研修歯科医の全身麻酔で心停止、男性遺族が告訴手続き（2008年12月3日21時52分 読売新聞）
告訴状によると、当時の指導医らは０６年１０月、重い腎臓病だった男性に人工透析のための手術を行った際、心機能が低下しているのに全身麻酔を選択するなど術前の評価を十分せず、麻酔も歯科医に単独で行わせた。その結果、男性は直後に心停止に陥り、意識不明のまま２か月後に死亡した、としている。
「麻酔も歯科医に単独で行わせた。」というところが一番問題視されているようですが、どうなんでしょ？
私の素人判断的には、重い腎臓病の患者に対する全身麻酔というのは、かなり神経を使いそうな感じがするんですが、つまり麻酔としては難しい部類じゃないのかな、という気がするんですが、ご遺族としては、そういう難しい麻酔を専門の麻酔医が担当しなかったことが納得できないように読めます。
ご遺族が、他の医師の意見を聞いた上での告訴かどうかは、記事からは分かりませんが。
院内の事故調査委員会でシロ判定したとのことです。
麻酔経過はモニターされているので、外部評価しやすい医療行為の部類に入ります。
クロをシロと強引に丸めることも考えにくいでしょう
歯科医といっても、麻酔研修で医師と同じ研修が受けられることは、研修制度として認められているものです
【研修歯科医の麻酔】に全く問題がなかった場合、タイトルに持ってきた読売新聞は、報道の責任をどう取るというのだろう？
麻酔直後に心停止ということは、直ちに麻酔科専門医含めた救命処置が行われたことでしょう。直ちにです。
相対当事者の風評被害を無視して、告訴状の内容が正しいかどうかの吟味ができないマスコミが報道するのは拙速すぎるでしょう
警察、検察の判定を待って報道するくらいの慎重さが必要なのではないのだろうか？
数日争うほどの意義がある報道かどうか？
自称”被害者”による他称”加害者”への人権侵害の回復をどうやって図るというのだろう？
>No.1 Med_Lawさん
・・・また「マスコミが」ですか。そういう問題じゃないと思いますよ。
それじゃネット上の掲示板で一方的に「告発」のキャンペーンでもやったほうがベターだとお思いですか？何でもかんでも「マスコミがマスコミが」と一つ覚え芸を繰り返すのはいかがなものでしょう。
記事によると「人工透析のための手術」とあります。私は高齢者医療や帝王切開のベビーキャッチ以外は手術室とはあまり縁がなく、新聞記事も情報が足りないため推測になってしまいますが....
この手術はブラッドアクセス造設術ではないかと思います。
リンク先にあるように局所麻酔で可能な手術ですが、麻酔法(局所麻酔か全身麻酔かの選択)は個々の患者さんの症例や希望にあわせた麻酔科医・執刀医の裁量が認められるべきだと思います。
この刑事告訴の争点は1.全身麻酔の必要性 2.麻酔指導医の立ち会いが無かったこと 3.研修歯科医による麻酔が、患者さんの死と因果関係があるかということになると理解していますが....
