What's up Daw(c)g?
Wherever you are, it doesn't hurt to pray before going to the doctor
I always say to my patients or parents of my patients (when they happen to be a drooling babies) that doctors are no different from car mechanics. Sure doctors have a unique set of skills. Sure people come to them with problems some serious. But there is always the possibility that the doctor doesn’t know what is wrong, doesn’t know how to treat what is wrong or worst case scenario, won’t admit either, sending the patient home with false information and assurance, or to complete the analogy, with the same broken vehicle, sometimes even with an essential part missing. It’s sort of just the facts. Statistically almost 40% of doctor decisions are wrong decisions and that proportion is in the United States. That means 40% of the time when doctors says you need antibiotics you don’t; when they palpate your liver, they are missing the organ; when they are explaining where antibiotic resistance comes from they neglect to tell you about factory farm cows; when they are performing CPR they aren’t pushing hard enough or giving breaths and pumps at the right intervals. There was a very cynical saying in medical school: “C” equals MD. What this meant was that you could get a C in your med-school classes; be perfectly mediocre in your pediatric, internal medicine, surgery, psychiatry, obstetrics and gynecology rotations and you would still be awarded a degree after four or five years, be able to post it on your wall and get patients to call you doctor as if you graduated Harvard magna cum laude. On Christmas you might even get fruitcake. The point is that patients and their families must be constantly vigilant. They must be active participants in their medical care. On the front side, they should choose a doctor based on recommendation, reputation and impression, just like you would select a car mechanic to fix a broken transmission when you are new to the block. On the back side, the nurse tells you to take off your clothes and put on a silly gown that actually exposes your back side and you may want to modify-- Keep your boxers on; lift the shirt, ask the doctor why before stripping what exactly s/he is about to do.
One part of my job, in light of the above, in a country where the proportion of medical errors likely exceeds that of the United States, is to make sure that the 40 clinics and 6 hospitals we support in Liberia are structured to avoid mistakes in care. I call this engineering good care. Making it easy to make the right decision because the evidence based protocol is sitting right in front of the clinician’s face, because the doctor knows his colleague is watching his/her performance, because a computer instead of a fallible brain is performing a complex medicine dosing calculation. Engineering good decisions is a matter of practice in many professions where precision is a matter of life and death and errors open to publicity. In the airline industry, pilots can’t just turn on the plane, rev the engine and take off. They must perform a rigorous checklist that goes over person, machine and passenger. Missing any one-criterion means the plane does not fly. Pilot has not flown for more than 24 hours straight. Check. Pilot not drunk. Check. Gas tank with more than two times the amount of fuel to reach its destination. Check. All gauges on the dashboard functioning. Check. 4 flight attendants present. Check. All passengers accounted for check. All pug dogs stowed. Check. While this means occasional takeoff delays and discomfort when the unionized flight attendant attacks the texting teen in economy class with an I-phone, the airline profession has decided to take away as many performance variables as possible because it cannot afford the public seeing planes fall from the sky. It is no accident then that flying is the safest mode of fast transportation. Every day about 100 Americans die on the road in traffic accidents. The airline industry doesn’t meet this number in a year. In fact, for the last two years the number of airplane fatalities has been zero. Zero.
A notorious cause of medical errors -- the hand-written note
The airline industry adds another interesting feature to quality assurance—a way to add to its safety check-list. It encourages colleagues to rat on one another when something or someone appears or feels wrong. Airline employees are guaranteed anonymity when reporting their concerns. Also, the reports are guaranteed a written response by management outsourced to NASA (yes NASA) to the reporter within 72 hours with a fix. Finally, it is the law of any airplane worker who sees any item on the safety list not met to stop the plane in its tracks. So in this case, the baggage guy is as responsible for safety as the co-pilot; the ticket counter boy as important as the maintenance man. Plane safety in short is everyone’s business. Gestapo like? A slippery-slope to communism? No, because the consumer would not want it any other way. Passengers do not want even the possibility of a pilot smoking a joint while landing in a rainstorm. They do not want the option of ½ a tank of gas being put on the loud speaker for a vote. Passengers like the 99.9% chance of arriving to their destination. So then, why then does the public accept a 40% medical error rate? There are 100,000 preventable deaths a year in the United States from medical errors. Is receiving medical care not as important as flying the friendly skies?
The biggest problem with safety in the medical profession is that patients don’t know about the extent of medical errors and the industry is not built to let patients know the truth. Society likes to think that doctors are infallible because on TV doctors study hard and in person, doctors only have to be nice and wear starched clean white coats to make a good impression. A treat if they wash their hands or are handsome or pretty. Doctors in turn are trained to think that with enough studying and experience in intuition, they will be able to recall vital information when they need to. If they make a mistake it is a Hester Prynne situation versus a lesson. And if their colleagues make a mistake they are idiots-- a reminder of how not to be.
