Saturday, June 1, 2013

Addressing Medical Errors -

IT was probably our eighth or ninth admission that day, but my intern and I had given up counting. I was midway through my medical residency, already a master of efficiency. You had to be, or you'd never keep up. This one was a classic eye-roller: a nursing home patient with dementia, sent to the emergency room for an altered mental status. When you were juggling patients with acute heart failure and rampant infections, it was hard to get worked up over a demented nonagenarian who was looking a little more demented.

The trick to surviving was to shuttle patients to another area of the hospital as quickly as possible. This patient was a perfect candidate for the intermediate care unit, a holding station for patients with no active medical issues who were awaiting discharge. First we just had to rule out any treatable medical conditions — get the labs, head CT scan and chest X-ray. But the docs at the intermediate ward left at 5 p.m. and it was 4:45. I quickly scanned through the labs, called the ward's doctor and ran through the case — demented patient, still demented, return to nursing home tomorrow.

I remember the doctor's voice so clearly: "You're sure the labs and everything are normal?" Yes, yes, I said, everything is fine. She hesitated, then said O.K. The intern and I high-fived each other, and bolted back to our other admissions.

The next afternoon the doctor tracked me down. Without mincing words, she told me that she'd been called overnight by the radiologist; the patient's head CT showed an intracranial bleed. The patient was now with the neurosurgeons, getting the blood drained from inside her skull.

My body turned to stone. An intracranial bleed? You couldn't do much worse than miss an intracranial bleed.

How had I let my craze to decrease my patient load overtake proper medical care? I had failed to check the head CT! I was appalled at myself, mortified by my negligence. I stumbled through the rest of the day, an acrid mix of shame and guilt churning inside me.

I never told anyone about my lapse — not my intern, not my attending physician, certainly not the patient's family. I tried to rationalize it: the radiologist had caught the bleeding, and no additional harm had come to the patient.

But what if I had discharged the patient? What if I had started her on a medication like aspirin that could have worsened the bleeding? My error could easily have led to a fatal outcome. The patient was simply lucky.

In hospital lingo, this was a "near miss." But a near miss is still an error, just one in which backup systems, oversight or sheer luck prevent harm.

A near miss, like any error, is an opportunity to examine how mistakes are made and what changes might prevent them. Yet we have no idea how many near misses there are. Many experts feel that near-miss errors dwarf the number of known errors, a number that is already too high for comfort. (According to a 2006 report, medication errors alone injure an estimated 1.5 million patients a year.)

But the instinct for most medical professionals is to keep these shameful mistakes to ourselves. For the past two years I've been interviewing doctors about the emotional experiences that have molded them. Though I was interested in the full range of emotions, nearly every single one brought up a medical error that they had been party to during their careers; many of them had never spoken about it before. The shame of their errors — including the near misses — was potent, even decades later.

Much attention has been paid to reducing medical errors. Electronic prescriptions avoid penmanship mistakes. Bar codes on wristbands ensure that medications go to the right patient. Checklists and timeouts before surgeries help prevent common oversights. But we can stop only the errors we know about. There remains a black hole of near misses, of uncharted errors — a black hole of shame that prevents caregivers from coming forward.

Medical culture is less overtly punitive than it used to be, but the guilt and blame are internalized, often savagely, by its practitioners. How can we ease the shame and help doctors and nurses come forward with their near misses?

This is not the type of thing we can orchestrate with a quality-improvement initiative and a zippy slogan. It has to come from inside the medical world, and it helps to start at the top.

When the chief of medicine or the director of nursing stands up and talks about his or her biggest medical error, it will get noticed by the rank and file. Hearing how a person in authority handled the emotional fallout and the feelings of incompetence may give others the courage to come forward. Until we attend to the culture of shame that surrounds medical error, we will be only nipping at the edges of one of the greatest threats to our patients' health.

Danielle Ofri, an associate professor at New York University School of Medicine, is the editor of the Bellevue Literary Review and the author of "What Doctors Feel: How Emotions Affect the Practice of Medicine."

Friday, May 31, 2013

For a Boomer, Sunscreens Came Late and Cancer Too Soon - NYT

In retrospect, I should have taken a last look at the nose I was born with. This was on the first Wednesday of November in 2011, the day of a scheduled appointment with a dermatological surgeon for Mohs micrographic surgery, the purpose of which was to carefully remove some previously discovered skin cancer from the lower left side of my nose. But it was also the fourth day after a surprise autumn snowstorm that had left our home in north central Connecticut without heat or electricity and the surrounding landscape devastated by thousands of fallen trees. On the morning of my procedure I washed my hair and sponged my body with a few quarts of water heated in a stockpot on a gas barbecue grill outside the house, threw on some clothes and rushed out the door. The entire exercise felt like an inconvenience. Looking back, taking proper care of my freckled, reddish skin, descended from somewhere on the moors of Ireland, had always felt like an inconvenience.

