PROFESSIONGeneral vs. regional anesthesia not an arbitrary decisionEthics Forum. Dec. 2, 2002. Scenario: How should health workers handle fear of HIV transmission? An anesthesia resident decides to administer regional anesthesia by way of epidural catheter to a patient about to undergo exploratory laparotomy. Although he has used this approach for the same surgery in the past, the attending tells the resident that they will be using only general anesthesia this time. When the resident asks why, the attending says, "The patient is HIV positive. Why expose yourself?" The resident wonders whether avoidance of regional anesthesia in HIV-positive patients is appropriate. Reply: The obvious question this consult raises is, what has happened to medical professionalism? Physicians are supposed to put the welfare of patients above their own. Physicians have exposed themselves since ancient times to a variety of hazards to care for the sick, injured and dying. In return for working long hours, possibly contracting diseases and knowingly exposing themselves to other hazards, physicians theoretically and practically enjoy spiritual satisfaction, the privilege of self-regulation and high social regard. The scenario also raises the importance of role modeling and the "informal curriculum" that shapes the beliefs and attitudes of residents. Clinical issues also come to mind when reflecting on this case. Is there valid evidence that central neuraxial or regional anesthetic techniques offer any benefit over general anesthesia? What do patients typically know about these matters, and what decision-making skills and attitudes do they bring to the discussion? What are the real exposure risks to physicians? What underlying forces might shape difficult decisions? Given what we are learning in health care about highly reliable industries, should we be giving worker safety a closer look in the drive to improve patient safety? While in-depth analysis of these issues is beyond the limits of this forum, further discussion of several points follows.
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