One Dozen Things
Informed Consent
Scenario Script
The patient is lying on an examination table wearing a hospital gown and covered with a sheet. The physician enters the room while making his opening remarks.
Doctor: OK, Mr. Hartman, let me tell you what I'm thinking based on the tests we've done so far and what needs to be done next.
Patient: Doc, did the CAT scan show what’s causing my headache?
Doctor: No, but unfortunately CAT scans don't show everything, particularly the things I'm most concerned about. The good news is there are no signs of increased pressure, at least for now.
Patient: So what are the things you are concerned about?
Doctor: With a severe headache coming on so suddenly in a healthy guy, I am concerned that you may have had a small bleed in your brain. We call them “subarachnoid hemorrhages.” Those represent an area of weakness in one of the blood vessels around the brain. Kind of like a bubble on an inner tube tire. And if that’s the case, the neurosurgeons would need to go in and put a clip on that area to prevent any further bleeding.
Patient: That sounds serious…
Doctor: It is, and I have to tell you that sometimes it can be fatal. So it’s really important that we find out what’s going on.
Patient: [rolling onto his side and facing away from the doctor] How are you gonna do that?
Doctor: [walking around to take a seat in front of the patient] Well, the first thing we need to do is called a spinal tap. There is a fluid that surrounds your brain that connects to the lower part of your back where your spinal cord is. We can go into that area, into the spinal canal area and get some fluid out of that. It’s much safer than going into the brain area. If there is bleeding we should either see some red blood cells or at least some chemicals that come from those cells breaking down.
Patient: Could it be anything else?
Doctor: The other thing that I would be most concerned about would be meningitis, which is an infection of the coverings of the brain. Actually, the spinal tap is also the best way to make that diagnosis. That fluid should have some white blood cells or pus cells in it; sometimes we even see bacteria. So the spinal tap is the best way to go to rule out both of the things I’m concerned about. And if we rule those out, we can relax a little bit.
Patient: So what does this spiral tap involve? Is it dangerous?
Doctor: It’s actually a spinal tap; we call it a lumbar puncture, that’s the medical term. We would kind of lie you on your back as you are now and put some numbing medicine in and around your low back, and go between two of your vertebrae and obtain some fluid out of there. Sometimes we can see red blood cells right away; that would indicate bleeding. But in any case we would send the fluid to the lab where they can look more closely and do the necessary tests.
Patient: But is it dangerous? What are the risks?
Doctor: There are risks with every procedure. The most common thing we see with this procedure is a severe headache but you are a guy who is already having a severe headache, and I don't think it’s going to make it any worse. There’s a very slight chance that some bleeding can occur around the spinal cord where we insert the needle but that usually is much more common in people that are on blood thinners or other medications and you’re not on those. And then any time we introduce a needle into the body there’s a chance of infection but we use very careful sterile techniques so that is highly unlikely also.
Patient: Is there anything else that we could do?
Doctor: Well, if the spinal tap is positive for blood, then we are going to need to do what’s called a cerebral angiogram. That’s where they take dye and shoot it into the arteries of your brain and then take some x-rays to identify the area of bleeding. That’s obviously much more expensive and has many more risks than a spinal tap, so I think the spinal tap is the way to go.
Patient: Will my insurance cover it?
Doctor: Absolutely.
Patient: But it’s going to hurt, right?
Doctor: We are gonna numb the area of your low back but it still involves a big needle. It should only take a few minutes to do though. So, do you feel ready to sign a consent?
Patient: Yeah.
Doctor: Do you understand what we want to do and why?
Patient: Yeah.
Doctor: Have I answered all your questions about risks?
Patient: Yeah, I guess… you really think we should do this?
Doctor: It would be very wrong not to…. [hands patient a form on a clipboard and a pen] I need you to read this and sign it for me, sir. Can you see it ok?
Patient: [reading the form] Yeah.
