taking time to care

Monday, April 13, 2015

After the first week of the season, the rules to speed up the game of baseball may be having some effect. Games are taking a little less than 3 hours to play, about 6 minutes shorter than last year’s average. It seems that what was once America’s past time, is suffering because the combination of a shortened attention span and the inability to be patient has caused its popularity to wane. People don’t tolerate waiting very well, even if the reason for that wait is compelling. And that brings us to why people wait in the ER.

If one were to watch Grey’s Anatomy ER or Nurse Jackie, it would be quite reasonable to assume that all medical problems could be solved in 44 minutes; the rest of the hour is filled with commercials and next week’s preview. But technology has yet to catch up to what is portrayed on television and movies. The idea that technology cannot be rushed is anathema, not only for the patient and family who are actively being cared for, but also those who are waiting fro the next ER bed to be open or nurse who can provide can provide care.

Patient flow in the ER is at the whim of available technology and even though the calendar says it’s the 21st century, high tech does not necessarily equal high speed. Consider the child with abdominal pain. Parents often are concerned about appendicitis, an inflammation that if unrecognized, can lead to bowel perforation, significant infection and major complications. Patients often don’t read the textbook and forget to present with the classic symptoms of umbilical pain moving to the right lower quadrant, accompanied by loss of appetite and vomiting. Physical examination can be compelling and an elevated white blood cell count, that often accompanies inflammation, seals the diagnosis and the patient is taken to the OR for an appendectomy. That was the standard of care forever, or until the availability CT scans became the norm, and that standard had surgeons removing normal appendixes 15-25% of the time. It was a reminder that other things could cause right lower quadrant abdominal pain.

The good news about using technology to look into the body is that it can help make the diagnosis. The bad news is that it takes time and radiation. And here is where technology can’t be rushed. In many hospitals, if appendicitis is a consideration, blood tests might be ordered to help give direction. Depending upon the tests ordered, it might take 30-60 minutes having the blood drawn, delivering the tubes to the lab and getting back the results. Instead of rushing to CT, an ultrasound might help make the diagnosis, but that is labor intensive and is helpful only if the appendix can be identified. If not, a CT scan might be required. Often the images can be taken with just intravenous contrast injected through a vein, but some radiologists prefer having the patient drink oral contrast to help outline the intestine. If that’s the case, the drinking time takes an hour, the scan itself 10-15 minutes and then another 30 minutes or more for the images to be reconstructed and interpreted by the radiologist. Even new math can’t make the answer add up to 44 minutes.

In chest pain patients, blood tests can help decide whether a heart attack has occurred. Troponin, a chemical contained within heart muscle cells, can leak out and be measured by a blood test. An elevated blood test equals a heart attack, but it may take 6-8 hours for the test to turn positive. That means a patient who presents within a few minutes after experiencing chest pain and has a normal EKG (electrocardiogram) might have to wait many hours to find out if his heart was damaged.

The worry for women who have vaginal bleeding in very early pregnancy is not only that they may be miscarrying, but instead might be experiencing a tubal or ectopic pregnancy. One test that might help guide diagnosis would be a quantitative beta HCG, a chemical that is produced by the placenta. Its value should double every couple of days in early pregnancy and in stable patients, they may need to return in two days to help sort out the diagnosis. Meanwhile, the evaluation and care of the patient involves significant amount counseling and that take time.

Medicine and baseball share the concept that the game is not a prisoner of the clock. It’s done when it’s done, when the final out is made and when the diagnosis and treatment are complete. It is fair to try to make efficient use of time but not at the expense of the integrity of the game or the care provided. While the late Ernie Banks was quoted as saying “it’s a beautiful day fro a ballgame…let’s play two”, most people would rather get the diagnosis right the first time, no matter how long it takes, and avoid a second trip to the ER.

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to err is human

Monday, June 30, 2014

Sometime mistakes come back to bite you and sometimes they don’t. World Cup has become must see TV, even if the match is between two countries most people would not be able to find on a map. But there are three teams on the field, if one counts the referees and while they qualify for the assignment just as much as the teams they officiate, the referees don’t get much love. While the game happens at real word speed, their work is dissected frame by frame in high definition slow motion replay and their missed calls can make or break a match. In the Greece-Costa Rica match a hand ball was missed that could have allowed a penalty kick for Costa Rica and a potential 2-0 lead. At the final whistle, Costa Rica still won the game but in not without the drama of a shootout after an overtime tie.

Medicine is not without its misses. Every patient encounter, from a doctor taking a history and performing a physical examination or interpreting a test, to a nurse injecting a medication, every interaction between a patient and a health care provider can yield an error. The mistake may have huge consequences or not even be recognized and found only at quality assurance review. While the goal is always to make medical care mistake free, the reality is that there is an “acceptable” miss rate in caring for patients.

Radiology is a prime example about why medicine fails perfection. How can an acceptable miss rate for a board certified radiologist be 3%? For residents in training that number climbs to 8% or higher. It has to do with systems and not being able to touch the patient. When a patient sees a doctor and an imaging test is ordered, (an x-ray, ultrasound, CT or MRI), the radiologist does not get much background information. With today’s technology, there is no film to touch and digital images are sent through the internet tubes to be interpreted, perhaps a continent away to be interpreted. Misses don’t necessarily mean that malpractice has occurred and there may be no consequence to the patient. The error might be an incidental finding or it might be a big deal.

Other areas of medicine are ripe for mistake as well. We know that long shifts, sleep deprivation, stressful environments and large patient loads lead to increased risk for error. For that reason, house staff, interns and residents who look after patients in hospitals, have had their work hours adjusted to provide more time away from work. That change has significantly decreased the error rate in diagnosis and treatment but it also increased the number of patient handoffs, increasing that potential for error. While the patient may be in hospital for days on end, the doctors and nurses responsible for their care change two or three times a day. The handoff from one shift to another may fully explain the situation and critical information or planning can be lost. Hospitals have systems to standardize the information transfer but in the end, medical care happens at the bedside and it’s tough to explain the whole situation of patient subtleties and provider gestalt.

And sometimes, too much information to minimize error can lead doctors astray and cause damage to the patient. Just as replay can stop the flow and grind a football or basketball game to a halt, increasing the tech of testing, can potentially yield false positive and false negatives that can damage a patient. For example, if a doctor is worried about appendicitis in and orders a CT scan to help make the diagnosis, the timing must be right. If the CT is done too early and the body’s immune system hasn’t had a chance to develop inflammation, the scan may be read as normal, even if there is an early case of appendicitis…a false negative.

False positive tests may lead the patient down an unwanted road. 3D breast mammography has become the latest tool to look for small cancers. It may be the next best thing but…the test may be so sensitive that it finds lumps so small that may not cause any danger for the patient in their lifetime. Research continues but the test has already been made available.

As long human judgment is involved in medicine, the risk for mistake exists; it will never be zero though that is an admirable goal. The same situation exists is sport. Technology can decrease the human error rate but at the expense of the game.

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