CNN makes mistakes reporting "10 shocking medical mistakes"

I am sympathetic to those who champion efforts to improve patient safety and am not against exposing gross errors as examples of what not to do. However, a recent article on the CNN website entitled “10 shocking medical mistakes” suffers from poor reporting.

The article cites anecdotes involving patients with bad outcomes because of medical errors. I am not trying to minimize the fact that people die or are disabled from medical errors, including those mentioned in the CNN piece, but can we get the facts straight?

6. Mistake: Air bubbles in blood
• Cause: The hole in a patient's chest isn't sealed airtight after a chest tube is removed.
• Consequences: Air bubbles get sucked into the wound and cut off blood supply to the patient's lungs, heart, kidneys and brain. Left uncorrected the patient dies.
• Prevention: If you have a chest tube in you, ask how you should be positioned when the line comes out.
• Example case: Blake Fought

Simply googling the patient’s name [Blake Fought] yields a number of hits. On the first page is a story that Fought’s tube was really a central venous catheter [not a chest tube] through which he had been receiving nutrition. An inexperienced nurse apparently used improper technique to remove the catheter and an air embolus occurred. Yes, it’s a tragic and preventable mistake and the patient died. But the advice about a chest tube is misleading.

9. Mistake: Lookalike tubes
• Cause: A chest tube and a feeding tube can look a lot alike.
• Consequences: Medicine meant for the stomach goes into the chest.
• Prevention: When you have tubes in you, ask the staff to trace every tube back to the point of origin so the right medicine goes to the right place.
• Example case: Alicia Coleman

Googling “Alicia Coleman tube” brings one to the third hit on Google [just below two citations of the CNN account], which is a story from the Omaha World Herald telling of this poor child’s demise from having been given a drug meant for the tube in her stomach via a catheter [not a chest tube] in her jugular vein. The advice about checking where the tube goes is not incorrect, but the reporting is sloppy.

4. Mistake: Fake doctors
• Cause: Con artists pretend to be doctors.
• Consequences: Medical treatments backfire. Instead of getting better, patients get sicker.
• Prevention: Confirm online that your physician is licensed.
• Example case: Sarafina Gerling

How does this qualify as a “mistake”?

5. Mistake: The ER waiting game
• Cause: Emergency rooms get backed up when overcrowded hospitals don't have enough beds.
• Consequences: Patients get sicker while waiting for care.
• Prevention: Doctors listen to other doctors, so on your way to the hospital call your physician and ask them to call the emergency room.
• Example case: Malyia Jeffers

A crowded ER is not a “mistake,” nor is it shocking. It’s an everyday occurrence. Calling your doctor will not alleviate crowding unless your doctor decides to see you herself. That will at least keep you from making the crowding worse. Don’t use the ER for non-urgent or chronic problems. ER patients are not seen on a “first come, first served” basis. The sickest patients are seen first. Stories [one of which appeared on the CNN website in 2011] about Malyia Jeffers describe waiting but more importantly what appears to be human error in recognizing severe sepsis on the part of the ER triage nurse.

Many of my Twitter followers picked up on the above problems with the CNN article. Reasoned discourse about medical errors can help us all try to prevent them. This sort of story diverts our attention from the real issues. 

Maybe CNN should ask a doctor, or at least a fact checker, to vet articles such as this.

Overuse of proton pump inhibitors is expensive & dangerous

Let’s talk about proton pump inhibitors [PPIs]. These drugs, successors to the innovative H2 blockers, have revolutionized the treatment of gastro-esophageal reflux disease [GERD] and peptic ulcers.

But like all good things, too much can be a problem, and that’s where we are today.

A new study shows that of 90 patients who were tested and found NOT to have GERD, 38 [42%] continued to take PPIs which had been prescribed prior to the testing. Some apparently were not always told to stop the medication and others continued it because they remained symptomatic.

Ambulatory patients are not the only ones overusing PPIs. According to UpToDate, the indications for stress ulcer prophylaxis in hospitalized patients are as follows:

Mechanical ventilation for more than 48 hours, coagulopathy, GI ulceration or bleeding within the past year, traumatic brain injury, traumatic spinal cord injury, severe burns, or two or more minor risk factors, including sepsis, ICU admission lasting >1 week, occult GI bleeding lasting ≥6 days, or high-dose glucocorticoid therapy.

