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The part of Gawende’s piece that struck me is the distinction he makes is between what we should do (but too often don’t) and what we do that may not be necessary. A lot has been said about the high cost of end of life care, and a lot of emphasis has been placed on the cost savings that could result in forgoing that care. But the fears that efforts to reduce costs will lead to “rationing” are real, weather you agree with the use of that term or not, and a focus on increased access to palliative care seems like the better approach. If the evidence he points to is true, then increasing access to palliative care improves outcomes while decreasing costs. That seems like a no-brainer and begs the question why we still have such hurdles in the way of hospice/palliative care like poor reimbursement and a requirement that patients stop “traditional” care in order to enroll in hospice.
Actually, I guess there is an antidote to Tylenol overdose: Mucomyst, but it doesn't always work, and the point stands that both drugs can be dangerous.
I agree- a good discussion. There are a few more comments I’d like to make though: Regarding the diagnosis: There seems to be confusion regarding the difficulty of this diagnosis. We have a quote from Dr. Tagge where he calls it a very unusual presentation of an ulcer, and says its “1 in a zillion, ” which some of the commentary seems to accept. On the other hand we have Dr. Korbon quoted as saying “"Even a Boy Scout could have done better," than these residents did, suggesting that this shouldn’t have been so hard after all. Some comments (including my own) seem to agree with this view. So who’s right? I think both are. To have figured out, especially early on when the only symptom was abdominal pain, that Lewis was having a Toradol induced ulcer with impending perforation and peritonitis, would have taken a very astute clinician. I can’t fault anyone for missing that, but this is a known risk with that drug, and perhaps there should be mechanisms to ensure people are mindful of this risk when Toradol is used. Perhaps Toradol wasn’t the best choice, as I’ll get to. But the other view is right too, because the residents didn’t need to make a complete diagnosis. They only needed to realize that he was having a new, severe pain, at a site different from where his surgery was, and that it needed further work-up. That’s all. It's hard to argue that it takes a master clinician to have seen that when the one person who did see it (Helen) has no medical training. I think they should have recognized this on Saturday, but the really outrageous part came on Sunday morning when they failed to recognize and react to clear evidence of clinical decompensation, up to and including the syndrome known as “shock”. Again, they didn’t need to immediately deduce that he was having an NSAID induced ulcer with perforation, they just needed to realize that he was in shock, and that given the abdominal complaints, an abdominal catastrophe was possible. Regarding pain control: I completely disagree with Jenga’s position that adequate post-operative pain control should not be routinely attempted due to safety concerns. Jenga- correct me if that’s not a fair paraphrase, but that’s what I get from your comments. I agree with Maggie that many physicians are overly afraid of opiates and many patients suffer with uncontrolled pain as a result. PCA (patient controlled analgesia) pumps, for example, are quite safe when used and monitored appropriately. Bolus dosing of opiates is also safe when done properly, and if you are really that worried about causing respiratory depression and death, than use the old adage “start low and go slow” when titrating the dose. If you stop increasing the dose when mild symptoms of sedation develop you won’t kill anybody. You won’t even have to break out the Narcan. You might take longer than you need to getting their pain under control, but it’s better than not trying at all. Tylenol is a useful drug, but it’s only a mild analgesic and not adequate as monotherapy to deal with severe pain. Like opiates, it can kill people who take too much of it, and unlike opiates, there’s no antidote to a Tylenol overdose. There are some patients with difficult to control pain, and there are patients who begin to develop sedation while still having uncontrolled pain. And there are patients (especially the elderly demented ones) that just don’t tolerate narcotics well. But none of those caveats seems to apply to the present case. It’s not clear to me why Toradol was chosen in this case instead of opiates but there is, in general, a reluctance to use opiates among many doctors. I think if we’re going to be honest with ourselves this reluctance has more to do with the stigma of narcotic analgesics, and with past experiences in which patients have been manipulative and confrontational with us about these drugs, than it does with legitimate safety concerns. That said, I completely agree with your position that what Lewis needed more than pain control was a diagnosis, and the work-up and interventions that would have resulted from it. I’m not sure that “inadequate supervision” is a fair summary of why he didn’t get that, but I’ve already tried to make that point twice, so I won’t try again. Weather "inadequate supervision" is the big, systemic cause of this or not, I do applaud the efforts on the part of Lewis's parents, and the reporter (Mr. Monk) and Maggie, to try to find the big structural, systemic issues at work here. Because as decades of malpractice litigation and an ongoing patient safety crisis clearly show, pointing the finger of blame doesn't make the system safer. Thanks for the discussion.