There was scarcely time to squint at my reflection in the near-darkness and run cold fingers over the contours of a nose that over the course of my five and a half decades on earth had been broken, punched, cut, slapped, tweaked, swollen, nuzzled, kissed, blown and sunburned (boy, had it been sunburned), and, unbeknown to me, would be roughly half gone in a few hours. I was in a hurry. The appointment was at eight in the morning, so I plotted out the rest of the day as I drove through a snowy, battered moonscape en route to the procedure: Home by 10, cut up and stack tree limbs until early afternoon, scarf down some lunch, work until darkness. No problem. This was the norm for me: to schedule my hours aggressively and resent any intrusion on my plans, whether for a day, a week or the rest of my life.

Mohs surgery involves progressively removing sections of cancer-afflicted tissue, microscopically examining the tissue and, if cancer is found, taking yet another larger and deeper slice. This process is repeated — in "stages," according to the language of the profession — until the cancer is gone. It's even more primitive than it sounds but it almost always leaves the infected area cancer free (though disfigured to varying degrees). The statistic quoted reassuringly by the surgeon's scheduler was that 80 percent of their patients are out of the office after one stage. Because my tumor (a basal cell carcinoma, the most common form of skin cancer) was in the thin, alar wall of the nose, and near the bottom, I had been warned that some plastic surgery might be needed to smooth out the cosmetic damage (would it ever). In fact, removal of my cancer required 6 stages, 8 hours and 29 shots of Novocain. Office assistants who had been cheerful in the morning were averting their gazes by late afternoon. One of them blinked back tears when she gave me a phone charger to use.

A plastic surgeon was brought in from a neighboring office suite and tipped his head to the side as he assessed the damage, which I had not seen and would purposely not examine for another five days. "You know,'' he said, "there are some great prosthetic noses out there.'' Hence the first of many decisions was made: That guy wasn't getting near me with a scalpel or a rubber nose, which I imagined would look like Bozo's. I walked into the fading daylight with a bandage the size of a throw pillow taped to my face, very much in need of a skilled facial plastic surgeon and with no conventional Internet access to find one. I tapped out e-mails and texts to college and professional friends on my phone, looking for advice. The local guy was prepared to operate in two days, and with my nose a wasteland of exposed tissue, cartilage and bone, the clock was ticking. Two hours after the last stage of cancer was removed, I had made an appointment with a New York plastic surgeon who was recommended by a family friend with high standards. In truth, my decision was based almost solely on my long-held belief that the best of almost everything is in New York, especially doctors and pastrami.

The reconstruction would take place in three surgeries over six weeks, during which a chunk of tissue from my forehead would be used to build a new nose. This sounds medieval, but it's older than that: the Mayans had used forehead flaps to repair warriors whose noses had been sheared off in battle or by torture. Two days before the first procedure, my surgeon, Dr. Adam R. Kolker, insisted that I look at the damaged area so that I would understand the starting point in this process. I had avoided looking beneath my dressings, fearing that I would become emotionally engaged when I needed a clear head to make decisions. I looked in a hand-held mirror for less than 10 seconds. A notch the size of the first joint of my pinkie was entirely gone, extending from the rim into the middle of the nose; a much larger area, probably a little bigger than a quarter, was an open wound, dark brown in color, with flecks of white cartilage. Frankly, it was disgusting. And deeply dispiriting. Dr. Kolker explained that my "defect,'' (a technical term that seems to imply some sort of manufacturer's error) was in the upper 5 percent of skin cancer damage, in terms of size and severity. (The good news: basal cell carcinomas rarely metastasize, so this was a cosmetic issue, albeit a significant one). I would later learn that damage of this variety is usually seen in patients in their 70s and 80s, whose faces have already undergone many Mohs procedures.

Many in my generation resent the inconveniences of aging, injury and illness and regard them as if they are optional. This is delusional, but there you go. I had long expected that with enough vigorous exercise and attention to popular music tastes I could live indefinitely as I had in my 20s. I would be the cool dad to my kids (they would debate that this was ever true) and later drink tankards of beer after winning a road race trophy in the 80 to 84 age group. The reality is that life changes in a heartbeat. Mine changed when I looked in that mirror. (At the time I told Dr. Kolker to save me a photograph of the "before'' nose. He told me I would never want to see it, and he was right. I don't want to see it).

How did I get myself into this mess? The same way that Hemingway's Mike Campbell went broke in "The Sun Also Rises," "Gradually, then suddenly.''

