They Took This Lady To Court While She Was In Labor

Dr. Chang (00:04):
You are listening to Secret Services, where we discuss the procedures nobody admits to, but everyone's curious about. I'm your host, Dr. Christopher Chang. Hey, everyone. We're back.

Jackie (00:15):
Hi, welcome. I'm Jackie.

Dr. Chang (00:17):
I'm Dr. Chang.

Jackie (00:18):
All right, guys. We're going somewhere unexpected today. Stay with us. This story involves a woman in a hospital bed, a judge on Zoom, and a decision that should make every doctor and every patient uncomfortable.

Dr. Chang (00:34):
You're already making me uncomfortable. So yeah, we hate those kinds of situations, but so-

Jackie (00:40):
It happens.

Dr. Chang (00:40):
You've been in the OR a lot. Can you give us any thoughts or experiences or stories that you've had where the patient said no, but the care team had a conflict and they wanted to do something different and there was a conflict that you had to resolve on the nursing or the operating room side?

Jackie (00:58):
There's definitely been ... I worked at a level two trauma center, and so the operating room had to respond to every trauma that would come through the ER. So we were always present at the bedside as everyone's coming in. And I feel like in those trauma situations, you definitely have a lot of back and forth between patient, family, doctors, and what's best. It definitely does get dicey though, because the care team is really just following protocol, this is what we need to do in this moment. But there's definitely times where the patient's like, "No, I'm good." Family's like, "No, they're fine." It's always difficult when you have family versus patient. I found that to be pretty difficult to navigate. Of course, if the patient is with it enough, they consent, but in certain circumstances, you need the family to make that decision for the patient.

(01:57):
And so it does get a little dicey. And sometimes you have to bring in the head of the hospital to come in and make these choices. But at the end of the day, we're just looking out for the safety of the patient, but there's times where the patient or the family is advocating for something that you know is not what we should be doing. And so that's difficult. Yeah.

Dr. Chang (02:20):
I don't know if this is in nursing school, but in medical school, they start early with the ethics training. So throughout medical school, you get exams or even enrichment courses or lectures that talk about these ethical conflicts between patient autonomy over their own body or own decision-making process, the family's involvement, as well as your duty as the caretaker. So there are these challenges that come up and usually they're built out of real life scenarios. They're not made up and these conflicts become things. And that gets propagated into your specialty training, your board certification, training and exams. And it's constantly tested even after you're board certified in our continuous certification exams. And so I'm sure for all specialties, not just plastic surgery, but those things come up, as you said, in trauma, general surgery, emergency medicine, nursing.

Jackie (03:12):
Yeah. And I mean, there's times also that I've been in where patients in the ICU or making the decision, do we bring them down emergently to the OR to operate on them? Luckily in my situation, I've been with a lot of really good skilled surgeons that I feel like are able to verbalize either to the patient or the family the importance of what needs to be done. So luckily in all these situations I've been in, it's been resolved. They have chosen to finally listen no matter how difficult the conversation was to go forward with what we all thought was best. But I do think it takes a very skilled conversation with the surgeons.

Dr. Chang (03:53):
Yeah. And also everybody has to be on the same page.

Jackie (03:56):
Yes. Yes.

Dr. Chang (03:56):
Because in some of those situations in ICU care and trauma care, the surgeon and the team from the day shift may be different from the night shift or they may do a 24-hour shift and then the next day may be a different shift. And so the conversation has to seem continuous based on the patient's needs.

Jackie (04:12):
Absolutely.

Dr. Chang (04:13):
And you're building a relationship with this family to say, "Listen, trust me. This decision, I know you don't want to do this, but this is what we believe." And then the next team comes in and you're trying to really sort of continue that conversation with a different relationship. So there's a lot of dynamics.

Jackie (04:28):
Yeah. And then also the hospitals have the patient care advocates, so it's good to bring them in as soon as something weird like this is happening where you can just tell there's a disconnect between everyone and they kind of help be a mediator and bring everyone together to make sure everyone's goals are being met.

