risk reward

Tuesday, March 20, 2018

Before UMBC beat Virginia, no other 16th ranked team had won a game in the NCAA’s March Madness. Not in 135 previous games. Before that win, #1 never lost and #16 never won. But those words changed from always and never to rarely. The odds of the upset rose to 1 out of 136 or less than 1%. Fans of college basketball fans learned an important lesson; always and never do not exist in the real world and especially in medicine.

Risk-reward is always at play when a patient received advice for medical care. Surgeons who are technically gifted have patients who develop complications during and after surgery, from infection and bleeding to non-healing wounds. A gifted clinical doctor may have a misstep or two in proving a diagnosis caring for a patient who presents with confusing symptoms. Even when the diagnosis is firm, treatment options may have a potential for causing harm. Often there is time for discussion and contemplation before choosing a treatment plan but in emergency situations, decisions need to be made in minutes or less.

Heart Cath

Heart catheterizations have become almost routine. A cardiologist threads a thin catheter through an artery in the groin or arm and directs it into the coronary arteries that supply blood to heart muscle, looking for a narrowing or blockage. If found, blood flow can be improved or restored using a balloon to restore flow and a stent to keep the artery propped open. The benefit is preventing a heart attack and keeping the heart muscle pumping as normally as possible. There are minor complications, like bleeding or infection where the catheter is inserted through the skin. But here are also major complications like heart attack, stroke and death. Depending upon the health of the patient, statistics suggest the risk of complication is between 0.06% and 0.17% (between 1 in 600 and 1in 1600).

In an emergency situation, in the midst of a heart attack, where a coronary artery is completely blocked and heart muscle is dying, most people would accept a 1 in a thousand chance of harm when they are 100% having a heart attack.

Stroke

The numbers aren’t always so easy. Strokes occur when an artery in the brain is blocked preventing blood supply. That part of the brain turns off and the part of the body it controls stops working. The window of time to intervene with clot busting drugs (thrombolytics: thrombo=clot + lytic= dissolve) is very narrow, about 3-4 ½ hours after the onset of symptoms. If the patient is a thrombolytic candidate, the treatment can help return blood supply to the brain in more than one third of patients, but the complication of causing irreparable bleeding into the brain can be as high as 6%. The sooner the patient gets to the ER and the sooner the clot busting drug is given, the less likely the complication of bleeding. Other therapies, including removing the clot using catheters are also a possible, but not necessarily available at most hospitals. Treatment decisions by patient and family about risk-reward have to be made in minutes, and sometimes that decision is not clear cut.

Atrial Fibrillation

Preventing a stroke in the first place would be the way to go. Atrial fibrillation an irregular heart rhythm, is one of the major risk factors for causing stroke. Blood clots can form inside the heart and then potentially break off and travel (embolize) to the brain, blocking an artery and causing a stroke. Anticoagulation with a blood thinner may be an appropriate treatment, but its complication is bleeding. The question becomes how much benefit versus how much risk. Calculators (like CHADS-VASC) can be used to help decide whether anticoagulation is beneficial and other calculators (HasBled) to decide their risk of bleeding. Together, the doctor and patient can sit down and decide. At the end of the day, regardless of the decision that might be addressed and revised over the years, the patient will either 100% have prevented a stroke or not, and 100% would have bled or not.

Always and never do not exist in medicine. Minimizing risk is the goal of any treatment that has potential benefit, but that risk is never zero and treatment does not always work. Virginia learned a valuable lesson; a #1 team had never lost in the NCAA first round, but never no longer exists for them. They 100% lost and UMBC 100% won, no matter what the statistics might have predicted. It’s that lesson that also applies to doctors, patients and families. Medicine isn’t a black and white science, but people aren’t always happy with shades of gray.

 

 

 

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intubation

Tuesday, January 16, 2018

Make a catch, miss a tackle. A miracle play or a disaster. The coming together of Stephon Diggs’ catch combined with the Maurice Williams’ missed tackle at the end of a playoff game made for one special play, instantly turning people’s emotions from Saint jubilation and Viking despair, to just the reverse. For fans, players, coaches and color commentators, it was life or death…but it was just a game. Real life and death happens in medicine when the ability to perform may make the difference in a patient’s survival. Not all medical moments or procedures are memorable, but the fear of being unable to intubate a patient makes for many an ER doc nightmare.

When a patient can’t breathe on their own, a tube needs to be placed into the trachea and air pumped into the lungs. In most situations, like surgery, intubations are planned. The patient hasn’t had anything to eat or drink, they have been evaluated by the anesthesiologist, and even if potential difficulties might exist, they are at least known and plans made. And then there is the rest of the world. Patients show up unannounced, or their condition unexpectedly deteriorates; their ability to breathe is compromised and nightmare scenarios rear their ugly heads. Be it heart attack, congestive heart failure, COPD, asthma, pneumonia, trauma, overdose, uncontrolled seizure, stroke …the list is long and each patient, with unknown pitfalls, makes placing that tube a journey into the potential unknown disaster.

 

The intubation procedure isn’t a difficult concept. With the patient on their back, and the intubator standing at the head of the bed, the laryngoscope, a lighted blade is used to sweep the tongue out of the way, while at the same time, lifting the jaw and allowing a clear view to the back of the throat, the epiglottis and the vocal cords, signalling the entrance to the trachea. The scope lifts the epiglottis that covers the vocal cords and a tube is passed through the cords, secured in placed and then usually hooked up to a ventilator to breathe for the patient. What could possibly go wrong?

 

    

Ideal conditions don’t always exist.

  • It is the rare patient who is unconscious, perfectly still and relaxed, and allows somebody to jam a tube down their throat. Often, a patient needs to be sedated or even paralyzed. Give those drugs and it’s game on. Don’t put the tube in the right place, breathe and supply oxygen for the patient and pretty soon, brain cells start to die.
  • Operating rooms and ERs have lots of extra hands to help when the patient’s condition goes south. Imagine the paramedic on the side of the road on a rainy, dark night trying to intubate a combative trauma patient? And imagine if there are family members hovering over your every move.
  • We’re not all the same size and a 4-week-old infant with RSV infection needs different techniques than an 80-year-old with congestive heart failure.
  • Not everybody is built the same and anatomy changes in trauma. With a face or neck injury, there can be blood everywhere and those vocal cords, the target for the tube, may not be able to be seen.
  • There can be other problems with seeing the cord, from vomit, to dentures being lodged in the back of the throat, to bullnecked patients whose mouths don’t open wide.
  • If there is tongue swelling, like in angioedema or a major allergic reaction, the tongue can fill the mount and there might not be room to slide the laryngoscope into place to see the vocal cords.
  • Don’t forget potential technique issues. In trauma, if there is the possibility of a neck fracture, don’t flex the neck in attempts to see the cords otherwise you might end up damaging the spinal cord. It’s also bad form to lever the laryngoscope and break off teeth.

Intubation seems easy in concept but it can be a tough skill to perfect. Most doctors don’t get enough practice and training to be proficient. Those with great skill still fear that one patient might show up who evokes nightmares. Presumably, if intubation were easy, there would not continuing education courses that teach management of the patient with a difficulty airway.

Most medical care is not witnessed by millions of people and procedures that do not go well are not seen repeatedly in slow motion on SportsCenter. Care providers go home and replay the events until they come to grips with the fact that sometimes best effort is not good enough. Maurice Williams missed a tackle that led to a final second touchdown. He needs to remember that it was just one play…in a game… and the next season will bring the opportunities for many more plays to be made. The life lesson to be learned from intubation is that in times of patient disaster, even with the best training, with the best effort and with the best care, that life and death moments often favor death.

 

 

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