders responsible? In an attempt to answer this question, The author elaborates a broad perspective of responsible leadership and address both internal and external stakeholders to which a leader is responsible. Recommendations and principles are provided for how to balance the needs and interests of various stakeholders when leading one's practice. The article ends with a consideration of important caveats with regard to responsible leadership.