Tuesday, February 7, 2012
The latest Super Bowl is now history with memorable runs, catches and tackles. It commands a huge stage and it is a reminder that most fans want to see one team perform at a high level to win the game instead of making mistakes to lose it. Tony Dungy, television commentator and former NFL coach commented that he would speak to his players and remind them that mental preparation was key to winning the big game and they did not want to be that person to make a mental error. While it was acceptable to lose the physical battle on the field, a mental lapse was inexcusable. The same philosophy rings true for many who perform including those whose stage is the patient bedside.
Medical errors will happen regardless of the caring and well-meaning of the physician and nurse. The complexity of the human body and the increasing sophistication of medical care create many opportunities where things will go wrong. From complex technology to the most simple of medications, from the initial evaluation of the patient through diagnosis and treatment, every step of medical care can be the site where an error may occur.
While it may be an individual who makes a mistake, according to the 2007 Joint Commission Annual Report on Quality and Safety, the reason for the majority of bad outcomes is poor communication, not only between doctors and nurses but between doctors, patients and families. Less experienced providers sometimes rely on technology to affirm their clinical opinions and patients take comfort when xrays, CTs and other tests are used to look for the reason for their complaints. This reliance can lose sight of the fact that most diagnoses are made by talking to the patient and listening carefully. Patients and family need to listen as well and understand what the doctor recommends and how that might impact their situation.
A couple of examples:
Pulmonary embolus or blood clot to the lung can be a life threatening condition and the patient may complain of chest pain and shortness of breath. Usually the clots arise in the veins of the leg and pelvis and travel to get lodged in the lungs to cause symptoms. Usual risk factors include long travel in a plane or car, surgeries that require the patient to be bedridden and trauma. D-dimer is a screening blood test that measures blood clot breakdown products. It can be used to exclude the diagnosis of pulmonary embolus in LOW risk patients but a negative test in a high risk patient is not helpful. As well, the test is always positive in many situations like pregnancy, cancer and trauma (the test doesn’t care where the blood clot is located. The test to confirm a pulmonary embolus is a CT scan. Reliance on the results of a d-dimer demands that the doctor know the situation, otherwise a decision error can occur and a CT that should be done isn’t or a CT that shouldn’t be ordered is.
Many people take Coumadin to thin their blood and prevent blood clots. Atrial fibrillation, an irregular heartbeat is one indication as are deep vein thrombosis and pulmonary embolus. The dosage of Coumadin needs to be individualized for each patient just like the three bears, not too much, not to little but just right. When antibiotics are prescribed, the metabolism of Coumadin can be affected and the dosage adjusted. The doctor needs to remember to do this but the patient and family also need ot be aware that drug interactions may occur and question that potential. Too much anticoagulation can cause life threatening bleeding.
When a patient presents with abdominal pain, one worry is appendicitis. The classic symptoms of pain in the right lower quadrant pain, fever, vomiting and loss of appetite help make the clinical diagnosis. Some patients, though, don’t read the textbook and if the physical examination isn’t compelling, a CT may be ordered to look inside the bely without necessarily cutting into it. Unfortunately, it may take 12 hours for a CT to show inflammation surrounding the appendix and if the test is done too early, a false sense of security may develop and the diagnosis is missed. When the diagnosis is uncertain and the patient is stable, watchful waiting may be the best test to do. Talking to the patient combined with a repeat exam may help sort things out. However, both patients and doctors sometimes lack the patience for this approach. It takes communication and trust.
Some bad outcomes cannot be prevented. Some patients with diabetes or peripheral vascular disease are at increased risk of infection and poor healing. Some patients who need to be on blood thinners like Coumadin or Plavix will bleed even if their medications are appropriately adjusted. Some patients will be too ill or injured to survive an injury. Like on the football field, games can be lost if the other team plays better and infections, diseases and trauma are formidable opponents. For that reason, Hippocrates’ writing in Epidemics becomes a mandate for those practice medicine: Primum non nocere, first do no harm. Though the phrase is not found in his oath, its words bind those who care for patients.
Winning is the only thing that counts in medicine but complications and bad outcomes do occur. The goal is not to be the person who makes the mental error that loses the game.