DISCIPLINE SUMMARIES
Health also conducted a look-back of patients who had a procedure at the clinic in the five years prior to the date of transmission and were cared for by Dr . Young . No additional newly Hepatitis C or HBVinfected individuals were found . While observing that Dr . Young separated unused and used syringes on the anesthesia cart , and observing that needles were not re-used and re-inserted into the medication bottle if more medication was required , Toronto Public Health noted that the literature supported the theory that Hepatitis C transmission occurs in health-care settings as a result of mishandling of multi-dose injectable medications .
The use of multi-dose injectables , while common , presents greater risk when used in a high volume , rapid turnover environment . Toronto Public Health concluded that it was possible that a multi-dose vial of medication , most likely lidocaine , became contaminated with blood from Patient A , and was used during the subsequent procedures on that day . It noted that lidocaine was the one vial used for all patient procedures that day , while the propofol vial would not have provided enough doses for all patient procedures subsequent to Patient A .
Clinical Care Issues The College retained two medical inspectors to conduct an investigation into Dr . Young ’ s practice . The College ’ s experts reviewed the charts of the patients who had been provided with anesthesia by Dr . Young during their procedures at the clinic on the day in question , interviewed Dr . Young and observed his practice providing anesthesia for endoscopy procedures at the hospital . The first College expert opined that :
• Dr . Young failed to properly review Patient A ’ s chart , including the pre-anesthesia questionnaire , to determine whether there were any anesthesia associated risks ;
• Dr . Young did not see that the patient had checked off “ hepatitis ” in the questionnaire , which may have led him to take additional precautions based on this information ;
• This failure created a significant risk to patient safety ;
• Dr . Young should have been aware of the risks of using a multi-dose vial regardless of time or cost pressures that might have been in play ;
• Despite Dr . Young ’ s statement that he never reenters a multi-dose vial with a used syringe , this is the most plausible explanation for the sequence of Hepatitis C cases that occurred on March 15 , 2013 ;
• Dr . Young should have been aware of the importance of reviewing a patient ’ s medical history ;
• Dr . Young ’ s care did display a lack of judgment , but did not display a lack of skill or knowledge ;
• Despite the fact that he could not control what the Ontario Endoscopy Clinic ordered in terms of stack vial size , he could have exercised increased caution when using large multi-dose vials .
The first expert concluded that transmission of Hepatitis C likely occurred as a result of contamination of a multi-dose vial , likely of propofol , by Dr . Young . The expert concluded that the degree of deficit in this case was mild and that Dr . Young appeared to have learned from the experience and concluded that Dr . Young ’ s current clinical practice , behaviour or conduct does not expose and is not likely to expose patients to harm or injury . The second College expert opined that the documentation in the anesthetic record completed by Dr . Young for Patient A and the six patients who followed her was deficient and below standards of practice in one or more of the following areas :
• No pre-operative vitals ( in two out of seven cases );
• No post-operative vitals or level of consciousness ;
• No discharge orders ;
• No pre-operative airway assessment .
The second expert opined that , with respect to Patient A , the anesthetic record was deficient in having no pre-operative blood glucose despite her history of diabetes and insulin use , no notation of the patient ’ s history of Hepatitis C , and no documentation of her history of chest pain . The second expert concluded that Dr . Young did not meet standards of practice , in that he was not aware that Patient A was Hepatitis C positive although the patient questionnaire indicated a history of Hepatitis C . There was an increased potential for harm in not being aware that the patient was Hepati-
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DIALOGUE ISSUE 2 , 2018