I made one big mistake my first year of residency that almost killed a girl. It was this experience that helped me understand how behavior is influenced by environmental cues and how good decision making can actually be structured. A child was transferred from the intensive care unit to the pediatric ward where I was working having recovered from the worst of her newly diagnosed diabetes. She had been given insulin before her transfer to the ward but no one knew about it. The record was buried within a fifty page disorganized chart which took a lot of time to find and read. Normally there would have been a face-to-face, nurse-to-nurse sign out where there would be an exchange of vital information like patient just got her insulin, but it was 7:30 at the change in shift and one nurse had already gone home and the one taking over didn’t have the whole story. It was also breakfast time, the patient was hungry and the food had just arrived at her door. I was running around as usual like a crazed headless Taiwanese-American chicken to complete my patient rounds. A new nurse who was caring for the new patient asked me in a cloud of rushing feathers if I might give a verbal order for insulin since the parents were asking to feed their daughter. I said of course while running in a different direction to a different room. The nurse realized the error just as she redrew the syringe from the child’s arm when the parents asked, “Didn’t Kailee already get her insulin?” I was immediately called to the bed-side. Kailee was at high risk of going into hypoglycemic induced seizures but we gave her food, started a slow sugar drip and monitored her blood sugars hourly until lunch. I sat with the patient through the morning and while outwardly comforting Kailee felt like a full-fledged lummox. It wasn’t long before the other residents heard about the case and though folk were sympathetic I knew they were thinking, ah ha, another instance of Wilson not being careful. The worst was facing Kailee’s parents. I explained the situation and took full responsibility for the error, but they were understandably upset. I think they knew that there were many factors in the mistake but since they couldn’t locate or understand them really, they blamed me and I whole-heartedly accepted the blame. Even today I wonder if Kailee’s parents hadn’t been in the room if I would have called them to explain the error, since Kailee recovered and didn’t seem any worse for the wear. I would like to think so, but I don’t know.
We have started a process of chart review for all JDJ patients who die in our care. We see over 1000 patients a month at JDJ and with a 5% death rate this means 50 dead children to learn from a month. There I said it. The review reveals tremendous variability in care quality from two year old boys being treated for three diseases simultaneously, to burn patients not getting their wounds bandaged for two days because the floor is out of gauze and doctors not seeing patients daily. The traditional approach would be to first declare all involved care-givers incompetent. Second, make this information public to shame the incompetents to excellence. And third, have an educational session to teach our 15 physician assistants and one doctor that if we don’t have bandages say something or care enough to buy it. Oh, and someone please see the patient once in while or be fired. But this wouldn’t work. At least it doesn’t work on any planet I have ever been on. It just makes people hide more.
What does work? 40% of our admissions are for malaria, the next 30% from respiratory illness, the next 20% from diarrhea. Instead of teaching our clinicians the right dose of arthemeter, or ceftrixone or IV fluids, respectively, we are preprinting diagnosis and treatment sheets for these major diseases which have verification panels to help the clinician confirm the diagnosis and have the corresponding drug doses pre-calculated so that the nurses upstairs don’t have to read bad handwriting with the dose calculated wrong anyway. So you think this is malaria? The paper will ask you, is the rapid malaria test positive, is the patient having waxing and waning fever, is there anemia, is there vomiting or diarrhea? If the first three criteria are met, continue. If the fourth, rethink. Continuing, the paper will have the dose of arthemeter pre-populated or if this is complicated malaria, the dose of quinine with proper volume, rate of infusion and frequency of 5% dextrose, the carrier fluid.
To confirm this brand of decision support makes a difference, we will study the before and after effects of this intervention on hospitalization duration and death. I have also just written a USAID grant to bring smart phones with the most up-to-date medical software to provide the latest evidence based information to our clinicians when they see patients. No more looking for the single torn copy of the Ministry Clinical protocols under a pile of junk. No more climbing stairs to borrow a book from the mirage of a reference library. Though I am getting a lot of push back from my expat colleagues who think the smart phones will just disappear, be sold or be used exclusively for chatting and music and photos, I think this is extremely paternal and not fair at all. I use the medical software on my iphone every time I take care of patients to learn or confirm. If I who has had seven years of medical education and 10 years of clinical practice feel figuratively naked without my handheld computerized device, how do my Liberian medical colleagues feel in a country where there are only 150 doctors and one sort of functioning medical school?
High stakes game of medicine-- people
