High praise

John Rogers of KungFu Monkey says of Orac:

I enjoy the way he crotch-kicks modern medievalism with reason and science, while he seems to be amused at the way I just mercilessly mock it into submission. Despite our differing approaches, go hang with the smart guy.

Hear, hear!

Speaking of Orac, he's got a great post about the Taran Francis tragedy unfolding at Montefiore Medical Center in the Bronx.

This case sums up so much of what's wrong with our health care system.

Evidently, the 13-year-old Francis was turned away from his root canal appointment at Bronx-Lebanon Hospital because he wasn't accompanied by a legal guardian. I didn't know New York as parental notification for root canals. Over the next few days, Francis's untreated infection spread from the tooth to his brain and killed him.

Thanks to the tactlessness of the Montefiore medical center, Francis's body is still on life support:

When a doctor appeared, the two women asked, "Should we be worried about anything?" Douglas said.

"The doctor said, 'Yes. He's literally brain dead.' " Soon after, they were approached by a hospital social worker, who told them, "We're going to give you time to mourn. You have 24 hours," said Douglas.

Asked what that meant, the social worker explained, "Legally, in New York state, the hospital has the right to take a person off life support when he's brain dead," Douglas said.

That's when Marcerlyn called a lawyer.

Douglas noted, "We pleaded with the doctors, 'This child needs time, for Christ's sake. Give him time.' "

In a chilling response, she said, the social worker told them that the only reason the hospital was giving Taran medical attention at that point was "to keep his organs functioning in case you want to donate them." [New York Post]

None of this would have happened to a white middle class family with good insurance. First off, the tooth would have been taken care of. What kind of hospital just sends a kid home with a severe infection without following up with his parents?

I bet the medical staff would have been much more solicitous towards a socially prominent family with a brain dead child. If Frances were a senator's son, a social worker wouldn't have just barged in and dictated a 24-hour mourning deadline. (Not that brain dead people don't need to come off life support, and not that organ donation isn't a wonderful option to discuss with families, of course.)

I should add that Orac's post is one of the many fine pieces of medical blogging on display at Grand Rounds XXXI, chez Dr. Tony.

Comments

[Kevin T. Keith]

Your comments are well taken, but note also that the story only quotes one party's report of this conversation (as given in the most sensationalistic tabloid in the city). I'm at least a little skeptical that the hospital representative actually said "We're giving you time to mourn. You have 24 hours. The only reason we're treating him is so you can donate his organs."

As for the handling of the root canal, there should surely have been some followup, but, then, he shouldn't have been sent without a guardian. It's not a question of "parental notification" - at 13 years old he's legally incapable of signing his own consent form, and his underage teenage cousins are in no better position. New York, like every other state, requires competent consent for medical treatment, particularly one requiring general anaesthesia. There is a carve-out for sexual-health-related treatments including STDs, birth control, and abortion, on the theory that guaranteeing anonymity will prevent scaring away desperate teens who otherwise wouldn't seek treatment at all, but for other kinds of care he needs an authoritative signature. You're right that they should have made more of an effort to contact his mother, but they could not simply have treated him without her (nor could they, and, I'm sure, would they have, with a white kid either).

It's a terrible combination of bad circumstances (the mother herself fell ill and was hospitalized during part of these events, and had to check out AMA to go over to the other hospital her son had been transferred to for neurological care) and bad communication. Still, I have seen nothing reported that indicates the treatment was actually mismanaged. One of the Post's columnists is fanning the issue with pointed questions about "what happened that we don't know about?", but the facts seem simply to be that, in the time between when he showed up for his scheduled surgery without a legal guardian and the time he fell ill a few hours later, he had a freak infiltration of his tooth canal infection into his bloodstream and brain; he then rapidly deteriorated to the point of brain death. Of course his mother is beside herself - he went in for dental work and less than two days later was declared brain dead - and there seems to have been very bad support and communication, which turned this into an antagonistic situation. (The family sought and won a court order mandating continued vent support for the boy's dead body until further notice.) But that doesn't change the facts of the case: he couldn't be treated without a guardian's consent; nobody could have known there would be such a dire outcome; when he became seriously ill they did the best they could, including shipping him to another hospital for more advanced treatment, but he was too sick.

What else was either of the treating hospitals supposed to do? Operate on him without legal consent? Make his mother come to the appointment she was supposed to come to in the first place? Predict an unpredictable outcome of routine dental work? (Imagine that they had done any of those things, and something went wrong - what would the headlines be then? "Hospital operates on boy without mother's consent! Boy dies of brain infection!" "Hospital orders mother out of sick bed to sign forms for son! Boy dies while waiting!" "Hospital tells mother 'Your son will die of bizarre brain infection if he doesn't get a root canal!'")

It seems clear that Montefiore did not communicate effectively with the mother, but it also seems clear that nothing they could have done realistically would have changed the outcome. They bungled the family-relations aspect of the case - which is certainly very important - but the medical outcome doesn't seem, even from the Post's inflammatory reports, to be anything more than freak bad luck, exacerbated by the fact that a 13-year-old boy was sent by his mother for surgery under general anaesthesia without any authoritative guardian, and the hospital - as they legally had to - insisted on a valid signature. If they had done otherwise, they would have been in for just as much bad press (led by the Post, beyond a doubt), and legally in the wrong to boot. As it is, they're now required to treat a dead body for an indefinite period while the Post and the angry family call them murderers. The judge who mediated the "compromise solution" has essentially given the family carte blanche to indulge their unrealistic expectations:

"'We are not giving up. We believe in God. He has life. I don't care what they say. Until that heart stops, we're not letting go of him," [the patient's aunt] said.

It was Montefiore's responsibility to help the family understand the sequence of events, grasp the enormity of the outcome, and come to terms with it - and they clearly blew it. But we also have to be able to make rational decisions about limited resources. Anger or irrational religious beliefs too often become trump cards in situations like this.

[Lindsay Beyerstein]

Most root canals don't require general anesthesia, do they?

Generally speaking even young teens are allowed to give consent for medical treatment. A 13-year-old with an infected tooth who needs a pre-scheduled root canal should be able to consent to it. I was required to give consent for my own tonsillectomy at 12, including the general anesthetic. This was British Columbia in 1990. I don't know what the law says in New York. But if it's not similar, I'd object on general principle.

Even so, somebody from the hospital dropped the ball. A medical system that allows a kid to walk away from his root canal without follow-up is seriously flawed. The next question is why the kid stayed away for 11 days without treatment (this according to Orac's post).

Infected teeth hurt a lot. I'm sure Francis was highly motivated to do something about it. With adequate follow up the hospital could have worked around the fact that his only guardian was incapacitated. If they don't have a mechanism for dealing with problems like that, they should. In fact, they're probably criminally negligent if they don't.

Granted, the tabloid (and/or the lawyer) may have blown the entire post brain-death episode. On the other hand, I wouldn't be at all surprised if the family was treated disrespectfully, or was deeply suspicious about the reaction they got, given the level of service they'd gotten so far (albeit, the hospital where the kid died was a different institution from the one that refused to do the root canal).