Monday, March 20, 2017

There are many lessons to be learned from March Madness, but for the sports fan, there is perhaps nothing worse than watching your team lose a close game and not because of the success of an opponent, but because of a referee’s error. Officiating mistakes happen and are usually forgotten, except when they occur at a pivotal moment late in the game, leaving no opportunity for recovery. From a goaltending call that wasn’t made or a travel not called, to a decision on intentional fouls, each team’s fan base will see the exact same slow motion replay and come away with a different truth. It’s not common for NCAA administration to apologize for an error and by then, both teams have gone home and the damage has been done.

In medicine, mistakes are inevitable and while the individual provider aims for perfection, it really is a pipe dream. The complexity of the human body and the way it is attacked by disease, infection and trauma makes for a moving target when it comes to trying to prevent or fix problems. Once upon a time, medical care was mostly diagnosis driven and while doctors could be elegant in deciding what was wrong, they had few tools to treat the things that they found wrong. It’s only been very recently that medical care moved from comfort to cure, but that move has opened the Pandora’s box of error.

There are a variety of errors that are possible in the care of a patient and they mirror what happens on the basketball court. The care provider, whether a doctor in the office, a paramedic in the field or a nurse at the bedside, has to put themselves in the proper positon to collect information, process it and make a diagnostic decision. This is no different than a referee who have to be in position to watch a play, know the rules and make a call. A diagnosis or call is missed if any steps fails.

In medicine, diagnosis needs the information gathering skills of talking to the patient, asking the right questions and performing a physical examination. If the information is misleading, a wrong test might be ordered, driving the diagnosis and treatment in the wrong direction. A patient with indigestion might actually be complaining of pain from the heart and coronary artery disease. If early in the disease process, the patient ignores the symptoms or the care provider misinterprets the symptoms, the opportunity to avert a heart attack might be lost. On the other hand, the indigestion might be gallbladder disease and if that diagnosis is missed, the patient might develop a major abdominal infection. Or just maybe the indigestion is “just” indigestion and heartburn, caused by the reflux of acid into the esophagus. Miss this diagnosis and treatment and chronic reflux can result in Barrett’s esophagus, changes in its lining, that can be a cancer precursor. And these are just the common causes of heartburn; textbooks are filled with plenty more.

The right diagnosis is no guarantee of making the right call when it comes to treatment. While there are guidelines for many situations just like a sports rulebook that lay out the call for most situations. However, it’s hard to know or remember every single nuance, especially when time is of the essence and there are some situations where the rules just don’t apply. There may times at the bedside where decisions have to be made and there are no “best “options. Even if there are, no guarantee exists that picking the right treatment will result in a positive result. A bad outcome does not mean that a mistake was made, and sometimes a mistake happens and doesn’t cause harm.

Mistakes happen in medicine happen but most go unrecognized or unreported; the no harm no foul rule. But medical systems are learning that a near miss is a learning opportunity, to make certain “minor” misses don’t become major disasters. The concept of whistleblowing is encouraged to look for ways to improve and in this way, it becomes the medical equivalent of instant replay. The reporting systems also help sort out what happened when major errors occur and the patient is injured and it often takes a disaster for a system to change.

College basketball may be life and death for some fans and their happiness may depend upon a referee’s call. Some of their mistakes are fixable and can be reversed by instant replay but in many cases, there is only an apology that is issued well after the fans have gone home. Who knew that the same situation exists in medicine. The life, death, happiness paradigm is literally true when it comes to medicine. Mistakes happen and many can be overcome but sometimes all that can be offered is an apology.


Images: NY Post, WCRBtv.com

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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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