3.に関しては市立札幌病院の前例があり、医師法違反になるのではないでしょうか。(実情と理想は別として)
業務上過失致死に関しては、起訴されたら新過失論に従えば予見可能性アリ・結果回避可能性アリ・結果回避義務アリで有罪になってしまいそうですから....起訴前弁護次第と考えてよろしいでしょうか？
個人的には麻酔科医が行っても致死的不整脈やアナフィラキシーショックなどは起こりえますし、死を回避できないことは十分あり得るため、過失は認められるものの死との直接の因果関係は認められないという考えもあり得るのではないかと思っています。
あと、当該病院の手術室のスタッフ充実度がどの程度かは知りませんが、、麻酔科医の数が十分足りず、指導医が複数の手術室を掛け持ち、研修医が麻酔をかけているという風景は至極自然だと思います。というのも全例麻酔指導医が常時立ち会っていなければならないとすると、現状では手術件数は激減させざるをえないからです。
言い捨てたようなコメントになっているので付言しておきます。
>警察、検察の判定を待って報道するくらいの慎重さ
これは言葉を変えると「大本営発表」があるまでマスコミは黙っていろ、ということです。「大本営発表」準拠以外のことを報じるのは「自粛」しろと。そうして「自粛」して「大本営発表」以外のことを報じなくなれば、当局が報道機関に干渉することもなくなるから安泰だろう、と言っているも同然です。
それは、国民主権を謳い、それがために報道の自由を保障した民主主義国家のあり方とは、相容れません。
報道にバランスが必要なこと、一方の言い分のみに依存してその言い分こそが事実であるかのごとく報じてはならないことは当然ですが、それは決して「警察、検察の判定を待って報道するくらいの慎重さ」などではありません。
ネタとしては、これを検察が不起訴にして、検察審査会が二回、不起訴不適当にするくらいでないと、犬も食わないでしょう。
告訴というものは、書類送検以前の段階です。
取り下げられなければ、いずれ確実に少なくとも書類送検にはなりますが（法律の規定によって嫌疑の有無にかかわらず送検しなければならない）、告訴の段階では、それは私人たる被害者の主張に過ぎません。
ですから、この報道というのは、要するに今回の死亡案件について、病院側と遺族側の間に揉め事がある、または揉め事が解決していない、ということを示しているだけです。
それによって、直ちに医師の刑事責任があるのではないかという認識が生じるとしたら、そういう認識が生じることを問題にすべきことになります。
要するに、一般読者の刑事手続に対する誤解を解いていく必要があるということです。
この件については、歯科麻酔科学会のホームページに載っていましたので、見てみてください。
問題点があるとして、いわゆる過熟研修という状況だったはずですので、医師法との問題だと思っておりました。ただ、医科の麻酔研修医であれば、あのような薬の使い方をすれば、指導医にかなり怒られるような量がホームページ上に書かれてはいます。
いったん、示談になっていたはずですが？
個人的には「研修歯科医の練習台（言い方は悪いですが）」に同意した時点で（事前にムンテラしてなければ論外ですがさすがにそれはないでしょうから…）自己責任な気がするなあ。オレだったら断固断る。
この件については、確か、歯科医であることをはっきりさせていなかったはずです。
初めて書き込みます
モトケンさまはこのエントリーを立ち上げるにあって
①医療行為に対する刑事告訴
②歯科医師が医療行為を行うことにあたってのグレーゾーン
のどちらを主にお考えなのでしょうか？
①についてはいまさらお話するのも憚られるかとも思います。しかし②については札幌の救急医が告訴され敗訴しているままだったかと思います。なにかその後、制度変更などの進展があったのでしょうか？
差支えないようでしたら教えてください。
これですね。
三井記念病院および日本大学歯学部歯科麻酔科の医科麻酔科研修に関する 2学会合同特別調査委員会報告書
2007年9月14日
社団法人日本麻酔科学会の2007年09月18日のニュースと添付の報告書を読みました。
麻酔医不足が、問題の本質と思います。
余り知識・情報は持っていませんが、三井記念病院は、場所も東京であるし、他の病院よりも恵まれた環境にある。しかし、麻酔について、このように対応せざるを得ないのかなと感じました。
タカ派の麻酔科医様
ご紹介の歯科麻酔科学会の調査委員会報告書を読んで見ました。
厚生労働省の研修ガイドラインに適合していない事例であることは、病院側も認めているのですね。認めている違反についてご遺族に対する説明や慰謝の提示は、実際どういう経過だったのでしょうか？