The damage that led to my skin cancer was almost certainly done in childhood and adolescence, when I was sunburned frequently. I could blame my mother for this, but in truth she took care to keep me in hats and T-shirts and slathered me in white, goopy suntan lotion, which was the standard of care in the 1960s and '70s. But she wasn't always there. I once spent the afternoon at a friend's pool and was burned so badly that my small town doctor made a house call and bathed me in ice water cooled with rubbing alcohol because I was covered in water blisters and running a dangerously high fever. There were other occasions: at daylong high-school track meets, on beaches in Florida and Cape Cod during college breaks and countless times on golf courses. Sun protection was an annoyance. (How could I approach that girl at the ocean with white gunk on my nose?). As a professional journalist, I incurred many surprise sunburns, like the time when an N.F.L. player decided he would prefer to do our 45-minute interview out on the field, rather than in the locker room, and I hadn't worn a hat or applied sunscreen. Through much of this, skin cancer was a distant echo. I denied its existence, I suppose, like a smoker pretends he is not destroying his lungs (though I'm guessing at this, because I've never smoked).

In my 40s, I began getting annual skin checks from a dermatologist, most of which resulted in dozens of precancerous keratoses being frozen with liquid nitrogen. (This was around the same time that my sister was found to have a serious melanoma, a far more dangerous form of skin cancer, although I was already getting checked by then). In the fall of 2009, I noticed what looked like peeling skin on my nose and made an unscheduled visit to the dermatologist. He froze the area and sent me along. The peeling returned, and bled when disturbed. The dermatologist froze it again and again it returned. Eighteen months passed before he elected to perform the biopsy that turned up the cancer. By then I could feel what seemed to be a pea-size lump in the wall of my nose, and was, in fact, a basal cell tumor. It's pointless to wonder if I should have pushed for a biopsy earlier, but I wonder nonetheless. I take some solace in my plastic surgeon's assurance that my outcome would have been similar, "18 months earlier or later,'' because skin cancer cells grow slowly.

Through the reconstructive surgeries, I spent six weeks with my nasal tissue graft tethered to its original home on my forehead by a tentacle of flesh and arteries, providing it with a blood supply to grow in its new home. It looked deeply weird. If I tapped the graft on my nose with my index finger, I would feel it on my forehead. I went out in public only to see the surgeon (and once for an emergency visit to my dentist; you should have seen the look on his face). In late December of that year, the graft was separated and allowed to live on its own, in essence giving me a new nose.

It is not a perfect nose. We get only one of those, and we get it at birth. The procedure has left me with a vertical scar from my rapidly (and naturally) disappearing hairline to the inside edge of my left eyebrow, which is a little asymmetrical from the cutting. The nasal graft itself is slightly different in texture from the rest of my original nose, because forehead tissue is the closest match to nasal tissue, but it's not exactly the same. The graft is slightly enlarged where cartilage was transplanted from my left ear. There is a parabola-shaped scar line where the graft was sewn into my nose to cover the defect. The entire ensemble often feels strange; part of me, yet not fully mine. My surgeon will tinker some more before we're done, and nature will continue to blend the new into the old for years. Yet, the nose works fine now — I can breathe through it, blow it and sneeze with it. I have begun a collection of sun hats and bought a supply of sunscreen that costs more for three ounces than a bottle of decent wine. The truth is that given where I started, I am very fortunate.

Yet not a day passes that I don't wish I had stayed indoors more often as a kid, or worn a dorky, wide-brimmed hat as a college student. This regret accomplishes nothing useful, but I find it inescapable. I am keenly aware that I could have drawn much worse numbers in the cancer lottery; I never worked a day for the editor who gave me the most important break of my career 25 years ago, because he was given a diagnosis of pancreatic cancer right after hiring me and was gone in 13 months at age 50. I have a very healthy heart from lifelong exercise, a reasonably good diet and solid genes (the same ones that gave me red skin; DNA giveth and DNA taketh away). There's nothing I could do before the surgery that I can't do now, except possibly reprise my stirring cameo in the movie "Secretariat."

I am a sports journalist by trade, which means that much of my work revolves around one-on-one interviews in which I'm trying to earn a subject's trust with my intelligence, preparation and, not least, appearance. My profession has a reputation for slovenliness, and I've always tried to defeat that stereotype. I had been a high school and college athlete and ran until age 50 before arthritis (more inconvenience!) forced me to become a cyclist, all in the name of staying lean and vibrant. I would dress professionally. Now I find myself wondering what subjects think of my face, and the only way to get past that worry is to focus more intensely on the substance of the interview. Paradoxically, it's made me better at my job.

Vanity is a complex partner. "Fortunately," I would tell people, "I wasn't attractive before the surgery." That's half true. Like most humans, I also wasn't unattractive. Now I pause to look at my reflection in mirrors, car windows, elevator walls and pretty much any reflective surface, trying to convince myself that others' assurances of my normalcy are sincere. (My wife and grown children are exhausted with this exercise, presumably, because one can only say ``You look fine,'' so many times before giving up). I study people's noses, coveting some and drawing strength from the imperfections of others, of which there are many.

There is a constant energy in all of this. Life relentlessly doesn't pause for earthquakes and hurricanes, so it sure doesn't wait for a sportswriter to mourn the loss of his old nose or become accustomed to a new one. Family and friends thrive and grow or suffer and struggle. Seasons shift. Games are played and articles written. Lives change, but life surges forward.