The Orthopedic Trauma Unit in the hospital is an an exceptionally busy unit.

They are celebrating the 50th birthday of one of their consultants and have had a late night partying at a local pub.

One of the Interns is supposed to be on duty the morning after. He feels he has consumed more than his usual tolerance of alcohol and feels he will not be able to perform his duties the morning after.

The registrar offers to make alternative arrangements and speaks to his consultant, seeking approval. The party continues.

The next day, the intern does not attend his duties and the intern on call the previous night is asked by the registrar to continue till the duty intern feels fit enough able to attend to his duties.

Late in the afternoon, the intern reports to work and resumes his duties.

You are the head nurse of the ward.

What are your views on these arrangements ?

Sally is a registrar in a medical unit that also oversees a geriatric in-patient facility where many patients are from a local geriatric care home.

One of the attending medical student notices that Sally wears gloves when examining patients in the geriatric care facility. She does not wear them when she is in the acute care medical ward.

When asked by the student she explained that she did not trust the hygiene standards of patients admitted in the geriatric ward as many of them came from an old-age home with poor sanitation and a poor history of care.

You are the nursing officer in charge of this facility.

What is your view?

Peter is an Intern in the medical ward. He is a hardworking intern and the nursing staff and his colleagues have no complaints.

However, he is habitually late for the consultant’s rounds, the outpatient clinic and even the operating theatres where he is often scheduled to attend.

He has also missed some journal club sessions citing ward work as a reason.

The consultant is extremely displeased has warned him about his punctuality and wants him to repeat his rotation.

You are the administrative head of the unit.

What is your view?

Alex is a Hepatobiliary Surgeon and has an Honorary attending appointment at a regional transplant unit.

He has been called in to help with a Liver transplant and is the chief surgeon responsible for the recipient surgical procedure.

Midway through the procedure, Alex leaves the operating theatre to perform another operation in a private hospital.

He returns to the OT 4 hours later and completes the transplant successfully.

As a senior administrator of the hospital, you have been made aware of this event.

Alex sees nothing objectionable in his actions and feels he had a duty towards his equally important and critical private patient.

What is your view?

JC is a pharmacist in a tertiary regional hospital. Ms B has been prescribed TAMOXIFEN by her Orthopaedic surgeon.

She suffers from a condition known as Fibromatosis – for which drug treatment with Tamoxifen is often quite successful. Yet Tamoxifen therapy for fibromatosis is still considered off-label.

JC notices that Ms B has been prescribed 120 Mg of Tamoxifen and is alarmed. The usual daily dose of the drug is 20-40 mg. The prescribed dose is 6 times the usual.

He informs Ms B that the correct dose should be 20 Mg, and not 120 Mg. Ms B is confused, she has taken the drug for 6 months at the previously prescribed dose and her condition has stabilized. She has less pain and improved shoulder movements.

JC explains that the drug at such a high dose is likely to be dangerous and gives her the correct dosages. She is rather angry at the Orthopaedic surgeon for having prescribed the wrong dose and makes a formal complaint.

You are a senior administrator of the hospital.

What is your view?

Rex is an intern working in the Orthopaedic Unit. This is his first week, fresh after graduation.

Rex is sitting at the nursing station filling up discharges and drug prescriptions when a nurse rushes and informs him that an elderly lady has sustained a cardiac arrest. Two other nurses are performing CPR and have requested his assistance.

The 79 year old lady has had hip surgery a few days ago but has been suffering from unstable atrial fibrillation and has had a poor cardiac function to begin with.

She and the family were warned of possible peri-operative deterioration and even death. The family were informed that the lady would not receive any ICU support in the event of significant deterioration. However, no advance directives or Do-Not-Resucitate orders were in place.

Rex refuses to attend saying that any CPR would be futile and cause more misery than benefit. The crash call team arrives but the patient has died. The nursing staff were critical of Rex’s refusal to attend CPR.

You are a senior administrator of the hospital.

What do you think of his actions?

Mr. Y. presented to a regional hospital with severe knee pain. He was febrile and a Septic Arthritis was suspected. The admitting officer wrote the need for appropriate antibiotics but did not prescribe them.

Y remained in the wards but did not receive antibiotics and his knee became worse. The on-call medical officer decided that the joint needed surgical drainage but Y did NOT want surgery. His family was also against surgery and the consultant was called in to discuss with the family. They reluctantly agreed and he was taken to the operating theatre where surgical drainage and 120 ml of purulent fluid was drained..

Y's condition deteriorated 2 hours after surgery and he developed severe sepsis leading to multi-organ failure and death. A coroners inquest was ordered.

The family believed that something must have gone wrong with the SURGERY and insisted that the surgery may have been unnecessary.

The MO in charge wrote in is report that the failure to administer antibiotics were a critical lapse that may have led to uncontrollable sepsis. The Hospital administration ( and the legal team) however did not allow such an admission to be made. They said that it was a matter of speculation and should be left to the coroner to decide. Instead they insisted that the report should state the chronological sequence of events as they happened, including the time at which various drugs and procedures were instituted. What measures should have been done and what treatments, drugs were appropriate or otherwise should be left to the expert ( coroner) to judge.

"From a legal viewpoint, What is not asked for is not necessary to disclose"? What is your view ?

There has been an alarming increase in the severity of Influenza in the last few weeks.

The possibility of an avian influenza pandemic has been considered and people are extremely worried.

The supply of TAMIFLU - the only effective available drug against this particular strain is running out.

A regional private pharmacy has been stocking up its supplies.

However they have recently tripled the cost of the drug, making it impossible for working class people to afford.

A group of family doctors has called this action unprofessional and even inhuman.

The private pharmacists argue that it is only business – a matter of supply and demand.

They also accuse the doctors of similar business practices.

What is your view ?

Family meeting was conducted.

Mr. H's wife and younger son had come to consensus that they would respect patient's elder son as surrogate decision-maker.
Elder son reported that Mr. H used to see food as life enjoyment and hope his father can pass away with full stomach. He also acknowledged risks of feeding tube insertion and tube feeding per se.
Given terminal state, they also acknowledged that the patient might pass away shortly after the procedure as a chronological coincidence.

After the family meeting, the family and the palliative care team aligned the treatment goal to minimize suffering.
A trial of tube feeding was offered with particular stress on the plan that feeding tube insertion or tube feeding would be aborted if Mr. H showed signs of increased suffering.

Mr. H passed away shortly after receiving tube feeding once with family members by bedside.