The Internet book, "Force Majeure in Surgery" released with an international book mark - LAP LAMBERT Academic Publishing (Germany), 2018, attracted the interest of even people far from medicine, not because it reflects purely medical issues in the practice of doctors, but also raise, if not strange, other topical issues related to another sphere of human activity and acting in the form of a complex tangle of this causal relationship. The material is systematized and studied for the first time from the standpoint of other humanitarian disciplines (psychosocial and issues of jurisprudence, ethics of deontology). This required a philosophical understanding, an assessment from the point of view of epistemology. This article contains excerpts from the book "Force Majeure in Surgery". The originality of the observations of the above-mentioned book is that, from somewhere, not by chance, completely different phenomena are revealed, which are intertwined in the context of medical issues. But this is not all, the most interesting thing is that with the search for diagnostics, questions of jurisprudence or socio-psychological problems emerge, which are somehow caused by each other. Especially, in their genesis, some act as the main subject of search, while the other creates an accompanying background to the first. Sometimes, in this "bundle" of causation, the doctor himself is captured with his desire to treat the patient, although his latent psychosomatic state does not allow him to adequately fulfill his holy mission. Errors are allowed. Sometimes the patient himself is disoriented by the diagnostic line of thought. In the end, on their basis, the question arises where it is necessary to understand from the standpoint of the epistemological discipline of philosophy.
Force majeure in surgery, situational diagnostics, epistemology, diagnostic circumstance in matters of jurisprudence, psycho-sociology in medical practice, ethics, deontology. Errors in surgery, government officials in the patient-doctor relationship
Prophylactic appendectomy
In the friendly team of the surgical department of one of the regional hospitals, a celebration has been outlined, which they decided to celebrate in a picturesque corner of the district. Everyone went there, except for the emergency brigade. They naturally remained in the department with great sorrow, which, unfortunately, did not participate in this significant celebration. But they were determined to get there by any means as far as possible, completing their work. And suddenly 2 patients with acute appendicitis come in a row. The surgeon quickly performed both operations and sighed with relief and thought that the time was not far away when he would join the merry gang. I was just about to take off my operating clothes and suddenly a nurse from the preoperative room knocks on the window and shows her index finger, saying that there is another operation and expressively showing that after that – "go Vasya". She made this gesture so expressively, the surgeon was already amused that the old excitement took possession of new forces. "The third appendicitis" is completed with the same speed. Now you can "guln", saying, the surgeon was about to take off his robe. Suddenly the patient on the operating table in a trembling voice says: - "Doctor, will you excise my lipoma on the skin?" The surgeon, in the heat of the upcoming celebration, did not ask - what is the diagnosis? So, this time it was not necessary to "hang out" in full with fun. For the deed done, the answer had to be kept oh - oh - oh. Simple explanation: The surgeon's emotion completely clouded the doctor's mind. No wonder they say: the surgeon's knife should be controlled by the surgeon's head. Not an obsession with the surgeon: this is a symptom that will entail professional trouble. Consultation of the relevant specialists is required to the surgeon himself. [1, 2, 4, 6].