Dr. Chang (04:46):
Right. Yeah. No, I think that's where I've seen it, or at least it seems like it comes up classically in some exams or are people who have religious things such as Jehovah's Witness patients-

Jackie (04:58):
Yeah, with the blood. ...

Dr. Chang (04:59):
That don't want to get a blood transfusion. So they have a hemorrhage, they're dying or they're unstable, they need a blood transfusion, but they do not want to have any-

Jackie (05:09):
That's a tough one. Yeah.

Dr. Chang (05:10):
And so your hands are tied a little bit. Modern medicine blood transfusion is not that controversial of treatment in those situations, but there is an exception for that. Do you know the exception for those?

Jackie (05:22):
No.

Dr. Chang (05:23):
So if the patient is unconscious or something or is given this stuff in a sense of an emergency and they were not consented, let's say you're in the middle of surgery, you couldn't wake them up to say, "Do you consent?"

Jackie (05:35):
Yeah.

Dr. Chang (05:36):
Then they give it to them, then actually it's okay. They'd say, "Okay, well you did..." But I think it's for them. They didn't agree to that, but it's not such a personal, I guess, compromise for them based on their beliefs. But anyway, that was the correct answer 20 years ago.

Jackie (05:54):
Right. Yeah, because I mean, they do have all those consent forms and everything they can fill out. But yeah, in a trauma, if you don't know or have any of that on hand, you really are just making the best decision you can in that moment for the patient. So we have an anonymous patient question. It's kind of related. So I went in for a consultation about one thing and came out with a quote for four procedures. The surgeon said they would give me better results altogether if I did all four. I only want the one thing I came in for. Is it okay to say no to the rest?

Dr. Chang (06:27):
Well, first of all, it's always okay to say no to the things you don't want to do. You just went in for a consultation to hear what the surgeon had to say. So it's pretty common. I think there's ... Let me give you an example. There's patients that will come in and say, "Well, I would just like liposuction." And the surgeon might say, "Well, I can do just liposuction, but I recommend that you also get a tummy tuck and we tighten the muscles and remove a little bit of excess skin here or there." The patient might feel like, "Hey, well, you're trying to upsell me or you're committing me too too much surgery that I'm not ready for. " Or similarly, somebody might say, "Hey, I want a neck lift." And they come in-

Jackie (07:07):
Always.

Dr. Chang (07:08):
... and the surgeon ends up talking to them about a facelift, a neck lift, fat grafting, maybe some eyelid surgery, lasering, and a brow. And they say, "Wait a minute, that's four surgeries," like this question, four surgeries that I wasn't thinking about, and it's way more expensive. But I think that, at least in our practice, we want to see the whole picture and get them the best result. And sometimes it takes a little bit more of a comprehensive plan to do that. And we can see beyond what just liposuction might do. You're going to have a lot of loose skin. The stretching of the rectus muscles that causes a little abdominal weakness and bulging, that's never going to get better. You are not going to be satisfied. I know this is not going to be the result I can produce for you if you give me all the tools.

Jackie (07:57):
Yeah. I find myself, even now having this conversation with friends, people not in the industry because yeah, I can see from the outside how it seems like, oh, we're just trying to take your money, but it's just knowing the bigger picture and knowing that I can see what you want and you're not going to achieve this look with just the one procedure.

Dr. Chang (08:18):
Right.

Jackie (08:19):
So like you said, it's always good to say no, but you also have to listen to the advice of your surgeon and understand, okay, I don't want all of this, but maybe I won't look like this photo I brought in.

Dr. Chang (08:30):
Right. I tell patients, I want to hit a home run. I want to make sure that this is perfect, you're happy and-

Jackie (08:38):
Yeah, you want the best result. Yeah.