私には麻酔処置の当否を論ずる医学的知識がありませんが、どうも報告書や報道されたご遺族代理人弁護士の談話などからすると、病院側が責任逃れと受け取れる態度に終始して、誠実な態度とは言えない対応だったことが本質であるように思えます。事故直後の病院側とご遺族との擦れ違いが、２年経過して刑事告訴に発展してしまった印象が否めません。病院側の初期危機管理対応の不手際の結果の告訴、と言えるのではないでしょうか。
私の主眼は１です。
モトケンさんの主眼が,医療行為に対する刑事告訴であるということなので、敢えて非難覚悟でコメントします。
麻酔方法の選択も、薬剤の選択も、おかしいと考えます。透析を長期に受けている患者の動脈硬化は当然予測されるべきであるし、水分量についてもかなり細やかな管理が必要です。それは、路面凍結した道路を運転するような慎重さが必要です。それを普通の道路のように運転すれば、どうなるかは、経験のあるドライバーならわかるはずです。血圧が下がりやすい薬を使って、血圧が下がれば危険な患者の麻酔をするのが、過失というレベルの話ですむというのはおかしいだろうと思います。
一定の確率で発生する、医療行為中の不良事象。ご遺族と病院の認識に差があれば告訴や民事提訴はやむを得ないでしょう。検察が起訴しないことを期待しています。
血液内科医です。初めて書き込みます。
刑事告訴ということですから、今回のケースの問題点は
(1) 業務上過失致死：麻酔にかかわる一連の医療行為に患者を死に至らしめる過失があったか否か
(2) 医師法違反：歯科医が（指導医の下とは言え一時的にでも）単独で麻酔を行ったことが違法か否か
であり、インフォームドコンセントや研修ガイドラインの遵守といったことは民事の範疇だと認識しています。外していたらすみません。
(2)に関しては正直分かりません。局麻は普通にOKのはずですから、全麻をかけたことが問題なのでしょうか？
(1)については、自分は麻酔科も血管外科もほぼ素人ですが、次の2点が疑問です。
− 日本透析医学会のガイドライン（http://www.jsdt.or.jp/jsdt/17.shtml、第6章）によれば、上腕動脈の動脈表在化の利点は「手術が容易」「局所麻酔で施行可能」。今回のケースでなぜ全麻が選択されたのか？
− 上記ガイドラインでは、動脈表在化の適応として第1番に「内シャントによる心負荷に耐えられないと予想される症例」が挙げられる。No.10の報告書によれば、この患者さんは「過大シャントによる心不全を発症」とあるので、心機能低下は術前に認識できでいた可能性が高い。心機能低下が明らかな慢性透析患者に全麻となれば、かなりのハイリスク麻酔だと思うが、報告書を見る限りAラインも確保せず、気道確保はラリンゲアルマスクとのこと。これはこの患者さんのリスクを甘く見すぎていなかったのか？
以上、専門の先生のご意見も伺いたいです。
個人的には、リスクを甘く見ていたのであれば、仮に麻酔医が担当していても結果はさして変わらなかったと思うので、
「麻酔医が担当していれば死なずに済んだのでは」
という遺族側代理人のコメントは本質から外れており、「（家族の）死が無駄にならぬよう」にしたいのなら、担当した歯科医を刑事で吊るし上げても意味がないように思います。
三井記念病院のホームページに、事故調査委員会の報告書がUpされています。
インフォームドコンセントやチーム医療の面で問題はあったようです。しかし、2つのケース（事故調査委員会の報告書にはK氏のケースについても記載があり。）共、歯科医師の歯科麻酔研修と関係がなかったなら、何も起こらなかった気がしました。三井記念病院は、2007年6月1日で歯科医師の歯科麻酔研修は終了したと述べており、今度はどこかの病院で麻酔医不足が生じているのでしょうか？残念ながら、麻酔に関する全体像が今ひとつ把握できていません。
これは、鈴木利廣弁護士が委員として参加された２学会合同調査委員会が作成した調査報告書が、ガイドラインからの刑事罰相当の逸脱を指摘し、ために遺族からの刑事告発が行われていると考えるのが順当であろうと思います。
以下は一般論ですが、透析９年の高齢患者さんに全身麻酔が必要となった場合、多くは動脈硬化が年齢相応以上に進み、循環の管理が難しくなります。
また、術前の透析での除水量などについては、透析担当医とのやりとりも必要で、多めに引けているようであれば血圧低下ではボリューム不足を考えますし、残っているようであれば逆に溢水気味となっている可能性を考えます。
医師としても難しいのではないかというご指摘はごもっともですが、歯科医師であっても、そういう患者さんに歯科口腔外科の治療の必要上、単独で全身麻酔をかけることは、特に珍しいことではなくなりつつあります。
結果として、予備力の少ない厳しい症例に対して歯科麻酔医が充分な評価と対応ができなかったという指摘はあまりにも表層的であると言わねばなりません。
問うべきは指導体制とガイドラインの遵守もさることながら、ガイドライン自体の成熟度の方でしょう。
