Monday, December 5, 2011
Instant replay has challenged the way we watch sports. Referees making a decision in real time have their accuracy compared with a review run in slow motion, from different angles and repeated until frame –by-frame there is irrefutable evidence that their call cannot be reversed. The replay routine has become part of the television culture. A play on the field and a referee’s decision leads to a timeout. This invariably leads to a commercial break and upon return, the viewer often continues to watch and wait along with the players, coaches and fans in the stadium as to the final verdict. Sometimes calls are overturned and results reversed. If only the real world could work that way.
In medicine, there is usually plenty of time to make a decision about a diagnosis or treatment but on occasion, that time frame can shrink to minutes or seconds depending upon the clinical situation. In emergencies, recognizing the problem needs to be followed by quick action if the patient is going to do well but along with that speed comes the potential for error.
A stroke patient has a treatment window of 4½ hours from onset of symptoms to get TPA, a clot busting drug that can potentially restore blood supply to the damaged part of the brain. In that time, the patient or family has to recognize the situation and get to a hospital, the stroke has to be diagnosed clinically, CT scan and blood tests completed, indications and contraindications for the drug need to be considered and a discussion with patient and family about the risks and rewards of giving TPA. There is a time crush since the earlier the drug is administered, the better the chance for brain recovery. But if the drug is given to the wrong patient, disaster can occur with potential catastrophic bleeding into the brain. There is no instant replay and no do overs.
The heart is a two stage electrical pump and palpitations or skipped beats are a common patient complaint. Most often, the cause of the skipped beat is benign and a variation of normal. Reading an EKG and rhythm strip can be challenging and missing a potential life threatening rhythm disturbance can be potentially life threatening. Medications or electric shock may be needed to stabilize the heart rhythm. Protocols exist to help guide care if the care giver can recognize the type of abnormal rhythm and combine that decision making with the clinical presentation of the patient. One can take all the time in the world to evaluate the patient who is awake with a normal blood pressure and decide what to do. The urgency increases if the patient is unconscious, ashen gray and barely breathing since time is of the essence. Stress levels can be high in the ER when a patient presents in extremis but if the care happens in the patient’s home with the paramedic providing care in a poorly lit bedroom with no backup at the bedside, the decision making stress is immeasurable. If the wrong drug is used, an abnormal heart beat can turn into no heart beat at all.
There is replay in medicine but it usually isn’t instant. Bad things can happen to patients. Diagnoses can be missed or wrong. Complications can occur due to medications errors or surgery technique. Patients can fall going to the bathroom or roll out of bed. Figuring out what went wrong not only focuses on the individual situation but also where there was a system issue that could have prevented the error. Peer review allows doctors to explain their thinking to their colleagues. It isn’t meant to be punitive but instead a learning opportunity for the doctor and those who are on the review committee. Fear of punishment might prevent openness of discussion, and for that reason peer review is often shielded from the courts. Some hospitals use safety huddles as soon after the incident as possible to review protocols to determine if they were followed. And if they were, perhaps the protocols needed revision. Learning happens when the patient does well and when the patient does poorly. But people in the medical field, like in most jobs, tend to forget their victories and dwell instead on the one time a mistake occurred.
There are seven officials on the field for an NFL game and more than that many cameras watching every play from a variety of angles. Yet Monday morning quarterbacks have plenty to complain about. In medicine, decisions are made without the safety net of an instant replay. When time allows, consultations and other the gathering of other opinions are a nice option but some situations demand urgency and emergency. Yogi Berra said “When you come to a fork in the road, take it.” Sometimes a decision just has to be made…now. Being perfect is the goal but being wrong is the real world.