complications

Monday, March 23, 2015

One of the joys of the college basketball post season is the potential for the unexpected. The small school underdog can celebrate a Cinderella win against a larger and stronger opponent, at least for one round. Upsets occur and those filling out their bracket bemoan the fact that what was expected did not occur. They play the games because nothing is guaranteed. Welcome to March Madness. That same lack of a guaranteed win also exists in the medical world, where things don’t always go according to plan, but it’s call a complication, not an upset.

Some complications are inconveniences. After surgery, there may be a little bleeding from a wound and nothing more than an extra bandage is needed. There may be an extra day of discomfort. Nausea can occur after taking a pain pill. Other complications, however,  can be devastating. Death comes to mind as one particular example. The goal of modern medicine is to minimize complication rates by improving techniques and care, yet for the individual patient who experiences a complication, theirs happens 100 per cent of the time. For that reason, the patient and family need to pay special attention to the informed consent discussion that happens with every medical encounter.

Not so long ago, the relationship between doctor and patient was one sided and paternalistic. The science of medicine was progressing nicely by improving diagnostic skill, but there were few treatment options available to offer to a patient. It was easy for the doctor to dictate the terms of treatment. There was but one way to treat a specific problem. Over time, the medical world has evolved and alternative treatment approaches exist for many illnesses and injuries. Ear infections can be observed for a few days before jumping to write an antibiotic prescription. Some fractures do not need emergent surgery. Cancer therapy can offer a myriad of experimental options. But each option carries its own risks and rewards.

Not so long ago, a knee injury ended an athlete’s career, but with technical advances like arthroscopic surgery, it is almost routine to “fix” knees. The goal is to return elite athletes and weekend warriors alike to their previous level of activity. However, that routine surgery is anything but. Some type of complication may occur in almost 5% of arthroscopic knee surgeries, and the more complicated the knee repair, the higher the potential risk. Infections may affect 1% of patients, anesthetic problems occur in 1 out of 250 operations and a pulmonary embolus, or blood clot to the lung, occurs in 1 out of 1000. This last number is very tiny, but pulmonary embolus is one of the most common causes of sudden death.

The discovery of antibiotics changed the world for medicine and allowed infections, like pneumonia, that were once a death sentences to be treated and cured. Doctors liked antibiotics so much that their indiscriminate prescribing increased resistance rates, making some bacteria relatively immune to common drugs. Plus, docs felt that patients would be less than satisfied if they did not leave their appointment with a prescription in hand. Some complications were irritating. Patients who were prescribed amoxicillin for a presumptive sore throat and strep infection, would develop a whole body rash if their real diagnosis was infectious mononucleosis…but who wanted to bother with the time and expense of a doctor’s visit if a prescription could be called in over the phone instead. But even with the proper use of antibiotics, unintended consequences could occur. Clostridium difficile, C Diff, can cause significant diarrhea due to colitis, or inflammation of the colon, in some patients who have been treated with antibiotics. The drug wipes out the normally present colon bacteria and lets the C Diff run wild. This infection can be devastating and may take weeks to cure. Once thought only to be a hospital acquired infection, C Diff, now rears its ugly head, even in the outpatient world.

Every doctor patient interaction has the ability to have an unintended consequence or complication. Care and treatment plans have become a collaborative decision making process. Deciding to watch and wait may cause an illness or injury to worsen instead of improve. Being aggressive with a medication can lead to cure or complication. The same holds true for the timing and type of surgery that might be recommended. The doctor has the responsibility to explain the ups and downs of alternative treatments. The patient has the responsibility to listen and ask question so that an informed decision can be made.

And there is one certainty that holds true. There is never a sure thing in medicine or March Madness.

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