そういう意味で、研修症例数の「過剰」を指摘しておきながら、安全な歯科麻酔という目的に到達できていない現状のガイドラインの内容の適否に踏み込むことなく、その遵守体制の徹底のみに着眼した２学会合同調査委員会報告書は不当であり、それによって刑事告発を惹起したことに対して深刻な反省と再発防止の求められるところでもあると考えます。
確かに、このガイドラインはなかば突貫工事で作られたものではあります。しかしながら、であるが故に、修正の必要な事態を見逃すことなく、改定に向けた努力が為されるべきであろうと思います。
自己レスです。
三井記念病院の事故調査報告書
http://www.mitsuihosp.or.jp/contents9/pdf/dental_houkoku.pdf
を読みました。
より詳細な経過が記載されていますね（ある経営コンサルタントさん、ありがとうございます）。
やはり心機能低下は術前に認識されていたようです。
ただ「ボウリングをしている（ボウリングができるくらい予備能力がある）」という情報が一人歩きしてしまったため、スタッフの誰もが全身麻酔リスクについて深刻に考えなかった結果、不十分な体勢で麻酔に臨んでしまった、という経過が見てとれます。
一連の医療行為全体を通して、民事的なところも含めて、違法性が全くなかった、というのは困難な事例と思われます。しかし、当事者全員に刑事罰を科すのが相当かということになると、私にはすぐ答えが出せません。
ただ、医療をよりよくするという立場で考えれば、歯科医師であったということをもって、直接の担当医に医師法違反で刑事罰を科すことは、やはり意味がないだろうと思います（記事からは、担当医も告訴されたかどうかはわかりませんが）。
お返事ありがとうございます。
個別の事故はわからない情報も多くて難しいものですね。
ちょっと話がそれてしまうので申し訳ないのですが、厚生労働省からガイドラインがでていれば医師法違反が疑わしいような行為もクリアできるものなのですか？ まったく他意はなく単純に法的な問題としてはいかがなのでしょうか？
市立札幌病院歯科医師研修に関して、歯科医師の医行為は研修の一環であっても違法と高裁判決がでていますが（下記URLなど）、そのあと法改正がされたわけでなくガイドラインが出ただけだと思います。
http://plaza.umin.ac.jp/~GHDNet/03/n6-shika.htm
救急救命士の気管内挿管実習なんかも法的に問題ないのかどうなのでしょうか？（それとも私が無知なだけ？）
一般論としてお答えしますが、検事が行政取締法規違反を処理するときには、所管省庁に関連条文の解釈を問い合わせることをよくします。
そういう意味では、厚生労働省からガイドラインがでていれば医師法違反が疑わしいような行為もクリアできる場合はあると思います。
ガイドライン自体が明らかにおかしい、というような場合はクリアできない場合もありますが、そういう場合でもガイドラインが定められており、医師がそれを守っていれば、情状、つまり処分のレベルはかなり軽くなると思われます。
場合によっては、法律違反であるが起訴猶予（不起訴）という処理も考えられます。
本事件については、読売新聞が報道しているように、現段階は、次の通り。
多分、警察はなんらかの捜査をする。捜査をすれば、検察庁に書類及び証拠物を送らなければならないのではと思います。（刑事訴訟法246条）
結果、検察庁は、公判を維持できずとして、不起訴処分にすると私は予想します。
一方で、今になって何故告訴したかですが、やはりインフォームドコンセントが不十分であったから、「麻酔医が担当していれば死なずに済んだのでは、と思うと悔やみきれない。」になってしまったのかと思います。
もう一つは、賠償金・民事訴訟に対する戦略ではないか？そして、読売新聞を利用することに現時点では成功したと思えてしまうのです。事故調査報告書の最後にも、遺族の了解が得られる範囲で公開と書いてあるので、遺族とある程度の話し合いはあったのだろうと思います。まさか、賠償金交渉でもつれた結果、遺族側が告訴状を送付するという手段をとった。（金銭解決が悪いとすると、問題解決にならないと思います。金銭以外で処理するとなると、処理できず、刑事罰を求めてしまう。医療費も保険料をカバーできるように、せざるを得ないと思います。）
なるほど、ガイドラインや通達というのはそのようになっているんですね。法改正は問題を含む場合もあるので現実的なパッチ修正といったところでしょうか。
お忙しいところありがとうございました。
＞読売新聞を利用することに現時点では成功したと思えてしまうのです。
この報道は読売の特ダネではないようです。その証拠に読売の報道（）2008/12/03 21:52より、共同通信（2008/12/03 19:23）の配信が先行しています。多分、ご遺族代理人弁護士は司法記者クラブなどに、プレスリリースを一斉に行ったのではないでしょうか。記事の文字量や読売がやや多いようですが、弁護士が特に読売だけに情報を出したとは思えません。
