timing is everything

Monday, September 2, 2013

In football, as in life, timing is everything. On the field, waiting for a play to develop allows the quarterback to find the open receiver and the running back to hit the open hole. Defending a pass, arriving too early may result in an interference penalty, too late and the reception is made. Timing matters off the field as well. Green Bay Packer general manager, Ted Thompson, explained that the fault was his for the failure of quarterback Vince Young to make the team. He signed too late to allow him to maximize his performance. “I probably should have had him in here earlier.” Too early, too late, is also the mantra in medicine. Too early and the diagnosis is missed. Too late and the opportunity to treat is lost.

Medicine has become very sophisticated in using technology to diagnose and treat illness and injury, and those tests need to be interpreted in context. It’s all about timing and deciding what to do with the test results, either positive or negative. Consider these examples about being too early:

  • No matter what, the unasked question that parents worry about when they bring their child in with abdominal pain is whether they have appendicitis. A variety of things can cause the pain and often all that is needed to make the diagnosis is a solid history and physical exam, meaning that the doctor, parent and child make clinical decisions at the bedside. Sometimes, if the suspicion exists that appendicitis may be the diagnosis, a CT scan of the abdomen may be warranted. However, it may take up to12 hours after onset of symptoms for inflammation to be seen on the CT. Do the test too early and there may be a false sense of security that an operation is not needed; too late, the inflamed appendix may have leaked or ruptured and the operation to repair the damage more complex.
  • Mention chest pain as your chief complaint in the ER and a flurry of activity will occur. Aside from seeing the nurse or doctor to explain the symptoms, an EKG is usually done within minutes. Good news if it’s normal; it means that an artery to the heart is not completely blocked and you aren’t rushed to the cath lab to have angioplasty to open the artery and have a stent placed to keep it open. However, a normal EKG does not mean that there is no narrowing to a heart artery and the potential for a heart disaster in the future. Irritated heart muscle leaks troponin into the blood stream, a chemical that can be measured. Unfortunately, it takes 6 to 12 hours for the blood tests to turn positive. That means if you’re in the midst of a major heart attack in the cath lab, your blood test would initially be normal. It also means that a single normal test, drawn too early within that first few hours, is misleading and may miss heart damage that has occurred. For that reason, chest pain patients are often observed if the pain potentially originated from the heart since irritated heart muscle can cause electrical disturbances leading to sudden death.
  • Overdoses can be lethal. The problem is that many medications don’t kill immediately but become lethal days later. Tylenol or acetaminophen is the prime example. If too much is taken at once or over a period of hours, intentionally or accidentally, it can overwhelm the body’s ability to metabolize the drug and may lead to liver failure. Acetaminophen levels can be measured in the blood to know whether a toxic level exists and whether an antidote should be administered. To interpret the level, you need to know when the drug was taken, what type of acetaminophen tablet and whether it was taken once or at numerous times. For a single ingestion of regular Tylenol, you need to wait at least 4 hours after ingestion to draw the blood and be able to adequately interpret the results. Draw it too early and what appears to be a non-toxic result could be wrong and the opportunity missed to treat and prevent liver failure. Another problem with Tylenol is that the numbers don’t work with extended release tablets or when the medicine was taken at more than one time.

Ted Thompson regrets that he didn’t sign Vince Young sooner, but many other quarterbacks were readily available and one was quickly signed. Mr. Young was not so lucky as the victim of the mistimed signing and suffered the consequence. In medicine, doctors, patients and families increasingly depend upon technology to make a diagnosis or seek reassurance when a test is negative. However, it’s all about context. In the scheme of things NFL quarterbacks are an easy find; it’s harder to sign a replacement heart or liver.

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