"Stepping on a rake" or risk of involuntary
To a familiar dentist, a patient complained of unbearable pain in his teeth. He did not sleep with this problem for two days. The doctor carefully examined, diagnosed and explained to a friend-patient that the tooth, unfortunately, cannot be treated, it is necessary to remove it. Such a verdict was accepted with pleasure, demanded an immediate procedure even "without anesthesia." "This does not happen in modern medicine," the doctor muttered and took up anesthesia. After he made a conduction block, the patient had an instant picture of an anaphylactic reaction to novocaine. Appropriate therapy was urgently carried out. The patient regained consciousness in 2-3 minutes. The medical staff got scared. Fortunately, the allergic reaction went away literally in 10-15 minutes without consequences. After this alarming procedure, the intensity of the pain in the aching tooth became even greater. The client began to demand the removal of a diseased tooth by any means. The nurse took another anesthetic drug (Lidocaine), from which there were practically no complications, into a syringe and put it on the doctor's table. Now the doctor began to inject the drug more carefully into the right place. And suddenly the same reaction as the previous one. More pronounced this time than the first. The doctor dropped his hands, was in despair. Let’s repeat the same anti-shock measures again, thank God, it didn’t come to a serious complication. The question is what is the matter: it turned out that the doctor confused the syringe and injected the same novocaine in the first syringe. After all, the syringes were the same, and they lay side by side. As the saying goes, "here's a rake." However, the patient's intrusive demand is met by the target on the third risky attempt. The doctor should always be careful, such negligence could cost the patient's life. Situational statement: 1. An attempt to provide medical assistance. 2. A sudden allergic reaction from an anesthetic drug (novocaine) from which the dentist lost his composure 3. There was a second anaphylactic reaction against the background of the first, as a result of an erroneous repetition of the injection of the same novocaine. It turns out that the doctor, in fear, confused the syringe with another anesthetic. The situation was brought about by the doctor's hysteria. Fortunately, the threatening condition has been eliminated. At the patient's insistence, the doctor's risky ordeal continued and achieved the desired success, fortunately. Yes, the doctor is not young, it is highly undesirable to follow the patient's lead, as we have seen. Here we must not forget about the categorical insistence of the patient, even in this critical condition. Comments: Unfortunately, the ending could have ended in death from anaphylactic shock. This happens, while the quality of the medicine cannot be fully monitored. The doctor was losing his composure. Panic. In this situation, a positive thought is not expected. For information, a very frightening anaphylactic reaction can be cited: Lyell's syndrome of an allergic nature. The chances of this fulminant disease are 30% of those affected. The risk in medical practice, in general, is absolutely nonsense. Is it really possible in our new century to change something in the training of surgeons, changing teaching methods, and with this to improve the quality of Aesculapius? [5].
Unprofessional interference from high-ranking officials
The girl, 14 years old, was delivered to the surgical department at 23 o'clock. An hour and a half ago, dancing barefoot on the carpet, I felt a stabbing pain in my foot. On the roentgenogram, between the 1st and 2nd metatarsal bones of the right foot, the shadow of a gramophone needle was found.
The surgical team was busy performing urgent abdominal operations, and the surgeon in charge decided to hospitalize the patient and operate on her in the morning under fluoroscopic control. At 3 am the phone rang. The secretary of the regional committee, who turned out to be a friend of the girl's parents, demanded that the operation be performed immediately. [6].
The surgeon on duty, having completed the next operation, at 5 o'clock in the morning took the patient to the operating table, cut the skin over the supposed localization of the foreign body and did not find the needle. The operation was supposed to continue in the X-ray room. Introducing the patient in the morning to the head of the department, the surgeon on duty turned pale and barely audibly said: "This is not that leg!" The morning shift removed the needle and the girl was safely discharged.
The surgeon was taken to the intensive care unit a day later with myocardial infarction. A criminal case was opened against him, which did not reach the court, since the investigator proved that the medical error was committed due to overwork during the 19th hour of continuous work. The surgeon recovered, but did not return to his profession.
The intervention of the "big boss" ended up with a myocardial infarction of the surgeon with subsequent dismissal. [3,4].
Unreasonable insult
The chief doctor of the regional hospital, he and the chief surgeon of the region, perfidiously entered a woman, the wife of a high-ranking government official, and expresses her complaint with such indignation. She brought her daughter, a schoolgirl, to the surgeon's appointment with vague complaints of abdominal pain. The daughter was examined by an experienced admission doctor and an ultrasound examination was recommended for an ectopic pregnancy. Then the mother threw a tantrum, insulted the doctor. How can you think of this about a ninth-grader and be caught in such nonsense. The chief physician reassured the woman, examined the girl and suggested an emergency operation, which was performed. During the revision of the abdominal organs, it was established that the doctor of the admission department was right … [6].