If I’m not mistaken, surgical residents are usually “chief” in their 5th year of residency. Surgical residencies run 5-7 years, but usually its 5 years of clinical training, with the remainder being research. So, it may very well be that this chief surgical resident was in his final year of residency. If that’s so, then in July he’ll magically become an attending, just as he magically became “a doctor” after graduating medical school, and then there will not be anyone supervising him; he’ll be the most senior doctor on the team, the one Helen was asking for. I share your hope that the attending would have taken the situation more seriously if he had been contacted, but I don’t know if that’s the case or not. The attending’s reaction probably would have depended, at least in part, on who did the contacting, and what, exactly, they said. I can imagine that waking up the surgeon in the middle of the night to say, “Lewis Blackman is having some really severe gas pains” might have resulted in an angry outburst and offered minimal benefit for Lewis. On the other hand, a call saying something like, “Lewis is having severe abdominal pain; he is distended and tachycardic, he’s not producing much urine and he’s generally looking sick” would probably have resulted in some very helpful instructions. But in order to say that, the resident would first have to see it that way. It’s not unreasonable, especially in the case of a chief resident who will graduate and become an attending surgeon in a few months, to expect that he could see this situation for what it is. At a minimum, he should recognize that this is potentially serious, and investigate further. To be clear, I definitely do think that the attending should have been contacted in this case. Helen recognized the seriousness of the situation and tried to get the attending involved, but her concerns were ignored because the residents didn’t agree with her assessment that her son was in serious trouble. Since the attendings are not in the hospital all the time, they rely on their residents’ assessments to keep them abreast of what’s happening, and to decide when they need to be more involved. Maybe that should change; maybe there should be other ways to get the attending involved, as you suggest. But the residents, especially the chief, need to be able to get the assessment right. Any solution that doesn’t involve the residents getting this right is inadequate. They can, and should ask for help if they need it, but if they get through residency unable to do this, then they are not adequately trained, and may represent a danger to their patients for the rest of their careers.
What an incredibly tragic story. My heart goes out to the family, and I applaud their effort to prevent this kind of thing in the future. That said, I have to quibble with Mr. Monk's focus on the absence of the attending surgeon as the cause of this event. By Sunday morning, according to the article, Lewis was tachycardic, hypotensive and hypothermic, with a distended and painful abdomen. It shouldn't take an attending surgeon to diagnose this as shock, likely due to an abdominal catastrophe. An intern 5 months into his residency (they start in July, so Nov is the 5th month) and certainly a chief resident should easily make that call. The important question here, and I don't claim to have the answer, is why they didn't. I don't think it is routine to call an attending surgeon about a patient with gas pain. So as long as that was the diagnosis, and the house staff was confident in that diagnosis (even though it was wrong,) their decision not to call makes perfect sense. I suspect they would have called if they had realized the severity of the situation. But why didn't they? Was it because they had worked too long and slept too little? Was it because of too much focus on cutting costs by not ordering unnecessary tests? Was it because they had learned poor physical exam skills from their mentors? or were operating in a a cultural environment where listening to the patient isn't encouraged? I think these are the bigger questions.
Thanks for the warm welcome. You caught me- I hadn't really looked at the charts closely and having now done so, I agree. My risk is surprisingly low. What I found even more surprising is that even a 75 year old smoker has a less than 50% chance of dying within 10 years from any cause, not just cancer, or heart disease. But, I still don't think it's fair to say that the 1 in 4 claim made by NYT is "a complete fabrication". It seems that it's an accurate number for men and nearly accurate for women. Just because the average NYT reader has a below average risk doesn't mean they can't cite the overall average.
Maggie- I am fairly new to your site, and have enjoyed a number of your articles, but I find this one a bit tendentious. A couple of points: First, regarding the headline that the 1 in 4 claim is wrong: Ok, so it's 1 in 5 for women instead of 1 in 4. If we figure that about half of Americans are men and half are women, the overall number is probably somewhere around 1 in 4.5. Is that really so different? Is funding for cancer research not worth it if the average American born in '85 only has a 22.5% chance of dying of it instead of a 25% chance? And what about the cancer patients who are lucky enough to survive their ordeal? Some cancers are highly treatable, even curable, but many of the therapies are toxic, disfiguring, or associated with significant side-effects. Research into new therapies can reduce these burdens. It seems to me, for example, that the research showing lumpectomy with radiation is (usually) just as good as radical mastectomy represents an important advance, even if it doesn’t increase the cure rate. Second, regarding your hypothetical 50 year olds: Obviously the likelihood of a 50 year old man dying within 10 years of 3 pre-selected cancers is not directly comparable to the proportion of men or women who will, when they ultimately die, die of cancer. So regardless of what the numbers are, there just isn’t a way for this kind of analysis to refute the claim you are supposedly refuting. But I use the word tendentious because the study you cite uses several factors that will artificially lower the mortality rate. They selected lung cancer as 1 of the 3 cancers that they track for both men and women, but then stipulate that these are non-smokers. Lung cancer is not a common cancer in non-smokers. Thanks to Pap smears, cervical cancer is also not a common cancer in America anymore (it’s the 8th most common cause of cancer death in American women according to wikipedia.) Prostate cancer is slow growing and not usually diagnosed before age 50. So the number of men who die of prostate cancer before age 60 is very different from the number who will ultimately die of it. In fact, that’s true of most cancers. As you note in the article, most people who die of cancer are older than 60. So why follow 50 year olds and only count deaths that occur within 10 years? Maybe it’s to intentionally underestimate the cancer death rate.
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