Firefighters execute dramatic rescue of children overcome by carbon monoxide

You’ve got to love and respect firefighters but occasionally they say some interesting things.

From Bay News 9 in Florida. Carbon monoxide sickened some children at a hockey rink in Clearwater. A malfunction of a machine that helps keep the ice cold was the cause. The fire department came and some children were treated at a hospital and released. Everyone is fine.

Here are quotes from two different fire officials. They occur one after the other in the article.

"This may be a mechanical failure. This is a rare occurrence," [Largo Fire Chief Mike] Wallace said. "There were lethal levels of carbon monoxide."

"Upon arrival, they found carbon monoxide levels at 96 parts per million. That's elevated -- nothing immediately dangerous to health and life -- but that we needed to evacuate the building," Largo Fire District Chief David Mixson said following an investigation.

Just for the record, the level of 96 ppm is a little short of “lethal.” Here’s a chart showing the symptoms usually seen at various levels of carbon monoxide exposure.

“System Failure” Often Really Means Someone Made a Mistake

Last week, Cleveland Browns quarterback Colt McCoy suffered a helmet-to-helmet hit by Steeler linebacker James Harrison. Controversy arose over the fact that McCoy was allowed to continue playing after a brief absence from the game. Later he exhibited many of the classic symptoms of a concussion.

The players’ union said a “blatant system failure” had occurred and that McCoy had not been examined adequately. Apparently the NFL’s protocol for ruling out a concussion was not followed.

Because the rules were not followed does not mean the system broke down. What it does mean is that one or more individuals did not comply with the rules, i.e., human error occurred. The league is now said to be considering hiring independent neurologists for each game venue.

UPDATE 12/15/2011
The Browns now admit that McCoy was not examined on the sideline after the hit. The medical staff was busy attending to other injured players and didn't see McCoy go down. This does not explain why the coaches and players who did see the hit didn't feel the need to tell the medical staff how violent the collision was. Bottom line: Not a system failure.

It’s easier to blame the system than to admit that someone made a mistake.

This all reminds me of a hospital with which I am familiar. Whenever a medical error happened, investigations took place, risk management meetings were held and many times a “root cause analysis” [RCA] was undertaken. Although in the majority of cases it was obvious that human error was the cause of the adverse event, the decision was usually that a “corrective action” involving what was perceived to be a system problem needed to be taken.

The corrective action meant that a new policy, something like having a neurologist on the sidelines, had to be created. There was no proof that the corrective action would be effective. There was evidence that a lot of work would result from the monitoring and documenting that the corrective action was ongoing. After a while, the corrective action was gradually forgotten.

Let’s look at some literature on the causes of medical error.

In 2010, van Wagtendonk et al published a paper in the British Journal of Surgery about unintended events in surgery units. Of the 881 events studied, 72.3% were the result of human error. A 2008 paper from the University of South Florida reviewed a hospital’s 12-month experience with surgical complications. Technical and judgment errors predominated, with system errors accounting for only 2% of the major complications seen. Surgeons at the University of Southern California looked at their trauma deaths over an 8-year period. Of 51 deaths classified as preventable or potentially preventable, surgeon error was the cause in nearly all cases.

Dr. Peter J. Pronovost, the noted Johns Hopkins patient safety guru, and colleagues reported in JAMA that root cause analysis is not very useful in preventing medical errors. Here are some quotes from that paper.

Many RCAs are performed incorrectly or incompletely and do not produce usable results. Anecdotally, officials in state health departments observe that the quality of the RCAs they receive varies widely.

Formulating corrective actions is more difficult than finding problems, and follow-up on outcomes is rare. A sign of the incomplete adoption of recommendations is that despite having recently completed an RCA for a specific incident, hospitals commonly experience repeat events, which is a reminder of words attributed to Einstein, “Insanity is doing the same thing and expecting a different result.”

Although there have been some benefits, including increased awareness of faulty processes and fixes to specific problems, there is an undercurrent of sentiment that this approach [root cause analysis ] has limited effectiveness.

Luckily, I no longer must sit through 3-hour RCAs. Or as a friend once said, “Would you rather have a root cause analysis or a root canal?” Tough choice.