＞賠償金・民事訴訟に対する戦略ではないか？
この可能性は、私も大いにありうると思います。
> この可能性は、私も大いにありうると思います。
人によるとは思うのですが、この代理人弁護士は医療問題弁護団所属の弁護士でしょうか？
私も、読売新聞にのみ情報を流したとは、思いませんし、読売新聞は事実関係を（とりあえずは）正しく伝えていると思います。
但し、ごく一般の読者が読んだ場合に、どのような印象を受けるかと言えば、「三井記念病院ケシカラン」、「医者はトンデモナイ」のような印象を持ってしまうと想像します。
特に不況で、人員削減のような世相において、怖いと懸念します。
連投を失礼します。
No.27 を書いて思ったことですが、小泉容疑者が厚生労働省の元役人を殺害したことです。社保庁、厚生労働省、・・・医師・・・は、不公正な悪い人が多いといった風潮を許してしまっているように感じる部分があります。批判するなら具体的な事項をあげるべきが、感情のみで批判する。大勢の人がいる組織なら、中にはトンデモナイ人が混じるのは避けられない。にもかかわらず、組織全員が悪人だと批判する。
「大いにありうる。」の部分ですが、この件ではなく、一般的なこととして、変な風潮を意図的に利用する人がいたら、恐ろしいと思いました。
＞もう一つは、賠償金・民事訴訟に対する戦略ではないか？
残念ながら、刑事手続きを民事の有利に利用しようという戦略は、医療問題に限らず、よくあります。
ただ、民事を有利にするための告訴の利用は、受ける側も嫌がりますので、受理自体されないことも多いです。
ただ、本件のような、マスコミが食いついてきそうな「事象」については、告訴自体は受理せざるを得ないのでしょう（調査報告書も出ていますし）。
＞批判するなら具体的な事項をあげるべきが、感情のみで批判する。大勢の人がいる組織なら、中にはトンデモナイ人が混じるのは避けられない。
禿同です。
報道する側ばかりを罵倒するだけでは解決できない問題だと愚考します。自分の周りから、すこしづつでもいいので、受け取る側の「見方」を変えていくしかない、と思います。
>この件については、確か、歯科医であることをはっきりさせていなかったはずです。
あ、そらあダメだわ。同情の余地なし。まあ「練習台にさせてもらっていいですか？」とか言われて承諾する筈はないやね。
いつも思うんですが、「練習台」になる患者様にはなんらかのメリットがあってしかるべきです。割増料金払わなくてすむとか、２年待たなくていいとか、「ウチは研修指定病院だ！イヤなら他所へ行け！」と病院追い出されないですむとか…。
研修医がいる病院はそれなりに医療水準は高い、また研修医が手技がヘタとかで迷惑をかけるかもしれないけど指導医がいるから大ポカは起きにくいなどのメリットがあったと思います。
それが指導医レベルの人手不足がおきてるのが問題なのかと。
今後、急速に医師数を増員しようとしているのと指導医クラスが研修病院からいなくなるのがあわさって、指導の目がいきわたらないという事態は増えるんじゃないかと心配です。
医療を提供する側、受ける側どちらから見ても不幸です。
> 「大いにありうる。」の部分ですが、この件ではなく、一般的なこととして、変な風潮を意図的に利用する人がいたら、恐ろしいと思いました。
共同通信によると、主任弁護人は、調査報告書を作成した鈴木利廣弁護士が代表を務める医療問題弁護団に属する大森夏織弁護士であるようです。
（共同通信のHPの元記事からは相当する記述は削除されています。）
すぐＲＯＭに戻りますが，
＞指導医レベルの人手不足がおきてるのが問題なのかと
トップは変わらず，ロ－テ－ションで来ているひとの
経験年数が徐々に減っています。スレ違いなのでこのへ
んで。
2学会合同特別調査委員会報告書の15ページの「三井記念病院および日本大学歯学部歯科麻酔科の医科麻酔科研修に関する2学会合同特別調査委員会委員名簿」に、外部委員：鈴木 利廣（明治大学法科大学院教授）として書かれていますね。
ビジネス・スキームの透明性が問われるべきと思います。
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What consequence, if any, do pets have on older adults? Can a furry good friend inside the house counteract the feelings of lonliness and reduced blood pressure?
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