Tuesday, January 22, 2008

Chapter 93

As a non-MD, I don't often get to attend M&M (mortality and morbidity) conferences of our various departments. These are usually highly technical sessions where doctors discuss cases that have gone awry or otherwise have educational value for the residents and attendings.

I was invited to attend one today, though, where a special guest was present, the patient who arrived in the Emergency Department and went through an incredible medical process, leading very close to death. He and his mother were at the M&M to offer the capstone comments after the medical discussion. Back to that in a minute.

This was a very challenging case. A patient with many medical problems. A difficult diagnosis. A delay in the diagnosis that probably led to "coding" and a need to resuscitate the patient. For those of you who have not been through an M&M, you would be impressed by the candor of the discussion and the lack of blame and recrimination -- so that lessons from the case can be clearly identified and applied in the future.

The diagnosis was delayed because of "diagnostic anchoring," a topic discussed in Jerry Groopman's recent book, How Doctors Think. If you put blinders on the diagnostic path based on early indicators or predispositions, you will miss things that are important. That happened here. Luckily, though, the ultimate diagnosis was obtained in this case because the doctor in charge refused to close off other avenues of inquiry when the facts did not seem to support the initial presumption.

The successful resolution for this patient required incredible amounts of teamwork among emergency department doctors, internists, radiologists, pulmonologists, anaesthesiologists, respiratory therapists, transporters, and nurses. Here is a summary of the people and resources applied to this case.

•> 100 lab tests
•10 Electrocardiograms
•Continuous telemetry monitoring
•3 Chest X-Rays
•1 Echocardiogram
•2 Line placement procedures
•Seen by 9 physicians, 4 nurses
•Administered 12 medications

Back to the patient, a devout Muslim, who finished the case discussion by saying that he had woken up the next morning after dreaming about the number 93. He looked out the window to see the bright sun and blue sky and realized he was dreaming about Chapter 93 of the Holy Qur'an. I quote an excerpt:

The Brightness

In the name of Allah, the Beneficent, the Merciful.

I swear by the early hours of the day,
And the night when it covers with darkness.
Your Lord has not forsaken you, nor has He become displeased,
And surely what comes after is better for you than that which has gone before.


Anonymous said...

Curiosity killed the cat - if it doesn't violate confidentiality (and it might), what was the diagnosis?

Anonymous said...

Does not in this case. Pulmonary embolism. Many compounding factors may have made it not obvious to start with.

Anonymous said...

Aha; not surprising. There was a post with interesting comments on the Happy Hospitalist about a week or more ago on this subject; where he 'lucked' into the same diagnosis. As I mentioned in my comment there, as a (now retired) pathologist I used to see many cases of fatal undiagnosed PE; and dissecting aortic aneurysm was the second most common non diagnosis antemortem.
Not to hijack your blog for medical trivia, Paul, but we can all learn something from knowing the dx; thanks.

Anonymous said...


Thank you for an interesting post.

One question. What do you think would happen if the principles that have been so successful in the exact sciences -- physics, chemistry, biology, etc., -- were applied to the management of organizations themselves?

For example, I am an advocate of Goldratt's "Theory of Constraints" or TOC. In that methodology, one of the things we do is use a set of tools for doing what I call "structured speculation." Basically, we try to link via chains of cause and effect what we (believe we) see in reality back to a set of suspected causes.

Because this is speculation, it only goes so far, and there is a very real danger of not doing a sufficient level of testing of the speculations before rushing to implement something that "just has to be" an improvement.

Nevertheless, I find the tools as valid and useful today as I did fifteen years ago, when I stumbled upon them.

I'd be interested in your thoughts and the benefit of your experience. What tools do you use at BIDMC to speculate about the causes of undesirable effects in your organization and to plan improvement efforts?

Thanks again for some wonderful posts.


John Sambrook
Common Sense Systems, Inc.

Anonymous said...

The only amendment I would suggest to this story is that the "summary of the people and resources" occurred in just the *first 12 hours* of his care, rather than during his entire stay. I think this would probably be a meaningful edit for your readers who are also clinicians.

Unknown said...

I would be curious to know how all these people collaborated and how the information was disseminated.

Does it all work through formal, official channels, or in times like these do "shortcuts" come into play? Is The System flexible enough to handle this?

It would be interesting to get an Informaticians view of the M&M.

Kudos to all involved.

heartsaver said...

Great post. Your description of how benign the M&M conference was caught my attention. Believe me when I tell you that not all of them, at least when I was training in IM (not so long ago), were all benign in nature. There is no doubt that they are always great learning opportunities, but sometimes the learning environment is not the best. I do believe that the spirit of this conference has changed over time as it has included other health realted proffesionals that bring a different perspective to the discussion.

Juan Rivera

Anonymous said...

How is it that you were invited?
Is this your first and not your last?

Anonymous said...

Are M&M conferences at BIDMC usually closed except for special occasions such as this? I have always had an interest in attending as a healthcare professional but am not an MD. These meetings are not posted on any hospital calendar.
Thanks for writing such an educational blog.

Anonymous said...

M&M's are subject to the legal protection of peer review, in order to ensure a forthright, comfortable, and open discussion of errors and other problems. This is the case throughout the country, as far as I know.

As CEO, I am of course allowed to attend this department's or any toher department's M&M, and I try to from time to time. But for the most part, it is not part of my job. Further, since I am not a trained physician, I truly don't understand a lot of the highly technical stuff that is important for a full understanding of each case.

Anonymous said...

i thought there were some issues raised in florida a few years back regarding the confidentiality of discussions during m&m. there were some concerns that these discussions were not protected from lawyers seeking information regarding patient's case?

we have always discouraged non physicians or at least non clinical providers from attending to allow truly open and spirited discussion to occur. certainly some of the comments could be interpreted in the wrong way, or people who don't regularly attend might get the idea that certain providers are not as good as others, without an appropriate basis for the conclusion. sometimes we get a younger clinician inviting someone from industry or pharma to attend and we strongly, strongly discourage that. we always get a, what could it hurt? response from said clinician. ymmv.

Anonymous said...

Obviously, in this case, rules of peer review did not apply because the patient was present in the room.

Anonymous said...

Dear John Sambrook,

I don't think I understand your question. I think the answer is that we think about things, try them out, and if they don't work, figure out why and we try something else.

Anonymous said...

Dear John Norris,

A very, very good question. Of course, we have excellent information systems in place on which patient data is available to all. But the coordination is mainly people talking to each other at the patient's side or very nearby in an ED or ICU situation. It is the least complicated form of communication and is designed to avoid problems during the handoff from one doctor to another.

Anonymous said...

Dear Heartsaver,

A no-blame mentality is ESSENTIAL to a proper educational environment and also to an organization that is seeking constant improvement. As noted by one of my VPs, who was invited to another M&M:

"I completely agreed with your reaction…I was so impressed with the level of root cause analysis, open and honest discussion and self-criticism, and larger reflection about what related issues were also being raised. I think it would be great if administrators had opportunities to attend these. I think we’d have a lot to learn about how to analyze and problem solve complex problems."