UPDATE 12/17/2011
See followup post on this subject

Hospital politics, patient care and a doctor's suicide

What causes a doctor to commit suicide? A tweet from Helen Haskell (@hask) linking to a story about a radiation oncologist from Springfield, IL brought this strange case to my attention. Dr. Thomas G. Shanahan committed suicide by cutting his throat in November of 2011. He was respected in his field, having published many research papers and traveled the world helping to set up brachytherapy clinics in several countries. He also had been an acting alderman in his home city. He left his wife and three daughters.

Why did he do it? He had a history of depression. But an event occurred the year before his death that apparently significantly affected his personal and professional life.

Perhaps this story will puzzle you as much as it did me.

A patient with a diagnosis of advanced lung cancer was transferred to Memorial Medical Center where Shanahan worked. She had fallen and broken her leg and developed massive distension of the colon. She was having difficulty breathing. All of her doctors assumed she was terminally ill and advised the family to place her on a comfort care only status. Dr. Shanahan had received a request to see her and did so the next day. After evaluating her and her biopsy results from the first hospital, he felt that she was not necessarily terminally ill and should have a colonoscopy to decompress her colon. The other physicians declined to do so although inexplicably, a colorectal surgeon agreed to colonoscope her and ruled out obstruction but felt decompressing the colon would have been futile.

Shanahan then instructed a nurse to insert a rectal tube which evacuated all the gas and promptly resolved the breathing difficulty. The patient survived for seven more months with some diminished mental capacity thought to be related to the relative lack of oxygen when she was getting only comfort measures. She and her family were pleased with Dr. Shanahan’s efforts on her behalf.

The patient had Ogilvie’s syndrome, also known as pseudo-obstruction of the colon. It occurs in bedridden patients and those with recent orthopedic problems who receive large doses of narcotic pain medication. The treatment Shanahan ordered was correct.

But Dr. Shanahan admitted he had "ruffled the feathers" of some colleagues. He was called a “disruptive physician.” Memorial Medical Center conducted “an inquiry” to investigate his conduct. It was eventually dropped without any formal action being taken.

The chief medical officer at Memorial said, “Shanahan portrayed himself as ‘somewhat heroic’ to Reindl's family and was unnecessarily abrasive toward Springfield Clinic doctors and Memorial employees.”

Another account reported the following. Shanahan moved his office earlier this year from Memorial to St. John’s Hospital, telling friends and colleagues in an email June 28: “The last six months have been hard on me, deciding to defend a patient or turn my head and follow the herd. … I have received over 500 letters and emails supporting my decision.”

We will never know how deeply this situation affected Dr. Shanahan. He left no note.

Having learned all I can about this tragedy, I have some questions. Why was a radiation oncologist able to correctly diagnose and treat this patient while several more clinically oriented specialists could not? How is it that the doctor who made the right call over the objections of several colleagues is the one who is subjected to an inquiry and feels the need to move to another hospital? Is it OK to be “abrasive” when you are the only one who got the diagnosis right? Wasn’t he in fact a “hero” for refusing to back down and saving the patient’s life?

[This post used material from three newspaper reports (here, here, and here) and other sources.]

Airline food kills passenger. Maybe, but I don't think so,

In May of this year, a man named Othon Cortes died while flying from Barcelona to Miami. His family has filed suit against American Airlines. They claim he died of food poisoning acquired on the Barcelona to New York leg of the trip. He became ill at JFK airport and subsequently died before the plane diverted to Norfolk, Va.

Their lawyer says the death was caused by a chicken dinner tainted with Clostridium perfringens provided by the airline. The victim was said to have suffered “sharp stomach cramps and sudden thirst and other clear outward manifestation of severe physical illness."

I have a lot of problems with the way this poor man’s demise is being handled.

First the media. Here’s the way the Consumerist, an arm of Consumer Reports and a popular tweeter delivered the news.

And here are the headlines from some well-known news sources.

USAToday: Lawsuit: In-flight meal led to AA flier's death

CNN: Family: In-flight meal killed flier

Gizmodo: Airplane Food Finally Kills Someone, Says Lawsuit

DailyMail (UK): American Airlines sued after man DIES after in-flight meal [DIES is the way they printed it.]

To be fair, the articles use terms like “allegedly” but the reporters apparently did not ask many questions.

For example, did anyone else on the plane get sick? It is doubtful that food poisoning would have occurred in just one of say 200 passengers.

The death occurred in May. I would assume there was an autopsy. What were the findings?

