$12.2 million verdict raises concern about physician training, supervision

HIV-positive occupational health physician wins suit against Yale

An occupational health physician who acquired HIV from a contaminated needlestick as an intern 10 years ago has won $12.2 million in a civil suit against Yale University in New Haven, CT, home of one of the country’s most prestigious medical schools. In making the largest personal injury award in the state’s history, the jury found that inadequate medical training and supervision were largely to blame for the injury.

The case also brings up the question of who is primarily responsible for that training and supervision: the university that provides the medical school education, or the hospital that provides the front-line experience?

While a first-year intern at Yale-New Haven Hospital in 1988, the physician became infected after sticking herself with a catheter needle she had inserted into the artery of an AIDS patient. The doctor — who remained anonymous during court proceedings and is known as "Jane Doe" — said she had performed the arterial line insertion successfully only once before, but was sent in to do the procedure alone.

In addition, her previous experience with the procedure had been on a hypotensive patient, not a patient with normal blood pressure, which contributed to the needlestick injury, says Doe’s attorney, Michael P. Koskoff, JD, of Koskoff, Koskoff, and Bieter in Bridgeport, CT.

"The evidence was that Dr. Doe was misinstructed in the insertion of an arterial line, that she was taught it was acceptable to remove the stylet from the catheter and to reinsert it if necessary to stop the flow of blood or to reposition the catheter. That was the way she was instructed, and her supervisor testified that the way she was doing it was perfectly acceptable, but plaintiffs’ experts said that method of doing the procedure was flat-out wrong, that it was not acceptable, that it was a dangerous way of doing it, and that instruction for doing the procedure was faulty," Koskoff tells Hospital Employee Health.

Doe intended to withdraw the needle and hold it at the opening of the catheter until she saw blood return through the catheter, which would confirm that she had found the artery. At that point, she would have disposed of the needle. If she hadn’t seen a return of blood, she would have reinserted the needle. Instead, as Doe removed the needle, "a surge of blood came up through the catheter under pressure," he says. Trying to stop it, Doe placed her thumb over the opening of the catheter, and because the needle was there, she stuck her thumb.

Courtroom testimony shows that a nurse who was standing in the room heard the doctor say, "There goes my life."

‘Just a very unlucky woman’

Doe, now 35, has not developed AIDS, but has an impaired immune system, Koskoff says. She is working as an occupational health physician at an unidentified university, where she also is co-director of the residency training program.

Yale defense attorney William Doyle, JD, of Wiggin & Dana law firm in New Haven, says the jury’s decision was based on sympathy, not facts.

"The claim was improper training and supervision, but the evidence showed that she did the procedure perfectly. She was well-trained. All the things that could go wrong with this procedure went right, except that she didn’t remove the needle from the field as soon as she was finished using it and that’s why she stuck herself," he tells HEH. "She is just a very unlucky woman because there are a million needlesticks among health care workers every year, and of a thousand health care workers who are stuck with an HIV-contaminated needle, less than three of them convert."

Doyle says there is "no magic formula" for determining when an intern is competent to perform a procedure alone. Doe’s supervising resident ordered her to perform the arterial line insertion because Doe had observed the supervisor perform it and then had performed one herself while the supervisor watched.

But Koskoff says the case implies that "the days of see one, do one, teach one" in residency programs, "especially as related to performance of procedures, has got to be a thing of the past. What happened in this case exemplifies how dangerous that can be, because Dr. Doe was instructed by her senior resident in a methodology that was faulty, but the senior resident didn’t know it was faulty. She thought it was perfectly proper because she had learned it from someone before her."

Residency training programs should include uniform policies and methods for performing procedures such as arterial line insertions, he states. A doctor’s competency to perform a procedure must be assessed before the doctor is permitted to do it alone.

"That’s what is done with all other hospital workers except for doctors," Koskoff says. "It’s done with nurses and with phlebotomists."

Koskoff had asked for an award of $21.7 million in the case, but the amount was reduced by 22.5% because the jury found the doctor partially responsible for her injury. They felt she should have insisted on not performing a procedure with which she was uncomfortable.

"I hope that message goes out, too," Koskoff adds. "To the extent that the jury is saying that, it’s important for new residents and interns to understand that even though all the pressures are against them, they have to speak up for themselves because no one else will speak up for them."

