A recent event at the trauma center where I work raised some serious questions regarding the use of video recording for education and quality improvement. We have done this in the trauma bays for several years with the idea that the recordings were protected under the peer review umbrella. They have been useful in analyzing problems, improving workflow, and investigating medical error in the trauma setting. I have generally been in favor of such recordings as they have helped improve our protocols, identified inefficiencies in our evaluations of trauma patients, and in one or two incidents, identified critical errors that could have led to significant harm.
Recently, we treated a patient who has made me rethink the wisdom of such recordings. The man was brought in after an unwitnessed head injury. He had contusions on his face and a scalp laceration. He was uncommunicative with the medics and combative with the staff on arrival. In response to his shouting and flailing about, he was restrained and ultimately sedated. A head CT showed no intracranial trauma, and he was reexamined once he was calmer. At that point, he complained that he had been restrained against his will and made allegations of assault against the trauma team.
Due to a previous lawsuit, the hospital has a protocol for patients who allege assault. Under that protocol, the local police are informed and come to talk to the patient. If the patient continues to claim assault, a formal police investigation starts.
Such was the case with this patient. The officers opened a criminal assault investigation based on the patient’s claim and proceeded to take statements from the entire trauma team. The patient was intoxicated and had a long history of mental health issues, and the team statements were all consistent and appropriate.
Then the police inquired about any video recording that might be available. Initially, the administrative assistant on call that evening told them that there were no recordings, in good faith. She was unaware that they existed. The trauma charge nurse corrected that but tried to maintain that they were privileged. It took the police less that an hour to obtain a court order to release the recordings to them.
In the end, the recording vindicated the trauma team and confirmed their version of events. All good. But what troubled me was the rapidity with which the peer review wall was breached. Yes, this was a potential criminal assault case, and yes, the recording vindicated the trauma team, but their statements alone should have been enough to do that. I fear that it will only be a matter of time before some litigator manages to breach that protection in a malpractice case. Why is that a problem? Anyone who has worked trauma for a while knows that things in the trauma bay often look brutal and chaotic. Even when everything is done right, the blow by blow is often not pretty. There is plenty of room for misinterpretation of events that could prejudice a jury of laypeople, or even non-surgical medical professionals. These recordings can be valuable to those of us who live in this environment and can see events in the context of our experience. To someone unaccustomed to this world, that context may be lost.
Similar objections have been raised over suggestions that routine surgery be recorded, or for that matter over the use of recording devices by police departments.
I have always maintained that recordings of this type can be an important part of our efforts to improve our performance and to learn from other’s experiences. But unless that record is protected, I fear we will be inhibited in our responses to adverse events and too conscious of someone looking over our shoulder and judging our actions. The ease with which the police in this case were able to access the recording was, to me, worrisome and suggests that the peer review protections we depend upon for uninhibited analysis and review may be thinner that we imagined.
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Bruce Davis, MD, is a Mesa AZ based general and trauma surgeon. He finished medical school at the University of Illinois College of Medicine in Chicago way back in the 1970’s and did his surgical residency at Bethesda Naval Hospital. After 14 years on active duty that included overseas duty with the Seabees, time on large grey boats and a tour with the Marines during the First Gulf War, he went into private practice near Phoenix. He is part of that dying breed of dinosaurs, the solo general surgeon. He also is a writer of science fiction novels. His works include the YA novel Queen Mab Courtesy, published by CWG press (and recently reissued by AKW Books as the e-book Blanktown). Also published through AKW Books are his military science fiction novel That Which Is Human and the Profit Logbook series, including Glowgems For Profit and Thieves Profit.