Dr. Chang (08:40):
I want to put you on a billboard or American Airlines Magazine and say, look at this incredible before and after and look how wonderful my happy patient is. But if you don't give me all the tools and you tie one hand behind my back, that makes it a lot harder to achieve that. And I also tell patients, I don't want to make a big incision. That's more incisions for me to stitch up, more things for us to watch heel and worry about and make sure you're doing well and scars to fade. But if you need to have something to tighten up the skin, there's not another choice. If we need to lift the breast, we have to do that. Otherwise, the shape will look bad.

Jackie (09:19):
So how do you handle that in a consultation? Say they're there for implants and you're like, "It's not going to look good." You also need a lift and they're very anti. Are there times where you just say, "Well then I can't do this or do you compromise or is it patient specific?"

Dr. Chang (09:35):
So in the case where I am sure that they need a lift, I often will explain to them why I think they need a lift. I will draw it for them as to what we are planning to do and why we need to do that. I'll show them, look at the measurements of how far this has to come up. If we were to skip this part, yes, you'll have a mound on your chest, you will have a volume, but it won't be in the right places. It won't look right. And once you can kind of show that to them, they understand still patients may not agree to it. They may say, "I'm still not ready for that. I didn't have my mind wrapped around that. " That's okay. And they can just sort of go home and think about it. But oftentimes patients say, "Okay, I get it. " In the back of their mind, they kind of knew.

(10:28):
They say, "Oh, well, I wish my breasts were up here like this. Well, what are you doing?You're pulling your skin up. Oh, I wish my face was just a little..." You're pulling your face up, you're lifting it with your fingertips. So you kind of know what we're doing here. It just sounds scary and may not be ready to actually hear it from the doctor.

Jackie (10:48):
Right. So then we get to surgery, you have agreed on everything, the consent process, the surgeon will come in the day of surgery, they'll write out the full procedure on the consent form, kind of go over what we're doing and the risks, and then we have the patient sign before the surgery just to make sure everyone is on the same page of exactly what we're doing. And so the patient will sign that form, the surgeon will sign that form. And then we always have a witness, which is usually the nurse that's going to be in the room for the procedure, sign that consent form as well. And then another safety step that we do is the surgical timeout where before we begin the procedure, we will read the exact consent that the surgeon and the patient signed in the room so that everyone in the room knows exactly what procedures we're doing for that case.

Dr. Chang (11:47):
Yeah. We're fortunate in the sense that we're doing elective surgery.

Jackie (11:50):
Yes.

Dr. Chang (11:51):
So we get to plan things out knowing pretty much exactly what's going to happen. There's always a chance something will be different from what we expect, but that is very, very rare.

Jackie (12:01):
Very rare.

Dr. Chang (12:01):
Extremely rare. And it should be in elective surgery. You should have thought out the plan. Everybody agrees on the plan, including the patient and the staff, and then the whole team is on board, including the patient and the surgeon.

Jackie (12:12):
Is there any circumstance in plastics where you would override patient's expressed wishes?

Dr. Chang (12:20):
So I actually saw this online, a question that somebody had put into a discussion forum that they had gone into surgery for an breast implant exchange. And they discussed with the surgeon, "Oh, I'm going to go between 300 and 400 ccs, a little upgrade." And they thought they had like 250 or 300 CC implants to start with. So they were going to go maybe a hundred ccs more. When they came out, they had a card that said they were in 500 or 600 ccs and they freaked out. But lo and behold, when the surgeon to remove the implants, they were bigger implants. They were like 400 Cc implants.

(12:58):
So the surgeon knew that in order to achieve what the patient wanted, which was an increase in size with new breast implants, that they had to have a delta or a difference of at least a hundred ccs. And so they made the decision under anesthesia to increase the size. And so that's a very tricky thing. And I think that's hard because neither the patient nor the surgeon knew the accurate number in the first place.

Jackie (13:23):
That is tricky. And that's why when we give you your breast implant card, it is very important to save it and keep it in a nice place because in 20 years when you're coming to get an exchange, it's very helpful to know what's in there. And a lot of patients do not know.

