to err is human

Monday, June 30, 2014

Sometime mistakes come back to bite you and sometimes they don’t. World Cup has become must see TV, even if the match is between two countries most people would not be able to find on a map. But there are three teams on the field, if one counts the referees and while they qualify for the assignment just as much as the teams they officiate, the referees don’t get much love. While the game happens at real word speed, their work is dissected frame by frame in high definition slow motion replay and their missed calls can make or break a match. In the Greece-Costa Rica match a hand ball was missed that could have allowed a penalty kick for Costa Rica and a potential 2-0 lead. At the final whistle, Costa Rica still won the game but in not without the drama of a shootout after an overtime tie.

Medicine is not without its misses. Every patient encounter, from a doctor taking a history and performing a physical examination or interpreting a test, to a nurse injecting a medication, every interaction between a patient and a health care provider can yield an error. The mistake may have huge consequences or not even be recognized and found only at quality assurance review. While the goal is always to make medical care mistake free, the reality is that there is an “acceptable” miss rate in caring for patients.

Radiology is a prime example about why medicine fails perfection. How can an acceptable miss rate for a board certified radiologist be 3%? For residents in training that number climbs to 8% or higher. It has to do with systems and not being able to touch the patient. When a patient sees a doctor and an imaging test is ordered, (an x-ray, ultrasound, CT or MRI), the radiologist does not get much background information. With today’s technology, there is no film to touch and digital images are sent through the internet tubes to be interpreted, perhaps a continent away to be interpreted. Misses don’t necessarily mean that malpractice has occurred and there may be no consequence to the patient. The error might be an incidental finding or it might be a big deal.

Other areas of medicine are ripe for mistake as well. We know that long shifts, sleep deprivation, stressful environments and large patient loads lead to increased risk for error. For that reason, house staff, interns and residents who look after patients in hospitals, have had their work hours adjusted to provide more time away from work. That change has significantly decreased the error rate in diagnosis and treatment but it also increased the number of patient handoffs, increasing that potential for error. While the patient may be in hospital for days on end, the doctors and nurses responsible for their care change two or three times a day. The handoff from one shift to another may fully explain the situation and critical information or planning can be lost. Hospitals have systems to standardize the information transfer but in the end, medical care happens at the bedside and it’s tough to explain the whole situation of patient subtleties and provider gestalt.

And sometimes, too much information to minimize error can lead doctors astray and cause damage to the patient. Just as replay can stop the flow and grind a football or basketball game to a halt, increasing the tech of testing, can potentially yield false positive and false negatives that can damage a patient. For example, if a doctor is worried about appendicitis in and orders a CT scan to help make the diagnosis, the timing must be right. If the CT is done too early and the body’s immune system hasn’t had a chance to develop inflammation, the scan may be read as normal, even if there is an early case of appendicitis…a false negative.

False positive tests may lead the patient down an unwanted road. 3D breast mammography has become the latest tool to look for small cancers. It may be the next best thing but…the test may be so sensitive that it finds lumps so small that may not cause any danger for the patient in their lifetime. Research continues but the test has already been made available.

As long human judgment is involved in medicine, the risk for mistake exists; it will never be zero though that is an admirable goal. The same situation exists is sport. Technology can decrease the human error rate but at the expense of the game.

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medical stuff we learn from the sports world

Monday, June 16, 2014

Medical stuff we might learn this week from the sports world:

How amazed are we about Erik Compton. Before this week, most pro golfers knew of his tenacity to make it on the PGA Tour and perhaps a few dedicated fans knew his name, but after his second place finish in the US Open at Pinehurst, the world should beat a path to his door to learn of the physical and emotional strength required to overcome adversity. At age 12, Mr. Compton required a heart transplant because he had developed cardiomyopathy, a condition where the heart muscle does not squeeze enough to supply oxygen rich blood to the body. Medications can help temporize but eventually, a new heart was needed. 6 years later, he reigned as the top junior player in the country and began his rise up the college and pro ranks. At age 28, his golf career was derailed again because of a second heart transplant, and now at age 34, he has qualified for another year on the pro tour and a starting time at the Masters.

The most common cause of cardiomyopathy in kids is idiopathic, meaning that in two thirds of cases, nobody knows. For the other third, myocarditis, an inflammation of the heart muscle and familial inherited diseases are the most common causes of this rare disease (less than one kid in 100,000). There are different types of cardiomyopathy and some children can lead relatively normal lives with treatment, while others deteriorate, leaving their only hope as heart transplant. The challenge facing these kids, including the 12 year old Mr. Compton, is that the one year survival rate after heart transplant is about 80%.

 

Jozy Altidore damaged his hamstring. Matt Besler tweaked his. Alejandro Bedoya cramped up. The body was not designed to exert itself in a high temperature, high humidity environment. The body cools itself by sweating, but if the air is already holding as much water as it can (high relative humidity), sweat doesn’t evaporate and body cooling fails. Increased sweating leads to dehydration and the combination of loss of body water and rising temperatures results in heat cramps and heart exhaustion. Foundry and construction workers, roofers and bakers can also get into trouble if the temperature is too high and not enough air circulates to allow sweat to evaporate. The US soccer team was given a pass by public opinion as they won their game against Ghana. LeBron James was not so lucky.

 

Tony Gwynn passed away, succumbing to salivary gland cancer. News articles will no doubt comment upon his tobacco chewing as a potential cause and this is not to give tobacco companies a free pass, but their product has not been associated with causing this type of cancer. Chewing tobacco increases the risk of other cancers of the mouth and tongue, but salivary gland cancers are more likely associated with things out of the patient’s control: old age, being male, family history and being exposed to medical radiation. This type of cancer is relatively rare, making up less than1% of cancers in the United States. Survival depends upon how early the cancer is found, smaller is always better, as is lack of spread. Still even the smallest cancers that haven’t spread, still have only a 90% survival rate after 5 years. That seems like a lot, unless you happen to be one of the unlucky 10%. Statistics are sometimes less than helpful in medicine. They describes what happens to population as a whole and can offer some guidance, but when it comes to the individual patient, they either 100% live or 100% die. May Mr. Gwynn rest in peace.

 

And finally, how the media affects medicine: the first pick in the NFL draft, Jadaveon Clowney, is recovering from surgery to repair a sports hernia. It seems pretty simple, except that there is no such thing as a sports hernia. The term has made its way into the medical literature after being propagated by the media. There are a variety of structures that make up the floor of the inguinal canal, where hernias do occur, and any of those structures can become inflamed or damaged, leading to lower abdominal pain. The specific cause may not be known and non-surgical treatment includes rest, physical therapy and anti-inflammatory medications. If that fails, surgery may be considered and only when the surgeon is inside the area may the actual diagnosis be made. The injury may occur to one of many structures: a torn external oblique or internal oblique muscle insertion into the pubic bone, a transversalis fascia tear, a conjoint tendon tear, inflammation of the pubic symphysis and more. The anatomy is complicated and every strand of tissue is a potential target to fail. The “official” medical term is athletic pubalgia (pubic + algia=pain)…or you can call it a sports hernia. As for Mr. Clowney, he is expected to recover in time for training camp in July. The textbooks say that it takes 6-12 weeks and more than 90% of players will return to form. But you know what they say about statistics.

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