Medical Complications by Ana (Installment #1)

April 12^th Report by Ana

Topic: Medical Complications

It’s a beautiful day outside and you and your family decide to enjoy the sunshine by taking a walk around the local park. You haven’t been feeling well that last 24-36 hours, but it’s just too nice of a day to pass up so you push through and convince yourself to go. After passing the ¼ of a mile marker the pain, that you’ve been ignoring on your side, sharpens suddenly causing you to collapse on the ground. Your family calls for help and you're quickly rushed to the local hospital. Upon arrival, you are assessed and diagnosed with appendicitis. Your appendix must be removed immediately. This is a routine procedure and the Doctor and Staff assure you there is nothing to worry about. Or is there?

According to the National Practitioner Data Bank, the numbers tell a different story. What is the National Practitioner Data Bank? The NPDB was established by Congress in 1986 and is a database that tracks practitioners previous damaging performance and prevents them from moving state to state without disclosure to their new employers or government agencies.¹ The reports are confidential and not available to the public.¹

Below is the latest report from NPDB. In addition, to view reports by state, simply click on the VIEW MAP link.

All Locations - All Practitioners

View Map (https://www.npdb.hrsa.gov/resources/npdbstats/npdbStatistics.jsp#contentTop)

All counts are based on NPDB calendar year data. Inflation Adjustment provided by the U.S. Bureau of Labor Statistics.

Location	Population (Census)	NPDB All Practitioners 2006-2016	Medical Malpractice Payment Reports	Adverse Action Reports	Reinstatement Restore Reports	Total Reports
United States	323,700,309	385,824	143,713	433,151	60,778	637,642
Tennessee	6,651,194	8,068	1,998	8,971	1,882	12,851

As myself and many of our fellow classmates pursue a career in the medical field, the NPDB list is one list none of us want to be on. But mistakes happen; accidents will occur. After all, we are human.

Below is a small section of Dr. Atul Gawande’s book Complications. The book revisits his time as a surgical resident during the 90’s and several of the cases he witnessed. It further discusses his own personal experiences and some of the mistakes he made.

In addition, a video will be played in class to provide another example of medical complications regarding an appendectomy. Please note, the video does contain a surgical procedure with blood. I understand completely if anyone needs to excuse themselves and return once the 5-minute video has played.

There are quiz questions posted below for the enclosed literature and the upcoming in-class video. Feel free to answer the video questions while the video is playing.

To ensure ample time for all other presenters, we will review the answers to the quiz questions after the video has played and then capture your immediate reaction from the video. Let’s keep the conversation going by kindly posting additional thoughts, questions, comments, and reactions to this blog.

Thank you for your time!

Ana

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“Complications” by Atul Gawande

The Computer and the Hernia Factory (pgs. 35-37)

“One summer day in 1996, Hans Ohlin, the fifty-year-old chief of coronary care at the University of Lund Hospital in Sweden, sat down in his office with a stack of two thousand two hundred and forty electrocardiograms. Each test result consisted of a series of wavy lines, running from left to right on a letter-size page of graph paper. Ohlin read them alone in his office so that he would not be disturbed. He scanned them swiftly but carefully, one at a time, separating them into piles according to whether or not he thought that the patient was having a heart attack at the time the electrocardiogram (EKG) was recorded. To avoid fatigue and inattention, he did his work over the course of a week, sorting through the EGKs in shifts no longer than two hours, and taking long breaks. He wanted no careless errors; the stakes were too high. This was the medical world’s version of the Deep Blue chess match, and Ohlin was cardiology’s Gary Kasparov. He was going head to head with a computer.

The EKG is one of the most diagnostic tests, performed more than fifty million times a year in the United States alone. Electrodes are placed on the skin to pick up the low-voltage electrical impulses that, with each beat, travel through the heart muscle, and those impulses are reflected in the waves on an EKG printout. The theory behind an EKG is that in a heart attack a portion of the muscle dies, causing the electrical impulses to change course when they travel around the dead tissue. As a result, the waves on the printout change, too. Sometimes those changes are obvious; more often they are subtle – or, in medical argot, “nonspecific.”