But in most hospitals, intravenous PPIs are routinely ordered for any patient who is npo [not taking food or drink by mouth]. There is not one shred of evidence that PPIs are indicated in this setting. I am old enough to remember the days before PPIs and H2 blockers existed. I assure you that millions of patients were npo and did not develop gastritis or ulcers.

Of course, PPIs are available over the counter [OTC] now, and although they are meant to be taken for only 3 weeks at a time and for no more than 3 such courses per year, there is really no limit to the number of PPIs purchased and used.

In 2010, an estimated $11.4 billion of prescription PPIs alone were sold. The amount of OTC drugs sold is not included, but Consumer Reports noted that in 2009, Nexium OTC sales amounted to $6.3 billion.

Among the adverse effects associated with PPIs reported in a recent systematic literature review are these:

Clostridium difficile-associated diarrhea

Community-acquired pneumonia

Osteoporotic fracture

Vitamin B12 deficiency

Inhibition of antiplatelet therapy

Other studies show that hospital-acquired pneumonia may also be more frequent in patients on PPIs.

Many experts feel that the current epidemic of C. diff colitis is being fueled not only by the indiscriminate use of antibiotics, but also by the overuse of PPIs.

How can the overuse of PPIs be stopped? When I was teaching residents, I tried to confront them with the evidence of harm and lack of evidence of utility of PPIs for patients who were simply npo. It didn’t seem to matter. Someone or something had gotten into their heads, and I couldn’t convince them.

I can’t count the number of outpatients I see who say they are on PPIs for GERD or “gastritis” but have never had a proper workup to establish those diagnoses. I have no idea how to stop the wholesale use of PPIs by primary care MDs, gastroenterologists and people who self-medicate.

It may be hopeless.

Resident fatigue & medical errors

The media frenzy about the latest entry in the resident fatigue research sweepstakes was predictable. There were many websites carrying the story with the usual misleading headlines, hand-wringing and “Oh, the humanity” quotes. There are too many such articles to cite them all. Here are a few.

Fox News Tired surgical residents may up error risk, study suggests
LA Times Study finds residents often fatigued
Daily Briefing Despite new rules, residents' fatigue continues to cause errors
MedPage Today Too little sleep makes Jack a dull surgeon
Orlando Personal Injury Legal Blog [one of many such blogs] Fatigued Hospital Residents Make More Mistakes

If one takes the time to read the paper, one will find the following:

• It studied only 27 orthopedic residents.
• It did not study medical errors but rather sleep and wakefulness.
• The amount of time that a resident moved his arm was measured by a device. The movements were then converted into “predictions” of fatigue which were then extrapolated into levels of risk of error.

Regarding the results, here are some important issues:

• Although residents working night shifts got less sleep than those working in the daytime, the difference was only 0.6 of an hour [36 minutes] and was not statistically significant, p = 0.08.
• When awake, all residents were fatigued about half of the time.
• More than 25% of the time, all 27 residents allegedly worked in a mental state equivalent to a blood alcohol level of 0.08% because of fatigue.
• Due to their pervasive fatigue, night-float residents were predicted to have a 24% increased risk of medical error, and even day shift residents had a 19% increased risk of medical error (P=.045).

This leads to some questions:

• Why are day shift residents so tired?
• Why do day shift residents get only 5.7 hours of sleep per night?
• If day shift residents are tired and night shift residents are even more tired, what is the solution?
• Could it be that a facetious suggestion I made in a blog that residents should work like sailors aboard ship in rotations of 4 hours on duty and 8 hours off duty is not so unrealistic?
• Will this paper be cited by plaintiffs’ lawyers?

What do you think?

Folding a paper airplane. Amazing feat by the surgical robot?

A number of people have tweeted about a video that shows a surgeon using a Da Vinci robot to fold and throw a paper airplane.

Watch for yourself.

On Twitter, I commented facetiously that there is finally a use for the robot.

Then I watched it again and realized that the video is actually a good illustration of what I’ve been saying all along about what is wrong with robotic surgery.

Even with the apparent use of several edits, it takes the surgeon over two and a half minutes to fold the airplane, a task which might take about 30 seconds by a human hand. Also despite the edits, there are several shots of missteps and fumbling. Finally, the airplane does not fly. When thrown, it drops like a stone.

Rather than convincing me that the robot is great, it makes me even more skeptical about its utility.