Dr. Chang (13:40):
This is also a good segue into another point, right? People can get hung up on the number, but what she really wants is the look. She's there because she wants to switch them out to improve the look a little bit bigger, not totally different, not smaller. Those objectives are very clear. So in the end, the surgeon delivers what she's looking for a little bit bigger. Ultimately, she was comforted by the comments because everybody in the comments and the discussion thread were very supportive and said, the surgeon did what they had to do.

Jackie (14:19):
Well, and I think also that's just a conversation you have beforehand. Everyone knows we're going in blind, we don't know what's in there. I think just setting the expectation for the patient like, "Hey, we're going to try to achieve your goals based off what we find when we're in there." So I think transparency and just having these conversations while you're consenting the patient can eliminate these issues, right.

Dr. Chang (14:46):
100%.

Jackie (14:47):
So this brings us to this headline, I don't know if you saw this, in September 2024, Cherise Doiley, a professional birthing doula and mother of three, was 12 hours into labor when nurses wheeled a tablet to her hospital bed and put her in a Zoom courtroom. She had refused a fourth C-section after a prior surgery left her hospitalized for a week with hemorrhage. The hospital went to the state attorney, a judge, a dozen doctors, and lawyers on screen, and Doyle alone, no lawyer from a hospital bed. So did you see this story?

Dr. Chang (15:19):
So you know I saw this.

Jackie (15:20):
Yeah.

Dr. Chang (15:20):
I'm on social media way too much.

Jackie (15:22):
Yeah. And Reddit.

Dr. Chang (15:24):
My wife just makes fun of me and teases me all the time and I'm on social media. So I did see this. I didn't dive that deep into it actually, but you didn't see it, did you?

Jackie (15:36):
I didn't.

Dr. Chang (15:39):
So I scrolled upon this and this woman is on a Zoom call with probably nine other screens and she was getting mad at the judge and mad at the proceedings. And the clip that I saw was she was upset, one, that there was having this Zoom court intervention, but two, also that there were no people of color. She was upset that everyone was white on the call and there were no African American or people of color in the courtroom or in the representation and physicians. So it brings up a couple different things, but essentially she was in the care of an obstetrics team and I didn't read these details, so I don't know, but I assumed that there was ... She had had previous C-sections and she, I guess, was laboring or not progressing or something like that. And so the care teams decided we need to do a C-section here because of your history or because of the clinical situation. And so they were pushing for that and she was refusing. She's a doula, so she has some background knowledge of the birth process. She's had kids before. She's also done that. And so she's there advocating for herself, but she also feels that the proceeding is somewhat biased against her because of the makeup of the group. And so she's upset. And I believe later on that day, she ends up going forward. They take her for an emergency C-section, right?

Jackie (17:21):
Right. So apparently in Florida, the only condition where you can be forced into a procedure against your will is pregnancy. And so their argument was the fetal life.

Dr. Chang (17:35):
Right. Obviously there's two-

Jackie (17:37):
There's two people now that you're caring for.

Dr. Chang (17:41):
I mean, everybody wants to say who's right and wrong. Ultimately, everybody wants a happy ending in this situation. I think too often in our world, in our country, and we're fighting each other, but we all want a happy mom, a happy, healthy baby, happy doctor, happy nurses that are like, "This all worked out great. And congratulations. You have your fifth kid or whatever." So the goals are all aligned and I think that we have to be careful because everything seems like we're always fighting each other in the media world, but this is tricky. This is tricky.

Jackie (18:18):
It is.

Dr. Chang (18:19):
I think that the real problem that also comes into play here is the legal process, right? So the doctors are like, "Well, if this baby dies and we didn't push hard enough against this woman-

Jackie (18:33):
Right. Is this on us?"

Dr. Chang (18:34):
Yeah. Right. So can the mom legally sign a way that say, "Listen, I understand the risk. If my baby dies, then that's on me. " I don't know if that's an okay defense.

