Best of one…winner takes all

Tuesday, June 2, 2009

The basketball and hockey finals remind me that sport doesn’t always reflect life. Best four of seven to win a Stanley Cup or NBA championship may develop drama that plays out over a couple of weeks, but life is more like the Super Bowl. One kick at the can is all that you get and replays rarely occur.

The playbook for medical care is pretty straight forward. You take a history of what’s happening, examine the patient and decide what the potential diagnosis might be. You order some tests, make the diagnosis, offer some treatment options and hopefully the patient gets better. Some doctors are better at taking a history; others have magic fingers to examine a patient and may be able to feel a lump or hear an unusual heart sound that may elude their colleagues. Some have better intuition and can sense disease before it becomes readily apparent.

The kick at the can often happens when a patient with chest pain arrives at the door and an EKG happens. The heart is a two stage electrical pump and the electrocardiogram can help evaluate the electrical flow as well as the heart muscle that’s doing the pumping. The squiggles that appear on the paper are electrical impulses generated by the heart muscle cells as they contract. The 10 measuring electrodes (1 on each arm and leg and 6 across the chest) allow the doc to look at the electrical signals from a variety of angles. Interpretation takes skill and practice but reading an EKG is like learning to read and write English. There are plenty of exceptions to the rule of what is normal and what isn’t.

The stakes are pretty high. If the patient is in the midst of a heart attack, meaning that a blood vessel is blocked and part of the heart muscle isn’t getting oxygen, every minute delay in restoring blood flow equates to muscle tissue death. Lose enough muscle and quality of life suffers dramatically. Sometimes the EKG, by itself, makes the diagnosis but sometimes the EKG is stone, cold normal during a heart attack and sometimes the EKG shows a heart attack when one isn’t happening.

The key to making the diagnosis is the marriage of the patient’s history and the EKG reading. Add the risk assessment of high blood pressure, high cholesterol, diabetes, family history and smoking and the doctor’s experience and hopefully the one kick at the can gets it right.

EKGs aren’t easy. Dozens of textbooks are devoted to their interpretation. Subtleties are decided by half a millimeter here or a millimeter there. Changes in body temperature, electrolyte levels in the blood stream and medications can all cause EKG tracings to look like a heart attack or appear as if the heart is about to stop beating. And just as it’s bad form to miss a heart attack on the EKG, it’s equally bad form to pronounce disaster when it doesn’t exist.

One kick at the can happens in a lot of jobs. Car mechanics need to get things right so that wheels don’t fall off at 65 mph and plumbers prefer not to have houses flood after their work is done. But people have an intimate relationship with their doctor. It’s tough to realize that the life and death decisions depend upon a squiggle on a piece of paper and there is no best of seven to decide the winner.

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