On coronavirus
Fresh example. The XXI century did not have time to begin The world is shuddering, and is concerned about the coronavirus-19 pandemic. Yes, history knows what a pandemic of viral-infectious etiology of microorganisms is, which claimed the lives of hundreds of thousands of people. At present, no one knew, the dormant known COVID-19 would take such a turn. People are shocked that there is no effective treatment for this infection. How to survive? Doctors realized that individual self-isolation from crowds, avoiding contacts, simply wearing an individual protective mask, as well as observing other non-burdensome protective measures, it is quite possible to protect yourself and your loved ones. All over the world, starting with the heads of state and doctors, every day, if not hourly, the population was informed by the available mass media about the dynamics and statistics of the disease. To our deep regret, simple security measures were not followed, despite the intensified and convincingly visual notification of specialists. Accordingly, the results were very deplorable. As for the criminal silence, I give examples. In one and the other cases, in the family of two officials, of a fairly high rank, they had a party and from where they contracted the disease. The source was the wives of officials who had traveled to countries where the outbreak had just begun. The family members knew about this information, they invited guests in honor of the pilgrimage of the holy places. What a luxury. Such a stupid tendency exists in our area. As a result, some of the invited guests of the officials became infected. Most importantly, on the initiative of their husbands, officials, they deliberately participated and concealed, making an "anti-popular criminal deal" by making it secret. But they themselves were treated incognito. Fortunately, the focus was somehow eliminated by the efforts of doctors. Here is the other side of the medal of the elites respected by "us".
The ethical component is one of the central ones in creating a rational model of public service. The regulation of the official behavior of officials at the moral and value level and the cruel control over their observance of high ethical standards is a necessary condition for a real improvement in the quality of public administration as a whole, as a result, an increase in the level of public trust in relation to it, which can be dreamed of by ordinary citizens, unfortunately. Obolonsky A.V. Ethics and responsibility. E-mail abolonsky@hse.ru
In practical medicine, there are mostly kind and good sayings about surgeons. What we have demonstrated are the same errors, but they have their own peculiarities, i.e. here they focus on the humanitarian problem of both the patient himself and his doctor. It is not competent to draw conclusions about the "chairmen" from our own bell tower, for this there is a supervisory body and, unfortunately, it is difficult to prove, but we will hide it with pain in our heart. To do this, I cite separate opinions on this topic, from published works in the media. For example, in one author's article it is noted, “… today, we can confidently say that 80% of the country's population has deep disrespect for the authorities. Ludicrous laws and restrictions for the entire population of the country have already become the norm and it is very difficult to change this order of things. On the Top-life TV channel he writes: For officials, the law is not written: in this regard, everything can do whatever comes to mind! Laws for the people. The only hope is for good officials who are able (from a tightening) to correct or correct "bad laws" into "good" ones.
To prosecute an official for violation of the rights and freedoms of a citizen in medical practice, as recognized by the lawyers themselves, is a complex and difficult issue. Well, this is when there is or is there anything criminally proving the relationship between patients and doctors in the provision of medical care. And when the main argument of motivation is the doctor's resentment, the violation of moral ethical standards is not tolerated, we are usually accustomed to seeing from the side of the doctor, but if it is not strange from the side of the patient's close people, what to do? It's easier for ordinary citizens, you can freely say what you think, if you are still brave. And if you run into the clerk, like in our example, you will remain silent, although cats scratch at heart. Your silent experiences, heart attacks and strokes only lead you to the grave ahead of schedule.
At our discretion, one conclusion follows from this: both doctors and officials who work for the good of the people are not young people, experienced responsible ones and they intend to avoid such mistakes in their work, this is unambiguous. From their student days, they know the corresponding strict instructions, rules, even codes, while when a question concerns their own interests, at that moment, these postulates are forgotten, unfortunately. Here its own pragmatism seems to prevail! Individual psychology: self-preservation, self-respect? How to be?
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6. Ludupova E.Yu. Medical errors. Literary review / E.Yu. Ludupova P. 2-3.
7. Toktomushev A.T. Force majeure in surgery. LAP LAMBERT/ Internation Book Market Service Ltd., member of OmniScriptium Publishing Group.2018. P.