Jackie (18:46):
I agree. Yeah. And someone had mentioned, well, she had previous hemorrhage, that's why she's refusing. I also don't think it's necessarily true just because you had one issue with one procedure, that doesn't mean that you're going to hemorrhage again from another C-section.You could also argue, "Well, if we don't do the C-section, you could hemorrhage vaginally and lose the baby altogether." So I don't know if using a past C-section is a good enough reason to say, "Well, I never want one again."

Dr. Chang (19:21):
Yeah. I think the other thing is that there's always a risk of doing a procedure, but there's also a risk of not doing the procedure. And as surgeons, as doctors, we're always balancing those things and people don't understand that part of it. I think people are so scared of the intervention being the dangerous part, like, "Oh, the anesthesia did. Well, if we did this without anesthesia, I'll be way more dangerous."

Jackie (19:47):
Right.

Dr. Chang (19:47):
We can't control your airway, can't control your blood pressure, can't control all these other things or whatever." So in surgery at some times, although there is a scary part upfront, the amount of control you can get in those situations can be well worth the uncontrolled part of doing a VBAC or vaginal birth after cesarean, which you could rupture your uterus, you could have all sorts of other problems that could be much more dangerous. And so I think that's where they're coming from. But ultimately, I think she had the baby. I think she had the baby. The baby was healthy or maybe I'm just making this assumption, but I think afterwards she was still upset, but she was just like, "Leave me alone. Let me go be with my child." So I think it ended up okay in terms of that such part of the thing, but the process was quite harrowing, I think.

Jackie (20:40):
It's a weird situation because there is a baby involved, but at the end of the day, we want what's best for the patient and we want the patient's voice to be heard too. So that's why we do those surgical timeouts. We have multiple people in the room, the anesthesia provider's also talking to the patients beforehand. So we've all spoken to the patient. We all hear what the patient wants and desires. And then that's our role in the operating room is to speak up, say something if the surgeon's trying to veer from the plan. I think that's why those safety measures exist.

Dr. Chang (21:15):
Yeah. And that's why it's good to also have a team that's taking care of you instead of one person in the back of the office one-on-one. I mean, that's not a good setup for success, I think, in most cases.

Jackie (21:29):
All right. So when a patient says no to something that you're recommending and you actually listen, what does that do for everything that comes after? Say you asked-

Dr. Chang (21:40):
I actually listen once in a while.

Jackie (21:43):
You suggested the four procedures. They said, "No, I just want the one." So you go forward, maybe you don't love the result you got, so now what?

Dr. Chang (21:52):
Well, it's always a combination for the outcome of what do I love? Do I love the result and am I satisfied and what does the patient want and what are they satisfied? Sometimes we have to check our egos as surgeons and say, "You know what? It's not my favorite outcome, but if the patient is getting what they want, that's what my job is, is to deliver the patient what they want. " Now, there are certain times when you have to reign it in a little bit, but if it's reasonable and it's safe, in my opinion, I think that we can often come to a compromise as long as the patient is making what I feel is an educated decision. So ultimately, I think my judgment or my satisfaction is important in terms of making sure I did my best work, but the patient is even more important.

Jackie (22:50):
All right. Love that. All right, guys. Well, I guess we got to go see some patients, right?

Dr. Chang (22:54):
Yeah, it's time. I got to go back.

Jackie (22:57):
Please comment, let us know what you think about this crazy situation, and then also give us a like and a follow and a subscribe.

Dr. Chang (23:05):
Yeah, we'll be back soon.

Jackie (23:06):
All right. Thanks guys.

Dr. Chang (23:08):
Thanks for listening to Secret Services, the podcast where we see everything and say nothing except right here. I'm Dr. Christopher Chang, double board certified plastic surgeon located in Tysons, Virginia. Follow us on TikTok @CongressionalPsurgery or on Instagram @congressionalplasticsurgery. To send us a classified message or to hear more episodes, go to secretservicespodcast.com. Links to everything we talked about on today's show are available in the show notes. Oops, patient's here. We got to go.