To medical students, EKGs seem unmanageably complex at first. Typically, an EKG uses twelve leads, and each one produces a different-looking tracing on the printout. Yet students are taught to discern in these tracings a dozen or more features, each of which is given an alphabetical label: for instance, there’s the downstroke at the start of a beat, (the Q wave), the upstroke at the peak of heart contraction (the R wave), the subsequent downstroke (the S wave). Sometimes small changes here and there add up to a heart attack; sometimes they don’t. When I was a medical student, I first learned to decode the EKG as if it were a complex calculation. My classmates and I would carry laminated cards in our white-lab-coat pockets with a list of arcane instructions: calculate the heart rate and the axis of electrical flow, check for a rhythm disturbance, then check for an ST-segment elevation greater than one millimeter in leads V1 to V4, or for poor R-wave progression (signifying one type of heart attack), and so on.

With practice, it gets easier to manage all this information, just as putting a line in gets easier. The learning curve operates in matters of diagnosis no less than technique. An experienced cardiologist can sometimes make a heart attack at a glance, the way a child can recognize his mother across a room. But at the bottom, the test remains stubbornly opaque. Studies have shown that between 2 and 8 percent of patient with heart attacks who are seen in emergency rooms are mistakenly discharged and a quarter of these people die or suffer a complete cardiac arrest. Even if such patients aren’t mistakenly sent home, crucial treatment may be delayed when an EKG is misread. Human judgment, even expert human judgment, falls well short of certainty. The rationale for trying to teach a computer to read an EKG, therefore, is fairly compelling. If the result should prove to be even a slight improvement on human performance, thousands of lives could be saved each year.

The first suggestion that a computer could do better came in 1990, in an influential article published by William Baxt, then an emergency physician at the University of California at San Diego. Baxt described how an “artificial neural network” – a kind of computer architecture – could make sophisticated clinical decisions. Such expert systems learn from experience much as humans do: by incorporating feedback from each success and each failure to improve their guesswork. In a later study, Baxt showed that a computer could handily outperform a group of doctors in diagnosing heart attacks among patients with chest pain. But two-thirds of the physicians in his study were inexperienced residents, whom you’d expect to have difficulties with EKG’s. Could a computer outperform an experienced specialist?

This question was what the Swedish study was trying to answer. The study was led by Lars Edenbrandt, a medical colleague of Ohlin’s and an expert in artificial intelligence. Edenbrandt spent five years perfecting his system, first in Scotland and then in Sweden. He fed which ones represented heart attacks and which ones did not until the machine grew expert at reading even the most equivocal of EKGs. Then he approached Ohlin, one of the top cardiologists in Sweden and a man who ordinarily read as many as ten thousand EKGs a year. Edenbrandt selected two thousand two hundred and forty EKGs from the hospital files to test both of them on, of which exactly half, eleven hundred and twenty, were confirmed to show heart attacks. With little fanfare, the results were published in the fall of 1997. Ohlin correctly picked up six hundred and twenty. The computer picked up seven hundred and thirty-eight. Machine beat man by 20 percent.”

Sources

1.      https://www.npdb.hrsa.gov/topNavigation/aboutUs.jsp

2.      Gawande, Atul. (2002) Complications. New York, New York: Henry Hold and Company, LLC

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Quiz Questions

“Complications” by Atul Gawande

1.      What is Dr. Ohlin’s role at the hospital he works at? Chief of Coronary Care

2.      What does EKG stand for? Electrocardiogram

3.      In a heart attack a portion of what dies? Muscle

4.      What are the letters for the three main waves from an EKG? Q, R, S

5.      What percentage of patients with heart attacks who are seen in emergency rooms are mistakenly discharged? 2-8%

6.      Baxt described an “artificial neural network” as a "kind of computer architecture".

In Class Video (feel free to answer while the video is playing)

1.      How many medical personnel are in the room? 5

2.      What won’t put the blood back in the patient? CPR

3.      Did the patient survive the procedure? No

4.      What hour of the surgeon’s rotation was he on? 30

5.      What will the family be told? Heartattack

6.      What happened to the photos taken?  Deleted

Discussion Questions

1.      After watching the in-class video, do you believe this could happen or was this just “entertaining TV”? If yes or no, what are your reasons?

2.      What do you think are a few reasons why mistakes are made?

3.      Is there a shortage of Doctors?

4.      Can machines and technology be the solution to fill the shortage gap of Doctors?

5.      Is making a mistake in the medical field a doctor’s worst fear?

6.      Have you witnessed or experienced medical errors? How did this make you feel?

7.      What steps can we take as individuals, as a family, as a community, as a nation, as a planet to decrease mistakes?