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