Residency programs could change

Doyle says Yale University will appeal the verdict, but if it is upheld, residency programs at teaching hospitals nationwide could change in other ways, as well. The issue centers on which institution has primary responsibility for residency programs: either the medical school, or the hospital that employs and trains interns. In this case, Doe sued the university, not the hospital. But Doyle points out that Doe’s supervisor was an employee of the hospital, not the university.

"Our position is that the hospital is responsible for the residency program," he maintains. "The situation here is no different from any major medical teaching institution that’s affiliated with a neighboring medical school. The residents are not trained and supervised just by hospital employees, but also by community physicians with admitting privileges, by members of the medical school faculty when they are practicing medicine in the hospital with their own patients, and by the people at other hospitals through which they rotate."

No jury could "reasonably conclude" that the university or the medical school breached any obligation to Doe, "and that’s going to be a big issue on appeal. You can’t have it both ways," he says.

Basically, Doe’s injury was work-related; therefore, she should have been limited to workers’ compensation benefits. However, the law states that if a third party is also responsible for a worker’s injury, the worker can sue the third party and reimburse workers’ comp benefits to the employer if she wins the suit.

"If you’re going to hold Yale Medical School responsible for the alleged negligence of Yale-New Haven Hospital, there has to be some kind of nexus, and the only nexus could be that it was a joint undertaking," Doyle explains. "If an employee of one [entity] of the joint venture is injured, other [entities] are entitled to the same immunity to common lawsuit as the employer is. That’s going to be an issue upon appeal. If we’re not entitled to immunity, there’s no nexus. It wasn’t somebody from Yale Medical School who was training and supervising her for this procedure. There’s something wrong with someone in a residency training hospital getting comp, but also being able to sue other folks who participated in that residency program."

The plaintiff’s position was that the university was ultimately responsible for the training program.

"The training originated with the program director, who was an employee of Yale University School of Medicine," Koskoff states.

Either the hospital or the university could be primarily responsible for training programs, says Arnold J. Berry, MD, MPH, a professor of anesthesiology at Emory University School of Medicine in Atlanta and a researcher in health care worker safety and prevention of occupational transmission of bloodborne infections.

"In some cases, the ultimate responsibility would belong to the parent of the training program, which in most cases would be the university, while for other programs it would be the hospital. There are both university- and hospital-affiliated training programs. It is probably more complex from a legal standpoint, since hospitals usually provide the equipment used by residents, so there could be responsibility at many levels," Berry says.

As an anesthesiologist, Berry frequently performs arterial line insertions. He says that procedure is more difficult than inserting the same type of catheter into a vein because it must be done solely by feel. Veins usually are visible, while arteries are not; therefore, they must be located by feeling a pulse. Another concern is that arteries are "high-pressure systems," so blood spurts out when a catheter is inserted. Proper procedure for preventing that calls for doctors to compress the artery upstream from the catheter with their finger.

"That’s what we teach our trainees," Berry states. The method Doe says she was taught — placing her thumb over the catheter hub after withdrawing the stylet — is "an unusual way of doing it; it’s not what is commonly taught," he says.

Currently, there are no safety devices on the market for arterial line insertion. Safer intravenous catheters are available, but they are not optimal for starting arterial lines due to necessary differences in technique between insertion into veins and insertion into arteries. Safety devices for arterial line insertions are needed, Berry says.1

But the larger issue remains the need for better training. Residents and interns must have the skills necessary to perform procedures safely, especially if they are working on patients who are known to be HIV-positive.

"The question is whether you would have a trainee do it, or whether you would have your most experienced person do it," he states. "[Doe] was instructed to do things that really put her at risk. With trainees, the level of the procedures that are performed independently need to be commensurate with their abilities."

At Emory, anesthesia residents are not permitted to perform procedures alone until they have demonstrated that they can successfully complete them under observation, he says. Anesthesia residents at Emory University Hospital are evaluated daily, and faculty at the hospital meet monthly to discuss residents’ progress. Decisions about whether residents are competent to perform procedures independently are based on that information.

Reference

1. Berry AJ. Injury prevention in anesthesiology. Surg Clin North Am 1995; 75:1123-1132.