Thursday, September 27, 2012

It made me think

A physician friend writes:

Last night I was traveling back from California to Ohio.  As we landed in Denver, there was severe weather in the area--mostly rain and lightning--but also some minor hail.

FAA regulations require that, with any hail, every plane has to be inspected. I heard some of the ground crew bemoaning the fact that they had to do this, that it was a waste of time, as we loaded onto our connecting flight.

After the 30 minute inspection, the pilot explained to us that they found some minor damage on the plane from the hail and, therefore, we would have to get on another plane. Most likely, this damage would have never amounted to anything.

Deplaning at 11:30 at night for people headed east who were tired and grumpy was not a popular procedure. But it was the right thing to do. They were forced to put safety first. It wasn't what any of us wanted last night--but in the light of day, I am much happier being alive and back with my family--even if three hours later than anticipated.

It made me think--how often do we in health care push forward, ignore possible safety/quality issues, out of convenience or concern of causing someone temporary discomfort?


Anonymous said...

The crew's grumbling over the rules, followed by a significant finding, illustrates how the much-reviled cookbook can counteract the universal human tendency to skip steps in the exigency of the moment. In health care, we are still in the Dark Ages of not only relying on but celebrating this tendency, under the guise of 'medical judgment'.


e-Patient Dave said...

I had exactly the same thoughts on a flight last week.

I'm getting sick of air travel in my peak season, and this was the 4th of 8 boardings in 4 days ... there was a delay to check something, and whatever the check was, it didn't reset; and it's not POSSIBLE to reset it again. My guess is (strongly) that they'd had cases of someone inappropriately forcing a reset due to pressures to keep the equipment in the air, so the systems were ordered (by someone) to be configured to prevent that.

We all had to get off the plane and wait while another plane was pulled out of a hangar. And as I waited, it made me think: I'm glad they have to do it - and this is the price of safety.

(Conversely, tonight my wife reminded me that when my kidney was taken out, the LACK of reliable systems meant the nurses forgot to remove my catheter. This made the surgeon blow his top the next day, and increased the risk of my getting a retrograde infection, AND cost us all an extra day in the hospital. Which, of course, was good for revenue, not that it was anyone's GOAL. It was just not a reliable system... .which is what we're talking about.)

Anne Wells said...

Hi Paul. I found this post really interesting because I recently read another blog posting discussing a woman who sued a hospital for leaving a piece of surgical gauze behind from an operation that caused her severe health issues. The cause: the nurses apparently miscounted the surgical tools before closing her up, and no amount of recounts enabled the team to catch the mistake. The most appalling part was that the hospital, instead of accepting the settlement for its transgression, appealed, leaving the woman in a large amount of toil to try and salvage a “win”. I feel like the fact that this is a common issue is enough to make one think…

(link to the post)

I feel like this is a prime example of how some of the most fundamental practices in medicine are simply being overlooked due to apparent carelessness. I am currently in a class where we analyze the manner at which the public opinion towards medicine has allowed for increased skepticism and how as a result, the extent to which the patient is involved in the medical decision making process has grown exponentially more common simply due to the capacity to “google”. The fact is that ever since live surgeries were first imagined, things such as gauze and tools have commonly been left behind in patients, causing severe issues down the line. True, significant strides have been made in perfecting the art form, but technology grew all around medicine and spread beyond just the extensively educated few into the general public. The difference now is that because of the internet, forums and blog sites such as this one, and more technological advances in communication such as texting and emailing, anyone can know the instant anything happens with a simple touch: such as when a woman sues after a traumatic surgery experience. What happens when someone decides to look up the risks of the operation? Now the fact that there is a chance that a scalpel could be left in their abdomen is the most appalling statistic out there, a certain level of distrust arises in the professionals that will be cutting them open and poking around. Not to discredit medicine as a profession, but a mass freak out simply could be stopped.

This brings me to the key issue presented in the post: the fact that the hospital appealed the settlement, leaving the woman seemingly in ruins. No matter how cruelly the hospital may have acted, they will probably end up worse off simply due to the power of a digital “word of mouth”. The question is how much damage the general public could do to the world’s view of medicine before all medical decisions, such as the proper method to account for surgical tools, is entirely governed on the reactions of the common man.

Tom said...

My son, who flies a 747, would agree. Another reason why Hospitals Should Fly. Appreciate the reminder.

Priyanka said...

I also found it interesting that you drew this comparison. I was recently reading Atul Gawande’s The Checklist Manifesto and his entire argument is based on the idea that in health care, we often skip steps, ignoring possible safety/quality issues. In the book, Gawande argues for the implementation of checklists similar to the ones that pilots and airplane staff use in order to improve outcomes during surgery. He describes instances where objects are left in patients, as Dave and Anne refer to, and attributes this to a lack of standardized surgery procedure. I think you would find his argument and research compelling.

However, while I agree that health care providers have a tendency to push forward, I believe that much of the pressure to push forward comes from patients. We currently live in an instant-gratification world, where patients expect doctors and nurses to ‘fix’ them NOW. They come into the doctor’s office “knowing” what is wrong with them because they looked it up on WebMD, and they have all the symptoms of this illness or that disease. They come in wanting a pill, so the doctor writes the prescription, and the patient leaves happy. This is convenient for doctors because they are making their patients happy, but most doctors know that a pill is often not the answer. In the case of antibiotics, over- and unnecessarily prescribing is the number one cause of antibiotics eventually becoming ineffective due to resistance built up by bacteria. However, doctors keep prescribing because that’s what the patients want.

Doctors are humans too and they fall prey to carelessness and convenience. They just need reminders like everyone else. As Gawande shows, a checklist system has the potential to eliminate careless mistakes, just as the checklists that pilots and airline crews prevents crashes and airplane malfunctions. I also think that doctors also need to be reminded that they are in the position of giving advice and should not be coerced into a diagnosis of a patient based on the beliefs of the patient. Doctors go through years and years of training to do what they do, so they should listen to their training and remember to put the best interest of the patient first, which is not necessarily what the patient believes is best for them. Which brings me back to your friend’s experience, he did not want the three-hour delay, but in the end, he knew that the airline was doing what was in his best interest.

Nick Genes said...

Was your friend flying American Airlines? Because, as part of a labor dispute, the pilots are refusing to troubleshoot issues, warning lights, and the like - and following every regulation to the letter, consequences be damned. As a result, 50% of their planes in recent weeks have been delayed or canceled. More at Slate.

There's no danger to passengers - just a lot of inconvenience all around because of a breakdown of trust between corporate and pilots. I suppose the pilots are thinking that if their bosses don't trust them, they needn't exercise their judgment or particular skills to keep things running on time.