15-year-old (female) after motor vehicle accident

00:02 A 15 year old girl presents to the emergency department via EMS status post a motor vehicle accident.

00:11 The patient is in critical condition and is hemodynamically unstable.

00:16 It becomes apparent that the patient may require a blood transfusion and the parents are approached for consent.

00:23 They are Jehovah’s Witnesses and deny the blood transfusion.

00:27 However, the patient insists that she wants the transfusion if it will save her life.

00:33 The parents again refuse.

00:35 What is the correct course of action? Answer choice (A) - give the patient the blood transfusion.

00:41 Answer choice (B) - do not give blood transfusion due to parent’s refusal Answer choice (C) - give intravenous fluids to attempt to stabilize the patient Answer choice (D) - consult the hospital ethics committee.

00:56 or answer choice (E) - obtain a court order to give blood products Now take a moment to think of the answer before we go through it together.

01:07 Now let’s attack this question.

01:09 This is a ethics question and this is actually a 2-step question.

01:14 First we need to figure out wether or not blood transfusion is life-saving for the patient, and then we need to decide, “is it appropriate to give to a minor whose parents are Jehovah’s Witness and who are denying the transfusion?” Now hence, to the 2-step question.

01:32 And of course in this case, the stem is required because there’s lots of critical information in it.

01:36 Now let’s walk through this question together.

01:38 The first thing we need to do is determine wether a blood transfusion is life-saving for this patient.

01:45 Now, this patient has lost significant blood following the motor vehicle accident.

01:51 Now you could use intravenous fluids that can initially provide relief to a haemodynamically unstable patient but we still need to provide blood products given the amount of significant blood loss.

02:07 Fluids themselves won’t give enough hemoglobin back to do oxygen transport.

02:11 You can’t just give NS or LR, you do need true hemoglobin and blood products to go back in to do proper hemodynamics and to give you proper oxygen carrying.

02:20 So in this case, a blood transfusion is life-sustaining for this patient.

02:25 And that’s very important.

02:27 This is a emergency, life-sustaining and life-saving decision we are going to be making.

02:34 That's how we are gonna get around these ethical questions.

02:36 It’s not the grey area of, 'oh is the patient fine or not?' In this case, USMLE is only goinna ask you clear cut questions regarding ethics, and it is going to be essentially, 'is it a emergency or not?' So that’s the first thing we need to find out.

02:51 This is clearly an emegency - the patient's been in a motor vehicle accident.

02:55 They'll tell you the patient's in critical condition and they are haemodynamically unstable.

02:59 So we’re definitely in an emergency situation and given the situation of significant blood loss, we do need to give a blood transfusion to provide not only hemodynamic stability but also to give the blood back so that we can do proper oxygen transport.

03:14 Now step 2 of this question is, okay now we know well, we wanna give blood, it’s life-sustaining, it's emergency - we wanna do that.

03:22 But we need to think, what are the rights of this 15 year old girl to decide her treatment? Now as a general rule, and you can use this for all ethics questions for USMLE.

03:35 The interest of the child outweighs the religious rights of the parent.

03:41 That’s a very important principle to understand.

03:44 You can memorize that, I definitely would.

03:47 You’re going to see things like this in all of USMLE step 1, step 2 and step 3 These kinds of quest do not go away.

03:56 So in this case, the interest of saving a child’s life outweighs the religious rights of the parent.

04:04 That means in this case, the parents saying 'I don't wanna give blood because we're Jehovah's Witness and giving blood to us would be a way for us to go like indefinitely into hell'.

04:15 That gets overriden when someone is going to die in a clinical situation under your care.

04:21 So that's what that means.

04:23 The interest of keeping the child alive in this critical condition outweighs whatever religious beliefs or rights the parents have.

04:32 Now as in this case, the blood transfusion is a life saving treatment.

04:38 It does not require consent of the parent.

04:41 The patient is critically ill, they are haemodynamically unstable, we do not need consent.

04:46 This is emergency, life sustaining treatment, we can just save a life.

04:51 Now in the case of life threatening condition, minors have the right to overrule the decision of their parents with respect to their medical treatment.

05:00 So in this case, we have a minor whose parents are Jehovah's Witness but she is critically ill and hemodynamically unstable.

05:10 So the correct answer is answer choice (A) - give the patient the blood transfusion.

05:15 It is life sustaining and the interest of saving the child’s life outweighs the religious rights of the parents in a critically-ill, life-saving emergency situation.

05:30 And that’s the case that the USMLE is going to be giving you just like this question.

05:35 So now lets go through some high-yield facts together Let's talk about blood transfusion.

05:40 Now in the case of significant blood loss, a replacement through blood transfusion is traditionally indicated.

05:47 Not very complex there - if you've lost lots of blood, simply giving you fluids is not going to work because we need hemoglobin, we need platelets, we need plasma, we need coagulation factors, etc Simple NS or LR doesn't have that.

06:00 Now if a patient is hemodynamically unstable, giving fluids and also giving blood transfusion is considered a life sustaining or excuse me, a life- saving therapy.

06:12 Now, initially patients can be given IV fluids to kind of short term control them while the blood products are obtained from the laboratory, they’re gonne be doing crossmatching, they're gonna be making sure the donor blood type is the same.

06:27 So correct, in the initial phase, and this could be a separate question you may see in the exam, we can give fluids to kind of maintain blood pressure but we ultimately need to transfuse and fluids are just a thing to buy us time until the blood arrives.

06:41 Now let's discuss some high-yield component of consent.

06:45 Now Jehovah's Witnesses do not accept blood transfusion based on their religious beliefs.

06:52 This is not a belief based on medical grounds, just their religious beliefs.

06:56 Although parental consent is generally required for medical treatment, that’s in the case of a NON life-threatening condition: outpatient surgery, traditional clinic visits, yes.

07:09 You have to get the parents consent for a minor but in a life-threatening condition, the health of the minor overtakes priority for any beliefs of the parents.

07:21 Now minors have capacity to make medical decisions for themselves in life threatening conditions.

07:28 So again in this case, the young girl wanted to receive the blood transfusion to save her life so we will accept that because it is a life-saving decision to provide in a critically-ill patient.

07:42 Now, let's just quickly discuss answer choices (D) and (E) because these are gonna be common distractors that you will see in other USMLE questions.

07:52 However in certain circumstances, they may be correct.

07:55 Now answer choice (D) and (E); (D) says, 'let’s go talk to the hospital ethics committee' and answer choice (E) says, 'lets get a court order' Now both these things are going to take a lot of time.

08:09 You're gonna have to ask for a committee to come gather, people there'll review the case, this could take days.

08:15 And getting a court order will also take days.

08:17 You have a critically-ill, haemodynamically unstable patient on your bed and and usually in an emergency room setting, we don't even have an hour to spare let alone days.

08:27 So both of those things are chronic things that you can do in an outpatient slow setting, but not in a critically-ill setting.

08:35 So immediately we can get rid of those two.

08:37 Answer choice (C) is correct, you can give fluids but ultimately that's just a temporizing measure.

08:42 Answer choice (A) is what we care about the most- give blood in a critically ill patient and of course, answer choice (B) is wrong.

08:51 because we don't care what the parent say in this case because the patient is critically-ill and wants life-sustaining treatment.