seeking perfection

Tuesday, December 1, 2015

Another week of NFL football is in the books, as well as another week of referee controversy. The Monday morning quarterback mantra from fans has always been “just get it right” and that led to the use of coaches’ challenge, referee review and the frustration of the home viewer having better angles on replay than what was available to the people actually at the game. Not so long ago, missed calls were part of the game experience and allowed players, coaches and fans to know that referees would miss calls. Seeking perfection led to the realization that perfection may not be attainable even with all the technology in the world. Welcome to the world of medicine where perfection is expected regardless of the price and the use and abuse of technology is an expected consequence.

Let’s talk about what happens with a patient complaining of chest pain or shortness of breath happen. Everybody worries about a heart attack, but there are other potentially life threatening diagnosis options that need to be considered. Pulmonary embolism, a blood clot to the lung, may be tough a diagnosis to make and it is hammered into every medical student, intern and resident that a PE needs to be considered in any chest pain patient. Their mantra: do NOT miss this diagnosis. Historically, the diagnosis was tough to make and relied on tests that would indirectly help find the lung blood clot. Ultrasound of the legs would look for a clot that might have travelled to the lung. A lung ventilation perfusion scan might show a lack of blood flow to part of the lung and presume that a blood clot was stopping blood circulation. The gold standard was an angiogram where catheters were threaded into the pulmonary arteries and dye injected.

Technology changes and gets better over time. CT scan is now the test of choice to look at the blood vessels in the chest and find blood clots. CT is readily available in even the smallest hospitals and with the marvels of the internet and virtual radiology; a specialist sitting at a monitor thousands of miles away can interpret the images immediately. But technology has spawned a new problem; the mantra of perfection to never miss a pulmonary embolus has led to a spike in chest CT scans to look for the elusive diagnosis.

But there may be a flaw in technology. Unlike the images, the result of the CT scan may not black and white. There is no controversy when a large pulmonary embolus is present in the large lung arteries, but as the arteries branch and get smaller, the ability to see the clot on CT gets more difficult. Radiologists can disagree as to whether a blood clot exists and whether the scan is positive or negative. Adding to the confusion is the idea that a tiny PE may be no big deal and people may have always had small clots that were never appreciated in the past, because old technology couldn’t find them.

The quest to find every last clot has led to doctors in North America to perhaps order too many CTS. With the fear of missing a diagnosis and perhaps being named in a lawsuit, only 1 in 8 CTs performed for a pulmonary embolus is positive for a clot. In Europe, where risk tolerance might be higher, that number is 1 in 4. More than 85% of scans in North America are normal!

So who cares if more CTs are done? Aside from the price, (technology does not come cheap), there is the risk of excess radiation exposure, the potential kidney damage from the intravenous dye injection, and the long-term risks of anticoagulation. Blood thinners will be prescribed even for the tiniest of clot, regardless if the clot was responsible for the patient’s symptoms. Patients with pulmonary embolus are prescribed six months of blood thinning medications with all the potential bleeding complications.

NFL officiating perfection is a potential. Enough camera angles combined with unlimited time to review each video clip would make certain that every referee call as correct but that would deliver an unwatchable game. There is big cost to achieve perfection in medical diagnosis, both financial and with medical compilations. Perhaps it may be that not being perfect may be perfectly reasonable.

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