lessons from the super bowl

Monday, February 6, 2017

At Super Bowl half time, the New England Patriots adapt to the reality of their situation, losing by 25 points and to win, they will have to overcome the greatest deficit in the game’s history. At the same time, the Atlanta Falcons will have to maintain the performance and momentum that allowed their lead to accumulate. The Patriots adapt and prevail and there are lessons in patient care that can be learned from the game.

A sure thing doesn’t exist

Patients and families always ask about the odds of what might happen next. Whether it is a heart attack, stroke, infection or surgery, people want the future predicted. Statistics can help guide decision making and suggest who might do better or worse, but until the dust settles, nobody really knows. Ultimately, the patient will do well…or they won’t.

The Patriots overcame the largest deficit ever to win the Super Bowl. They weren’t supposed to win. In-game statistics suggested that the Falcons had a greater than a 97% chance of winning with less than 5 minutes to go.

Every doctor has a had a patient who was doing well, recuperating from a procedure or recovering from an infection, when minutes later, without warning, they crash: blood pressure drops, heart and breathing rates spike, the patient becomes unconscious and quickly dies. No reason, no warning…bad karma.

There’s always hope

The corollary to an unexpected patient crash is the patient who seemingly has no chance of recovery and almost miraculously wakens to walk out of the hospital. Ironically, while these experiences can give hope to patients, families and doctors, the reality is that patients who are in end-of-life situations most often die.

Sports fans almost never give up hope, whether their team is down by 25 points or needs a miracle to make the playoffs, hope springs eternal. Many Patriot fans, including President Trump, were reported to have not watched the last half of the game because of the presumed forgone conclusion.

The issue in medicine is that sometimes care can be futile, causing pain and suffering for the patient. It can be very difficult for a doctor to present that situation to the family, especially if a crisis arises quickly and there has been no time to prepare. The doctor remembers that one patient, years ago, who miraculously survived.

It’s usually more than one thing

When a patient does poorly, it is usually more than one event that causes the situation to deteriorate. The body’s many systems are closely intertwined. An illness or injury causes the body to turn on its response systems but some diseases inhibit the body’s ability to react. Diabetics and patients who take medications that decrease immunity may have a hard time generating a response to infection and stress. Some heart medications inhibit the body from reacting to blood or fluid loss. Every patient is unique and as the body ages, it loses gradually its ability to overcome the stress of illness or injury.

Sportswriters, radio talk show hosts and a variety of analysts and experts try to define the one play that allowed the Falcons to collapse, but it was more than a Ryan fumble, or an Edelman catch. Perhaps it was a well-placed Patriot kickoff or a sack in the last few minutes of the game. More likely, it was a combination of all. Each by itself is not a catastrophe, but together, they changed the tide of the game.

Medicine is the same way. Patients can tolerate one or two system failures but keep adding malfunctions and the body reaches a point of no return. When things go bad, the body is programmed to sacrifice less important organs, to allow the brain to survive. The body is happy to maintain circulation to the vital organs (think heart, lung, liver, kidney and of course brain) to the detriment of all else. If one or more of these organs is already compromised, the body has a decreased ability to respond and recover.

Finding the scapegoat

The Patriots won as a team and the Falcons lost as one as well. There may have been individual efforts or decisions that were in the spotlight, but many events had to occur both good and bad, that resulted in the outcome of each play. Tom Brady might have been given time to throw a pass because of an exceptional effort by a lineman. A defensive player may have occupied two blockers to allow a teammate to make a tackle. The purpose of film review is to find the small things that can lead to big differences both  positive and negative and game plan fro the future.

When a patient develops a complication, a similar review happens in the hospital. M&M rounds, morbidity and mortality, demand that adverse patient outcomes be presented in an open forum for discussion. It is a learning environment, where medical care is reviewed to see whether warning signs of impending badness were missed, whether the outcome was inevitable or whether the patient just had bad karma. Bad outcomes can happen, even if everybody does the right thing, but the review has to happen. Medical care can’t get better unless doctors ask why.

Sport is life

We learned many lessons from this historic Super Bowl and not surprisingly, they are as applicable to medicine as they are to football. And just as likely, they apply to everything else in life just as well.

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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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