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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the risk of decision making

Monday, July 13, 2015

There is a joy to be found in numbers and many sports fans have translated their appreciation of statistics to the level of passion because of fantasy sport leagues. The concept is simple. Managers and coaches devise on-field strategy based on their expectation of how the past might predict the future, and bettors rely on the same thought process. As it turns out, medicine works the same way, but the stakes may be a little higher.

A good example might be the approach to the patient with chest pain. While appreciating that there are many serious diseases and illnesses that can cause chest pain, pressure or tightness, most people and doctors worry about heart disease. The heart is a muscle and like any other muscle in the body, requires arteries to deliver oxygen and nutrients. If plaque and calcium narrow those arteries, a patient might experience symptoms during exercise or work or even walking upstairs. This is called angina and it may not be pain, but could be pressure or tightness of indigestion or perhaps nothing more than n indigestion or mild shortness of breath. If a plaque ruptures and a blood clot forms to completely block the artery, the section of heart muscle that it supplies will die if the blood flow is not re-established quickly. This is called a myocardial infarction or heart attack.

When a patient presents with chest pain to the ER, as protocol, the nursing staff may do an EKG, even before a doctor sees the patient. That EKG may diagnose the acute heart attack and the patient will head off to the cath lab to have a cardiologist open the blocked artery. But if the EKG isn’t exciting, it’s up to the doctor to decide whether to proceed down the “is it the heart?” pathway. Sometimes, clinical judgment says that the pain is coming from the esophagus, or lung or chest wall and no further heart testing is needed; but if the symptoms are suspicious and risk factors are present (smoking, high blood pressure, high cholesterol, diabetes and family history), more needs to be done.

Heart muscle that is irritated can leak a chemical, called troponin that can be measured in the blood. It takes a couple of hours or more for that test to turn positive, so an initial normal troponin is heartening but not necessarily conclusive. It means that no heart damage has yet been uncovered but a repeat test may be worthwhile.

A normal EKG and normal blood test means looking back in time that no heart damage has occurred, but does that mean that the heart arteries aren’t partially blocked? Is there a possibility of a heart attack in the near future? What do the statistics say about predicting the future and how low does the risk have to be before the patient and the doctor are happy?

The American Heart Association recommends that patients with chest pain, who are found not to have heart damage, should have their heart imaged in some way, within 72 hours of their visit. That imaging could be a stress test while walking on a treadmill, a radioactive dye injected to show blood flow to the heart, an echocardiogram (ultrasound of the heart), a cardiac CT or the gold standard and most invasive test, a cardiac catheterization. Each has its indications and place in the risk stratification of the patient, but the decision as to which test to order has some art mixed in with the science. All these tests are not cheap and requires a fair amount of technology, and may not readily be available.

Or the patient can assume some risk. There have been research and studies that have tried to put a number to that risk. In one group  of patients who wee followed whose chest pain story was slightly or not suspicious for heart disease, who were younger and also had normal EKG and blood tests, the chance of having a major adverse heart issue within six weeks, was 1.7%. This number could drop to below 1%, if the patient were watched for a longer time frame and more blood tests done, but theirs never became zero.

Many patients and their families would accept a risk of less than 2%, meaning that more than 98 times out of 100, their heart was healthy. But the numbers also need to be looked at from the doctor and hospital perspective. A busy hospital ER might see a hundred or more chest pain patients each week. That less than 2% risk could add up to hundreds of missed heart attacks a year… not very acceptable numbers. While the Heart Association guidelines may be too strict, others may be too lenient and that is where clinical judgment, practical experience and common sense come into play.

Statistics may help drive strategy, but a manager’s gut feeling or game savvy may suggest a road less travelled when shifting fielder or changing pitchers. The art of medicine uses the same intuition to help guide the doctor and the patient to decide which plan of action is appropriate for one particular situation at one particular time. In medicine, statistics are fine for the general population, but when a complication happens, it happens 100% of the time to that patient. The goal of medicine is to maximize care, minimize risk and use resources wisely… and for that reason, doctors could learn a thing or two from managers, coaches and fantasy draft junkies.

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