Just how lethal is food poisoning due to Clostridium perfringens?

I don’t know the answers to the first two questions but I do know something about Clostridium perfringens. According to the CDC, “Persons infected with C. perfringens develop watery diarrhea and abdominal cramps within 6 to 24 hours (typically 8-12).” He would likely have diarrhea at some point. There was no mention of diarrhea in Mr. Cortes’s case. And the CDC says: “C. perfringens is one of the most common causes of foodborne illness in the United States. It is estimated that it causes nearly a million cases of foodborne illness each year.” 

So how common is death in this type of food poisoning? Not very. Wikipedia: “Very rare, fatal cases of clostridial necrotizing enteritis (also known as pigbel) have been known to involve "Type C" strains of the organism, which produce a potently ulcerative β-toxin. This strain is most frequently encountered in Papua New Guinea.” The FDA: “The disease generally lasts 24 hours. In the elderly or infirm, symptoms may last 1-2 weeks. Complications and/or death only very rarely occur.”

 

But it makes a much more interesting story if an inflammatory headline is used, doesn’t it?

Law School Goes to the Dogs

Thanks to the Washington Post for its exposé on the enormous difficulties plaguing stressed-out law students. According to the article, law students are so overwhelmed by the looming specter of exams that many CANNOT GO HOME FOR THANKSGIVING!

Schools such as George Mason University are dealing with this crisis. The school, along with others, has gone all out to help by bringing in puppies “to break the stifling pressure that blankets their campuses.”

As a mere physician, I had no idea what traumas one must endure to become a lawyer.

Can you believe what they go through? Here is an example.

“Many law schools now teach students how to balance the stress of late-night legal research, tort outlines and case summaries with healthy habits: running marathons, volunteering or hanging out with a pet.”

My God, “legal research, tort outlines and case summaries” and late at night too! How do they do it? It’s no wonder they need puppies.

University of Maryland Assistant Dean of Student Affairs Dawna Cobb meets with incoming students and tells them, “It’s okay to cry, but not for hours each day.”

How about this comparison? “For high-strung law students, dogs and other animals can also provide a soothing presence. That’s a lesson researchers have learned from others in stressful environments, including soldiers in war zones and patients in rehabilitation centers.” [emphasis added]

The article also says “Studies have found that the legal profession has higher-than-average rates of depression and problems with substance abuse.”

Is it those damn tort outlines or could it be that they begin to realize in law school that there are no jobs for lawyers?

Even the dogs know the truth. “When the puppies arrived, many seemed nervous around the mob of strangers.” The poor puppies probably were afraid to bark for fear of being subjected to a class-action lawsuit.

The Washington Post has really opened my eyes. I'm glad I took the easy way out by choosing medical school and five years of training in general surgery.

Single incision laparoscopic surgery for appendicitis may not be better

I don’t usually like to review papers that have only been published in abstract form or orally presented because complete data are not available for analysis. But I’m going to make an exception here because a recent paper presented at the American College of Surgeons annual meeting in October and featured on page 1 of Surgery News supports one of my many biases.

Researchers at the Chinese University of Hong Kong performed a trial involving 200 patients undergoing laparoscopic appendectomy randomized into two groups, conventional 3-port [3P] and laparoscopic single-site access [LESS]. The 3P approach uses 3 small incisions to insert the scope/camera and instruments while the LESS uses a single incision at the umbilicus with the scope/camera and instruments all inserted via the one incision.

Guess what? LESS was not only harder to perform [due to the inability to triangulate the instruments which are too close to each other] but it also caused significantly more postoperative pain.

Although LESS theoretically might result in a better cosmetic result because the only incision is in the umbilicus, the 3P procedure results in one scar in the umbilicus and two 5 mm scars in the lower abdomen. The two 5 mm scars are often invisible several months after surgery.

This study is one of the few large randomized trials on any type of single incision surgery and may be the first to show that LESS is inferior to the current standard. Because of their findings, lead author Dr. Anthony Y. B. Teoh said that his group “reverted to the three-port procedure” for patients presenting with appendicitis.

I previously blogged about a small study extolling the virtues of single-port robotic cholecystectomy, which purported to show [but did not] that it was better than the standard laparoscopic method.

Will there be more disillusionment with single-port surgery as larger and better designed studies emerge?